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Background Family-centered rounds (FCR) are fundamental to pediatric inpatient care. During the COVID-19 pandemic, we aimed to design and implement a virtual family-centered rounds (vFCR) process that allowed continuation of inpatient rounds while following physical distancing guidelines and preserving personal protective equipment (PPE). Methods A multidisciplinary team developed the vFCR process using a participatory design approach. From April through July 2020, quality improvement methods were used to iteratively evaluate and improve the process. Outcome measures included satisfaction, perceived effectiveness, and perceived usefulness of vFCR. Data were collected via questionnaire distributed to patients, families, staff and medical staff, and analyzed using descriptive statistics and content analysis. Virtual auditors monitored time per patient round and transition time between patients as balancing measures. Results Seventy-four percent (51/69) of health care providers surveyed and 79% (26/33) of patients and families were satisfied or very satisfied with vFCR. Eighty eight percent (61/69) of health care providers and 88% (29/33) of patients and families felt vFCR were useful. Audits revealed an average vFCR duration of 8.4 min (SD = 3.9) for a single patient round and transition time between patients averaged 2.9 min (SD = 2.6). Conclusion Virtual family-centered rounds are an acceptable alternative to in-person FCR in a pandemic scenario, yielding high levels of stakeholder satisfaction and support. We believe vFCR are a useful method to support inpatient rounds, physical distancing, and preservation of PPE that may also be valuable beyond the pandemic. A rigorous process evaluation of vFCR is underway.

Background The use of virtual care has increased dramatically in response to the COVID-19 pandemic, yet evidence is lacking regarding the impact of virtual care on patient outcomes, particularly in pediatrics. A standardized evaluation approach is required to support the integration of virtual care into pediatric health care delivery programs. The objective of this work was to develop a comprehensive and structured framework for pediatric virtual care evaluation. This framework is intended to engage and guide care providers, health centres, and stakeholders towards the development of a standardized approach to the evaluation of pediatric virtual care. Methods We brought together a diverse multidisciplinary team, including pediatric clinicians, researchers, digital health leads and analysts, program leaders, a human factors engineer, a family advisor and our manager of health equity and diversity. The team reviewed the literature, including published evaluation frameworks, and used a consensus-based method to develop a virtual care evaluation framework applicable to a broad spectrum of pediatric virtual care programs. We used an iterative process to develop framework components, including domains and sub-domains, examples of evaluation questions, measures, and data sources. Team members met repeatedly over seven months to generate and provide feedback on all components of the framework, making revision as needed until consensus was reached. The framework was then applied to an existing virtual care program. Results The resulting framework includes four domains (health outcomes, health delivery, individual experience, and program implementation) and 19 sub-domains designed to support the development and evaluation of pediatric virtual care programs. We also developed guidance on how to use the framework and illustrate its utility by applying it to an existing pediatric virtual care program. Conclusions This virtual care evaluation framework expands on previously developed frameworks by providing additional detail and a structure that supports practical application. It can be used to evaluate a wide range of pediatric virtual care programs in a standardized manner. Use of this comprehensive yet easy to use evaluation framework will inform appropriate implementation and integration of virtual care into routine practice and support its sustainability and continuous improvement.

Abstract Background A consistent and predictable discharge process is difficult to achieve, yet essential for good patient flow, appropriate resourcing, and safe patient care. At our institution, physicians predicted the estimated discharge date (EDD) for patients with bronchiolitis with 70.5% accuracy (January – March 2019). A key driver of this unpredictability is a lack of consensus on “medical discharge readiness” criteria across providers, which also has impacts on communication within the health care team and with patients and families. Objectives 1. To improve the ability to predict discharge date for patients with bronchiolitis by implementing a standardized medical discharge criteria checklist tool for one month (April 2019). 2. To more fully engage nurses in their patients’ care by improving transparency and accuracy of information about discharge. 3. To increase patient and family satisfaction with the discharge process. Design/Methods Meetings with key stakeholders determined drivers of discharge. Data on national practice variation in the management of patients with bronchiolitis was reviewed and informed the creation of a set of medical discharge criteria. Criteria were reviewed and accepted by the Division of Pediatric Medicine and presented to key stakeholders for feedback. Patient inclusion and exclusion criteria were developed. Feedback on the intervention was sought via surveys to physicians, nurses and patients/families. Results There was significant improvement (70.5% to 92.3%) in accuracy of predicting EDD with use of the medical discharge criteria checklist tool. There was also a reduction in length of stay. There were no patient bounce-backs to ED or patient readmissions. There was high satisfaction and support of the checklist tool from nursing and caregivers. Conclusion The development of standardized medical discharge criteria for patients with bronchiolitis is a safe and effective way to improve predictability, transparency, communication and patient flow, while enhancing engagement of the health care team and patient and family satisfaction. Its use is also associated with a reduced length of stay. Future directions include integrating the checklist tool into the electronic health record and moving towards a nurse-facilitated discharge process. Exploring and addressing non-medical barriers to discharge should also be a priority.

Abstract Background Virtual care has seen exponential growth since the onset of the COVID-19 pandemic, however, the evaluation of virtual care tools and services is lacking, particularly in the inpatient setting. In April 2020, we virtualized our in-person family-centered rounds (FCR) process and demonstrated the ability to perform virtual family-centered rounds (vFCR). In this study, we evaluate vFCR against the accepted standard of in-person FCR to ensure high quality care is maintained and encourage adoption by health care providers, administrators, patients and caregivers. Objectives The objective of this study is to compare vFCR to established core components and timing for in-person FCR. Perceptions of overall satisfaction, safety and technology usability were also explored. Design/Methods This is a mixed methods process evaluation of vFCR. Data collection was through virtual and in-person observation and post-vFCR survey of participants. Virtual observations focused on timing and adherence to core components of FCR, while in-person naturalistic observations focused on technology interaction and usability. Observation data underwent quantitative and content analysis. Data from post-vFCR questionnaires were subject to descriptive statistical analysis and content analysis of free-text responses. Results Sixty-two vFCR were observed virtually and 35 vFCR were observed in-person. Adherence to the core components of FCR during vFCR was variable (Table 1). Mean duration of a single patient round was 8.44 ± 4.93 minutes, with a mean transition time between patients of 3.96 ± 2.96 minutes. One hundred and four surveys were completed (76% response rate), 42 by patients and caregivers and 62 by members of the interdisciplinary medical team. The majority (93%) of respondents surveyed were satisfied or very satisfied with vFCR, and 67% felt it was important or very important to do FCR virtually during the pandemic to keep people safer. Importantly, vFCR was perceived by 96% of medical team members as supporting shared decision making with patients and caregivers, and 78% of patients/caregivers felt like a valued partner in their (child’s) care. Virtual family-centered rounds technology was perceived as easy or very easy to use by 95% of respondents. Additional positive and negative comments were submitted by 38% of respondents about their experience with vFCR (Figure 1). Conclusion Virtual family-centered rounds afford adherence to the core components of family-centered rounds. Satisfaction with vFCR and perceived usability of vFCR technology were both highly rated. Respondents also felt vFCR were important for safety during the pandemic. Rounds duration and transition times between patients were seen as opportunities for improvement. Observation and questionnaire data suggest the efficiency and quality of vFCR may be optimized through routine training on the rounding process and technology, as well as recognition of family-centered rounds as a component of inpatient pediatric care that should be prioritized.

Abstract Objectives We examined trends in patient volumes and care intensity among children admitted with laboratory-confirmed respiratory viral infections over 5 years in Ottawa, following the most recent and intense respiratory viral season experienced throughout the Ontario paediatric health system. Methods This was a retrospective cohort study of patients at the Children’s Hospital of Eastern Ontario (CHEO) in Ottawa, who were diagnosed with a laboratory-confirmed respiratory viral infection in the first 72 h of admission between October 22, 2017 and March 25, 2023. Their admissions were stratified by age groups and level of care intensity, based on unit of admission and/or additional ventilatory needs, with Level 3 patients requiring intensive care unit admission, and evaluated for trends over six surveillance periods that began in Week 35 (early September) and ended in Week 34 (end-August) of the following year. Results During the surveillance period from August 28, 2022 to March 25, 2023, there was an early, steep and twofold increase in admissions due to respiratory viral infections compared to previous periods, driven largely by Respiratory Syncytial Virus and Influenza A. Despite similar age distributions, there was a larger volume of Level 2 and 3 admissions, and higher proportion of patients requiring Level 2 care intensity in inpatient medicine units (23.4% versus 10.4% in pre-pandemic years; P < 0.001). Conclusions The most recent viral season was associated with elevated volumes and higher inpatient acuity compared to previous years and underscores the need for additional operational and human health resources to support paediatric health systems through these predictable surge periods.

Abstract Background Despite stewardship efforts, laboratory testing overuse persists across medicine. Objectives To understand laboratory stewardship perceptions and testing patterns at a tertiary care pediatric hospital so that we could identify potential improvement opportunities. Methods An electronic survey exploring laboratory stewardship was sent to all pediatric medicine resident and staff physicians. Laboratory testing data were also assessed for patterns of testing and overuse. Results The survey response rate was 54% (43/80). The results indicated good familiarity with stewardship but poor familiarity with testing specifics (eg, cost). A mobile reference application was the most preferred quality improvement intervention, and online modules were the least desired. Overuse was apparent, with as many as 53% of laboratory tests being repeated within 7 days and only half of repeated tests subsequently yielding abnormal results. Conclusions Altogether, the data we collated demonstrated poor understanding of laboratory stewardship and substantial repeat testing with few abnormal results. These study findings suggest that laboratory stewardship is lacking at our center, and that multiple improvement opportunities exist.

Abstract Introduction/Background Suicide remains the second leading cause of death in Canadian children and youth (Public Health Agency of Canada, 2019). Recent studies show that 50-80% individuals who die by suicide have had contact with a healthcare provider within one month prior to their death (Ahmedani et. al., 2014; Vasiliadis et. al., 2015). Unfortunately, these patients often present solely with physical complaints and infrequently discuss suicidal thoughts and plans unless asked directly. Those with medical conditions are also at a higher risk of experiencing mental health difficulties. Following a critical incident in our hospital, the corporate leadership committee addressed opportunities for improvement, and recommended the integration of routine suicide screening into standard care for all pediatric patients admitted to hospital. Objectives Prior to implementation of the transformative Head to Toe (term coined by a family caregiver during stakeholder interviews) initiative, suicide screening was routinely part of the admission assessment in the inpatient mental health units and for patients presenting to the emergency department with mental health concerns. In February 2019 we began a step-wise implementation of the Head to Toe suicide screening for all youth 12 and older admitted to the medical and surgical inpatient units at out institution using a psychometrically validated tool, the Ask Suicide Screening Questionnaire (ASQ) (Horowitz et. al, 2012). Design/Methods During the admission process, the nurse administers the ASQ and documents patients’ eligibility for screening and their responses on the ASQ items in the electronic health record. If a patient positively endorses an ASQ item(s) the nurse communicates this to the most responsible physician, who initiates a consult to mental health. Youth who endorse a positive screen receive a brief mental health risk assessment within 24 hours conducted by a mental health nurse. Patients who disclose active suicidal thoughts on the ASQ are assessed directly by psychiatry as soon as possible and actions are taken to ensure patient safety. A framework was developed for continuous evaluation of key components of the Head to Toe practice. Since the end of July 2019, when all medical/surgical units went live with the Head to Toe project, we have monitored compliance with the screening protocol on a daily, weekly, and monthly basis. Results We are the first pediatric hospital in Canada to implement systematic screening for suicide risk in medically or surgically hospitalized children and youth. Initial data indicate that during the first six months of the full implementation of the Head to Toe suicide screening, 72% (396) of eligible patients were screened with 14% (57) of these identified as having thoughts of suicide or a previous attempt and proceeding to further mental health assessment. Daily review of compliance rates on each unit allows us to identify omissions in patient screening and provide one-on-one support to staff to facilitate timely completion of the ASQ, while the weekly and monthly compliance reports are reviewed with unit staff and leadership to identify and address factors impeding compliance with Head to Toe care pathways and monitor change in adherence patterns. This ensures the sustainability of the Head to Toe initiative and provides opportunities for celebrating successes. We are also currently collecting qualitative feedback from youth and families about their experiences participating in the Head to Toe process. Conclusion This presentation will describe the steps to ensure successful implementation of suicide screening in our hospital setting, the challenges encountered and possible solutions. The hope is that this new practice will reduce emergency hospital visits for mental health crises and facilitate early access to mental health services. This initiative can be used to support other hospitals in implementing their own suicide prevention screening programs, along with informing policy about ways to help prevent suicide in youth populations.

Abstract Health care systems and providers have rapidly adapted to virtual care delivery during this unprecedented time. Clinical programs initiated a variety of virtual care delivery models to maintain access to care, preserve personal protective equipment, and minimize infectious disease spread. Herein, we first describe the context within paediatric health delivery during the COVID-19 pandemic in Canada that fueled the rise of virtual care delivery. We then summarize the development, implementation, and beneficial impact of the innovative virtual care delivery programs currently in use at Children’s Hospital of Eastern Ontario (CHEO) for both inpatient and outpatient care, specifically in our ambulatory clinics, emergency department, and mental health program. We highlight the transferable unique ways CHEO has integrated virtual care delivery through our governance structure, stakeholder engagement including patient, caregivers and health care providers and staff, development, and use of eHealth tools and novel approaches for patient care requiring physical assessment. We conclude with our vision for the future of virtual care, one component of paediatric care delivery in the post-COVID-19 era, which requires a common framework for virtual care evaluation. Importantly, rapid implementation of a primarily virtual care model at CHEO sustained high volume quality paediatric care. We believe many of these programs should and will remain in the post-pandemic era. A comprehensive, unified approach to evaluation is essential to yield meaningful results that inform sustainable care delivery models that integrate virtual care, and ultimately help ensure the best health outcomes for our patients.