A qualitative systematic review of the reasons for parental attendance at the emergency department with children presenting with minor illness

Introduction: Over 5 million children attend the Emergency Department (ED) annually in England with an ever-increasing paediatric emergency caseload echoed globally. Approximately 60% of children present with illness and the majority have non-urgent illness creating burgeoning pressures on children’s ED and this crisis resonates globally. To date no qualitative systematic review exists that focuses on the parental reasons for childhood attendance at the ED in this subgroup. Aim: To identify parental reasons for attending ED for their children presenting with minor illness. Method: A qualitative systematic review was conducted against inclusion/exclusion 10 criteria. Five electronic databases and key journals were searched in June 2015. Findings: 471 studies were identified and following study selection, 4 qualitative studies 12 were included. Nine themes were identified e.g. dissatisfaction with family medical services, perceived advantages of ED and ‘child suffering’ with novel and insightful sub-themes of ‘hereditary anxiety’, ‘taking it off our hands’, ED as a ‘magical place’. Conclusion: This novel qualitative systematic review examined parental attendance presenting with childhood minor illness of interest to emergency care reformers and clinicians. ED attendance is complex and multifactorial but parents provide vital insight to ED reformers on parental reasons for ED attendance in this sub group

Protocol for a longitudinal qualitative study: survivors of childhood critical illness exploring long-term psychosocial well-being and needs–The SCETCH Project

Life-threatening critical illness affects over a quarter of a million children and adolescents (0-18 years old) annually in the USA and the UK. Death from critical illness is rare; however, survivors and their families can be exposed to a complex array of negative physical, psychological and social problems. Currently, within the literature, there is a distinct paucity of child and adolescent survivor self-reports, thus limiting our understanding of how survivors perceive this adversity and subsequently cope and grow in the long-term following their critical illness. This study aims to explore and understand psychosocial well-being and needs of critical illness survivors, 6-20 months post paediatric intensive care admission

The experience of decision making in the care of children with palliative care needs: the experiences of Jordanian mothers

The purpose of this study was to explore the experience of decision making in the care of children with palliative care needs in Jordan, from the perspective of their mothers. This study employed a collective qualitative case study approach. Data were collected in 3 pediatric wards in a Jordanian hospital. The study used 2 data collection methods: participant observation (197 observational hours) and 56 semi-structured interviews with 24 mothers, 12 physicians and 20 nurses. The findings show how Jordanian mothers seek to transfer the role of decision making to physicians, as they perceive themselves to be unable to make decisions about critical issues related to the treatment of their children. Mothers had a widespread apprehension of “future guilt,” especially when they feared that any decisions they might make could have an adverse impact on their children. Contrary to the predominant pattern, some mothers took a proactive approach towards decision making about their children’s treatment. These mothers requested detailed information from primary physicians and sought different sources of knowledge such as second opinions, reading online resources, or talking to other parents who had a child with similar circumstances. The study concludes that mothers prefer to involve physicians in decisions about their children’s healthcare and treatment to eliminate their fear of probable future guilt; this modifies any tendency to autonomously decide for their children. These findings are underpinned by the Jordanian culture in which doctors’ opinions are highly regarded

Stories of survival: children’s narratives of psychosocial well-being following paediatric critical illness or injury

Survival from critical illness can expose children to an array of negative physical and psychological problems. While the perspective of parents and professionals have been well documented, there is limited understanding of how childhood critical care survivors make sense of their experiences in relation to psychosocial well-being. We aimed to explore long-term psychosocial well-being of childhood survivors of critical illness through their stories. A qualitative, exploratory study using serial in-depth interviews was employed. Nine children (aged 6–15 years) were recruited to the study, 6–14 months post-discharge from a paediatric intensive care unit. Qualitative art-based methods were used with a responsive interviewing technique and data were analysed using narrative psychological analysis. Four themes emerged: disrupted lives and stories; survivors revealed uncertainties in their stories as they recalled their critical care event, exposure to death and dying; talking about extreme physical vulnerability provoked anxieties, mediating between different social worlds and identities; revealed the dynamic nature of survival and getting on with life; the prospective outlook survivors had on their existence despite newly manifesting adversities. Childhood survivors’ stories identify challenges and adversities that are faced when attempting to readjust to life following critical illness that both enhance and impair psychosocial well-being

What are the predictors, barriers and facilitators to effective management of acute pain in children by ambulance services? A mixed-methods systematic review protocol

Introduction: The management of pain is complex, especially in children, as age, developmental level, cognitive and communication skills and associated beliefs must be considered. Without effective pain treatment, children may suffer long-term changes in stress hormone responses and pain perception and are at risk of developing posttraumatic stress disorder. Pre-hospital analgesic treatment of injured children is suboptimal, with very few children in pain receiving analgesia. The aim of this review is to identify predictors, barriers and facilitators to effective management of acute pain in children by ambulance services. Methods: A mixed-methods approach has been adopted due to the research question lending itself to qualitative and quantitative inquiry. The segregated methodology will be used where quantitative and qualitative papers are synthesised separately, followed by mixed-methods synthesis (meta-integration). We will search from inception: MEDLINE, CINAHL and PsycINFO via EBSCOHost, EMBASE via Ovid SP, Web of Science and Scopus. The Cochrane Library, the Joanna Briggs Institute, PROSPERO, ISRCTN and ClinicalTrials.gov will be searched. We will include empirical qualitative and quantitative studies. We will exclude animal studies, reviews, audits, service evaluations, simulated studies, letters, Best Evidence Topics, case studies, self-efficacy studies, comments and abstracts. Two authors will perform full screening and selection, data extraction and quality assessment. GRADE and CERQual will determine the confidence in cumulative evidence. Discussion: If confidence in the cumulative evidence is deemed Moderate, Low or Very Low, then this review will inform the development of a novel mixed-methods sequential explanatory study which aims to comprehensively identify predictors, barriers and facilitators to effective pain management of acute pain in children within ambulance services. Future research will be discussed among authors if confidence is deemed High. Systematic Review Registration: PROSPERO: CRD42017058960

Ambulance clinician perspectives of disparity in pre-hospital child pain management: A mixed methods study

Background: When children suffer acute pain, the ambulance service is often involved to provide initial assessment, treatment and transport. Several predictors of effective pain management have been identified, including children who are younger (0-5 years), administered analgesics and living in homes from more affluent areas. Objective: To explain previously identified predictors of effective pre-hospital pain management in children. Design: Mixed methods sequential explanatory study. Setting and participants: East Midlands Ambulance Service National Health Service Trust paramedics and emergency medical technicians (EMTs) participated in face-to-face semi-structured interviews. These were audio recorded, transcribed verbatim and coded using thematic analysis. Meta-inferences were generated and illustrated within a joint display. Results: 12 clinicians (9 paramedics and 3 EMTs) were interviewed. Median (interquartile range) age was 43.5 years (41.5, 45.75), 58% were male (n=7) and 58% were parents (n=7). Possible explanations were provided for all predictors. Younger children were perceived to express more emotion, were easier to distract and lived more in the moment than their older counterparts, which explained why younger children were more likely to achieve effective pain management. Analgesics were perceived to have a psychosocial benefit in addition to the pharmacological action. Ambulance clinicians felt that children living in more affluent areas were more likely to achieve effective pain management because the kempt environment facilitated assessment and management and clinicians spent more time on scene; this allowed more time for analgesics to take effect. Participants perceived paramedics to be more confident, and it was found that paramedics were older, more experienced, had a greater scope of practice and spent more time on scene than EMTs. Conclusion: Pre-hospital pain management in children could be improved by facilitating and prioritising analgesic administration and by ambulance services ensuring a paramedic, or highly training clinician, is present on each vehicle, necessitating long-term commitment to staff development

Mixed methods in pre-hospital research : understanding complex clinical problems

Healthcare is becoming increasingly complex. The pre-hospital setting is no exception, especially when considering the unpredictable environment. To address complex clinical problems and improve quality of care for patients, researchers need to use innovative methods to create the necessary depth and breadth of knowledge. Quantitative approaches such as randomised controlled trials and observational (e.g. cross-sectional, case control, cohort) methods, along with qualitative approaches including interviews, focus groups and ethnography, have traditionally been used independently to gain understanding of clinical problems and how to address these. Both approaches, however, have drawbacks: quantitative methods focus on objective, numerical data and provide limited understanding of context, whereas qualitative methods explore more subjective aspects and provide perspective, but can be harder to demonstrate rigour. We argue that mixed methods research, where quantitative and qualitative methods are integrated, is an ideal solution to comprehensively understand complex clinical problems in the pre-hospital setting. The aim of this article is to discuss mixed methods in the field of pre-hospital research, highlight its strengths and limitations and provide examples. This article is tailored to clinicians and early career researchers and covers the basic aspects of mixed methods research. We conclude that mixed methods is a useful research design to help develop our understanding of complex clinical problems in the pre-hospital setting

The predictors, barriers and facilitators to effective management of acute pain in children by ambulance services: A systematic mixed studies review

Background: Pre-hospital analgesic treatment of injured children is suboptimal with very few children in pain receiving analgesia. Without effective pain treatment, children are at risk of adverse consequences including posttraumatic stress disorder and altered pain perception. The aim of this review was to identify predictors, barriers and facilitators to effective management of acute pain in children by ambulance services. Methods: A segregated systematic mixed studies review was performed. We searched from inception to 01-Aug-2019: MEDLINE, CINAHL, PsycINFO, EMBASE, Web of Science Core Collection and Scopus. Empirical quantitative, qualitative and multi-methods studies of children under 18 years, their relatives or EMS staff were eligible. The outcome measure for quantitative studies was effective pain management, defined as a pain score reduction ≥2 out of 11. Two authors independently performed screening and selection, quality assessment, data extraction and quantitative synthesis. Three authors performed thematic synthesis. GRADE and CERQual were used to determine the confidence in cumulative evidence. Results: From 3526 articles screened, 70 were selected for full text review, with 7 quantitative and 5 qualitative studies included. Considerable heterogeneity precluded meta-analysis. Predictors of effective pain management included: “child sex (male)”, “child age (younger)”, “type of pain (traumatic)” and “analgesia (administered)”. Barriers and facilitators included internal (fear, clinical experience, education and training) and external (relatives, colleagues) influences on the clinician along with child factors (child’s experience of event, pain assessment and management). Confidence in the cumulative evidence was deemed low. Conclusions: To improve prehospital pain management in children, efforts to facilitate analgesia administration should take priority, perhaps utilising the intranasal route. The culture of treating traumatic pain more readily than medical pain should also be addressed. Further research is recommended to explore the child’s perspective, investigate the conflicting data around “child age” and unexplained data around “child sex” and to improve the confidence in cumulative evidence

Weekly variation in health-care quality by day and time of admission: a nationwide, registry-based, prospective cohort study of acute stroke care.

Studies in many health systems have shown evidence of poorer quality health care for patients admitted on weekends or overnight than for those admitted during the week (the so-called weekend effect). We postulated that variation in quality was dependent on not only day, but also time, of admission, and aimed to describe the pattern and magnitude of variation in the quality of acute stroke care across the entire week.Accepted manuscript (12 month embargo

Reducing Repeat Paediatric Emergency Department Attendance for Non-urgent Care: A Systematic Review of the Effectiveness of Interventions

Objective Non-urgent paediatric ED (PED) visits appear to contribute a large portion to the growing use of EDs globally. Several interventions have tried to curb repeated non-urgent attendances, but no systematic review of their effectiveness exists. This review examines the effectiveness of interventions designed to reduce subsequent non-urgent PED visits after a non-urgent attendance. Method A systematic review design. A systematic search of four databases and key journals was conducted from their inception to November 2018. Experimental studies, involving children aged 0-18 years presenting to an ED for non-urgent care, which assessed the effectiveness of interventions on subsequent non-urgent attendance were considered. Results 2120 studies were identified. Six studies, including four randomised controlled trials (RCTs) and two quasi-experimental, were included. Studies were of moderate quality methodologically. All studies originated from the USA and involved informational and/or follow-up support interventions. Only two RCTs demonstrated the longest duration of intervention effects on reducing subsequent non-urgent PED attendance. These studies identified participants retrospectively after ED evaluation. The RCT with the largest number of participants involved follow-up support by primary physicians. Meta-analysis was impractical due to wide heterogeneity of the interventions. Conclusions There is inconclusive evidence to support any intervention aimed at reducing subsequent non-urgent PED visits following a non-urgent attendance. The long-term impact of interventions is limited, although the effect may be maximised if delivered by primary care providers in children identified after their ED attendance. However, further research is required to evaluate the impact of any such strategies in settings outside the USA