Shannon Scott

Assessment of variation in the alberta context tool: the contribution of unit level contextual factors and specialty in Canadian pediatric acute care settings

BackgroundThere are few validated measures of organizational context and none that we located are parsimonious and address modifiable characteristics of context. The Alberta Context Tool (ACT) was developed to meet this need. The instrument assesses 8 dimensions of context, which comprise 10 concepts. The purpose of this paper is to report evidence to further the validity argument for ACT. The specific objectives of this paper are to: (1) examine the extent to which the 10 ACT concepts discriminate between patient care units and (2) identify variables that significantly contribute to between-unit variation for each of the 10 concepts.Methods859 professional nurses (844 valid responses) working in medical, surgical and critical care units of 8 Canadian pediatric hospitals completed the ACT. A random intercept, fixed effects hierarchical linear modeling (HLM) strategy was used to quantify and explain variance in the 10 ACT concepts to establish the ACTs ability to discriminate between units. We ran 40 models (a series of 4 models for each of the 10 concepts) in which we systematically assessed the unique contribution (i.e., error variance reduction) of different variables to between-unit variation. First, we constructed a null model in which we quantified the variance overall, in each of the concepts. Then we controlled for the contribution of individual level variables (Model 1). In Model 2, we assessed the contribution of practice specialty (medical, surgical, critical care) to variation since it was central to construction of the sampling frame for the study. Finally, we assessed the contribution of additional unit level variables (Model 3).ResultsThe null model (unadjusted baseline HLM model) established that there was significant variation between units in each of the 10 ACT concepts (i.e., discrimination between units). When we controlled for individual characteristics, significant variation in the 10 concepts remained. Assessment of the contribution of specialty to between-unit variation enabled us to explain more variance (1.19% to 16.73%) in 6 of the 10 ACT concepts. Finally, when we assessed the unique contribution of the unit level variables available to us, we were able to explain additional variance (15.91% to 73.25%) in 7 of the 10 ACT concepts.ConclusionThe findings reported here represent the third published argument for validity of the ACT and adds to the evidence supporting its use to discriminate patient care units by all 10 contextual factors. We found evidence of relationships between a variety of individual and unit-level variables that explained much of this between-unit variation for each of the 10 ACT concepts. Future research will include examination of the relationships between the ACTs contextual factors and research utilization by nurses and ultimately the relationships between context, research utilization, and outcomes for patients.

The effect of a cold environment on protein and energy metabolism in calves

Eleven Holstein bull calves 35 d of age were assigned to one of three treatment groups: (1) W72, warm environment (20 degrees), 72 g feed/kg body weight (BW)0.75 per d, (2) C72, cold environment (-5 degrees), 72 g feed/kg BW0.75 per d, or (3) C90, cold environment (-5 degrees), 90 g feed/kg BW0.75 per d. Fractional synthesis rates (FSR) of protein in the rumen wall, rumen papillae, omasum, duodenum, kidney, liver, heart, longissimus dorsi, biceps femoris and skin were determined following a continuous infusion of [3H]phenylalanine. Phenylalanine flux was elevated in both groups of cold-adapted calves. FSR of protein in the two muscles and skin were reduced along with N retention in the calves in the C72 group compared with the other two groups. Muscle protein degradation, estimated from urinary N tau-methylhistidine excretion, tended to be elevated in both groups of cold-adapted calves. Reduced protein synthesis and increased protein degradation in the C72 group contributed to reduced muscle protein gain. It appears that when feed intake is limited in cold-adapted animals, muscle and skin have a lower priority for nutrients than other organs and tissues, resulting in reduced protein synthesis. It seems unlikely that thermogenesis due to enhanced protein synthesis contributed to the increased heat production in the cold.

A systematic review of crisis interventions used in the emergency department: recommendations for pediatric care and research

Objective: In this systematic review, we evaluated the effectiveness of emergency department (ED)-based management interventions for mental health presentations with an aim to provide recommendations for pediatric care. Methods: A search of electronic databases, references, key journals, and conference proceedings was conducted, and primary authors were contacted. Experimental and observational studies that evaluated ED crisis care with pediatric and adult patients were included. Adult-based studies were evaluated for potential translation to pediatric investigation. Pharmacological-based studies were excluded. Inclusion screening, study selection, and methodological quality were assessed by 2 independent reviewers. One reviewer extracted the data, and a second checked for completeness and accuracy. Presentation of study outcomes included odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CI). Meta-analysis was deferred due to clinical heterogeneity in intervention, patient population, and outcome. Results: Twelve observational studies were included in the review with pediatric (n = 3), and adult or unknown (n = 9) aged participants. Pediatric studies supported the use of specialized care models to reduce hospitalization (OR, 0.45; 95% CI, 0.33-0.60), return ED visits (OR, 0.60; 95% CI, 0.28-1.25), and length of ED stay (MD, −43.1 minutes; 95% CI, −63.088 to −23.11 minutes). In an adult study, reduced hospitalization was reported in a comparison of a crisis intervention team to standard care (OR, 0.59; 95% CI, 0.43-0.82). Five adult-based studies assessed triage scales; however, little overlap in the scales investigated, and the outcomes measured limited comparability and generalizability for pediatrics. In a comparison of a mental health scale to a national standard, a study demonstrated reduced ED wait (MD, −7.7 minutes; 95% CI, −12.82 to −2.58 minutes) and transit (MD, −17.5 minutes; 95% CI, −33.00 to −1.20 minutes) times. Several studies reported a shift in triage scores of psychiatric patients dependent on the scale or nurse training (psychiatric vs emergency), but linkage to system- or patient-based outcomes was not made, limiting clinical interpretation. Conclusions: Pediatric studies have demonstrated that the use of specialized care models for mental health care can reduce hospitalization, return ED visits, and length of ED stay. Evaluation of these models using more rigorous study designs and the inclusion of patient-based outcomes will improve this evidence base. Adult-based studies provided recommendations for pediatric research including a focus on triage and restraint use.

Storytelling as a communication tool for health consumers: development of an intervention for parents of children with croup. Stories to communicate health information

BackgroundStories may be an effective tool to communicate with and influence patients because of their ability to engage the reader. The objective of this paper is to describe the development of a story-based intervention for delivery of health evidence to parents of children with croup for use in a randomized controlled trial.MethodsA creative writer interviewed parents of children with croup presenting to the pediatric emergency department (ED) and drafted stories. We revised the stories based on written participant feedback and edited the stories to incorporate research evidence and health information. An illustrator and graphic designer developed story booklets which were evaluated through focus groups.ResultsTen participants provided feedback on the five stories drafted by the creative writer. Participants liked the concept but found the writing overly sophisticated and wanted more character development and more medical/health information. Participants highlighted specific story content that they liked and disliked. The revised stories were evaluated through focus groups involving eight individuals. Feedback was generally positive; one participant questioned the associated costs. Participants liked the graphics and layout; felt that they could identify with the stories; and felt that it was easier to get information compared to a standard medical information sheet. Participants provided feedback on the story content, errors and inconsistencies, and preferences of writing style and booklet format. Feedback on how to package the stories was provided by attendees at a national meeting of pediatric emergency researchers.ConclusionsSeveral challenges arose during the development of the stories including: staying true to the story versus being evidence based; addressing the use of the internet by consumers as a source of health information; balancing the need to be comprehensive and widely applicable while being succinct; considerations such as story length, reading level, narrative mode, representation of different demographics and illness experiences, graphics and layout. The process was greatly informed by feedback from the end-user group. This allowed us to shape our products to ensure accuracy, credibility, and relevance. Our experience is valuable for further work in the area of stories and narratives, as well as more broadly for identifying and developing communication strategies for healthcare consumers.

Standard 2: containing risk of bias.

* Abbreviations: CONSORT — : Consolidated Standards of Reporting Trials ITT — : intention to treat SPIRIT — : Standard Protocol Items: Recommendations for Interventional Trials StaR Child Health — : Standards for Research in Child Health There is a crisis of credibility facing the child health research community because of the paucity of reliable estimates of the effects of interventions in children. Associations between risk of bias assessments and treatment effect estimates have important implications, for the clinician, and the families face important challenges as decision-makers stemming from results that exaggerate treatment effectiveness or safety. Consequently, interventions that are not efficacious and potentially harmful may be prescribed, whereas interventions that truly are efficacious may be withheld.1–5 Positive trends in pediatric research have been observed since the first trial was published in 1948. Specifically, there has been a substantial increase in the number of trials published over time, the proportion of randomized to nonrandomized controlled trials, and the proportion of child to adult trials.6 Reporting of methods has also improved; however, methodological quality remains modest.6 Three studies have specifically examined risk of bias in pediatric trials by using the Cochrane Risk of Bias tool.7–9 The results are summarized in Table 1 by risk of bias domain. In 2 reviews, the overall risk of bias was unclear or high for the vast majority of trials.7,8 Both of these articles also revealed that trials at high or unclear risk of bias had exaggerated treatment effects compared with those at low risk of bias. Sequence generation and allocation concealment appear to be the domains that are consistently problematic. Importantly, several variables have been found to be associated with risk of bias including source of funding (industry-sponsored research revealing higher risk of bias), nature of the interventions (behavioral/educational interventions having higher risk of bias), and number of authors (higher risk of bias with fewer authors).9 View this table: TABLE 1 Summary of Reviews Documenting Risk of Bias by Domain Using Cochrane Collaboration Risk of … Address correspondence to Martin Offringa, MD, PhD, Senior Scientist and Program Head, Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada M5G 1X8. E-mail: martin.offringa{at}sickkids.ca

Mapping the waters: A scoping review of the use of visual arts in pediatric populations with health conditions

Objectives: Visual art is a powerful and expressive communication tool with utility in pediatric settings. We undertook a scoping review to understand how visual arts (e.g. drawing, painting) are used in pediatric populations with health (i.e. medical and psychiatric) conditions. Methods: CINAHL, SCOPUS and PubMed were searched (2001–2011). We used systematic methods for study selection and data extraction. We conducted a descriptive analysis and categorized studies according to the purpose of the artistic intervention. Results: Of 1767 articles retrieved, 16 met the inclusion criteria. Visual art was most commonly used with the conditions of autism and post-traumatic stress disorder. Findings illuminate the use of art visual as a mechanism to facilitate or reduce specific child attributes (e.g. self-efficacy, anxiety) and to facilitate understanding through communication or assessment. Conclusions: This review provides information about the uses of visual art in pediatric populations with health conditions, as well as gaps in existing research.

Improving Outcomes for Ill and Injured Children in Emergency Departments: Protocol for a Program in Pediatric Emergency Medicine and Knowledge Translation Science

Approximately one-quarter of all Canadian children will seek emergency care in any given year, with the two most common medical problems affecting children in the emergency department (ED) being acute respiratory illness and injury. Treatment for some medical conditions in the ED remains controversial due to a lack of strong supporting evidence.The purpose of this paper is to describe a multi-centre team grant in pediatric emergency medicine (PEM) that has been recently funded by the Canadian Institutes of Health Research (CIHR). This program of research integrates clinical research (in the areas of acute respiratory illness and injury) and knowledge translation (KT). This initiative includes seven distinct projects that address the objective to generate new evidence for clinical care and KT in the pediatric ED. Five of the seven research projects in this team grant make significant contributions to knowledge development in KT science, and these contributions are the focus of this paper.The research designs employed in this program include: cross-sectional surveys, randomized controlled trials (RCTs), quasi-experimental designs with interrupted time-series analysis and staggered implementation strategies, and qualitative designs.This team grant provides unique opportunities for making important KT methodological developments, with a particular focus on developing a better theoretical understanding of the causal mechanisms and effect modifiers of different KT interventions.

Setting New Directions for Research in Childhood Nephrotic Syndrome: Results From a National Workshop

Background: We report on the proceedings of a national workshop held in Canada with the aims to identify priorities for research in childhood nephrotic syndrome and to develop a national strategy to address these priorities. Methods: A diverse group of participants attended the meeting, including patients, family members, researchers, and health care providers. We used small group discussions to explore priorities as perceived by patients and families and by health care providers and researchers. Results: Research evaluating glucocorticoid minimization or glucocorticoid-sparing regimens was a consistent theme in the patient and family discussion group. Families also indicated the need for precise prognostic information at diagnosis, more information to help them choose the best available therapy, and more resources for disease management. Health care providers emphasized the importance of better disease characterization including genotyping and phenotyping patients, better understanding the pathogenesis, and the need of providing targeted therapy and precise prognostic information. Conclusions: These priorities will inform the development and future directions of the Canadian Childhood Nephrotic Syndrome (CHILDNEPH) project, a national research initiative to improve care and outcomes of patients with childhood onset nephrotic syndrome.

Understanding Parents’ Experiences and Information Needs on Pediatric Acute Otitis Media: A Qualitative Study

Background: Acute otitis media (AOM) is the most common pediatric bacterial ear infection, affecting up to 75% of children younger than 5 years. Despite the high incidence of AOM in children, the condition presents a number of challenges to parents. The objectives of this study were to describe parents’ experiences of taking care of a child with AOM and to identify their information needs to manage their child with AOM. Methods: A qualitative, descriptive design was used to gain insight into information needs of parents’ of children with AOM. Participants were recruited from a specialized pediatric emergency department in a major Canadian urban center (Edmonton, Alberta). Individual semi structured interviews were conducted with 16 parents. Results: Seven major themes were identified and described: (1) frequency of AOM, (2) symptoms of AOM experienced by children and parents, (3) AOM symptom management strategies used by parents, (4) parent’s beliefs about AOM, (5) parent’s satisfaction with treatment prescribed by physicians, (6) the effect of AOM on family’s quality of life, and (7) parent’s information needs about AOM. Findings indicate that AOM has considerable negative outcomes for both children and families and that parents would benefit from having more evidence-based resources. Conclusions: This study provides important information around parents’ experiences and information needs for pediatric AOM. Identifying parents’ information needs and developing innovative and communicatively responsive educational approaches for parents are warranted that reflect patient-centered nursing care.

Parent experiences and information needs relating to procedural pain in children: a systematic review protocol

BackgroundThere exist many evidence-based interventions available to manage procedural pain in children and neonates, yet they are severely underutilized. Parents play an important role in the management of their child’s pain; however, many do not possess adequate knowledge of how to effectively do so. The purpose of the planned study is to systematically review and synthesize current knowledge of the experiences and information needs of parents with regard to the management of their child’s pain and distress related to medical procedures in the emergency department.MethodsWe will conduct a systematic review using rigorous methods and reporting based on the PRISMA statement. We will conduct a comprehensive search of literature published between 2000 and 2016 reporting on parents’ experiences and information needs with regard to helping their child manage procedural pain and distress. Ovid MEDLINE, Ovid PsycINFO, CINAHL, and PubMed will be searched. We will also search reference lists of key studies and gray literature sources. Two reviewers will screen the articles following inclusion criteria defined a priori. One reviewer will then extract the data from each article following a data extraction form developed by the study team. The second reviewer will check the data extraction for accuracy and completeness. Any disagreements with regard to study inclusion or data extraction will be resolved via discussion. Data from qualitative studies will be summarized thematically, while those from quantitative studies will be summarized narratively. The second reviewer will confirm the overarching themes resulting from the qualitative and quantitative data syntheses. The Critical Appraisal Skills Programme Qualitative Research Checklist and the Quality Assessment Tool for Quantitative Studies will be used to assess the quality of the evidence from each included study.DiscussionTo our knowledge, no published review exists that comprehensively reports on the experiences and information needs of parents related to the management of their child’s procedural pain and distress. A systematic review of parents’ experiences and information needs will help to inform strategies to empower them with the knowledge necessary to ensure their child’s comfort during a painful procedure.Systematic review registrationPROSPERO CRD42016043698