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Primary Subject area Emergency Medicine - Paediatric Background Needle-related procedures such as intravenous (IV) insertion, venipuncture, and lumbar puncture (LP) are commonly performed in children, particularly in the emergency department (ED). Children consistently rate these needle-related procedures as very distressing. While topical anesthetics have been shown to be highly effective and are available, they are inconsistently used. The Children’s Comfort Promise was originally developed at the Minnesota Children’s Hospital. It requires nursing staff to use four strategies for children undergoing needle-related procedures: (1) topical anesthetic, (2) sucrose or breastfeeding if ≤ 12 months, (3) Comfort positioning (swaddling, skin-to-skin, or facilitated tucking if ≤ 12 months and sitting upright for children > 12 months), and (4) age-appropriate distraction. Objectives We sought to evaluate compliance with all 4 Comfort Promise strategies for managing children’s pain and anxiety during needle-related procedures in a Canadian paediatric ED. Design/Methods Implementation of The Comfort Promise in March 2020 included a focus group to perform a root cause analysis, designation of nurse champions, monthly steering committee and ED working group meetings, and didactic education sessions. Our institution’s decision support unit identified all encounters of children 0-17 years who underwent at least one needle-related procedure at our paediatric ED from January 1 to November 30, 2020. The outcome was compliance with all 4 Comfort Promise strategies. Balancing measures included adverse drug reactions and vasoconstriction. We used statistical process control to analyze the outcome from 2 months preceding and 7 months following implementation. Results From January 1 to November 30, 2020, 21,600 encounters were identified, of which 10,294/21,600 (47.7%) were female. Age ranged from 0-17 years with a mean (SD) of 6.9 (5.5) years. Needle-related procedures were performed in 730/21,600 (3.4%) encounters, most commonly IV insertion (289/730, 39.6%) and venipuncture for blood sampling (232/730, 31.8%). Half of all encounters had no compliance strategies electronically recorded (363/730, 49.7%). Compliance with all Comfort Promise strategies increased over the study period (Figure 1). Topical anesthetic increased from 3/35 (8.6%) to 35/83 (42.2%). Sucrose or breastfeeding increased from 0/6 (0%) to 2/16 (12.5%). Comfort positioning increased from 0/35 (0%) to 26/83 (31.3%). Distraction increased from 0/35 (0%) to 22/83 (26.5%). There were no adverse drug reactions or vasoconstriction. Conclusion Implementation of The Comfort Promise in a Canadian paediatric ED resulted in greater use of strategies, particularly topical anesthetic, to reduce needle-related distress in children. Ongoing compliance will depend on consistent electronic recording and provider education.

OBJECTIVES: In children, peripheral intravenous catheters (PIVs) are maintained by either a continuous infusion of fluid “to keep vein open” (TKO) or a saline lock (SL). There is a widespread perception that TKO prolongs PIV patency, but there is a lack of evidence for this. We hypothesized that there would be no significant difference in duration of PIV patency between TKO and SL. PATIENTS AND METHODS: This prospective, time-allocated study included patients from newborn to 17 years of age admitted to our pediatric ward. Patients enrolled in the first 3 months were assigned to TKO, and patients in the latter 3 months were assigned to SL. Primary outcome was duration of functional patency of the first PIV during the time of TKO or SL. Secondary outcomes included PIV-related complications and patient and caregiver satisfaction. RESULTS: Complete PIV data were available on 172 (n = 85 TKO, n = 87 SL) of 194 enrolled patients. The mean (SD) duration of PIV patency was 41.68 (41.71) hours in the TKO group and 44.05 (41.46) hours in the SL group, which was not significantly different (P = .71). There were no significant differences in complication rates or overall patient and caregiver satisfaction. One patient in the TKO group had their PIV removed because of risk of strangulation from tubing. CONCLUSION: There were no significant differences between TKO and SL in the duration of PIV patency, complication rates, and overall patient and caregiver satisfaction in our pediatric population. Overall, SL is a safe and reasonable alternative to TKO in maintaining PIV patency in children.

Background Peripheral intravenous catheter (PIVC) insertion is a painful and invasive procedure performed on most paediatric patients. In children, PIVCs are maintained by either a continuous infusion of fluid “to keep vein open” (TKVO) or a saline-lock (SL). There is little uniformity between pediatric centres as to which method is used, and evidence is required to decide which method, if any, best maintains PIVC access. Objectives The primary objective was to compare duration of functional PIVC patency between TKVO and SL in children. Secondary objectives included assessing PIVC-related complications and patient/caregiver satisfaction. Design/Methods This prospective, time-allocated trial enrolled eligible patients from newborn to 17 years of age admitted to our pediatric ward. Patients enrolled in the first 3 months were assigned to TKVO, and patients in the latter 3 months were assigned to SL. Time of PIVC insertion and removal, PIVC-related complications, and satisfaction surveys were collected. Independent t-tests and chi-square tests were used to compare differences between arms for continuous and categorical outcomes, respectively. Results Complete PIVC data was available on 172 (n=85 TKVO, n=87 SL) of 194 enrolled patients. The mean (SD) duration of PIVC patency was 41.68 (41.71) hours in the TKVO group, and 44.05 (41.46) hours in the SL group, which was not statistically significant (p=0.71). There were no significant differences in complication rates or overall patient/caregiver satisfaction between the two groups. One patient in the TKVO group had their PIVC removed due to risk of strangulation from tubing. Conclusion There were no significant differences between TKVO and SL in the duration of PIVC patency in our pediatric population. This is consistent with previous results in neonates. There were also no significant differences in complication rates and overall patient/caregiver satisfaction. Overall, SL is a safe and reasonable alternative to TKVO in maintaining PIVC patency in children.

BACKGROUND: The requirement for a tracheostomy in children is associated with significant morbidity, mortality, and healthcare utilization. Easy identification of children with tracheostomies would facilitate important research on this population and provide quality improvement initiatives. AIM: The purpose of this study is to determine whether an algorithm of diagnostic and procedural codes can accurately identify children hospitalized with a tracheostomy using routinely collected health data. METHODS: Chart reviews were performed at the Children's Hospital of Eastern Ontario (CHEO) and the London Health Sciences Center (LHSC) to establish a true positive cohort of pediatric patients with tracheostomies admitted between 2008 and 2016. A multidisciplinary team developed algorithms of diagnostic and procedural codes contained within the Canadian Institute for Health Information Discharge Abstract Database. Algorithms were tested and refined against the true-positive and true-negative cohort. The accuracy of the diagnostic codes related to tracheostomy complications was also evaluated. RESULTS: A chart review identified 158 unique children with tracheostomies (77 at CHEO, 81 at LHSC) with 901 individual admissions (401 at CHEO, 507 at LHSC). The best algorithms for identifying children with a tracheostomy had a sensitivity and specificity of more than 99%, a positive predictive value (PPV) of 94.0% and negative predictive value (NPV) of 100%. The algorithm for the identification of tracheostomy-related complications had a sensitivity of 76.7%, a specificity of 65%, PPV of 52.3%, and an NPV of 84.7%. CONCLUSIONS: This study provides an algorithm for the accurate identification of children hospitalized in Canada with a tracheostomy, facilitating population-level epidemiological research and quality improvement initiatives.

Pediatric in-patients with tracheostomy (PIT) are at high risk for clinical deterioration. Medical emergency teams (MET) have been developed to identify high-risk patients. This study compared MET activation rates between PITs and the general ward population. This was a retrospective cohort study conducted at a tertiary pediatric hospital. The primary outcome (MET activation) was obtained from a database. Between 2008 and 2014, the MET activation rate was significantly higher in the PIT group than the general ward population (14 vs. 2.9 per 100 admissions, p

Trauma centres are required to continuously measure, evaluate and improve care. Severe traumatic brain injury (sTBI) patients are highly susceptible to adverse events (AE; unintended, potentially harmful events resulting from health care) due to their unstable condition requiring high risk interventions, multiple medications and invasive monitoring. Objectives were to describe: (1) a process for identifying AE in pediatric sTBI patients to identify safety risks, target and implement evidence-based prevention strategies; and (2) a tertiary care PICU's sTBI AE experience.Merging databases, Trauma Registry with Adverse Events Management System, identified AE in patients. Details on the event location, type and severity of harm were combined with patient demographics, injury data, costs and outcomes in a cohort of 193 PICU sTBI patients (2000-15). Descriptive statistics and multivariate logistic regression were undertaken to describe AE, and their association with risk factors and outcomes.103/193 sTBI patients (53%) suffered at least one AE. 238 AE occurred (1.23 AE/patient), with 30% of patients having 2+ AE. Most resulted in no harm (54%) with decubitus ulcers (15%) the most common AE. AE patients were more likely to be monitored for elevated ICP (p0.001), with fewer ventilator-free days (p=0.015), longer LOS for PICU (11 vs. 3.5 days; p0.001) and in-hospital (31 vs. 11 days; p0.001) with higher median costs ($121,234 vs. $53,341; p=0.031). AE patients required a higher level of care on discharge (p=0.035).Merging databases is an effective practice to identify AE and safety risks in trauma populations. Utilizing this method, a PICU AE rate of 1.23 events per patient was found with TBI severity the most important factor to increase the odds of AE. AE represent performance improvement events, opportunities to optimize care, decrease costs, as well as improve outcomes, to ultimately improve patient safety in this vulnerable population.

Background: Infections leading to sepsis are major contributors to mortality and morbidity in children world-wide. Determining the capacity of pediatric hospitals in Nigeria to manage sepsis establishes an important baseline for quality-improvement interventions and resource allocations. Objectives: To assess the availability and functionality of resources and manpower for early detection and prompt management of sepsis in children at tertiary pediatric centers in Nigeria Methods: This was an online survey of tertiary pediatric hospitals in Nigeria using a modified survey tool designed by the World Federation of Pediatric Intensive and Critical Care Societies (WFPICCS). The survey addressed all aspects of pediatric sepsis identification, management, barriers and readiness. Results: While majority of the hospitals 97% (28/29) reported having adequate triage systems, only 60% (16/27) follow some form of guideline for sepsis management. There was no consensus national guideline for management of pediatric sepsis. Over 50% of the respondents identified deficit in parental education, poor access to healthcare services, failure to diagnose sepsis at referring institutions, lack of medical equipment and lack of a definitive protocol for managing pediatric sepsis, as significant barriers. Conclusions: Certain sepsis-related interventions were reportedly widespread, however, there is no standardized sepsis protocol, and majority of the hospitals do not have pediatric intensive care units (PICU). These findings could guide quality improvement measures at institutional level, and healthcare policy/spending at the national level.

KEY POINTS An eight-day-old full-term baby girl presented to our centre with a one-day history of fever, poor feeding and fussiness. There was no history of respiratory symptoms, drowsiness, seizures, vomiting or rash. Her prenatal history was unremarkable. Rupture of membranes had preceded vaginal