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Reference: Ma K et al. A national survey of children’s experiences and needs when attending Canadian pediatric emergency departments. PLoS One. June 2024

Date: Oct 1, 2024

Guest Skeptic: Dr. Andrew (Andy) Tagg is an Emergency Physician with a special interest in education and lifelong learning. He is the co-founder of website lead of Don’t Forget the Bubbles (DFTB).

Dr. Andrew Tagg

Case: You are working with a medical trainee on her first clinical rotation through the emergency department (ED). One of the first patients she sees is a 12-year-old boy presenting with lower abdominal pain. He is accompanied by his worried parents. Before entering the room, she says to you, “This is the first time I’ve seen a pediatric patient. Do you have any tips for getting the history or performing the physical exam?”

Background: Through the course of one emergency department (ED) shift, we have countless interactions with patients from the initial history, examination, assessment, plan, updates on results from laboratory and imaging testing, reassessments, and eventually a final disposition. Working with children in the ED adds another layer of complexity as we are often trying to explain to them and their caregivers what is going to happen during their time in the ED.

Dr. Samina Ali

Children’s healthcare experiences can have a lasting impact on their understanding of health and their comfort in future medical settings.

For example, we discussed the importance of pain management with another Peds EM superstar, Dr. Samina Ali, on an SGEM Xtra and learned that poor pain management contributes to avoiding medical care in the future and even vaccine hesitancy.

While caregivers often advocate for their children, trying to understand the child’s needs and perspectives directly from the child is crucial for optimizing care.

Clinical Question: What are children’s perspectives on their needs and experiences during visits to Canadian pediatric EDs?

Reference: Ma K et al. A national survey of children’s experiences and needs when attending Canadian pediatric emergency departments. PLoS One. June 2024

  • Population: Children aged 7-17 years and their caregivers who presented to ten Canadian pediatric EDs between 2018 and 2020
    • Excluded: Children who remained medically unstable during their ED stay, had altered levels of consciousness, were suspected of being abused, or had a caregiver who was not their legal guardian​. The children and caregivers also had to speak either English or French.
  • Intervention: A cross-sectional survey designed for both children and caregivers. The child survey included 24 questions, focusing on emotional, practical, and communication needs, along with satisfaction with care.
  • Comparison: None
  • Outcome:
    • Primary Outcome: Children’s perspectives on their emotional, practical, and general informational needs and experiences.
    • Secondary Outcomes: Compare caregiver vs child perspectives on needs and experiences and relate demographic characteristics and needs within the ED to child’s understanding of their diagnosis and treatment
  • Trial: Descriptive cross-sectional survey

Authors’ Conclusions: “While almost all children felt well taken care of and were happy with their visit, close to 1/3 did not understand their diagnosis or its management. Children’s reported satisfaction in the ED should not be equated with understanding of their medical condition. Further, caution should be employed in using caregiver satisfaction as a proxy for children’s satisfaction with their ED visit, as caregiver satisfaction is highly linked to having their own needs being met.”

CROSS Quality Checklist for Survey Study

  1. Did the study address a clearly focused issue? Yes
  2. Did the authors use an appropriate method to answer their question? Yes
  3. Was the cohort recruited in an acceptable way? Yes
  4. Have the authors identified all-important confounding factors? No
  5. Was the follow-up of subjects complete enough? Yes
  6. How precise are the results? Unsure
  7. Do you believe the results? Yes
  8. Can the results be applied to the local population? Unsure
  9. Do the results of this study fit with other available evidence? Yes
  10. Funding of the Study: Women and Children’s Health Research Institute at the University of Alberta. The authors declare no competing interests.

Results: They included 514 children and their caregivers. The mean age of children was around 12 years with 56.5% female. Mean age of caregivers was around 43 years and the majority (78%) were mothers. Most (87%) were discharged home and the rest were admitted or transferred.

The survey was split into four categories including: emotional, practical, and communication needs, and overall satisfaction with care.

Emotional: Close to 80% of children felt there was enough privacy during conversations with healthcare staff and during the examination. While this is not bad, it also means that 1 in 5 kids did not feel like their privacy was respected.

Communication: Over 90% of children said that the doctor or nurse spoke to them directly which is great. Unfortunately, only around 70% understood their diagnosis. Interestingly, more children (89%) reported understanding the rationale behind the tests that were done compared to their caregivers (78.5%).

Practical: The top three things to make kids happy were electronics, non-electronic entertainment (toys and crafts), and food and drinks. There were 40% who said nothing would make them more comfortable.

Overall: Most children (94.8%) were happy at the end of their ED visit. Is this because of the care received? Or just relieved that they were able to go home.

Key Results: Nearly all children (95%) reported being happy with their ED visit, and over 90% felt well taken care of by both nurses and doctors. However, close to 1/3 of children did not fully understand their diagnosis or treatment​.

Biases

The participants were recruited via convenience sample over 1-week periods per season for four weeks total over a year. They were not able to recruit overnight. Recruitment was capped at 50 caregivers per seasonal week and 200 caregivers per site. The authors state this was for pragmatic and cost-related reasons. Were all those captured in this study necessarily reflective of the overall population seen in the emergency department?

Patients were recruited with all types of chief complaints. Most were deemed Urgent or Semi-Urgent Acuity on the Canadian Triage and Acuity Scale. It makes us wonder how responses to these questions may have changed in higher stress and higher-acuity situations.

Approximately 1 in 10 included in this study (12.9%) did not speak English at home. The study was limited to child-caregiver dyads who spoke English or French. There were practical considerations, but it is important to consider this as differences in language and culture may also impact the experiences.

In the United States, patients who are non-English speaking tend to be  under-triaged and non-white children tend to have longer wait times. [1,2]

Age Range

This study included a patient population over a wide age range (7 years to 17 years). 17-year-olds are not the same as 7-year-olds. We have to think hard about how we tailor our interaction and communication across this age spectrum. There’s a series from Wired called 5 Levels where they have an expert communicate a concept or topic at 5 different levels (child, teen, college student, etc.) at increasing complexity. This is a skill that we need to work on in medicine as our patients can vary in age and health literacy.

Their full survey did include a component to assess health literacy using a nutrition label for the caregivers, which was reported in a separate study. [3]

Talk Directly With Children

One easy thing to do for the age-appropriate child seems to be just talking directly with the kid. This was associated with a better understanding of treatment (OR 2.19) and decreased fear.

We’ve had experiences talking to children younger than seven where they can give a good history and answer questions. Sometimes parents also appreciate us talking directly with children because it’s a way for the kids to practice taking some responsibility for their health.

Community Involvement

Survey items were created with a literature review, team input, and parent advisory group review. They had a six-member expert panel that was multidisciplinary (emergency medicine, nursing, child life, parents, youth, and ED administrators). This resulted in a separate child survey in simpler language.

These patient and family partners can and should also be included as authors on the publication. We hope that this practice becomes more mainstream. It is an asset in studies to make sure we’re asking the right questions and looking at patient-oriented outcomes.

Patient Satisfaction Metric

This study demonstrates that patient satisfaction is an incomplete and imperfect metric. In this study over 90% of children felt well taken care of and were happy with their ED visit but only around 70% understood their diagnosis. Which one is more important? Despite many institutions emphasizing satisfaction or using Press Ganey scores, viewing it in isolation as a measurement of quality of care is inadequate. There are times when we should say “Sorry, antibiotics are not indicated for a cold or viral infection.” That’s better care although the patient may be disgruntled. We need to try and help them understand the clinical decision-making process.

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusion.

SGEM Bottom Line: There are many opportunities to improve the ED experience for children and help them understand their diagnosis and treatment.

Case Resolution: You applaud the medical trainee for her awareness of the differing needs of children. You encourage her to introduce herself to the boy and family and sit during the examination. Because the boy is twelve years old, you encourage her to start by first engaging the boy and then asking the parents for any additional information. If there are any sensitive questions (sexual health), you encourage her to ask the parents to leave the room briefly to ask those questions directly to the patient.

Clinical Application: There are simple actions we can take to improve our clinical interactions. One basic thing we try to do is to sit when talking with our patients. [4,5] When seeing children in the emergency department, we encourage everyone to speak directly with the child if they are age-appropriate and respect their privacy when asking sensitive questions. Additional work needs to be done to determine best strategies for explaining diagnoses, testing, and treatment to children of various ages.

What Do I Tell My Student?

Thank you for asking that question. When seeing pediatric patients, we often can get history from the patient and the family. I try to start the conversation with the patient first and ask the family to fill in the parts that they might not know. This patient is presenting with lower abdominal pain. You may want to consider asking him some questions related to his sexual health. These questions are better asked in private, so it is appropriate to request the parents step out briefly. We also need to try and explain what we think is going on and what we’re going to do in language that the patient can understand.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

References

  1. Rojas CR, Chamberlain JM, Cohen JS, et al. Undertriage for children with caregivers preferring languages other than english. Pediatrics. 2023;151(6):e2022059386.
  2. Johnson TJ, Goyal MK, Lorch SA, et al. Racial/ethnic differences in pediatric emergency department wait times. Pediatr Emerg Care. 2022;38(2):e929-e935.
  3. Ali S, Maki C, Rahimi A, et al. Family caregivers’ emotional and communication needs in Canadian pediatric emergency departments. PLoS One. 2023;18(11):e0294597.
  4. Golden BP, Tackett S, Kobayashi K, et al. Sitting at the bedside: patient and internal medicine trainee perceptions. J Gen Intern Med. 2022;37(12):3038-3044.
  5. Orloski CJ, Tabakin ER, Shofer FS, Myers JS, Mills AM. Grab a seat! Nudging providers to sit improves the patient experience in the emergency department. J Patient Exp. 2019;6(2):110-116.