Are Increasing Volumes of Children and Young People Presenting to Emergency Departments Due to Increasing Severity of Illness?

A systematic review of the organizational, environmental, professional and child and family factors influencing the timing of admission to hospital for children with serious infectious illness

Background

Infection, particularly in the first 5 years of life, is a major cause of childhood deaths globally, many deaths from infections such as pneumonia and meningococcal disease are avoidable, if treated in time. Some factors that contribute to morbidity and mortality can be modified. These include organisational and environmental factors as well as those related to the child, family or professional.

Objective

Examine what organizational and environmental factors and individual child, family and professional factors affect timing of admission to hospital for children with a serious infectious illness.

Design

Systematic review.

Data sources

Key search terms were identified and used to search CINAHL Plus, Medline, ASSIA, Web of Science, The Cochrane Library, Joanna Briggs Institute Database of Systematic Review.

Study appraisal methods

Primary research (e.g. quantitative, qualitative and mixed methods studies) and literature reviews (e.g., systematic, scoping and narrative) were included if participants included or were restricted to children under 5 years of age with serious infectious illnesses, included parents and/or first contact health care professionals in primary care, urgent and emergency care and where the research had been conducted in OECD high income countries. The Mixed Methods Appraisal Tool was used to review the methodological quality of the studies.

Main findings

Thirty-six papers were selected for full text review; 12 studies fitted the inclusion criteria. Factors influencing the timing of admission to hospital included the variability in children’s illness trajectories and pathways to hospital, parental recognition of symptoms and clinicians non-recognition of illness severity, parental help-seeking behaviour and clinician responses, access to services, use and non-use of ‘gut feeling’ by clinicians, and sub-optimal management within primary, secondary and tertiary services.

Conclusions

The pathways taken by children with a serious infectious illness to hospital are complex and influenced by a variety of potentially modifiable individual, organisational, environmental and contextual factors. Supportive, accessible, respectful services that provide continuity, clear communication, advice and safety-netting are important as is improved training for clinicians and a mandate to attend to ‘gut feeling’.

Implications

Relatively simple interventions such as improved communication have the potential to improve the quality of care and reduce morbidity and mortality in children with a serious infectious illness.

Coaching for Chaos: A Qualitative Study of Instructional Methods for Multipatient Management in the Emergency Department

BACKGROUND

Busy environments, like the emergency department (ED), require teachers to develop instructional strategies for coaching trainees to function within these same environments. Few studies have documented the strategies used by emergency physician (EP)-teachers within these busy, chaotic environments, instead emphasizing teaching in more predictable environments such as the outpatient clinic, hospital wards, or operating room. The authors sought to discover what strategies EP-teachers were using and what trainees recalled experiencing when learning to handle these unpredictable, overcrowded, complex, multipatient environments.

METHOD

An interpretive description study was conducted at multiple teaching hospitals affiliated with McMaster University from July 2014 to May 2015. Participants (10 EP-teachers and 10 junior residents) were asked to recall teaching strategies related to handling ED patient flow. Participants were asked to describe techniques that they used, observed, or experienced as trainees. Two independent coders read through interview transcripts, analyzing these documents inductively and iteratively.

RESULTS

Two main types of strategies to teach ED management were discovered: 1) workplace-based methods, including both observation and in situ instruction; and 2) principle-based advice. The most often described techniques were workplace-based methods, which included a variety of in situ techniques ranging from conversations to managerial coaching (e.g., collaborative problem-solving of real-life administrative dilemmas).

CONCLUSIONS

A mix of strategies are used to teach and coach trainees to handle multipatient environments. Further research is required to determine how to optimize the use of these techniques and innovate new strategies to support the learning of these crucial skills.