Video Discharge Instructions for Acute Otitis Media in Children: A Randomized Controlled Open-label Trial

The behavioural and cognitive impacts of digital educational interventions in the emergency department: A systematic review

Ensuring patients and their caregivers understand the health information they receive is an important part of every clinical visit. Digital educational interventions like video discharge instructions, follow-up text messaging, or interactive web-based modules (WBMs) have the potential to improve information retention and influence behaviour. This study aims to systematically evaluate the impact of these interventions on patient and caregiver cognition and behaviour, as well as identify the characteristics of successful interventions and observe how success is measured. In December of 2022, a systematic literature search was conducted in several databases (Cochrane, Embase, MEDLINE (Ovid), Web of Science, ClinicalTrials.gov, and Google Scholar) for randomized controlled trials (RCTs) published between 2012 and 2022. In 2024, an identical search was performed for articled published between 2022 and 2024. Studies testing patient- and caregiver-facing digital educational interventions in the emergency department for behavioural and cognitive outcomes were included. Data from 35 eligible studies encompassing 12,410 participants were analyzed and assessed for bias using the Cochrane RoB2.0 tool. Video was used in 22 studies (63%), making it the most common modality. Seventy-three percent (16/22) of these studies reported statistically significant improvements in their primary outcomes. Text messaging was used in eight studies, with two (25%) reporting significant improvement in their primary outcomes. WBMs and apps were used in seven studies, 71% (5/7) of which reported statistically significant improvements in primary outcomes. Statistically significant improvements in cognitive outcomes were reported in 64% (18/28) of applicable studies, compared with 17% (4/23) for behavioural outcomes. The results suggest that digital educational interventions can positively impact cognitive outcomes in the emergency department. Video, WBM, and app modalities appear particularly effective. However, digital educational interventions may not yet effectively change behaviour. Establishing guidelines for evaluating the quality of digital educational interventions, and the formal adoption of existing reporting guidelines, could improve study quality and consistency in this emerging field. Registration The study is registered with PROSPERO ID #CRD42023338771.

Effectiveness of safety-netting approaches for acutely ill children: a network meta-analysis

BACKGROUND

Safety-netting advice (SNA) can help in the management of acutely ill children.

AIM

To assess the effectiveness of different SNA methods on antibiotic prescription and consumption in acutely ill children.

DESIGN AND SETTING

Systematic review and network meta-analysis of randomised controlled trials, cluster randomised trials, non-randomised studies of interventions, and controlled before-after studies in ambulatory care in high-income countries.

METHOD

MEDLINE, Embase, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials were searched (22 January 2024). Risk of bias (RoB) was assessed with Cochrane's RoB 2 tool, the Revised Cochrane Tool for Cluster-Randomised Trials, and the Risk Of Bias In Non-randomised Studies - of Interventions tool. Certainty of evidence was assessed using the Confidence in Network Meta-Analysis approach. Sensitivity analyses and network meta-regression were performed.

RESULTS

In total, 30 studies (20 interventions) were included. Compared with usual care, paper SNA may reduce: antibiotic prescribing (odds ratio [OR] 0.66, 95% confidence interval [CI] = 0.53 to 0.82, I 2 = 92%, very low certainty, three studies, 35 988 participants), especially when combined with oral SNA (OR 0.40, 95% CI = 0.08 to 2.00, P-score = 0.86); antibiotic consumption (OR 0.39, 95% CI = 0.27 to 0.58, low RoB, one study, 509 participants); and return visits (OR 0.74, 95% CI = 0.63 to 0.87). Compared with usual care, video SNA, read-only websites, oral SNA, and web-based SNA (in descending order of effectiveness) may increase parental knowledge (ORs 2.33-4.52), while paper SNA may not (ORs 1.18-1.62). Similarly, compared with usual care, video SNA and web-based modules may improve parental satisfaction (ORs 1.94-4.08), while paper SNA may not (OR 1.85, 95% CI = 0.48 to 7.08).

CONCLUSION

Paper SNA (with oral SNA) may reduce antibiotic use and return visits. Video, oral, and online SNA may improve parental knowledge, whereas video SNA and web-based modules may increase parental satisfaction.

Experimental Study on Video Discharge Instructions for Pediatric Fever in an Emergency Department

BACKGROUND AND OBJECTIVES

Fever is a frequent cause of consultation in the pediatric emergency department (PED). Adequate discharge instructions are essential to guarantee good management at home and can reduce caregivers' anxiety and re-consultations. This study compares the improvement of caregivers' knowledge regarding fever between verbal discharge instructions and the addition of a video to verbal information. As a secondary outcome, we compared the rate of return visits.

METHODS

An experimental, prospective, single-center study was conducted in a tertiary hospital PED. Patients between 3 months and 5 years old with febrile syndrome were enrolled. Patients with comorbidities or SARS-COV2 infection were excluded. First, caregivers answered a written test concerning fever characteristics, management, and warning signs. Patients were assigned by simple randomization to a control group (standard verbal and written instructions) or to an intervention group (which additionally received video instructions). After discharge, investigators contacted caregivers by telephone. Caregivers were asked to answer the same questions as in the written test in addition to the need for subsequent visits (at the PED or any other healthcare facility) after discharge.

RESULTS

Seventy-three patients were randomized to the intervention group and 77 to the control group (2 were lost during follow-up). There were no differences in the acquisition of caregiver's knowledge, with a median score improvement of 2 points in both groups (control group interquartile range (IQR) 1-2; intervention group IQR 1-3) (P = .389). In the intervention group, we observed a significant increase of correct answers in 4 out of 7 questions compared to 3 out of 7 questions in the control group. In the control group, 18.7% reconsulted compared to 10.9% in the intervention group (P = .188).

CONCLUSIONS

Video instructions were not superior to verbal instructions at improving caregivers' knowledge of fever overall. However, more questions obtained a significant score increase in those that received video and verbal instructions. Our results suggest that the addition of video instructions could help reduce return visits.

ISOM 2023 Research Panel 5: Interventions- Vaccines and prevention, medical and surgical treatment, and impact of COVID-19 pandemic

OBJECTIVES

To identify and synthesize key research advances from the literature published between 2019 and 2023 on the advances in preventative measures, and medical and surgical treatment of uncomplicated otitis media (OM) including the impact of the COVID-19 pandemic on OM management.

DATA SOURCES

Medline (PubMed), Embase, and the Cochrane Library.

REVIEW METHODS

All relevant original articles published in English between June 2019 and February 2023 were identified. Studies related to guideline adherence, impact of treatment on immune response and/or microbiology, tympanoplasty, Eustachian tube balloon dilatation, mastoidectomy procedures, and those focusing on children with Down's syndrome or cleft palate were excluded.

MAIN FINDINGS

Of the 9280 unique records screened, 64 were eligible for inclusion; 23 studies related to medical treatment, 20 to vaccines, 13 to surgical treatment, 6 to prevention (excl. vaccines) and 2 to the impact of COVID-19 on OM management. The level of evidence was judged 2 in 11 studies (17.2 %) and 3 or 4 in the remaining 53 studies (82.8 %) mainly due to the observational design, study limitations or low sample sizes. Some important advances in OM management have been made in recent years. Video discharge instructions detailing the identification and management of pain and fever for parents of children with acute otitis media (AOM) was more effective than paper instructions in reducing symptomatology; compared to placebo, levofloxacin solution was more effective for treating chronic suppurative otitis media, whereas AOM recurrences during two years of follow-up did not differ between children with recurrent AOM who received tympanostomy tube (TT) insertion or medical management. Further, novel pneumococcal conjugate vaccines (PCV) schedules for preventing OM in Aboriginal children appeared ineffective, and a protein-based pneumococcal vaccine had no added value over PCV13 for preventing AOM in native American infants. During the COVID-19 pandemic, a decline in OM and TT case volumes and complications was observed.

IMPLICATION FOR PRACTICE AND FUTURE RESEARCH

Whether the observed impact of the COVID-19 pandemic on OM management extends to the post-pandemic era is uncertain. Furthermore, the impact of the pandemic on the conduct of urgently needed prospective methodologically rigorous interventional studies aimed at improving OM prevention and treatment remains to be elucidated since the current report consisted of studies predominantly conducted in the pre-pandemic era.

Australian general practitioners' views on qualities that make effective discharge communication: a scoping review

Transitions of patient care between hospital discharge and primary care are known to be an area of high-risk where communication is imperative for patient safety. Discharge summaries are known to often be incomplete, delayed and unhelpful for community healthcare providers. The aim of this review was to identify and map the literature which discusses Australian general practitioners' (GPs) views on the qualities that make up effective discharge communication. Medline, Scopus and the Cochrane register of controlled drug trails and systematic reviews were searched for publications until October 2021 that discussed Australian GPs' views on discharge communication from hospital to general practice. Of 1696 articles identified, 18 met inclusion and critical appraisal criteria. Five studies identified that GPs view timeliness of discharge summary receipt to be a problem. Communication of medication information in the discharge summary was discussed in six studies, with two reporting that GPs view reasons for medication changes to be essential. Five studies noted GPs would prefer to receive clinical discipline or diagnosis specific information. Four studies identified that GPs viewed the format and readability of discharge summaries to be problematic, with difficulties finding salient information. The findings of this scoping review indicate that GPs view timeliness, completeness, readability, medication related information and diagnosis/clinical discipline specific information to be qualities that make up effective discharge communication from hospital to the community. There are opportunities for further research in perspectives of effective discharge communication, and future studies on interventions to improve discharge communication, patient safety and policy in transfers of care.

Triage through telemedicine in paediatric emergency care—Results of a concordance study

Background

In the German health care system, parents with an acutely ill child can visit an emergency room (ER) 24 hours a day, seven days a week. At the ER, the patient receives a medical consultation. Many parents use these facilities as they do not know how urgently their child requires medical attention. In recent years, paediatric departments in smaller hospitals have been closed, particularly in rural regions. As a result of this, the distances that patients must travel to paediatric care facilities in these regions are increasing, causing more children to visit an ER for adults. However, paediatric expertise is often required in order to assess how quickly the patient requires treatment and select an adequate treatment. This decision is made by a doctor in German ERs. We have examined whether remote paediatricians can perform a standardised urgency assessment (triage) using a video conferencing system.

Methods

Only acutely ill patients who were brought to a paediatric emergency room (paedER) by their parents or carers, without prior medical consultation, have been included in this study. First, an on-site paediatrician assessed the urgency of each case using a standardised triage. In order to do this, the Paediatric Canadian Triage and Acuity Scale (PaedCTAS) was translated into German and adapted for use in a standardised IT-based data collection tool. After the initial on-site triage, a telemedicine paediatrician, based in a different hospital, repeated the triage using a video conferencing system. Both paediatricians used the same triage procedure. The primary outcome was the degree of concordance and interobserver agreement, measured using Cohen’s kappa, between the two paediatricians. We have also included patient and assessor demographics.

Results

A total of 266 patients were included in the study. Of these, 227 cases were eligible for the concordance analysis. In n = 154 cases (68%), there was concordance between the on-site paediatrician’s and telemedicine paediatrician’s urgency assessments. In n = 50 cases (22%), the telemedicine paediatrician rated the urgency of the patient’s condition higher (overtriage); in 23 cases (10%), the assessment indicated a lower urgency (undertriage). Nineteen medical doctors were included in the study, mostly trained paediatric specialists. Some of them acted as an on-site doctor and telemedicine doctor. Cohen’s weighted kappa was 0.64 (95% CI: 0.49–0.79), indicating a substantial agreement between the specialists.

Conclusions

Telemedical triage can assist in providing acute paediatric care in regions with a low density of paediatric care facilities. The next steps are further developing the triage tool and implementing telemedicine urgency assessment in a larger network of hospitals in order to improve the integration of telemedicine into hospitals’ organisational processes. The processes should include intensive training for the doctors involved in telemedical triage.

Trial registration

DRKS00013207.

Video discharge instructions for pediatric gastroenteritis in an emergency department: a randomized, controlled trial

The aim was to evaluate if the addition of video discharge instructions (VDIs) to usual verbal information improved the comprehension of information provided to caregivers of patients who consult for acute gastroenteritis (AGE). We conducted an open-label, parallel, randomized trial, enrolling patients who consulted for AGE at a tertiary hospital. First, caregivers answered a written test concerning AGE characteristics and management. They were randomly allocated to a control group, which received the usual verbal instructions, or to an intervention group, which additionally received VDI. After discharge, caregivers were contacted by telephone and answered the same test, satisfaction questions, and follow-up information. From September 2019 to March 2020, 139 patients were randomized, 118 completed follow-up. The mean score was 3.13 (SD 1.07) over 5 points in the initial test and 3.96 (SD 0.96) in the follow-up test. Patients in the intervention group had a greater improvement (1.17 points, SD 1.11) than those in the control group (0.47 points, SD 0.94, p < 0.001). In the follow-up test, 49.1% in the intervention group and 18.6% in the control group answered all questions correctly (p < 0.001). There were no significant differences in return visits. Caregivers gave high satisfaction scores regardless of the allocation group.Conclusion: Video instructions improve caregivers' understanding of discharge information.Trial registration: [NCT04463355, retrospectively registered July 9, 2020]. What is Known: • Poor comprehension of discharge instructions leads to incorrect treatment after discharge, increased readmissions and a reduction of caregivers' satisfaction. • Video discharge instructions are useful providing concise information independently of the patients' health literacy level or communication skills of the health care provider What is New: • The addition of video discharge instructions to verbal instructions improves caregivers' knowledge about AGE improved with respect to those who only receive verbal instructions • Video instructions do not add extra time to the emergency department visits.