Practice variation across five European paediatric emergency departments: a prospective observational study

Child-TRACH: Management of tracheostomy in children, a Yo-IFOS survey

OBJECTIVES

The number of tracheostomies in children has increased the last twenty years thanks to neonatal and pediatric intensive care improvement. As it is often a difficult situation to deal with for children and their caregivers, we wished to draw up the inventory of the management protocols of pediatric tracheostomies around the world.

METHODS

We performed an online international survey for ENTs managing children with tracheostomies. The survey was in English and diffused through ENT national and international societies (International Federation of Otorhinolaryngologists Societies, IFOS and French Society of Otorhinolaryngologists, SFORL). Answers were anonymized and collected online between September 2021 and January 2022. All data were analyzed as a whole and according to the continent.

RESULTS

119 ENTs from the different continents responded to the survey: Europe (45.4 %), Asia (16 %), North America (14.3 %), South America (10.9 %), Africa (6.7 %) and Oceania (6.7 %). The most common indication for tracheostomy was laryngeal obstruction (77.3 %). Once initial management and surgical procedure performed, the majority of children returned home with their tracheostomy; tracheostomy was a contraindication for only 1.7 % of the responders. Concerning patient autonomy on daily care of the cannula at home, it was acquired in only 27.7 % of the cases, no difference was observed between countries (p = 0.22). Therapeutic patient education (TPE) was offered for 86.9 % of the patients taken care by the responders: it was dedicated to training the parents (96.8 %), with no differences between countries; however, in some countries, TPE for could also be offered to other caregivers. The mean delay between surgery and first change of cannula was 27.3 days (1-100) but varied depending on the country (4 days in Nigeria, 20 days in north America, 40 days in Europe, Asia and south America).

CONCLUSION

Although tracheostomies in children can encompass several indications, practices across the world are similar and aim to offer a life as normal as possible for these children.

Diagnostic testing in children: A qualitative study of pediatricians' considerations

AIMS AND OBJECTIVES

Studies in adult medicine have shown that physicians base testing decisions on the patient's clinical condition but also consider other factors, including local practice or patient expectations. In pediatrics, physicians and parents jointly decide on behalf of a (young) child. This might demand more explicit and more complex deliberations, with sometimes conflicting interests. We explored pediatricians' considerations in diagnostic test ordering and the factors that influence their deliberation.

METHOD

We performed in-depth, semistructured interviews with a purposively selected heterogeneous sample of 20 Dutch pediatricians. We analyzed transcribed interviews inductively using a constant comparative approach, and clustered data across interviews to derive common themes.

RESULTS

Pediatricians perceived test-related burden in children higher compared with adults, and reported that avoiding an unjustified burden causes them to be more restrictive and deliberate in test ordering. They felt conflicted when parents desired testing or when guidelines recommended diagnostic tests pediatricians perceived as unnecessary. When parents demanded testing, they would explore parental concern, educate parents about harms and alternative explanations of symptoms, and advocate watchful waiting. Yet they reported sometimes performing tests to appease parents or to comply with guidelines, because of feared personal consequences in the case of adverse outcomes.

CONCLUSION

We obtained an overview of the considerations that are weighed in pediatric test decisions. The comparatively strong focus on prevention of harm motivates pediatricians to critically appraise the added value of testing and drivers of low-value testing. Pediatricians' relatively restrictive approach to testing could provide an example for other disciplines. Improved guidelines and physician and patient education could help to withstand the perceived pressure to test.