Definition and Assessment of Paediatric Breakthrough Pain: A Qualitative Interview Study

Infants, children and young people with life-limiting or life-threatening conditions often experience acute, transient pain episodes known as breakthrough pain. There is currently no established way to assess breakthrough pain in paediatric palliative care. Anecdotal evidence suggests that it is frequently underdiagnosed and undertreated, resulting in reduced quality of life. The development of a standardised paediatric breakthrough pain assessment, based on healthcare professionals' insights, could improve patient outcomes. This study aimed to explore how healthcare professionals define and assess breakthrough pain in paediatric palliative care and their attitudes towards a validated paediatric breakthrough pain assessment. This was a descriptive qualitative interview study. Semi-structured interviews were conducted with 29 healthcare professionals working in paediatric palliative care across the UK. An inductive thematic analysis was conducted on the data. Five themes were generated: 'the elusive nature of breakthrough pain', 'breakthrough pain assessment', 'positive attitudes towards', 'reservations towards' and 'features to include in' a paediatric breakthrough pain assessment. The definition and assessment of breakthrough pain is inconsistent in paediatric palliative care. There is a clear need for a validated assessment questionnaire to improve assessment, diagnosis and management of breakthrough pain followed by increased healthcare professional education on the concept.

A multicentre survey investigating the knowledge, behaviour, and attitudes of surgical healthcare professionals to frailty assessment in emergency surgery: DEFINE(surgery)

PURPOSE

Screening for frailty in people admitted with emergency surgical pathology can initiate timely referrals to enhanced perioperative services such as intensive care and geriatric medicine. However, there has been little research exploring surgical healthcare professionals' opinions to frailty assessment, or accuracy in identification. This study aimed to assess the knowledge, behaviour, and attitudes of healthcare professionals to frailty assessment in emergency surgical admissions.

METHODS

We designed a cross-sectional multicentre study developed by a multiprofessional team of surgeons, geriatricians, and supported by patients. A semi-structured survey examined attitudes and behaviours. Knowledge was assessed by comparing respondents' accuracy in scoring twenty-two surgical case vignettes using the Clinical Frailty Scale.

RESULTS

Eleven hospitals across England, Wales, and Scotland participated. Two hundred and eleven clinicians responded-20.4% junior doctors, 43.6% middle grade doctors, 24.2% senior doctors, 11.4% nurses and physician associates. Respondents strongly supported perioperative frailty assessment. Most were already assessing for frailty, although frequently not using a standardised tool. There was a strong call for more frailty education. Participants scored 2175 vignettes with 55.4% accurately meeting the gold standard; accuracy improved to 87.3% when categorised into "not frail/mildly frail/severely frail" and 94% when dichotomised to "not frail/frail".

CONCLUSION

Frailty assessment is well supported by healthcare professionals working in surgery. However, standardised tools are not routinely being used, and only half of respondents could accurately identify frailty. Better education around frailty assessment is needed for healthcare professionals working in surgery to improve perioperative pathway for people living with frailty.

The association between frailty and survival in patients with pleural disease: a retrospective cohort study

BACKGROUND

There are currently no data on the relationship between frailty and mortality in pleural disease. Understanding the relationship between frailty and outcomes is increasingly important for clinicians to guide decisions regarding investigation and management. This study aims to explore the relationship between all-cause mortality and frailty status in patients with pleural disease.

METHODS

In this retrospective analysis of a prospectively collected observational cohort study, outpatients presenting to the pleural service at a tertiary centre in Bristol, UK with a radiologically confirmed, undiagnosed pleural effusion underwent comprehensive assessment and were assigned a final diagnosis at 12 months. The modified frailty index (mFI) was calculated and participants classified as frail (mFI ≥ 0.4) or not frail (mFI ≤ 0.2).

RESULTS

676 participants were included from 3rd March 2008 to 29th December 2020. The median time to mortality was 490 days (IQR 161-1595). A positive association was found between 12-month mortality and frailty (aHR = 1.72, 95% CI 1.02-2.76, p = 0.025) and age ≥ 80 (aHR = 1.80, 95% CI 1.24-2.62, p = 0.002). Subgroup analyses found a stronger association between 12-month mortality and frailty in benign disease (aHR = 4.36, 95% CI 2.17-8.77, p < 0.0001) than in all pleural disease. Malignancy irrespective of frailty status was associated with an increase in all-cause mortality (aHR = 10.40, 95% CI 6.01-18.01, p < 0.0001).

CONCLUSION

This is the first study evaluating the relationship between frailty and outcomes in pleural disease. Our data demonstrates a strong association between frailty and 12-month mortality in this cohort. A malignant diagnosis is an independent predictor of 12-month mortality, irrespective of frailty status. Frailty was also strongly associated with 12-month mortality in patients with a benign underlying cause for their pleural disease. This has clinical relevance for pleural physicians; evaluating patients' frailty status and its impact on mortality can guide clinicians in assessing suitability for invasive investigation and management.

TRIAL REGISTRATION

This study is registered with the Health Research Authority (REC reference 08/H0102/11) and the NIHR Portfolio (Study ID 8960).

The Care and Management of Children and Young People with Ataxia Telangiectasia Provided by Nurses and Allied Health Professionals: a Scoping Review

Ataxia telangiectasia (A-T) is a rare, multisystem progressive condition that typically presents in early childhood. In the absence of cure, people with A-T require coordinated multidisciplinary care to manage their complex array of needs and to minimize the disease burden. Although symptom management has proven benefits for this population, including improved quality of life and reduced complications, there is a need for guidance specific to the nursing and allied healthcare teams who provide care within the community. A scoping review, adopting the Joanna Briggs Institute methodology, was undertaken. It aimed to identify and map the available expertise from nursing and allied healthcare and management of children and young people with A-T ≤ 18 years of age. A rigorous search strategy was employed which generated a total of 21,118 sources of evidence, of which 50 were selected for review following screening by experts. A range of interventions were identified that reported a positive impact on A-T-related impairments, together with quality of life, indicating that outcomes can be improved for this population. Most notable interventions specific to A-T include therapeutic exercise, inspiratory muscle training, and early nutritional assessment and intervention. Further research will be required to determine the full potential of the identified interventions, including translatability to the A-T setting for evidence related to other forms of ataxia. Large gaps exist in the nursing and allied health evidence-base, highlighting a need for robust research that includes children and young people with A-T and their families to better inform and optimize management strategies.

The Concept of Child-Centred Care in Healthcare: A Scoping Review

Although child-centred care is increasingly referred to within the nursing literature, a clear definition of child-centred care and clarity around the concept is yet to be achieved. The objectives of this review were to examine the following: (1) What constitutes the concept of child-centred care in healthcare? (2) How has the concept of child-centred care developed? (3) What is the applicability of child-centred care and what are its limitations? (4) How does the concept of child-centred care benefit and inform children's healthcare? In total, 2984 papers were imported for screening, and, following the removal of duplicates and screening, 21 papers were included in the scoping review. The findings suggest that child-centred care is an emerging, ambiguous poorly defined concept; no clear consensus exists about what constitutes child-centred care. Although it seems antithetical to argue against child-centred care, little robust evidence was identified that demonstrates the impact and benefit of child-centred care. If child-centred care is to be a sustainable, convincing model to guide practice and compete with other models of care, it needs to establish robust evidence of its effectiveness, the impact on children and their families, as well as the wider impacts on the healthcare system.

Parental sleep-related practices and sleep in children aged 1-3 years: a systematic review

The current systematic review sought to identify the relationship between the range of different parental sleep-related practices that had been explored in relations to child sleep outcomes in children aged 1-3 years. A systematic literature review was carried out in CINAHL, The Cochrane Library, PsycArticles, PsycInfo, PubMed and Web of Science, as well as relevant grey literature in August 2022 using the terms; population (children, aged 1-3 years), exposure (parental sleep-related practice) and outcome (child sleep). Any quantitative study published between 2010 and 2022 that explored the relationship between parental sleep-related practices and the sleep of children aged 1-3 years were included. The Mixed Methods Appraisal Tool was employed to quality appraise included studies and results were narratively synthesised. In all, 16 longitudinal and cross-sectional quantitative studies met inclusion criteria. Parental presence or physical involvement, as well as broader parental practices including using screens or devices at bedtime and night-time breastfeeding were all related to poorer child sleep outcomes. Consistent and relaxing routines, sleeping in a cot, and spending all night in their own sleep location were associated with better child sleep outcomes. Acknowledging the plethora of diverse parental sleep-related practices, which may have varying relationships with child sleep outcomes, could be usefully considered in theoretical models and to inform clinical practice. Issues of definitional and measurement ambiguity are highlighted and discussed.

'It's my back…'; developing the coming to spinal clinic resource to improve the health literacy of young people with adolescent idiopathic scoliosis and their parents

This study focussed on identifying the key concerns and information needs of young people with Adolescent Idiopathic Scoliosis (AIS) and their parents and examined what resources might help improve young people's 'participativeness' and health literacy during clinic consultations. A qualitative participatory design underpinned the study. Workshops involving multiple methods were used to engage with young people with AIS and their parents, who were recruited through a regional children's hospital. The study design was informed by patient and public consultation with eight young people and two parents. 10 young people (aged 14-16 years) and 11 of their parents participated in the study. Young people and their parents reported uncertainty and anxiety before coming to clinic and faced issues participating in the consultation, being involved in decision-making and understanding the information and language. These challenges resulted in unmet information needs. Young people's health literacy relating to an AIS diagnosis and treatment is facilitated by them being prepared and informed before coming to clinic and be actively supported to be involved during the consultation. We collaboratively developed the 'Coming to Spinal Clinic' resource to help young people with AIS and parents prepare for and get the most out of their visit.

A cross-sectional survey of healthcare professionals supporting children and young people with epilepsy and their parents/carers: which topics are raised in clinical consultations and can healthcare professionals provide the support needed?

BACKGROUND AND PURPOSE

Children and young people (CYP) with epilepsy see healthcare professionals (HCPs) for management of their seizures but may require information, advice and support with a range of broader topics. The purpose of the survey was to identify from HCPs, which topics CYP with epilepsy and their parents/carers ask about other than seizure management, and how adequately HCPs feel able to support them with these topics.

METHOD

A cross-sectional online survey was used to collect data. Adverts which included a link to the survey were shared via social media channels, professional networks and United Kingdom (UK)-based epilepsy networks. Eighty-eight HCPs in the UK (who worked with CYP with epilepsy and their parents/carers) completed the survey. Quantitative data are presented descriptively. Qualitative data (free-text responses) were reflexively thematically analysed.

RESULTS

CYP with epilepsy and their parents/carers were reported to ask HCPs for information, advice and support about a range of topics, most commonly, cognition and mental health. CYP were reported as also frequently asking about aspects of their social life while parents/carers commonly asked about sleep. HCPs varied in how able they felt to adequately support families about these topics, as well as in their views about which resources could be most useful. Having insufficient time and a lack of suitable services and resources to refer to, or draw upon, were key barriers to HCPs being able to support CYP and their families.

DISCUSSION

Findings highlight the broad array of topics CYP with epilepsy and their families are reported as seeking support for. HCPs identified gaps in services and their abilities to meet those needs. There appeared to be a mismatch between the support that families were seeking and the ability of HCPs to meet these needs. Findings have implications for how HCPs could best be supported to deal with topics raised by CYP and families in clinic, highlighting the potential usefulness of informational resources on key topics for HCPs, parents/carers and CYP.

Developing rights-based standards for children having tests, treatments, examinations and interventions: using a collaborative, multi-phased, multi-method and multi-stakeholder approach to build consensus

Children continue to experience harm when undergoing clinical procedures despite increased evidence of the need to improve the provision of child-centred care. The international ISupport collaboration aimed to develop standards to outline and explain good procedural practice and the rights of children within the context of a clinical procedure. The rights-based standards for children undergoing tests, treatments, investigations, examinations and interventions were developed using an iterative, multi-phased, multi-method and multi-stakeholder consensus building approach. This consensus approach used a range of online and face to face methods across three phases to ensure ongoing engagement with multiple stakeholders. The views and perspectives of 203 children and young people, 78 parents and 418 multi-disciplinary professionals gathered over a two year period (2020-2022) informed the development of international rights-based standards for the care of children having tests, treatments, examinations and interventions. The standards are the first to reach international multi-stakeholder consensus on definitions of supportive and restraining holds.    Conclusion: This is the first study of its kind which outlines international rights-based procedural care standards from multi-stakeholder perspectives. The standards offer health professionals and educators clear evidence-based tools to support discussions and practice changes to challenge prevailing assumptions about holding or restraining children and instead encourage a focus on the interests and rights of the child. What is Known: • Children continue to experience short and long-term harm when undergoing clinical procedures despite increased evidence of the need to improve the provision of child-centred care. • Professionals report uncertainty and tensions in applying evidence-based practice to children's procedural care. What is New: • This is the first study of its kind which has developed international rights-based procedural care standards from multi-stakeholder perspectives. • The standards are the first to reach international multi-stakeholder consensus on definitions of supportive and restraining holds.

The novel Next Step test is a reliable measure of anticipatory postural adjustments made by children with cerebral palsy prior to taking a step

BACKGROUND

Children with cerebral palsy (CP) make smaller medio-lateral anticipatory postural adjustments (APAs) than typically developing peers when stepping forward to a medial target. They are also less accurate at reaching the stepping target. The Next Step test involves the biomechanical measurement of APAs and foot placement error. These may be useful outcome measures to evaluate dynamic balance in a clinical trial. The reliability of the measures must be assessed to establish their reliability as research tools.

RESEARCH QUESTION

What is the inter-rater and intra-rater reliability of stepping accuracy and measures of APAs made by children prior to taking a step?

METHODS

Typically developing (TD) (n = 14) or children with CP (n = 16) were recruited from local clinics. Children stepped to electro-luminescent targets placed medially and laterally to each foot. Stepping responses were measured using a force plate and 3D motion analysis of markers placed on the feet and pelvis. The APA was defined as the movement of the centre of pressure (COP) and the centre of mass (COM) estimated via pelvic markers, prior to lifting the lead leg. Stepping accuracy was defined as the absolute distance between the target and end foot position. Participants undertook two data collection sessions separated by at least one week. In session one, the test was measured by rater 1 who repeated this in session two, along with another data collection by a rater 2 or rater 3, after a rest period. Where data were normally distributed, they were assessed for inter-rater and intra-rater reliability using an intra-class correlation coefficient (ICC) and Bland-Altman plots. The standard error of measurement was calculated to determine the minimum difference needed to detect true change.

RESULTS

There was no between-group differences in group characteristics (age, weight, height) or in stepping velocity. We found good to excellent reliability when measuring the amplitude and velocity of medio-lateral APAs (ICC range 0.73-0.89). The reliability of antero-posterior APAs was more variable (ICC range 0.08-0.92). The minimum difference to detect a true change for peak medio-lateral motion of COP ranges from 23.7 mm to 29.6 mm and for peak velocity of medio-lateral COM estimate 41-61.9 mm. Stepping accuracy was not normally distributed.

SIGNIFICANCE

The Next Step test is a reliable measure of dynamic balance. The peak medio-lateral motion of the COP and medio-lateral velocity of the COM estimate are reliable when measured during a constrained stepping task in ambulant children with cerebral palsy.

The economic burden experienced by carers of children who had a critical deterioration at a tertiary children's hospital in the United Kingdom (the DETECT study): an online survey

BACKGROUND

Unplanned critical care admissions following in-hospital deterioration in children are expected to impose a significant burden for carers across a number of dimensions. One dimension relates to the financial and economic impact associated with the admission, from both direct out-of-pocket expenditures, as well as indirect costs, reflecting productivity losses. A robust assessment of these costs is key to understand the wider impact of interventions aiming to reduce in-patient deterioration. This work aims to determine the economic burden imposed on carers caring for hospitalised children that experience critical deterioration events.

METHODS

Descriptive study with quantitative approach. Carers responded to an online survey between July 2020 and April 2021. The survey was developed by the research team and piloted before use. The sample comprised 71 carers of children admitted to a critical care unit following in-patient deterioration, at a tertiary children's hospital in the UK. The survey provides a characterisation of the carer's household and estimates of direct non-medical costs grouped in five different expenditure categories. Productivity losses can also be estimated based on the reported information.

RESULTS

Most carers reported expenditures associated to the child's admission in the week preceding the survey completion. Two-thirds of working carers had missed at least one workday in the week prior to the survey completion. Moreover, eight in ten carers reported having had to travel from home to the hospital at least once a week. These expenditures, on average, amount to £164 per week, grouped in five categories (38% each to travelling costs and to food and drink costs, with accommodation, childcare, and parking representing 12%, 7% and 5%, respectively). Additionally, weekly productivity losses for working carers are estimated at £195.

CONCLUSION

Unplanned critical care admissions for children impose a substantial financial burden for carers. Moreover, productivity losses imply a subsequent cost to society. Even though subsidised hospital parking and on-site accommodation at the hospital contribute to minimising such expenditure, the overall impact for carers remains high. Interventions aiming at reducing emergency critical care admissions, or their length, can be crucial to further contribute to the reduction of this burden.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN61279068, date of registration 07/06/2019, retrospectively registered.

Using technology to reduce critical deterioration (the DETECT study): a cost analysis of care costs at a tertiary children's hospital in the United Kingdom

BACKGROUND

Electronic early warning systems have been used in adults for many years to prevent critical deterioration events (CDEs). However, implementation of similar technologies for monitoring children across the entire hospital poses additional challenges. While the concept of such technologies is promising, their cost-effectiveness is not established for use in children. In this study we investigate the potential for direct cost savings arising from the implementation of the DETECT surveillance system.

METHODS

Data were collected at a tertiary children's hospital in the United Kingdom. We rely on the comparison between patients in the baseline period (March 2018 to February 2019) and patients in the post-intervention period (March 2020 to July 2021). These provided a matched cohort of 19,562 hospital admissions for each group. From these admissions, 324 and 286 CDEs were observed in the baseline and post-intervention period, respectively. Hospital reported costs and Health Related Group (HRG) National Costs were used to estimate overall expenditure associated with CDEs for both groups of patients.

RESULTS

Comparing post-intervention with baseline data we found a reduction in the total number of critical care days, driven by an overall reduction in the number of CDEs, however without statistical significance. Using hospital reported costs adjusted for the Covid-19 impact, we estimate a non-significant reduction of total expenditure from £16.0 million to £14.3 million (corresponding to £1.7 million of savings - 11%). Additionally, using HRG average costs, we estimated a non-significant reduction of total expenditure from £8.2 million to £ 7.2 million (corresponding to £1.1 million of savings - 13%).

DISCUSSION AND CONCLUSION

Unplanned critical care admissions for children not only impose a substantial burden on patients and families but are also costly for hospitals. Interventions aimed at reducing emergency critical care admissions can be crucial to contribute to the reduction of these episodes' costs. Even though cost reductions were identified in our sample, our results do not support the hypothesis that reducing CDEs using technology leads to a significant reduction on hospital costs.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN61279068, date of registration 07/06/2019, retrospectively registered.

A shared love: reciprocity and hopefulness in romantic relationships of young adults with chronic pain

Introduction

Chronic pain (≥3 months) creates pain-related challenges that may negatively affect how young adults perceive themselves, and, indeed, they often report feeling different compared to peers and prospective romantic partners. Most studies of romantic relationships in young adults living with a long-term condition (including pain), do not consider the perspective of their partner. We present the findings of a qualitative, exploratory interview study (Phase 2 of a mixed methods study). This qualitative phase aimed to explore how young adults with chronic pain and their partners navigate romantic relationships. We focused on how young adults perceive and experience their romantic relationships and the impact, challenges, and benefits associated with living with chronic pain.

Methods

This study used remote (videoconferencing) photo-elicitation interviews with a convenience sample of young adults with chronic pain (aged 18-25 years, UK and Canada) and their partners. Recruitment occurred via social media, pain-related websites and organizations, and professional networks. Five young adults with chronic pain from the UK and Canada formed the e-Advisory Group and provided detailed advice throughout the study. Data analysis used the principles of inductive reflexive thematic analysis to explore the dimensions and meaning of romantic relationships from the views of young adults with chronic pain and their romantic partners.

Findings

Sixteen young adults participated (seven couples plus two young adults with pain who were interviewed without their partner). The young adults with chronic pain were ages 18-24 years (mean 21.88 years, SD 2.23). Four major interpretive themes were generated: Kindred spirits-we just sort of work; Loving in everyday acts-it's not above and beyond, it's concerned supportiveness; It's OK to be vulnerable with each other-we can talk it through; and You can't see over the horizon-hopes and fears for the future.

Discussion

Hopefulness and reciprocity were key to the stories shared by the young adults in the current study. Despite the challenges and limitations imposed by chronic pain, their relationships were characterized by partnership and reciprocity, and they were able to be vulnerable with each other and offer each other support.

Feeling stretched: Parents' narratives about challenges to resilience when their child has a tracheostomy

This study aimed to examine how parents develop personal resilience when facing the challenges of caring for a child with tracheostomy. This study employed a longitudinal qualitative design. Unstructured narrative interviews with 12 parents (from nine families) whose child had a new tracheostomy were undertaken at three time points over 12 months. Data were analysed using a socio-narratology method. Findings reveal the journey parents experienced, how their feelings changed and the processes involved in developing resilience over the first 12 months of their child having a tracheostomy. Stories told by parents early in their journey revealed emotional upheaval, negative emotions, stress and shock. Due to medical need, parents had little or no choice for their child to have a tracheostomy. Once their child's life was out of danger, parents started to reframe their experiences and beliefs. Resilience played a major part in how parents perceived and faced their situation, allowing them to deal with what came their way and to move forward with their lives. Different aspects of resilience such as self-awareness, grit, gratitude, internal locus of control and reframing came to the fore at different time points. Parents talked feeling stretched by the challenges they faced and how they reframed their perspectives about their child's tracheostomy. Parents' resilience and reframing is discussed in relation to the ABC-X model. This study identifies a theoretical model that explains this process of change, this results in transferable knowledge, useful for understanding and explaining the experience of other parents and families.

A cluster randomised, 16-week, parallel-group multicentre trial to compare the effectiveness of a digital school-based cognitive behavioural resilience/wellbeing-building intervention targeting emotional and behavioural problems in vulnerable Year 4 primary school children in whole classes, to the usual school curriculum: a study protocol to the "CUES for Schools" trial

BACKGROUND

Around 10% of school-aged children experience mental health difficulties. Many more are 'vulnerable': experiencing emotional and/or behavioural problems reaching clinical levels, and thus at greatest risk of future mental illness. The trial aim is to evaluate the effectiveness of the CUES for schools programme in reducing emotional and behavioural problems in vulnerable children.

METHODS

The "CUES for Schools" study is a multicentre cluster randomised controlled trial in primary schools in south east England. Schools will be randomised to receive the usual school curriculum, or the CUES programme (1:1). We aim to enrol 74 schools (5550 children including 2220 vulnerable children). CUES is a whole-class teacher-facilitated interactive digital cognitive-behavioural intervention, delivered as 24 short (20-min) modules over 12 weeks, targeting emotional/behavioural regulation skills. Children self-report emotional/behavioural problems at baseline, 8, and 16 weeks, and wellbeing and cognitive vulnerability at 0 and 16 weeks. Adverse events are assessed at 8 and 16 weeks. Teachers rate classroom behaviour at baseline and 16 weeks. School senior leadership teams and individual teachers consent to involvement in the study; parents can opt their child out of CUES sessions, assessments, or research. Children can similarly opt out and assent to research participation. The primary objective of this trial is to evaluate the effectiveness of CUES for schools compared to the usual school curriculum in improving emotional/behavioural problems for vulnerable Year 4 (8-9 years old) children at 16 weeks post-randomisation, as measured using a standardised questionnaire designed for primary schools. The secondary objective is to investigate the impact of the CUES for schools programme on both vulnerable and non-vulnerable children on wellbeing and teacher-rated classroom behaviour.

DISCUSSION

The study will show whether CUES for schools is more effective than the usual curriculum in reducing emotional and behavioural problems in vulnerable Year 4 children, and thus reducing the risk of mental health difficulties in later adolescent and adult life. As a digital, teacher-facilitated intervention, CUES for schools can be readily implemented, at minimal cost. If effective, CUES for schools therefore has the potential to reduce the impact of emotional/behavioural difficulties on children's learning, behaviour, and relationships and the burden of future mental health morbidity.

TRIAL REGISTRATION

Trial Registration ISRCTN11445338. Registered on September 12, 2022.

Unsettling the fluidity of practice and dealing with threat: the experiences of paediatric pharmacists in response to the admission of adult COVID-19 patients requiring intensive care in a paediatric tertiary hospital

OBJECTIVES

The COVID-19 pandemic impacted the lives of pharmacists, resulting in new ways of working. Little literature focuses on the experiences and well-being of hospital pharmacists, particularly on paediatric pharmacists. The setting - a paediatric stand-alone tertiary hospital - opened to adult ICU COVID-19 patients for two time periods. Paediatric pharmacists had to shift their roles; this impacted their well-being. Paediatric ICU clinical psychologists provided support using a compassion-focused therapy (CFT) model to guide thinking, reflection and promoting behaviour change. This study aimed to explore the experiences and perceptions of the paediatric pharmacists working in a paediatric stand-alone tertiary hospital before, during and after the admission of adult COVID-19 patients into ICU and their experiences of support offered by clinical psychologists.

METHODS

A qualitative interpretative design using remote photo-elicitation interviews was adopted. Data analysis was undertaken using the six stages of reflexive thematic analysis.

KEY FINDINGS

Five paediatric pharmacists participated; four deployed to work in the A-ICU (from PICU) and one deployed to work in the PICU (from ward-based work). An overarching theme, 'Unsettling the fluidity of practice and dealing with threat', is supported by four key themes 'Context and preparation', 'Dread and challenges', 'Keeping it together' and 'Lessons learned'. The fluidity of the pharmacists' practice was unsettled as they dealt with the threats and sought resources (drive) to enable optimal care delivery. Soothe techniques helped compensate for threats, and promote resilience and well-being.

CONCLUSION

The CFT model has been useful in the longer term with the adoption of a more open, compassionate approach to their work and colleagues.

‘ZOOMing’ in on Consulting with Children and Parents Remotely to Co-Create Health Information Resources

The COVID-19 pandemic altered the way many people worked. Remote and creative ways were favoured and utilised for consultation activities. In this paper, we draw attention to how we have used creative methods over the teleconferencing platform ‘ZOOM’ to consult with children and their parents when we were unable to consult with them face-to-face. We document a clear timeline of how we have worked together to co-create an animation and information sheet about receiving outpatient parenteral antimicrobial therapy (OPAT). We identify the opportunities and challenges we faced.

Changing Agendas on Sleep, Treatment and Learning in Epilepsy (CASTLE) Sleep-E: a protocol for a randomised controlled trial comparing an online behavioural sleep intervention with standard care in children with Rolandic epilepsy

INTRODUCTION

Sleep and epilepsy have an established bidirectional relationship yet only one randomised controlled clinical trial has assessed the effectiveness of behavioural sleep interventions for children with epilepsy. The intervention was successful, but was delivered via face-to-face educational sessions with parents, which are costly and non-scalable to population level. The Changing Agendas on Sleep, Treatment and Learning in Epilepsy (CASTLE) Sleep-E trial addresses this problem by comparing clinical and cost-effectiveness in children with Rolandic epilepsy between standard care (SC) and SC augmented with a novel, tailored parent-led CASTLE Online Sleep Intervention (COSI) that incorporates evidence-based behavioural components.

METHODS AND ANALYSES

CASTLE Sleep-E is a UK-based, multicentre, open-label, active concurrent control, randomised, parallel-group, pragmatic superiority trial. A total of 110 children with Rolandic epilepsy will be recruited in outpatient clinics and allocated 1:1 to SC or SC augmented with COSI (SC+COSI). Primary clinical outcome is parent-reported sleep problem score (Children's Sleep Habits Questionnaire). Primary health economic outcome is the incremental cost-effectiveness ratio (National Health Service and Personal Social Services perspective, Child Health Utility 9D Instrument). Parents and children (≥7 years) can opt into qualitative interviews and activities to share their experiences and perceptions of trial participation and managing sleep with Rolandic epilepsy.

ETHICS AND DISSEMINATION

The CASTLE Sleep-E protocol was approved by the Health Research Authority East Midlands (HRA)-Nottingham 1 Research Ethics Committee (reference: 21/EM/0205). Trial results will be disseminated to scientific audiences, families, professional groups, managers, commissioners and policymakers. Pseudo-anonymised individual patient data will be made available after dissemination on reasonable request.

TRIAL REGISTRATION NUMBER

ISRCTN13202325.

Communication during children's X-ray procedures and children's experiences of the procedure: A scoping review

INTRODUCTION

Communication is a central part of radiological procedures and influences children's experiences. Previous research concentrates on communication and experiences during complex radiological procedures such as magnetic resonance imaging (MRI). Less is known about the communication that occurs with children undergoing procedures, such as non-urgent X-ray procedures, or the impact communication has on a child's experience.

OBJECTIVES

This scoping review examined evidence relating to the communication which occurs between children, parents and radiographers during children's X-ray procedures and how children experience undergoing X-ray procedures.

KEY FINDINGS

The comprehensive search identified eight papers. Evidence shows that radiographers dominate communication during X-ray procedures, with their communication in many cases being instructional, closed and limiting the opportunities for children to be involved. Evidence indicates that radiographers have a role in facilitating children in actively engaging in communication during their procedure. The papers that sought children's first-hand experiences highlight children's mainly positive experiences of having an X-ray, and the importance of informing children about their X-ray before and during the procedure.

CONCLUSIONS

The scarcity of literature highlights a need for research exploring communication during children's radiological procedures and children's first-hand experiences of undergoing these procedures. Findings highlight a need for an approach that recognises the importance of dyadic (radiographer and child), and triadic (radiographer, parent and child) communication opportunities during an X-ray procedure.

IMPLICATIONS FOR PRACTICE

This review highlights a need for an inclusive and participatory approach to communication that recognises children's voice and agency in X-ray procedures.

How parents share and limit their child’s access to information about COVID-19: A mixed methods online survey study

This study aimed to understand the role that parents play in sharing or limiting their child's access to information about coronavirus disease 2019 (COVID-19). A subset of data from an international mixed methods online survey study was analysed to elucidate the findings from Brazil. An online survey, conducted between April and June 2020, gathered closed and open text views from parents of children aged 7-12 years old. Quantitative data were analysed using descriptive statistics. Qualitative open text data were analysed using the three stages of the Bardin content analysis framework: pre-analysis (data organisation and initial full-content reading); exploration of the material (thematic coding to identify major motifs and develop thematic categories) and interpretation (treating the data as significant and valid). The sample consisted of 112 (89%) mothers and 14 (11%) fathers. The analysis of the parents open text resulted in two categories: 'How parents share information with their children about COVID-19' and 'How parents limit information to their children about COVID-19'. Some parents reported adopting an honest and open approach on how they shared information with their children, whilst some parents chose to minimise their child's access to information about the pandemic over concerns of the mortality related to COVID-19.

A cross sectional study investigating dynamic balance when stepping to targets in children with cerebral palsy compared to typically developing children

BACKGROUND

Children with Cerebral Palsy (CP) have altered anticipatory postural adjustments (APAs) during gait initiation. These APAs may affect dynamic balance in tasks such as stepping.

RESEARCH QUESTIONS

How are APAs in children with CP affected during stepping to precise targets? How do children with CP modulate APAs when stepping to medial and lateral targets? What is the association between APAs and symptom severity, movement quality and impairment profile?

METHOD

Children undertook a stepping task to laterally and medially placed targets with either leg, in a randomised order. Movement of the centre of pressure (COP) and markers at the pelvis and foot were measured via a force plate and 3D motion analysis. Motion of the centre of mass (COM) was estimated via pelvic markers. APAs were assessed prior to leading leg lift-off in medio-lateral and antero-posterior directions. Stepping error was calculated. Baseline characteristics of children with CP included Gross Motor Function Measure (GMFM), Quality Function Measure (QFM), leg muscle hypertonia (Tardieu test) and strength (manual dynamometry).

RESULTS

Sixteen ambulant children with CP (12.2 years ± 2.2) and 14 typically developing (TD) children (11.6 years ± 2.9) were assessed. In children with CP, APAs in the medio-lateral direction were 20-30% smaller. Children with CP were less able to modulate their APAs with steps to medial and laterally placed targets, than TD children. Medio-lateral COP motion was associated with movement quality assessed by QFM subsections, GMFM (correlation coefficient r = 0.66-0.80) and hip abductor strength (r = 0.75). Antero-posterior APAs were significantly smaller when stepping with the non-paretic leg in children with CP. APA size was positively related to the length of the contralateral, paretic gastrocnemius (r = 0.77). Stepping error was higher in children with CP and inversely correlated to the size of the medio-lateral APA.

DISCUSSION

Children with CP show smaller medio-lateral APAs especially when stepping to medially placed targets. APA size may be limited by proximal muscle strength and gastrocnemius length.

The impact of parent treatment preference and other factors on recruitment: lessons learned from a paediatric epilepsy randomised controlled trial

BACKGROUND

In paediatric epilepsy, the evidence of effectiveness of antiseizure treatment is inconclusive for some types of epilepsy. As with other paediatric clinical trials, researchers undertaking paediatric epilepsy clinical trials face a range of challenges that may compromise external validity MAIN BODY: In this paper, we critically reflect upon the factors which impacted recruitment to the pilot phase of a phase IV unblinded, randomised controlled 3×2 factorial trial examining the effectiveness of two antiseizure medications (ASMs) and a sleep behaviour intervention in children with Rolandic epilepsy. We consider the processes established to support recruitment, public and patient involvement and engagement (PPIE), site induction, our oversight of recruitment targets and figures, and the actions we took to help us understand why we failed to recruit sufficient children to continue to the substantive trial phase. The key lessons learned were about parent preference, children's involvement and collaboration in decision-making, potential and alternative trial designs, and elicitation of stated preferences pre-trial design. Despite pre-funding PPIE during the trial design phase, we failed to anticipate the scale of parental treatment preference for or against antiseizure medication (ASMs) and consequent unwillingness to be randomised. Future studies should ensure more detailed and in-depth consultation to ascertain parent and/or patient preferences. More intense engagement with parents and children exploring their ideas about treatment preferences could, perhaps, have helped predict some recruitment issues. Infrequent seizures or screening children close to natural remission were possible explanations for non-consent. It is possible some clinicians were unintentionally unable to convey clinical equipoise influencing parental decision against participation. We wanted children to be involved in decisions about trial participation. However, despite having tailored written and video information to explain the trial to children we do not know whether these materials were viewed in each consent conversation or how much input children had towards parents' decisions to participate. Novel methods such as parent/patient preference trials and/or discrete choice experiments may be the way forward.

CONCLUSION

The importance of diligent consultation, the consideration of novel methods such as parent/patient preference trials and/or discrete choice experiments in studies examining the effectiveness of ASMs versus no-ASMs cannot be overemphasised even in the presence of widespread clinician equipoise.

The Effect of Sarcopenia on Postoperative Outcomes Following Emergency Laparotomy: A Systematic Review and Meta-Analysis

Emergency laparotomy procedures have high rates of postoperative mortality and morbidity in older patient. Sarcopenia is associated with poor postoperative outcomes in elective surgeries and there is growing evidence for its use as a risk predictor in the emergency setting. The study aimed to evaluate the effect of sarcopenia on postoperative mortality and morbidity following emergency laparotomy. Five electronic databases were systematically searched (MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and Web of Science) from conception until the 14th February 2022. All prospective cohort studies were included. Risk of bias was assessed with the Newcastle-Ottawa score. Pooled meta-analyses were estimated using the Mantel-Haenszel and inverse-generic variance method for mortality and morbidity outcomes. Eleven retrospective cohort studies were included, of which ten were included in the meta-analysis comprising of 3492 patients (1027 sarcopenic, 2465 non-sarcopenic). The study level incidence of sarcopenia ranged from 24.6 to 50.3% with a median rate of 25.1%. Sarcopenia was associated with increased 30-day mortality (OR 2.36, 95% CI, 1.66, 3.37, I2 = 43%), 90-day mortality (OR 2.51, 95% CI, 1.79, 3.52, I2 = 0%), and length of hospital stay (in days) (MD 1.18, 95% CI, 0.42, 1.94, I2 = 0%, P=0.002), but not incidence of postoperative major complications (OR 1.49, 95% CI, 0.86, 2.56, I2 = 70%, P = 0.15). Sarcopenia predicts poor outcomes following emergency laparotomy. We suggest assessment of sarcopenia should be incorporated into acute surgical assessment to identify high risk patients and inform clinical decision-making prior to an emergency laparotomy.

'I feel like my house was taken away from me': Parents' experiences of having home adaptations for their medically complex, technology-dependent child

Technology-dependent children are a sub-population of seriously ill children with life-limiting conditions who are being cared for at home by their families. Although home-based care has been the model of care for these children since the late 1980s, there is a paucity of literature about parents' experiences of having home adaptations made to enable their home to be a place of care for their child. Using the findings from auto-driven photo-elicitation interviews conducted between August 2017 and June 2018 with 12 parents (10 mothers and 2 fathers) who have a technology-dependent child (aged 5-25 years) living in England, Scotland and Wales and David Seamon's five concepts of at-homeness (appropriation, at-easeness, regeneration, rootedness and warmth) as a conceptual framework, this paper addresses how parents' experienced home adaptations. Thematic analysis generated a meta-theme of 'Home needs to be a home for all family members' and the three key themes: (1) 'You just get told' and 'you're not involved'; (2) It's just the 'cheapest', 'quickest', 'short-term' approach; (3) Having 'control' and 'thinking things through.' The need to involve parents in decision-making about adaptations that are made to their home (family-informed design) is clear, not only from a cost-saving perspective for the state, but for creating an aesthetic and functional home that optimises health, well-being and feelings of at-homeness for the entire family.

Clinical utility and acceptability of a whole-hospital, pro-active electronic paediatric early warning system (the DETECT study): A prospective e-survey of parents and health professionals

Background

Paediatric early warning systems (PEWS) are a means of tracking physiological state and alerting healthcare professionals about signs of deterioration, triggering a clinical review and/or escalation of care of children. A proactive end-to-end deterioration solution (the DETECT surveillance system) with an embedded e-PEWS that included sepsis screening was introduced across a tertiary children’s hospital. One component of the implementation programme was a sub-study to determine an understanding of the DETECT e-PEWS in terms of its clinical utility and its acceptability.

Aim

This study aimed to examine how parents and health professionals view and engage with the DETECT e-PEWS apps, with a particular focus on its clinical utility and its acceptability.

Method

A prospective, closed (tick box or sliding scale) and open (text based) question, e-survey of parents (n = 137) and health professionals (n = 151) with experience of DETECT e-PEWS. Data were collected between February 2020 and February 2021.

Results

Quantitative data were analysed using descriptive and inferential statistics and qualitative data with generic thematic analysis. Overall, both clinical utility and acceptability (across seven constructs) were high across both stakeholder groups although some challenges to utility (e.g., sensitivity of triggers within specific patient populations) and acceptability (e.g., burden related to having to carry extra technology) were identified.

Conclusion

Despite the multifaceted nature of the intervention and the complexity of implementation across a hospital, the system demonstrated clinical utility and acceptability across two key groups of stakeholders: parents and health professionals.

Defining usual physiotherapy care in ambulant children with cerebral palsy in the United Kingdom: A mixed methods consensus study

BACKGROUND

Ambulant children with cerebral palsy (CP) undertake physiotherapy to improve balance and walking. However, there are no relevant clinical guidelines to standardize usual physiotherapy care in the United Kingdom. A consensus process can be used to define usual physiotherapy care for children with CP. The resulting usual care checklist can support the development of clinical guidelines and be used to measure fidelity to usual care in the control groups of trials for children with CP.

METHODS

Twelve expert physiotherapists were recruited. In Phase 1, statements on usual care were developed using a survey and two nominal groups. Phase 2 included a literature review to support usual physiotherapy interventions. Phase 3 used a confirmatory survey, which also captured changes to provision during the COVID-19 pandemic. Consensus was calculated by deriving the mean of the deviations from the median score (MDM). High consensus was deemed to be where MDM < 0.42.

RESULTS

Physiotherapists reached high consensus on five outcome measures (MDM range 0-0.375) and nine areas of assessment (MDM range 0-0.25). Physiotherapists reached moderate consensus on task-specific training (MDM = 0.75), delivered at weekly intensity for 4-6 weeks (MDM = 0.43). There was high consensus (MDM = 0) that children should participate in modified sport and fitness activities and that children with Gross Motor Function Classification System Level III should be monitored on long-term pathways (MDM = 0.29).

CONCLUSIONS

Physiotherapists reached consensus on two usual care interventions, and a checklist was developed to inform the control groups of future randomized controlled trials. Further consensus work is required to establish clinical guidelines to standardize usual physiotherapy care in the United Kingdom.

Navigating uncertain illness trajectories for young children with serious infectious illness: a modified grounded theory study

Background

Infectious illness is the biggest cause of death in children due to a physical illness, particularly in children under five years. If mortality is to be reduced for this group of children, it is important to understand factors affecting their pathways to hospital.

The aim of this study was to retrospectively identify organisational and environmental factors, and individual child, family, and professional factors affecting timing of admission to hospital for children under five years of age with a serious infectious illness (SII).

Methods

An explanatory modified grounded theory design was used in collaboration with parents. Two stages of data collection were conducted: Stage 1, interviews with 22 parents whose child had recently been hospitalised with a SII and 14 health professionals (HPs) involved in their pre-admission trajectories; Stage 2, focus groups with 18 parents and 16 HPs with past experience of SII in young children. Constant comparative analysis generated the explanatory theory.

Results

The core category was ‘navigating uncertain illness trajectories for young children with serious infectious illness’. Uncertainty was prevalent throughout the parents’ and HPs’ stories about their experiences of navigating social rules and overburdened health services for these children. The complexity of and lack of continuity within services, family lives, social expectations and hierarchies provided the context and conditions for children’s, often complex, illness trajectories. Parents reported powerlessness and perceived criticism leading to delayed help-seeking. Importantly, parents and professionals missed symptoms of serious illness. Risk averse services were found to refer more children to emergency departments.

Conclusions

Parents and professionals have difficulties recognising signs of SII in young children and can feel socially constrained from seeking help. The increased burden on services has made it more difficult for professionals to spot the seriously ill child.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08420-5.

Health professionals' initial experiences and perceptions of the acceptability of a whole-hospital, pro-active electronic paediatric early warning system (the DETECT study): a qualitative interview study

Background

Paediatric early warning systems (PEWS) alert health professionals to signs of a child’s deterioration with the intention of triggering an urgent review and escalating care. They can reduce unplanned critical care transfer, cardiac arrest, and death. Electronic systems may be superior to paper-based systems. The objective of the study was to critically explore the initial experiences and perceptions of health professionals about the acceptability of DETECT e-PEWS, and what factors influence its acceptability.

Methods

A descriptive qualitative study (part of The DETECT study) was undertaken February 2020–2021. Single, semi-structured telephone interviews were used. The setting was a tertiary children’s hospital, UK. The participants were health professionals working in study setting and using DETECT e-PEWS. Sampling was undertaken using a mix of convenience and snowballing techniques. Participants represented two user-groups: ‘documenting vital signs’ (D-VS) and ‘responding to vital signs’ (R-VS). Perceptions of clinical utility and acceptability of DETECT e-PEWS were derived from thematic analysis of transcripts.

Results

Fourteen HPs (12 nurses, 2 doctors) participated; seven in D-VS and seven in the R-VS group. Three main themes were identified: complying with DETECT e-PEWS, circumventing DETECT e-PEWS, and disregarding DETECT e-PEWS. Overall clinical utility and acceptability were deemed good for HPs in the D-VS group but there was diversity in perception in the R-VS group (nurses found it more acceptable than doctors). Compliance was better in the D-VS group where use of DETECT e-PEWS was mandated and used more consistently. Some health professionals circumvented DETECT e-PEWS and fell back into old habits. Doctors (R-VS) did not consistently engage with DETECT e-PEWS, which reduced the acceptability of the system, even in those who thought the system brought benefits.

Conclusions

Speed and accuracy of real-time data, automation of triggering alerts and improved situational awareness were key factors that contributed to the acceptability of DETECT e-PEWS. Mandating use of both recording and responding aspects of DETECT e-PEWS is needed to ensure full implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03411-1.

Multicentre, randomised controlled feasibility study to compare a 10-week physiotherapy programme using an interactive exercise training device to improve walking and balance, to usual care of children with cerebral palsy aged 4-18 years: the ACCEPT study protocol

INTRODUCTION

Children with cerebral palsy (CP) frequently undertake physiotherapy programmes to improve walking and balance. They often require adult support to exercise in a functional position. A novel interactive exercise trainer has been devised to enable children to exercise with against resistance in a functional position, but its efficacy has yet to be proved. A novel protocol has been developed to determine whether a randomised controlled trial (RCT) is feasible.

AIM

To establish whether it is feasible to conduct an RCT to assess the effectiveness of a 10-week physiotherapy intervention using an interactive trainer in children with CP.

METHODS AND ANALYSIS

This study is multicentre randomised controlled feasibility trial with an embedded qualitative study. Forty children with CP, Gross Motor Function Classification System (GMFCS) I-III will be recruited from community paediatric physiotherapy caseloads. Participants will be randomised to 10 weeks of training with the interactive training device or to usual physiotherapy care. The mediolateral motion of the centre of mass estimate and Paediatric Balance Scale will be explored as potential primary outcomes measures, tested at baseline, 10 weeks and follow-up at 20 weeks. The views of child participants, their parents and physiotherapists will be gained through e-diaries and qualitative interviews.Feasibility will be determined by examining recruitment and retention rates, completeness of, adherence to the intervention, appropriateness of outcome measures and effectiveness of blinding. Results will be reported in accordance to Consolidated Standards of Reporting Trials (CONSORT) guidelines.

ETHICS AND DISSEMINATION

Physiotherapists, children and parents have informed trial design and information leaflets. Results will be disseminated via publications, conferences and to families. This study has approval from North of Scotland Research Ethics Committee (20/NS/0018).

TRIAL REGISTRATION NUMBER

ISRCTN80878394.

'It doesn't feel like our house anymore': The impact of medical technology upon life at home for families with a medically complex, technology-dependent child

The study aimed to identify how medical technology impacts upon the home and life at home. Inductive auto-driven photo-elicitation or semi-structured interviews were conducted with technology-dependent children/young people (n = 2) and their family members (n = 15) from 10 families. Thematic analysis generated three themes: Altered physicality and look of the home; Altered sounds in the home; and 'It's worth it! Technology enables us to stay as a family'. Fundamentally, the detrimental impacts of living with medical technology were perceived as worth it as these enabled their child to be at home. Home was not home, and families were incomplete without their child at home.

“Communicating Lily’s Pain”: A reflective narrative commentary about co‐creating a resource to provoke thinking and change about assessing and managing the pain of children with profound cognitive impairment

This paper draws together about 20 years of research work and discovery and the development of a resource about pain assessment and management in children with profound cognitive impairment. The animation tells the story of an imagined child called Lily and the skills her mother uses and the challenges that her mother faces in assessing and managing Lily's pain. The animation is built on stories drawn from qualitative research findings, conversations while in clinical practice and with members of the general public, parent advisers and other sources. Most of the “evidence” came from stories shared by parents and healthcare professionals. This paper draws on some elements of socio‐narratology and is predicated on the basis that stories are important and they can act on and with us. By using an animation to tell Lily's story, the intention was to communicate research findings to a wider and more diverse audience than the typical readership of an academic journal. The intention was to act in and on people's consciousness about children's pain and to strengthen relationships and create bonds between clinicians, parents, and children in pain to make their dialog more social, connected, and meaningful. All three of us—the researcher, the writer, and the animator—have been marked and “re‐shaped” by our work related to creating Lily; we have learned more about children like Lily and their mothers, and we have learned more about ourselves and our humanity. This animation is still a story in progress, a story ‘in the wild’, a story (and a resource) we would like you to re‐tell and share. The story of Lily's pain aimed to change the lives of parents and children and professionals. Our hope is that you can be part of that change.

How children in Sweden accessed and perceived information during the first phase of the Covid-19 pandemic

AIM

To describe how children in Sweden accessed and perceived information about SARS-CoV2 and Covid-19 during the first phase of the outbreak.

METHODS

This study is a substudy of an international cross-sectional online mixed methods survey examining elements of children's health literacy in relation to Covid-19. The survey included multiple-choice questions, open-ended questions and drawings and collected information from 50 Swedish children (7-12 years). Data were analysed concurrently on a descriptive level using statistics and content analysis. Quantitative and qualitative data, including the drawings, were considered equally important and resulted in six categories, illuminating how children accessed and perceived information about the pandemic.

RESULTS

The survey showed that children accessed information mainly from school but also from TV. They preferred information from reliable sources. Children reported the information they accessed as easy to understand and it prompted them to ask new questions. They reported they knew a lot about the pandemic, for example, the potential danger to themselves and others and how to act to protect themselves and others. They perceived the pandemic as an intrusion on their lives.

CONCLUSIONS

This study indicates that Swedish children between 7 and 12 years old were well informed about SARS-CoV2 and Covid-19 during the first phase of the pandemic. School was shown to be an important source of information. The children could explain how to act to protect themselves and others from becoming infected by the virus.

Healthcare Professionals' Experiences of the Barriers and Facilitators to Pediatric Pain Management in the Community at End-of-Life: A Qualitative Interview Study

CONTEXTS

Inadequate pain management in community pediatric palliative care is common. Evidence to inform improved pain management in this population is limited.

OBJECTIVES

To explore the barriers and facilitators to pediatric community-based pain management for infants, children and young people at end-of-life as perceived by healthcare professionals.

METHODS

A qualitative interview study was conducted. Semi-structured interviews were undertaken with 29 healthcare professionals; 12 nurses, five GPs, five consultants and registrar doctors, two pharmacists and five support therapists working in primary, secondary or tertiary care in the United Kingdom and involved in community end-of life care of 0 to 18-year-olds.

RESULTS

The data corpus was analyzed using an inductive thematic analysis and seven themes emerged: parents' abilities, beliefs and wellbeing; working relationships between families and healthcare professionals, and between healthcare teams; healthcare professionals' knowledge, education and experience; health services delivery; nature of pain treatment; and pediatric-specific factors. Across themes, the concepts of partnership working between families and healthcare professionals, and within healthcare teams, and sharing expertise were prevalent.

CONCLUSION

Partnership working and trust between healthcare professionals and parents, and within healthcare teams, is needed for effective at-home pediatric palliative pain management. Community healthcare professionals require more education from experienced multidisciplinary teams to effectively manage pediatric pain at end-of-life and prevent emergency hospice or hospital admissions, particularly during the COVID-19 pandemic.

Parents' experiences and perceptions of the acceptability of a whole-hospital, pro-active electronic pediatric early warning system (the DETECT study): A qualitative interview study

BACKGROUND

Failure to recognize and respond to clinical deterioration in a timely and effective manner is an urgent safety concern, driving the need for early identification systems to be embedded in the care of children in hospital. Pediatric early warning systems (PEWS) or PEW scores alert health professionals (HPs) to signs of deterioration, trigger a review and escalate care as needed. PEW scoring allows HPs to record a child's vital signs and other key data including parent concern.

AIM

This study aimed to explore the experiences and perceptions of parents about the acceptability of a newly implemented electronic surveillance system (the DETECT surveillance system), and factors that influenced acceptability and their awareness around signs of clinical deterioration and raising concern.

METHODS

Descriptive, qualitative semi-structured telephone interviews were undertaken with parents of children who had experienced a critical deterioration event (CDE) (n = 19) and parents of those who had not experienced a CDE (non-CDE parents) (n = 17). Data were collected between February 2020 and February 2021.

RESULTS

Qualitative data were analyzed using generic thematic analysis. Analysis revealed an overarching theme of trust as a key factor that underpinned all aspects of children's vital signs being recorded and monitored. The main themes reflect three domains of parents' trust: trust in themselves, trust in the HPs, and trust in the technology.

CONCLUSION

Parents' experiences and perceptions of the acceptability of a whole-hospital, pro-active electronic pediatric early warning system (The DETECT system) were positive; they found it acceptable and welcomed the use of new technology to support the care of their child.

“Pain talk”: A triadic collaboration in which nurses promote opportunities for engaging children and their parents about managing children’s pain

Effective communication with children about pain is important and has the potential to mediate the short‐ and longer‐term effects of pain on children. Most communication studies relating to children's pain have focused on language children use to describe everyday pain experiences. However, little is known regarding how health professionals, particularly nurses, communicate with children in healthcare settings about pain. This study aimed to explore how nurses talk to children and their parents about pain and what factors influence nurses’ use of language and non‐verbal communication. A cross‐sectional mixed‐methods (predominantly qualitative) survey (“pain talk”) was conducted, comprising qualitative items about pain communication and four vignettes portraying hypothetical cases of children representing typical child pain scenarios. Participants were recruited via email, social media, newsletters, established networks, and personal contacts. A total of 141 registered (68.1%) or in‐training nurses across 11 countries with experience of managing children's pain completed the survey. Textual survey responses were analyzed using conventional qualitative content analysis. Qualitative content analysis generated a meta‐theme “Being confident and knowing how to do ‘pain talk’” and four main themes that described the functions, purpose, and delivery of “pain talk”: (a) “contextualizing and assessing,” (b) “empowering, explaining, and educating,” (c) “supporting, affirming, and confirming,” and (d) “protecting, distracting, and restoring.” “Pain talk” was a triadic collaborative communication process that required nurses to feel confident about their role and skills. This process involved nurses talking to children and parents about pain and creating engagement opportunities for children and parents. “Pain talk” aimed to promote the agency of the child and parent and their engagement in discussions and decision‐making, using information, support, and comfort. Nurses shaped their “pain talk” to the specific context of the child's pain, previous experiences, and current concerns to minimize potential distress and adverse effects and to promote optimal pain management.

Physical restraint of children and adolescents in mental health inpatient services: A systematic review and narrative synthesis

Physical restraint is regularly used in children and adolescent mental health care, often as a reactive behaviour management strategy. Physical restraint has been associated with physical injury, but psychological consequences are poorly understood. The aim of this systematic review was to examine physical restraint of children and adolescents in inpatient mental healthcare services. Healthcare databases were searched to identify English language publications discussing anyone aged ≤18 years who had experienced physical restraint as a mental health inpatient. No date restrictions were applied. Sixteen quantitative studies are included within this review. Most studies are retrospective in nature. Publications were appraised using the Critical Appraisal Skills Programme quality assessment tool. Common characteristics associated with children and adolescents who experience physical restraint include age, gender, diagnosis, and history. Most studies associate physical restraint with the management of aggression. Findings suggest that it may be a combination of patient (intrinsic) and environmental (extrinsic) factors which ultimately lead to children and adolescents experiencing restraint. This review confirms that little is known about children and adolescents' first-hand experiences of physical restraint. Future research should address children and adolescents' perceptions and first-hand experiences of physical restraint.

Communication styles between family carers and children with leukaemia in occupied Palestinian territory

This study explores the experience of communication regarding the care of children with cancer, from the perspective of family carers, children and health professionals in occupied Palestinian territory. This study employed an ethnographic collective qualitative case study approach, which was applied in one oncology unit in a Palestinian hospital. Participant observation and semi-structured interviews were used. This study only reports the findings of the interviews with the participating family carers. Fifteen interviews were conducted with family carers (n = 14 children), namely mothers (n = 7), grandmothers (n = 7) and a father (n = 1). The findings reveal that styles of information were given to children by their family carers: minimal/practical information, gradual information, false information, reassuring information and several sources of information. The term cancer was avoided in the discussion of the disease to ameliorate the negative effect of this term, which is considered taboo in the studied culture. Despite the recent trend emphasising the importance of parents communicating openly with their children with cancer, the findings of this study suggest that such open communication is not accepted by all parents. Hence, a case-by-case strategy could be adopted to treat each child in a way that is individual to that child and their culture.

Impact of Digital Educational Interventions to Support Parents Caring for Acutely Ill Children at Home and Factors That Affect Their Use: Protocol for a Systematic Review

Background

Urgent and emergency care health services are overburdened, and the use of these services by acutely ill infants and children is increasing. A large proportion of these visits could be sufficiently addressed by other health care professionals. Uncertainty about the severity of a child’s symptoms is one of many factors that play a role in parents’ decisions to take their children to emergency services, demonstrating the need for improved support for health literacy. Digital interventions are a potential tool to improve parents’ knowledge, confidence, and self-efficacy at managing acute childhood illness. However, existing systematic reviews related to this topic need to be updated and expanded to provide a contemporary review of the impact, usability, and limitations of these solutions.

Objective

The purpose of this systematic review protocol is to present the method for an evaluation of the impact, usability, and limitations of different types of digital educational interventions to support parents caring for acutely ill children at home.

Methods

The review will be structured using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) and Population, Intervention, Comparator, and Outcome (PICO) frameworks. Five databases will be systematically searched for studies published in English during and after 2014: Medline, EMBASE, CINAHL, APA PsycNet, and Web of Science. Two reviewers will independently screen references’ titles and abstracts, select studies for inclusion based on the eligibility criteria, and extract the data into a standardized form. Any disagreements will be discussed and resolved by a third reviewer if necessary. Risk of bias of all studies will be assessed using the Mixed-Methods Appraisal Tool (MMAT), and a descriptive analysis will be used to evaluate the outcomes reported.

Results

The systematic review will commence during 2021.

Conclusions

This systematic review will summarize the impact, usability, and limitations of digital interventions for parents with acutely ill children. It will provide an overview of the field; identify reported impacts on health and behavioral outcomes as well as parental knowledge, satisfaction, and decision making; and identify the factors that affect use to help inform the development of more effective and sustainable interventions.

International Registered Report Identifier (IRRID)

PRR1-10.2196/27504

558 PREVALENCE AND IMPACT OF FRAILTY IN PATIENTS HOSPITALISED WITH COVID-19. THE SALFORD EXPERIENCE IN WAVES 1 AND 2

Introduction

The COVID-19 pandemic has had an extensive impact on the frail older population, with significant rates of COVID-related hospital admissions and deaths amongst this vulnerable group. There is little evidence of frailty prevalence amongst patients hospitalised with COVID-19, nor the impact of frailty on their survival.

Methods

Prospective observational study of all consecutive patients admitted to Salford Royal NHS Foundation (SRFT) Trust between 27th February and 28th April 2020 (wave 1), and 1st October to 10th November 2020 (wave 2) with a diagnosis of COVID-19. The primary endpoint was in-hospital mortality. Patient demographics, co-morbidities, admission level disease severity (estimated with CRP) and frailty (using the Clinical Frailty Scale, score 1–3 = not frail, score 4–9 = frail) were collected. A Cox proportional hazards regression model was used to assess the time to mortality.

Results

A total of 693 (N = 429, wave 1; N = 264, wave 2) patients were included, 279 (N = 180, 42%, wave 1; N = 104, 38%, wave 2) were female, and the median age was 72 in wave 1 and 73 in wave 2. 318 (N = 212, 49%, wave 1; N = 106, 39%, wave 2) patients presenting were frail. There was a reduction in mortality in wave 2, adjusted Hazard ratio (aHR) = 0.60 (95%CI 0.44–0.81; p = 0.001). There was an association between frailty and mortality aHR = 1.57 (95%CI 1.09–2.26; p = 0.015).

Conclusion

Frailty is highly prevalent amongst patients of all ages admitted to SRFT with COVID-19. Higher scores of frailty are associated with increased mortality.

466 PREVALENCE AND IMPACT OF FRAILTY IN PATIENTS HOSPITALISED WITH COVID-19. THE SALFORD EXPERIENCE IN WAVES 1 AND 2

Introduction

The COVID-19 pandemic has had an extensive impact on the frail older population, with significant rates of COVID-related hospital admissions and deaths amongst this vulnerable group. There is little evidence comparing the prevalence and impact of frailty amongst patients hospitalised with COVID-19 in wave 1 vs wave 2 of the pandemic.

Methods

Prospective observational study of all consecutive patients admitted to Salford Royal NHS Foundation Trust (SRFT) between 27th February and 28th of April 2020 (wave 1), and 1st October to 10th November 2020 (wave 2) with a diagnosis of COVID-19. The primary endpoint was in-hospital mortality. Patient demographics, co-morbidities, biochemical parameters, and frailty (using the Clinical Frailty Scale, score 1–4 = not frail, score 5–9 = frail) were collected. A Cox proportional hazards model associating wave and frailty with mortality was used. A logistic regression model was used to associate patient characteristics with wave. Both models adjusted for patient characteristics.

Results

A total of 700 patients were included (N = 429, wave 1; N = 271, wave 2). In wave 1, 42% (N = 180) were female; median age was 72; 37% (N = 160) were non-survivors, 49% (N = 212) were frail (CFS 5–9). In wave 2, 38% (N = 104) were female; median age was 73; 30% (N = 80) were non-survivors, 39% (N = 106) were frail. There was a reduction in mortality in wave 2, aHR = 0.71 (95% CI 0.53–0.94). Frailty was associated with increased mortality, after adjustment for age, wave and other patient characteristics. Patients were more frail in wave 1, and the effect of frailty was more pronounced in wave 1 vs wave 2.

Conclusion

Frailty is highly prevalent amongst patients of all ages admitted to SRFT with COVID-19. Higher scores of frailty are associated with increased mortality.

Children and young people's contributions to public involvement and engagement activities in health-related research: A scoping review

BACKGROUND

There has been an increasing interest in how children and young people can be involved in patient and public involvement and engagement (PPIE) in health research. However, relatively little robust evidence exists about which children and young people are reported as being involved or excluded from PPIE; the methods reported as being used to involve them in PPIE; and the reasons presented for their involvement in PPIE and what happens as a result. We performed a scoping review to identify, synthesise and present what is known from the literature about patient and public involvement and engagement activities with children and young people in health related research.

METHODS

Relevant studies were identified by searches in Scopus, Medline, CINAHL, Cochrane and PsychInfo databases, and hand checking of reference lists and grey literature. An adapted version of the Guidance for Reporting Involvement of Patients and the Public (GRIPP2) was used as a framework to collate the data. Two reviewers independently screened articles and decisions were consensually made.

MAIN FINDINGS

A total of 9805 references were identified (after duplicates were removed) through the literature search, of which 233 full-text articles were assessed for eligibility. Forty studies published between 2000 and 2019 were included in the review. The review reveals ambiguities in the quality of reporting of PPIE with children with clear reporting on demographics and health conditions. The review found that children and young people were commonly involved in multiple stages of research but there was also significant variation in the level at which children and young people were involved in PPIE. Evaluation of the impact of children and young people's involvement in PPIE was limited.

CONCLUSIONS

Consultation, engagement and participation can all offer children and young people worthwhile ways of contributing to research with the level, purpose and impact of involvement determined by the children and young people themselves. However, careful decisions need to be made to ensure that it is suited to the context, setting and focus so that the desired PPIE impacts are achieved. Improvements should be made to the evaluation and reporting of PPIE in research. This will help researchers and funders to better understand the benefits, challenges and impact of PPIE with children and young people on health research.

Non-steroidal anti-inflammatory agents and anastomotic leak rates across colorectal cancer operations and anastomotic sites: A systematic review and meta-analysis of anastomosis specific leak rate and confounding factors

BACKGROUND

Surgical intervention presents a fundamental therapeutic choice in the management of colorectal malignancies. Complications, the most serious one being anastomotic leak (AL), still have detrimental effects upon patients' morbidity and mortality. We aimed to assess whether NSAIDs, and their sub-categories, increase AL in colonic anastomoses and to identify whether this affects specific anastomotic sites.

MATERIALS AND METHODS

A systematic search of MEDLINE, Cochrane Library, ClinicalTrials.gov, Web of Science, Science Direct, Google Scholar was conducted between January 1, 1999 till the October 30, 2020. Cohort studies and randomized control trials examining AL events in NSAID-exposed, colorectal cancer patients were included. NSAIDs were grouped according to the 2019 NICE guidelines in non-specific (NS-NSAIDs) and specific COX-2 inhibitors. The primary outcome was AL events in NSAID-exposed patients undergoing operations with either ileocolic, colocolic or colorectal anastomoses. Secondary outcomes included NSAID category-specific AL events and demographic confounding factors increasing AL risk in this patient population.

RESULTS

Fifteen studies involving 25,395 patients were included in the systematic review and meta-analysis. Of all anastomoses, colocolic anastomoses were found to be statistically more prone to AL events in the NS-NSAID-exposed population [OR 3.24 (95% CI 0.98-10.72), p = 0.054]. Male gender was an independent confounder increasing AL rate regardless of NSAID exposure.

CONCLUSION

The association between NSAID exposure and AL in oncology patients remains undetermined. Whilst in present work, colocolic anastomoses appear to be more sensitive to AL events, the observed association may be anastomotic site and NSAID-category dependent.

Is paediatric endotracheal suctioning by nurses' evidence based? An International Survey

BACKGROUND

Endotracheal suction (ETS) is essential in intubated patients to prevent tube occlusion and is one of the most common nursing interventions performed in intensive care.

AIMS AND OBJECTIVES

To explore how paediatric ETS practices reflect evidence-based practice (EBP) recommendations in paediatric intensive care units (PICU) worldwide.

STUDY DESIGN AND METHODS

A cross-sectional electronic survey linked to a real patient suction episode. Nurses completed the survey following a recent ETS episode. Evidence-based practice (EBP) was defined based on four of the American Association for Respiratory Care (AARC) best evidence recommendations: pre-oxygenation before suction, use of a suction catheter no more than half the diameter of the tracheal tube, shallow depth of suction, and the continuous suction applied upon withdrawal of the catheter. Participants included PICU nurses who performed ETS in children (0-17 years) excluding preterm neonates.

RESULTS

Four hundred forty-six complete surveys were received from 20 countries. Most nurses (80%, 367/446) reported that their units had local guidelines for ETS. The most common reason for suctioning (44%) was audible/visible secretions. Over half of ETS episodes (57%) used closed suction. When exploring the individual components of suction, 63% (282/446) of nurses pre-oxygenated their patient prior to suction, 71% (319/446) suctioned no further than 0.5 cm past end of the endotracheal tube (ETT), 59% (261/446) used a catheter no more than half the diameter of the ETT, and 78% (348/446) used continuous negative pressure. 24% of nurses gave patients an additional bolus of sedative, analgesic, and/or muscle-relaxant medication prior to suction; this decision was not related to the child's history of instability with suction, as there was no significant difference in those who reported patients had a history of being unstable with suction (P = .80). 26% (117/446) of nurses complied with all four EBP components in the reported suctioning episode.

CONCLUSIONS

Considerable variation in paediatric endotracheal suctioning practices exists internationally. Although most nurses applied single components of evidence-based recommendations during ETT suctioning, just a quarter applied all four elements.

RELEVANCE TO CLINICAL PRACTICE

Nurses' need to consider and strive to apply EBP principles to common nursing interventions such as ETS.

Paediatric Outpatient Parenteral Antimicrobial Therapy (OPAT): An e-survey of the experiences of parents and clinicians

BACKGROUND

Little evidence exists about parental satisfaction and their influence on referral to paediatric Outpatient Parenteral Antimicrobial Therapy (OPAT).

AIM

This study aimed to examine the experiences of parents, children and clinicians of OPAT at a large tertiary children's hospital.

METHOD

A prospective e-survey, using closed and open questions, of parents (n = 33) of 33 children who had received OPAT (3 children completed a survey), and clinicians (n = 31) involved in OPAT at a tertiary hospital. Data were collected September 2016 to July 2018.

RESULTS

Data were analysed using simple descriptive statistics. The results show that OPAT offered benefits (less stress, re-establishment of family life) compared to hospital-based treatment for parents and children, although some were anxious. Clinicians' referral judgements were based on child, home, and clinical factors. Some clinicians found the process of referral complex.

CONCLUSION

Most parents and children were satisfied with the OPAT service and preferred the option of home-based treatment as it promoted the child's comfort and recovery and supported family routines.

Two-Stage Revision Hip Arthroplasty with or without the Use of an Interim Spacer for Managing Late Prosthetic Infection: A Systematic Review of the Literature

The aim of the present paper was to identify, appraise, and synthesize the available evidence on two-stage revision hip arthroplasty with or without the use of an interim spacer for managing late prosthetic infection. The review methodology was designed by referencing the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist and flow diagram, and a Population, Intervention, Comparator, Outcomes and Study (PICOS) design framework was used to search for studies to incorporate within the review. Two independent investigators were involved in searching for relevant articles that fulfilled the inclusion criteria for the study. Critical appraisal of the selected articles was carried out using the relevant Critical Appraisal Skills Programme checklists. From an initial pool of 125 articles, four studies satisfied the inclusion criteria and quality assessment and were included for final review. Two patient groups were identified from within the selected studies: spacer and non-spacer. Both groups were assessed in terms of functional outcome, infection cure rates, and technical difficulties encountered during treatment. Better functional outcome was reported in the spacer group, both in the interim period between the two stages and after completion of treatment. The use of spacers reduced operative difficulty during the second stage and accelerated patient discharge. Reinfection and infection persistence rates were higher in the non-spacer group. Within the spacer group, articulated spacers performed better in all parameters. The results of this review reinforce the available evidence supporting the use of interim hip spacers in revision hip arthroplasty for managing prosthetic infection and also indicate that articulated hip spacers could be an attractive option going forward.

Romantic Relationships in Young People with Long-Term Health Conditions: A Scoping Review

OBJECTIVE

Forming and maintaining romantic relationships is an important developmental task in adolescence and young adulthood. This scoping review seeks to explore how young people with long-term physical health conditions understand and experience romantic relationships.

METHODS

Using Arksey and O'Malley's scoping review framework, a systematic search of five databases was conducted (PsychINFO, Cinahl, MEDLINE, Embase, and Web of Science). Studies were eligible for inclusion in the review if they were published in peer-reviewed journals, used primary data collection methods, and adopted quantitative, qualitative, or mixed-methods approaches to study romantic relationships in 11-25 year olds with long-term physical health conditions. Using a data extraction form, data pertaining to demographic characteristics of young people with long-term physical health conditions and relationship engagement were extracted from eligible papers.

RESULTS

Searches returned 4645 papers after duplicate removal, with a two-stage screening process resulting in 111 full-text papers being reviewed. Thirty-three eligible papers were included across a range of long-term physical health conditions. Findings identified that living with a long-term physical health condition impacted young people's perceptions and experiences of romantic relationships across the relationship lifespan, from envisaging future relationships, to forming relationships, and sustaining relationships. Issues around body confidence and self-esteem were identified as challenging in terms of perceptions and experiences of romantic relationships.

CONCLUSIONS

Findings demonstrate that young people wish to engage with romantic relationships, yet many report particular challenges associated with forming and sustaining relationships due to the constraints of their condition and treatment. Future research should consider nonheterosexual relationships.