Pediatric care quality in emergency departments: a view of children, parents, nursing staff, and administrative data

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DISSERTATIONS | KATJA JANHUNEN | PEDIATRIC CARE QUALITY IN EMERGENCY DEPARTMENTS... | No 615

KATJA JANHUNEN

PEDIATRIC CARE QUALITY IN EMERGENCY DEPARTMENTS

A VIEW OF CHILDREN, PARENTS, NURSING STAFF,

Dissertations in Health Sciences

PUBLICATIONS OF

THE UNIVERSITY OF EASTERN FINLAND

uef.fi

PUBLICATIONS OF

THE UNIVERSITY OF EASTERN FINLAND Dissertations in Health Sciences

This study focused on pediatric emergency care quality from the view of children, parents, nursing staff, and administrative data. The results showed that pediatric emergency care is assessed to be of a high quality by children, parents, and nursing staff. However, differences between assessments were addressed. The findings suggest that care

quality should be developed by focusing on encountering pediatric patients, modeling nurse staffing allocations, and further evaluating quality

simultaneously with staff, children, parents and administrative data. The result of this study can be utilized in the development of pediatric care quality in emergency departments as well as in

nursing management.

KATJA JANHUNEN

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PEDIATRIC CARE QUALITY IN EMERGENCY DEPARTMENTS

A VIEW OF CHILDREN, PARENTS, NURSING STAFF, AND ADMINISTRATIVE DATA

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Katja Janhunen

PEDIATRIC CARE QUALITY IN EMERGENCY DEPARTMENTS

A VIEW OF CHILDREN, PARENTS, NURSING STAFF, AND ADMINISTRATIVE DATA

To be presented by permission of the Faculty of Health Sciences, University of Eastern Finland for public examination in Mediastudia 302

Auditorium, Kuopio

on June 11^th, 2021, at 12 o’clock noon

Publications of the University of Eastern Finland Dissertations in Health Sciences

No 615

Department of Nursing Science University of Eastern Finland, Kuopio

2021

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Series Editors

Professor Tomi Laitinen, M.D., Ph.D.

Institute of Clinical Medicine, Clinical Physiology and Nuclear Medicine Faculty of Health Sciences

Professor Tarja Kvist, Ph.D.

Department of Nursing Science Faculty of Health Sciences Professor Ville Leinonen, M.D., Ph.D.

Institute of Clinical Medicine, Neurosurgery Faculty of Health Sciences

Professor Tarja Malm, Ph.D.

A.I. Virtanen Institute for Molecular Sciences Faculty of Health Sciences

Lecturer Veli-Pekka Ranta, Ph.D.

School of Pharmacy Faculty of Health Sciences

Distributor:

University of Eastern Finland Kuopio Campus Library

P.O.Box 1627 FI-70211 Kuopio, Finland

www.uef.fi/kirjasto

Name of the printing office/kirjapaino Grano, 2021

ISBN: 978-952-61-3758-2 (nid.) ISBN: 978-952-61-3759-9 (PDF)

ISSNL: 1798-5706 ISSN: 1798-5706 ISSN: 1798-5714 (PDF)

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Author’s address: Department of Nursing Science University of Eastern Finland KUOPIO

FINLAND

Doctoral program: Doctoral program in Health Sciences Supervisors: Professor Tarja Kvist, Ph.D.

Department of Nursing Science University of Eastern Finland KUOPIO

FINLAND

Docent Päivi Kankkunen, Ph.D.

Department of Nursing Science University of Eastern Finland KUOPIO

FINLAND

Reviewers: Docent Hanna Hopia, Ph.D.

School of Health and Social Studies JAMK University of Applied Sciences, JYVÄSKYLÄ

FINLAND

Docent Meeri Koivula, Ph.D.

Faculty of Social Sciences| Health Sciences University of Tampere

TAMPERE FINLAND

Opponent: Professor Sanna Salanterä, Ph.D.

Department of Nursing Science University of Turku

TURKU FINLAND

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Janhunen, Katja

Pediatric care quality in emergency departments.

A view of children, parents, nursing staff, and administrative data Kuopio: University of Eastern Finland

Publications of the University of Eastern Finland Dissertations in Health Sciences 615. 2021, 72 p.

ISBN: 978-952-61-3758-2 (nid.) ISSNL: 1798-5706

ISSN: 1798-5706

ISBN: 978-952-61-3759-9 (PDF) ISSN: 1798-5714 (PDF)

ABSTRACT

Pediatric patients are a significant group in emergency care due to the high number of annual visits and special needs within this population. Therefore, the quality of pediatric emergency care is an essential research topic of health care and nursing science. The purpose of this study was to describe and explain pediatric care quality in emergency departments (EDs) through the assessment of children, parents, and nursing staff, as well as from the view of administrative data.

The research included three quantitative cross-sectional sub-studies. In sub- study I, the nursing staff (n=147) assessed the care quality in general and pediatric emergency departments (PEDs) by participating in a survey. The instrument used for this study modified the Children Revised Humane Caring Scale (CRHCS) with 41 items (scale 0–10) and four satisfaction items. The study was conducted in two PEDs and two general EDs in Finland. In sub-study II, 98 children and 98 parents assessed pediatric care quality in the same four EDs using the CRHCS instrument.

In addition, the relationship between ED process factors (length of stay [LOS], number of diagnostic tests and procedures, admission/discharge, triage level) and children’s (n=89) and parents’ (n=89) assessed care quality was analyzed. In sub- study III, the relationship between nurse staffing and patients’ ED LOS and the number of patients who left before treatment completion (LBTC) was assessed using the administrative data of 21 956, patient visits, and nurse staffing (n=50). In addition, the survey data of nursing staff, children, and parents were used to determine if there are differences in the assessments about care quality. In all sub-

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studies, data was analyzed using statistical analyses, descriptive methods, Mann- Whitney U test, Kruskal-Wallis test, and logistic and linear regression.

Nursing staff assessed pediatric emergency care quality using values between 4 and 8. The higher values were given the staff’s professional practice (8.1) and the lowest value was given the ED’s human resources (mean 4.7). Nurses in general EDs gave significantly lower assessments for pediatric patients’ information, participation in their care, and pediatric patients’ pain and apprehension

management. Children and parents assessed quality in all six subscales between 7 and 9. Children’s assessments were lower than their parents’ with regard to three items: professionalism of the nursing staff, the ability to participate in planning their care, and the ability to talk privately with the staff. Parents’ vocational degrees and the smaller number of previous ED visits were predicted, such as children’s and parents’ high satisfaction with care in the ED. Children’s LOS varied between 11 minutes and 8 hours, and triage levels varied between high acuity (level 2) and low acuity (levels 4 and 5). One or fewer diagnostic tests and procedures were most commonly conducted on the children. Child–parent pairs with higher evaluations of care and satisfaction with care were predicted on the pediatrician care track. Pairs’

high satisfaction with care was related to the more acute triage level and the larger number of procedures.

PEDS’ nurse-patient ratios varied for the day shift with one nurse per five patients; on the evening shift, the ratio was six patients per nurse, and night shifts had three nurses per four patients. The decrease in ED LOS was related to the increase of the nurse-patient ratio. Patients’ high acuity (Emergency Severity Index 1–3), hospital admission, and increases in patients’ age increased ED LOS. Those LBTC patients had a significantly lower nurse-patient ratio during their visit. In the survey, participating children’s, parents’, and nursing staff’s assessments about pediatric care quality were statistically significantly lower through nurses’

assessments in four subscales: interdisciplinary collaboration, professional practice, information, and participation in their own care and human resources.

In conclusion, pediatric emergency care is assessed to be of a high quality;

however from the view of nursing staff, the quality of pediatric care appeared to be at a lower level in general EDs than in PEDs. Overall, nursing staff assessed

pediatric care quality more critically than did children and parents. A bidirectional relationship was observed between the care process factors and the satisfaction of children and parents. In addition, in study addressed a relationship between nurse staffing and the pediatric emergency care process factors LOS and LBTC.

Keywords: Child; Pediatrics; Quality of Health Care; Patient Satisfaction; Emergency Service, Hospital; Emergency Nursing

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Janhunen, Katja

Lasten päivystyshoidon laatu. Lasten, vanhempien, hoitohenkilökunnan ja hallinnollisen aineiston näkökulmat.

Kuopio: Itä-Suomen yliopisto

Publications of the University of Eastern Finland Dissertations in Health Sciences 615. 2021, 72 s.

ISBN: 978-952-61-3758-2 (nid.) ISSNL: 1798-5706

ISSN: 1798-5706

ISBN: 978-952-61-3759-9 (PDF) ISSN: 1798-5714 (PDF)

TIIVISTELMÄ

Lapsipotilaat ovat merkittävä potilasryhmä päivystyshoidossa, koska alle 16- vuotiaiden lasten ja nuorten päivystyskäyntejä on merkittävä määrä vuosittain ja heillä on erityistarpeita hoitoonsa liittyen. Erityisesti lasten päivystyshoidon laatu on vähän tutkittu ja tärkeä terveydenhuollon sekä hoitotieteen tutkimusaihe. Tämän tutkimuksen tarkoituksena oli kuvata ja selittää päivystyspoliklinikoilla lasten hoidon laatua arvioimalla sitä lasten, vanhempien ja hoitohenkilökunnan näkökulmasta sekä hallinnollisten tietojen kautta.

Tutkimukseen muodostivat kolme kvantitatiivista poikkileikkauksellista osatutkimusta. Osatutkimuksessa I hoitohenkilökunta (n = 147) arvioi hoidon laatua kahdessa lasten sekä kahdessa lasten ja aikuisten päivystyksessä vastaamalla kyselyyn. Mittarina käytettiin tähän tutkimukseen modifioitua Ihmisläheinen hoito (lapset) mittaria (asteikko: 0 – 10), jossa oli 41 kysymystä hoidon laadusta ja neljä tyytyväisyyteen liittyvää kysymystä. Osatutkimukseen II, osallistui 98 lasta (ikä 7 – 15 vuotta) ja 98 vanhempaa neljällä päivystyspoliklinikalla Suomessa. He arvioivat lasten hoidon laatua Ihmisläheisen hoidon (lapset)

mittarilla. Lisäksi analysoitiin prosessitekijöiden (käynnin kesto, tutkimuksien ja toimenpiteiden lukumäärä, osastohoito, kiireellisyys) suhdetta lasten (n = 89) ja vanhempien arvioimaan hoidon laatuun (n = 89). Osatutkimuksessa III tutkittiin lastenpäivystyksessä puolen vuoden aikana toteutuneiden päivystyskäyntien (n=21 956) ja hoitohenkilökunnan (n=50) mitoituksen yhteyttä päivystyksen potilaiden käynnin kestoon ja hoidotta poistuneiden potilaiden lukumäärään. Lisäksi yhteenveto-osassa analysoitiin uudelleen hoitohenkilökunnan, lasten ja vanhempien

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Kaikissa osatutkimuksissa aineistot analysoitiin käyttämällä tilastollisia analyysejä;

kuvailevia menetelmiä, Mann-Whitney U ja Kruskal-Wallisin testiä sekä logistista ja lineaarista regressioanalyysiä.

Hoitohenkilökunta arvioi lasten päivystyshoidon laadun arvosanojen neljä ja kahdeksan välillä. Korkeimmat arvioinnit saivat henkilökunnan ammatillinen osaaminen (8,1) ja matalimmat arvioinnit päivystyksen henkilöstöresurssit (keskiarvo 4,7). Hoitajat lasten ja aikuisten päivystyksissä antoivat merkittävästi alhaisemmat arvioinnit kuin lastenpäivystyksissä työskentelevät hoitajat

lapsipotilaiden hoidon laadusta osa-alueilla potilaan tiedon saanti ja osallistuminen hoitoon sekä kivun ja pelon hoito.

Lapset ja vanhemmat arvioivat hoidon laadun kaikilla kuudella osa-alueella olevan arvosanojen seitsemän ja yhdeksän välillä. Lasten arviot kolmessa

yksittäisessä kysymyksessä olivat alhaisemmat kuin heidän vanhempansa arvioinnit;

hoitohenkilökunnan ammattitaito, mahdollisuus osallistua hoidon suunnitteluun ja mahdollisuudet puhua yksityisesti henkilöstön kanssa. Korkeampaa tyytyväisyyttä hoitoon ennustivat vanhempien ammatillinen tutkinto ja pienempi määrä käyntejä päivystyspoliklinikalla kuluneen vuoden aikana. Prosessitekijöitä analysoidessa havaittiin, että lasten päivystyskäynnin kesto vaihteli 11 minuutin ja kuuden tunnin välillä ja kiireellisyysluokitus vaihteli kiireettömästä kiireelliseen hoidon tarpeeseen.

Yleensä tutkimukseen osallistuneille lapsille tehtiin yksi tutkimus ja toimenpide.

Lapsi- vanhempi-parien antamat positiiviset arvioinnit hoidon laadusta ja tyytyväisyydestä hoitoon olivat yhteydessä hoidon toteutetukseen lastentautien erikoisalalla yhteispäivystyksessä. Lisäksi korkeaa tyytyväisyyttä ennusti lapsen korkeampi kiireellisyysluokitus ja suurempi toimenpiteiden määrä.

Osatutkimuksessa III havaittiin, että lasten päivystyksessä hoitajamitoitus vaihteli työvuoroittain. Päivävuorossa oli keskimäärin yksi sairaanhoitaja viittä potilasta kohti, iltavuorossa kuusi potilasta yhtä sairaanhoitajaa kohti ja yövuorossa kolme sairaanhoitajaa neljää potilasta kohti. Päivystyksen läpimenoajan

lyhenemisen havaittiin olevan yhteydessä hoitajien lukumäärän kasvuun.

Läpimenoaikaa kasvattavia tekijöitä olivat potilaiden korkea kiireellisyysluokitus, päätyminen sairaalahoitoon sekä potilaan vanhempi ikä. Potilailla, jotka poistuivat kesken hoidon oli matalampi hoitajamitoitus käyntinsä aikana (kuusi potilasta hoitajaa kohti) kuin niillä jotka saivat päivystyskäynnin päätökseen (viisi potilasta hoitajaa kohti).

Kun annettuja lasten, vanhempien ja hoitohenkilökunnan antamia arviointeja (osatutkimus I ja II) hoidon laadusta verrattiin keskenään, havaittiin

hoitohenkilökunnan arvioineen lasten hoidon laadun päivystyspoliklinikalla

tilastollisesti merkitsevästi matalammaksi kuin lapset ja vanhemmat neljässä laadun osa-alueessa; moniammatillinen yhteistyö, ammatillinen toiminta, tiedonsaanti ja osallistuminen hoitoon sekä henkilöstöresurssointi.

Johtopäätöksinä voidaan esittää, että lasten hoidon laatu päivystyspoliklinikoilla koetaan korkeatasoiseksi. Kuitenkin sairaanhoitajien laadun arvioinnit lasten ja

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aikuisten päivystyksissä olivat matalammat kuin lasten päivystyksissä. Kaikkiaan hoitohenkilökunta arvioi laatua lapsia ja vanhempia kriittisemmin. Päivystyshoidon prosessitekijöiden ja lasten ja vanhempien laadun arviointien ja tyytyväisyyden väliltä löydettiin monitahoinen yhteys. Lisäksi havaittiin, että hoitajamitoitus on yhteydessä lapsen päivystyskäynnin kestoon ja hoidon keskeyttäneiden potilaiden määrään.

Avainsanat: päivystys; poliklinikat; hoitotyö; laatu; arviointi; tyytyväisyys; lapset

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ACKNOWLEDGMENTS

This study was conducted at the University of Eastern Finland, Department of Nursing Science. I would like to thank the department for this opportunity and the support during this dissertation work.

I would like to warmly thank my supervisors, Professor Tarja Kvist and Adjunct professor Päivi Kankkunen, for their belief in me and for sharing their expertise with me. Tarja, I felt supported and encouraged by you from the beginning of this study and Päivi, your positive and accurate comments promoted both my work and the research.

I am thankful to the reviewers, Adjunct professor Hanna Hopia and Adjunct professor Meeri Koivula, for your thoughtful reviews, which improved this thesis.

I owe gratitude to the professionals who were consulted during this process: MD Anniina Kyrönlahti, thank you for your medical expertise which helped with data analysis, and statistician Matti Estola Ph.D., thank you for your advice on statistical analysis.

This work was funded by the Helsinki University Hospital Nursing Research Center, the Finnish Nursing Association, and the Finnish Foundation of Nurse Education. I want to show my gratitude for the trust these organizations had in the study, and with it, the financial support which made it possible to work as a full- time researcher and thus contributed to the study’s completion.

I would like to thank all the children and parents who participated in this study during a sudden childhood illness. Your contribution to this study was essential. I want to thank all the participating hospitals and nurse managers and deputy nurse managers who enabled the practical implementation of the study. Also, I want to show my humblest thanks and respect to all of my nurse colleagues who

participated in the study: your major participation showed the importance of researching pediatric emergency care.

I would like to thank Inger Mäenpää, Director of Nursing, for making research periods possible and always encouraging me to take advantage of them, and my colleagues at the HUS Children and Adolescents, for your great support and encouragement during this study. In particular, the conversations which we had during these years from time to time challenged my thoughts, but this meant major progress in the study and my perceptions about pediatric emergency care quality.

Finally, I want to thank my friends and family for living with me during these years. Friends, each time I have needed to air my thoughts, you were there for me and if I had rough times, you believed in me and my work. My lovely children and husband, this work is dedicated to you: thank you for being there.

Espoo, April 2021 Katja Janhunen

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LIST OF ORIGINAL PUBLICATIONS

This dissertation is based on the following original publications:

I Janhunen K, Kankkunen P & Kvist T. (2017) Nursing Staff's Perceptions of Quality of Care for Children in Emergency Departments—High Respect, Low Resources. Journal of Pediatric Nursing e37, e10-e15. doi:

10.1016/j.pedn.2017.08.029

II Janhunen K, Kankkunen P & Kvist T. (2019) Quality of Pediatric Emergency Care as Assessed by Children and Their Parents, Journal of Nursing Care Quality 34(2), 180-184. doi: 10.1097/NCQ.0000000000000346

III Janhunen K, Kankkunen P & Kvist T. (2021) Pediatric emergency care:

associations between process factors and outcomes – children’s and parents’

views combined with register data. Journal of International Emergency Nursing, 54. doi:10.1016/j.ienj.2020.100937

IV Janhunen K, Kankkunen P & Kvist T. (2020) Nurse staffing and care process factors in the paediatric emergency department—An administrative data study.

Journal of Clinical Nursing, 29, 4554-4560 doi: 10.1111/jocn.15482

The publications were adapted with the permission of the copyright owners.

The summary of the study also includes unpublished material.

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ABBREVIATIONS

CTAS Canadian Triage Scale Cl Confidence interval

CRHCS Children Revised Humane Caring Scale ED Emergency department

ESI Emergency Severity Index MTS Manchester Triage Scale LOS Length of stay

LBTC Left before treatment completed LWBS Left without being seen

RV Return visit

STM Finland’s Ministry of Social Affairs and Health

THL National Institute for Health and Welfare of Finland PED Pediatric emergency department

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1 INTRODUCTION

Pediatric patients are a significant group in emergency care due to the high number of visits and special needs within this population. In emergency departments (EDs) in the United States, roughly 20% of patients are children under 18 years old (McDermott et al. 2018); for example, in Italy, the

prevalence of annual ED visits among children under 18 years of age was 27%

(Riva et al. 2018). The number of annual emergency visits for pediatric patients in Finland is not available. In 2019, 871,036 citizens under 15 years of age lived in Finland (Tilastokeskus 2019).

Emergency care differs from other health care due to its acute need and the limited number of service providers. In Finland, emergency care is provided in joint primary and specialized health care EDs, which are limited in number within the hospital districts (Health Care Act 1326/2010). Limitation in the number of emergency care providers ensures that patients’ volume per ED is adequate in ensuring that the staff’s competencies remain due to repetitions (STM 2017). Pediatric emergency care is settled in conjunction with adults, whereas only a few hospital districts offer dedicated pediatric emergency care services. Finnish hospital districts organize emergency care in their area and ensure that ED units have sufficient resources and expertise in providing quality of care and patient safety (Health Care Act 1326/2010).

The quality of pediatric emergency care is an essential research topic with regard to health care and nursing. In Finland, the quality of care, in general, has been studied for a long time at the University of Eastern Finland and is focused on patient care in different nursing environments (i.e. Kvist et al. 2013;

Kvist et al. 2014). Quality research is important due to organizations’ desire to produce and highlight their quality of care (IOM 2007). Ensuring transparency in the quality of pediatric care by measuring it has been a key international issue for decades (Alessandrini et al. 2011; IOM 2006).

Regarding nursing in general, nurses’ and parents’ perceptions about empowering health counseling have been studied in the primary care

environment in Portugal (Rodrigues et al. 2020). Hospitalized children’s views about their quality of care in pediatric nursing have been studied in Finland (Pelander et al. 2009; Pelander et al. 2007) and Italy (Comparcini et al. 2018).

These previous studies focused on children’s quality of care. Alternatively, a limited number of studies in nursing science have analyzed the views of pediatric emergency care quality among children, parents, and nurses.

Internationally, there have only been a relatively limited number of studies about pediatric emergency care in recent years. Even though children represent

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a significant proportion of emergency patients and the number has increased in recent years (Doan et al. 2014), research around this topic has not expanded in the same proportion. In nursing science, pediatric emergency care has been studied through key stages of the process—for example, from the perspective of the ED triage assessment, the patients’ teaching techniques in discharging from the ED (Gozdzialski et al. 2012), communication between the staff, the child, and the family (Grahn et al. 2016), and non-pharmacological pain- relief practices (Wente et al. 2013).

Thus, there exists a need to increase knowledge on the quality of pediatric care and the outcomes of nursing in the field of pediatric emergency care. This study belongs to the long-lasting research profile of quality of care in the Department of Nursing Science, University of Eastern Finland. This study is concerned with the health service research in nursing science. Therefore, the purpose of this study is to describe and explain the quality of pediatric care in EDs through the assessment of children, parents, and nursing staff, as well as from the view of administrative data.

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2 REVIEW OF THE LITERATURE

2.1 MOVING TOWARD QUALITY OF PEDIATRIC EMERGENCY CARE

Quality of care is a common term and has several different definitions. Avedis Donabedian developed the oldest and most widely spread health care quality model in the 1960s. He defined a conceptual model, including health care structure, care process, and the outcome as independent parts of quality that are still related to each other. He defined the base of care as a structure of health care: care organization, environment, facilities, and human resources, including staff levels and training. The care process was considered as all acts performed by health care providers to help patients with their health problems.

The care outcome includes the results of the care and patient satisfaction for received care. Donabedian emphasized that quality assessments should be measurable, easily achieved, routinely used, and valid measurements.

(Donabedian 1966.)

Finland’s Health Care Act declares that the provided health care shall be of high quality, safe, and appropriately organized, and the law requires that every health care provider should develop a plan for patient safety and quality (Health Care Act 1326/2010). For emergency care, the Social and Health Ministry of Finland (2014) has defined quality of care and complementary measurements belonging to the care structure, process, outcome, and risk management. Core measurements include the number of patients who left before treatment completion (LBTC) (i.e. less than 5% of all patients), ED length of stay (LOS) less than 4 hours, and regularly measured patient satisfaction with care (STM 2014).

At the beginning of the last decade, Finnish hospitals have started to develop a quality of care according to international programs. As a reference framework for the development of nursing quality, the Magnet Hospital model is in use in the hospital districts of Helsinki and Uusimaa (HUS) and the hospital district of Pohjois-Savo (KUH) (Kvist et al. 2013; Torppa 2018). Besides achieving the Magnet Hospital model, the HUS hospital districts are also preparing to seek recognition for their quality of care following the Joint Commission International (JCI) program (HUS 2019).

The United States Institute of Medicine (IOM 2006) has defined six domains for producing high-quality care in the United States; thus, care should be “safe,

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effective, patient-centered, timely, efficient, and equitable” (IOM 2006). These aims do not include specific measurements, but there are mentioned acts that are mandatory in a way to produce high-quality emergency care for children. In addition, IOM (2006) presented recommendations on how health care

organizations can achieve high-quality care. These included re-planning care processes, comprehensive use of information technologies, managing the staff’s knowledge and maintenance, creating operative care teams, and developing care coordination across patient conditions, services, and care units (IOM 2006).

The Emergency Nurses Association (ENA 2013) has given a position statement on the role of nurses in promoting patient satisfaction and quality of care in the ED. The organization has stated that achieving patient satisfaction in a unique emergency environment can be challenging and that emergency nurses are in a position to improve patient care outcomes by using a satisfaction-enhancing strategy. Such methods include the fact that the primary customers of

emergency care are children and families, and respect should be reflected in the care of pediatric patients. In nursing, continuous feedback from children and families about services, the quality of care, and their satisfaction with care should be collected. Studies should focus on emergency nursing, and valid indicators should be developed for the use of nursing-sensitive indicators in emergency care. (ENA 2013.)

A significant factor related to emergency care quality is the staff’s emergency care competency and ED staffing (STM 2017). Nursing staff typically have a permanent position as ED staff, whereas other staff such as physicians visit the ED one shift at a time. In a study of adults’ care, Ramsay et al. (2018) showed that reducing the number of hours worked by nursing staff statistically

significantly increased patients’ LOS in the ED and the number of LBTC patients, regardless of the number of patients per day, the hospital utilization rate, or the number of patients transferred to the ED. (Ramsay et al. 2018.)

2.2 PEDIATRIC EMERGENCY CARE

Most commonly, a pediatric patient refers to either a child or adolescent under 16 or 18 years of age. However, especially in the United States, someone under the age of 21 is also defined as a pediatric patient (i.e. Rutherford et al. 2010).

In this study, pediatric patients are considered children and adolescents under 16 years of age, according to the Finnish Health Care Act definition (Health Care Act 1326/2010).

Pediatric patients are a significant part of the users of emergency services. In

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age (McDermott et al. 2018). In addition, in Italy, the prevalence of children under the age of 18 visiting the ED at least once is analyzed as being nearly 27% (Riva et al. 2018). In England and Italy, Poropat et al. (2017) found that children’s reasons for ED attendance were similar in both countries, and the main ED patients were children under the age of one. Also, fever, breathing difficulties, gastrointestinal problems, and trauma were the most represented reasons for children’s ED attendance. (Poropat et al. 2017.)

2.2.1 Pediatric emergency care organization

In Finland, the municipalities or hospital districts organize emergency care, and 24-hour primary health care emergency service is organized in cooperation with specialized health care, hereby referred to as a joint ED. Twelve hospitals, five university hospitals, and seven central hospitals provide an extensive 24-hour emergency service. These are all joint emergency services, including social emergency amenities. Finland’s Ministry of Social Affairs and Health (STM) is responsible for the general planning, steering, and monitoring of specialized care (Health Care Act 1326/2010). Pediatric emergency care is settled either as a part of joint general emergency services in university hospitals or dedicated PEDs in university hospitals (STM 2017).

Globally and in Finland, the method as to how pediatric emergency care is organized differs (STM 2017; IOM 2007). There are two types of organizations of care: mixed general EDs for children and adults and pediatric emergency departments (PEDs) for children and adolescents only (e.g. Hudgings et al.

2017; Peeler et al. 2016). Finland’s Ministry of Social Affairs and Health (2017) emphasized that, in emergency services, pediatric patients and families will benefit from well-designed facilities, a safe environment, and experienced pediatric staff (STM 2017).

Pediatric patients differ from adult ED patients based on physical and emotional needs. Children need equipment to fit their specific sizes, medication calculated for specific doses, and trained staff for pediatric care (IOM 2007).

Therefore, in the United States, the ENA has set a specific guideline for the care of children in EDs (ENA 2013). This guideline emphasizes how vital it is for EDs to be prepared to care for children of all ages with appropriate resources:

facilities, equipment, policies, education, and staff (ENA 2013). Globally, the World Health Organization (WHO 2018) has developed “Standards for improving the quality of care for children and young adolescents in health facilities” (WHO 2018). This is a comprehensive description of the ways and principles according to how pediatric patients should be treated in health care. The WHO principles emphasize the child as an individual in both care and facilities and as an active actor in care, as well as his/her right to quality care and support.

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2.2.2 Elements of pediatric emergency care

The pediatric emergency care process consists of the child’s triage assessment, examinations and care, and discharge or admission to a hospital (Rutherford et al. 2010; Green et al. 2012; Ortiz et al. 2012; Doyle et al. 2012). The pediatric patients’ care process begins with patient triage assessments. The main purpose of the protocol is to differentiate patients who need life-saving care from those who can wait (Green et al. 2012; WHO 2018). The other purpose is related to ED functionality when dividing patients into different ED areas and/or teams according to the acuity of care track, such as the fast track (i.e. Doyle et al. 2012). Pediatric triage systems that are globally used are Emergency Severity Index (ESI), Manchester Triage Scale (MTS), and Canadian Triage Scale (CTAS) (Green et al. 2012; Gravel et al. 2013; De Magalhães-Barbosa et al. 2017). These are five-category assessment scales with individual criteria: ESI is based on patients’ acuity and ED resource needs, and MTS and CTAS are based on patients’ acuity. Finland has also used the five-level ABCDE triage, which is based on patients' acuity (Kantonen et al. 2010). Finland’s Ministry of Social Affairs and Health (2017) has stated that triage assessment from a pediatric nurse is more appropriate than from a general emergency nurse, which is why large pediatric emergency services should have pediatric nursing staff. (STM 2017.)

According to a Mexican study (Ortiz et al. 2012), a child undergoes

approximately two diagnostic or care-related procedures during his/her ED visit.

Children often experience these situations as painful or stressful, and therefore pain and stress relief are an important part of pediatric emergency care (Ortiz et al. 2012). According to the literature review (Wente 2013), non-

pharmacological pain treatment is a protocol used in pediatric nursing in EDs, and it relieves children’s pain and anxiety. Techniques included a distraction, parental holding/positioning, cold treatment, and the use of sucrose (Wente 2013).

Pediatric care in the ED involves the child’s parent or guardian. Hemingway and Redsell (2011) addressed challenges in communication between ED professionals and children and parents. Challenges were related to the ED environment, time limitations, and the child’s level of sickness (Hemingway &

Redsell 2011). However, communication between children and nurses during emergency care, including asking for and following children’s suggestions related to care, has been found to increase the child’s and family’s experience of safety and to strengthen their involvement in care (Grahn et al. 2017).

Overall, in pediatric emergency care, it is recommended to conduct family- centered care (FCC) (ENA 2013; IOM 2006).

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When emergency care is completed, discharge guidance is essential from the perspective of safety and quality of care as well as from the perspective of the number of ED revisits. There is a possibility to teach patients and families about the proper use of the ED and where to seek care for children if needed.

(Gozdzialski et al. 2012.)

2.3 PEDIATRIC EMERGENCY CARE QUALITY

This literature review aimed to describe pediatric emergency care quality. The literature searches were conducted in November 2019 and updated in October 2020. The inclusion criteria were as follows: ED, pediatric patients, the general quality of care and patient satisfaction, the years 2009–2020, and use of the English language. Exclusion criteria included the following: the study was not conducted in the ED, the study focused on adults’ emergency care, and the study focused on a specific disease or the condition of care quality. The

searches were done in CINAHL, PubMed, and SCOPUS databases and through a manual search using free words and MeSH terms (Figure 1).

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Figure 1. A flow diagram of the study selection process

Most of the selected (N=28) articles were from the United States (n=18), and others were from Canada (n=4), Switzerland and Belgium (n=2), Australia (n=3), and Brazil (n=1) (Appendix 1). Two of the selected articles were qualitative studies. The rest of the studies (n=26) used quantitative methods:

23 cross-sectional studies, two cohort studies, and one case-control study.

The study appraisal was used as an appropriate checklist by the Joanna Briggs Institute (Appendix 1). The researcher conducted the appraisal of studies. When using an appraisal checklist for cross-sectional studies, high scores (8/8) were received in two studies (Byczkowski et al. 2013; Gaushe-Hill

Records were searched from databases (n=302) in terms (”emergency department” AND pediatric OR/AND child* AND “quality of care” OR/AND satisfaction), 2009–2020, CINAHL n=70, PubMed

n=86, Scopus n=146

Duplicate articles excluded (n=92)

Articles excluded (n=178) Articles screened (n=210)

Inclusion criteria:

Study’s focus on pediatric emergency care

and pediatric patients and quality of care

—not related to a specific disease or the

condition of care quality

IdentificationScreeningEligibilityIncluded

Full-text articles assessed for

eligibility (n=32) Full-text articles excluded (n=4)

Studies included in review (n=28)

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scores of 6-7/8. The studies’ scores usually displayed decreased identification of possible confounders and described how the confounders were adjusted during data analysis. In all studies, participants' inclusion criteria, study design, and statistical methods were well described. The lowest scores of cross-sectional studies were 5/8. Both cohort studies and the case-control study received moderate scores of 9–10/12 as they lacked descriptions of the confounding factors found. Qualitative studies received scores of 8–9.

Sections 2.4–2.6 below describe the results of the literature review by Donabedians’ quality aspects structures, processes, and outcomes. Characters of the selected publications used a quality appraisal checklist, and Appendix 1 describes the given scores.

2.3.1 Pediatric emergency care structure

Based on the literature review, 12 studies were concerned with the pediatric emergency care structure (Table 1). These studies were from the US (n=10), Australia (n=1), and Belgium (n=1). In the structure were categorized studies related to ED use (Marcin et al. 2018; Jaeger et al. 2015) and ED use by patients’ acuity (triage level) (Benagdemed et al. 2012; Kubisek et al. 2012).

Also, some studies were related to the emergency type being a general or pediatric emergency (Goldman et al. 2018; Hudgins et al. 2017; Peeler et al.

2016), staffing (Krinsky-Diener et al. 2017; Michelson et al. 2016), and ED facilities (Schroder et al. 2016; Gausche-Hill et al. 2015; Robison & Green 2015).

Pediatric emergency care facilities

Pediatric patients’ emergency care is organized either in general EDs or in dedicated PEDs (Goldman et al. 2018; Hudgins et al. 2017; Peeler et al. 2016).

In general EDs, pediatric patients receive care from a staff who care for patients of all ages, and the facilities of ED are the same for pediatric and adult patients. PEDs have facilities specifically for children that are staffed by

pediatric nurses and physicians. When comparing those two settings in the study (Hudgins et al. 2017) of the US, PEDs had a greater proportion of children under 1 year of age (18%), and PEDs had greater complexity and higher rates of hospitalization (10%) than general EDs (Hudgins et al. 2017).

Also, the patient volume has an impact on ED readiness for pediatric care patients. In the Gausche-Hill et al. study (2015), the pediatric readiness score means varied with a lower level at low-volume pediatric patients units and a higher level in high-volume pediatric units. The presence of pediatric

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coordinators increased the likelihood of having all recommended components (Gausche-Hill et al. 2015).

The use of colorful lighting in the care environment has been found to be associated with children’s and their parents’ ED experiences. Children who received treatment in an ambient environment rated lower pain scores, and their caregivers experienced higher quality of care and the possibility of becoming better involved in their child’s care than in the traditional

environment. Parents in the traditional environment expected longer waiting times, felt more anxious, and were more scared than their parents in the ambient environment (Robinson & Green 2015).

Pediatric emergency patients

The number of PED patients has increased during the 21st century. In particular, this phenomenon has demonstrated an increased number of non- urgent visits (Doan et al. 2014.) In the literature, these PED patients are called either non-urgent patients or patients with ambulatory care service (ACS) conditions. According to a US study (Jaeger et al. 2015), of all ED visits in the US in 2010, 13% were patients with ACS conditions. Those patients presenting to the ED for ACS were related to have no insurance or to have public

insurance, lower household income, and younger age (Jaeger et al. 2015).

A study in Belgium (Benahmed et al. 2012) found that 40% of participants were considered low-acuity patients who do not need hospital-level care.

Factors related to low-acuity ED visits included the age of the child, the proximity of the ED location, the time of the visit being outside office hours, lacking a family doctor, the geographical location, parents’ perceptions of EDs’

high-quality care, and the convenience of using emergency services (Benahmed et al. 2012). In a survey study of caregivers/parents of non-urgent pediatric patients, nearly half of the annual incomes were less than $20,000, and 43%

did not have health insurance. Two out of three of them defined their child’s condition as acuity or high acuity, and half of them claimed that they had not previously received information about normal pediatric diseases (Kubisec et al.

2012). According to a previous study by Doan et al. (2014), from 2002 to 2011, the pediatric patient volume increased by 30%, and the hospitalization rate has remained at approximately 10% (Doan et al. 2014). This reflects the growing number of non-urgent patients, and it has led to the ED phenomenon called overcrowding. Related to the factors’ influence on care quality, it was found (Marcin et al. 2018) that patients’ age, sex, race/ethnicity, and payment source have not been related to care quality from the perspective of care process’

content. Instead, regarding pediatric patients’ chief complaints, fewer

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respiratory symptoms have been found to be associated with lower care quality when assessed by the content of the care. (Marcin et al. 2018.)

Emergency department’s staffing

A limited number of studies have focused on PEDs’ staffing (Alessandrini et al.

2011). Pediatric emergency care staffing should be based on the number of patients. Among other things, planning of adequate staffing can be difficult because of patient flow’s fluctuating. A previous study (Krinsky-Diener 2017) addressed the holiday seasons, especially the summer season, and compared the lower number of patient visits with other holiday seasons. In addition, on Thanksgiving and Christmas Day, fewer patients visited the ED compared to non-holiday times, as well as other holidays, and fewer patients visited in the evenings in particular (Krinsky-Diener 2017). Limited staffing in the ED has been found to impact pediatric patients’ care process. A study aiming to test modeling that identifies the times of staffing limitations by provider types (physician, nurse), established space, and limited staffing times were associated with significantly longer LOS. (Michelsson et al 2016.)

Table 1. Summary of studies according to pediatric emergency care structure (n=12)

Author,

country Purpose Methods Results

Benahmed et al. (2012)

Belgium

To evaluate pediatric patients’

ED low-acuity use and identify factors

related to it.

Observational prospective survey

from 12 EDs in Belgium; 2-week period in August 2010; data from 3,117 ED visits by

children.

40% of patients were not assessed as requiring hospital-level care, and

factors related to this were child’s age, ED proximity, existence of a family doctor, visiting after

office time, and family’s living area.

Gausche-Hill et al. (2015)

USA

To assess US EDs’

readiness for pediatric care patients and the impact of pediatric coordinators on ED

readiness.

A web-based assessment survey

(55 items) was sent to 5,017 nurse managers in

EDs; N=4149 assessments.

Weighted pediatric readiness scores varied according to the volume of pediatric patients. In a

low patient volume, EDs’

readiness score mean was 68.9, and in a high patient volume, EDs’ mean score was 89.8. The presence of

a pediatric coordinator increased the likelihood of

having all recommended components.

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Goldman et al.

(2018) USA

To explore general ED providers’

perceptions of caring for pediatric

patients.

Survey to 171 professionals (49%

nurses, 23%

physicians, and 22% technicians).

Regarding care for pediatric patients, professionals expressed

that it was difficult to maintain competency due to fluctuations in pediatric patients’ numbers. Also,

they reported having difficulties regulating their

emotions when caring for sick children. The quality and safety of pediatric

patients' care were perceived as lacking.

Hudgins et al.

(2017) USA

To compare pediatric patients’

severity in the PED and general ED

environments.

Cross-sectional register study;

national ED sample 2008–2012; data included 9.6 million

visits in a PED and 169 million visits in

a general ED.

The PED had a greater proportion of children under 1 year (18%), and encounters in the PED had

greater complexity and higher rates of hospitalization (10%).

Jaeger et al.

(2015) USA

To determine the proportion of ambulatory care

service (ACS) conditions treated

in EDs and patients’ billing

information of received care.

Register study; US nationwide ED sample of patients aged 0–19 years in the year 2010;

data from N=30 million patient

visits.

Of all ED visits, 13% were ACS conditions. Those patients presenting to the ED for ACS were assumed to have no insurance or to have public insurance, lower household income,

and a younger age.

Krinsky-Diener (2017)

USA

To determine if it is possible to predict the patient

volume in a PED on holidays and to

determine if the staffing and resource allocation

can be based on patient volume.

Retrospective register study; a total of 223,677 patient visits;

comparative analysis of the number of patient

visits during holiday versus

non-holiday periods.

The smallest number of patient visits (median=74)

was in the summer; in other seasons, the median

was 89–91 visits per day.

Holidays, especially Thanksgiving and Christmas Day, saw fewer

visits than during other times.

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Kubicek et al.

(2012) USA

To develop a descriptive profile

of parents/caregivers

who bring their children to EDs for

non-urgent reasons.

A survey study in the ED;

participants included 106 caregivers/parents

of children who were classified in an ED triage for a non-urgent level.

Of all caregivers, 49% of the annual incomes were less than $20,000, and 43% did not have health

insurance. 63% of participants described their child’s condition as urgent or very urgent, and

half of them reported not having information about basic childhood illness.

Reasons for ED visits included their perceptions

of high-quality care and convenience using the ED.

Marcin et al.

(2018) USA

To examine the quality of pediatric

care in EDs associated with

patient-level factors.

Retrospective cohort study; 620

patients’ (0–18 years) data, from

12 EDs; the provided quality of care was assessed using the implicit review instrument;

scores between 5 and 35 were given

for patients who received quality

care.

Patient age, sex, race/ethnicity, and payment source were not

related to the quality of care. Chief complaints and

fewer respiratory symptoms were associated with lower

quality of care.

Michelson et al. (2016)

USA

To test a model of staffing that identifies times of staffing limitation by provider types (physician, nurse).

Data from one PED; staffing data

(physician and nurse) from January 1, 2011, to December 31,

2012, and administrative

patient data.

Limited space and staffing times were associated with patients’ significantly

longer ED LOS.

Peeler et al.

(2016) Australia

To describe ED staff members’

perception of pediatric care reorganization, from general ED to

PED.

A descriptive qualitative study.

The used method was semi- structured interviews.

Participants included 10 members of the nursing staff and 8

The staff expressed fears regarding inadequate knowledge of pediatric

emergency care.

Training and clear communication supported

their transition in caring for pediatric patients in the new PED facilities.

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members of the medical staff.

Robinson &

Green (2015) USA

To examine the effect of the ambient PED environment (colorful lightning)

versus the traditional PED

environment.

Participants were caregivers (n=70)

and pediatric patients (n=70);

data included instruments, questionnaires, pain scales, and recorders of patients’ waiting

times.

In the ambient group, children rated lower pain

scores. In the ambient environment, caregivers

experienced a higher quality of care and the

possibility of involving themselves in their child’s

care better than in the traditional environment.

Caregivers in the traditional environment expected longer waiting times, felt more anxiety, and experienced more fear than caregivers in the

traditional environment.

Schroder et al.

(2016) USA

To assess structural pediatric care quality in EDs.

In a survey of 42 EDs in America, 22

PEDs participated in the study.

Participated PEDs had a high quality of care when

measuring the structural elements of care.

2.3.2 Pediatric emergency care process

In the previous study of existing ED quality measurements (Alessandrini et al.

2011), most of the measurements (67%) were categorized as process

measurements. The most commonly measured PED process indicators included the rate of LBTC patients and patients’ ED LOS (Alessasandrini et al. 2011).

Another process measurement that recent studies have used is the rate of return visits (RVs) to the ED (i.e. Augustine et al. 2018; Truong et al. 2017). In these quantitative studies, the process measurements have been treated as independent indicators of care quality or care efficiency, and the aim has been to find the explanatory factors for LOS in the patients’ related factors. Table 2 shows the characteristics of studies concerning the pediatric care process.

Pediatric patients’ emergency department length of stay

ED LOS is a routinely used measurement, which has been used to measure ED process efficiency. LOS, usually time in minutes, is measured from ED arrival at

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that ED LOS should be under 240 minutes, and any time over this period is considered prolonged ED LOS (Hofer et al. 2017). ED LOS of over 4 hours among pediatric patients has been found to be related to hospital admissions, the morning hour of attendance, and attendance in wintertime (Bekmezian et al. 2011). Also, prolonged LOS is related to pediatric patients with physician referrals, morning admissions, and gastrointestinal infections. Pediatric patients’

shorter ED LOS was related to their low-acuity triage level and having an upper respiratory infection. (Hofer et al. 2017.)

Patients who left before treatment completion

One measurement of the pediatric emergency care process is the rate of LBTC patients. That term describes all those emergency patients who exit the ED before receiving all elements of the care process (Alessandrini et al. 2011). The term LBTC was used in this study when describing patients whose care was not finished. The literature has also used the concept “left without being seen”

(LWBS), which has been used when describing the number of patients who leave the ED before examination by a physician or other medical professional, and the definition of the term varies by site (Doan et al. 2014; Gaucher et al.

2011).

The number of patients with LBTC proportions among low-acuity patient (CTAS levels 3–5) groups has progressively increased from 2% to as high as 7%, from 2002 to 2011, respectively (Doan et al. 2014). Factors that have been found to be related to pediatric patients leaving the ED without receiving care included a low-acuity triage class (CTAS levels 4–5), evening arrival to the ED, and attending with self-referral (Gaucher et al. 2011).

Pediatric patients’ return visits to emergency departments ED return visits (RVs) are used as ED process measurement. Usually, the number of RVs is measured either 72 hours from discharge (i.e. Augustine et al.

2018) or 7 days after ED discharge (Truong et al. 2017). When using the RV rate of one area, nearly 9% of all pediatric visits in Canadian hospitals were RVs over the course of a week (Truong et al. 2017). Parents/caretakers return to the ED because their child’s symptoms continue to worsen and they lack the knowledge to help him/her at home. In the parents’ opinion, during the first visit to the ED, more tests, treatments, medications, and information should be provided (Augustine et al. 2018).

Giving and receiving care information seem to be important factors influencing ED RVs. A previous study (Gallagher et al. 2013) focused on pediatric patients

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and their families who had limited English proficiency (LEP) and a higher risk for ED RVs than the English-speaking population (Gallagher et al. 2013). Hospitals with the highest RV rates were those whose population had lower household incomes and more likely governance insurance, as well as those with less staff specialized in pediatric medicine (Pittsenbarger et al. 2017). In the previous study (Alessandrini et al. 2011) of existing ED quality measurements, most of the measurements (67%) were categorized to be process measurements. The most commonly measured PED process indicators included the rate of patients who left without treatment completion (LBTC), patients’ ED length of stay (LOS). (Alessasandrini et al. 2011.) Another process measurement that is used in recent studies is the rate of return visits to ED (i.e. Augustine et al. 2018;

Truong et al. 2017). In these quantitative studies the process measurements have been treated as independent indicators of care quality or care efficiency and the aim has been to find the explanatory factors for LOS in the patients' related factors. Table 2. shows the characteristics of studies concerning the pediatric care process.

Table 2. Summary of studies according to pediatric emergency care process (n=9)

Author, year Purpose Methods Results

Alessandrini et al. (2011)

USA

To describe and categorize

existing performance

measures relating to pediatric emergency

care.

Survey of current literature (n=215), organizations’

web-pages (n=17), and organizations’

leaders (n=22).

A total of 405 performance measurements were found.

From IOM (2007) quality standards, most of the measures were related to ED effectiveness.

According to Donabedian’s quality model, 67% of measures were linked to the care process, 29% to the outcome, and 4% to

the structure.

Augustine et al.

(2018) USA

To identify parents’

reasons for bringing their child to revisit

the ED.

Survey of parents who brought their child to the ED within 72 hours of ED discharge;

convenience sample (n=72).

The main reasons for returning to the ED were a child’s symptoms continuing (92%) or

getting worse (70%), lack of parents’ knowledge with helping

methods at home, or not understanding their child’s illness

(569%). Parents thought that a larger number of tests (55%) and treatments (45%) should be done to the child at first ED visit,

and they also supported

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medication (41%) and giving more information (28%).

Bekmezian et al.

(2011) USA

To assess the prevalence of prolonged LOS

and search factors related

to it.

2001–2006 National Hospital

Ambulatory Medical Care

Survey data (N=2643 PED

visits).

Prolonged ED-LOS was found more frequently for admitted pediatric patients and

was associated with Hispanic ethnicity, ED visit during the winter season, and patients’

early morning arrival.

Doan et al.

(2014) Canada

To describe the trend of PED

use (patient volume and acuity) and find

the degree of overcrowding of PED by measuring LOS

and the number of

LWBS.

A cohort study with administrative data from the PED from 2002

to 2011.

Patient volumes increased by 30% within the 10-year study period. The hospitalization rate remained at approximately 10%.

Increased LWBS proportions among low-acuity triage levels of 2% to near 7% (CTAS3–CTAS5).

Patients’ ED LOS at all triage levels was increased during the

study period.

Gallagher et al.

(2013) USA

To compare RVs between

English- speaking patients and their families and patients with limited

English proficiency

(LEP).

Retrospective register study over 32 months

in the PED;

sample size included a total of 119,782 visits.

11.7 % of patients were with LEP. Out of English-speaking patients, the rate of RVs was 1.2%, and for patients with LEP,

it was 1.6%. Patients with LEP had a higher risk of ED re- admission than the English-

speaking population.

Gaucher et al.

(2011) Canada

To describe the factors related

to leaving the PED without being seen by

a physician (LWBS).

One-year 2008–

2009 case- control study;

PED administrative data (n=60,525)

of visits of patients 0–18

years old.

Patients’ LWBS-related factors were low-acuity triage class

(CTAS levels 4–5), evening arrival to ED, attendance with

self-referral, age between 3 months and 11 years, and living

near the hospital.

Hofer &

Saurenmann (2017) Switzerland

To search for factors related

to prolonged ED LOS.

Retrospective register analysis

of ED visits in one hospital for one year; 4,885

pediatric

Prolonged LOS was related to physician referral, morning admission, and gastrointestinal

infections. Inversely related to LOS were triage level 5 and upper respiratory infections.

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patients’ ED visits.

Pittsenbarger et al. (2017)

USA

To identify hospital-level factors related

to pediatric patients’ RVs

and RVs leading to admission in

EDs.

Multicenter mixed-methods

study (register and survey).

Participants were 24 hospitals*EDs.

Served populations of hospitals with the highest RV rate had lower household incomes, and

the hospitals had greater likelihood of governance insurance and lower pediatric

medicine specialist staffing.

Truong et al.

(2017) Canada

To measure the frequency of

pediatric patients’ RVs and describe those patients’

directional patterns.

Multicenter cross-sectional

study; 1-year sample of pediatric visits (n=139,278) in Vancouver area

EDs.

For 7 days after the first ED visits, nearly 9% of all visits were linked to RVs. RVs in PEDs

comprised 22% and those in general EDs 78%.

2.3.3 Pediatric emergency care outcomes

Previous literature regarding pediatric emergency care outcomes was found in two studies measuring adolescents’ satisfaction with care (Sefrin et al. 2012;

Rutherford et al. 2010) but not emergency care satisfaction of children under 13 years of age. Parents’ satisfaction with pediatric emergency care was studied in four quantitative studies (Macedo & D’Innocenzo 2019; Fitzpatric et al. 2014;

Byczkowski et al. 2013; Locke et al. 2011). ED staff’s perceptions of pediatric care quality were studied with both qualitative (Phonbruk et al. 2018; Peeler et al. 2016) and quantitative methods (Goldman et al. 2018). Studies are

described in table 3.

Children’s assessments of emergency care

In previous studies, adolescents felt that the quality of care they received at an ED was good (Rutherford et al. 2010, Shefrin et al. 2012). The single factor found to decrease satisfaction was the length of waiting time (Shefrin et al.

2012). Adolescents considered important aspects of their care to be the organization of separate waiting rooms for them and the ability to meet professionals alone (Shefrin et al. 2012), as well as the interaction with and appreciation of nursing staff (Rutherford et al. 2010). Adolescents’ satisfaction was not related to the patient’s triage level or LOS (Rutherford et al. 2010).

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communication and the comfort of their stay and shortening the LOS (Rutherford et al. 2010).

Parents’ assessments of pediatric emergency care

Locke et al. (2011) and Byczkowski et al. (2013) studied parental satisfaction with children’s ED care and found that satisfaction was enhanced by

collaboration between the physician and nurse (Byczkowski et al. 2013), responding to the needs of the family, and informing about delays (Locke et al.

2011) and shorter waiting times (Byczkowski et al. 2013; Fitzpatric et al. 2014).

The same situation was described in a study in Brazil where a longer waiting time decreased parents’ satisfaction with care (Macedo & D’Innocenzo 2019).

Also, the patient’s acuity level was found to be related to parents’ experience of their child’s care. Parents whose child was classified as semi-acuity were less satisfied with the care than parents of children who were classified as acuity or low-acuity (Fitzpatric et al. 2014).

Nursing staff evaluations of pediatric care quality

There is limited literature on nursing staff evaluations of pediatric care quality.

An Australian study (Phonbruk et al. 2018) with interviews of nurses identified barriers to pediatric patients’ care in parents’ understanding of discharge information. The nurses considered that factors in understanding instructions included difficulties with interaction, parental factors, lack of time and human resources in an ED, and lack of nurses’ skills. Nurses felt that a key factor in providing parents high-quality and useful guidance was their professional skills and previous work experience. (Phonbruk et al. 2018.)

A survey study (Goldman et al. 2018) of general ED staff members’

perceptions of caring for pediatric patients found that physicians and nurses had limited knowledge and skills for caring for pediatric patients and that they suffered emotional tolls from caring for sick children (Goldman et al. 2018). The same situation was established in an interview study (Peeler et al. 2016) pertaining to nursing and medical staff members’ major concern in moving from a mixed ED to a PED. The staff perceived that they didn’t have enough

competence and knowledge needed to provide pediatric care. After a

reorganization, the staff felt that pediatric patients were receiving better-quality care than they were earlier, that they had all the needed equipment for

pediatric care, and that children would not have to wait in the same area as adult patients. (Peeler et al. 2016.)

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Table 3. Summary of studies relating to pediatric care outcome (n=9).

Author,

country Purpose Methods Results

Byczkowski et al.

(2013) USA

To describe factors related to parents’

satisfaction regarding their child’s care in an ED

visit.

Telephone survey of parents with

structured and open questions

(n=2442);

statistical and content analysis.

Parents’ satisfaction with their child’s care was enhanced by

the collaboration between physicians and nurses, length of waiting time, and the child’s

pain management.

Fitzpatrick et al.

(2014) Australia

To evaluate parental perceptions of pediatric emergency care and satisfaction with care, triage,

and ED waiting times.

Survey with a structural instrument for parents (n=133);

data was analyzed with statistical methods.

Parents’ expectations of and satisfaction with their care were not primarily related to the LOS or the care received by their child. Instead, the triage level was found to be related to parents’ experience with their child’s care. Parents whose child was classified as semi-urgent were less satisfied

with the care than parents of children who were classified as

urgent or non-urgent.

Goldman et al.

(2018) USA

To explore general ED providers’

perceptions of caring for pediatric

patients.

Survey of 171 professionals (49%

nurses, 23%

physicians, and 22% technicians).

Professionals’ perceived care for pediatric patients was challenging due to pediatric patients’ numbers fluctuating.

Also, they reported bearing an emotional toll of caring for sick children. Participants found some deficiencies in the quality

and safety of pediatric patients.

Locke et al. (2011)

USA

To investigate whether a child’s

and parent’s communication with

professionals and the post-discharge

call are related to high satisfaction of

the parent.

Press Ganey satisfaction survey

of PED patients’

parents (N=456), and respondents’

electronic medical records.

Parental satisfaction included reporting delays in care, taking

into account the child’s needs, relieving pain, facilitating the insurance process, and calling home after discharge. ED LOS was not related to patient

satisfaction.

Pediatric care quality in emergency departments: a view of children, parents, nursing staff, and administrative data

KATJA JANHUNEN

PEDIATRIC CARE QUALITY IN EMERGENCY DEPARTMENTS

Dissertations in Health Sciences

uef.fi

KATJA JANHUNEN

PEDIATRIC CARE QUALITY IN EMERGENCY DEPARTMENTS

Katja Janhunen

PEDIATRIC CARE QUALITY IN EMERGENCY DEPARTMENTS

ACKNOWLEDGMENTS

LIST OF ORIGINAL PUBLICATIONS

CONTENTS

ABBREVIATIONS

1 INTRODUCTION

2 REVIEW OF THE LITERATURE

2.1 MOVING TOWARD QUALITY OF PEDIATRIC EMERGENCY CARE

2.2 PEDIATRIC EMERGENCY CARE

2.3 PEDIATRIC EMERGENCY CARE QUALITY