a b s t r a c t

Objective: Despite growing interests in patient-reported outcomes, youth and families are rarely involved in de- signing quality improvement measures. Few quality indicators exist for the care of children with injuries in the Emergency Department (ED) and extremity fractures are among the most common injuries in children. This study’s aim was to identify both parents’ and youth’s perspectives about ED care in the context of a suspected Long-bone fracture.

Methods: Youth (10-18 years old) and their parents were surveyed prospectively during their ED visit. Partici- pants were asked: 1) to identify their main concerns, 2) to identify quality measures that were most important to them, and 3) to evaluate the ED care they received. Descriptive analyses present participants’ responses. Continuous data was analyzed using a Student t-test and categorical data using a Chi-square test.

Results: Over 15 months, 350 families met eligibility criteria and were approached to participate, of which 300 participants consented and 249 surveys were completed (71% response rate): 148 parents and 101 youth (me- dian age: 12) completed their respective surveys. Participants placed a high importance on several themes: pain management, short length of stay, and quality interactions with ED clinicians. Youth as a group prioritized their overall wellbeing and the ED environment (e.g., waiting room comfort, signage), while parents focused on accurate diagnoses and treatments. The following items were less prioritized: that radiology be close to the ED, to see the radiograph, to have access to a wheelchair, to know the identities of clinicians on the team, and to have access to entertainment. Parents and youth within the same family often did not share the same priori- ties. Ninety-two percent of parents reported their child’s pain was treated, while 81% and 63% of youth reported their pain was treated sufficiently and quickly, respectively.

Conclusions: Parents and youth can identify their priorities for ED care and should be engaged in efforts to im-

prove and report on the quality of care in the ED. Youths’ and parents’ perspectives are complimentary and may not align, even within families. The priorities identified in this study can help inform quality improvement initiatives and personalizED patient care.

(C) 2022

Abbreviations: ED, Emergency Department; GCS, Glasgow Coma Score; CTAS, Canadian Triage and Acuity Scale.

* Corresponding author at: Universite de Montreal, Sainte-Justine Hospital, Department of Medicine, Division of Pediatrics, 3175 Chemin de la Cote-Sainte-Catherine, Montreal QC H3T 1C5, Canada.

E-mail address: [email protected] (N. Gaucher).

1. Introduction

long-bone fractures are treated daily in the pediatric emergency department (ED). Each year, one in four children will sustain an injury requiring medical attention, and up to 25% of these injuries will be frac- tures [1,2]. Quality indicators for pediatric trauma care are rarely

https://doi.org/10.1016/j.ajem.2022.12.005

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studied and usually derived from adult studies [3,4]. However, defining quality can be complex as it comprises many topics, including Clinical performance and outcomes, patient safety, and patient satisfaction. Families and clinicians may have different perspectives, and parents’ priorities may differ from children, even within the same family. To date, in the pediatric ED literature, very few quality measures address patient-centered outcomes [4,5]. Studies have begun including parents’ perspectives in the development of quality measures, but none have in- cluded the voice of children [6]. Investigating patient-centered out- comes and including youth in quality improvement initiatives has been found to be essential to Optimize patient care [7,8]. For this reason, developing quality indicators based on parents’ and children’s perspec- tives is imperative. The objective of this study was to identify both par- ents’ and youth’s priorities and perspectives about the quality of their ED care when presenting with suspected long bone fracture. We hy- pothesized that some priorities would be important to all stakeholders while others may differ from one family to another or within the same family.

1. Methods
   1. Study design and setting

This prospective study examined both parents and youth who pre- sented to the ED of a tertiary care pediatric university-affiliated regional trauma referral center (85,000 annual visits) for upper or lower limb in- jury with suspected long bone fracture.

• 1. Participants

All families of children presenting with a chief complaint of upper or lower extremity trauma with suspicion or confirmed fracture were eligi- ble to participate. Given that most patients do not present to the ED with an established diagnosis, participants were recruited based on their chief complaint (injury and suspected fracture) to prospectively gather data on their ED visit experience, and to identify their priorities in the care of suspected or confirmed long-bone fractures throughout their ED visit. Inclusion criteria were: 1) parents of a child with suspected or con- firmed long-bone fracture at triage or by physician assessment (includ- ing more than one injury); 2) injured children between 10 and 18 years old; 3) ability to read English or French. Exclusion criteria were:

1) clinical instability defined as requiring trauma team activation, ICU ad- mission, GCS < 15, or multiple Organ injuries; 2) suspected non- accidental trauma; 3) open fracture; 4) healthcare conditions affecting fracture management (e.g., osteogenesis imperfecta, hemophilia).

• 1. Procedure

After triage, potential participants were approached by a research assistant who explained the study and obtained signed consent for those interested. The survey was designed on the REDCap electronic capture tool hosted at CHU Sainte-Justine and completed on an elec- tronic device (either the participant’s own device or a device provided by the research team) during the ED visit [9].

Consenting participants completed the questionnaire in a three-step prospective fashion throughout their ED visit: 1) Immediately after tri- age, parents and children were asked to report their main concern and to list up to three things most important to them (open-ended ques- tion); 2) then, they were asked about their ED care priorities; and

3) at the end of the ED visit, they were asked to evaluate their care.

• 1. Questionnaire development

The prospective questionnaire gathered information from parents and youth throughout their ED visit with three main aims: 1) to identify their main concerns, 2) to identify quality measures that were most

important to them, and 3) to evaluate the ED care they received. Similar topics were addressed in different ways to triangulate and validate our findings internally. Two questionnaires were designed using grade 6 level French and English: one for youth and one for parents.

An extensive list of all quality indicators was developed using a two- step process. Independently, two stakeholder groups produced their list of quality indicators: 2 parents who had consulted for fractures in their children (the study’s parent-partners), 5 youth who had consulted the ED for various reasons. To facilitate their work, stakeholders were instructed to list all items in 8 domains reported as important to families consulting the ED [10]: 1) emotional support; 2) coordination; 3) elicit and respect preferences, and involve the patient and family in care de- cisions; 4) timely and attentive care; 5) information, communication, and education; 6) pain management; 7) safe and child-focused environ- ment; and 8) continuity and transition. Using the stakeholders’ lists and based on a review of the literature, a preliminary extensive list of poten- tial quality indicators was then developed by a team of 7 ED nurses and physicians (with experience in trauma, pediatric emergency care and quality assessment). This list comprised 98 potential quality indicators. By generating indicators through this two-step process, content and face validity was ensured [11,12]. This list was used to develop the final list of indicators to assess using a modified Delphi method. During 2 interdisciplinary meetings, clinical researchers and parent-partners co-developed the questionnaires. Quality indicators judged essential in the literature and those that were important to all team members were maintained. Items addressing similar topics were grouped in over- arching themes. Finally, the indicators were transformed into questions, all with the introduction: “In your opinion, how important is ?” The parent questionnaire listed 25 potential indicators, while for children it inquired about 17 indicators (some questions are not asked for chil- dren, for example missing workdays or the impact on the family as a whole). Participants were asked to assess the importance of each item on 4-point Likert scales.

To ensure the survey could differentiate between the relative impor- tance of these various quality indicators, skip-logic was used to rank items identified as “important” or “very important”. Parents were asked to identify the 3 indicators most important to them among their list of important indicators. A simpler approach was used for children who were asked to rank 5 quality indicators in order of priority. A score was assigned for each response, as per ranking. For parents, items ranked first, second and third were assigned scores of 3, 2, and 1, respectively. For youth, items ranked first, second, third, fourth and fifth were assigned scores of 5, 4, 3, 2, and 1, respectively.

Because this questionnaire was not externally validated, to triangu-

late our findings, the survey also included two open-ended questions that were asked to participants upon arrival in the ED: 1) their main concern, and 2) to list up to three things most important to them.

Participants were also asked to evaluate the care their family re- ceived throughout their ED visit by answering yes or no questions. Over- all satisfaction was captured on a 100 mm visual analog scale. Both surveys are provided online.

The surveys were pre-tested using cognitive interviews with 26 pre- test participants (12 youth and 14 parents). This validation process en- abled final adjustments in the questionnaires and skip-logic sequence, and generated two items that were included in the survey. The ED ques- tionnaire took on average 15 min to complete during pre-testing.

Patients’ medical records were reviewed to extract basic demo- graphic information, such as age, gender, and clinical information in- cluding whether the child was referred to the ED for suspected fracture or management of a confirmed fracture, final diagnosis, and ED disposition.

• 1. Sample size

We estimated that obtaining the opinions of 100 parents and 100 youth regarding their experiences of ED care would represent a

sufficient sample to gain initial insights in this unexplored field. In- deed, we calculated that if the expected response distribution for a given question was assumed to be 50%, 100 respondents would be needed to have a 10% margin of error for measured responses, with a 95% confidence interval, which we estimated would be sufficiently precise for this exploratory study. To account for seasonal variations in ED crowding, which influence the ED experience, we recruited a convenience sample of youth and parents over a 15-month period, from 8 am to 8 pm, 7 days per week, until the sample sizes for both youth and parents were attained.

• 1. Data analysis

All data was collected into an Excel database (Microsoft Inc., Rich- mond, VA) and analyzed using SPSS v.20 (IBM Inc.). Descriptive anal- ysis generated frequencies of answers for individual quality indicators. For the parents’ ranking of indicators, a score was gener- ated to reflect the overall importance of each indicator: items with a priority of 1 were given 3 points, items with a priority of 2 were given 2 points, items with a priority of 3 were given 1 point. A similar technique was used for the youth’s prioritization question (on a maximum total of 5 points). Independent samples t-tests were per- formed to compare youths’ and parents’ mean measures of satisfac- tion with their ED care (on a 100 mm visual analog scale) to independent categorical variables regarding their ED care. Continu- ous data was analyzed using a Student t-test. Categorical data was analyzed using a Chi-square test.

Answers to short open-ended questions were analyzed using the- matic analysis. Codes were identified by the principal investigator (NG) and frequencies of responses reported.

• 1. Ethics

The study obtained ethics approval from the institution’s research ethics board. Parents and youth were approached together as a family unit. Parents’ written informed consent was obtained when children

<14 years old agreed to participate. Youth 14 years old and older consented themselves to participate in this minimal risk study. Parents and youth over the age of 14 from the same family independently chose to participate in this study. Within each family, a parent, the youth pre- senting to the ED, or both could consent to participate in the study. In some cases, both youth and their parent participated, while in others parents or youth participated. Participants did not receive compensa- tion for participating in this study.

1. Results

From March 2018 to June 2019, a convenience sample of 432 fami- lies were screened for inclusion in this study; 350 families met eligibility criteria and were approached to participate in the study. Of these, 300 participants consented to the study (175 parents and 125 youth), and 249 surveys were completed (71% response rate): 148 parents and 101 youth completed their respective surveys. In 189 of cases, at least one member of the family participated; in 60 families, both parents and youth participated. Participants’ demographic characteristics and ED visit characteristics are presented online (Supplementary material). Two families completed the survey but left before seeing the ED physi- cian; their data was included in the analysis.

• 1. Answers to open-ended questions

Following triage, all participants were asked the three things that were most important to them and their main concern in open-ended questions. Participants answered in their own words without being prompted to potential answers. The main themes invoked are reported in Tables 1a and 1b. Two main themes were invoked by participants: youth-centered answers and/or ED-oriented answers. Many sub- themes were present in both parental and youth answers, such as pain management; but to differing degrees. Some themes were only present in youth’s answers, such as the impact on their personal activi- ties, which was a main concern.

• 1. Most important items

Table 2a presents the five items identified as “Very important” most often by parents and youth, respectively. Both groups reported pain management and quality interactions with clinicians (e.g., trust, feeling listened to, having questions answered) as most important. Parents pri- oritized short ED visits, while children favored clear signage in the ED. Most items were judged as important, and the items identified most often by parents and youth as “not important at all” or “not important” were similar (Table 2b), these five items were nonetheless often consid- ered important or very important by a majority of responders. Even within the same family, parents and youth did not always agree on the importance of different items (online).

• 1. Ranking of top quality of care items

Fifteen items were considered a top three priority by at least one parent (Table 3); of these fifteen, the first three were: 1) that the visit be as short as possible, 2) that their child’s pain be treated, and 3) to

Table 1a

Three things most important to parents and their main concerns (148 parents).

Main themes Things most important (n = 436) Main concerns (n = 142)

		%	Example		%	Example
Youth-centered	Health and healing	8	“My child’s wellbeing“		22	“That my child has a fracture“
	Long-term outcome	-	-		32	“How the injury will heal“
						“Know the impacts of the injury on his growth and sport“
						“How will he live with a cast“
ED-centered	Minimal delays and short visit	30	“See the doctor ASAP“		21	“To have to wait several hours in the ED“
	Best quality care and treatment	28	“The quality of care received“		-	-
			“Make sure she is properly diagnosed“
			“Obtain X-Ray quickly“
	Quality interactions	17	“Compassion“		-	-
			“Empathy“
			“Professionalism“
			“That the physician take the time to explain to me well“
	pain treatment	6	“Stabilise and control pain“		9	“Too long a wait for children in pain“
	Clean environment	6	“Cleanliness“		-	-
None		-	-		11	“None“
Other		5	-		5	-

Table 1b

Three things most important to youth and their main concerns (94 youth).

Main themes Things most important (n = 280) Main concerns (n = 94)

		%	Example		%	Example
Youth-centered	Health and healing	33	“Getting better“		33	“That my bone be broken“
			“To know if it’s a severe fracture or not“
	Loss in leisure, sport, and school	13	“To know if I’ll get the doctor’s Ok to go back [to sports] in the fall“		16	“That I won’t be as competitive in my sport“
			“The government exams“
			“My friends“
	Long-term outcomes	-	-		25	“To have a chronic problem after my injury“
						“Will I need to keep using crutches?“
ED-centered	Minimal delays and short visit	14	“I think it’s important to have the shortest wait time possible“		-	-
	Pain treatment	12	“To have the least amount of pain possible“		11	“That it hurts a lot for a long time“
	Best quality care	7	“To be cared for well“		-	-
	Quality interactions	5	“That all workers be nice to patients at all times“		-	-
	Family presence	6	“To be with my family“		-
	Other	10			15

Table 2a

Five items most often assessed as “Very important” by parents and youth (among 25 items for parents and 17 items for youth).

Items assessed for importance Very

important (%)

• 1. Evaluation of ED care

On a 100 mm visual analog scale, parents and youth reported very high satisfaction with the ED visit [Median in mm (Interquartile rage): 88 (79;95) and 81 (74;96), respectively]. Parents and youth assessed the quality of the care they received in the ED (Table 4). Ninety-two per- cent of parents reported their child’s pain was treated, while 81% and

Parents’ responses

Youths’ responses

That you trust the ED healthcare team? (n = 146) 93

To receive clear information about your child’s health 92

problem (diagnosis and treatment)? (n = 117)

That your visit to the ED be as short as possible? 91

(n = 148)

That the ED healthcare team answer your questions? 90

(n = 148)

That the ED healthcare team treat your child’s pain? 90

(n = 114)

That we treat your pain well and quickly? (n = 92) 90

To feel listened to by the people taking care of you? 88

(n = 81)

That the signs to get around the hospital be clear? 85

(n = 97)

63% of youth reported their pain was treated sufficiently and quickly, re- spectively. Adequate pain treatment as reported by parents was not as- sociated with a difference in satisfaction [mean difference (95% confidence interval): -2 (-14;10)], neither was sufficient pain treat- ment as reported by youth [-5 (-16;6)]. However, youth reporting that their pain was treated fast enough was associated with an increase in youth satisfaction [9 (1;18)]. There was no correlation between length of stay and caregiver or youth satisfaction, but reporting that the ED visit lasted longer than expected was associated with a decrease in satisfaction for youth and parents [-13 (-19;-6) and -18 (-25;

-10), respectively]. Parental median satisfaction and median ED length

of stay did not differ if families were referred to the ED nor if the parent

That we answer your questions? (n = 82) 84

That we talk to you and explain to you what is going on 80

(and not only to your parents)? (n = 80)

receive clear information about their child’s diagnosis. Ten items were not included in parents’ priorities, for example: to know the side effects of medicine administered; that the signage to radiology be clear; that the ED visit be organized; to have frequent updates on wait times; that radiology be close; to see their child’s radiograph; to be informed as soon as their child can eat. Seventy-seven youth ranked 5 items in the following order of priority: 1) that their pain be treated, 2) that their visit be as short as possible, 3) that they be informed as soon as possible to eat and drink, 4) to stay with their parents at all times, and 5) that there be enough entertainment in the ED waiting room.

worked in healthcare.

1. Discussion

This study provides insight into parents’ and youth’s priorities when presenting to the pediatric ED for extremity trauma and suspected long bone fracture. To our knowledge, it is the first study to explore this topic. Our study is unique in that it sought not only parents’ views but also youth’s perspectives of their own ED care, and triangulated the results of standard survey items with open-ended unbiased respondents’ an- swers. Overall, top priorities for parents included length of stay and pain management, as well as key elements of high-quality interactions with clinicians, such as trust, clear communication, and answers to questions. Youth’s priorities included pain relief, ED length of stay,

Table 2b

Five items most often assessed as “Not important at all” or “Not important” by parents and youth (among 25 items for parents and 17 items for youth).

Items assessed for importance Not important at all/

Not important (%)

Important (%)

Very important (%)

Parents’ responses	That ED and radiology be close? (n = 89)	35	47	18
	That there be ways to entertain your child while waiting in the ED? (n = 148)	25	45	30
	To see your child’s radiography? (n = 88)	22	35	43
	To know who are the different members of the healthcare team and their roles? (n = 148)	20	44	36
	That wheelchairs be available at all times? (n = 147)	14	30	56
Youths’ responses	To know who the different people taking care of you are? (n = 96)	38	36	26
	To have access to wheelchairs all the time? (n = 96)	24	24	52
	That the ED and radiology be close (n = 58)	21	40	38
	That there be entertainment while you wait in the ED? (n = 99)	18	46	35
	To see your radiography (X-ray, picture)? (n = 56)	16	36	48

Table 3

Parents’ priorities.

Item	N	Priority 1	Priority 2	Priority 3	Overall score
That the visit to the ED be as short as possible	157	53	19	20	217
That the ED healthcare team treat their child’s pain	72	47	18	7	184
To receive clear information about their child’s health problem	71	28	30	13	157
To be allowed to stay beside their child throughout the ED visit if they so wish	63	19	27	17	128
To trust the ED healthcare team	52	27	18	7	124
To be informed of the different steps of their ED visit	49	10	18	21	87
That the ED healthcare professionals work together as a team to treat their child	44	14	13	17	85
That the ED healthcare team answer their questions	41	13	12	16	79
To be listened to by ED healthcare professionals	26	3	10	13	42
That wheelchairs be available at all times	18	6	4	8	34
That the signage to get around the ED be clear	17	3	6	8	29
That the ED healthcare team talk to their child and explain treatments to them	19	2	5	12	28
That the ED waiting room be comfortable	16	0	10	6	26
That there be ways to entertain their child while waiting in the ED	10	3	4	3	20
To know who are the different members of the healthcare team and their roles	3	0	3	0	6

long-term recovery, quality interactions with the healthcare team, and items that have an impact on their personal life (e.g., involvement in sport, leisure, and school).

Our findings suggest that institutional quality improvement initia- tives should also be interested in improving measures that are impor- tant to most stakeholders. Some of these measures are more readily available and can be measured and tracked (e.g., the Administration of analgesia, length of stay, signage). Others require asking patients and their families (e.g., feeling listened to and trusting the healthcare team). In a 2011 review of pediatric emergency quality indicators, Alessandrini et al. found that most measures were concerned with

effectiveness, while only 5% were family-centered [4]. Similarly, a list of Canadian pediatric emergency quality measures focused on measures of effectiveness, but considerations about staff-patient interactions were absent [13]. One survey has been developed to assess the quality of family-centered care in pediatric emergency medicine, but this mea- sure only applied to parents [14]. Recent efforts have led to the develop- ment of patient-reported outcome measures for adult EDs [15-17]. It is fundamental to consider all stakeholders’ perspectives (clinicians, par- ents, and children) when seeking to improve pediatric ED care [18]. Children have rarely been involved in studies regarding their ED care preferences [19-22]. In fact, we believe this to be the first study of its

Table 4

Parents’ and youths’ experiences of their ED visit.

Themes	Items assessed	Parents	Youth
		(%)	(%)
Length of stay and structure	Length of ED visit:
	- Longer than expected	56	72
	- Shorter than expected	43	27
	They were informed of wait times repeatedly during the ED stay	33	32
	The ED visit was as short as possible	58	-
	They were informed of the different ED visits’ steps	72	61
	The ED visit was well organized	89	-
	They were notified quickly once allowed to eat/drink	68	-
Pain	The ED team treated their child’s pain	92	-
	Was their pain treated well enough	-	81
	Was their pain treated quickly	-	63
ED and hospital	Ways available to distract/entertain while waiting	71	66
	Waiting room was comfortable	68	75
	Wheelchairs were accessible at all times	78	85
	Signage to get around ED was clear	74	89
	Signage to get to radiology was clear	72	-
ED team - family relationship	Amount of information received on diagnosis or health problem: - No information	3	4
	- A little information	11	16
	- Enough information	81	75
	- Too much information	5	4
	They knew the different members of the healthcare team and their roles	61	33
	They felt listened to by the ED team	92	100
	The ED healthcare team answered their questions	94	96
	The ED team spoke directly to the child and explainED treatments	97	89
	They saw their radiograph	38	39
	The ED team reassured their parents	-	90
	They trusted the ED healthcare team	95	-
	Parent was involved in the child’s care, as much as would have liked to be	90	-
	They were allowed to stay beside their child throughout the ED visit, if wished	92	-
	The ED healthcare professionals worked as a team to treat their child	92	-
	They received information about potential side effects of medicines being given to ir child	61	-
	They received clear information about their child’s health problem	87	-
	They received information on how to treat their child’s pain at home, after their ED visit	80	-
	They received information about how to take care of their child at home, after their ED visit	50	-

kind in the pediatric ED. Youth as young as 10 years old were willing to participate and provided essential insights into their ED care priorities and experiences.

Consensus on several potential quality measures could not be achieved. Indeed, the 5 items least important to both youth and parents were nonetheless reported as very important by up to 50% of other re- spondents. While some items are important to all, such as pain manage- ment and Waiting times, others need personalized interactions with clinicians. Institutional quality improvement initiatives should focus on improving those priorities most important to all. Nonetheless, par- ents and children are all different. Comparisons between caregiver and youth pairs found that youth and their parents do not always agree on the relative importance of various items. Differences in care priorities have been described in studies of parent/youth pairs in outpa- tient clinics [23]. It is important to personalize care during ED visits by asking patients and their parents what matters most to them (e.g., wheelchairs, seeing radiographs, etc.), while using this informa- tion to improve the ED environment. Clinicians can ask parents ques- tions such as “some parents and children want to see the pictures of the fracture on the x-ray, it helps then understand what is happening, while for others this is not very important. Would you want to see the x-ray?” Addressing children’s concerns regarding their long-term out- comes and functioning in school, leisure, and sport is essential.

Pain management is a well-recognized metric for assessing the qual-

ity of ED care and was a top priority for all participants in our study. De- spite clear protocols in our ED, many children reported their pain was undertreated or not treated fast enough, and this was associated with a decrease in satisfaction with care. In contrast, most parents reported their child’s pain had been treated and this was not associated with a difference in satisfaction. Ali et al. also found that parents reported sat- isfaction with their ED care even when their child reported persistent severe pain, following musculoskeletal injuries [24]. These findings highlight the importance of using well-validated, age appropriate pain scales to measure pain directly with patients, and to not rely on proxy evaluations of pain [25]. These findings also highlight the importance of continuous quality improvement initiatives to improve pain manage- ment in the pediatric ED, especially in the context of injuries, as demon- strated by previous initiatives [26]. Similarly, overall length of stay was not associated with satisfaction, but perception that the visit was longer than necessary was, suggesting that keeping patients and parents in- formed of the steps and delays during ED visits likely improves satisfac- tion with the ED visit. Patient satisfaction measures of their care are not necessarily associated with the provision of care consistent with ac- cepted standards of care [27,28]. Asking pediatric patients about their experiences is essential [29].

Although an important first step in identifying families’ priorities in pediatric ED trauma care, this tertiary care single center study’s re- sults may not be applicable to all settings. Surveys were distributed to all interested eligible participants, with a high response rate, but parent respondents were overall highly educated and many worked in healthcare; this may have caused a bias in the answers collected, a frequent concern in survey studies. Although not all patients had a final diagnosis of fracture, they almost all had an x-ray as part of their management, indicating that our sample represented a group of patients in whom fracture was suspected, a frequent and impor- tant patient presentation in the pediatric ED. Because of the high response rate, the results of this study adequately reflect the per- spectives of families who come to our ED with suspected long bone fractures and likely reflect those of families seeking similar care in other pediatric EDs. It is possible that it may not reflect all the con- cerns families have in different countries. As the survey used in this study was not externally validated, to triangulate and validate our findings internally, participants’ priorities were sought through three different parts of the survey: importance on Likert scales, prior- itization of items, and open-ended items. Overall, youth and care- givers prioritized similar items throughout the survey.

1. Conclusions

Parents and youth can identify their priorities for ED care and should be engaged in efforts to improve and report on the quality of care in the ED. Youths’ and parents’ perspectives are complimentary and may not align, even within families. It is essential to personalize ED care to indi- vidual patients and their families. The priorities identified in this study can help inform quality improvement initiatives and personalized pa- tient care.

Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2022.12.005.

Funding

This study was funded by a research grant from the Programme de Subvention pour la Recherche en Trauma Pediatrique awarded by the CHU Sainte-Justine du Comite de Traumatologie et de la Fondation Sainte-Justine.

Role of funder/sponsor

The funder/sponsor did not participate in the work.

CRediT authorship contribution statement

Nathalie Gaucher: Writing - review & editing, Writing - original draft, Visualization, Validation, Supervision, Software, Resources, Pro- ject administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Evelyne D. Trottier: Writing - review & editing, Supervision, Methodology, Investigation, Funding acquisition, Conceptualization. Zainab Ridha: Writing - review & editing, Writing - original draft, Formal analysis, Data curation. Francois Simard: Writing - review & editing, Methodology, Funding ac- quisition, Conceptualization. Brenda Duran: Writing - review & editing, Investigation, Funding acquisition, Conceptualization. Celine Pinard: Writing - review & editing, Methodology, Investigation, Funding acqui- sition, Conceptualization. Guylaine Larose: Writing - review & editing, Methodology, Investigation, Funding acquisition, Conceptualization. Michael Arsenault: Writing - review & editing, Methodology, Investi- gation, Funding acquisition, Conceptualization. Antonio D’Angelo: Writing - review & editing, Resources, Investigation, Funding acquisi- tion, Conceptualization. Annie Janvier: Writing - review & editing, Writing - original draft, Supervision, Methodology, Investigation, Funding acquisition, Formal analysis, Conceptualization.

Declaration of Competing Interest

The authors have no relevant conflicts of interest to disclose.

Acknowledgements

The authors would like to thank the youth and families who took the time to participate in our study.

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