SGEM#278: Seen Your Video for Acute Otitis Media Discharge Instructions?

Date: December 13th, 2019 Reference: Belisle et al. Video discharge instructions for acute otitis media in children: a randomized controlled open-label trial. AEM December 2019 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and assistant Professor at the University of Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM. Case: An 18-month-old, previously healthy female presents to the emergency department with 24 hours of fever. The past few days the parents note there has been some rhinorrhea and cough. She looks well, immunizations are up to date and her examination reveals right sided acute otitis media (AOM). When discussing discharge instructions for her AOM, you wonder whether having the parents watch a video will be more beneficial for the child’s symptoms, rather than giving the parents oral instructions with a paper handout. Dr. Chris Bond Background: AOM is the second most commonly diagnosed illness in children and the most common indication for antibiotic prescription [1-2]. There are significant costs associated with AOM and parents often bring their children to health care providers for evaluation of pain and fever [3-4]. More than one third of children experience pain, fever or both three to seven days following treatment, and nearly seventy-five percent of parents identify pain and disturbed sleep as the most important sources of AOM related burden [5-6]. There is significant parental uncertainty regarding treatment of AOM and less than 30% of US parents receive instructions on appropriate analgesia for their children [7-8]. Discharge instruction complexity and inadequate comprehension is associated with medication errors, suboptimal post-discharge care and unnecessary recidivism [9-12]. Medication errors can be reduced using standardized discharge instructions, and parents prefer these to verbal summaries [13-15]. Video discharge instructions have been shown to be preferred over paper instructions in many pediatric presentations, however no study has explored the effectiveness of video instructions for AOM [16-17]. Clinical Question: Are video discharge instructions superior to a paper handout with respect to the Acute Otitis Media – Symptom Severity Score (AOM-SOS)? Reference: Belisle et al. Video discharge instructions for acute otitis media in children: a randomized controlled open-label trial. AEM December 2019 Population: Parents of children age 6 months to 17 years with a chief complaint of otalgia in the setting of URTI and where the treating physician was at least 50% certain of a clinical diagnosis if AOM. Diagnostic certainty was on a 100mm visual analog scale based on the physicians’ rate of color photos of AOM. Excluded: Parents who were not the primary care provider, had poor English proficiency, lacked internet or telephone access, and whose children had: a pre-existing diagnosis of AOM (<72 hours old); other concomitant diagnoses (pneumonia, urinary tract infection, gastroenteritis, sinusitis, or any other condition requiring antibiotics and/or hospital admission); tympanostomy tubes; acute tympanic membrane perforation. Intervention: Video discharge instructions Comparison: Paper-based discharge instructions identical to the video discharge instructions Outcome: Primary Outcome: AOM Severity of Symptom (AOM-SOS) score on day three post-discharge. Secondary Outcomes: Knowledge questionnaire scores, parental satisfaction with the intervention, number of days of missed school or daycare (child) and work (parent), proportion of children with at least one return visit to a healthcare provider, and proportion of children who received analgesia. Dr. Naveen Poonai This is an SGEMHOP episode which means we have the lead author on the show.  Dr. Naveen Poonai is a Paediatric Emergency Medicine physician at the Children’s Hospital, London Health Sciences Centre, Associate Professor of Paediatrics and Internal Medicineat Western University, Canadian Association of Paediatric Health Centres (CAPHC) project lead for Paediatric Pain Assessment, and has a cross-appointment with the Department of Epidemiology and Biostatistics. He was previously on SGEM#177 discussing POCUS for diagnosing pediatric fractures. This episode we are going to be talking about acute otitis media. There are a number of different guidelines out there for acute otitis media (Canadian Pediatric Society, American Academy of Pediatrics, American Association of Family Physicians, United Kingdom, and Australia) Naveen prefers the Canadian Pediatric Society guidelines. Canadian Pediatric Society algorithm for the management of AOM in children over 6 months of age. Authors’ Conclusions: "Children of parents with AOM who watched a five-minute video in the ED detailing the identification and management of pain and fever experienced a clinically important and statistically significant decrease in symptomatology compared to a paper handout.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The study participants were adequately randomized. Yes The randomization process was concealed. Yes The participants were analyzed in the groups to which they were randomized. Yes The study participants were recruited consecutively (i.e. no selection bias). No The participants in both groups were similar with respect to prognostic factors. Unsure All participants were unaware of group allocation. No All groups were treated equally except for the intervention. Yes Follow-up was complete (i.e. at least 80% for both groups). No All patient-important outcomes were considered. Yes The treatment effect was large enough and precise enough to be clinically significant. Yes Key Results: Overall, 5334 parents were screened for eligibility, 219 were randomized and analyzed and 149 completed the primary outcome (77 video; 72 paper instructions). Children included 107/219 (49%) females with an overall mean age of 2.9 years and 41/219 (18.7%) were not offered analgesia prior to arrival. There were no crossovers in the trial. AOM-SOS score was significantly lower on day 3 in the video group Primary Outcome: AOM-SOS score on day three (0 to 14 with higher scores indicative of greater symptom severity) 1 video group vs. 3 paper group (p=0.004) even after adjusting for pre-intervention AOM-SOS and medication use (analgesics and antibiotics) Secondary Outcomes:  There were no significant differences in secondary outcomes, including knowledge gain, functional outcomes or the number of children receiving antibiotics or analgesics following discharge. 1. Children:You included children age 6 months to 17 years of age. There is a big difference between an infant and a teenage. Why not just limit it to children under 5 years old? The mean age was 2.9 years with a SD of 2.8 years. It is true that a young child is quite different from a teenager.  We decided to cast a wide net to be more instead of less inclusive.  Older children suffer from AOM as well and inclusion of these individuals extends the generalizability of our findings. 2. Diagnosis of AOM: The diagnosis of AOM can be a bit tricky. You included patients that the physician was 50% certain of a clinical diagnosis of AOM using a 100mm visual analog scale. That was based on color photos of AOM from published diagnostic criteria. Why not use a more objective criteria like tympanometry or acoustic reflectometry to increase diagnostic certainty? In an ideal world we would have been able to use tympanometry or acoustic reflectometry, however these tools are unfortunately not available in our emergency department. 3. Convenience Sample: Recruitment was done seven days a week from 10am to 10pm. We understand the realities of conducting research and having someone available 24 hours a day. However, do you think parents that present overnight with sick children a different than those who present during the day? It is possible that children that present in the middle of the night are experiencing more pain than those that present during daytime or evening hours. But is more likely that the pain they are experiencing is disruptive to their sleep and perhaps more so, their parents’ sleep. Parents that present with their child overnight may process discharge information quite differently from daytime hours. 4. Single Tertiary Pediatric Centre:This was a single centre study done at a pediatric emergency department. Do you think this data can be extrapolated to other pediatric emergency departments in Canada or internationally? I think that this data can certainly be extrapolated to other Canadian pediatric emergency departments as other tertiary care pediatric centres are likely to have populations similar to ours. However further study would have to be undertaken to determine if the data would be applicable to international populations of differing languages and cultures.  We excluded non-English speaking populations for feasibility purposes and so this study would have to be repeated including those speaking other languages to be able to confidently say the data apply more broadly. In addition, I work in a rural community emergency department. We see adults and children. Do you think these results would apply to non-pediatric emergency departments? I think these results would definitely apply to rural community emergency department pediatric patients of English speaking families. 5. Education Level: The parents in your study were well educated. More than 70% had at least a college education. How do think this could have impacted your results? I think this may have contributed to the reason we saw no difference in knowledge acquisition between groups.