By Maria Sarrouh

(December 14, 2020) – Stickers, crayon packs, comfort positions and consent; these are just a few of the ways the assessment centres at St. Michael’s and St. Joseph’s have adapted their COVID-19 testing protocols for children.

A COVID-19 test can intimidate anyone. But walking into a hospital full of people wearing yellow gowns, face shields and gloves can be particularly scary for kids.

“It’s important that the experience isn’t traumatizing,” said Sarah Mattok, a Care and Transitions Facilitator at St. Michael’s who worked with the assessment centre to adapt it to young people. “The child might have to go through the test again, so we don’t want them to remember it as something terrible. We want to do everything we can to make it more comfortable.”

Staff have worked to make the space more welcoming to children since mid-August, when the St. Michael’s Assessment Centre began seeing more young people as schools prepared to re-open. They decorated the walls of testing booths with stickers of alphabets, animals, planes and trains – a way to establish rapport with children and help distract them from the difficulty of the test.

On Halloween, children walking into St. Michael’s COVID-19 Assessment Centre found the staff’s yellow medical gowns decorated to look like Minions costumes, another effort to make the testing space more welcoming.

“It’s something for the children to look at and concentrate on, and helps make the space less sterile and hopefully less intimidating,” said Mattok.

Staff also worked with the Centre for Clinical Ethics (CCE), realizing that families could face challenges, including daycare costs and missed work, if their children were too afraid to be tested.

“We tried to put in place all the mechanisms we could so testing would be less intimidating, and families wouldn’t be put in a more difficult position,” said Dr. Jamie Robertson, a Clinical Ethicist at the CCE who serves Unity Health Toronto.

For toddlers or school age children, parents are now asked to hold their children in their lap or sit directly next to them, helping to hold their arms gently out of the way. This is an example of “comfort positioning”, a technique that can prevent injury during the procedure.

“It’s not a comfortable test. Even when I had it done, I wanted to yank the nurse’s hand away,” said Dr. Robertson. “To expect a five-year-old to go through it without some extra help and physical support is asking a lot.”

Parents who indicate their child is coming for testing also receive a resource document with tips on how to talk to their children about the test, and explanatory videos from the B.C. Children’s Hospital and SickKids. There’s also a link to a “social story”, a form of sharing information with children with autism spectrum disorders by describing a situation through pictures and relevant social cues.

Mattok recommends that parents speak honestly with their children, use simple words and not mislead them about the test.

“Don’t say it’s not going to hurt. Say that staff will do their best, but it’s possible it’ll be uncomfortable, and it’ll be over quickly,” Mattok said.

But what happens if a child refuses a COVID-19 swab? This is a question staff have considered since children first began walking into the assessment centre. There is no stated age of consent for health care treatment — including tests — in Ontario. According to the Health Care Consent Act, minors that are deemed capable of understanding treatment information and reasonably foreseeable consequences are able to make their own treatment decisions.

When children are unable to do this, parents must make the decision on their behalf, taking the children’s views and best interests into account. If parents are able to engage children in an age-appropriate way to gain their cooperation, the test can be performed safely and ethically. However, Dr. Robertson explained if a child can understand the process of the nasal swab and the implications of the test, they are within their legal right to refuse it.

“If they say ‘no’, that has to be the answer,” Dr. Robertson said. “We have to respect that, even though that’s a hard thing for parents to understand.”

At St. Joseph’s COVID-19 Assessment Centre, children are gifted an “activity kit” packed with crayons, puzzles and toys as a reward for undergoing the test. The kits were donated to the hospital by the Starlight Children’s Foundation.

“They’re going through them in leaps and bounds,” said Tina Allain-Rooney, Assistant Patient Care Manager for the Women’s and Children’s Program at St. Joseph’s.

The Paediatrics team decided to redeploy two nurses to the testing centre every shift for the month of October to serve as “in-person resources” for staff members less familiar with providing health care to children.

“There were many shifts when the nurses redeployed to the testing centre from departments that focus on adult health care would request support from physicians for pediatric swabbing,” Allain-Rooney said. “Many weren’t comfortable doing it.”

To further ensure staff members were prepared to test children, Carly O’Brien, an Advanced Practice Clinical Educator at St. Joseph’s created a mandatory Learning Management Solution module that is completed by all assessment centre staff at the hospital. The module’s content revolves around how to create a positive experience for children and their families and includes information about distraction techniques and comfort positions. The Paediatrics nurses serving as in-person resources helped implement the techniques outlined in the module.

“We’re looking at the experience from a staff point of view as well as a family point of view,” Allain-Rooney said. “We’ve been called on to do whatever we can to make COVID-19 testing more comfortable. By implementing some of these techniques, we can create an overall better experience for both sides.”