Emergency DepartmentReadiness For PediatricIllness And Injury Abstract

There are approximately 25 million emergency department visits by children each year in the United States. It can be challenging for healthcare providers to maintain the readiness of emergency depart-ments in terms of equipment availability, policies and procedures for the care of children, and quality improvement for pediatric patients. Nearly 90% of children are seen in general emergency departments, and 50% of emergency departments see fewer than 10 pediatric patients per day, resulting in somewhat limited experience with criti-cally ill and injured children for most emergency care clinicians. In the framework of the current healthcare system that is wrought with overcrowding, underfunding, and highly variable pediatric capabili-ties, children are arguably at the greatest risk for medical error. This issue reviews the current state of pediatric readiness in emergency departments, the necessary steps to ensure day-to-day readiness, the published guidelines for pediatric readiness, and systems-based in-novations in pediatric readiness.

December 2013Volume 10, Number 12

Authors

Katherine Remick, MD, FAAPAssociate Medical Director, Austin-Travis County EMS System; Pediatric Emergency Medicine; Dell Children's Medical CenterSally Snow, BSN, RN, CPEN, FAENTrauma Program Director, Cook Children's Medical Center, Fort Worth, TXMarianne Gausche-Hill, MD, FACEP, FAAPProfessor of Clinical Medicine, David Geffen School of Medicine at the University of California at Los Angeles; Vice Chair and Chief, Division of Pediatric Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles, CA

Peer Reviewers

Stuart A. Bradin, DO, FAAP, FACEPAssistant Professor of Pediatrics and Emergency Medicine, The University of Michigan Health System; Attending Physician, Children’s Emergency Services, Ann Arbor, MIBarry Gilmore, MD, MBAChief of Emergency Services, Associate Professor of Pediatrics, LeBonheur Children’s Hospital, Memphis, TN

CME Objectives

Upon completion of this article, you should be able to:1. Review patient safety risks associated with the care of

children in the ED.2. Outline the guidelines on and describe the current state of

pediatric readiness in EDs.3. Discuss the various roles of hospitals and clinicians to

ensure pediatric readiness.

Prior to beginning this activity, see “Physician CME Information” on the back page.

Editor-in-ChiefAdam E. Vella, MD, FAAP Associate Professor of Emergency

Medicine, Pediatrics, and Medical Education, Director Of Pediatric Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY

Associate Editor-in-ChiefVincent J. Wang, MD, MHA Associate Professor of Pediatrics,

Keck School of Medicine of the University of Southern California; Associate Division Head, Division of Emergency Medicine, Children's Hospital Los Angeles, Los Angeles, CA

AAP SponsorMartin I. Herman, MD, FAAP, FACEP Professor of Pediatrics, Attending

Physician, Emergency Medicine Department, Sacred Heart Children’s Hospital, Pensacola, FL

Editorial BoardJeffrey R. Avner, MD, FAAP

Professor of Clinical Pediatrics and Chief of Pediatric Emergency Medicine, Albert Einstein College of Medicine, Children’s Hospital at Montefiore, Bronx, NY

Richard M. Cantor, MD, FAAP, FACEP

Professor of Emergency Medicine and Pediatrics, Director, Pediatric Emergency Department, Medical Director, Central New York Poison Control Center, Golisano Children's Hospital, Syracuse, NY

Ilene Claudius, MD Associate Professor of Emergency

Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA

Ari Cohen, MD Chief of Pediatric Emergency

Medicine Services, Massachusetts General Hospital; Instructor in Pediatrics, Harvard Medical School, Boston, MA

T. Kent Denmark, MD, FAAP, FACEP

Medical Director, Medical Simulation Center, Professor, Emergency Medicine, Pediatrics, and Basic Science, Loma Linda University School of Medicine, Loma Linda, CA

Marianne Gausche-Hill, MD, FACEP, FAAP Professor of Clinical Medicine,

David Geffen School of Medicine at the University of California at Los Angeles; Vice Chair and Chief, Division of Pediatric Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles, CA

Michael J. Gerardi, MD, FAAP, FACEP

Associate Professor of Emergency Medicine, Icahn School of Medicine at Mount Sinai; Director, Pediatric Emergency Medicine, Goryeb Children's Hospital, Morristown Medical Center, Morristown, NJ

Sandip Godambe, MD, PhD Vice President, Quality & Patient

Safety, Professor of Pediatrics and Emergency Medicine, Attending Physician, Children's Hospital of the King's Daughters Health System, Norfolk, VA

Ran D. Goldman, MD Professor, Department of Pediatrics,

University of British Columbia; Co-Lead, Division of Translational Therapeutics; Research Director, Pediatric Emergency Medicine, BC Children's Hospital, Vancouver, BC, Canada

Mark A. Hostetler, MD, MPH Clinical Professor of Pediatrics and Emergency Medicine, University of Arizona Children’s Hospital Division of Emergency Medicine, Phoenix, AZ

Alson S. Inaba, MD, FAAP Associate Professor of Pediatrics,

University of Hawaii at Mãnoa John A. Burns School of Medicine, Division Head of Pediatric Emergency Medicine, Kapiolani Medical Center for Women and Children, Honolulu, HI

Madeline Matar Joseph, MD, FAAP, FACEP

Professor of Emergency Medicine and Pediatrics, Chief and Medical Director, Pediatric Emergency Medicine Division, University of Florida Medical School-Jacksonville, Jacksonville, FL

Anupam Kharbanda, MD, MS Research Director, Associate

Fellowship Director, Department of Pediatric Emergency Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN

Tommy Y. Kim, MD, FAAP, FACEP Assistant Professor of Emergency

Medicine and Pediatrics, Loma Linda Medical Center and Children’s Hospital, Loma Linda, CA

Brent R. King, MD, FACEP, FAAP, FAAEM

Professor of Emergency Medicine and Pediatrics; Chairman, Department of Emergency Medicine, The University of Texas Houston Medical School, Houston, TX

Robert Luten, MD Professor, Pediatrics and

Emergency Medicine, University of Florida, Jacksonville, FL

Garth Meckler, MD, MSHS Associate Professor of Pediatrics,

University of British Columbia; Division Head, Pediatric Emergency Medicine, BC Children's Hospital, Vancouver, BC, Canada

Joshua Nagler, MD Assistant Professor of Pediatrics,

Harvard Medical School; Fellowship Director, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA

Steven Rogers, MD Clinical Professor, University of

Connecticut School of Medicine, Attending Emergency Medicine Physician, Connecticut Children's Medical Center, Hartford, CT

Ghazala Q. Sharieff, MD, FAAP, FACEP, FAAEM

Clinical Professor, Children’s Hospital and Health Center/University of California; Director of Pediatric Emergency Medicine, California Emergency Physicians, San Diego, CA

Gary R. Strange, MD, MA, FACEP Professor and Head, Department of Emergency Medicine, University of Illinois, Chicago, IL

Christopher Strother, MD Assistant Professor, Director,

Undergraduate and Emergency Simulation, Mount Sinai School of Medicine, New York, NY

International EditorLara Zibners, MD, FAAP Honorary Consultant, Paediatric

Emergency Medicine, St Mary's Hospital, Imperial College Trust; EM representative, Steering Group ATLS®-UK, Royal College of Surgeons, London, England

Pharmacology EditorJames Damilini, PharmD, MS,

BCPS Clinical Pharmacy Specialist,

Emergency Medicine, St. Joseph's Hospital and Medical Center, Phoenix, AZ

Pediatric Emergency Medicine Practice © 2013 2 www.ebmedicine.net • December 2013

pediatric readiness of EDs can be a challenge, but it can be accomplished with dedicated staff assigned to the role of ensuring readiness.

Pediatric Patient Safety In The United States Healthcare System

Healthcare providers and patients have long been aware of patient safety issues in the United States healthcare system. Over the last decade, such issues have come under increasing public scrutiny, due in large part to publication of the 2000 Institute of Medicine (IOM) report, To Err is Human, in which a reported 44,000 to 98,000 deaths were estimated to occur each year from preventable medical error.3 These results prompted a call to action. In 2001, the National Quality Forum identified a number of envi-ronmental factors associated with increased risk for medical error, including high patient volumes, high-acuity illnesses, and the need to make rapid health-care decisions while under severe time constraints.4 In addition, overcrowding and boarding have been cited repeatedly as barriers to safe, high-quality care in the ED setting.5,6 In such a healthcare environment, it is reason-able to assume that certain populations with spe-cial needs (such as children or the elderly) may be at even greater risk for medical error. The elderly population is expanding as the baby boomer genera-tion ages, and many healthcare providers will have additional experience caring for this population; however, few healthcare providers have enough ongoing experience with critically ill or injured children to maintain their knowledge and skills. This, in turn, may lead to failures in an emergency clinician’s ability to recognize severity of illness and may cause subsequent errors in decision-making. In fact, one-half of all United States EDs see fewer than 10 pediatric patients per day.1 Children require a unique set of competencies, policies, equipment, and patient safety initiatives to meet their needs. In response to growing concerns that the needs of children were not being met, in 1985 the United States Congress developed the Emergency Medical Services for Children (EMS for Children) program with the stated goal of reducing childhood death and disability due to injury or illness. The EMS for Children program has been extremely active and highly successful through the development of clini-cal protocols and guidelines for pediatric equip-ment, medications, and staffing; the establishment of resource centers to facilitate state and national research in pediatric emergency care; and education and training programs for emergency clinicians.7 Since its inception, the EMS for Children program has remained the largest single source of support for research and education initiatives in pediatric emergency care in the United States.7

Case Presentation

A 14-month-old boy in respiratory distress is carried into your ED by his parents after choking on a piece of meat. Upon presentation, he is noted by the nurse to have audible stridor and severe retractions. His initial vital signs are: heart rate, 190 beats/min; respiratory rate, 10 breaths/min; oxygen saturation, 78% on room air; temperature, 37.4ºC; and blood pressure, 90/54 mm Hg. The patient is rapidly triaged using the Emergency Sever-ity Index, and on arrival at the patient’s bedside, you are immediately notified by the staff of abnormal vital signs. You initiate bag-mask ventilation for hypoventilation and hypoxia. There is poor chest rise, and you feel resistance to ventilation. You recognize that this child is in respiratory failure with an upper airway obstruction, and you begin the process of relieving the obstruction. The scenario calls to mind a meeting you had earlier that morning regarding treatment of pediatric patients in your ED and equipment you might need. You think about some of the questions that were brought up and how they might apply to care for this child, such as: 1. Was the triage tool that was used adequate for this

child, and did the staff notify you in an appropriate time frame of abnormal vital signs?

2. Are the critical pediatric resuscitation equipment and supplies stored in a location that makes them readily available for use?

3. Which staff members should be identified to ensure that necessary equipment is immediately available, including pediatric Magill forceps and a difficult airway kit?

4. How will our ED staff ensure that medications given to this child to facilitate intubation are dosed accu-rately?

5. How will the family be updated on the child’s man-agement?

6. Once stabilized, will this child be admitted for defini-tive care, or will the child require transfer to another facility for pediatric intensive care services?

Introduction

Because parents are most likely to take sick children to the closest emergency department (ED), 90% of children are seen in general EDs.1,2 On the emergen-cy clinician's side, however, opportunity to care for critically ill or injured children is relatively uncom-mon, and anxiety can be high when such children present. Discovering that the necessary equipment and personnel are not available to respond effi-ciently should never occur at the moment they are needed. Just as hospitals anticipate and prepare for the care of trauma, stroke, and cardiac patients, preparation for the care of children should also be in place. Guidelines for pediatric readiness are well defined and readily available from many sources. Developing the expertise within hospitals to ensure

3 Pediatric Emergency Medicine Practice © 2013December 2013 • www.ebmedicine.net

young children are at increased risk of medical error due to their inability to communicate effectively and localize key symptoms such as pain or the site of injury. This becomes even more challenging when children are unaccompanied by a parent or guard-ian. Finally, children with complex medical histo-ries and special healthcare needs often exhibit less obvious signs of underlying illness, which can result in failure to recognize the critical nature of their presentation.

Guidelines Development For Pediatric ReadinessWhile various organizations had worked individu-ally to define “pediatric readiness” in EDs, it was not until 2001 that the American Academy of Pediatrics (AAP) and the American College of Emergency Physicians (ACEP) joined forces to create a compre-hensive set of guidelines.11,12 Through collaboration with the Emergency Nurses Association (ENA), these guidelines were further revised and expanded in 2009 to include family-centered care and patient safety recommendations as well as recommenda-tions for the care of children in disasters.13,14 The guidelines target 7 areas of focus: 1. Administration and coordination2. Physicians, nurses, and other healthcare clini-

cians3. Quality improvement 4. Patient safety 5. Policies, procedures, and protocols 6. Support services 7. Equipment, supplies, and medications

Furthermore, these guidelines are intended for all EDs that provide emergency care 24 hours a day, including those with limited resources.

Literature On Pediatric ReadinessSeveral studies have attempted to assess pediatric readiness in EDs. In 2001, a survey of 737 hospi-tal EDs in Canada revealed significant gaps in the availability of pediatric equipment.15 The gaps were linked to a low percentage of pediatric visits (< 10%), the lack of the presence of an emergency clinician trained in Pediatric Advanced Life Support (PALS), and the lack of an on-call pediatrician. The United States Consumer Product Safety Commission conducted a 2001 survey of 101 hospital EDs that participated in the National Electronic Injury Sur-veillance System, and they extrapolated the results to all hospitals in the United States.2 They found that nearly 60% of EDs see fewer than 50 patients per day (adult and pediatric) and designate themselves as “standby” (physician on call to the ED) or “ba-sic” EDs. Pediatric-sized equipment was less often available, and the great majority of hospitals lacked pediatric-specific inpatient services despite the fact

Despite the EMS for Children program’s nu-merous early accomplishments, based on a grow-ing awareness that the needs of children were not being met, the IOM commissioned 2 key reports on the state of emergency care. In the first report, published in 1993, the IOM provided recommen-dations in 5 specific areas: (1) provider education and training, (2) essential tools needed for pediatric care, (3) communications, (4) system evaluation and research, and (5) leadership by federal and state agencies.8 More specifically, the IOM advised that “children needed to be more widely recognized and made a genuine priority,” and that regulatory agencies should “…require hospital emergency departments and emergency response and transport vehicles to have available and maintain equipment and supplies appropriate for the emergency care of children.” While the call to action was echoed by the EMS for Children program and numerous medical and nursing professional organizations, its impact was lessened by the increasing strain on resources in the emergency care systems. Over the following decade, the number of emer-gency care visits steadily increased while hundreds of hospitals and EDs closed, leading to increasing overcrowding in facilities that remained open. In response, the IOM commissioned and published in 2006 a second analysis and a subsequent 3-part report entitled, The Future of Emergency Care in the United States Health System. Here, the IOM cited not only the rising number of ED visits and overcrowd-ing, but also the critical shortages of healthcare pro-viders and increasing ambulance diversions. Such strains in the system were recognized as contribut-ing to poor overall quality of care and unnecessary medical errors. In addition, the IOM noted that, while children account for approximately one-quar-ter of all ED visits, most EDs and emergency medi-cal services (EMS) agencies do not routinely require specialized pediatric training for clinical staff, and some lack the full scope of recommended pediatric equipment, medications, and supplies. The IOM cautioned that such an environment has created a clear “unevenness” in the ability of emergency care systems to treat children.9,10

Pediatric-Specific Safety RisksIn the setting of the current healthcare system, factors affecting pediatric patient safety include limited emergency clinician training and/or limited experience in pediatric emergency care and uncer-tain availability of pediatric-sized equipment and supplies. In addition, children have unique charac-teristics and needs that require a higher level of at-tention. Such needs include the use of weight-based or length-based dosing rather than standardized dosing. The simple misplacement of a decimal point may result in a 10-fold medication error. In addition,

Pediatric Emergency Medicine Practice © 2013 4 www.ebmedicine.net • December 2013

of a comprehensive disaster plan that incorporates the needs of children represent common barriers to pediatric readiness. Cost is often one of the greatest concerns voiced by administrators; however, the cost of pediatric readiness is far less than many assume. One study indicates that the cost to the average ED for pediatric supplies is < $1000.1,15 A potential strategy to reduce the cost of replacing infrequently used pediatric emergency supplies is to purchase supplies in bulk and distribute them to different areas of the hospi-tal or to exchange the supplies with hospitals with higher pediatric volume or with EMS provider agen-cies, to allow for cost sharing.

Recommendations For Preparing The Emergency Department For Treatment Of Pediatric Patients

Despite the enormous effort employed to promote pediatric readiness, previous studies confirm that there is still much work to be done. Focus-ing on a few specific areas of pediatric readiness could make a significant difference in the ability of EDs to care for children. With few hospitals being aware of the national guidelines for pe-diatric readiness, this is a clear first step. As the healthcare system struggles to find a balance between overcrowding and underfunding, quality improvement plans that target pediatric-specific needs must be in place. A number of resources are available to assist in pediatric readiness.

Resources For Emergency Department Assessment And ManagementPediatric Readiness ChecklistA pediatric readiness checklist to support the 2009 national guidelines is available online through the AAP. To download this checklist, scan the QR code below with your smartphone or visit http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Documents/Checklist_ED_Prep.pdf.

This checklist can be used by ED managers to evaluate their ED's pediatric readiness as defined in national guidelines and to identify gaps in care.

that three-quarters of the hospitals admitted pediat-ric patients to their facilities. Additionally, less than half of hospitals without a pediatric intensive care unit (PICU) had written transfer agreements with other facilities. In 2002, the United States Centers for Disease Control and Prevention (CDC) supported a survey of 839 nonfederal hospitals with 24-hour EDs that participated in the National Hospital Ambulatory Medical Care Survey to assess the availability of pediatric services, expertise, and supplies.16 In this report, Middleton and Burt found that only 5.5% of hospitals had all of the recommended equip-ment (per the 2001 guidelines), and approximately 50% of hospitals without a PICU lacked written transfer agreements. In a 2003 study of United States EDs, Gaus-che- Hill et al found that nearly 90% of children are seen in nonchildren’s hospitals, 25% of children are seen in rural or remote areas, and 50% of all EDs see fewer than 10 pediatric patients per day.1 Similar to the findings of Middleton and Burt, they also found that 6% of EDs had all of the recommended pediatric equipment; however, 90% of responding hospitals had at least 81% of the recommended equipment. A large majority of the responding EDs also had all of the recommended medications. Of note, < 60% of hos-pitals reported awareness of the 2001 guidelines. Fi-nally—and perhaps most importantly—they showed that the presence of a physician or nurse coordinator for pediatric emergency care resulted in an approxi-mately 60% improvement in pediatric readiness over hospitals lacking such coordinators. Unfortunately, of the responding hospitals, only 18% had physician pe-diatric coordinators and only 12% had nurse pediatric coordinators available. In 2006, 4 years after the Middleton and Burt study, the CDC conducted a follow-up survey of pediatric services and equipment in United States EDs.17 Unfortunately, little change was noted from the previous study, as only 7% of hospitals had 100% of the recommended pediatric supplies, and 45% of hospitals had 85% of the recommended pediatric supplies. Finally, following publication of the 2009 guide-lines, Sullivan et al conducted a telephone survey of 279 United States EDs on the presence of pedi-atric services.18 Only 17% reported the presence of a nurse and/or physician coordinator for pediatric emergency care. Furthermore, the majority of hospi-tals reported a lack of inpatient resources to manage severe illness and injury in children.

Barriers To Pediatric Readiness Reasons often cited for the lack of pediatric readi-ness in the ED include the multitude of barriers perceived by hospital and nurse leaders. The lack of pediatric quality improvement plans and the lack

5 Pediatric Emergency Medicine Practice © 2013December 2013 • www.ebmedicine.net

titioners any vital signs that are abnormal for the patient’s age. Implementation of such processes is likely to heighten provider awareness and expedite patient assessment and management.24,25

Pediatric Surge Capacity PlanningWhile no one wants to believe that a disaster will strike their community, every hospital is likely to be involved in a surge plan should such an event occur, and, therefore, all hospitals need to be prepared to care for patients of any age. Although children are disproportionately affected in the wake of a disaster, few comprehensive disaster plans at state and local levels have incorporated the needs of children within their plans.26-31 Mass casualty and surge events will bring children and their families to any hospital, regardless of whether plans have been established or not.32-34

Given that natural disasters and terrorist attacks can strike in small towns and large cities alike, hos-pitals must know their pediatric surge capacity, and it is essential that they have a disaster plan in place that targets the specific needs of children.

SafetyPediatric patient safety should remain a core focus for ED leaders. In the setting of a busy ED with sig-nificant time constraints, overcrowding, and infre-quent encounters with critically ill children, an event such as a pediatric resuscitation may be a source of high anxiety that can increase the likelihood of medical error. Rapid drug administration and im-mediate access to appropriately sized equipment can be life-saving. In such situations, the presence of length-based tapes with precalculated drug dos-ing and equipment sizing (such as Broselow tape) is crucial. The suggested drug dosing by weight on the Broselow tape is based on average body weight or length. While a patient’s body habitus should be taken into consideration, as obesity can affect dos-ing, the American Heart Association (AHA), in their 2010 Pediatric Advanced Life Support guidelines, states, “Regardless of the patient's habitus, use the actual body weight for calculating initial resusci-tation drug doses or use a body-length tape with precalculated doses.”35 These guidelines suggest that if actual weight is used to calculate medication doses in obese children, overdosing may occur, and if lean body mass is used to calculate doses, underdosing may occur.36-39 Furthermore, because standardized pediatric dosing is based on weight measured in kilograms, all children aged < 18 years should have their weight measured and recorded solely in kilo-grams. Failure to do so creates another opportunity for medical error and decreases patient safety.

Assessment ToolkitThe National Pediatric Readiness Project (support-ed by the EMS for Children program, AAP, ACEP, and ENA) has completed a nationwide assessment of pediatric readiness. Participating hospitals were able to benchmark their pediatric readiness with aggregated data from similar hospitals as well as with overall national averages. Each participating hospital also received a gap analysis to assist hos-pital staff in closing the pediatric readiness gap. With gaps identified, hospitals were then able to access the online national pediatric readiness tool-kit, which can be found at www.pediatricreadi-ness.org. The toolkit was developed based on the 7 areas targeted in the 2009 guidelines and provides links to essential resources to help hospital-based clinicians begin the necessary changes, whether it be policy development or quality improve-ment processes. Regardless of participation in the National Pediatric Readiness Project, the toolkit is free and readily available.

Pediatric CoordinatorThe responsibilities of physician and nurse coordi-nators for pediatric emergency care vary based on the specific needs of each facility. Ensuring that all pediatric patients receive high-quality care accord-ing to standards of practice requires a more in-depth approach. The identification of a pediatric coordina-tor allows pediatric needs to be made known and addressed at hospital, community, and regional lev-els. Pediatric-specific indicators should be integrated into the ED quality improvement plan and a process should be implemented to verify that emergency clinicians maintain pediatric competencies. Other responsibilities might include periodic review of ED policies, procedures, and supplies; ensuring pedi-atric needs are addressed in hospital disaster plans; and promoting pediatric emergency education for emergency clinicians. See page 9, Special Consider-ations, for further discussion.

Triage ToolsVirtually all EDs use a triage system to assess patients on arrival. Numerous triage scales, both 3- and 5-level, are currently available. Department-wide adoption of a validated pediatric triage tool is essential to identify children in need of rapid assessment and treatment. The ENA advocates the use of validated 5-level triage scales. Three such tools have been validated in the pediatric popula-tion and include the Emergency Severity Index,19,20 the Canadian Triage and Acuity Scale,21 and the Manchester Triage System.22,23 These pediatric tri-age scales address resource utilization and the need for hospital admission. Such triage systems can be used concomitantly with procedures to identify and communicate to physicians and midlevel prac-

Pediatric Emergency Medicine Practice © 2013 6 www.ebmedicine.net • December 2013

by the receiving centers must be in place to facilitate the timely transfer of critical cases. The establish-ment of outreach programs in which regional pedi-atric critical care centers provide community-based hospitals with pediatric emergency care education and protocols would facilitate a team-based ap-proach to meeting the needs of children in the com-munity. In addition, consultations via telemedicine may serve to decrease the disparity between rural and urban pediatric emergency care access.46,47 Both critical care and rural emergency clinicians report improvement in patient management as a result of such consultations.48 Furthermore, telemedicine may reduce transfers and facilitate ongoing management at rural, community-based facilities.49,50

Such a hub-spoke model requires significant cooperation among facilities, but also provides tremendous benefits. This regionalized approach has the potential to facilitate limitation of unnecessary transfers that might otherwise overwhelm pediatric regional centers; expedite the care of critically ill children, resulting in improved outcomes; and sup-port the management of less critically ill children at community-based facilities near the patient’s/fam-ily’s home in a generally more cost-effective manner. State EMS for Children programs can assist with the development of regionalized systems of pediatric care through the development of state regulations, an assessment of the optimal distribution of pediat-ric regional centers, and the continual monitoring of regionalized services.

Support In Pediatric Readiness

Federal EMS For Children ProgramSince its inception in 1985, the federal EMS for Chil-dren program has provided support to all 50 states, the District of Columbia, and 8 United States ter-ritories to further integrate the treatment of children into EMS systems. Specific contributions to pediatric emergency care have included the development of the following:1. Training programs for prehospital and hospital-

based emergency care clinicians.2. Education programs for school nurses.3. Protocols for pediatric trauma and disasters.4. State partnership grants to support integration

of pediatric needs into the larger EMS system.5. Resource centers (such as the National EMS for

Children Data Analysis Resource Center [NE-DARC]; the EMS for Children National Resource Center; and a multicenter research network, the Pediatric Emergency Care Applied Research Network [PECARN]) to promote advances in pediatric emergency care.

6. Guidelines for pediatric equipment, medica-tions, and staffing.

(See pages 8-9 for links to these resources.)

Prehospital And Hospital Clinician TrainingPediatric patients account for approximately 10% of all EMS patients,40,41 yet only 1% of these may be medical or traumatic cardiopulmonary arrests.40 The amount of didactic and skills training in pediatrics can be highly variable across professional training programs; however, regardless of baseline knowledge and hands-on training, pediatric skills will undoubt-edly wane over time, given limited exposure. There-fore, it becomes critical that EMS systems ensure adequate ongoing skills training for clinicians. The majority of EDs are staffed by emergency medicine-trained and family medicine-trained physicians, and the quantity and quality of pedi-atric training varies among residency programs. According to a survey of board-certified emergency medicine physicians, 84% felt they were at least “ad-equately” prepared to manage pediatric cardiopul-monary arrests and 92% felt they were at least "ad-equately" prepared to manage acutely ill children.42 These results were lower than the percentage of board-certified emergency medicine physicians who felt adequately prepared to manage adult patients (96% for treatment of adult cardiopulmonary arrests and 97% for acute illness). The availability of an inhouse or on-call pediatrician may be an important resource, yet as many as 38% of EDs lack around-the-clock access to a board-certified pediatrician.18 This highlights the importance of ongoing main-tenance of pediatric knowledge and skills through continuing medical education, pediatric life-support courses (such as PALS through the AHA), and an-nual competency evaluations.

Regionalization Of Pediatric CareStatewide designation programs are often seen as a first step toward regionalization of pediatric care. Effective management of the critically ill or injured child involves numerous steps, including a rapid EMS response, transport to a nearby facility with the ability to stabilize pediatric medical emergen-cies, the possible transfer to a regional center with pediatric critical care services for high-risk illnesses, and eventual transition back to the community-based medical home.43 Each of these steps must be fully functioning in order to prevent unnecessary death or disability. Given that pediatric critical care centers are few in number and often located some distance from the child’s home, the benefit of such services must outweigh the cost of transferring the child and the subsequent strain on the child’s family due to travel.44

The development of a regionalized system of pediatric care, although controversial, may assist in ensuring that children receive “the right care, in the right place, at the right time.”45 Such a system would invariably require the back-and-forth exchange of information and resources between receiving facili-ties. Regional transfer agreements and coordination

7 Pediatric Emergency Medicine Practice © 2013December 2013 • www.ebmedicine.net

tion. The responsibility for such efforts generally falls on the shoulders of hospitals and their health-care providers who often have limited time and funding available to support such efforts. Children are often overlooked in the development of such quality improvement processes. This may be due, in part, to the lack of well defined pediatric-specific measures of quality of care. Fortunately, through the work of Alessandrini et al and the support of the EMS for Children program, 60 pediatric-specific measures have been identified through the consen-sus of an expert panel.52 These were further refined by the EMS for Children program to highlight the top 15 hospital-based pediatric emergency care performance measures. (See Table 2, page 8.) Such a framework allows even small hospitals with limited resources the opportunity to identify and address weaknesses in pediatric emergency care.

Emergency Medical Services Role In Ensuring Pediatric ReadinessEnsuring pediatric readiness within the larger EMS system can be challenging. It cannot be overempha-sized that simply stocking pediatric equipment and supplies is not sufficient to ensure pediatric readi-ness. Rather, readiness implies preparation at all levels, from the creation of pediatric-specific policies to the identification of pediatric champions of ongo-ing quality improvement processes that address the care of children. Setting baseline expectations and providing educational initiatives can be starting points. Similar to readiness initiatives within the hospital setting, the EMS system must include pediatric-specific indica-tors in quality improvement efforts, incorporation of pediatric-specific needs in state disaster plans and drills, and identification of facilities throughout the state that are ready and best able to care for children. Throughout the country, state governments are ap-pointing pediatric emergency and trauma care special-ists to state advisory committees. These experts can aid in identifying pediatric needs within the system and can target solutions. State regulations that specifi-cally address children within the EMS system can set baseline standards for statewide quality improvement, categorization of facilities, and overall regionalization of care. Finally, state EMS agencies may also provide educational forums covering pediatric emergency care topics geared toward the prehospital professional. Similar actions can be initiated at the local level as well. Some EMS systems have pediatric advisory councils and/or pediatric medical directors to ad-dress regional pediatric needs. Continuing educa-tion and training programs can reinforce provider skills. Other regional systems have developed veri-fication programs to ensure that critically ill and injured children are transferred to pediatric-ready facilities. One example is Los Angeles County, Cali-

Many of the EMS for Children initiatives focus on systems-based performance improvement ef-forts. Through the support of the State Partnership Grant Program, the EMS for Children program facilitates the integration of pediatric needs into state EMS systems. Grantees are, in turn, asked to ensure the program’s success by focusing their efforts and reporting back on 10 core performance measures identified by the EMS for Children program. (See Table 1.)51 The measures include developing a standardized system within the state, region, or territory to recognize hospitals that are able to stabilize and/or manage pediatric medical emergencies. Through these efforts, the EMS for Children program has been able to change the way children are addressed and cared for within the larger healthcare system. Performance improvement at the local level is also critical to ensuring that healthcare services are meeting the needs of the pediatric patient popula-

Table 1. EMS For Children State/Territory Partnership Performance Measures

Performance Measure # Description of Measure

71 Percent of EMS provider agencies with online

pediatric medical direction

72 Percent of EMS provider agencies with offline pedi-

atric medical direction

73 Percent of patient care units (ambulances) with es-

sential pediatric equipment and supplies

74 Standardized system to identify EDs that are able

to stabilize and/or manage pediatric medical

emergencies

75 Standardized system to identify EDs that are able

to stabilize and/or manage pediatric traumatic

emergencies

76 Percent of EDs with written interfacility transfer

guidelines that include pediatric patients

77 Percent of EDs with written interfacility transfer

agreements that include pediatric patients

78 Requirements for pediatric emergency education

for the license/certification renewal of ALS and

BLS providers

79 Incorporation of EMS for Children into the state/

territory EMS system through establishment of an

EMS for Children advisory committee, pediatric

representation on EMS board, and full-time EMS

for Children program manager

80 Integration of EMS for Children priorities into state/

territory statutes and regulations

Abbreviations: ALS, advanced life support; BLS, basic life support; ED,

emergency department; EMS, emergency medical services; EMS for

Children, Emergency Medical Services for Children program.

Adapted with permission, Health Resources and Services Admin-

istration, Maternal and Child Health Bureau, Emergency Medical

Services for Children Program.

Pediatric Emergency Medicine Practice © 2013 8 www.ebmedicine.net • December 2013

• Pediatric Pain Management • Pediatric Patient Safety • Prehospital Pediatric Education • Translational Research

One toolkit (developed by the ENA, the NRC, and the Society of Trauma Nurses) provides resourc-es for EDs to improve the interfacility transfer of children, and can be found at www.pediatricreadi-ness.org. Sample policies and procedures are also available to address those items necessary to comply with the 2009 Joint Policy Statement: Guidelines for Care of Children in the Emergency Department. Listed below are some of the tools available to assist in preparing the ED for treatment of pediatric patients:a. Checklist:

http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Documents/Checklist_ED_Prep.pdf

b. Interfacility transfer kit: http://www.pediatricreadiness.org/PRP_Re-sources/Policies_Procedures_Protocols.aspx#Interfacility

c. Disaster readiness site: http://cpem.med.nyu.edu/teaching-materials/pediatric-disaster-preparedness

d. National Pediatric Readiness Project site: www.pedsready.org

e. Pediatric Readiness website and toolkit: www.pediatricreadiness.org

f. EMS for Children State Partnership Performance

fornia, in which hospital EDs voluntarily submit to annual assessments by the local EMS agency and are designated as Emergency Departments Ap-proved for Pediatrics (EDAPs).53

Tools To Assist In Pediatric Readiness Of Emergency Departments Fortunately, tools to assist with pediatric readi-ness are numerous and readily available. The ENA Institute for Quality, Safety, and Injury Preven-tion is rich with resources in pediatric emergency care.54 Additionally, the 2009 Pediatric Preparedness Checklist (developed by the AAP, ACEP, ENA, and the EMS for Children program) facilitates regular ED assessments by nurse coordinators. Finally, the United States National Research Council (NRC) has online toolkits that are easily searchable and contain specific tools that can be implemented with very little alteration. These can be found at http://www.childrensnational.org/emsc/pubres/emsc_toolbox.aspx. The following topics are included:• Cultural Competency • Emergency Department Pediatric Performance

Measures • Exception from Informed Consent • Facility Categorization • Interfacility Transfer • Medical Direction • Patient- and Family-Centered Care • Pediatric Disaster Preparedness • Pediatric Equipment Guidelines

Table 2. Top 15 Performance Measures In Pediatric Emergency Care52

System-Based Measures

Patient triage 1. Measurement of weight in kilograms for patients < 18 years of age

2. Method to identify age-based abnormal pediatric vital signs

Infrastructure and personnel 3. Presence of all recommended pediatric equipment in the emergency department

4. Presence of physician and nurse coordinators for pediatric emergency care

Patient-centered care 5. Patient and/or caregiver understanding of discharge instructions

Emergency department flow 6. Door-to-provider time

7. Total length of stay

Pain management 8. Pain assessment and reassessment for children with acute fractures

Quality and safety 9. Number of return visits within 48 hours resulting in hospitalization

10. Medication error rates

Disease-Specific Measures

Trauma 11. Use of head computed tomography in children with minor head trauma

12. Protocol for suspected child maltreatment

Respiratory diseases 13. Administration of systemic steroids for pediatric asthma exacerbations

14. Use of an evidence-based guideline to manage bronchiolitis

Infectious diseases 15. Use of antibiotics in children with suspected viral illness

Based on the 2009 Guidelines for Care of Children in the Emergency Department; American Academy of Pediatrics, the American College of Emer-

gency Physicians, and the Emergency Nurses Association.

Adapted with permission, Health Resources and Services Administration, Maternal and Child Health Bureau, Emergency Medical Services for Chil-

dren Program. Available at: http://www.childrensnational.org/files/PDF/EMSC/PubRes/Hospital-based_Performance_Measures/Website_toolkit_docu-

ment_aggregate_10.6.10_top_15.pdf

9 Pediatric Emergency Medicine Practice © 2013December 2013 • www.ebmedicine.net

Partnerships with regional and state EMS for Children activities may also provide opportunities for involvement in community and EMS education as well as sharing of resources. In high-volume EDs, the role of the pediatric nurse coordinator for pedi-atric emergency care may require a full-time posi-tion, while in others, this responsibility may only be part of a nurse’s regularly assigned duties. For some hospitals, a sample job description might include quality improvement, disaster preparedness, clinical responsibilities, and ensuring pediatric readiness initiatives are implemented. A commitment to pediatric readiness (as evidenced by the appointment of a champion for pediatrics) ensures that pediatric emergency care is a priority. Armed with the Guidelines for Care of Chil-dren in the Emergency Department, the preparedness checklist, and knowledge of the resources available from the ENA, AAP, ACEP, and the EMS for Chil-dren program, all hospitals and ED nurse leaders can be ready when the need arises.

Controversies And Cutting Edge

The outcomes of patients with traumatic injuries have improved significantly over the last several decades due, in part, to verification programs that allow for categorization of centers according to their resources and abilities. Critically ill children would also likely benefit from the categorization of EDs based on their pediatric resources, but there is not yet a national organization or credentialing body to facilitate this. However, several state and regional EMS systems have realized the importance of developing a pedi-atric designation process for their medical centers. Beginning in 1998, the Illinois EMS for Children program developed a voluntary facility recognition program to identify hospitals that are ready and able to meet the needs of critically ill children.57 Through this process, hospitals apply for 1 of 3 possible desig-nations: Pediatric Critical Care Center, Emergency Department Approved for Pediatrics, or Standby

Measures: http://www.childrensnational.org/EMSC/ForGrantees/Performance_Measures.aspx

g. Performance Measures for Pediatric Emergency Care: http://www.childrensnational.org/files/PDF/EMSC/PubRes/Hospital-based_Performance_Measures/Website_toolkit_document_aggre-gate__1 0.6.10__top_15.pdf

h. EMS for Children National Resource Center Toolboxes: http://www.childrensnational.org/EMSC/PubRes/toolbox.aspx

i. ENA Institute for Quality, Safety, and Injury Prevention: http://www.ena.org/practice-research/Prac-tice/Safety/IQSIPInjuryPrev/Pages/Default.aspx

j. Tennessee EMS for Children website: www.tnemsc.org

Special Considerations: The Nursing Perspective

Nurses who are in leadership roles in EDs are administratively responsible for implementation of policies and procedures that establish the ac-tions to be taken for both common and infrequent events. Because emergency nurses are resourceful and knowledgeable about common barriers, op-portunities for sharing policies and procedures are often plentiful. Nurse leaders are responsible for establishing standards for documentation of skills and competencies for the nursing and ancillary staff across the patient age continuum. They must advocate for education of the staff that will provide didactic and psychomotor skills training based on identified needs. This includes supporting advanced certification in pediatric emergency nursing for staff members who demonstrate interest, knowledge, and/or expertise in the care of children. As previously noted, the most critical aspect of pediatric readiness that ED nurse leaders must recog-nize is the importance of appointing a “champion,” or coordinator for pediatric preparedness. This may be a nurse who simply has a passion for pediatric emer-gency care; someone who is willing to participate in the establishment of staff education programs, who demonstrates competencies in treatment of pediatric patients, and ensures that needed equipment is avail-able. The ENA Emergency Nursing Pediatric Course (ENPC) is a comprehensive course that includes didactic and psychomotor skills education to prepare nurses to treat children in emergency care settings. This course can help support the nurse coordinator in his or her role and can serve as additional training for other nurses involved in pediatric emergency care.55 The Certified Pediatric Emergency Nurse (CPEN) credential demonstrates knowledge and expertise in the care of children in emergency settings.56

1. Identify pediatric champions or coordinators (nurse and physician).

2. Develop a pediatric-specific quality improve-ment plan.

3. Include pediatric issues in disaster planning. 4. Ensure written transfer agreements are in place. 5. Utilize telemedicine to minimize the need to

transfer patients. 6. Ensure that the ED is stocked with equipment

that is sized appropriately for pediatric patients.

Time- And Cost-Effective Strategies

Pediatric Emergency Medicine Practice © 2013 10 www.ebmedicine.net • December 2013

1. “We do not see many pediatric patients, so we do not have a physician or nurse coordinator for pediatric emergency care.” All EDs have the responsibility to care for patients of any age who present for care and treatment. Designating someone to serve as a champion for pediatric emergency care issues ensures that the needs of children are being met, resulting in enhanced pediatric readiness. While high-volume facilities may choose to assign this role to a full-time position, smaller hospitals may choose a part-time or shared role.

2. ”Our quality improvement plan does not ad-dress pediatric-specific metrics.” In order to ensure that the care received is as intended, quality improvement plans must be in place to identify and correct systems-based errors. While quality improvement plans may be broad, such plans must target all populations, including children.

3. ”Our patients’ vital signs are easily visible on the chart. Therefore, there is no need to notify the physician specifically.” Prompt physician notification of the presence of abnormal vital signs leads to more rapid assessment and intervention. Failure to institute policies to notify physicians of abnormal vital signs may lead to significant delays in care and increase the potential for adverse outcomes.

4. “We do not need a pediatric transfer plan or agreement since we rarely transfer pediatric pa-tients.” While pediatric transfers may be rare occurrences for some facilities, it is important to have a transfer plan and agreement in place in order to expedite access to a higher level of care. Transfer plans may include mode of transport, communication elements, and other requirements. It is important to ensure all necessary communication and documentation is completed, as lack of agreements with outlying facilities may result in significant delays in care and a struggle to identify an appropriate receiving facility.

5. “Our healthcare providers choose what CME they complete. We do not have any specific pediatric CME requirements.” Pediatric patients account for approximately 25% of ED visits.9,10,60 When a pediatric patient presents in extremis, it is critical that providers are prepared to manage the child effectively and efficiently. Given the relatively infrequent encounters with critically ill pediatric patients, pediatric-specific CME becomes even more important in order to maintain the skills needed to treat the pediatric population. All providers caring for children should be encouraged to complete pediatric-specific CME annually.

Risk Management Pitfalls For Pediatric Readiness (Continued on page 11)

Emergency Department for Pediatrics. The Illinois EMS for Children program staff is responsible for verifying resources via scheduled onsite visits. To date, more than 100 hospitals throughout the state have participated in this program. Similarly, Tennessee developed mandatory legislative rules establishing Standards for Pediatric Emergency Care Facilities through the Department of Health.58 Facilities are categorized into 1 of 4 levels of care: Comprehensive Regional Pediatric Care (CRPC) Facility, General Pediatric Care Facility, Primary Pediatric Care Facility, and Basic Pediatric Care Facility. Every hospital in the state is required to self-designate based on set criteria that are then verified through annual inspections. Tennessee has 4 CRPC centers across the state. Each has a region with associated hospitals tied through transfer agreements. The CRPCs have staff members who provide training and feedback on the treatment of pediatric patients. A statewide database developed by Vanderbilt University (REDCap) also tracks trends in problematic pediatric transports and

provides feedback. Other states are also developing similar programs. While California does not yet have a formal statewide categorization process, in 2012 all acute care hospitals in the state were given the opportu-nity to verify their pediatric resources and capabili-ties through a statewide assessment. Through the California Pediatric Readiness Project, 300 out of 335 EDs received immediate feedback along with an individualized gap analysis to facilitate improve-ment in pediatric readiness.59 While the results are forthcoming, such a program has allowed the Cali-fornia EMS for Children program to determine the distribution of pediatric emergency care resources throughout the state and assist hospitals to better meet the needs of critically ill and injured children.

Summary

Children account for nearly 25% of ED patients, and the great majority are seen in hospitals that are not children’s hospitals.9,10,60 While as many as 50% of

11 Pediatric Emergency Medicine Practice © 2013December 2013 • www.ebmedicine.net

Case Conclusions

The 14-month-old boy was moved to a medical resus-citation room and placed on a monitor. Physicians and nurses who had undergone annual continuing medical education in pediatric airway management immediately recognized that he was in extremis and responded accord-ingly. Nurses used a Broselow tape to quickly estimate the child’s weight for medication dosing while you provided bag-mask ventilation. You made sure that a difficult airway kit and pediatric Magill forceps were readily available and were brought to the bedside. You also called a respiratory therapy to the bedside. The parents were allowed to be present, and the medical staff members that were not involved in the resuscitation provided support to the family during the resuscitation. The foreign body was removed using pediatric Magill forceps, and bag-mask ventilation was continued. The child’s oxygen satura-tion improved, but he required endotracheal intubation. You gave him etomidate and succinylcholine through an intraosseous needle, and intubated with a 4-mm cuffed

hospitals see fewer than 10 pediatric patients per day, all hospitals can and should be pediatric-ready. Critically ill and injured children are often transport-ed by private car to the most geographically acces-sible facility. Healthcare clinicians must, therefore, be ready before the child arrives in order to provide basic stabilization and timely transfer to a pediatric critical care center, if necessary. Fortunately, nation-al guidelines and numerous resources are available to aid in understanding the components of pediatric readiness. Furthermore, the National Pediatric Read-iness Project provides a unique opportunity for ED leaders to assess their current state of readiness and identify gaps through the use of multiple web-based resources. While numerous regional and state EMS systems are making children a priority, there is still much work to be done. Nurse and physician lead-ers should take this opportunity to become pediatric champions at their facilities.

6. ”Our scale only weighs children in pounds.” Standard pediatric dosing is based on weight in kilograms. Weighing children in pounds requires the added step of converting weight into kilograms, which can create additional room for error. Also, utilizing both pounds and kilograms may lead to errors in documentation. All children should be weighed only in kilograms, and weight should be recorded only in kilograms to avoid miscalculations.

7. “We do not require annual competency evalua-tions of our providers, as this is included in the certification process.” While recertification may test the current knowledge base, it is important that providers maintain pediatric-specific skills. This is particularly important when these skills are not practiced regularly. Annual competency evaluations provide a means for ensuring skills maintenance.

8. “We do not use a validated pediatric triage tool.” The use of a validated pediatric triage tool is important to help predict resource utilization. Triage tools used for adults may under- or over-triage pediatric patients, leading to a mismatch in prioritization. A higher triage category alerts physicians to the need for rapid assessment or intervention. Particularly in the setting of overcrowding, failure to utilize a validated pediatric triage tool may result in delays in care and poor patient management.

9. ”We have a hospital-wide disaster preparedness plan, but no separate plan or inclusive guidelines for children.” Children are disproportionately affected during disasters. In addition, children have special needs that are often not considered when managing adult patients in the setting of a disaster. Specific needs include pediatric triage, a pediatric approach to decontamination, surge capacity, reunification services, medications, and supplies. Pediatric-specific elements must be included in a hospital-wide disaster plan.

10. ”We have a calculator set up in the resuscitation bay for children.” When a child presents in extremis, the use of a calculator or other real-time dose calculation tools creates multiple opportunities for error. The likelihood of error may be increased during stressful situations such as resuscitations. While slight underdosing and overdosing may occur based on body habitus, the AHA recommends the use of a length-based tape or actual weight to eliminate unnecessary steps in calculation that may lead to significant dosing errors.

Risk Management Pitfalls For Pediatric Readiness (Continued from page 10)

Pediatric Emergency Medicine Practice © 2013 12 www.ebmedicine.net • December 2013

gency department: guidelines for preparedness. Pediatrics. 2001;107(4):777-781. (National guidelines)

12. American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Committee. Care of children in the emergency department: guidelines for preparedness. Ann Emerg Med. 2001;37(4):423-427. (National guidelines)

13.* American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Phy-sicians Pediatric Committee, Emergency Nurses Association Pediatric Committee. Joint policy statement--guidelines for care of children in the emergency department. Ann Emerg Med. 2009;54(4):543-552. (National guidelines)

14.* American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Committee, Emergency Nurses Associa-tion Pediatric Committee. Joint policy statement--guidelines for care of children in the emergency department. Pediatrics. 2009;124(4):1233-1243. (National guidelines)

15. McGillivray D, Nijssen-Jordan C, Kramer MS, et al. Criti-cal pediatric equipment availability in Canadian hospital emergency departments. Ann Emerg Med. 2001;37(4):371-376. (Cross-sectional survey; 737 hospitals, 88% response rate)

16.* Middleton KR, Burt CW. Availability of pediatric services and equipment in emergency departments: United States, 2002-03. Adv Data. 2006(367):1-16. (Cross-sectional survey; 839 hospitals, 86% response rate)

17. Schappert SM, Bhuiya F. Availability of pediatric services and equipment in emergency departments: United States, 2006. Natl Health Stat Report. 2012(47):1-21. (Cross-sectional survey; Emergency Pediatric Services and Equipment Supplement (EPSES), added to the 2006 National Hospital Ambulatory Medical Care Survey [NHAMCS]; 80% response rate)

18. Sullivan AF, Rudders SA, Gonsalves AL, et al. National survey of pediatric services available in US emergency de-partments. Int J Emerg Med. 2013;6(1):13. (Telephone survey; random sample of 279 hospital EDs; 85% response rate)

19. Green NA, Durani Y, Brecher D, et al. Emergency Severity Index version 4: a valid and reliable tool in pediatric emer-gency department triage. Pediatr Emerg Care. 2012;28(8):753-757. (Retrospective chart review; 780 patients; prospective cohort study; 100 patients)

20. Emergency Severity Index (ESI): A Triage Tool for Emergency Department: DVDs and 2012 Edition of the Implementation Handbook. Rockville, MD: Agency for Healthcare Research and Quality; February 2013. (Educational materials)

21. Warren DW, Jarvis A, LeBlanc L, et al. Revisions to the Canadian Triage and Acuity Scale paediatric guidelines (PaedCTAS). CJEM. 2008;10(3):224-243. (Review)

22. Roukema J, Steyerberg EW, van Meurs A, et al. Validity of the Manchester Triage System in paediatric emergency care. Emerg Med J. 2006;23(12):906-910. (Review; 1065 patients)

23. van Veen M, Steyerberg EW, Ruige M, et al. Manchester Triage System in paediatric emergency care: prospective observational study. BMJ. 2008;337:a1501. (Prospective observational study; 17,600 patients)

24. Sklar DP, Crandall CS, Loeliger E, et al. Unanticipated death after discharge home from the emergency department. Ann Emerg Med. 2007;49(6):735-745. (Retrospective cohort study; 186,859 patients)

25. CRICO/RMF Strategies Emergency Medicine Leadership Council 2010. Optimizing physician-nurse communication in the emergency department: strategies for minimizing diagnosis-related errors. Available at: https://www.rmf.harvard.edu/~/media/Files/_Global/KC/PDFs/ed_white_paper_min_diagnosis_errors.pdf. Accessed August 15, 2013. (Website resource)

endotracheal tube. The boy's vital signs stabilized, you started continuous sedation, and updated the parents on the child’s management plan. The nearest PICU was contacted and the transfer agreement was activated so that the child could be trans-ferred in a timely fashion to a pediatric critical care cen-ter. Within 30 minutes, an advanced life support trans-port team arrived, and he was successfully transferred to a pediatric critical care facility for ongoing treatment.

References

Evidence-based medicine requires a critical ap-praisal of the literature based upon study methodol-ogy and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report. To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references, where available. The most informa-tive references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.

1. Gausche-Hill M, Schmitz C, Lewis RJ. Pediatric prepared-ness of US emergency departments: a 2003 survey. Pediatrics. 2007;120(6):1229-1237. (Cross-sectional survey; 5144 hospi-tals, 29% response rate)

2. Athey J, Dean JM, Ball J, et al. Ability of hospitals to care for pediatric emergency patients. Pediatr Emerg Care. 2001;17(3):170-174. (Cross-sectional survey; 101 hospitals, 100% response rate)

3. Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. Washington DC: Institute of Medicine; 2000. 1st ed. 2000. (IOM report)

4. Kizer KW. Patient safety: a call to action. A consensus statement from the National Quality Forum. Med Gen Med. 2001;3:1-11. (Consensus statement)

5. Derlet RW, Richards JR. Overcrowding in the nation’s emer-gency departments: complex causes and disturbing effects. Ann Emerg Med. 2000;35(1):63-68. (Review)

6. Trzeciak S, Rivers EP. Emergency department overcrowding in the United States: an emerging threat to patient safety and public health. Emerg Med J. 2003;20(5):402-405. (Review)

7. Ball JW, Liao E, Kavanaugh D, et al. The Emergency Medical Services for Children program: accomplishments and contri-butions. Clin Pediatr Emerg Med. 2006;7(1):6-14. (Review)

8. Committee on Pediatric Emergency Medical Services. Emer-gency Medical Services for Children. Washington DC: Institute of Medicine; 1993. (IOM report)

9. Committee on the Future of Emergency Care in the U.S. Health System. Hospital-Based Emergency Care: At the Breaking Point. Washington DC: Institute of Medicine; 2006. (IOM report)

10 Committee on the Future of Emergency Care in the U.S. Health System. Pediatric Emergency Care: Growing Pains. Washington DC: Institute of Medicine; 2006. (IOM report)

11. American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Phy-sicians Pediatric Committee. Care of children in the emer-

13 Pediatric Emergency Medicine Practice © 2013December 2013 • www.ebmedicine.net

26. Broughton DD, Allen EE, Hannemann RE, et al. Getting 5000 families back together: reuniting fractured families after a di-saster: the role of the National Center for Missing & Exploited Children. Pediatrics. 2006;117(5 Pt 3):S442-S445. (Report)

27. Chung S, Shannon M. Reuniting children with their families during disasters: a proposed plan for greater success. Am J Disaster Med. 2007;2(3):113-117. (Report)

28. Gnauck KA, Nufer KE, LaValley JM, et al. Do pediatric and adult disaster victims differ? A descriptive analysis of clini-cal encounters from four natural disaster DMAT deploy-ments. Prehosp Disaster Med. 2007;22(1):67-73. (Retrospective cohort review; 2196 total patients, 643 pediatric patients)

29. Sirbaugh PE, Gurwitch KD, Macias CG, et al. Caring for evacuated children housed in the Astrodome: creation and implementation of a mobile pediatric emergency response team: regionalized caring for displaced children after a disaster. Pediatrics. 2006;117(5 Pt 3):S428-S438. (Report)

30. Gausche-Hill M. Pediatric disaster preparedness: are we re-ally prepared? J Trauma. 2009;67(2 Suppl):S73-S76. (Review)

31. Mace SE, Bern AI. Needs assessment: are disaster medical assistance teams up for the challenge of a pediatric disaster? Am J Emerg Med. 2007;25(7):762-769. (Needs assessment)

32. Shirm S, Liggin R, Dick R, et al. Prehospital preparedness for pediatric mass-casualty events. Pediatrics. 2007;120(4):e756-e761. (Cross-sectional survey; 3748 ambulance services, 51% response rate)

33. Graham J, Shirm S, Liggin R, et al. Mass-casualty events at schools: a national preparedness survey. Pediatrics. 2006;117(1):e8-e15. (Cross-sectional survey; 3670 schools, 58% response rate)

34. Barfield WD, Krug SE, Kanter RK, et al. Neonatal and pedi-atric regionalized systems in pediatric emergency mass criti-cal care. Pediatr Crit Care Med. 2011;12(6 Suppl):S128-S134. (Consensus statement)

35. Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: pediatric advanced life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 Suppl 3):S876-S908. (National guidelines)

36. Kleinman ME, de Caen AR, Chameides L, et al. Pediatric ba-sic and advanced life support: 2010 international consensus on cardiopulmonary resuscitation and emergency cardio-vascular care science with treatment recommendations. Pediatrics. 2010;126(5):e1261-e1318. (Review)

37. So TY, Farrington E, Absher RK. Evaluation of the accuracy of different methods used to estimate weights in the pediat-ric population. Pediatrics. 2009;123(6):e1045-e1051. (Prospec-tive nonblinded observational study; 1011 children, 3 methods of weight estimation)

38. Luten R, Wears RL, Broselow J, et al. Managing the unique size-related issues of pediatric resuscitation: reducing cognitive load with resuscitation aids. Acad Emerg Med. 2002;9(8):840-847. (Review)

39. Nieman CT, Manacci CF, Super DM, et al. Use of the Brosel-ow tape may result in the underresuscitation of children. Acad Emerg Med. 2006;13(10):1011-1019. (Cross-sectional observational study; 7500 children)

40. Tsai A, Kallsen G. Epidemiology of pediatric prehospital care. Ann Emerg Med. 1987;16(3):284-292. (Retrospective review; 3184 patients)

41. Seidel JS, Hornbein M, Yoshiyama K, et al. Emergency medi-cal services and the pediatric patient: are the needs being met? Pediatrics. 1984;73(6):769-772. (Retrospective review of prehospital care reports in Los Angeles County, CA)

42. Langhan M, Keshavarz R, Richardson LD. How comfortable are emergency physicians with pediatric patients? J Emerg Med. 2004;26(4):465-469. (Survey)

43. American Academy of Pediatrics. Committee on Pediatric Emergency Medicine. American College of Critical Care Medicine. Society of Critical Care Medicine. Consensus re-port for regionalization of services for critically ill or injured children. Pediatrics. 2000;105(1 Pt 1):152-155. (Consensus statement)

44. Randolph AG, Gonzales CA, Cortellini L, et al. Growth of pediatric intensive care units in the United States from 1995 to 2001. J Pediatr. 2004;144(6):792-798. (Cross-sectional sur-vey; 306 PICUs, 1995-1996; 349 PICUs, 2001-2002)

45. Kocher KE, Sklar DP, Mehrotra A, et al. Categorization, des-ignation, and regionalization of emergency care: definitions, a conceptual framework, and future challenges. Acad Emerg Med. 2010;17(12):1306-1311. (Consensus conference proceedings)

46. Spooner SA, Gotlieb EM. Telemedicine: pediatric applica-tions. Pediatrics. 2004;113(6):e639-e643. (Report)

47. Kofos D, Pitetti R, Orr R, et al. Telemedicine in pediatric transport: a feasibility study. Pediatrics. 1998;102(5):E58. (Prospective study; 15 patients)

48. Heath B, Salerno R, Hopkins A, et al. Pediatric critical care telemedicine in rural underserved emergency departments. Pediatr Crit Care Med. 2009;10(5):588-591. (Prospective study; 63 telemedicine consultations, 10 rural EDs)

49. Finley JP, Sharratt GP, Nanton MA, et al. Paediatric echocardiog-raphy by telemedicine--nine years’ experience. J Telemed Telecare. 1997;3(4):200-204. (Prospective study; 324 transmissions)

50. Sable CA, Cummings SD, Pearson GD, et al. Impact of telemedicine on the practice of pediatric cardiology in com-munity hospitals. Pediatrics. 2002;109(1):E3. (Prospective study; 2 community hospital nurseries, 500 echocardiogram studies, 364 patients)

51. EMS for Children Performance Measures website. Available at: http://www.childrensnational.org/EMSC/ForGrantees/Performance_Measures.aspx. Accessed June 12, 2013. (Na-tional guidelines)

52.* Alessandrini E, Varadarajan K, Alpern ER, et al. Emer-gency department quality: an analysis of existing pediatric measures. Acad Emerg Med. 2011;18(5):519-526. (Consensus recommendations)

53. Los Angeles County EMS Agency website. Available at: http://ems.dhs.lacounty.gov. Accessed June 12, 2013. (Re-port; annual data)

54. Institute for Quality, Safety, and Injury Prevention Practice & Research website. Available at: http://www.ena.org/practice-research/Pages/about.aspx. Accessed June 8, 2013. (National guidelines)

55. Emergency Nursing Pediatric Course. Available at: http://www.ena.org/education/enpc-tncc/Pages/Default.aspx. Accessed June 8, 2013. (Website resource)

56. The Certified Pediatric Emergency Nurse Exam. Available at: http://www.pncb.org/ptistore/control/exams/cpen/index. Accessed June 8, 2013. (Website resource)

57.* Cichon ME, Fuchs S, Lyons E, et al. A statewide model program to improve emergency department readiness for pediatric care. Ann Emerg Med. 2009;54(2):198-204. (Review)

58. Hohenhaus SM, Lyons E, Phillippi RG. Emergency depart-ments and pediatric categorization, approval, and recogni-tion: a review of two states. J Emerg Nurs. 2008;34(3):236-237. (Review)

59. Remick KE, Gausche-Hill M. California Pediatric Readiness Project. California EMS Authority 2010-2012. Presented at: State of California EMS System Administrators Association Annual Conference; May 2013; California. (Preliminary report of cross-sectional survey; 335 hospitals; 90% response rate)

60 Nawar EW, Niska RW, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 emergency department sum-mary. Adv Data. 2007;(386):1-32. (Cross-sectional survey)

Pediatric Emergency Medicine Practice © 2013 14 www.ebmedicine.net • December 2013

5. Which of the following is NOT one of the 7 areas of focus in the AAP Guidelines for Care of Children in the Emergency Department?a. Equipment, supplies, and medicationsb. Support services c. Care provided in urgent care and primary care settingsd. Administration and coordination

6. What percentage of EDs lack written transfer agreements for the transfer of pediatric pa-tients to pediatric critical care centers and other higher levels of care? a. ≤ 50% b. 60%c. 75% d. 90%

7. Pediatric surge capacity planning is: a. Necessary only in large urban hospitalsb. An essential part of a hospital disaster plan c. Necessary only in community hospitalsd. The responsibility of the federal government

8. The EMS for Children program state partner-ship grants were designed for:a. Purchasing pediatric ED equipment b. Facilitating the integration of pediatric needs into state EMS systems c. Parent education programsd. Developing triage tools

9. Which of the following provides resources to assist with pediatric readiness? a. EMS for Children National Resource Center b. Emergency Nurses Association Institute for Quality, Safety, and Injury Prevention c. National Pediatric Readiness Toolkit d. All of the above

10. Which of the following interventions would most significantly improve the pediatric readi-ness of an ED? a. Assigning the role of physician and/or nursing coordinator for pediatric emergency care b. Developing a family-centered care plan c. Developing and training staff in the use of pediatric difficult airway kits d. Purchasing a cricothyrotomy kit appropriate for children

CME Questions

Take This Test Online!

Take This Test Online!

Current subscribers receive CME credit absolutely free by completing the following test. Each issue includes 4 AMA PRA Category 1 CreditsTM, 4 ACEP Category I credits, 4 AAP Prescribed credits, and 4 AOA cat egory 2A or 2B credits. Monthly on line testing is now available for current and archived issues. To receive your free CME credits for this issue, scan the QR code below or visit www.ebmedicine.net/P1213.

1. What percentage of pediatric ED patients are seen in general EDs?a. 10% b. 25% c. 50%d. 90%

2. Which of the following factors is most likely to be considered by parents when determining where to take a child with an emergent condi-tion?a. The ED that is closestb. The ED with pediatric emergency physicians on staff c. The hospital with an academic programd. The hospital with a PICU

3. The EMS for Children program was funded by Congress with the stated goal to: a. Enforce prehospital protocols for children b. Maintain a research network for pediatric emergency care c. Reduce childhood death and disability due to injury or illnessd. Reduce ED overcrowding

4. According to national statistics, children ac-count for what percentage of ED visits? a. 10% b. 25% c. 40% d. 50%

15 Pediatric Emergency Medicine Practice © 2013December 2013 • www.ebmedicine.net

In 2006, at only 9 days old, Rebecca Ava Rabinowitz passed away from an enteroviral infection that was not recognized during an emergency department visit the day before. To help prevent other families from facing this tragedy, R Baby Foundation was born. It is the first and only not-for-profit foundation uniquely focused on saving babies’ lives through improving pediatric emergency care. R Baby focuses on ensuring that babies (including those in the first months of life) suffering from viral infections and other infectious disease receive the highest quality of care and service through supporting life-saving pediatric training, education, research, treatment, and equipment.

R Baby has developed a wide breadth of programs to address many of the challenges in pediatric emergency care, including:

1. Pediatric simulation training through programs that include the INSPIRE network led by Yale School of Medicine and Columbia University and the Yale-led Sim-Mobile training program

2. Rapid viral detection technology at the University of Maryland Children’s Hospital

3. An annual symposium led by Mount Sinai Hospital in New York for top pediatric speakers nationwide to share the most current and ground-breaking information with pediatric specialists across the nation

4. R Baby’s online fever and respiratory guidelines established by Columbia University Morgan Stanley Children’s Hospital for training thousands of doctors with statistically proven improvements

5. Parent education programs to improve communication

Please visit www.rbabyfoundation.org for more information and to access valuable resources.

The Emergency Medical Services for Children Program, funded by the Health Resources and Services Administration, Maternal and Child Health Bureau, is a national initiative designed to reduce childhood death and disability due to severe illness or injury. Celebrating its 30th anniversary in 2014, the Program has successfully raised awareness among healthcare professionals, EMS and trauma system planners, and the general public that children respond differently – physically, emotionally, and psychologically – to medical emergencies. The National Pediatric Readiness Project, conducted in partnership with EMSC grantees and key stakeholder organizations such as the AAP, ACEP, and ENA, will strive to ensure that the nation’s emergency departments are equipped to meet the special needs of ill or injured children. For more information, please visit:

www.PediatricReadiness.org

Emergency Medical

Services for Children

For more information on readiness in the pediatric emergency department, the author of this issue recommend the websites below:

Pediatric Emergency Medicine Practice © 2013 16 www.ebmedicine.net • December 2013

Pediatric Emergency Medicine Practice (ISSN Print: 1549-9650, ISSN Online: 1549-9669, ACID-FREE) is published monthly (12 times per year) by EB Medicine. 5550 Triangle Parkway, Suite 150, Norcross, GA 30092. Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. This publication is intended as a general guide and is intended to supplement, rather than substitute, professional judgment. It covers a highly technical and complex subject and should not be used for making specific medical decisions. The materials contained herein are not intended to establish policy, procedure, or standard of care. Pediatric Emergency Medicine Practice is a trademark of EB Medicine. Copyright © 2013 EB Medicine All rights reserved. No part of this publication may be reproduced in any format without written consent of EB Medicine. This publication is intended for the use of the individual subscriber only, and may not be copied in whole or in part or redistributed in any way without the publisher’s prior written permission – including reproduction for educational purposes or for internal distribution within a hospital, library, group practice, or other entity.

CEO & Publisher: Stephanie Williford Director of Editorial: Dorothy Whisenhunt Content Editors: Erica Carver, Lesley Wood Assistant Editor: Kay LeGree Director of Member Services: Liz Alvarez Member Services Representatives: Kiana Collier, Paige Banks

Director of Marketing: Robin Williford Marketing Communications Specialist: Aron Dunn

Direct all questions to:

EB Medicine Phone: 1-800-249-5770 or 678-366-7933

Fax: 1-770-500-13165550 Triangle Parkway, Suite 150

Norcross, GA 30092E-mail: ebm@ebmedicine.net

Website: EBMedicine.netTo write a letter to the editor, email: vellaadam@gmail.com

Subscription Information: 1 year (12 issues) including evidence-based print issues;

48 AMA PRA Category 1 CreditsTM, 48 ACEP Category 1 Credits, 48 AAP Prescribed credits, and 48 AOA Category 2A or 2B credit; and full online access

to searchable archives and additional free CME: $299(Call 1-800-249-5770 or go to www.ebmedicine.net/subscribe to order)

Single issues with CME may be purchased at www.ebmedicine.net/PEMPissues

Physician CME InformationDate of Original Release: December 1, 2013. Date of most recent review:

November 15, 2013. Termination date: December 1, 2016.Accreditation: EB Medicine is accredited by the Accreditation Council for

Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the Essential Areas and Policies of the ACCME.

Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.

AAP Accreditation: This continuing medical education activity has been reviewed by the American Academy of Pediatrics and is acceptable for a maximum of 48 AAP credits per year. These credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics.

AOA Accreditation: Pediatric Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2A or 2B credit hours per year.

Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.

Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.

Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical ED presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.

Discussion of Investigational Information: As part of the newsletter, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.

Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Remick, Ms. Snow, Dr. Gausche-Hill, Dr. Bradin, Dr. Gilmore, Dr. Vella, Dr. Wang, Dr. Damilini, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.

Commercial Support: This issue of Pediatric Emergency Medicine Practice did not receive any commercial support.

Method of Participation:• Print Semester Program: Paid subscribers who read all CME articles

during each Pediatric Emergency Medicine Practice 6-month testing period, complete the CME Answer And Evaluation Form distributed with the June and December issues, and return it according to the published instructions are eligible for up to 4 hours of CME credit for each issue.

• Online Single-Issue Program: Current, paid subscribers who read this Pediatric Emergency Medicine Practice CME article and complete the test and evaluation at www.ebmedicine.net/CME are eligible for up to 4 hours of CME credit for each issue. Hints will be provided for each missed question, and participants must score 100% to receive credit.

Hardware/Software Requirements: You will need a Macintosh or PC with internet capabilities to access the website.

Additional Policies: For additional policies, including our statement of conflict of interest, source of funding, statement of informed consent, and statement of human and animal rights, visit http://www.ebmedicine.net/policies.

Pediatric Emergency Medicine Practice Has Gone Mobile!

You can now view all Pediatric Emergency Medicine Practice content on your iPhone

or Android smartphone. Simply visit www.ebmedicine.net from your mobile

device, and you’ll automatically be directed to our mobile site.

On our mobile site, you can:

• View all issues of Pediatric Emergency Medicine Practice since inception

• Take CME tests for all Pediatric Emergency Medicine Practice issues published within the last 3 years – that’s over 100 AMA Category 1 CreditsTM!

• View your CME records, including scores, dates of completion, and certificates

• And more! Check out our mobile site, and give us your feedback! Simply click the link at the bottom of the mobile site to complete a short survey to tell us what features you’d like us to add or change.