optimal care for children in the emergency department

Did you know that of the approximately 119 million visits to an emergency department (ED) each year, nearly 20% are made by children? That means that nearly 24 million children are seen in EDs each year. There are nearly 4000 EDs in the US, and only a minority of those are in children's hospitals, or hospitals with pediatric training programs, or clearly identified pediatric ED's. Emergency care for children was identified by the institute of medicine (IOM) in 2003 as woefully in need of improvement. The IOM found that EDs often lack the expertise and equipment needed to provide appropriate care for childre during emergencies.

In 2009, a joint policy statement was published by the American Academy of Pediatrics (AAP), the Emergency Nurses' Association (ENA), and the American College of Emergency Physicians (ACEP), detailing ways to optimize the care of children who present to community hospitals in need of emergency care. You can read the statement by clicking this link:  joint_policy_statement_guidelines_care_of_children_emergency_department.

Because many of the issues noted by the IOM continue today, just this August the same group, in conjunction with the Emergency Medical Services for Children (EMSC) National Resource Center, and Children's National Medical Center in Washington, DC,  released a checklist ( ED_CHecklist_aap) to help guide all community hospitals that have a 24-hour service, regardless of how frequently they see pediatric patients, to know what they should have in the way of supplies, personnel and policies.

It is encouraging to me that the checklist starts with what is the most important aspect--personnel--that every hospital should have a physician coordinator and a nursing coordinator for pediatric care. It goes on to describe competencies for all physicians and nurses who will provide care to children in the ED, and what kind of quality improvement/process improvement activities ought to be in place to assure children are cared for optimally.

It talks about policies and guidelines for management of a variety of situations, and  only at the end does it mention equipment. In my experience, too often we believe if we have the equipment, we can handle the situation. In medicine it does not work like that. Without appropriate  knowledge and experience (in other words, well trained people), equipment and supplies can be useless.

Just this weekend, we received a few patients into our inpatient unit here at the Carilion Clinic Children's Hospital in transfer from community hospitals. Parents told me that they were happy to be in our hospital because of issues with obtaining the proper equipment, or providing the necessary therapy for their children. Our transport team, made up of nurses and respiratory therapists with specialized training in emergencies, critical illness and trauma in neonates and children, often is asked to move those patients from the referring hospital ED or elsewhere to our hospital. Our physicians are available to provide input and guidance at all times.

The five pediatric tertiary centers in the Commonwealth of Virginia--Inova/Fairfax, Children's Hospital of the Kings Daughters, VCU, UVA and Carilion, all participate in regional tranport arrangements to assist patients in moving as safely and rapidly as possible when the need arises.

In addition, due to one of my very special interests--disaster preparedness for children--we have been able, here at Carilion, to help discuss preparations for a variety of types of unexpected emergencies in children. A few years ago through a grant from the  office of the Assistant Secretary for Preparedness and Response (ASPR), we ran a conference and "tabletop" scenario for participants from many area hospitals as well as local community agencies such as the schools, health departments, fire, police and rescue, daycare centers, etc, to help prepare these groups to identify the needs of children during a disaster.

This fall, we will be embarking on a program aimed at identifying and training "pediatric champions" throughout  Southwest Virginia, again through a grant from ASPR. We will bring the physician and nursing pediatric champions together for didactic training, and most importantly, hands-on experience with pediatric patients and equipment.

I am delighted that we will be able to do this, and looking forward to being able to share our expertise with those in our communities who are often the first to see and respond to a child who is in need of definitive care for acute and critical illness and injury.

I would love to hear comments from those of you in the community, regarding the potential usefulness of the checklist, and I would love to hear from anyone concerning how we can continue to improve emergency care and disaster preparedness for children in our region.

Comments

Our Pediatric Transport Team did two outreach programs yesterday. They visited the ED programs at Bedford Memorial and Lynchburg General Hospital. These visits are opportunities to build an onging and collaborative relationships with our regional ED's with mulitple goals in mind. First and foremost is to aid these programs in insuring their capabilities in managing pediatric emergencies whether they be medical or surgical in nature. This includes discussions of equipment, technology, personnel, best-evidence protocols and training. We reinforce these discussions by reviewing real cases that arrive to their ED and require transport to our facility.
I must say that many of our regional ED's have done outstanding jobs at addressing these challenges over the past decade and it shows in their ability to stabilize pediatric patient while preparing for transport to our or other tertiary centers. Programs such as PALS and APLS have also assisted in this effort over the years.
That said the major challenge for the smaller regional ED's are few index cases of critical illness in the pediatric age group.
I think other ways to improve the care and preparedness in these facilities is to begin to employ the technologies we have available to bring more expertise to the bedside, ie, telemedicine. This will add another layer of support to assist the regional ED's with a live feed.
Regionalization of pediatric critical care is anothe approach that aids in the process that Dr. Ackerman has addressed in her post. Improved collaboration, coordination and communication within our region to support our regional ED's care for the sickest children is an ongoing challenge.

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