Measure quality of pediatric care or risk 'disastrous' consequences

Most quality initiatives focus only on adults

Do you have an effective system in place to evaluate the quality of care received by children at your organization? If not, you may find dangerous inconsistencies, lack of equipment, and inadequate training, according to several recent studies that have reported on quality problems with pediatric care. In addition, quality measures and performance improvement (PI) initiatives typically focus on adults and leave out children, say experts in pediatric care.

In one study, only 6% of 1,489 emergency departments surveyed had all the equipment recommended by the American Academy of Pediatrics (AAP)/American College of Emergency Physicians. Half lacked laryngeal mask airways used for ventilating children, only 12% had vascular access supplies for children, and 17% lacked Magill forceps for removing foreign bodies from a child's airway.1 A 2006 Institute of Medicine report concluded that EDs are not well equipped to care for children, and that most children are cared for at general hospitals, which are less likely to have pediatric expertise, equipment, and policies.2

A 2003 study got a lot of attention when researchers reported that only 54.9% of adult care adhered to recommended processes, but a subsequent study, published in 2007, found that the percentage was even lower (46.5%) for children, based on 1,536 medical records from pediatric patients in 12 metropolitan areas.3,4 Children received 67.6% of the indicated care for acute medical problems, 53.4% of the indicated care for chronic medical conditions, and 40.7% of the indicated preventive care.

"Everyone assumed that care for kids wouldn't be worse than adult care, but in fact it is," says Charles Homer, MD, CEO of the Cambridge, MA-based National Initiative for Children's Healthcare Quality (NICHQ). "It's becoming clear that there is actually an even greater problem with kids. And I do think that it is starting to get people's attention."

The consequences of poor quality pediatric care are "disastrous," says Ameer Mody, MD, MPH, clinical director for pediatric emergency medicine at Children's Hospital of Orange County, CA. "The wrong-sized equipment in a child's resuscitation can be life-threatening."

Pediatric patients have always been a challenge for hospitals, largely because there are so many variables when caring for children of different sizes and ages, whereas adult care is more standardized, says David Jaimovich, MD, chief medical officer of Joint Commission Resources, which recently launched a consulting program to help hospitals improve the safety of ED services for children. Normal vital signs differ depending on the child's age, medications are weight-based and not standardized, and infants and young children are unable to communicate with health care providers, he notes.

Though much of the recent research has focused on the ED, other areas of the hospital are also at risk for giving poor care to children. "There really isn't one specific area that is immune to quality issues in pediatric patients," says Jaimovich. "It really transcends all departments and permeates into every area, from radiology to laboratory."

He gives the example of the ability to perform microsampling for an infant, so that 5 ML of blood is not needed for a simple lab test. "That would be nothing for adults, but it may be a lot for a 3-kilogram baby who comes to the ED in respiratory distress," says Jaimovich.

There is no question that someone trained in adult medicine is much more comfortable caring for a 55-year-old patient with respiratory distress than a 5-month-old infant, says Jaimovich. "The needs of the infant are different, the size of the equipment is smaller, and the training and skills that are necessary for the staff to care for that child are different," he says.

Attention is increasing

Quality problems with pediatric care are getting increasing attention, and that is likely to continue. "Sometimes it takes something catastrophic for the media to put a spotlight on something," says Mody. "It may take one case that finds the right media outlet."

And in November 2007, a much-publicized story broke about actor Dennis Quaid and his newborn twins. The two, along with a third pediatric patient, received an overdose of the anti-clotting drug heparin at Cedars-Sinai Medical Center in Los Angeles. The year before, three infants died after receiving an adult dose of heparin at an Indianapolis hospital.

"People are beginning to understand that there are special issues for kids that we need to pay attention to, such as dosages and mislabeling," says Homer. "The stories that grab peoples' heartstrings are often pediatric stories, because there is nothing more tragic than error harming a child. But while those stories get people's attention, the systematic strategies to address them tend not to address kids' issues."

The recent medication events in neonates with heparin shine a light on an important issue, says Karen Cox, RN, PhD, FAAN, executive vice president/co-chief operating officer at Children's Mercy Hospitals and Clinics in Kansas City, MO: Infants and children are not "little adults."

"A medication error that would be insignificant in an adult could have potentially devastating results in a child," she says.

In any hospital, large or small, where children make up a small percentage of patients, they are cared for in a place surrounded by systems, equipment, medications, and clinicians who for the most part are focused on adults. "These hospitals must insure that care to this vulnerable population is separate and pediatric-specific," says Cox. "It is not so much limited resources as the wrong kind."

The Institute of Medicine's landmark 1999 report, To Err is Human, which estimated that up to 100,000 people die each year because of preventable medical errors, was a huge wake-up call for the public and jump-started many quality initiatives, but it was focused only on adult care, says Homer.5

"The fact is that the same deficiencies apply to kids. And in fact, care of children may be even more error prone, because of the variable weights of kids, lower frequency of many conditions, and the fact that most systems such as medication administration systems and computerized physician order entry really aren't designed for kids," he says. "The attention paid to the quality of care of kids is long overdue."

Separate pediatric measures on the horizon?

Hospitals are required by the Centers for Medicare & Medicaid Services (CMS) to report compliance with numerous quality measures to show that adults with stroke, chest pain, pneumonia, and other conditions are getting evidence-based care, but no such system exists for children. "Medicare has a huge influence on the quality of care. But the reality is with children, there is not a big payer that can influence things at a national level," Mody says. "If hospitals don't see many children, it's more challenging to have systems to monitor the care. There is also a financial element — pediatric visits don't make the hospital a lot of money."

Children's health care is not a major source of expense or revenue for general hospitals, where attention and resources tend to be funneled into areas where the cost of care is greatest, says Homer. "The federal government has powerful leverage over the adult health care system, and Medicare has many innovative initiatives around quality," he says. "But while the federal government pays a very large amount for children's health care through Medicaid, it hasn't taken the same leadership role in developing models, which the private insurers would then emulate."

Currently, Joint Commission standards cover all ages and don't specifically address niche populations such as pediatrics. "It may be that at some point in time we may look at that, and whether we need to create a safer environment for pediatric patients," says Jaimovich.

A consortium of organizations, including the AAP, is advocating for separate quality measures to be developed for pediatric patients by The Joint Commission and the National Quality Forum. "My belief is that if CMS were to drive this program, then we'd start to see private insurers following their lead. And then we would see some interest on the part of The Joint Commission," says Homer.

As it stands now, pediatric care is usually not evaluated at hospitals. "They are clearly not measuring this," says Homer. "I've had many conversations with hospital CEOs and everyone says they care deeply about children. But from their perspective, this is just such a small portion of their overall mission and business. And there are competing priorities."

Do a baseline assessment

To assess the quality of pediatric care at your organization, "start from the ground floor up," says Mody, and examine equipment and supplies, staff training, policies, support services, and quality improvement processes.

The first step is to do a baseline self-assessment and answer these questions, says Jaimovich: What is our leadership doing to create a safe environment for pediatric patients? How do our policies impact the care of pediatric patients? What pediatric training do medical and nursing staff have? What about the entire team caring for an infant —does the nurse have the education to make sure medication is provided in a safe and effective manner? Is the pharmacy equipped to handle microdosages depending on the size of the patient?

"No one institution can be everything to everybody," says Jaimovich. "Organizations need tools, assistance, and education to help them with specific areas to meet the needs of the community they serve."

Designating a pediatric patient safety champion is one way to address this. Jaimovich recommends selecting someone with a clinical background who can take a leadership role "in the trenches."

A nurse or pharmacist with significant experience in pediatrics would be ideal for this role, says Cox. "If there is not enough for full-time work specific to pediatrics, they could do other things within the quality department," she says. "However, they would always be expected to be an advocate for issues specific to children."

The champion would provide the organization with a "very distinct process for QI in the pediatric area," Jaimovich says. For example, if the champion discovered near misses in the medication management area, he or she would work with pharmacy to create a safety initiative to prevent it from happening again, and then revisit it to measure improvements.

The pediatric champion's role should be incorporated into the hospital's overall quality improvement system, says Homer. "The institution needs somebody whose paid job includes specific responsibility for pediatric safety," he underscores.

Look at the National Patient Safety Goals with an eye toward children and their specific needs, says Cox. For example, pain management requires a number of valid and reliable tools to assess pain at different ages, and when establishing a patient fall program, the focus has to be much different for pediatric patients. "There are issues with adolescents who may be embarrassed to ask for help to the bathroom," she says. "Approaches to risk mitigation have to be developmentally based."

Cox recommends benchmarking with other organizations and sending staff to the NICHQ's annual forum. "Using trigger methodology on 100% of pediatric health records has been shown to yield higher numbers of adverse events than traditional incident reporting systems," adds Cox.


  1. Gausche-Hill M, Schmitz C, Lewis RJ. Pediatric preparedness of US emergency departments: A 2003 survey. Pediatrics 2007; 120:1229-1237.
  2. The Institute of Medicine. Emergency care for children: Growing pains. Washington, DC: National Academy Press, 2006.
  3. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348:2,635-2,645. 
  4. Mangione-Smith, DeCristofaro AH, Setodji CM, et al. The quality of ambulatory care delivered to children in the United States. N Engl J Med 2007; 357:1515-1523.
  5. Institute of Medicine. To err is human: Building a safer health system. Washington, DC: National Academy Press, 1999.

[For more information, contact:

Karen Cox, RN, PhD, FAAN, Executive Vice President/Co-Chief Operating Officer, Children's Mercy Hospitals and Clinics, 2401 Gillham Rd., Kansas City, MO 64108. Phone: (816) 234-3933. Fax: (816) 346-1333. E-mail:

Charles Homer, MD, CEO, National Initiative for Children's Healthcare Quality, 20 University Rd., 7th Floor, Cambridge, MA 02138. Phone: (617) 301-4881. E-mail:

Ameer Mody, MD, MPH, Clinical Director, Pediatric Emergency Medicine, Children's Hospital of Orange County, 455 S. Main St., Orange, CA 92868-3874. E-mail:

A 2007 report from The Institute of Medicine entitled Emergency Care for Children: Growing Pains covers pediatric emergency care planning, preparedness, coordination and funding, and pediatric training in professional education. To order the report, contact: The National Academies Press, 500 Fifth Street NW, Lockbox 285, Washington, DC 20055. Phone: (888) 624-8373 or (202) 334-3313. Fax: (202) 334-2451. E-mail:

A December 2007 American Academy of Pediatrics policy statement gives recommendations for improving safety for pediatric patients in emergency departments. To obtain a copy of the policy statement at no charge, go to the AAP web site:]