Are you really ready for any child in your ED? New guidelines can tell you
Are you really ready for any child in your ED? New guidelines can tell you
Make your emergency nursing care consistent
If a woman came to your ED with suspected stroke or acute myocardial infarction, her treatment would be based on standards of care from Centers for Medicare & Medicaid Services (CMS) and The Joint Commission. "But those haven't been established yet for children," says Michael Vicioso, RN, MSN, CCRN, CPEN, pediatric nurse manager of the ED at Children's Hospital of Orange County in Orange, CA. "There is much more variability in treatment in the pediatric world than the adult world."
New guidelines on care of children in the ED have been published jointly by The American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association (ENA). According to ENA president-elect Diane Gurney, RN, MS, CEN, ED nurses should use the guidelines "to address safety issues with regard to staffing, equipment, medication administration, patient identification issues, and other processes that support pediatric patient care."
As an ED nurse, "your professional responsibility is to be prepared to handle anything that walks in the front door, whether your hospital supports you in that or not," warns Vicioso. "Community EDs don't have the same resources they have in the big centers. You have to figure out how to take care of patients without all the bells and whistles. The question may be, 'What can I do with what little I have to save this patient's life?'"
Less than 10% of the patients seen by ED nurses at Philadelphia-based Thomas Jefferson University Hospital are children. "The challenge is for each and every ED nurse to get hands-on experience in caring for pediatric patients and feel comfortable with the care of these patients as well as the pediatric equipment," says Jenny Bosley, RN, MS, CEN, ED clinical nurse specialist. "We do not have a designated pediatrics section or room in the ED. Therefore, any ED nurse, at any given time, may be faced with caring for an acutely ill or injured child."
To improve care of pediatric patients in your ED:
• Ensure nurses receive hands-on experience with rarely used equipment.
The guidelines state that pediatric equipment, supplies, and medications should be appropriate for children of all ages and sizes and easily accessible. "Once you get the proper-sized equipment and it's available to you and your ED is fully stocked, do you know how to use it? The next step is to do a lot of drills and mock codes," says Vicioso. "That's really the meat of what's going to take your community hospital up to the level that's needed to care for pediatric patients."
He says to "do whatever it takes to get familiar with it, because the one or two times that you need to use it, will really have an impact on that patient's life."
Vicioso notes that it isn't very often that a community ED nurse is confronted with a decompensating pediatric patient with a known congenital anomaly. For example, children with congenital heart defects or children with metabolic disorders who are in acute crisis will present to smaller community EDs.
"They sometimes present with a similar profile to sepsis or acute gastroenteritis," says Vicioso. "Unless you are looking for these particular diseases and some of the subtle findings associated with them, you may miss the diagnosis or not provide the appropriate care."
ED nurses might be unfamiliar with devices such as an intraosseous drill for placing an intraosseous needle in a decompensating child, or they might be unable to recognize the proper size endotracheal tube for a child with Down syndrome. "[Short] change-of-shift briefings on evidence-based practices and treatment modalities, as well as case study presentations, have helped some facilities keep up with the latest trends," says Vicioso.
• Use standing orders.
Thomas Jefferson's ED nurses can implement orders to initiate care for pediatric fever, sickle cell crisis, and pediatric extremity injury. "These save time and decrease ED throughput for all ED patients," says Bosley.
• Review "missed opportunity" cases.
At Thomas Jefferson's ED, pediatric cases involving delayed care or improper dosages by ED nurses are flagged by the hospital's department of pediatrics. "Feedback is then shared one-on-one with the providers," says Bosley.
• Make age-appropriate supplies easier to find.
The guidelines specify that pediatric supplies must be "clearly labeled, and safely and logically organized." Thomas Jefferson's ED nurses are redesigning their pediatric supply cart to make locating and restocking equipment simpler. Baskets are being added to the side of the cart to store commonly used items such as bag valve masks and manual ventilation systems. "Once this is complete, the ED nursing staff will be inserviced on the new setup of the cart," says Bosley.
• Make weight-based dosages easier.
Vicioso says, "The weight based-issue is what separates pediatric care from adult ED care. Children need different size equipment and different dosages of medication."
ED nurses at Thomas Jefferson use a code sheet that lists all the dosages for medications that would be used in a code for a particular weight. "For example, a sheet for a 20 kg child has the specific dosages for epinephrine, lidocaine, and atropine, for that child's weight," says Bosley. [A sample code sheet used by Thomas Jefferson's ED nurses is included.]
Sources
For more information on improving pediatric ED care, contact:
- Jenny Bosley, RN, MS, CEN, Clinical Nurse Specialist, Emergency Department, Thomas Jefferson University Hospital, Philadelphia. Phone: (215) 955-2656. E-mail: [email protected].
- Gabe Campos, RN, MS, CEN, Clinical Nurse Educator, Emergency Departments, The University of Chicago Medical Center. Phone: (773) 702-1927. Fax: (773) 702-2837. E-mail: [email protected].
- Maria Christensen, RN, St. Joseph's Children's Hospital, Paterson, NJ. E-mail: [email protected].
- Alfred Sacchetti, MD, FACEP, Emergency Department, Our Lady of Lourdes Medical Center, Camden, NJ. Telephone: (856) 757-3803. E-mail: [email protected].
- • Barbara Schuessler, RN, BSN, MSN, MBA, Emergency Department, University of Iowa Hospitals and Clinics, Iowa City. Phone: (319) 356-2233. [email protected].
How you can address pediatric-specific training New guidelines on care of children in the ED, published jointly by The American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association, say competency evaluations for ED nurses should be age-specific and include neonates, infants, children, adolescents, and children with special health care needs. Barbara Schuessler, RN, BSN, MSN, MBA, an ED nurse at University of Iowa Hospitals and Clinics in Iowa City, says "while we do not have any protocols or standing orders for pediatric patients, we have high educational and skill set standards for the nurses working in our ED." All ED nurses are certified in Emergency Nursing Pediatric Course (ENPC), Trauma Nursing Care Course (TNCC), and advanced cardiac life support (ACLS). "We have two 12-hour educational retreats every year covering a broad range of topics, including best practices for the pediatric patient," adds Schuessler. ED nurses recently covered pediatric sedation, pediatric resuscitation, and proper pediatric medication dosages, and they attended a skill lab on heel sticks. Michael Vicioso, RN, MSN, CCRN, CPEN, ED pediatric nurse manager at Children's Hospital of Orange County in Orange, CA, says that on blogs and listservs, "there's a lot of debate on which course is best: ENPC vs. pediatric advanced life support [PALS]. But ultimately, if you take something and then apply it to your workplace, the information you're going to get there is going to be accurate and evidence-based." Both courses provide basic fundamental elements of emergency pediatric care. "If forced to choose one, I would go with ENPC since it provides more than just the 'rescue' aspect of pediatric care," says Vicioso. At Thomas Jefferson University Hospital in Philadelphia, all ED nurses are required to maintain PALS certification. "Because we are a trauma center, all of our nurses are required to complete a minimum amount of trauma continuing education hours. This includes a minimum of two hours of pediatric trauma credits," says Jenny Bosley, RN, MS, CEN, ED clinical nurse specialist. ED nurses are also required to read a monthly article and complete a post-test on an age-specific topic, such as inhalant abuse by adolescents. "The nurse then prints the certificate out and hands it in for tracking," she says. |
Don't buy into these myths on ED nursing care of kids Every year, ED nurses at St. Joseph's Children's Hospital in Paterson, NJ, care for about 30,000 pediatric patients, which is far more children than the average community ED nurse sees. "The beauty of a pediatric ED is that all of the supplies and medications are specific to the pediatric population," says Maria Christensen, RN, an ED nurse at the hospital. "Appropriate sizes are readily available. Nurses are familiar with weight-based dosing and management of pediatric illness and injury." In looking at new guidelines on care of children in the ED, published jointly by The American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association, Alfred Sacchetti, MD, FACEP, chief of emergency medicine at Our Lady of Lourdes Medical Center in Camden, NJ, says, "The one message that comes through very, very clearly is: If you are going to be in a facility that hangs the word 'emergency' anywhere outside its door, you are going to encounter children. And you should be prepared for how to stabilize them." The guidelines don't say that every ED nurse should know all the latest developments on how to care for a child with special needs, such as a liver transplant. "But if you are an ED nurse, you should under the basic differences in physiology between the different age groups," says Sacchetti. Gabe Campos, RN, an ED nurse at University of Chicago Medical Center, says that while working at a general ED, he was intimidated by caring for the pediatric population. "So that became my challenge," he says. "Whenever I worked the pediatric rooms, I tried to learn as much as possible. Whenever there was a class geared toward pediatrics, I was there." Sacchetti warns that these two misconceptions involving ED nurses and pediatric patients can be dangerous: • Community ED nurses don't care for many children. "In fact, the vast majority of children are treated in community EDs," says Sacchetti. "That is something that general ED nurses kind of sell themselves short on. In fact, community nurses are the No. 1 providers of care for children in the United States." • ED nursing care in community EDs can't be as good as pediatric EDs. You might see a smaller volume of pediatric patients, but that doesn't mean that a child can't get good care in your ED. Sacchetti says there are some EDs that give poor care to children. "There's no denying they exist. But painting all community EDs with that broad brush stroke is dangerous," he says. "To tell ED nurses that 'you're not as good as a children's hospital' puts a kernel of doubt in the back of everybody's mind when a sick child comes in." Sacchetti says that in fact, community ED nurses "are as dedicated and as good as any nurses in big teaching hospitals. In fact, they tend to be a little bit less confident, and as a result, a little bit more careful with management of sick children. They tend to double- and triple-check their doses of medicine." |
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