It’s been nearly 10 years since the Institute of Medicine (IOM) issued a report stating that hospitals needed to be better prepared for the smallest and youngest patients when they came into their emergency departments (available at http://www.iom.edu/Reports/2006/Emergency-Medical-Services-At-the-Crossroads.aspx).
Initial studies found that as few as 12% of hospitals had the recommended physician coordinators trained to deal with emergent cases. But a new study in the April issue of JAMA Pediatrics shows that hospitals are increasingly getting on board with this and other recommendations.
The IOM report included recommendations to appoint two pediatric emergency care coordinators (PECCs), at least one of whom was a physician. This and later guidelines for emergency preparedness for pediatric patients led to the National Pediatric Readiness Project (pediatricreadiness.org), suggesting hospitals have adequate pediatric-sized equipment, that staff be adequately trained in its location and use, and that quality improvement and patient safety efforts include thinking about pediatric patients.
Where are the stats?
The lead author of the current study, Marianne Gausche-Hill, MD, FACEP, FAAP, a professor of clinical medicine and pediatrics at UCLA’s David Geffen School of Medicine and the vice chair of the division of pediatric emergency medicine and director of that department at Harbor-UCLA Medical Center, looked at uptake of the recommendations in 2007 and found that only 18% had physician PECCs, and 12% had a nurse PECC. Other studies that included data from about 5% of US hospitals responding had similar results.
Yet there is hope
Things are improving, though, says Gausche-Hill. The results of the current survey on emergency readiness for pediatric patients, which came from an astounding 83% of US hospitals, found that 47% had a physician PECC, and almost 60% had a nurse. Just over 40% had both. Higher volume hospitals had emergency trained physicians while smaller facilities tended to have family physicians caring for children.
Findings
Other key findings from the study:
• Most respondents reported that staff knew where pediatric equipment was kept and had a cheat sheet, software, or another tool to help ensure they were using the proper size or giving the proper dose to these young patients.
• However, some important pediatric-sized equipment was missing in 15% of hospitals, according the study: laryngeal mask airways, umbilical vein catheters, central venous catheters, tracheostomy tubes, size 00 laryngoscope blades, continuous end-tidal carbon dioxide monitoring equipment, pediatric Magill forceps, and infant and child nasopharyngeal airways.
• One issue that continues to be a problem with pediatric patients – and which was highlighted in the cover story on patient safety hazards – is the tendency for many physicians to weigh patients in pounds and thus have to convert to kilograms for pediatric medications that are weight-based. A third of the respondents reported they do not routinely weigh pediatric patients in kilograms, and thus have to do conversions.
• Pediatric patients aren’t usually considered in QI projects for the ED, the survey found, with just 45% of respondents noting they have a plan that focuses on children at all. Of those, 58% have child quality indicators, 88% collect and evaluate data, 79% have a plan for addressing non-standard care, and 73% look at outcomes based measures like pain relief.
• More than half of the EDs report they do not consider children in their disaster plan, with even the highest volume hospitals faltering in this area. Just over two-thirds of those consider the special needs that pediatric patients might have in the event of a disaster. About 70% have pediatric transfer guidelines, and just under 90% have a child maltreatment policy.
The most important finding was that the most advanced hospitals in terms of pediatric readiness were the ones that had PECCs, says Gausche-Hill. If they did not have a PECC, there was little chance a facility was going to show readiness for pediatric emergencies, regardless of pediatric patient volume.
Barriers
The biggest barriers to implementing the guidelines reported by respondents were lack of awareness of them, as well as the cost of training. Just about everyone who responded expressed interest in implementing them fully.
Gausche-Hill says that while she did not look at outcomes as they related to complying with these guidelines, there is evidence that without them, there is a lack of quality. “The highest prepared hospitals have great quality,” she says.
And these recommendations aren’t reaches for hospitals, she continues. “These are minimal standards. It does not cost anything to weigh children in kilograms. No one should be doing conversions. If you weigh only in kilos, there will be no problem.”
Including children in your quality improvement indicators also does not add cost, and can potentially improve care and reduce risk. Ask your risk manager what patients bring the most litigation and see where pediatric patients fall on that list. Gausche-Hill says that bringing the best quality, safest care to those patients makes sense.
Gausche-Hill says the fact that they had such a large respondent base makes her confident in her findings, and hopeful that even the hospitals that are not currently ready are willing to get ready now. “They are very engaged in the ideas behind this,” she says. She knows that is true because there are many organizations that have made changes since first taking the survey and want to retake it. She is considering ways to keep the web portal where she asked for responses open.
She suggests that those with a desire to improve their pediatric readiness start at the National Pediatric Readiness Project website.
Editor’s Note: For more information on this topic, contact Marianne Gausche-Hill, MD, FACEP, FAAP, Director Pediatric Emergency Medicine and EMS Fellowships
Harbor-UCLA Medical Center, Department of Emergency Medicine, Torrance, CA. Telephone: (310) 222-6740.
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Gausche-Hill M, Ely M, Schmuhl P, Telford R, Remick KE, Edgerton EA, Olson LM. A National Assessment of Pediatric Readiness of Emergency Departments. JAMA Pediatr. 2015 Apr 13. doi: 10.1001/jamapediatrics.2015.138
