A new study suggests that EDs that have a pediatric emergency care coordinator (PECC) — a physician or nurse who is assigned to address staff training, equipment, and policies pertaining to the care of children — are better prepared to meet the needs of young patients than EDs that do not. This is among the findings gleaned from responses to a web-based assessment designed to measure compliance with national guidelines for pediatric readiness.1
The assessment, which was conducted between January and August 2013, is part of a collaborative quality-improvement initiative of the American Academy of Pediatrics (AAP), the American College of Emergency Physicians (ACEP), and the Emergency Nurses Association (ENA). Researchers received completed assessments from 4137 EDs for a response rate of 82.5%. They found that pediatric readiness, as defined by a weighted pediatric readiness score (WPRS), has improved markedly since a similar assessment was conducted in 2003. Overall, pediatric readiness increased to 70 out of 100, an increase of 15 points from the 2003 assessment. At the same time, the response rate to the survey greatly improved as well, as only 29% of the EDs queried in the earlier survey responded.
Investigators say the presence of a PECC was associated with higher WPRS measures across all pediatric volume categories, and that a PECC also increased the likelihood an ED possessed all the components for quality pediatric care recommended in national guidelines.
“We do know that by having [a PECC] you are much more likely to have a quality improvement plan, which, is, in and of itself, a quality measure,” explains Marianne Gausche-Hill, MD, FACEP, FAAP, the lead author of the research and the director of Emergency Medical Services at Harbor-UCLA Medical Center in Torrance, CA.
Gausche-Hill adds that EDs with a PECC are also more likely to have all the recommended equipment as well as all of the recommended policies in place to care for young patients. “We know from our paper that the likelihood of having all the things that are specified in the guidelines is four times more likely if you have a PECC,” she observes.
This focused attention on pediatric care needs is important because while most community EDs see a high volume of adults, and become accustomed to the care needs of adults, they generally see far fewer young patients.
“Sick children are not high-volume for a large majority of hospitals, even though more than 80% of children are seen in non-children’s hospitals in emergency settings,” Gausche-Hill notes. “So we have to, from a systems perspective, address the needs of children, and really the way we do that is by assigning these [PECC] roles.”
Gausche-Hill adds that while much depends on the resources and support that a PECC receives in a given ED, the research shows having a PECC makes a difference, although just under half of the nation’s EDs actually have someone filling this role, according to investigators.
Leverage networking opportunities
The role of PECC was originally created more than 20 years ago in Los Angeles. The precise title given to someone who assumes this role varies from region to region, but in Los Angeles, PECCs are referred to as pediatric liaison nurses, explains Nancy McGrath, MN, RN, CPNP-AC/PC, a pediatric nurse practitioner who has assumed this role at Harbor-UCLA Medical Center.
Here, having a pediatric liaison nurse is one of the requirements for having an EDAP designation, signifying the ED is approved to care for pediatric patients. Hospitals in Los Angeles are surveyed every three years to maintain the EDAP designation.
However, beyond the survey, McGrath acknowledges the success of the PECC/nurse liaison role depends both on support from administration and time to do the job.
“We do quality improvement, education for staff, and we attend hospital meetings that pertain to pediatric emergency care,” McGrath notes. “We also attend monthly pediatric liaison nurse meetings with the other 46 pediatric liaison nurses for Los Angeles County.”
This type of networking helps to insure that advances in quality and safety get disseminated to all the EDAP facilities quickly. For instance, McGrath recalls that when the ACEP and ENA both came out with position papers stating that all children should be weighed in kilograms, since medication dosages are based on weight in kilograms, McGrath made sure that all the scales in the ED were locked on kilograms. “We had them disabled so that they couldn’t weigh kids in pounds,” she says. “In Los Angeles County, at our monthly meeting of the pediatric liaison nurses, we shared this information, and then all of the facilities did the same thing, so kids in Los Angeles County are not weighed at all in pounds in any of the EDAP facilities.”
In addition to these activities, McGrath sits on a pediatrics advisory committee that oversees all the policies and procedures for the care of children in the pre-hospital arena. “You sometimes have to go the distance to find what is new and what is happening so that you can bring it back to your staff,” she explains.
Facilitate education
Laura Garcia, RN, the pediatric liaison nurse at PIH Health, a community hospital in Whittier, CA, agrees the networking meetings offer tremendous value.
“You don’t have to re-create the wheel every time. Within our pediatric liaison group we share policies, standards, and any new articles that are coming out,” she says. “I work at a community hospital, so I don’t have the resources that a children’s hospital has. I need to find out what they are doing and how I can best meet the same goal of care.”
Garcia spends much of her time doing chart audits and identifying problems so she can then set about the task of taking corrective action and educating staff on the change process. For instance, when a young pediatric patient who had presented to the ED later developed sepsis, Garcia spearheaded an educational initiative on septic shock for all the nurses and physicians in both pediatrics and the ED, and she worked with colleagues to implement the practice of running an early warning score for sepsis on all patients before they are transferred from the ED to an upper floor.
“In addition to that, we have now changed our practice in the entire ED so that every patient who comes through gets a sepsis screening exam on presentation,” she explains.
In addition to quality improvement activities, Garcia hosts educational conferences on pediatric issues every other year, and she runs through mock codes with nurses so they will be prepared to make use of tools or equipment designed for patients or events that do not occur that often.
“I also keep track of everyone’s education to make sure they are complying with the standards we have,” she explains. “It is a day in and day out type of thing. You have to live this role and not just try to make it about the survey.”
Keeping the focus on readiness
While investigators saw much improvement in pediatric readiness in the latest assessment, the exercise also highlighted areas that require attention. For instance, less than half of respondents (47%) reported having a disaster plan that specifically addresses the needs of children, at least 15% said they lacked at least one specific piece of equipment recommended in the guidelines, and more than 80% reported facing barriers to the implementation of the guidelines. The most common barriers cited were training costs and a lack of resources.
However, Gausche-Hill observes that simply doing the assessment should spur improvement in many of these areas.
“More than 80% of EDs are now aware these guidelines exist and that perhaps they should follow them,” she says. “We gave [respondents] immediate feedback, including a gap analysis with the top three things they needed to do to improve their readiness.”
In addition, Gausche-Hill notes respondents were also equipped with resources for improvement so that they would not have to start from scratch. She says the goal for the future is to keep re-evaluating and providing feedback so EDs can continue to make strides on pediatric readiness.
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Gausche-Hill M, et al. A national assessment of pediatric readiness of emergency departments. JAMA Pediatr 2015;169:527-534.
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Laura Garcia, RN, Pediatric Liaison Nurse, PIH Health, Whittier, CA E-mail: [email protected].
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Marianne Gausche-Hill, MD, FACEP, FAAP, Director, Emergency Medical Services, Harbor-UCLA Medical Center, Torrance, CA. E-mail: [email protected].
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Nancy McGrath, MN, RN, CPNP-AC/PC, Pediatric Nurse Practitioner/Liaison Nurse, Harbor-UCLA Medical Center. E-mail: [email protected].
