Best practices available for pediatric emergencies

How does your facility measure up?

Two multidisciplinary task forces representing leading professional associations and health care organizations recently released national guidelines for equipment in pediatric emergency departments (EDs) and a report on the educational needs of paramedics. Both efforts were convened by the Maternal and Child Health Bureau in collaboration with the National Highway Traffic Safety Administration as part of the Emergency Medical Service for Children program. (See list of organizations, below.)

The guidelines represent the first national consensus on what constitutes minimum equipment and supplies to care for pediatric patients in the ED, says Marianne Gausche, MD, FACEP, FAAP, associate professor of medicine and director of emergency medical services at Harbor-UCLA Medical Center. (See pp. 46-47.) Gausche served on both task forces.

She and the guidelines chair, James S. Seidel, MD, PhD, professor of pediatrics at the UCLA School of Medicine, explain how the consensus was reached. First, the guidelines task force determined that the list should represent minimum equipment and supplies. "We knew they had to allow for modification in order to address different severity levels of patient populations," he says. "For example, an emergency department with a high volume of ill and injured pediatric patients may need additional items."

The committee decided the list should not reflect what is needed in a pediatric tertiary care facility. It further narrowed the list by excluding routine equipment and supplies found in all EDs for care of adults and children, such as oxygen, tape, and dressings. Then the committee used templates of seven published lists and rated each equipment or supply item as "essential," "desirable," or "not needed," Gausche says. "Essential means the item is necessary and should be in the ED. A desirable item is worth having and may improve care, but its use depends on cost, policy, and staff's scope of practice," she says. "We were also given the opportunity to add any item we believed was necessary but not on the templates."

After tabulating the results, the committee reviewed areas of agreement and disagreement. "Those items with 90% or greater agreement were placed on the new list. Those with less than 90% agreement were discussed until we reached consensus on their inclusion or exclusion," she says.

The list also included drugs for cardiopulmonary resuscitation that reflected guidelines from the American Heart Associa tion. "We agreed that more extensive drug lists depend on the scope of practices of the staff as well as the pharmacy and therapeutics committee of the individual hospital." (See pediatric resuscitation medications, p. 45.)

But having all the items on the new list doesn't ensure staff will know how to use them, she says. "The guidelines are just a beginning. We're saying `Here's the list; check and see not only if you have it, but if you know how to use and use it quickly.'"

At Harbor Medical Center, for example, which already has listed items, a multidisciplinary team has just begun exploring whether the ED can do a better job of organizing and using the equipment, medication, and supplies. "During a pediatric resuscitation is not the time to discover where certain items are located or how they are used," says Seidel, who suggests "mock codes" for staff as they learn to find and use the list's items.

While you are evaluating equipment, supplies, and their organization and usage, don't forget the first line of pediatric defense: emergency medical service providers.

The second task force developed a report called Education of Out-of-Hospital Emergency Medical Personnel in Pediatrics: Report of a National Task Force, which identified essential topics and skills that should be included in paramedic education. Essential topics are patient assessment, child abuse and neglect, and infants and children with special needs. Essential skills include bag-valve-mask ventilation techniques and endotracheal intubation.

"When we looked in paramedic registry, these were the areas that pediatric paramedics felt were most important," Gausche says. "It's important for them to have pediatric information included in their education because originally paramedic practice developed around trauma and cardiac care for adults - not for children."

For example, a previous research project of Gausche's found that paramedics were not as competent in obtaining children's vital signs as they were for adults.

Teaching methods are critical

In assessing the educational component for your facility's paramedics, Gausche suggests not only examining the curriculum to make sure the essential topics and skills are covered but finding out how they are taught. "The material should be presented through cases, scenarios, and real-life presentations rather than didactic lecture," she explains. "Instead of giving them facts, teach them how to problem solve given the informa -tion they have available in the field."

The focus also should be on patient assessment. "Instead of teaching them about meningitis, teach them about altered mental status and fever; they need to know how the child will present in the field," she says.

Traditionally, paramedic education has been diagnosis-based. "The problem with that is that there is little opportunity to establish a diagnosis. What they can do is recognize signs and symptoms." The curriculum also should have well-defined objectives, lesson plans, and consistent and reliable evaluation tools, she adds.