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A child comes to the emergency department (ED) with abdominal pain and bruises on the legs and buttocks. A CT scan of the abdomen is negative for appendicitis, and his white blood cell count is normal. Child abuse is suspected immediately, and the boy is taken into protective custody.
The child is later found to have Henoch-Schonlein purpura, which is seen only in children between 4 and 10, says Barbara Weintraub, RN, MPH, MSN, pediatric critical care nurse practitioner at Northwest Community Hospital in Arlington Heights, IL. "These children can go on to have nephritis, nephrotic syndrome, and renal failure if the condition is not recognized and treated appropriately," she adds.
To avoid scenarios like this, you’ll need to comply with new guidelines for pediatric care. Care of Children in the Emergency Department: Guidelines for Preparedness was jointly published by the Dallas-based American College of Emergency Physicians (ACEP) and the Elk Grove Village, IL-based American Academy of Pediatrics (AAP).
If you don’t follow the guidelines, you face potential risk management problems, warns Marianne Gausche-Hill, MD, FACEP, FAAP, director of emergency medical services at Harbor-University of California at Los Angeles Medical Center in Torrance. "Certainly, not abiding by published guidelines creates potential liability," Gausche-Hill says. "For example, there would be no defense for not having the equipment necessary to care for children of all ages."
When national organizations publish guidelines, they tend to be interpreted in legal circles as standards, explains Weintraub. "You need to sit up and take notice of these guidelines," she urges. "Unfortunately, quality-of-care issues become litigation issues when the outcome is not good."
Following the guidelines will improve patient satisfaction and decrease poor outcomes, adds Weintraub. "This can help ensure consistent, quality, family-centered care for our smallest, most vulnerable patients," she says. "Parents expect that the care we give them will be specific to their child’s needs, and this is often not the case today."
Even if there is no adverse outcome, parents will not be happy if pediatric care is lacking in your ED, stresses Weintraub. She offers the following example: An 11-year-old boy presents with chest tightness. "This is a red flag for cardiac disease in the adult world, so he receives a chest X-ray and an ECG, both of which are read as normal, and the child is discharged," she says.
However, chest tightness in a child is more commonly respiratory-related, says Weintraub. "When the child returns later that afternoon to a pediatric ED with continued chest tightness, it is recognized that although wheezing couldn’t be heard, it was most likely due to decreased air entry," she says.
He receives an albuterol nebulizer treatment, with immediate relief of the chest tightness. "Although the parents are delighted that their child is better, they perceive that they wouldn’t have needed two visits had the ED staff at the first visit known kids better," she says.
Here are ways to comply with the guidelines:
• Find out if transport services are trained adequately.
Identifying the transport services with pediatric training is essential before you transfer seriously/ critically ill and injured children, warns Nancy Eckle, RN, MSN, program manager for emergency services at Children’s Hospital in Columbus, OH. You may be tempted to send a child with the first available transport service, she explains. "However, if the transport team is not trained in the care of children, changes in condition and needed interventions may not be recognized," Eckle says.
When assessing the team’s training, Eckle recommends asking the following questions:
• Designate a coordinator for pediatric emergency care.
The guidelines recommend that you have physician and nursing coordinators who will ensure that appropriate policies and procedures are in place, equipment and supplies appropriate for children are available, and a quality or performance improvement plan is in place.
The coordinator role can be a separate position or it can be an added role for a nurse manager or medical director, says Gausche-Hill. "These individuals ensure that the recommendations made in the guidelines would be appropriately addressed in the ED’s policies and procedures manual," she explains.
This recommendation, when followed, ensures that there is an identified person with a pediatric focus and expertise who can evaluate care issues, says Eckle. "That person is focused on the needs of pediatric patients in the ED, including staff education needs, equipment needs, and quality improvement," she adds.
At Northwest Community Hospital, the nursing coordinator recommends equipment and training needs, conducts inservices, and monitors pediatric quality improvement activities, Weintraub reports. "This individual ensures that the nursing care received by a pediatric patient anywhere within the emergency care continuum is research-based and family-centered," she says.
• Ensure that all staff members have appropriate pediatric training.
All emergency care providers must be able to evaluate and intervene for a child with an emergent condition, stresses Eckle. "Not being able to recognize an emergency condition and take the appropriate steps to stabilize the patient can cost the child his/her life," she warns. Age-specific competencies should include neonates, infants, children, and adolescents, she urges. (See table, below.)
|ED Guidelines for Physicians and Other Practitioners|
|•||Physicians staffing the emergency department (ED) have the necessary skill, knowledge, and training to provide emergency evaluation and treatment of children of all ages who may be brought to the ED, consistent with the services provided by the hospital.|
|•||Nurses and other practitioners have the necessary skill, knowledge, and training to provide nursing care to children of all ages who may be brought to the ED, consistent with the services offered by the hospital.|
|•||Competency evaluations completed by the staff are age-specific and include neonates, infants, children, and adolescents.|
|Source: American College of Emergency Physicians and the American Academy of Pediatrics. Excerpt of Care of Children in the Emergency Department: Guidelines for Preparedness. Ann Emerg Med 2001; 37:423-427.|
A report from Illinois Emergency Medical Services for Children (EMS-C) found that while 91% of ED physicians had taken an Advanced Cardiac Life Support (ACLS) course for adult resuscitation, only 63% had completed a pediatric equivalent such as Pediatric Advanced Life Support (PALS) or Advanced Pediatric Life Support (APLS). Similarly, 90% of ED nurses had completed an ACLS course, but only 35% had completed a formal pediatric resuscitation course.1 EMS-C is a Washington, DC-based national program to ensure that state-of-the-art emergency medical care is available for ill or injured children.
Weintraub recommends the Emergency Nursing Pediatric Course (ENPC) from the Des Plaines, IL-based Emergency Nurses Association as the "baseline" course for nurses. "It covers assessment, triage, and specific pediatric emergency conditions, as well as treatment of these conditions," she says. "It also addresses grieving, transport of ill children, trauma, and child abuse." (For information about pediatric courses, see "Pediatric ED resources," in this issue.) Weintraub also recommends that ED nurses take PALS, but notes that this course is more focused on the resuscitative aspect of pediatric care.
Research shows that in the vast majority of pediatric cases, if the assessment and treatment follow established guidelines, resuscitative measures will not be needed, she says. "Research also indicates that when children do require full resuscitation, the outcomes are even more dismal than for adults," she adds.2
All ED physicians should be PALS-certified and also should consider a neonatal resuscitation program certification, offered jointly by the AAP and the Dallas-based American Heart Association, adds Weintraub.
At Northwest’s ED, nurses are required to take ENPC, PALS, the Emergency Nurses Association’s Trauma Nursing Core Course, and 20 hours of pediatric-specific continuing education per year, says Weintraub. "We also offer a pediatric-specific IV skills lecture," she notes. "Even veteran ED nurses have indicated that this lecture has taught them new strategies."
[For more information about the guidelines, contact:
• Nancy Eckle, RN, MSN, Emergency Services, Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205. Telephone: (614) 722-4353. Fax: (614) 722-6890. E-mail: EckleN@chi.osu.edu.
• Marianne Gausche-Hill, MD, FACEP, FAAP, Harbor-UCLA Medical Center, 1000 W. Carson St., Box 21, Torrance, CA 90509. Telephone: (310) 222-3501. Fax: (310) 782-1763. E-mail: firstname.lastname@example.org.
• Barbara Weintraub, RN, MPH, MSN, Northwest Community Hospital, 800 W. Central Road, Arlington Heights, IL 60005. Telephone: (847) 618-5432. Fax: (847) 618-4169. E-mail: email@example.com.]
1. Illinois Department of Public Health. Illinois EMSC Needs Assessment Summary 1994-1995. Springfield, IL; 1996.
2. American College of Emergency Physicians and the American Academy of Pediatrics. Care of children in the emergency department: guidelines for preparedness. Ann Emerg Med 2001; 37:423-427.