Most ED nurses lack lifesaving pediatric equipment and training

Taking steps now could save a child's life

When a 2-year-old girl came to the Emergency Center at Carondelet St. Mary's Hospital in Tucson, AZ, with difficulty breathing and a bluish appearance, nurses set about preparing for an emergency tracheostomy to save the child's life. Suddenly, they determined a key piece of equipment was missing.

"We realized we didn't have a tracheostomy set small enough for this child — just adult sizes," says Diana Platt Lopez, RN, BSN, CCRN, CEN, the ED's clinical educator.

Fortunately, an airway was established without a tracheostomy, but otherwise the child could have died, she notes. As a result of that case, the ED ordered pediatric tracheostomy sets. "We split the cost with the OR since they were fairly expensive and there's a slim likelihood of needing them often," says Lopez.

Like most EDs, St. Mary's sees only a few children each year with significant airway problems, says Lopez. "Usually the physicians can intubate; but in this case, they were worried that intubation might not be successful due to an epiglottitis," she says. "In that case, you only get one pass at intubation. If not successful, you are left with few options."

When a very sick or seriously injured child comes to your ED, you want any potentially lifesaving piece of equipment to be readily available and you want your staff to have the training and skills to save the child's life — every time. However, this is not the case in the vast majority of EDs, according to a new study.1

Researchers surveyed 1,489 ED nursing and medical directors about whether their EDs were compliant with guidelines from the American Academy of Pediatrics/American College of Emergency Physicians.2 They found that only 6% of EDs had all recommended equipment, and half lacked laryngeal mask airways used for ventilating children. Only 12% of EDs had vascular access supplies for children, and 17% lacked Magill forceps for removing foreign bodies from a child's airway.

Marianne Gausche-Hill, MD, the study's lead author, says, "Death could potentially result due to the lack of the right equipment. Clearly, we have some work to do." Gausche-Hill also is director of the pediatric emergency medicine fellowship program at Harbor—University of California, Los Angeles Medical Center in Torrance.

The new research sends an urgent message to ED nurses: "Be proactive, evaluate your equipment and policies, and pay attention to the needs of children," urges Gausche-Hill.

It isn't easy for most

The study findings were not at all surprising to Mindi Huckabee, RN, BSN, CEN, director of emergency services at Trident Medical Center in Charleston, SC. "Unless you are a dedicated pediatric ED, the ability to have all necessary equipment and competent staff is not easy," Huckabee says. To improve care of pediatric patients, do the following:

• Give nurses additional training.

At St. Mary's, a Broselow tape-based code cart is used, along with a cart for specialty pediatric items, says Lopez. "However, it is always a concern that we not only have the right equipment, but also that the staff have the training and skills required to provide emergency care to the pediatric population," she says.

At Trident's ED, all nurses are required to attend Pediatric Advanced Life Support (PALS) and pediatric triage training, given by Fairview, NC-based Triage First. The triage course teaches ED nurses to identify the "worst-case scenario," says Huckabee. "For any child who comes in emergently, the chart is reviewed for quality assurance," she adds. "When we review the decisions made by our triage nurses, the benefits of the training is obvious."

Specialized pediatric training is key for nurses in nonpediatric EDs, says Huckabee. "You can train everyone and have all the right equipment; but if the process is not practiced, the staff do not stay comfortable," she says. "This is one reason that we have the mandatory training." Although the Emergency Nursing Pediatric Course (ENPC, offered by the Emergency Nurses Association) is not mandatory, it is recommended, and many ED nurses have attended the course, adds Huckabee.

"We are sponsoring an ENPC class at our facility so that our nurses can further their education regarding pediatric emergency care," says Tracy. ED nurses will be reimbursed for the cost of the class, and 12 nurses already have signed up for the next course, she says.

A computer-based learning module for pediatric emergency care recently was purchased from Dyer, IN-based Peds-R-Us Medical Education. "This is helping the nurses' comfort level and overall competence," says Tracy. "They have asked for more pediatric education and training." The module is now a part of the annual competency for ED nurses, who receive a certificate after completing the training, says Tracy.

Kanabec Hospital in Mora, MN, has set a goal of all ED nurses being PALS-trained, reports Dorothy A. Kohl, RN, CEN, ED manager. "At the present time, only our primary nurse has that as a requirement. But we have four PALS instructors and are working through all of our nursing staff." The ED also is looking into offering the American Heart Association's Pediatric Emergency Assessment, Recognition, and Stabilization (PEARS) course to nurses, says Kohl.

Recent cases of critically ill children at Kanabec involved a child who drank antifreeze and one with acute meningitis. Both of these children could have died if ED nurses lacked training, says Kohl. "We are a small critical access hospital and yet we are well prepared for pediatric patients," she reports. "Our department has a Broselow cart with medications and all equipment needed to manage critically ill children, from newborn to puberty. Having staff trained has made the difference between life and death."

• Order missing equipment.

Many EDs tend to focus on the needs of the patients that they see the most of and may overlook children, says Tracy. "Time has to be spent thinking about what education and supplies are needed to have on hand," she says. "Every time we get a pediatric patient in and we run into a concern regarding unavailability of equipment, it is immediately ordered."

• Have a team assess pediatric care.

At Carondelet St. Mary's, a Pediatric Care Practice Workgroup is reviewing protocols, equipment, and education needs. The team, co-led by an ED nurse and ED physician who is board-certified in pediatrics, is made up of 10 ED nurses from the day and night shifts, one ED patient care technician, and the ED nursing director.

"They are meeting routinely and working on issues identified in our assessment gap analysis to make sure that our care of pediatric patients is as it should be," says Lopez. "We will include other disciplines on an as-needed basis, such as pharmacy, respiratory therapy, medical imaging, and social work."

All areas of pediatric care will be evaluated, including equipment and supplies, triage, fast track, trauma, medication safety, and behavioral health emergencies, says Lopez.

• Look at medication protocols.

At Kanebec Hospital, a joint collaborative between the ED and pharmacy looked at premixed medications and dosing protocols for children, says Kohl. "We changed premixed dopamine and dobutamine so there was only one concentration hospitalwide," she says. "Pharmacy also calculated all of our IV push drugs for codes, such as epinephrine and atropine, and made sure we had the appropriate drug and concentration in those carts."

A protocol change was made for the ED's Broselow cart so that if a module is opened, it is replaced as opposed to only a single piece of equipment, says Kohl. "Our pre-hospital also has the Broselow bag. When they call in with a pediatric patient, they say, 'Yellow on the Broselow,' so we can have supplies ready to go on arrival." [Editor's note: The pediatric code blue supply list used by CSM Cardondelet Health Network is available .]

References

  1. Gausche-Hill M, Schmitz C, Lewis RJ. Pediatric preparedness of U.S. emergency departments: A 2003 survey. Pediatrics 2007; 120:1,229-1,237.
  2. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine and American College of Emergency Physicians. Care of children in the emergency department: Guidelines for preparedness. Pediatrics 2001; 107:777-781.

Sources

For more information on caring for pediatric patients in the ED, contact:

  • Marianne Gausche-Hill, MD. Department of Emergency Medicine, Harbor-University of California, Los Angeles Medical Center, Torrance, CA. Phone: (310) 222-3501. E-mail: mgausche@emedharbor.edu.
  • Mindi Huckabee, RN, BSN, CEN, Director of Emergency Services, Trident Medical Center, Charleston, SC. Phone: (843) 797-4104. E-mail: Mindi.Huckabee@HCAhealthcare.com.
  • Dorothy A. Kohl, RN, CEN, ED Manager, Kanabec Hospital, Mora, MN. Phone: (320) 225-3390. Fax: (320) 225-3405. E-mail: dkohl@kanabechospital.org.
  • Diana Platt Lopez, RN, BSN, CCRN, CEN, Clinical Educator, Emergency Center, Carondelet St. Mary's Hospital, Tucson, AZ. Phone: (520) 872-6193. E-mail: dplopez@carondelet.org.
  • Michelle Tracy, RN, MA, CPN, CEN, Assistant Director, Emergency Services,Osceola Regional Medical Center, Kissimmee, FL. Phone: (407) 518-3208. E-mail: Michelle.Tracy@HCAhealthcare.com.

Resources

  • A 2007 report from The Institute of Medicine titled Emergency Care for Children: Growing Pains covers pediatric emergency care planning, preparedness, coordination, and funding, and pediatric training in professional education. The hardback costs $43.95 (a web-only discount is available for $39.56) plus $5 shipping, and a PDF download is $34. To order the report, contact: The National Academies Press, 500 Fifth St. N.W., Lockbox 285, Washington, DC 20055. Phone: (888) 624-8373 or (202) 334-3313. Fax: (202) 334-2451. E-mail: zjones@nas.edu.
  • A December 2007 American Academy of Pediatrics (AAP) policy statement gives recommendations for improving safety for pediatric patients in emergency departments. To obtain a copy of the policy statement at no charge, go to the AAP web site (www.aap.org). Click on "Professional Education and Resources." On the right side of the page, click on "AAP Policy," then "AAP Policy Statements." Scroll down to the bolded title "Patient Safety in the Pediatric Emergency Care Setting." Or to access the guidelines developed by AAP and the American College of Emergency Physicians, on the same page click on the bolded title "Care of Children in the Emergency Department: Guidelines for Preparedness."
  • Joint Commission Resources (JCR) has launched a new consulting program to help hospitals improve the safety of ED services for children. Consultants identify the gaps between adult care procedures and evidence-based pediatric processes, including medication safety and infection control. For more information, contact JCR. Phone: (630) 268-7400. Web: www.jcrinc.com.
  • An online pediatric triage program offered by Triage First consists of clinical presentation scenarios for the Emergency Severity Index (ESI) or the Canadian Emergency Department Triage and. Acuity Scale (CTAS). The ESI or CTAS module is a prerequisite for the pediatric module. The cost for two modules for an individual is $129. Discounts are available for groups. For more information, contact: Triage First, P.O. Box 1924, Fairview, NC 28730. Phone: (828) 628-8022. Fax: (828) 628-8025. www.triagefirst.com.
  • The Pediatric Emergency Assessment, Recognition, and Stabilization (PEARS) is a seven-hour video-based course with instructor-led discussion. Key topics covered are respiratory compromise and arrest recognition and management, circulatory compromise and arrest recognition and management, shock recognition and management, and resuscitation team concepts. For more information, contact the American Heart Association at (877) 242-4277 or go to www.americanheart.org/cpr and click on "PEARS."
  • Video training kits for medical and traumatic pediatric emergencies are available for $198 including shipping. Included are two VHS tapes or DVDs, an Emergency Care of Crashing Kids handout and pediatric pocket reference guide. Peds-R-Us also offers full-day, half-day, and one-hour seminars on pediatric emergency topics. For more information, contact: Peds-R-Us Medical Education, P.O. Box 601, Dyer, IN 46311. Phone: (888) 280-7337. Fax: (866) 449-7337. E-mail: education@peds-r-us.com.
  • The Emergency Nursing Pediatric Course provides pediatric emergency nursing knowledge and psychomotor skill experience. For more information, go to the Emergency Nurses Association web site (www.ena.org). Scroll down to "CATN II/ENPC/TNCC" and click on "ENPC." Or contact the ENA's Course Operations Department by telephone at (800) 900-9659 or e-mail courseops@ena.org.