Work on Improving the Care of Children with Medical Complexity
By Stacey Kusterbeck
There is limited research on emergency care of children with medical complexity, “even though this represents a very challenging population to care for in the ED,” says Christian Pulcini, MD, MEd, MPH, a pediatric EP and health services researcher at University of Vermont Medical Center.
To identify future interventions to improve care of these patients, Pulcini and colleagues surveyed 151 pediatric EPs.1 “Emergency medicine physicians represent a group that is a key stakeholder when we think about how to improve emergency care of children with medical complexity,” Pulcini says.
Most of the survey respondents were EPs at children’s hospitals. The majority of those EPs reported seeing more than 10 children with medical complexity each month. “Community physicians certainly see less kids with medical complexity than this,” Pulcini says.
Despite the fact EP respondents worked at major children’s hospitals, they still identified significant challenges in providing high-quality emergency care to these patients. “The challenges in taking care of children with medical complexity in the ED are essentially universal, even among those at well-resourced institutions,” Pulcini says.
Surveyed EPs cited time constraints, the need to adequately review the expansive medical record for key information, and the need to contact known physicians when making treatment and disposition decisions. Respondents indicated communication with known providers and use of emergency information forms (EIFs) summarizing the child’s medical history were helpful.
However, most EPs did not report routine use of EIFs, despite the fact these forms can cut the time it takes to review the medical record, allowing EPs to provide timelier emergency care. “Concrete strategies such as EIFs need to be more widespread,” Pulcini recommends.
Children with medical complexity often present to EDs with common emergency conditions just like other children.
“But their baseline condition is different, which makes them more vulnerable to respiratory illnesses or dehydration,” says Marianne Gausche-Hill, MD, FACEP, FAAP, FAEMS, professor of clinical emergency medicine and pediatrics at David Geffen School of Medicine at UCLA. Gausche-Hill offers suggestions to improve the care of children with medical complexity:
• Call the patient’s other physicians to consult or arrange appropriate follow-up care. “Having information at hand about the underlying medical problems, medications, and important physician contacts is key to being able to optimize their care,” says Gausche-Hill, clinical faculty at Harbor-UCLA Medical Center’s departments of emergency medicine and pediatrics.
The EP might learn how the child responds to certain treatments considered standard care, such as fluid resuscitation or medications. For example, some children with seizures or epilepsy respond only to certain medications. “This important information may be available in a medical record, care plans that a parent may bring to the ED, or through talking with the child’s subspecialist, such as a pediatric geneticist or neurologist,” Gausche-Hill says.
• Ask the parent about baseline functioning vs. what is different now. “Understanding what has changed provides clues to the underlying illness,” Gausche-Hill says.
Some children with special healthcare needs, such as cerebral palsy, present with restrictive lung disease and a baseline oxygen saturation of 90% vs. 97% to 100% for children with normal lungs. If the EP knows this, he or she can strive to return the patient to their baseline functioning, instead of trying to achieve normal values.
• Document detailed patient information. This includes underlying medical problems, known diagnoses, medications, allergies, immunization status, previous hospitalizations, and primary and subspecialty physician participating in the patient’s ongoing care (if known). Additionally, include details about the physical exam, interventions in the ED, any consults, and discussion with the family on disposition and follow-up care.
“Probably for these children, the most important things to document are baseline status and function, treatment delivered, and documentation of status and function as a result of the therapy provided,” Gausche-Hill says.
• Arrange transfer, if appropriate. Some community EDs lack inpatient care for children or subspecialists needed to provide stabilizing or definitive care. In those cases, transfer may become necessary.
“The emergency physician should know regional hospital capabilities, and work with the family as well as their insurance providers to choose the appropriate facility and appropriate level of transport care,” Gausche-Hill says.
1. Pulcini CD, Dubuque A, Lamberson M, et al. Pediatric emergency medicine physicians’ perspectives on emergency care of children with medical complexity: A multi-institution mixed-methods assessment. Pediatr Emerg Care 2022; Apr 19. doi: 10.1097/PEC.0000000000002712. [Online ahead of print].
Emergency physicians identified significant challenges in providing high-quality emergency care to these patients. These include time constraints, the need to adequately review the expansive medical record for key information, and the need to contact known physicians when making treatment and disposition decisions. Respondents indicated communication with known providers and use of emergency information forms summarizing the child’s medical history were helpful.
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