PEDIATRICS Vol. 120 No. 6 December 2007, pp. 1229-1237 (doi:10.1542/10.1542/peds.2006-3780)
ARTICLE |
Pediatric Preparedness of US Emergency Departments: A 2003 Survey
a Department of Emergency Medicine, Harbor-University of California, Los Angeles Medical Center, Torrance, California
b Los Angeles Biomedical Research Institute, Torrance, California
c Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, California
d Department of Emergency Medicine, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, California
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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OBJECTIVES. Our goal was to assess the degree of pediatric preparedness of emergency departments in the United States.
METHODS. A closed-response survey based on the American Academy of Pediatrics/American College of Emergency Physicians joint policy statement, "Care of Children in the Emergency Department: Guidelines for Preparedness," was mailed to 5144 emergency department medical and nursing directors. A weighted preparedness score (scale of 0–100) was calculated for each emergency department.
RESULTS. A total of 1489 useable surveys (29%) were received, with 62% completed by emergency department medical directors. Eighty-nine percent of pediatric (age: 0–14 years) emergency department visits occur in non–children's hospitals, 26% of visits occur in rural or remote facilities, and 75% of responding emergency departments see <7000 children per year. The vast majority of visits (89%) occur in emergency department areas shared with adult patients; 6% occur in a separate pediatric emergency department. Only 6% of emergency departments had all recommended equipment and supplies. Emergency departments frequently lacked laryngeal mask airways for children (50%) and neonatal or infant equipment. In contrast, recommended medications were more uniformly available, as were transfer policies for medical or surgical intensive care. Fifty-two percent of emergency departments reported having a quality improvement/performance improvement plan for pediatric emergency patients, and 59% of respondents were aware of the American Academy of Pediatrics/American College of Emergency Physicians guidelines. The median pediatric-preparedness score for all emergency departments was 55. Pediatric-preparedness scores were higher for facilities with higher pediatric volume, facilities with physician and nursing coordinators for pediatrics, and facilities with respondents who reported awareness of the guidelines.
CONCLUSION. Pediatric preparedness of hospital emergency departments demonstrates opportunities for improvement.
Key Words: children • preparedness • emergency department • equipment and supplies
Abbreviations: ED—emergency department • EMSC—emergency medical services for children • AAP—American Academy of Pediatrics • ACEP—American College of Emergency Physicians • QI—quality improvement • PI—performance improvement • LMA—laryngeal mask airway • IQR—interquartile range
The 1993 Institute of Medicine report on emergency medical services for children (EMSC) recommended that "regulatory agencies require that hospital emergency departments (EDs) and emergency response and transport vehicles have available and maintain equipment and supplies appropriate for the emergency care of children."1 Subsequently, a number of guidelines were developed.2–9 In 1998, a multiorganizational effort to outline guidelines for pediatric preparedness of EDs in the United States was begun, sponsored by the Maternal and Child Health Bureau and spearheaded by the American Academy of Pediatrics (AAP) and the American College of Emergency Physicians (ACEP). The result of those efforts was a joint AAP/ACEP policy statement titled "Care of Children in the Emergency Department: Guidelines for Preparedness," which was published in 2001 and supported in concept by 17 organizations.10,11 The purposes of the guidelines were to provide a resource and to stimulate interest in improving preparedness of EDs to care for critically ill or injured infants and children.12 The guidelines outlined staff qualifications, components of a quality improvement (QI) plan, support services, and required equipment, supplies, and medications for the ED. The guidelines also called for hospital EDs to identify experts in emergency care for children (ie, physician and nurse coordinators for pediatric emergency care) who could drive the preparedness process forward within their EDs by monitoring staff competencies in the care of children, coordinating with prehospital and tertiary care services, and overseeing QI/performance improvement (PI) for children. In 2006, the Institute of Medicine published Emergency Care for Children: Growing Pains and, within that report, outlined recommendations that addressed some of the issues raised in the AAP/ACEP guidelines. Specifically, the report recommended arming the emergency care workforce with knowledge and skills, calling for emergency medical services agencies to appoint pediatric emergency coordinators, and instructing hospitals to appoint 2 pediatric emergency coordinators, one being a physician, to provide pediatric leadership for their organizations.13
Few studies have studied systematically the preparedness of EDs to care for children. In 2001, McGillivray et al14 showed that essential pediatric equipment was unavailable in a large proportion of EDs in Canada. Of note, an infant-warming device was unavailable in 59% of EDs, intraosseous needles in 16%, pediatric defibrillator paddles in 10%, infant blood pressure cuffs in 15%, infant bag-mask devices in 4%, and infant laryngoscope blades in 4%.14 Lack of equipment was associated with low pediatric volume, greater distance to a pediatric referral center, physician staff members who had not had formal Advanced Pediatric Life Support training, and a pediatric resuscitation volume of <3 cases per year.14
Athey et al15 used a stratified probability sample of 101 hospital EDs in the United States as part of the National Electronic Injury Surveillance System and found that 10% of hospitals without a PICU admitted critically injured children to their own facility, that few hospitals had protocols defining pediatric consultations for pediatric emergencies, and that hospitals were more often missing pediatric equipment than adult equipment for emergency care. Middleton and Burt,16 from the National Center for Health Statistics, surveyed US hospitals by using the Emergency Pediatric Services and Equipment Supplement of the 2002 to 2003 National Hospital Ambulatory Care Survey, to assess hospital compliance with the 2001 AAP/ACEP guidelines. Those authors found that 53% of hospitals that had no specialized ward for children still admitted pediatric patients and that 50% of hospital EDs stocked >85% of the pediatric supplies outlined in the published guidelines but only 6% of EDs had all recommended pediatric equipment.
Although the Centers for Disease Control and Prevention survey provided data on inpatient capability, transfer practices, and equipment availability in EDs, it did not address awareness of the guidelines by ED personnel or the impact of a physician or nursing coordinator for pediatric emergency care on preparedness. The objectives of this study were to evaluate compliance with the AAP/ACEP pediatric-preparedness guidelines among US EDs, to quantify pediatric volume for EDs nationwide, to assess awareness of and intent to implement the published AAP/ACEP guidelines, and to determine factors associated with pediatric preparedness of EDs.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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A closed-response survey was developed by the Steering Committee for the Implementation and Evaluation of Care of Children in the Emergency Department: Guidelines for Preparedness Project (Guidelines Project). The Steering Committee for the Guidelines Project is a multidisciplinary committee of members from the following organizations: AAP, ACEP, Maternal and Child Health Bureau, EMSC Program, National EMSC Data Analysis Resource Center, EMSC National Resource Center, Joint Commission on Accreditation of Healthcare Organizations, American Academy of Family Physicians, Emergency Nurses Association, National Rural Health Association, Center for Quality Improvement/Patient Safety, American Hospital Association, and National Committee for Quality Assurance. Consultants, including pediatric emergency physicians, pediatric emergency nurses, a statistician, and a health economist, also participated.
The Guidelines Project is a longitudinal study of factors affecting implementation of the AAP/ACEP guidelines for pediatric preparedness of EDs. A first step in the Guidelines Project was to determine baseline pediatric preparedness of EDs in the United States, the purpose of the current study. Survey items included all components of the AAP/ACEP guidelines, demographic information about the hospital and its available pediatric resources, awareness of the respondent of the AAP/ACEP guidelines, and willingness of the respondent to participate in a longitudinal study of guideline implementation. ED pediatric patient volume in 2001 was assessed by using each hospital's age definition of a pediatric patient, to ensure complete data, and then was assessed by using a standard age definition of 0 to 14 years of age in 2001. A patient age range of 0 to 14 years was chosen a priori, to ensure that a consistently defined pediatric patient volume could be compared between hospitals. Hospital type (community, university, county, children's, or other) and hospital location (remote, rural, suburban, or urban) were defined by self-report. Institution type was defined on the basis of the availability of a physician in the ED and inpatient pediatric resources, as follows: standby (physician on call to the ED, regardless of inpatient resources), basic (physician present 24 hours/day in the ED but with no pediatric inpatient services), general (physician present 24 hours/day in the ED and an inpatient pediatric ward, with or without a NICU), or comprehensive (physician present 24 hours/day in the ED, an inpatient pediatric ward, and a PICU, with or without a NICU).
The survey was mailed in 2003 to the medical directors of 5144 EDs in the United States. Additional letters were sent to the ED nursing directors and chief hospital administrators, informing them that the survey had been mailed. Information on the number and location of EDs (2003) was obtained from SK&A Information Services (Irvine, CA). This paid service was chosen to identify US EDs for inclusion in this survey because it had been used successfully by ACEP for society mailings.
Two postcard reminders and duplicate surveys were sent to hospitals that had not responded by the first survey deadline. Surveys were returned in a self-addressed, stamped envelope that was provided with the survey, and hospitals were given up to 6 months to return the survey. All respondents were recontacted in November 2003, to clarify responses to 2 questions that, in preliminary analyses, were found to be frequently answered inconsistently. These questions sought information on hospital inpatient pediatric resources (ie, number of ward beds and number of ICU beds).
Study data were entered into a Microsoft Access database (Microsoft, Redmond, WA), translated into native SAS format by using DBMS/Copy 8 (DataFlux, Cary, NC), and analyzed by using SAS 8.1 (SAS Institute, Cary, NC). A crude, unweighted, preparedness score was calculated for each hospital on the basis of the presence or absence of 162 items listed in the AAP and ACEP guidelines.
The AAP/ACEP guidelines were divided into 6 primary sections (administration and coordination; staffing of the ED; QI plans; policies, procedures, and protocols; support services and transport plan; and equipment and medications). We noted that the numbers of individual items in the primary sections varied widely and the number of items within a section did not reflect, in any fundamental way, the relative importance of the different components of preparedness. To create a single quantitative measure of overall preparedness that accounted for the perceived importance of different domains of preparedness and the different numbers of survey items in the primary sections, a subcommittee of the Guidelines Project Steering Committee, consisting of 5 experts in pediatric emergency medicine or research methods, was formed to assign weights to each primary section of the guidelines and then to assign weights to subgroups of items within each primary section. Within a subgroup, each item was weighted equally. The subcommittee members met twice via conference calls but scored items independently. Final relative weights for each of the primary sections, as determined by the subcommittee, are listed in Table 1 with each section's components. A weighted preparedness score (normalized scale of 0–100) was then calculated for each of the responding hospitals, as a measure of the overall degree to which the ED conforms to the AAP/ACEP guidelines. This project was approved by the institutional review boards of the AAP and the Los Angeles Biomedical Research Institute at Harbor-University of California, Los Angeles.
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Descriptive statistics were used to characterize the weighted preparedness scores, both across hospitals and within subgroups of hospitals. Numerical variables were summarized by using medians and interquartile ranges (IQRs) and were compared by using the Wilcoxon rank-sum test. Proportions were compared by using the
2 test or Fisher's exact test, as appropriate. A maximal P value of .05 was considered statistically significant, and no adjustment was made for multiple comparisons. Numerical variables potentially correlated with the overall preparedness score were assessed by using Spearman rank correlation. |
RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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A total of 1524 surveys (30%) were returned. Thirty-five of the surveys needed to be discarded because the hospital was closed or did not have an ED, leaving 1489 useable surveys (98%). The survey was most often completed by the ED medical director (62%), followed by the ED nurse manager (26%) and others (13%), including hospital administrators.
The definition of a pediatric patient was highly variable (Table 2), with the largest group of hospitals (25%) using 0 to 18 years of age. The median reported age cutoff value used by EDs to characterize a patient as pediatric was 16 years (IQR: 14–18 years). Overall, 96% of respondents defined a pediatric patient as within an age range of <19 years.
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Of 1485 surveys that included institution type, 184 hospitals (12%) were standby, 368 (25%) were basic, 748 (50%) were general, and 185 (12%) were comprehensive. Thirty-four (2%) of 1477 respondents reported their hospital as being located in a remote area, 721 (49%) in a rural area, 361 (24%) in a suburban area, and 361 (24%) in an urban area. Hospitals were classified as community hospitals (1123 of 1489 respondents [75%]), county hospitals (226 of 1489 respondents [15%]), university hospitals (105 of 1489 respondents [7%]), children's hospitals (53 of 1489 respondents [4%]), or other types (108 of 1489 respondents [7%]). Hospital classifications were not always mutually exclusive; for example, a hospital could be a university hospital as well as a children's hospital. Thirty-one respondents (2%) reported that their hospitals admitted only children.
A variety of ED configurations for the care of pediatric patients were also reported. Children were seen in the main ED alongside adult patients in 1320 (89%) of 1475 hospitals, children were seen in a separate area of the main ED in 57 (4%), children were seen in a separate ED of a non–children's hospital in 46 (3%), and children were seen in a children's hospital ED in 40 (3%). Hospitals with a separate pediatric ED reported significantly higher ED pediatric volumes (median: 12000 patients; IQR: 8782–20500 patients), compared with those in which pediatric patients were seen in the main ED (median: 3200 patients; IQR: 1500–6000 patients; P < .0001). The median number of ED beds for all patients was 12 (IQR: 6–22 beds); the median number of specifically pediatric beds was 0 (IQR: 0–1 bed).
The median ED volume for all patients in 2001 was 21334 patients (IQR: 10000–37674 patients). The median pediatric (0–14 years of age) volume in 2001 was 3700 patients (IQR: 1500–7000 patients). Approximately one half of the respondents reported that their ED saw <10 pediatric patients per day, and three fourths reported seeing <20 per day, or <1 patient per hour. Remote hospitals reported a median annual pediatric volume of 600 patients (IQR: 160–2165 patients), rural hospitals reported 2200 patients (IQR: 912–3900 patients), suburban hospitals reported 6000 patients (IQR: 3600–9985 patients), and urban hospitals reported 6876 patients (IQR: 3376–12400 patients). Remote hospitals saw a median of <2 pediatric patients per day, whereas urban hospitals saw a median of 19 pediatric patients per day. The median reported pediatric (0–14 years of age) volume in 2001 was 3500 patients (IQR: 1500–6723 patients) for non–children's hospital EDs and 23238 patients (IQR: 11000–37500 patients) for children's hospital EDs (P < .0001).
Of respondents, 1116 (76%) of 1489 stated that their facility had a newborn nursery and 847 (57%) reported having a pediatric ward. In contrast, 468 (31%) reported having a NICU and only 267 (18%) reported having a separate PICU. The vast majority (1281 hospitals [86%]) reported having adult ICU facilities. Interestingly, although 43% of respondents reported no pediatric ward facilities, 1323 (89%) of 1489 stated that their hospital admitted pediatric patients as inpatients. For the 82% of respondents who reported that their hospital had no PICU, the transfer of critically ill pediatric patients for intensive care seemed to be a key strategy; 96% of all hospitals reported having a plan for transfer of patients for medical or surgical intensive care.
More than 96% of respondents reported that their radiology department had the staff, skills, and equipment necessary to provide imaging studies for infants and children, and 98% stated that their laboratory had the staff, skills, and equipment necessary to perform laboratory tests for infants and children, including microtechniques for small samples.
Respondents were also asked whether they had identified physician and nurse coordinators for pediatric emergency medicine. A total of 257 (18%) of 1446 respondents reported having a physician coordinator, and 177 (12%) of 1473 reported having a nurse coordinator; 140 (10%) reported having both physician and nurse coordinators.
Only 757 (52%) of 1468 respondents stated that their ED had a QI/performance improvement (PI) plan for pediatric emergency patients. Of 722 who gave additional information, 411 (57%) stated that the plan for children was integrated into the overall QI/PI plan, 256 (35%) stated that the plan included some specific indicators for children but was otherwise integrated into the overall QI/PI plan, and 55 (8%) had a separate QI/PI plan for pediatric emergency patients.
Hospitals were also surveyed regarding whether they had 13 specific ED policies listed in the AAP/ACEP guidelines that addressed the needs of children in the ED (Table 3). The median reported number of these policies was 11 (IQR: 7–13 policies). A minority of respondents (392 of 1489 hospitals [26%]) reported having all 13 policies. A child maltreatment policy was most uniformly available (96%); least available was a policy concerning family issues (59%), which includes family presence during procedures or resuscitations. Seventy-six percent of respondents reported having a disaster plan that addressed the needs of children. A separate question dealt with recommended plans for transfer of pediatric ED patients for subspecialty care (ie, trauma, medical or surgical intensive care, reimplantation, burn care, psychiatric care, perinatal services, or child maltreatment). Seventy-four percent of respondents (1106 of 1489 respondents) reported having all 7 of these transfer plans for subspecialty care.
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Table 4 lists the median number of equipment and medication items available within each category recommended in the AAP/ACEP guidelines. More than 90% of the respondents reported that their EDs stocked at least 96 (81%) of the 118 recommended equipment items; however only 94 (6%) respondents stated that their ED stocked all of the recommended equipment. Equipment items often reported as missing are listed in Table 5. In general, equipment for neonates or infants was most often reported to be missing; however, laryngeal mask airways (LMAs) in all sizes were frequently reported to be missing from EDs. Although the optimal role of LMAs in pediatric airway management in the ED is not yet defined, the AAP/ACEP guidelines list LMAs as essential equipment. Although
47% of respondents stated that they did not stock 1 size of LMA, excluding LMAs from the required equipment list increased the proportion of EDs with all recommended equipment only to 8%. Medications were more universally available; the survey found that, for each of the medications listed, 96% of respondents reported their ED stocked that medication. In total, 1236 (83%) of 1489 respondents reported that their EDs had all 22 of the medications specified.
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Respondents were also queried regarding whether they were aware of the joint AAP/ACEP guidelines and were interested in implementing the guidelines in their ED. A total of 861 (59%) of 1457 respondents reported being aware that the guidelines had been published; 898 (65%) of 1378 respondents were interested in implementing the guidelines, 62 (4%) were not interested in implementing them, and 418 (30%) were undecided regarding whether they were interested in implementing them.
The median weighted preparedness score overall was 55 (IQR: 46–64), with a range of 2 to 100. Preparedness varied significantly according to institution type, hospital type, hospital location (remote, rural, suburban, or urban), inpatient pediatric resources, pediatric patient volume, and ED configuration for seeing pediatric patients. The weighted pediatric-preparedness score for standby hospitals was 44 (IQR: 39–53), that for basic hospitals was 52 (IQR: 44–59), that for general hospitals was 56 (IQR: 48–64), and that for comprehensive hospitals was 78 (IQR: 62–89; P < .0001). Community hospital EDs had a median preparedness score of 54 (IQR: 46–63), university hospitals had a median score of 68 (IQR: 55–85), and children's hospitals were the most prepared category of hospital, with a median score of 88 (IQR: 80–94; P < .0005). Remote hospitals had a weighted pediatric-preparedness score of 43 (IQR: 37–54), rural hospitals 53 (IQR: 44–60), suburban hospitals 57 (IQR: 49–68), and urban hospitals 61 (IQR: 51–78; P < .001).
The presence of inpatient pediatric resources was associated with higher weighted ED preparedness scores (Table 6). In univariate analyses, the presence of a NICU, pediatric ward, and PICU each was associated with higher preparedness scores.
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Hospitals were divided into quartiles according to reported pediatric ED patient volume, as follows: class 1, annual volume of <1500 patients per year; class 2, annual volume of 1500 to 3699 patients per year; class 3, annual volume of 3700 to 6999 patients per year; class 4, annual volume of
7000 patients per year. The median weighted preparedness scores varied according to pediatric patient volume, with lower-volume EDs having lower weighted preparedness scores; the median class 1 score was 47 (IQR: 40–55), the median class 2 score was 54 (IQR: 46–60), the median class 3 score was 55 (IQR: 49–65), and the median class 4 score was 64 (IQR: 54–83; P < .0001). Median weighted pediatric-preparedness scores also varied according to ED configuration, with significantly higher preparedness scores noted for hospitals with separate care for pediatric patients in the ED. For EDs in which pediatric and adult patients were both seen in the main ED, the median weighted preparedness score was 54 (IQR: 46–61). For EDs in which pediatric patients were seen in a separate area of the main ED, the median score was 75 (IQR: 63–83). When pediatric patients were seen in a separate pediatric ED in a non–children's hospital, the median score was 85 (IQR: 77–92). When pediatric patients were seen in a children's hospital ED, the median score was 89 (IQR: 83–94; P < .001 across all categories).
The weighted preparedness score explicitly considers the presence of nurse and physician coordinators as evidence of preparedness, making this score inappropriate to use to determine whether the presence of a nurse or physician coordinator for pediatrics results in better compliance with preparedness guidelines. To evaluate the preparedness of hospitals with and without nurse and physician coordinators for pediatric emergency medicine, a revised preparedness score was calculated by excluding the presence of physician and nurse coordinators in the calculation (Table 7). Although the number of standby facilities that reported the presence of both nurse and physician coordinators was small (1 of 33 hospitals [3%]), these data demonstrated that hospitals with both pediatric coordinators had statistically higher revised preparedness scores. Finally, respondents who were aware of the AAP/ACEP guidelines or were interested in guideline implementation reported significantly higher preparedness scores, compared with respondents who were either unaware of or disinterested in implementation of the guidelines (Table 8).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This study is the first to survey directly all EDs in the United States regarding pediatric preparedness and to provide information on the awareness of hospital ED managers regarding the AAP/ACEP guidelines. The study, although limited by the survey methods and a response rate of 29%, delineates some of the factors that are associated with self-reported compliance of EDs with published pediatric-preparedness guidelines. These factors include hospital and institutional characteristics, institution location, availability of inpatient resources, ED administrative issues, awareness of the guidelines, and interest in implementation of the guidelines.
Cabana et al,17 in a review of 76 published studies, described factors that create barriers to physician adherence to practice guidelines. Three domains of barriers were identified, namely, physician knowledge (lack of familiarity with or knowledge of guidelines), physician attitudes (lack of outcome expectancy, lack of self-efficacy, and lack of motivation), and physician behavior (external factors, such as patient preferences regarding guideline recommendations; guideline factors that affect physician acceptance, such as conflict with items in the guidelines or with other published guidelines; and environmental factors, such as lack of time, lack of resources, organizational constraints, lack of reimbursement, and perceived additional liability).
In this study, several barriers to guideline adherence were identified in all 3 domains described by Cabana et al.17 These barriers may play a significant role in the relatively low overall preparedness of EDs nationwide, and identifying these barriers may suggest potential interventions to improve pediatric preparedness. In the knowledge domain, only 59% of ED managers were aware of the published AAP/ACEP guidelines. Clearly, awareness of and familiarity with the guidelines is the first step to implementation. If hospital administrators or ED managers are unaware of published guidelines, then they are unlikely to adhere to them. Although the guidelines were published simultaneously in 2 major medical journals and were supported in concept by 17 professional organizations, additional resources may be needed to increase awareness in all stakeholders committed to pediatric emergency care.
In the attitude domain, several factors may play a role in reducing guideline adherence. One obvious factor identified by this survey was motivation; 30% of respondents were unsure whether they were interested in guideline implementation, and 4% were definitely not interested. Increasing the motivation of physicians or administrators will be challenging, and lack of motivation may be reinforced by factors in other domains, such as lack of resources, lack of time, and organizational constraints.
Another potential factor in the attitude domain that was identified in this study was the relative lack of experience with exposure to critically ill or injured pediatric patients among the workforce at many US hospitals. This may reduce physicians' self-efficacy or confidence in meeting published guidelines.18,19 We found that >50% of responding hospitals identified their location as remote or rural, seeing <6 pediatric ED patients per day. Furthermore, 12% of EDs did not have a physician present and on duty 24 hours per day. Athey et al15 noted an even greater proportion of standby facilities (23%) in the National Electronic Injury Surveillance System survey. Our data demonstrated that the median pediatric (0–14 years of age) volume seen in responding EDs was 3700 patients per year and <25% of those EDs saw >7000 patients per year. These data are consistent with Centers for Disease Control and Prevention data reported by Middleton and Burt.16 By extrapolating our volume data to the 4800 hospitals with 24-hour EDs reported to be in operation in 2003,20 we estimated that non–children's hospital EDs see 
89% of the 27 million pediatric visits annually, whereas children's hospital EDs see 11% of such visits annually. This suggests that key opportunities for improving pediatric emergency care lie in non–children's hospitals, where the vast majority of this care occurs.
Other workforce issues, such as the availability of board-certified emergency physicians and the presence of pediatric emergency medicine subspecialists, were not evaluated in this survey, but the 2005 National Hospital Ambulatory Medical Care Survey found that 64% of EDs had 1 board-certified emergency physician available 24 hours per day and 18% of EDs had pediatric emergency medicine subspecialists available.20 Those data suggest that more than one third of EDs do not have staffing that includes a physician trained in emergency medicine.
In the behavior domain, a number of factors that decreased guideline adherence were suggested by our data, including guideline factors, lack of resources, and organizational constraints. The AAP/ACEP guidelines contain 162 items that must be present for 100% compliance. Most of these items are equipment and supplies (118 items) and medications (22 items). The reported availability of equipment and supplies in the current study was remarkably similar to the Emergency Pediatric Services and Equipment Supplement data, although the Emergency Pediatric Services and Equipment Supplement data did not survey the availability of LMAs. Overall, we found that 6% of all EDs had all 118 of the recommended equipment and supply items; when LMAs were excluded, this number increased minimally, to 8%. Equipment and supplies for neonates and small infants were most often missing, including pediatric Magill forceps. Other investigators have reported similar findings.14,15 This study also demonstrated that many EDs lack LMAs of all sizes. This may indicate uncertainty regarding the role of LMAs in emergency airway management or may indicate that ED personnel lack training in LMA use. For a few items, such as the Seldinger technique vascular access kit and newborn kit, the respondents might not have been certain what type of equipment is being recommended; therefore, the availability of these items might not have been reported accurately.
Organizational constraints may include a lack of available personnel to ensure guideline adherence. In 2006, the Institute of Medicine published Emergency Care for Children: Growing Pains, which identified the need for integration, coordination, and accountability in emergency care for children.13 The Institute of Medicine committees recognized the need for the representation of pediatric issues in local, state, regional, and federal planning for emergency care and trauma systems and therefore included pediatric emergency care coordinators in the pediatric emergency care recommendations. Although this recommendation was suggested by a group of experts in the field, based on published guidelines and their collective experience, previously there were no data to support such a recommendation. This study adds support for this recommendation by demonstrating that, regardless of the type of institution (standby, basic, general, or comprehensive), hospital EDs are better prepared if they have both nurse and physician coordinators for pediatrics. Having a pediatric emergency care coordinator likely demonstrates a commitment by these hospitals to pediatric emergency care but does not imply that these hospitals provide higher-quality care. On the basis of our data, designation of a coordinator for pediatric emergency care, within the current ED administration or shared between institutions, may improve the likelihood of a hospital stocking all equipment, having policies designed for the care of children, and overall achieving full compliance with the AAP/ACEP guidelines.
Although the original survey and 2 postcard reminders were sent to hospital EDs, the overall return rate of 29% was low. The 8-page format and our need to complete the survey mailings and data entry within 6 months, for the purpose of selecting hospitals for a longitudinal component of a larger study, might have limited the response rate. In addition, ED medical and nursing directors/managers are often inundated with survey requests via mail or electronic mail, resulting in some apathy in responding.
Despite the low response rate, we think that our data agree with other data sets in terms of patient volume and the availability of equipment but differ in the distributions of institution types.15,16 Our data demonstrated larger proportions of comprehensive (12% vs 6%) and general (50% vs 28%) hospitals and smaller proportions of basic (25% vs 44%) and standby (25% vs 23%) hospitals, compared with data from the National Electronic Injury Surveillance System survey.15 Fifty-one percent of respondents in our study reported their hospitals as being located in a remote or rural area; in the 2003 National Hospital Ambulatory Medical Care Survey, it was reported that 42% of hospital EDs were located in nonmetropolitan statistical areas or areas with a smaller population base.20 Although our data are similar (but not identical) to the results of other preparedness survey efforts, we have no data on the preparedness of the 70% of nonresponding hospitals. It is likely that a small percentage of nonresponding hospitals have closed or do not care for children, but this number cannot be estimated accurately. On the basis of comparisons with other reported data sets, we think that survey respondents in this study might have been biased toward hospitals with EDs with higher pediatric volumes. If this bias existed, it would likely result in an overestimate of true pediatric preparedness/compliance with AAP/ACEP guidelines. Other limitations of this survey include variability in the ability of respondents to answer all questions accurately and challenges in determining whether responses from the survey represent the true characteristics of the population studied.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This study reports the results of a nationwide survey of EDs regarding pediatric preparedness, based on the 2001 joint policy statement from the AAP and ACEP. Overall weighted pediatric-preparedness scores of EDs nationwide were low. Hospitals that were more prepared tended to be urban, to have higher volumes, to have a separate care area for pediatric patients, to have physician and nursing coordinators for pediatrics, to be aware of the AAP/ACEP guidelines, and to be interested in guideline implementation.
The study also demonstrates that much work is left to be done to improve pediatric preparedness of EDs. Additional work should explore the relationship of preparedness to quality of care delivered, delineate barriers to guideline implementation, and identify best practices that can be coordinated within emergency care systems to improve the preparedness of EDs to care for children.
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ACKNOWLEDGMENTS |
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This project was supported by Maternal and Child Health Bureau project 1 U93 MC 00184.
The Guidelines Project Steering Committee included Marianne Gausche-Hill, MD, Roger J. Lewis, MD, PhD, Charles Schmitz, MD, Deborah P. Henderson, PhD, RN, Nancy McGrath, MN, RN, CPNP, CEN, Susan Tellez (AAP), Frederick Blum, MD (ACEP), Kim Bullock, MD (American Academy of Family Physicians), Forrest W. Calico, MD, MPH (National Rural Health Association), Rick Croteau, MD (Joint Commission on Accreditation of Healthcare Organizations), Dan Kavanaugh, MSW (EMSC Program), Marge Keyes (Center for Quality Improvement/Patient Safety, Agency for Healthcare Research and Quality), Steven E. Krug, MD (Children's Memorial Hospital), N. Clay Mann, PhD, MS (National EMSC Data Analysis Resource Center), Rick McClead, MD (American Hospital Association), Nancy B. Medina, CAE (ACEP), Gary Q. Peck, MD (AAP), Phillip Renner, MBA (National Committee for Quality Assurance), Sally Snow, RN (Emergency Nurses Association), J. Mick Tilford, PhD (Health Economics Center for Applied Research and Evaluation, Arkansas Children's Hospital), Brenda White, RN, BSN, MHA, MJ (Joint Commission on Accreditation of Healthcare Organizations), and Robert A. Wiebe, MD (University of Texas, Southwestern Medical Center, Dallas Children's Hospital).
We acknowledge Sue Tellez (Department of Community and Specialty Pediatrics, AAP) and the Guidelines Project Steering Committee for support and guidance in the implementation of this project.
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FOOTNOTES |
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Accepted Jun 11, 2007.
Address correspondence to Marianne Gausche-Hill, MD, Department of Emergency Medicine, Harbor-UCLA Medical Center, 1000 W Carson St, Box 21, Torrance, CA 90509. E-mail: mgausche{at}emedharbor.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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