Care of Children in the Emergency Department: Guidelines for Preparedness

ACKNOWLEDGMENTS

Development of this statement would not have been possible without the generous support for the initial November 15–16, 1998 minimum standards consensus meeting funded by Project No. 98-0156(P) from the Department of Health and Human Services, Health Resources and Services Administration and Maternal and Child Health Bureau. This statement has been reviewed by and is supported in concept by the Ambulatory Pediatric Association, American Association of Poison Control Centers, American College of Surgeons, American Hospital Association, American Medical Association, American Pediatric Surgical Association, American Trauma Society, Brain Injury Association Inc, Emergency Nurses Association, Joint Commission on Accreditation of Healthcare Organizations, National Association of Children's Hospitals and Related Institutions, National Association of EMS Physicians, National Association of EMTs, National Association of School Nurses, National Association of State EMS Directors, National Committee for Quality Assurance, and Society for Academic Emergency Medicine.

I. GUIDELINES FOR ADMINISTRATION AND COORDINATION OF THE ED FOR THE CARE OF CHILDREN

A. A Physician Coordinator for Pediatric Emergency Medicine is appointed by the ED Medical Director.

1.The Physician Coordinator has the following qualifications:

a. The Physician Coordinator meets the qualifications for credentialing by the Hospital as a specialist in emergency medicine, pediatric emergency medicine, or pediatrics.

b. The Physician Coordinator has special interest, knowledge, and skill in emergency medical care of children as demonstrated by training, clinical experience, or focused continuing medical education.

c. The Physician Coordinator may be a staff physician who is currently assigned other roles in the ED, such as the Medical Director of the ED, or may be shared through formal consultation agreements with professional resources from a hospital capable of providing definitive pediatric care.

2. The Physician Coordinator is responsible for the following:

a. Ensure adequate skill and knowledge of staff physicians in emergency care and resuscitation of infants and children.

b. Oversee ED pediatric quality improvement (QI), performance improvement (PI), and clinical care protocols.

c. Assist with development and periodic review of ED medications, equipment, supplies, policies, and procedures.

d. Serve as liaison to appropriate in-hospital and out-of-hospital pediatric care committees in the community (if they exist).

e. Serve as liaison to a definitive care hospital, which includes a regional pediatric referral hospital and trauma center; EMS agencies; primary care providers; health insurers; and any other medical resources needed to integrate services for the continuum of care of the patient.

f. Facilitate pediatric emergency education for ED health care providers and out-of-hospital providers affiliated with the ED.

B. A Nursing Coordinator for Pediatric Emergency Care is appointed.

1. The Nursing Coordinator has the following qualifications:

The Nursing Coordinator demonstrates special interest, knowledge, and skill in emergency care and resuscitation of infants and children as demonstrated by training, clinical experience, or focused continuing nursing education.

2.The Nursing Coordinator is responsible for the following:

a. Coordinate pediatric QI, PI, and clinical care protocols with the Physician Coordinator.

b. Serve as liaison to appropriate in-hospital and out-of-hospital pediatric care committees.

c. Serve as liaison to inpatient nursing as well as to a definitive care hospital, a regional pediatric referral hospital and trauma center, EMS agencies, primary care providers, health insurers, and any other medical resources needed to integrate services for the continuum of care of the patient.

d. Facilitate ED nursing continuing education in pediatrics and provide orientation for new staff members.

e. Provide assistance and support for pediatric education of out-of-hospital providers affiliated with the ED.

f. Assist in development and periodic review of policies and procedures for pediatric care.

g. Stock and monitor pediatric equipment and medication availability.

II. GUIDELINES FOR PHYSICIANS AND OTHER PRACTITIONERS STAFFING THE ED

A.  Physicians staffing the 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.

B.  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.

C.  Competency evaluations completed by the staff are age specific and include neonates, infants, children, and adolescents.

III. QUALITY IMPROVEMENT GUIDELINES FOR THE ED

A pediatric patient review process is integrated into the ED QI plan according to the following guidelines:

A.  Components of the process interface with out-of-hospital, ED, trauma, inpatient pediatrics, pediatric critical care, and hospital-wide QI or PI activities.

B.  Minimum components of the process include identifying indicators of good outcome, collecting and analyzing data to discover variances, defining a plan for improvement, and evaluating or measuring the success of the QI or PI process.

C.  A clearly defined mechanism exists to monitor professional education and staffing.

IV. GUIDELINES FOR POLICIES, PROCEDURES, AND PROTOCOLS FOR THE ED

A. Policies, procedures, and protocols for emergency care of children are developed and implemented; staff should be educated accordingly; and they should be monitored for compliance and periodically updated. These should include, but are not limited to, the following (items 3 through 12 indicate policies, procedures, and protocols that may be integrated into ED policies and procedures with pediatric-specific components):

1. Child maltreatment (physical and sexual abuse, sexual assault, and neglect)

2. Consent (including situations in which a parent is not immediately available)

3. Death in the ED

4. Do not resuscitate orders

5. Illness and injury triage

6. Sedation and analgesia

7. Immunization status

8. Mental health emergencies

9. Physical or chemical restraint of patients

10. Family issues, including:

a. Education of the patient, family, and regular caregivers

b. Discharge planning and instruction

c. Family presence during care

11. Communication with patient's primary health care provider

12. Transfers necessary for definitive care, according to the following guidelines:

a. Transfer policies or procedures should include access to consultation (telephone or telemedicine), transfer guidelines, interfacility transfer agreements, and a plan for return of the child back to his/her community as appropriate.

b. Transferring facility must ensure that the patient is stabilized before transport.

c. Transferring facility must transfer only patients who need a higher level of care, as per the Emergency Medical Treatment and Active Labor Act.¹¹

B. Hospitals may wish to adopt currently available clinical guidelines and protocols or develop their own.

V. GUIDELINES FOR SUPPORT SERVICES
FOR THE ED

A. A transport plan is in place to deliver children safely and in a timely manner to the appropriate facility capable of providing definitive care. The following pediatric specialty referral resources are incorporated into the transport plan:

1. Medical and surgical intensive care

2. Trauma

3. Reimplantation (replacement of severed digits or limbs)

4. Burns

5. Psychiatric emergencies

6. Perinatal emergencies

7. Child maltreatment (physical and sexual abuse and assault)

B. Radiology department has the skills and capability to provide imaging studies of children and has the equipment necessary to do so. The radiology capability of hospitals may vary from one institution to another; however, the radiology capability of a hospital must meet the needs of the children in the community it serves.

C. Laboratory has the skills and capability to perform laboratory tests for children of all ages, including obtaining samples, and has the availability of micro technique for small or limited sample size. The clinical laboratory capability must meet the needs of the children in the community it serves.

VI. GUIDELINES FOR EQUIPMENT, SUPPLIES, AND MEDICATIONS FOR CHILDREN IN THE ED

A.  Necessary medications, equipment, and supplies are listed in Table 1. Each hospital must develop a method for storage and provide accessibility of medications and equipment for children. The method used must ensure that the health care practitioner can easily identify appropriate dosages of medication based on the patient's weight and choose appropriately sized equipment. Length-based systems or precalculated drug systems should be used to avoid calculation errors of medications delivered.

B.  All equipment and supplies are listed in Table 2 and include age-appropriate and size-appropriate equipment for use for children of all ages and sizes from premature infants through adolescents.

C.  Quality indicators ensure regular periodic review of drugs and equipment, monitoring of expiration dates of items, and replacement of used items.

For periodic updates of this statement, including medications and equipment, see the American Academy of Pediatrics Web site (http://www.aap.org) or the American College of Emergency Physicians Web site (http://www.acep.org).

Committee on Pediatric Emergency Medicine, 1999–2000

Robert A. Wiebe, MD, Chairperson

Jane F. Knapp, MD, Chairperson-elect

Barbara A. Barlow, MD

Ronald A. Furnival, MD

Barry W. Heath, MD

Steven E. Krug, MD

Karin A. McCloskey, MD

Deborah Mulligan-Smith, MD

Lee A. Pyles, MD

Timothy S. Yeh, MD

Liaisons

Cindy R. Doyle, RN, BSN, MA

Maternal and Child Health Bureau

Marianne Gausche-Hill, MD

American College of Emergency Physicians

David Markenson, MD

National Association of EMS Physicians

Dennis W. Vane, MD

American College of Surgeons

Section Liaisons

M. Douglas Baker, MD

Section on Emergency Medicine

Joseph P. Cravero, MD

Section on Anesthesiology

M. Michele Moss, MD

Section on Critical Care

Dennis W. Vane, MD

Section on Surgery

Staff

Susan Tellez

ACEP Pediatric Committee, 1999–2000

Marianne Gausche-Hill, MD, Chairperson

Thomas Abrunzo, MD, MPH

Ann Dietrich, MD

Claudia Gold, MD

Ramon Johnson, MD

Stephen Knazik, DO

Sharon Mace, MD

Maureen McCollough, MD

Deborah Mulligan-Smith, MD

Mark Sochor, MD

Craig Warden, MD, MPH

Joseph Zibulewsky, MD

Liaisons

Michael Gerardi, MD

John Santamaria, MD

Robert A. Wiebe, MD

Staff

Elaine Jastram

Statement Consultants

Bob Bailey

National Association of State EMS Directors

Richard J. Crouteau, MD

Joint Commission on Accreditation of Healthcare Organizations

Ronald Dieckmann, MD

American Academy of Pediatrics

Susan Dull, RN, MSN, MBA

National Association of Children's Hospitals and Related Institutions

Susan Fuchs, MD

American Academy of Pediatrics

Carden Johnston, MD

American Academy of Pediatrics

Brent King, MD

National Institutions

Michael Rapp, MD

American College of Emergency Physicians

Robert Schafermeyer, MD

American College of Emergency Physicians

James Seidel, MD, PhD

American Academy of Pediatrics

Calvin Sia, MD

American Academy of Pediatrics