pediatrics
November 2018, VOLUME142 /ISSUE 5

Pediatric Readiness in the Emergency Department

  1. Katherine Remick, MD, FAAP, FACEP, FAEMSa,b,c,
  2. Marianne Gausche-Hill, MD, FAAP, FACEP, FAEMSd,e,f,
  3. Madeline M. Joseph, MD, FAAP, FACEPg,h,
  4. Kathleen Brown, MD, FAAP, FACEPi,
  5. Sally K. Snow, BSN, RN, CPENj,
  6. Joseph L. Wright, MD, MPH, FAAPk,l,
  7. AMERICAN ACADEMY OF PEDIATRICS Committee on Pediatric Emergency Medicine and Section on Surgery,
  8. AMERICAN COLLEGE OF EMERGENCY PHYSICIANS Pediatric Emergency Medicine Committee,
  9. EMERGENCY NURSES ASSOCIATION Pediatric Committee
    1. aNational Emergency Medical Services for Children Innovation and Improvement Center, Baylor College of Medicine, Houston, Texas;
    2. bDepartment of Pediatrics, Dell Medical School, The University of Texas at Austin, Austin, Texas;
    3. cDell Children’s Medical Center, Austin, Texas;
    4. dLos Angeles County Emergency Medical Services Agency, Santa Fe Springs, California;
    5. eDepartment of Emergency Medicine and Pediatrics, David Geffen School of Medicine and Harbor–University of California, Los Angeles Medical Center, University of California, Los Angeles, Los Angeles, California;
    6. fDepartment of Emergency Medicine, Los Angeles Biomedical Research Institute, Los Angeles, California;
    7. gDivision of Pediatric Emergency Medicine, Department of Emergency Medicine and Pediatrics, University of Florida College of Medicine–Jacksonville, Jacksonville, Florida;
    8. iDepartments of Pediatrics and Emergency Medicine, School of Medicine and Health Sciences, George Washington University and Children’s National Medical Center, Washington, District of Columbia;
    9. jEmergency Nurses Association, Des Plaines, Illinois;
    10. kUniversity of Maryland Capital Region Health, University of Maryland Medical System, Cheverly, Maryland; and
    11. hUniversity of Florida Health Sciences Center–Jacksonville, Jacksonville, Florida;
    12. lDepartment of Family Science, University of Maryland School of Public Health, College Park, Maryland
    1. Drs Gausche-Hill, Remick, Joseph, Brown, and Wright and Ms Snow were each responsible for all aspects of writing and editing the document and reviewing and responding to questions and comments from reviewers and the Board of Directors; and all authors approved the final manuscript as submitted.

    Abstract

    This is a revision of the previous joint Policy Statement titled “Guidelines for Care of Children in the Emergency Department.” Children have unique physical and psychosocial needs that are heightened in the setting of serious or life-threatening emergencies. The majority of children who are ill and injured are brought to community hospital emergency departments (EDs) by virtue of proximity. It is therefore imperative that all EDs have the appropriate resources (medications, equipment, policies, and education) and capable staff to provide effective emergency care for children. In this Policy Statement, we outline the resources necessary for EDs to stand ready to care for children of all ages. These recommendations are consistent with the recommendations of the Institute of Medicine (now called the National Academy of Medicine) in its report “The Future of Emergency Care in the US Health System.” Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that ED staff, administrators, and medical directors seek to meet or exceed these recommendations to ensure that high-quality emergency care is available for all children. These updated recommendations are intended to serve as a resource for clinical and administrative leadership in EDs as they strive to improve their readiness for children of all ages.

  1. Abbreviations:
    AAP
    American Academy of Pediatrics
    ACEP
    American College of Emergency Physicians
    ED
    emergency department
    EMS
    emergency medical services
    EMSC
    Emergency Medical Services for Children
    ENA
    Emergency Nurses Association
    IOM
    Institute of Medicine
    PECC
    pediatric emergency care coordinator
    PI
    performance improvement
    QI
    quality improvement
  2. Introduction

    In this Policy Statement, we delineate the recommended resources necessary to prepare emergency departments (EDs) to care for pediatric patients. Adoption of the recommendations in this Policy Statement will facilitate the delivery of emergency care for children of all ages and, when appropriate, timely transfer to a facility with specialized pediatric services. This joint Policy Statement is an update of previously published guidelines.14

    These recommendations are intended to apply to all EDs that provide care for children. In the United States, most children who seek emergency care (83%) present to general EDs versus specialized pediatric EDs.5 Intended users of these recommendations include all EDs that are open 24 hours per day, 7 days per week, including freestanding EDs and critical access hospital EDs. This Policy Statement is not intended to address urgent care centers because other recommendations are available to address those settings.6

    Background

    In the National Hospital Ambulatory Medical Care Survey, it was reported that in 2014, there were approximately 5000 EDs in the United States. Of the more than 141 million ED visits in the United States in 2014, approximately 20% were for children younger than 15 years old.7 Children have unique anatomic, physiologic, developmental, and medical needs that differ from those of adults. These differences must be considered when developing emergency services, training ED staff, and stocking equipment, medication, and supplies.

    Improving Pediatric Readiness in US EDs

    In 2006 in the “Future of Emergency Care” series, the Institute of Medicine (IOM) (now the National Academy of Medicine) noted ongoing deficiencies in both the prehospital and ED settings, including the availability of pediatric equipment, access to supplies and medications, training for staff, and policies in which the unique needs of children are incorporated.8 Although there have been marked improvements in many areas of everyday pediatric readiness, persistent variability and a need for improvement remain across the continuum of care.5,912

    One of the specific recommendations from the 2006 IOM report was that hospitals appoint coordinators for pediatric emergency care. At that time, only 18% of EDs in the United States reported having a physician coordinator, and only 12% had a nursing coordinator for pediatric emergency care. A national assessment performed in 200313 revealed that EDs that have staff in these positions tend to be more prepared, as measured by using compliance with the “Guidelines for the Care of Children in the ED” published by the American College of Emergency Physicians (ACEP) and American Academy of Pediatrics (AAP) in 2001.1 In 2009, the AAP, ACEP, and Emergency Nurses Association (ENA), with the support of the Emergency Medical Services for Children (EMSC) program, undertook a major revision of these guidelines.3,4 The 2009 joint Policy Statement is the subject for this policy revision.

    The National Pediatric Readiness Project, launched in 2013, is an ongoing quality improvement (QI) initiative among the federal EMSC program, AAP, ACEP, and ENA to ensure pediatric readiness of EDs.9 In phase 1 of the project, hospital ED leaders in all US states and territories were asked to complete a comprehensive Web-based assessment of their readiness to care for children. The assessment was based on the 2009 joint Policy Statement.3,4 The response rate was 83%, representing more than 4000 EDs.5 The data from this project reveal a snapshot of the nation’s readiness to provide care to children in the ED. They also provide information on gaps in readiness at the state and national levels, confidential site-specific needs, and recommendations to improve readiness. Key findings include the following:

    1. The majority of children who seek emergency care (69.4%) are cared for in EDs that see fewer than 15 pediatric patients per day, highlighting the need to provide additional pediatric emergency resources to smaller and often rural EDs.

    2. The overall median score for the nation was 70 (of 100 possible points). This represents an improvement when compared with a similar survey completed in 2003 (median score of 55 points).5,13

    3. The median score for EDs with a high volume of pediatric patients (>27 pediatric visits per day) was greater than that of EDs with medium, medium-high (5–27 pediatric visits per day), or low pediatric volume (<5 pediatric visits per day).

    4. Approximately half of EDs lacked a physician (52.5%) or nurse (40.7%) pediatric emergency care coordinator (PECC). The presence of a PECC is strongly correlated with improved pediatric readiness, independent of other factors.5 Another analysis of hospital-based EDs in the state of California also revealed that the presence of a PECC was associated with improved overall pediatric readiness scores.14

    5. Fifty-five percent of EDs reported the absence of a QI plan in which they address pediatric care, and of those that had a QI plan, 41.7% lacked specific quality indicators for children. The presence of a QI plan that included pediatric-specific indicators was independently associated with improved overall readiness scores in California.14

    6. In the absence of participation in a pediatric verification program, trauma center status was not predictive of higher pediatric readiness scores.14

    7. Approximately half of hospitals reported lacking disaster plans (53.2%) that include specific care needs for children.5

    8. A process to ensure that weights are measured and recorded in kilograms only, which is a pediatric safety concern, was also lacking in 32.3% of EDs completing the assessment.5

    Pediatric Readiness and Pediatric Facility Recognition

    The EMSC program has long promoted improved preparedness and recognition of prepared EDs. Current EMSC program performance measures address pediatric readiness for children with both traumatic and medical emergencies.10 Performance Measure 04 reads as follows: “the percent[age] of hospitals recognized through a statewide, territorial, or regional[ly] standardized system that are able to stabilize and/or manage pediatric medical emergencies.” At this time, 11 states have developed such a system (recognizing 8% of all US hospital-based EDs),15 and all have used the 2009 joint Policy Statement as the basis of their recognition criteria. Some states have published descriptions of the process they used to establish and maintain a pediatric recognition system.14,16

    Recognition and verification have been associated with improved readiness scores. Remick et al14 described an association between higher hospital readiness scores and an on-site verification program in California. National data reveal that states that have a recognition and/or verification system and have achieved EMSC program Performance Measure 04 have readiness scores that are an average of 10 points higher than those that do not have such a system.15 In addition, hospitals that have been recognized scored, on average, 22 points higher on the assessment than those that had not been recognized as pediatric ready by their states (National EMSC Data Analysis and Resource Center, unpublished observations, 2014).

    Pediatric Readiness: Improving the Safety and Quality of Pediatric Emergency Care

    Over the past 15 years, patient safety has become a key priority for health systems.17 In 2014, the AAP released the revised Policy Statement “Patient Safety in the Pediatric Emergency Care Setting.”18 This statement and other recent work have revealed the value of specific structural and process measures on improved patient safety and quality of care. For example, a weight-based, color-coded medication safety system can be used to decrease dosing errors and improve the timeliness of dosing,19,20 and order sets, reminders, and clinical practice recommendations embedded within information systems can be used to increase adherence to best practices.21,22

    Although previous guidelines1,2 were consensus based, several recent studies have revealed the effects of pediatric readiness on outcomes for children treated in EDs. Some investigators have examined the effect of improved pediatric readiness and/or facility recognition on the quality of pediatric emergency care. Ball et al23 compared outcomes in children with extremity immobilization and a pain score of 5 or greater in a state with a medical facility recognition program to similar facilities in a state without a facility recognition program. The children in the state with the recognition system had improved timeliness of the management of pain for fractures and decreased exposure to radiation use.23 Kessler et al24 demonstrated that teams of health care providers who practiced in EDs with higher pediatric readiness scores performed better in a standardized simulation of the care of children with sepsis. A statewide program in Arizona to improve the pediatric readiness of EDs has been associated with a decreased pediatric mortality rate after participation in a verification process based on compliance with published guidelines.25 Shared resources and coordination of care in emergency care systems is a strategy that may be used to improve pediatric readiness locally, regionally, and nationally. Further research should be supported to evaluate the effects of each of the recommended components of the guidelines on the quality of pediatric emergency care.

    The information from the pediatric readiness assessment, research described earlier in this Policy Statement, and expert opinion from the coauthoring organizations were used to inform this revised Policy Statement. These recommendations include current information on equipment, medications, supplies, and personnel that are considered critical for managing pediatric emergencies in EDs. In this Policy Statement, we also offer recommendations for the administration and coordination of pediatric care in the ED; pediatric emergency care QI, performance improvement (PI), and patient safety activities; policies, procedures, and protocols for pediatric care; and key ED support services. It is believed that all EDs in the United States can meet or exceed these recommendations and that some hospitals, such as those with pediatric critical care capabilities or children’s hospitals with greater resources, will develop and implement even more comprehensive recommendations and share their expertise with their local and regional communities. These updated recommendations are intended to serve as a resource for clinical and administrative leadership of EDs as they strive to improve their readiness for children of all ages.

    Administration and Coordination for the Care of Children in the ED

    A pediatric emergency care coordinator (PECC) is a physician coordinator identified by the ED medical director or a registered nurse coordinator identified by the ED nurse director. Identification of a physician and nurse PECC is central to the readiness of any ED that cares for children. Recommendations include the following:

    1. The physician and nurse PECCs may be concurrently assigned other roles in the ED (eg, frontline staff designated by leadership) or may oversee more than 1 program in the ED (ie, medical or nursing director or as coordinator for trauma, stroke, or cardiac [STEMI]). PECC roles may be shared through formal agreements with administrative entities, such as within hospital systems, when there is another ED capable of providing definitive pediatric care.

    2. Facilitate the following qualifications for physician and nurse PECCs:

      1. the physician PECC is qualified by the facility to provide emergency care. Optimally, the physician PECC is a board-certified and/or eligible specialist in emergency medicine or pediatric emergency medicine. Otherwise, the physician PECC must meet the qualifications for credentialing of the hospital as an emergency clinician specialist with special training and experience in the evaluation and management of the child who is critically ill. The physician PECC is credentialed by the facility and has verified competency in the care of children, including resuscitation, per the hospital policy. For EDs with limited resources, this administrative role may be shared with a clinical nurse specialist, nurse practitioner, or physician assistant (ie, advanced practice provider) who is credentialed to care for patients in the ED; and

        • b. the nurse PECC is a registered nurse who possesses special interest, knowledge, and skill in the emergency nursing care of children through clinical experience and has demonstrated competence in critical thinking and clinical skills. When available, a certified emergency nurse or, preferably, a certified pediatric emergency nurse is desirable. Otherwise, the nurse coordinator has verified competency per hospital policy and may have other credentials, such as certified pediatric nurse or certified critical care registered nurse.

    3. The physician and nurse PECCs work collaboratively and are responsible for the following:

      • a. promoting adequate skill and knowledge of ED staff physicians, nurses, and other health care providers and staff (ie, physician assistants, advanced practice nurses, paramedics, and technicians) in the emergency care and resuscitation of infants and children. PECCs should have significant input into the methods of demonstrating competency in pediatric emergency care for their respective disciplines;

      • b. participating in the development of the pediatric components of the QI plan and facilitating QI activities related to pediatric emergency care;

      • c. assisting with the development and periodic review of ED policies and procedures and standards for medications, equipment, and supplies to ensure adequate resources for children of all ages;

      • d. serving as liaisons and/or coordinators in collaboration with appropriate in-hospital and out-of-hospital pediatric care committees in the community and/or region and emergency medical services (EMS), trauma, and emergency preparedness coordinators (if they exist);

      • e. serving as liaisons to definitive-care hospitals, such as regional pediatric referral hospitals and trauma centers, EMS agencies, primary care providers, health insurers, and any other care resources needed to integrate services along the pediatric care continuum, such as pediatric injury prevention, chronic disease management, and community education programs;

      • f. facilitating pediatric emergency medical and nursing education for ED health care providers and staff, including but not limited to the identification of continuing pediatric emergency education resources;

      • g. facilitating the inclusion of pediatric-specific elements in physician and nursing orientation in the ED;

      • h. in coordination with the local credentialing processes, facilitating competency evaluations for staff that are pertinent to children of all ages. When available, simulation (ie, pediatric scenario–based mock codes) has been revealed to improve pediatric care in resuscitation and team settings2628;

      • i. facilitating the integration of pediatric needs in hospital disaster and/or emergency preparedness plans and promoting the inclusion of pediatric patients in disaster drills29;

      • j. collaborating with ED leadership to enable adequate staffing, medications, equipment, supplies, and other resources for children in the ED; and

      • k. communicating with ED and hospital leadership on efforts to facilitate pediatric emergency care.

    Competencies for Physicians, Advanced Practice Providers, Nurses, and Other ED Health Care Providers

    Recommendations include the following:

    • A. Physicians, advanced practice providers, nurses, and other ED health care providers, on the basis of their level of training and scope of practice, should have the necessary skill, knowledge, and training in the emergency evaluation and treatment of children of all ages consistent with the services provided by the hospital.

    • B. Baseline and periodic competency evaluations completed for all ED clinical staff, including physicians, advanced practice providers, nurses, and other health care providers are age specific and include neonates, infants, children, adolescents, and children with special health care needs. Competencies are determined by each institution’s hospital policy and medical staff privileges as a part of the local credentialing process for all licensed ED staff.

    • C. The demonstration and maintenance of pediatric clinical competencies may be achieved through continuing education, including participation in local educational programs, professional organization conferences, or national pediatric emergency care courses, or scheduled mock codes or patient simulation, team training exercises, or experiences in other clinical settings, such as the operating room (ie, airway management). The evaluation of such competencies may be achieved through direct observation, chart reviews, written knowledge tests, and/or the maintenance of physician or advanced practice provider board certification or nurse certification when pediatric emergency medicine is a significant component of annual continuing education requirements.

    • D. Potential areas for pediatric competency and professional performance evaluations may include but are not limited to the following:

      1. assessment and treatment, including the following: (a) triage, (b) illness and injury assessment and management, and (c) pain assessment and treatment, including nonpharmacologic pain management (eg, distraction techniques and comfort holds);

      2. medication administration and delivery;

      3. device and/or equipment safety (eg, low-volume infusion pumps);

      4. procedures, including the following: (a) airway management, (b) vascular access, and (c) sedation and analgesia;

      5. resuscitation, including the following: (a) critical care monitoring, (b) neonatal resuscitation, and (c) pediatric resuscitation;

      6. trauma resuscitation and stabilization,30 including the following: (a) burn management, (b) traumatic brain injury, (c) fracture management, (d) hemorrhage control, and (e) recognition and reporting of nonaccidental trauma;

      7. disaster drills that include a triage of pediatric victims, the tracking and identification of unaccompanied children, family reunification, and the determination of pediatric surge capacity29;

      8. patient- and family-centered care, including cultural competency; and

      9. team training and effective communication, including the following: (a) transitions of care and/or handoffs31 and (b) closed-loop communication.

    QI and/or PI in the ED

    Quality is best ensured by evaluating each of the 6 domains addressed by the IOM31,32: safe, equitable, patient centered, timely, efficient, and effective. PI processes are essential to evaluating the quality of care, and measurement is integral to PI activities. Pediatric-specific metrics should be carefully identified to assess the quality of care throughout each phase of health care delivery across the emergency care continuum. A pediatric patient care review process is integrated into the QI and/or PI plan of the ED according to the following recommendations:

    • A. The potential framework for QI efforts may be focused on the effectiveness of structural elements, processes, and clinical outcomes relative to pediatric emergency care. Minimum components of the QI and/or PI process should include collecting and analyzing data to discover variances, defining a plan for improvement, and evaluating the success of the QI and/or PI plan with measures that are outcome based. High-level QI efforts are used to facilitate education and training, the implementation of targeted system change, and the measurement of system performance over time until steady, high-level performance is achieved.

    • B. The QI and/or PI plan of the ED shall include pediatric-specific indicators. Pediatric emergency care metrics have been identified (Table 1) and should be strongly considered for inclusion in the overall QI plan. In addition, performance bundles may be used to assess the quality of care provided for specific clinical conditions (eg, pediatric septic shock, pediatric asthma, and pediatric closed head injury).

    • C. Components of the process are used to integrate out-of-hospital, ED, trauma, inpatient pediatrics, pediatric critical care, and hospital-wide QI or PI activities and may be interfaced with regional, state, or national QI collaboratives, including injury prevention efforts.3336

    • D. Mechanisms are in place to monitor professional performance, credentialing, continuing education, and clinical competencies, including the integration of findings from QI audits and case reviews for pediatric emergency care.

    TABLE 1

    Sample Performance Measures for Pediatric Emergency Care

    Numerous resources are available to assist ED staff with implementing QI and/or PI activities (Table 2).

    TABLE 2

    Examples of Pediatric Emergency Care PI Activities and Resources

    Policies, Procedures, and Protocols for the ED

    Recommendations include the following:

    • A. Policies, procedures, and protocols for the emergency care of children are age specific and include neonates, infants, children, adolescents, and children with special health care needs. Staff are educated accordingly and monitored for compliance and periodically updated. These include, but are not limited to, the following:

      1. illness and injury triage;

      2. pediatric patient assessment and reassessment;

      3. documentation of a full set of pediatric vital signs, including core temperature, respiratory rate, pulse oximetry, heart rate, blood pressure (including manual confirmation), pain, and mental status when indicated;

      4. identification and notification of the responsible provider of abnormal vital signs (age or weight based);

      5. immunization assessment and management (eg, tetanus and rabies) of the patient who is underimmunized37;

      6. sedation and analgesia (including nonpharmacologic interventions for comfort) for procedures, including medical imaging38,39;

      7. consent (including situations in which a parent or legal guardian is not immediately available)40;

      8. social and behavioral health issues, including parents and patients who are belligerent, impaired, or violent4143;

      9. physical or chemical restraint of patients;

      10. child maltreatment mandated reporting and assessment (physical and sexual abuse, sexual assault, human trafficking, and neglect)44;

      11. death of a child in the ED45,46;

      12. do-not-resuscitate orders;

      13. lack of a medical home;

      14. children with special health care needs, including developmental disabilities (eg, autism spectrum disorders and ventilator dependence);

      15. family-centered care,4752 including the following:

    • a. involving families and guardians in patient care decision-making and medication safety processes;

    • b. family and guardian presence during all aspects of emergency care, including resuscitation;

    • c. education of the patient, family, and caregivers and guardians;

    • d. discharge planning and education; and

    • e. bereavement counseling;

      1. communication with a patient’s medical home or primary health care provider at the time of the ED visit (this can help ensure that a judicious and appropriate approach to examination, testing, imaging, and treatment is coordinated and follow-up is arranged in the most cost-effective and up-to-date manner)53;

      2. telehealth and telecommunications54; and

      3. an all-hazard disaster preparedness plan in which the following pediatric issues are addressed55:

    • a. availability of medications, vaccines (eg, tetanus and rabies), equipment, supplies, and appropriately trained providers for children in disasters;

    • b. pediatric surge capacity for both children who are injured and noninjured;

    • c. decontamination, isolation, and quarantine of families and children of all ages;

    • d. minimization of parent-child separation and improved methods for reuniting separated children with their families;

    • e. access to specific medical and behavioral health therapies, as well as social services, for children in the event of a disaster;

    • f. disaster drills that include a pediatric mass casualty incident at least once every 2 years; all drills include pediatric patients; and

    • g. the care of children with special health care needs, including children with developmental disabilities.

    • B. Evidence-based clinical pathways, order sets, or decision support should be available to providers in real time. These may be systematically derived, consensus driven, or locally developed on the basis of available evidence. Many children’s hospitals and/or academic centers have developed such clinical pathways. Collaboration with regional pediatric centers and trauma centers may facilitate the use of standard, evidence-based guidelines. An updated and complete list is available on the National Pediatric Readiness Project Web site.5660

    • C. Hospitals should have written pediatric interfacility transfer procedures and/or agreements that include the following pediatric components6163:

      1. defined processes for the initiation of transfer, including the roles and responsibilities of the referring facility and referral center (including responsibilities for requesting transfer, method of transport, and communication);

      2. a transport plan to deliver children safely (including the use of child passenger–restraint devices) and in a timely manner to the appropriate facility that is capable of providing definitive care;

      3. processes for selecting the appropriate care facility for pediatric specialty services that are not available at the hospital; these specialty services may include the following: (a) medical and surgical specialty care, (b) critical care, (c) reimplantation (replacement of severed digits or limbs), (d) trauma and burn care, (e) psychiatric emergencies, (f) obstetric and perinatal emergencies, (g) child maltreatment (physical and sexual abuse and assault), (h) rehabilitation for recovery from critical medical or traumatic conditions, (i) orthopedic emergencies, and (j) neurosurgical emergencies;

      4. processes for selecting the appropriately staffed transport service to match a patient’s acuity level (ie, level of care required and equipment needed for transport) and that are appropriate for children with special health care needs;

      5. processes for patient transfer (including obtaining informed consent)64;

      6. a plan for the transfer of critical patient information (ie, medical record, imaging, and copy of signed transport consent) as well as personal belongings and the provision of directions and referral institution information to the family;

      7. processes for the return transfer of the pediatric patient to the referring facility as appropriate; and

      8. integration with telehealth and/or telecommunications processes and mobile-integrated health and/or community paramedicine as appropriate.54

    Pediatric Patient and Medication Safety in the ED

    The delivery of pediatric care should reflect an awareness of unique pediatric patient safety concerns and should include the following policies or practices65,66:

    • A. Children should be weighed in kilograms, with the exception of children who require emergency stabilization, and the weight should be recorded in a prominent place on the medical record, preferably with the vital signs.

      1. For children who require resuscitation or emergency stabilization, a standard method for estimating weight in kilograms should be used.

    • B. A full set of vital signs should be recorded and reassessed per hospital policy for all children.

    • C. The following processes for safe medication (including blood products) prescribing, delivery, and disposal should be established67,68:

      1. use precalculated dosing guidelines for children of all ages;

      2. consider adding a pharmacist with pediatric competency to the ED team, especially in large EDs, during times of higher volume;

      3. identify the administration phase as a high-risk practice (eg, the simple misplacement of a decimal point can result in a 10-fold medication error);

      4. promote distraction-free zones for medication preparation69,70;

      5. implement and use computerized physician order entry and clinical decision support with pediatric-specific, kilogram-only dosing rules, including upper dosing limits, within ED information systems;

      6. implement and use computerized physician order entry to create allergy alerts for all prescribed medications;

      7. practice vigilance for all administered or prescribed medications and consider developing standardized order sets, particularly for high-risk medications, such as opioids and antibiotics;

      8. implement an independent 2-provider cross-check process for high-alert medications;

      9. create a standard formulary for pediatric high-risk and commonly used medications;

      10. standardize concentrations of high-risk medications;

      11. reduce the number of available concentrations to the smallest possible number;

      12. implement systems in which weight-based calculations are bypassed during pediatric resuscitations and treatment to reduce potentially harmful mistakes;

      13. establish a culture of safety surrounding pediatric medication administration that encourages the reporting of near-miss or adverse medication events that can then be analyzed as feedback into the system in a continuous QI model;

      14. ensure that caregivers are well instructed on medication administration, particularly for pain and antipyretic medications, before being discharged from the ED; and

      15. promote the integration of health literacy concepts and skills, including the use of plain language, the teach-back method, pictograms, and lower-literacy instructions.7175

    • D. Pediatric emergency services should be culturally and linguistically appropriate,76 and the ED should provide an environment that is safe for children and supports patient- and family-centered care.48,49,77

      1. Enhance family-centered care by actively engaging patients and families in safety at all points of care, and address issues of ethnic culture, language, and literacy.

      2. Direct families to appropriate resources, and review patients’ rights and responsibilities from the perspective of safety.

      3. Include shared decision-making.

      4. Use trained language interpreter services rather than bilingual relatives.

    • E. Patient-identification policies, consistent with The Joint Commission’s National Patient Safety Goals, should be implemented and monitored.78

    • F. Policies for the timely tracking, reporting, and evaluation of patient safety events and for the disclosure of medical errors or unanticipated outcomes should be implemented and monitored, and education and training in disclosure should be available to care providers who are assigned this responsibility.65,66

    Support Services for the ED

    Recommendations include the following:

    • A. The radiology department should have the skills and capability to provide imaging studies of children, the equipment necessary to do so, and guidelines to reduce radiation exposure that are age and size specific.7981

      1. The radiology capability of hospitals may vary from 1 institution to another; however, every ED should promote on-site radiology capabilities to meet the needs of children in the community.

      2. Medical imaging protocols that are used to address age- or weight-appropriate dose reductions for children receiving studies in which ionizing radiation is imparted, consistent with “as low as reasonably achievable” principles, are necessary.82

      3. A process should be established for the referral of children to appropriate facilities for radiologic procedures that exceed the capability of the hospital.

      4. A process should be in place for timely review and interpretation reporting by a qualified radiologist for medical imaging studies in children.

      5. When a patient is transferred from 1 facility to another, to avoid unnecessary radiation exposure, all efforts should be made to transfer completed images. New technology (eg, Cloud file sharing or Health Insurance Portability and Accountability Act protection) may facilitate image sharing between facilities.83

    • B. The laboratory should have the skills and capability to perform laboratory tests for children of all ages, including obtaining samples, and have available microtechnology for small or limited sample sizes.

      1. The clinical laboratory capability must meet the needs of the children in the community it serves.

      2. There should be a clear understanding of what the laboratory capability is for any given community, and definitive plans for referring children to the appropriate facility for laboratory studies should be in place.

      3. Protocols should be developed for the screening and administration of blood and blood products for children who are ill or injured.

    Equipment, Supplies, and Medications

    Pediatric equipment, supplies, and medications shall be easily accessible, labeled, and logically organized (eg, kilogram weight, weight-based color coding, etc).

    • A. Medication chart, color-based coding, medical software, or other systems shall be readily available to ED staff to ensure proper sizing of resuscitation equipment and proper dosing of medications based on patient weight in kilograms.

    • B. Resuscitation equipment and supplies shall be located in the ED; trays and other items may be housed in other departments (such as the newborn nursery or central supply) with a process to ensure immediate accessibility to ED staff. A mobile or portable appropriately stocked pediatric crash cart should be available in the ED at all times.

    • C. ED staff shall be appropriately educated as to the location of all items (Supplemental Figs 1 and 2).

    • D. Each ED shall have a daily method to verify the proper location and function of equipment and expiration of medications and supplies.

    • E. Tables 3 and 4 and Supplemental Figs 1 and 2 outline medications, equipment, and supplies necessary for the care of children in the ED by qualified health care providers.84

    TABLE 3

    Resuscitation Medications for Use in Pediatric Patients in EDs

    TABLE 4

    Medications to Be Used in the ED for the Care of Children

    Conclusions

    In the 2006 report, “Emergency Care for Children: Growing Pains,” the IOM uses the word “uneven” to describe the current status of pediatric emergency care in the United States.8 Although much progress has been made to improve pediatric readiness across communities,5 there remains a significant opportunity for further progress nationwide. An important first step in ensuring readiness is the identification of a physician and nurse coordinator for pediatric emergency care.

    All EDs must be continually prepared to receive; accurately assess; and, at a minimum, stabilize and safely transfer children who are acutely ill or injured. This is necessary even for hospitals located in communities with readily accessible pediatric tertiary-care centers and regionalized systems for pediatric trauma and critical care. The vast majority of children requiring emergency services in the United States receive this care in a non–children’s hospital ED, with 69% of EDs providing care for fewer than 15 children per day.5 This relatively infrequent exposure of hospital-based emergency care professionals to children who are seriously ill or injured represents a substantial barrier to the maintenance of essential skills and clinical competency. Recognition of the unique needs of children who are ill and/or injured and served by an emergency care facility, including children with special health care needs; the commitment to better meet those needs through the adoption of these recommendations; and an ongoing commitment to evaluate care quality and safety and maintain pediatric competencies should provide a strong foundation for pediatric emergency care.

    Resources that can be used to assist with the implementation of all aspects of this document can be found at www.pediatricreadiness.org.

    Lead Authors

    Katherine Remick, MD, FAAP, FACEP, FAEMS

    Marianne Gausche-Hill, MD, FAAP, FACEP

    Madeline Joseph, MD, FAAP, FACEP

    Kathleen Brown, MD, FAAP, FACEP

    Sally K. Snow, BSN, RN, CPEN

    Joseph L. Wright, MD, MPH, FAAP

    AAP Committee on Pediatric Emergency Medicine, 2017–2018

    Joseph Wright, MD, MPH, FAAP, Chairperson

    Terry Adirim, MD, MPH, FAAP

    Michael S.D. Agus, MD, FAAP

    James Callahan, MD, FAAP

    Toni Gross, MD, MPH, FAAP

    Natalie Lane, MD, FAAP

    Lois Lee, MD, MPH, FAAP

    Suzan Mazor, MD, FAAP

    Prashant Mahajan, MD, MPH, MBA, FAAP

    Nathan Timm, MD, FAAP

    Liaisons

    Andrew Eisenberg, MD, MHA – American Academy of Family Physicians

    Cynthia Wright Johnson, MSN, RN – National Association of State EMS Officials

    Cynthiana Lightfoot, BFA, NRP – American Academy of Pediatrics Family Partnerships Network

    Charles Macias, MD, MPH, FAAP – Emergency Medical Services for Children Innovation and Improvement Center

    Brian Moore, MD, MPH, FAAP – National Association of EMS Physicians

    Diane Pilkey, RN, MPH – Health Resources and Services Administration

    Katherine Remick, MD, FAAP – National Association of Emergency Medical Technicians

    Mohsen Saidinejad, MD, MBA, FAAP, FACEP – American College of Emergency Physicians

    Sally Snow, RN, BSN, CPEN, FAEN – Emergency Nurses Association

    Mary Fallat, MD, FAAP – American College of Surgeons

    Former AAP Committee on Pediatric Emergency Medicine Members, 2012–2016

    Alice Ackerman, MD, MBA, FAAP

    Thomas Chun, MD, MPH, FAAP

    Gregory Conners, MD, MPH, MBA, FAAP

    Edward Conway Jr, MD, MS, FAAP

    Nanette Dudley, MD, FAAP

    Joel Fein, MD, FAAP

    Susan Fuchs, MD, FAAP

    Marc Gorelick, MD, MSCE, FAAP

    Natalie Lane, MD, FAAP

    Steven Selbst, MD, FAAP

    Kathy Shaw, MD, MSCE, FAAP, Chairperson (2008–2012)

    Joan Shook, MD, MBA, FAAP, Chairperson (2012–2016)

    Staff

    Sue Tellez

    AAP Section on Surgery Executive Committee, 2016–2017

    Kurt F. Heiss, MD, Chairperson

    Elizabeth Beierle, MD

    Gail Ellen Besner, MD

    Cynthia D. Downard, MD

    Mary Elizabeth Fallat, MD

    Kenneth William Gow, MD

    Staff

    Vivian Baldassari Thorne

    ACEP Pediatric Emergency Medicine Committee, 2016–2017

    Madeline Joseph, MD, FACEP, Chairperson

    Kiyetta Alade, MD

    Christopher Amato, MD, FACEP

    Jahn T. Avarello, MD, FACEP

    Steven Baldwin, MD

    Isabel A. Barata, MD, FACEP, FAAP

    Lee S. Benjamin, MD, FACEP

    Kathleen Berg, MD

    Kathleen Brown, MD, FACEP

    Jeffrey Bullard-Berent, MD, FACEP

    Ann Marie Dietrich, MD, FACEP

    Phillip Friesen, DO

    Michael Gerardi, MD, FACEP, FAAP

    Alan Heins, MD, FACEP

    Doug K. Holtzman, MD, FACEP

    Jeffrey Homme, MD, FACEP

    Timothy Horeczko, MD, MSCR

    Paul Ishimine, MD, FACEP

    Samuel Lam, MD, RDMS

    Katharine Long

    Kurtis Mayz, JD, MD, MBA

    Sanjay Mehta, MD, Med, FACEP

    Larry Mellick, MD

    Aderonke Ojo, MD, MBBS

    Audrey Z. Paul, MD, PhD

    Denis R. Pauze, MD, FACEP

    Nadia M. Pearson, DO

    Debra Perina, MD, FACEP

    Emory Petrack, MD

    David Rayburn, MD, MPH

    Emily Rose, MD

    W. Scott Russell, MD, FACEP

    Timothy Ruttan, MD, FACEP

    Mohsen Saidinejad, MD, MBA, FACEP

    Brian Sanders, MD

    Joelle Simpson, MD, MPH

    Patrick Solari, MD

    Michael Stoner, MD

    Jonathan H. Valente, MD, FACEP

    Jessica Wall, MD

    Dina Wallin, MD

    Muhammad Waseem, MD, MS, FACEP

    Paula J. Whiteman, MD, FACEP

    Dale Woolridge, MD, PhD, FACEP

    Former ACEP Pediatric Emergency Medicine Committee Members, 2012–2016

    Joseph Arms, MD

    Richard M. Cantor, MD, FACEP

    Ariel Cohen, MD

    Carrie DeMoor, MD

    James M. Dy, MD

    Paul J. Eakin, MD

    Sean Fox, MD

    Marianne Gausche-Hill, MD, FACEP, FAAP

    Timothy Givens, MD

    Charles J. Graham, MD, FACEP

    Robert J. Hoffman, MD, FACEP

    Mark Hostetler, MD, FACEP

    Hasmig Jinivizian, MD

    David Markenson, MD, MBA, FACEP

    Joshua Rocker, MD, FACEP

    Brett Rosen, MD

    Gerald R. Schwartz, MD, FACEP

    Harold A. Sloas, DO

    Annalise Sorrentino, MD, FACEP

    Orel Swenson, MD

    Michael Witt, MD, MPH, FACEP

    Staff

    Loren Rives, MNA

    Dan Sullivan

    Stephanie Wauson

    ENA Pediatric Committee, 2016–2017

    Tiffany Young, BSN, RN, CPNP, 2016 Chairperson

    Joyce Foresman-Capuzzi, MSN, RN, CNS, 2017 Chairperson

    Rose Johnson, RN

    Heather Martin, DNP, MS, RN, PNP-BC

    Justin Milici, MSN, RN

    Cam Brandt, MS, RN

    Nicholas Nelson, MS, RN, EMT-P

    Board Liaisons

    Maureen Curtis-Cooper, BSN, RN, 2016 Board Liaison

    Kathleen Carlson, MSN, RN, 2017 Board Liaison

    Staff

    Marlene Bokholdt, MSN, RN

    Footnotes

    • Address correspondence to Katherine Remick, MD. E-mail: kate.remick{at}gmail.com
    • Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

    • The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

    • All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

    • Published simultaneously on November 1, 2018, by the Annals of Emergency Medicine and the Journal of Emergency Nursing.

    • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

    • FUNDING: No external funding.

    • POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

    References