Emergency Department Readiness For Pediatric Illness And Injury

Emergency Department Readiness For Pediatric Illness And Injury

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Table of Contents
Table of Contents
  1. Case Presentation
  2. Introduction
  3. Pediatric Patient Safety In The United States Healthcare System
    1. Pediatric-Specific Safety Risks
    2. Guidelines Development For Pediatric Readiness
    3. Literature On Pediatric Readiness
    4. Barriers To Pediatric Readiness
  4. Recommendations For Preparing The Emergency Department For Treatment Of Pediatric Patients
    1. Resources For Emergency Department Assessment And Management
      1. Pediatric Readiness Checklist
      2. Assessment Toolkit
      3. Pediatric Coordinator
      4. Triage Tools
      5. Pediatric Surge Capacity Planning
      6. Safety
    2. Prehospital And Hospital Clinician Training
    3. Regionalization Of Pediatric Care
  5. Support In Pediatric Readiness
    1. Federal EMS For Children Program
    2. Emergency Medical Services Role In Ensuring Pediatric Readiness
    3. Tools To Assist In Pediatric Readiness Of Emergency Departments
  6. Special Considerations: The Nursing Perspective
  7. Controversies And Cutting Edge
  8. Summary
  9. Risk Management Pitfalls For Pediatric Readiness
  10. Time- And Cost-Effective Strategies
  11. Case Conclusion
  12. Tables
    1. Table 1. EMS For Children State Territory
    2. Table 2. Top 15 Performance Measures In Pediatric Emergency Care
  13. References

Case Presentation

A 14-month-old boy in respiratory distress is carried into your ED by his parents after choking on a piece of meat. Upon presentation, he is noted by the nurse to have audible stridor and severe retractions. His initial vital signs are: heart rate, 190 beats/min; respiratory rate, 10 breaths/min; oxygen saturation, 78% on room air; temperature, 37.4ºC; and blood pressure, 90/54 mm Hg. The patient is rapidly triaged using the Emergency Severity Index, and on arrival at the patient’s bedside, you are immediately notified by the staff of abnormal vital signs. You initiate bag-mask ventilation for hypoventilation and hypoxia. There is poor chest rise, and you feel resistance to ventilation. You recognize that this child is in respiratory failure with an upper airway obstruction, and you begin the process of relieving the obstruction. The scenario calls to mind a meeting you had earlier that morning regarding treatment of pediatric patients in your ED and equipment you might need. You think about some of the questions that were brought up and how they might apply to care for this child, such as:

  1. Was the triage tool that was used adequate for this child, and did the staff notify you in an appropriate time frame of abnormal vital signs?
  2. Are the critical pediatric resuscitation equipment and supplies stored in a location that makes them readily available for use?
  3. Which staff members should be identified to ensure that necessary equipment is immediately available, including pediatric Magill forceps and a difficult airway kit?
  4. How will our ED staff ensure that medications given to this child to facilitate intubation are dosed accurately?
  5. How will the family be updated on the child’s management?
  6. Once stabilized, will this child be admitted for definitive care, or will the child require transfer to another facility for pediatric intensive care services?


Because parents are most likely to take sick children to the closest emergency department (ED), 90% of children are seen in general EDs.1,2 On the emergency clinician's side, however, opportunity to care for critically ill or injured children is relatively uncommon, and anxiety can be high when such children present. Discovering that the necessary equipment and personnel are not available to respond efficiently should never occur at the moment they are needed. Just as hospitals anticipate and prepare for the care of trauma, stroke, and cardiac patients, preparation for the care of children should also be in place. Guidelines for pediatric readiness are well defined and readily available from many sources. Developing the expertise within hospitals to ensure pediatric readiness of EDs can be a challenge, but it can be accomplished with dedicated staff assigned to the role of ensuring readiness.

Risk Management Pitfalls For Pediatric Readiness

  1. “We do not see many pediatric patients, so we do not have a physician or nurse coordinator for pediatric emergency care.” All EDs have the responsibility to care for patients of any age who present for care and treatment. Designating someone to serve as a champion for pediatric emergency care issues ensures that the needs of children are being met, resulting in enhanced pediatric readiness. While high-volume facilities may choose to assign this role to a fulltime position, smaller hospitals may choose a part-time or shared role.
  2. ”Our quality improvement plan does not address pediatric-specific metrics.” In order to ensure that the care received is as intended, quality improvement plans must be in place to identify and correct systems-based errors. While quality improvement plans may be broad, such plans must target all populations, including children.
  3. ”Our patients’ vital signs are easily visible on the chart. Therefore, there is no need to notify the physician specifically.” Prompt physician notification of the presence of abnormal vital signs leads to more rapid assessment and intervention. Failure to institute policies to notify physicians of abnormal vital signs may lead to significant delays in care and increase the potential for adverse outcomes.
  4. “We do not need a pediatric transfer plan or agreement since we rarely transfer pediatric patients.” While pediatric transfers may be rare occurrences for some facilities, it is important to have a transfer plan and agreement in place in order to expedite access to a higher level of care. Transfer plans may include mode of transport, communication elements, and other requirements. It is important to ensure all necessary communication and documentation is completed, as lack of agreements with outlying facilities may result in significant delays in care and a struggle to identify an appropriate receiving facility.
  5. “Our healthcare providers choose what CME they complete. We do not have any specific pediatric CME requirements.” Pediatric patients account for approximately 25% of ED visits.9,10,60 When a pediatric patient presents in extremis, it is critical that providers are prepared to manage the child effectively and efficiently. Given the relatively infrequent encounters with critically ill pediatric patients, pediatric-specific CME becomes even more important in order to maintain the skills needed to treat the pediatric population. All providers caring for children should be encouraged to complete pediatric-specific CME annually.
  6. ”Our scale only weighs children in pounds.” Standard pediatric dosing is based on weight in kilograms. Weighing children in pounds requires the added step of converting weight into kilograms, which can create additional room for error. Also, utilizing both pounds and kilograms may lead to errors in documentation. All children should be weighed only in kilograms, and weight should be recorded only in kilograms to avoid miscalculations.
  7. “We do not require annual competency evaluations of our providers, as this is included in the certification process.” While recertification may test the current knowledge base, it is important that providers maintain pediatric-specific skills. This is particularly important when these skills are not practiced regularly. Annual competency evaluations provide a means for ensuring skills maintenance.
  8. “We do not use a validated pediatric triage tool.” The use of a validated pediatric triage tool is important to help predict resource utilization. Triage tools used for adults may under- or overtriage pediatric patients, leading to a mismatch in prioritization. A higher triage category alerts physicians to the need for rapid assessment or intervention. Particularly in the setting of overcrowding, failure to utilize a validated pediatric triage tool may result in delays in care and poor patient management.
  9. ”We have a hospital-wide disaster preparedness plan, but no separate plan or inclusive guidelines for children.” Children are disproportionately affected during disasters. In addition, children have special needs that are often not considered when managing adult patients in the setting of a disaster. Specific needs include pediatric triage, a pediatric approach to decontamination, surge capacity, reunification services, medications, and supplies. Pediatric-specific elements must be included in a hospital-wide disaster plan.
  10. ”We have a calculator set up in the resuscitation bay for children.” When a child presents in extremis, the use of a calculator or other real-time dose calculation tools creates multiple opportunities for error. The likelihood of error may be increased during stressful situations such as resuscitations. While slight underdosing and overdosing may occur based on body habitus, the AHA recommends the use of a length-based tape or actual weight to eliminate unnecessary steps in calculation that may lead to significant dosing errors.


Table 1. EMS For Children State Territory


Table 2. Top 15 Performance Measures In Pediatric Emergency Care



Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.

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  2. Athey J, Dean JM, Ball J, et al. Ability of hospitals to care for pediatric emergency patients. Pediatr Emerg Care. 2001;17(3):170-174. (Cross-sectional survey; 101 hospitals, 100% response rate)
  3. Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. Washington DC: Institute of Medicine; 2000. 1st ed. 2000. (IOM report)
  4. Kizer KW. Patient safety: a call to action. A consensus statement from the National Quality Forum. Med Gen Med. 2001;3:1-11. (Consensus statement)
  5. Derlet RW, Richards JR. Overcrowding in the nation’s emergency departments: complex causes and disturbing effects. Ann Emerg Med. 2000;35(1):63-68. (Review)
  6. Trzeciak S, Rivers EP. Emergency department overcrowding in the United States: an emerging threat to patient safety and public health. Emerg Med J. 2003;20(5):402-405. (Review)
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  8. Committee on Pediatric Emergency Medical Services. Emergency Medical Services for Children. Washington DC: Institute of Medicine; 1993. (IOM report)
  9. Committee on the Future of Emergency Care in the U.S. Health System. Hospital-Based Emergency Care: At the Breaking Point. Washington DC: Institute of Medicine; 2006. (IOM report)
  10. Committee on the Future of Emergency Care in the U.S. Health System. Pediatric Emergency Care: Growing Pains. Washington DC: Institute of Medicine; 2006. (IOM report)
  11. American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Committee. Care of children in the emergency department: guidelines for preparedness. Pediatrics. 2001;107(4):777-781. (National guidelines)
  12. American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Committee. Care of children in the emergency department: guidelines for preparedness. Ann Emerg Med. 2001;37(4):423-427. (National guidelines)
  13. * American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Committee, Emergency Nurses Association Pediatric Committee. Joint policy statement--guidelines for care of children in the emergency department. Ann Emerg Med. 2009;54(4):543-552. (National guidelines)
  14. * American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Committee, Emergency Nurses Association Pediatric Committee. Joint policy statement--guidelines for care of children in the emergency department. Pediatrics. 2009;124(4):1233-1243. (National guidelines)
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  16. * Middleton KR, Burt CW. Availability of pediatric services and equipment in emergency departments: United States, 2002-03. Adv Data. 2006(367):1-16. (Cross-sectional survey; 839 hospitals, 86% response rate)
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  18. Sullivan AF, Rudders SA, Gonsalves AL, et al. National survey of pediatric services available in US emergency departments. Int J Emerg Med. 2013;6(1):13. (Telephone survey; random sample of 279 hospital EDs; 85% response rate)
  19. Green NA, Durani Y, Brecher D, et al. Emergency Severity Index version 4: a valid and reliable tool in pediatric emergency department triage. Pediatr Emerg Care. 2012;28(8):753- 757. (Retrospective chart review; 780 patients; prospective cohort study; 100 patients)
  20. Emergency Severity Index (ESI): A Triage Tool for Emergency Department: DVDs and 2012 Edition of the Implementation Handbook. Rockville, MD: Agency for Healthcare Research and Quality; February 2013. (Educational materials)
  21. Warren DW, Jarvis A, LeBlanc L, et al. Revisions to the Canadian Triage and Acuity Scale paediatric guidelines (PaedCTAS). CJEM. 2008;10(3):224-243. (Review)
  22. Roukema J, Steyerberg EW, van Meurs A, et al. Validity of the Manchester Triage System in paediatric emergency care. Emerg Med J. 2006;23(12):906-910. (Review; 1065 patients)
  23. van Veen M, Steyerberg EW, Ruige M, et al. Manchester Triage System in paediatric emergency care: prospective observational study. BMJ. 2008;337:a1501. (Prospective observational study; 17,600 patients)
  24. Sklar DP, Crandall CS, Loeliger E, et al. Unanticipated death after discharge home from the emergency department. Ann Emerg Med. 2007;49(6):735-745. (Retrospective cohort study; 186,859 patients)
  25. CRICO/RMF Strategies Emergency Medicine Leadership Council 2010. Optimizing physician-nurse communication in the emergency department: strategies for minimizing diagnosis-related errors. Available at: https://www.rmf. harvard.edu/~/media/Files/_Global/KC/PDFs/ed_white_ paper_min_diagnosis_errors.pdf. Accessed August 15, 2013. (Website resource)
  26. Broughton DD, Allen EE, Hannemann RE, et al. Getting 5000 families back together: reuniting fractured families after a disaster: the role of the National Center for Missing & Exploited Children. Pediatrics. 2006;117(5 Pt 3):S442-S445. (Report)
  27. Chung S, Shannon M. Reuniting children with their families during disasters: a proposed plan for greater success. Am J Disaster Med. 2007;2(3):113-117. (Report)
  28. Gnauck KA, Nufer KE, LaValley JM, et al. Do pediatric and adult disaster victims differ? A descriptive analysis of clinical encounters from four natural disaster DMAT deployments. Prehosp Disaster Med. 2007;22(1):67-73. (Retrospective cohort review; 2196 total patients, 643 pediatric patients)
  29. Sirbaugh PE, Gurwitch KD, Macias CG, et al. Caring for evacuated children housed in the Astrodome: creation and implementation of a mobile pediatric emergency response team: regionalized caring for displaced children after a disaster. Pediatrics. 2006;117(5 Pt 3):S428-S438. (Report)
  30. Gausche-Hill M. Pediatric disaster preparedness: are we really prepared? J Trauma. 2009;67(2 Suppl):S73-S76. (Review)
  31. Mace SE, Bern AI. Needs assessment: are disaster medical assistance teams up for the challenge of a pediatric disaster? Am J Emerg Med. 2007;25(7):762-769. (Needs assessment)
  32. Shirm S, Liggin R, Dick R, et al. Prehospital preparedness for pediatric mass-casualty events. Pediatrics. 2007;120(4):e756- e761. (Cross-sectional survey; 3748 ambulance services, 51% response rate)
  33. Graham J, Shirm S, Liggin R, et al. Mass-casualty events at schools: a national preparedness survey. Pediatrics. 2006;117(1):e8-e15. (Cross-sectional survey; 3670 schools, 58% response rate)
  34. Barfield WD, Krug SE, Kanter RK, et al. Neonatal and pediatric regionalized systems in pediatric emergency mass critical care. Pediatr Crit Care Med. 2011;12(6 Suppl):S128-S134. (Consensus statement)
  35. Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: pediatric advanced life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 Suppl 3):S876-S908. (National guidelines)
  36. Kleinman ME, de Caen AR, Chameides L, et al. Pediatric basic and advanced life support: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Pediatrics. 2010;126(5):e1261-e1318. (Review)
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  38. Luten R, Wears RL, Broselow J, et al. Managing the unique size-related issues of pediatric resuscitation: reducing cognitive load with resuscitation aids. Acad Emerg Med. 2002;9(8):840-847. (Review)
  39. Nieman CT, Manacci CF, Super DM, et al. Use of the Broselow tape may result in the underresuscitation of children. Acad Emerg Med. 2006;13(10):1011-1019. (Cross-sectional observational study; 7500 children)
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  42. Langhan M, Keshavarz R, Richardson LD. How comfortable are emergency physicians with pediatric patients? J Emerg Med. 2004;26(4):465-469. (Survey)
  43. American Academy of Pediatrics. Committee on Pediatric Emergency Medicine. American College of Critical Care Medicine. Society of Critical Care Medicine. Consensus report for regionalization of services for critically ill or injured children. Pediatrics. 2000;105(1 Pt 1):152-155. (Consensus statement)
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  48. Heath B, Salerno R, Hopkins A, et al. Pediatric critical care telemedicine in rural underserved emergency departments. Pediatr Crit Care Med. 2009;10(5):588-591. (Prospective study; 63 telemedicine consultations, 10 rural EDs)
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  50. Sable CA, Cummings SD, Pearson GD, et al. Impact of telemedicine on the practice of pediatric cardiology in community hospitals. Pediatrics. 2002;109(1):E3. (Prospective study; 2 community hospital nurseries, 500 echocardiogram studies, 364 patients)
  51. EMS for Children Performance Measures website. Available at: http://www.childrensnational.org/EMSC/ForGrantees/ Performance_Measures.aspx. Accessed June 12, 2013. (National guidelines)
  52. * Alessandrini E, Varadarajan K, Alpern ER, et al. Emergency department quality: an analysis of existing pediatric measures. Acad Emerg Med. 2011;18(5):519-526. (Consensus recommendations)
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Publication Information

Katherine Remick, MD, FAAP; Sally Snow, BSN, RN, CPEN, FAEN; Marianne Gausche-Hill, MD, FACEP, FAAP

Publication Date

December 1, 2013

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