Guidelines for Pediatric Emergency Care Coordination

1. Summary of Guidelines for Care of Children in the Emergency Department American Academy of Pediatrics American College of Emergency Physicians Emergency Nurses Association

2. Background • Approximately 3833 emergency departments (EDs) in the United States (2006) • 119 million ED visits in 2006 • Almost 20% visits by children • 2001: Joint guideline from AAP/ACEP regarding ED preparedness for children AAP/ACEP, 2001; McCaig, 2006; Burt, 2006; Pitts 2008; Middleton, 2006

3. Barriers to Optimal Emergency Care for Children • Lack of equipment availability • Lack of appropriately trained staff • Absence of policies and procedures to ensure timely transfer to definitive care AAP, 2007.

4. Guideline Objectives Purpose: To delineate the resources necessary to prepare hospital emergency departments to serve pediatric patients

5. Guidelines for Administration and Coordination for the Care of Children

6. Physician Coordinator Qualifications • Specialist in emergency medicine (EM) or pediatric emergency medicine (PEM) • May be a staff physician currently assigned to other roles in the ED, or may be a physician shared through agreements with outside hospitals

7. Physician Coordinator Responsibilities • Promote/verify skill and knowledge of emergency providers • Oversee pediatric quality improvement (QI), performance improvement (PI), patient safety, injury/illness prevention, and clinical activities • Development and review of policies, procedures and standards for pediatric medications, equipment, and supplies • Liaison/coordinator to in-hospital and out-of-hospital pediatric care committees

8. Nursing Coordinator Qualifications • Registered nurse with special interest, knowledge, and skill in pediatric emergency care • May be a staff nurse currently assigned to other roles in the ED, or may be a nurse shared through formal consultation agreements with outside hospitals

9. Nursing Coordinator Responsibilities • Facilitate ED pediatric QI/PI activities • Serve as a liaison to in-hospital and out-of-hospital pediatric care committees • Facilitate ED nursing continuing education • Ensure nursing competency evaluations are pertinent to all children • Assure availability of pediatric equipment, medications, staffing ,and other resources

10. Physicians, Nurses, and Other Health Care Providers Staffing the ED

11. ED Providers Physicians, nurses and other health care providers staffing the ED have the necessary skill, knowledge, and training in the emergency evaluation and treatment of children of all ages who may be brought to the ED, consistent with the services provided by the hospital

12. Provider Competency Evaluation Baseline and periodic competency evaluations completed for all ED clinical staff are age specific and include neonates, infants, children, adolescents, and children with special health care needs

13. Guidelines for Quality Improvement/Performance Improvement in the ED

14. Pediatric Patient Care Review Process • Interfaces with out-of-hospital and in-hospital QI/PI activities • Includes pediatric specific indicators • Requires pediatric clinical competency evaluations • Mechanisms for monitoring professional performance, credentialing, continuing education and clinical competencies

15. Guidelines to Improve Patient Safety

16. Specific Guidelines • All children should be weighed in kilograms • For children requiring emergency stabilization, a standard method for estimating weight in kilograms should be used • All children should have a full set of vital signs, including temperature, heart rate, and respiratory rate • Blood pressure and pulse oximetry monitoring should be available for all children • Process should be in place to identify abnormal vital signs by age and to notify the physician of these abnormalities

17. Specific Guidelines • Processes for safe medication storage, prescribing and delivery should be established • Should include pre-calculated dosing guidelines • Implementation of infection control practices • Implementation of patient identification policies • Implementation of policies for reporting and evaluation of safety events and for the disclosure of errors or unanticipated outcomes

18. Specific Guidelines • Emergency services should be culturally and linguistically appropriate • The ED should provide an environment that is child-safe and supports patient and family-centered care

19. Guidelines for Policies, Procedures, and Protocols for the ED • Development and implementation of policies, procedures and protocols pertaining to the following topics: • Triage • Pediatric patient assessment • Documentation of vital signs, abnormal vitals signs and actions to be taken for abnormal vital signs • Immunization assessment and management of the under-immunized patient • Sedation and analgesia

20. Guidelines for Policies, Procedures, and Protocols for the ED • Development and implementation of policies, procedures and protocols pertaining to the following topics: • Consent • Social and mental health issues • Physical or chemical restraint of patients • Child maltreatment mandated reporting • Death of a child • Do not resuscitate orders

21. Guidelines for Policies, Procedures, and Protocols for the ED • Development and implementation of policies, procedures and protocols pertaining to the following topics: • Family centered care, including: • Involving families in patient care decision-making and in safety processes • Family presence during all aspects of emergency care • Education of the patient, family, and regular caregivers • Discharge planning and instruction • Bereavement counseling

22. Guidelines for Policies, Procedures, and Protocols for the ED • Development and implementation of policies, procedures and protocols pertaining to the following topics • Communication with patient’s medical home or primary health care provider • Medical imaging policies which address age- or weight-appropriate dose reductions for children

23. Guidelines for Policies, Procedures, and Protocols for the ED • Policies, procedures and protocols for emergency care of children should be developed and implemented pertaining to the following topics: • All-hazard disaster preparedness plan addressing the following pediatric issues: • Availability of medications, vaccines, equipment, and appropriately trained providers • Surge capacity for both injured and non-injured children • Decontamination, isolation and quarantine of families and children • Minimizing parent-child separation and improved methods for reuniting separated children with their families

24. Guidelines for Policies, Procedures, and Protocols for the ED • Policies, procedures and protocols for emergency care of children should be developed and implemented pertaining to the following topics: • All-hazard disaster preparedness plan addressing the following pediatric issues: • Access to specific medical and mental health therapies, as well as social services • Disaster drills that include a pediatric mass casualty incident at least once every two years • Care of children with special health care needs • Evacuation of pediatric units and pediatric specialty units

25. Pediatric Interfacility Transfer Procedures • Process for initiation of transfer • Transport plan to deliver children safely and in a timely manner to the appropriate facility • Process for selecting the appropriate care facility for pediatric specialty services not available at the hospital

26. Pediatric Interfacility Transfer Procedures • Process for selecting the appropriate transport service to match the patient’s acuity level • Process for patient transfer • Plan for transfer of patient information, belongings, and provision of directions and referral institution information to family • Process for return transfer of the pediatric patient to the referring facility as appropriate

27. Guidelines for ED Support Services: Radiology • The radiology department should have the skills and capability to provide imaging studies of children • Guidelines to reduce radiation exposure • The hospital’s radiology capability must meet the needs of the children in the community it serves • Process for the referral to appropriate facilities for procedures which exceed the capability of the hospital • Process for the timely interpretation and reporting of radiologic studies by a qualified radiologist

28. Guidelines for ED Support Services: Laboratory • The laboratory should have the skills and capability to perform laboratory tests for all children • The laboratory capability must meet the needs of the children in the community it serves • There should be a clear understanding of laboratory capability for any given community and definitive plans for referring children to the appropriate facility

29. Guidelines for Equipment, Supplies and Medications for the Care of Pediatric Patients

30. Guidelines for Equipment, Supplies and Medications for the Care of Pediatric Patients • Pediatric equipment, supplies, and medications shall be easily accessible, labeled, safely, and logically organized • ED staff should know the location of all items • Resuscitation equipment and supplies shall be located in the ED • Other items may be housed in other departments as long as the items are immediately accessible • A mobile pediatric crash cart is strongly recommended

31. Guidelines for Equipment, Supplies and Medications for the Care of Pediatric Patients • The ED shall have a method of daily verification of proper location and function of equipment and supplies • A medication chart, length-based tape, medical software, or another system shall be readily available to ED staff to assure proper sizing of resuscitation equipment and proper dosing of medication

32. Clinical and Professional Competency • Potential areas for development of pediatric competency and professional performance evaluations may include: • Triage • Illness and injury assessment and management • Pain assessment and treatment, including sedation and analgesia • Airway management • Vascular access • Critical care monitoring • Neonatal and pediatric resuscitation

33. Clinical and Professional Competency • Potential areas for development of pediatric competency and professional performance evaluations may include: • Trauma care • Burn care • Mass casualty events • Patient and family centered care • Medication delivery, and device/equipment safety • Team training and effective communication

34. Summary • All EDs must be prepared to receive, assess, and at a minimum, stabilize and transfer acutely ill and injured children • Strong foundation for pediatric emergency and all-hazard preparedness provided by: • Recognition of unique needs of ill and/or injured children • Commitment to better meeting those needs through adoption of these guidelines • Ongoing commitment to evaluating care quality and safety and maintaining pediatric care competencies

35. Appendices • Guidelines for medications for pediatric patients in the ED • Guidelines for equipment and supplies for pediatric patients in the ED http://pediatrics.aappublications.org/cgi/content/full/124/4/1233