FACILITY RECOGNITION OF EMERGENCY DEPARTMENT PEDIATRIC CAPACITY
Emergency medical professionals and providers want to give children the best of care.
However, weaknesses exist in our pediatric emergency care system. Researchers have clearly
established children have higher rates of mortality and morbidity than adults when treated
for life-threatening events. Two-thirds of pediatric emergency department visits are due
to illness, many of which are life-threatening and carry concomitant morbidity. However,
injuries surpass diseases as the foremost cause of childhood death and disability.1 Better emergency care, coupled with injury
prevention activities, could save the lives of many children.2
Nationally, the cumulative direct and indirect lifetime costs associated with injuries
to children under 15 years old have been estimated at over $13.8 billion.3
These costs, coined the hidden taxation of childhood injuries and deaths, include
medical and disability expenses, as well as enormous losses in future wages and taxes. The
tremendous pain and suffering such tragedies cause represents an additional expense, not
measurable in dollars. The 1993 Institute of Medicine report, Emergency Medical
Services for Children, estimates that the direct and indirect costs to society under
the current system greatly exceeds those of caring for ill/injured children under an
improved system that reduces morbidity. For economic and ethical reasons, the need to
strengthen our EMS for children is compelling!4
The urgent need for enhancement of emergency care for children has elicited
recommendations from the American Academy of Pediatrics, the American College of Emergency
Physicians, the American Medical Society, and the Emergency Nurses Association. These
organizations specify equipment and supplies, physician and nurse qualifications, staffing
patterns, and related services that should be in place at the various emergency department
levels. They also describe how levels should relate to one another to form a more
comprehensive and effective system.5,6,7,8
The Illinois health care community's call for leadership prompted the Illinois
Department of Public Health, in conjunction with Loyola University Medical Center, to seek
and obtain federal EMSC funding through the Maternal and Child Health Bureau and the
National Highway Traffic Safety Administration. Under these auspices, the state's major
health care professional associations, providers, injury control specialists, parents and
consumers came together to enhance pediatric emergency care in Illinois. Representatives
of this coalition consult on project activities and act as liaisons between their
organization and the coalition. This process is supported by the Illinois Chapter of the
American Academy of Pediatrics, the Illinois Academy of Family Physicians, the Illinois
College of Emergency Physicians, the Illinois Hospital and HealthSystems Association, the
Illinois Chapter of the Emergency Nurses Association, the Metropolitan Chicago Healthcare
Council, and others.
Pediatric care enhancement activities include the dissemination of continuing education
courses in pediatric emergency care, development and promulgation of pediatric protocols
and recommendations for all phases of care, establishment of a data linkage and
surveillance system, and initiatives in prevention and public education. A Facility
Recognition Task Force has guided the coalition's effort to develop
recommendations for emergency department care.
The 1994-1995 EMSC needs assessment evaluated the pediatric emergency care training of
physicians and nurses who staff emergency rooms with the following findings:
Most pediatric emergency care is provided
in "comprehensive" emergency departments. While ninety percent of emergency department
physicians possessed Advanced Cardiac Life Support (ACLS) training, only 63% completed
a formal pediatric resuscitation training course. Although 90% of emergency department nursing staff successfully completed an ACLS course, the percentage who completed a pediatric resuscitation course
(PALS) was 29%.
According to the Illinois Emergency Nurses Association's annual survey of their members'
educational needs, the most frequently requested course offering was for pediatric
emergency nursing care.
Facility Recognition: A Mechanism for Enhancement of Pediatric
Simply put, emergency care makes a difference. The success of emergent care for
children is directly related to the competence of caregivers at each juncture of the EMS
system. Assessment and treatment of children require knowledge of important anatomical,
physiological, and developmental differences that distinguish children from adults.
Emergency departments must be staffed by nurses, physicians, and other professionals with
the knowledge and ability to not only recognize and treat pediatric emergent conditions,
but also to stabilize and to resuscitate children suffering life-threatening events.
Currently, necessary equipment, supplies, and medications for treating children are not
consistently available. Essential pediatric equipment is as important to success in
achieving optimal outcomes as is provider skill and training. The cost of having materials
and supplies suitable for pediatric cases is reasonable. Such an investment would
significantly and cost-effectively improve the capacity of providers to render care to
When a child's needs require resources beyond those available at the receiving
facility, it is imperative that consultation and interfacility transfer to a higher level
of care be efficiently accomplished. More children with serious illnesses and injuries
survive when they receive critical care services in pediatric tertiary care centers.9,10 In addition, it is essential that children who are at
risk of incurring morbidity receive timely rehabilitative services, optimally initiated
during the acute stages of illness/injury. In these cases, access to subspeciality care
and rehabilitation services is made possible by interfacility transfers.
Protocols help guide treatment decisions, and should be available for every phase of
the EMS system. Since two-thirds of emergency department patients are adults, emergency
department clinicians experience relatively less opportunities in which to maintain
pediatric skills and practice. Standardized procedures or decision algorithms developed to
guide patient care will assist emergency departments to provide state of the art care
based on current pediatric clinical recommendations.
Systemic improvements may be accomplished and maintained by incorporating pediatrics
into quality improvement activities. A consistent standard of pediatric care against which
performance may be measured helps facilities identify problems and formulate plans for
remediation. In addition, the establishment of pediatric indicators allows clinicians to
assess the efficacy of their emergency department treatment approaches to pediatric
Parents want the best care possible for their children; healthcare providers and
facilities wish to fulfill their obligation to pediatric patients. Until now, however,
efforts to improve pediatric care were fragmented, and external supports minimal. The EMSC
initiative consolidates pediatric care into Illinois' EMS system, albeit as a component
with an independent identity. An EMSC Advisory Board has been appointed to advise the
Illinois Department of Public Health, Division of EMS and Highway Safety.
Enhancement of emergency department care is a key EMSC objective to reduce childhood
mortality and morbidity. California spearheaded, and several other states have now adopted
into their EMSC, the concept of a voluntary, tiered system of recognition for emergency
departments. Illinois also recognizes the mechanism as an effective way to support and
acknowledge local facilities' efforts to meet their responsibility to children. In
addition, the plan provides communities with a way to make informed decisions about the
level of care available when accessing emergency care for their youngest members.
SEDP, EDAP and PCCC Facilities
The EMSC program has identified three levels in this tiered system: Standby
Emergency Department for Pediatrics (SEDP), an Emergency Department Approved for
Pediatrics (EDAP), or Pediatric Critical Care Center (PCCC).
Recognition at one of these three levels is attained upon verification of a
facility's ability to deliver all of the following key pediatric emergency care services:
Professionals specially trained in pediatric emergency
and critical care;
Adequate staffing patterns, and provisions for pediatric consultation and backup to
support provision of pediatric emergency care services;
Availability of essential pediatric equipment, supplies and medication;
Protocols for the treatment of abused, and of
critically ill and injured children;
Protocols for interfacility transfers of critically ill and injured
patients to a tertiary care center; and
Incorporation of pediatrics into emergency
department quality improvement activities.
Currently, the Illinois Hospital Licensing Code (77 Ill. Adm. Code 250) identifies three
emergency department classifications:
Stand-by Emergency Department is a classification of a hospital emergency department
where at least one of the registered nurses on duty in the hospital is available for
emergency services at all times; and a licensed physician is "on-call" to the
emergency department at all times.
Basic Emergency Department is a classification of a hospital emergency department where
at least one physician is available in the emergency department at all times; physician
specialists are available in minutes; and ancillary services including laboratory, x-ray
and pharmacy are staffed or are "on-call" at all times.
Comprehensive Emergency Department is a classification of a hospital emergency
department where at least one licensed physician is available in the emergency department
at all times; physician specialists shall be available in minutes; and ancillary services
including laboratory and x-ray are staffed at all times; and pharmacy is staffed or
"on-call" at all times.
The ideal system supports facilities with varying resources. Facilities that may have
minimal pediatric resources, should still be able to stabilize seriously ill and injured
children before transfer. Comprehensive level emergency departments may have significant
pediatric resources to provide definitive care for most patients, but may lack
comprehensive critical care services and subspecialty expertise, while others may provide
tertiary care pediatric services. Because varying resources exist for pediatric care,
there will be differences from region to region in the way SEDP/EDAP/PCCC levels relate to
one another and to their tertiary care resources. Under the current EMS Act, each region
defines the way in which emergency care resources are used within an integrated regional
Fulfillment of Facility Recognition Recommendations:
The EMSC office can act as a resource in assisting facilities to meet facility
recognition criteria. EMSC will also provide facilities with support in the development of
treatment and transfer protocols. The EMSC Advisory
Board has gathered experts within Illinois to develop model protocols and
guidelines that may be adopted wholly, or used by facilities as templates.
The Illinois EMSC coalition invites facilities that
care for Illinois children to take their place
among others prepared to meet the emergency needs of children.
1 Barden, R. et al, Emergency Care
and Injury/Illness Prevention Systems for Children, Harvard Journal on Legislation,
30:2, 467, 479
2 Henderson, D.P., The Los Angeles Pediatric
Emergency Care System, Los Angeles: Los Angeles Pediatric Society. (Reprints available
on request from D. Henderson, National EMSC Resource Alliance, Harbor UCLA Medical Center,
1124 W. Carson St., Bldg. N-7, Torrance, CA 90502, (310) 328-0720.
3 Durch, J. and K. Lohr, Editors, The Institute of
Medicine Report, EMSC Report Summary, Washington, DC: National Academy Press, 1993,
4 Op sit, Barden et al, 462
5 American Medical Association
Commission on Emergency Medical Services, Pediatric Emergencies: An excerpt from
"Guidelines for the Categorization of Hospital Emergency Capabilities" endorsed
by the American Academy of Pediatrics, Pediatrics, 85:5, 879-887.
6 American Academy of Pediatrics, Committee on
Pediatric Emergency Medicine, Guidelines for Pediatric Emergency Care Facilities, Pediatrics,
7 American College of Emergency Physicians, ACEP
Policy Statement: Pediatric Equipment Guidelines, April 1994. Available from ACEP,
P.O. Box 619911, Dallas, Tx 75261-9911, (214) 550-0911.
Nurses Association, ENA Policy Statement, Emergency Nursing: Pediatric Emergency Care,
April 1995. Available from ENA, 216 Higgins Road, Park Ridge, IL 60068, (708) 698-9400.
Pollack, M.M. et al., Improved Outcomes from
Tertiary Center Pediatric Intensive Care: A Statewide Comparison of Tertiary and
Nontertiary Care Facilities, Critical
Care Medicine , 19:2, 150-159.
Bausche, M. et al., Pediatric Deaths and
Emergency Medical Services in Urban and Rural Areas, Pediatric Emergency Care,