FACILITY RECOGNITION OF EMERGENCY DEPARTMENT PEDIATRIC CAPACITY

Background
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 Emergency Care
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 children.

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 problems.

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 plan.
 

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.
 

Footnotes
¹ Barden, R. et al, Emergency Care and Injury/Illness Prevention Systems for Children, Harvard Journal on Legislation, 30:2, 467, 479

8 Emergency 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.

9 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.

10 Bausche, M. et al., Pediatric Deaths and Emergency Medical Services in Urban and Rural Areas, Pediatric Emergency Care, 158:5, 160-1.