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PEDIATRICS Vol. 107 No. 4 April 2001, pp. 777-781
AMERICAN ACADEMY OF PEDIATRICS:
Care of Children in the Emergency Department:
Guidelines for Preparedness
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ABSTRACT |
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Top
Abstract
Background
References
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Children requiring emergency care have unique and special needs. This is especially so for those with serious and life-threatening emergencies. There are a variety of components of the emergency care system that provide emergency care to children that are not limited to children. With regard to hospitals, most children are brought to community hospital emergency departments (EDs) by virtue of their availability rather than to facilities designed and operated solely for children. Emergency medical services (EMS) agencies, similarly, provide the bulk of out-of-hospital emergency care to children. It is imperative that all hospital EDs and EMS agencies have the appropriate equipment, staff, and policies to provide high quality care for children. This statement provides guidelines for necessary resources to ensure that children receive quality emergency care and to facilitate, after stabilization, timely transfer to a facility with specialized pediatric services when appropriate. It is important to realize that some hospitals and local EMS systems will have difficulty in meeting these guidelines, and others will develop more comprehensive guidelines based on local resources. It is hoped, however, that hospital ED staff and administrators and local EMS systems administrators will seek to meet these guidelines to best ensure that their facilities or systems provide the resources necessary for the care of children. This statement has been reviewed by and is supported in concept by the Ambulatory Pediatric Association, American Association of Poison Control Centers, American College of Surgeons, American Hospital Association, American Medical Association, American Pediatric Surgical Association, American Trauma Society, Brain Injury Association Inc, Emergency Nurses Association, Joint Commission on Accreditation of Healthcare Organizations, National Association of Children's Hospitals and Related Institutions, National Association of EMS Physicians, National Association of EMTs, National Association of School Nurses, National Association of State EMS Directors, National Committee for Quality Assurance, and Society for Academic Emergency Medicine.
Development of this statement would not have been possible without
the generous support for the initial November 15-16, 1998 minimum
standards consensus meeting funded by Project No. 98-0156(P) from
the Department of Health and Human Services, Health Resources and
Services Administration and Maternal and Child Health Bureau. This
statement has been reviewed by and is supported in concept by the
Ambulatory Pediatric Association, American Association of Poison
Control Centers, American College of Surgeons, American Hospital Association, American Medical Association, American Pediatric Surgical Association, American Trauma Society, Brain Injury
Association Inc, Emergency Nurses Association, Joint
Commission on Accreditation of Healthcare Organizations, National
Association of Children's Hospitals and Related Institutions, National
Association of EMS Physicians, National Association of EMTs, National
Association of School Nurses, National Association of State EMS
Directors, National Committee for Quality Assurance, and Society for
Academic Emergency Medicine.
According to the Child and Adolescent Emergency
Department Visit Data Book,1 there are 31 447 000
child and adolescent visits to emergency departments (EDs) every year,
corresponding to an annual rate of 41.2 visits/100 persons. Of these,
13 562 000 child and adolescent visits per year (17.8 visits/100
persons) were injury related. Children younger than 3 years represent
the largest proportion of medically and injury related visits in this
sample.
The Consumer Product Safety Commission surveyed a sample of 101 hospitals with EDs that were enrolled in the National Electronic Injury Surveillance System to identify the state of preparation of
hospital EDs for managing pediatric emergencies.2 The
survey results were extrapolated to the estimated 5312 hospitals in the
United States that have EDs. Although less than 10% have pediatric EDs
or intensive care services, 76% admit children to their own
facilities, and 25% of hospitals without trauma services admit
critically injured children to their own facilities.
When the US Congress approved and funded the Emergency Medical Services
for Children (EMS-C) program in 1984 to stimulate the organization of
emergency medical services (EMS) systems to respond to the needs of
children, a number of demonstration programs began to address issues
related to emergency care for children. In 1993, after nearly a decade
of efforts to integrate the needs of children into EMS systems, the
Institute of Medicine was asked to provide an independent review of
EMS-C and report to the nation on the state of the continuum of care
for children within the EMS system.3 This expert panel
concluded that EMS system design needed further improvement to meet the
needs of all patients served. Summary recommendations of that report
concluded that all agencies with jurisdiction over hospitals "require
that hospital emergency departments ... have available and maintain
equipment and supplies appropriate for the emergency care of
children" and that they "address the issues of categorization and
regionalization in overseeing and development of EMS-C and its
integration into state and regional EMS systems."
There has been a proliferation of guidelines to support the
preparedness of emergency facilities to care for
children.4-10 Available resources include guidelines
developed by the American Medical Association Committee on Emergency
Medical Services in 1990 and revised in 1995 by the American Academy of
Pediatrics Committee on Pediatric Emergency Medicine, those prepared by
the American College of Emergency Physicians, those proposed by an expert panel convened by the National Emergency Medical Services for
Children Resource, additional resources prepared by several states
through grants sponsored by the Maternal and Child Health Bureau and
the National Highway Traffic Safety Administration, and others
developed in individual counties within states. Available guidelines
suggest equipment and supplies that should be available for the care of
children and administration and staffing recommendations for ED
facilities.
The following guidelines are intended for all hospital EDs that provide
emergency care 24 hours a day, 7 days a week and are continuously
staffed by a physician. Children may be cared for in other emergency
settings, such as freestanding emergent or urgent care centers. These
care settings are not addressed in this document, but administrators,
physicians, nurses, and other health care providers staffing these
centers should ensure that the appropriate equipment and staff to care
for pediatric patients are available.
These guidelines provide current information on equipment and supplies
considered essential for managing pediatric emergencies. New technology
and research will require that such emergency drug, equipment, and
supply lists are kept current and are readily available to hospitals
providing emergency care to children.
A. A Physician Coordinator for Pediatric Emergency Medicine is
appointed by the ED Medical Director.
1.The Physician Coordinator has the following qualifications:
a. The Physician Coordinator meets the qualifications for credentialing by
the Hospital as a specialist in emergency medicine, pediatric emergency
medicine, or pediatrics.
b. The Physician Coordinator has special interest, knowledge, and skill in
emergency medical care of children as demonstrated by training,
clinical experience, or focused continuing medical education.
c. The Physician Coordinator may be a staff physician who is currently
assigned other roles in the ED, such as the Medical Director of the ED,
or may be shared through formal consultation agreements with
professional resources from a hospital capable of providing definitive
pediatric care.
2. The Physician Coordinator is responsible for the following:
a. Ensure adequate skill and knowledge of staff physicians in emergency
care and resuscitation of infants and children.
b. Oversee ED pediatric quality improvement (QI), performance improvement
(PI), and clinical care protocols.
c. Assist with development and periodic review of ED medications,
equipment, supplies, policies, and procedures.
d. Serve as liaison to appropriate in-hospital and out-of-hospital
pediatric care committees in the community (if they exist).
e. Serve as liaison to a definitive care hospital, which includes a
regional pediatric referral hospital and trauma center; EMS agencies;
primary care providers; health insurers; and any other medical
resources needed to integrate services for the continuum of care of the
patient.
f. Facilitate pediatric emergency education for ED health care providers
and out-of-hospital providers affiliated with the ED.
B. A Nursing Coordinator for Pediatric Emergency Care is appointed.
1. The Nursing Coordinator has the following qualifications:
The Nursing Coordinator demonstrates special interest,
knowledge, and skill in emergency care and resuscitation of infants and
children as demonstrated by training, clinical experience, or focused
continuing nursing education.
2.The Nursing Coordinator is responsible for the following:
a. Coordinate pediatric QI, PI, and clinical care protocols with the
Physician Coordinator.
b. Serve as liaison to appropriate in-hospital and out-of-hospital
pediatric care committees.
c. Serve as liaison to inpatient nursing as well as to a definitive care
hospital, a regional pediatric referral hospital and trauma center, EMS
agencies, primary care providers, health insurers, and any other
medical resources needed to integrate services for the continuum of
care of the patient.
d. Facilitate ED nursing continuing education in pediatrics and provide
orientation for new staff members.
e. Provide assistance and support for pediatric education of
out-of-hospital providers affiliated with the ED.
f. Assist in development and periodic review of policies and
procedures for pediatric care.
g. Stock and monitor pediatric equipment and medication availability.
A. Physicians staffing the ED have the necessary skill,
knowledge, and training to provide emergency evaluation and treatment of children of all ages who may be brought to the ED, consistent with
the services provided by the hospital.
B. Nurses and other practitioners have the necessary skill,
knowledge, and training to provide nursing care to children of all ages
who may be brought to the ED, consistent with the services offered by
the hospital.
C. Competency evaluations completed by the staff are age
specific and include neonates, infants, children, and adolescents.
A pediatric patient review process is integrated into the ED
QI plan according to the following guidelines:
A. Components of the process interface with
out-of-hospital, ED, trauma, inpatient pediatrics, pediatric critical
care, and hospital-wide QI or PI activities.
B. Minimum components of the process include identifying
indicators of good outcome, collecting and analyzing data to discover variances, defining a plan for improvement, and evaluating or measuring
the success of the QI or PI process.
C. A clearly defined mechanism exists to monitor professional
education and staffing.
A. Policies, procedures, and protocols for emergency care of children are
developed and implemented; staff should be educated accordingly; and
they should be monitored for compliance and periodically updated. These
should include, but are not limited to, the following (items 3 through
12 indicate policies, procedures, and protocols that may be integrated
into ED policies and procedures with pediatric-specific components):
1. Child maltreatment (physical and sexual abuse, sexual assault, and
neglect)
2. Consent (including situations in which a parent is not immediately
available)
3. Death in the ED
4. Do not resuscitate orders
5. Illness and injury triage
6. Sedation and analgesia
7. Immunization status
8. Mental health emergencies
9. Physical or chemical restraint of patients
10. Family issues, including:
a. Education of the patient, family, and regular caregivers
b. Discharge planning and instruction
c. Family presence during care
11. Communication with patient's primary health care provider
12. Transfers necessary for definitive care, according to the following
guidelines:
a. Transfer policies or procedures should include access to consultation
(telephone or telemedicine), transfer guidelines, interfacility
transfer agreements, and a plan for return of the child back to his/her
community as appropriate.
b. Transferring facility must ensure that the patient is stabilized before
transport.
c. Transferring facility must transfer only patients who need a higher
level of care, as per the Emergency Medical Treatment and Active Labor
Act.11
B. Hospitals may wish to adopt currently available
clinical guidelines and protocols or develop their own.
A. A transport plan is in place to deliver children safely and in a timely
manner to the appropriate facility capable of providing definitive
care. The following pediatric specialty referral resources are
incorporated into the transport plan:
1. Medical and surgical intensive care
2. Trauma
3. Reimplantation (replacement of severed digits or limbs)
4. Burns
5. Psychiatric emergencies
6. Perinatal emergencies
7. Child maltreatment (physical and sexual abuse and assault)
B. Radiology department has the skills and capability to provide
imaging studies of children and has the equipment necessary to do so.
The radiology capability of hospitals may vary from one institution to
another; however, the radiology capability of a hospital must meet the
needs of the children in the community it serves.
C. Laboratory has the skills and capability to perform laboratory tests
for children of all ages, including obtaining samples, and has the
availability of micro technique for small or limited sample size. The
clinical laboratory capability must meet the needs of the children in
the community it serves.
A. Necessary medications, equipment, and supplies are listed
in Table 1. Each hospital must develop a
method for storage and provide accessibility of medications and
equipment for children. The method used must ensure that the health
care practitioner can easily identify appropriate dosages of medication based on the patient's weight and choose appropriately sized
equipment. Length-based systems or precalculated drug systems should be
used to avoid calculation errors of medications delivered.
TABLE 1
ACKNOWLEDGMENTS
BACKGROUND
Top
Abstract
Background
References
I. GUIDELINES FOR ADMINISTRATION AND COORDINATION OF THE ED FOR THE
CARE OF CHILDREN
II. GUIDELINES FOR PHYSICIANS AND OTHER PRACTITIONERS STAFFING THE
ED
III. QUALITY IMPROVEMENT GUIDELINES FOR THE ED
IV. GUIDELINES FOR POLICIES, PROCEDURES, AND PROTOCOLS FOR THE ED
V. GUIDELINES FOR SUPPORT SERVICES
FOR THE ED
VI. GUIDELINES FOR EQUIPMENT, SUPPLIES, AND MEDICATIONS FOR
CHILDREN IN THE ED
Guidelines for Medications for Use in Pediatric Patients in
EDs*
B. All equipment and supplies are listed in Table 2 and include age-appropriate and size-appropriate equipment for use for children of all ages and sizes from premature infants through adolescents.
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C. Quality indicators ensure regular periodic review of drugs and equipment, monitoring of expiration dates of items, and replacement of used items.
For periodic updates of this statement, including medications and equipment, see the American Academy of Pediatrics Web site (http://www.aap.org) or the American College of Emergency Physicians Web site (http://www.acep.org).
Committee on Pediatric Emergency Medicine, 1999-2000
Robert A. Wiebe, MD, Chairperson
Jane F. Knapp, MD, Chairperson-elect
Barbara A. Barlow, MD
Ronald A. Furnival, MD
Barry W. Heath, MD
Steven E. Krug, MD
Karin A. McCloskey, MD
Deborah Mulligan-Smith, MD
Lee A. Pyles, MD
Timothy S. Yeh, MD
Liaisons
Cindy R. Doyle, RN, BSN, MA
Maternal and Child Health Bureau
Marianne Gausche-Hill, MD
American College of Emergency Physicians
David Markenson, MD
National Association of EMS Physicians
Dennis W. Vane, MD
American College of Surgeons
Section Liaisons
M. Douglas Baker, MD
Section on Emergency Medicine
Joseph P. Cravero, MD
Section on Anesthesiology
M. Michele Moss, MD
Section on Critical Care
Dennis W. Vane, MD
Section on Surgery
Staff
Susan Tellez
ACEP Pediatric Committee, 1999-2000
Marianne Gausche-Hill, MD, Chairperson
Thomas Abrunzo, MD, MPH
Ann Dietrich, MD
Claudia Gold, MD
Ramon Johnson, MD
Stephen Knazik, DO
Sharon Mace, MD
Maureen McCollough, MD
Deborah Mulligan-Smith, MD
Mark Sochor, MD
Craig Warden, MD, MPH
Joseph Zibulewsky, MD
Liaisons
Michael Gerardi, MD
John Santamaria, MD
Robert A. Wiebe, MD
Staff
Elaine Jastram
Statement Consultants
Bob Bailey
National Association of State EMS Directors
Richard J. Crouteau, MD
Joint Commission on Accreditation of Healthcare Organizations
Ronald Dieckmann, MD
American Academy of Pediatrics
Susan Dull, RN, MSN, MBA
National Association of Children's Hospitals and Related Institutions
Susan Fuchs, MD
American Academy of Pediatrics
Carden Johnston, MD
American Academy of Pediatrics
Brent King, MD
National Institutions
Michael Rapp, MD
American College of Emergency Physicians
Robert Schafermeyer, MD
American College of Emergency Physicians
James Seidel, MD, PhD
American Academy of Pediatrics
Calvin Sia, MD
American Academy of Pediatrics
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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ABBREVIATIONS |
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ED, emergency department; EMS-C, Emergency Medical Services for Children (program); EMS, emergency medical services; QI, quality improvement; PI, performance improvement.
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REFERENCES |
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Top
Abstract
Background
References
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- Weiss HB, Mathers LJ, Forjuoh SN, Kinnane JM. Child and Adolescent Emergency Department Visit Data Book. Pittsburgh, PA: Center for Violence and Injury Control, Allegheny University of the Health Sciences; 1997
- Athey J, Dean JM, Ball J, et al. Ability of hospitals to care for pediatric emergency patients. Pediatr Emerg Care. 2001; In press
- Institute of Medicine, Committee on Pediatric Emergency Medical Services. In: Durch JS, Lohr KN, eds. Institute of Medicine Report: Emergency Medical Services for Children. Washington, DC: National Academy Press; 1993
- Seidel JS, Gausche M. Standards for emergency departments. In: Dieckmann RA, ed. Pediatric Emergency Care Systems: Planning and Management. Baltimore, MD: Williams & Wilkins; 1992;267-278
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American Medical Association, Commission on Emergency Medical
Services
Pediatric emergencies. An excerpt from "Guidelines for
Categorization of Hospital Emergency Capabilities."
Pediatrics
1990;
85:879-887
[Abstract/Free Full Text] - American College of Emergency Physicians Emergency care guidelines. Ann Emerg Med 1997; 29:564-571 [CrossRef][Medline]
-
American Academy of Pediatrics, Committee on Pediatric Emergency
Medicine
Guidelines for pediatric emergency care facilities.
Pediatrics
1995;
96:526-537
[Abstract/Free Full Text] - American College of Emergency Physicians Pediatric equipment guidelines. Ann Emerg Med 1995; 25:307-309
- National Emergency Medical Services for Children Resource Alliance, Committee on Pediatric Equipment and Supplies for Emergency Guidelines for pediatric equipment and supplies for emergency departments. Ann Emerg Med 1998; 31:54-57 [CrossRef][Medline]
- Administration, Personnel, and Policy Guidelines for the Care of Pediatric Patients in the Emergency Department. Sacramento, CA: California Emergency Medical Services Authority; EMSC Project, Final Report, 1994
- The Comprehensive Omnibus Budget Reconciliation Act of 1986, Emergency Medical Treatment and Active Labor Act. 42 USC §1395dd (1988 Suppl II 1990)
Pediatrics (ISSN 0031 4005). Copyright ©2001 by the American Academy of Pediatrics
Statements of reaffirmation:
- AAP Publications Retired and Reaffirmed
- American Academy of Pediatrics
Pediatrics 2005 115: 1438.[Extract] [Full Text] [PDF]
-
AAP Publications Reaffirmed and Retired, February and May 2008
Pediatrics 2008 122: 450.[Extract] [Full Text] [PDF]
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