Growing pains: Report notes pediatric emergencies need greater emphasis

Article Outline

• Are EDs prepared for pediatric emergencies?
• A call for accountability and federal oversight

The Institute of Medicine subcommittee report Pediatric Emergency Care: Growing Up released on June 14 called for better preparation and training for the special needs of childhood emergencies.

The committee’s report stresses several goals for improving the quality of care given to children, including a regionalized approach in which facilities pool their resources for the delivery of high-level emergency care, and accountability, the establishment of evidence-based indicators to measure emergency department (ED) performance.

“Many elements of this vision have been advocated previously; however, progress toward achieving these elements has been derailed by deeply entrenched political interests and cultural attitudes, as well as funding cutbacks and practical impediments to change,” the report’s authors write. “Concerted, cooperative efforts at all levels of government, federal, state, regional, local and the private sector are necessary to finally break through and achieve optimum emergency care.”

The report was welcomed by emergency pediatricians who say their specialty is often an afterthought when efforts are undertaken to improve EDs or communities seek to ready themselves for disasters.

Dr. Joan Shook, ED Director at Texas Children’s Hospital in Houston, recalled a 150-page draft plan recently released by the Texas Department of Health and Human Services for dealing with emergencies.

“The word ‘child’ was not mentioned one time, but they did mention pets 5 times,” Shook said. “I was just blown away. I mean, you’re supposed to be worried about your cat, and not your kid? But I think that’s pretty typical.”

A member of the subcommittee, Dr. Jane Knapp, Vice Chair Graduate Medical Education, Children’s Mercy Hospital, Kansas City, Missouri, agreed with Shook’s sentiments.

“One thing we are saying is, don’t forget the children,” she said. “Anytime you sit down to think about emergency medical care, emergency medical response, you have to think about all those special populations out there.”

The report identified a host of issues faced by emergency physicians who treat children.

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Are EDs prepared for pediatric emergencies? 

Many hospitals are not well prepared to handle pediatric cases, the subcommittee found, even though children account for more than one-quarter of ED visits. Only about 6% of US EDs have all the “essential” supplies for managing pediatric emergencies, and only half have at least 85% of these supplies.

“There are many basic questions about pediatric emergency medical care and preparedness that we don’t know the answers to,” Knapp said. “I hope by pointing out that variation exists around the country and you don’t know necessarily if the emergency department you are going to in certain areas is equipped for children will be enough to push people to ask the right questions.”

The new report recognizes the need for the regionalization of pediatric care, in which advanced life support ambulances bring children with high-risk conditions, when possible, only to hospitals that have specific pediatric capabilities. Most states, however, have not formalized such a process. Therefore the subcommittee recommended that federal agencies such as the US Department of Health and Human Services (HHS) partner with professional organizations to develop an evidence-based system to measure the adult and pediatric capabilities of EDs and trauma centers. This, in turn, could lead to the development of protocols that would guide emergency medical technicians and paramedics in the transport of young patients.

The subcommittee also sought to identify the factors that can lead to a system failure–a lack of transfer agreements, providers who don’t receive continuing pediatric education and the unavailability of on-call pediatric specialists.

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A call for accountability and federal oversight 

Such failures could be averted by establishing performance measures for EDs, the report states. The subcommittee recommended that HHS convene a panel of emergency care experts to develop evidence-based markers of performance for pediatric emergency care. These nationally standardized measures should initially be reported in the aggregate, allowing individual institutions to identify their own deficiencies and correct them, before data from single institutions is made public.

By knowing their own limitations, and being held accountable, EDs would be more inclined to improve their pediatric care. What the subcommittee did not do is recommend that every hospital with an ED have its own pediatrics section. Implementing such a change would be too expensive for many existing hospitals. Still, the report recommends that doctors and nurses in all EDs receive more training for treating pediatrics cases, if only enough to allow them to keep children alive long enough to get them to tertiary pediatric facilities.

The report recommends that health profession credentialing and certification bodies define pediatric emergency care competencies, and require ED practitioners to receive the education needed to reach and maintain those levels.

Finally, in its report the pediatric subcommittee also expressed concern about the financial future of pediatric emergency centers, many of which rely upon charity to sustain themselves in ever more difficult financial times for health institutions. “Such a reliance could eventually lead to a funding squeeze,” said Dr. Marianne Gausche-Hill, a member of the subcommittee and Clinical Professor of Medicine and Director, Prehospital Care, Harbor-UCLA Medical Center, Torrance, CA.

“It is amazing to me that up to 40% of children’s hospital budgets are based on philanthropy,” she said. “If people stop donating, what’s going to happen to our tertiary care system for children?”