Most EDs Prepared for Pediatric Care; Barriers Still Exist

Diana Phillips

April 14, 2015

Emergency departments (EDs) in the United States are better prepared than they have been in the past to care for children of all ages, according to a web-based assessment of ED compliance with national guidelines for pediatric readiness.

Despite self-reported improvements in pediatric readiness, however, most EDs report myriad barriers to guideline implementation at the physician and nursing levels, Marianne Gausche-Hill, MD, from Harbor-University of California, Los Angeles, Medical Center, and colleagues report in an article published online April 13 in JAMA Pediatrics.

In 2001, the American Academy of Pediatrics and the American College of Emergency Physicians developed joint guidelines on the care of children in EDs, and updated guidelines were published in 2009.

Although much attention has been directed toward the importance of maintaining a state of readiness to care for children, previous assessments have indicated that emergency care settings in the United States have relatively poor pediatric readiness, the authors write.

To identify barriers to pediatric readiness, a national steering committee of pediatric and emergency medicine stakeholder organizations implemented a public health initiative in 2011. The current report addresses findings of the first step of the initiative: a 55-question assessment of ED pediatric readiness based on the sections of the 2009 guidelines addressing coordination of patient care, physician/nurse staffing and training, quality improvement activities, patient safety initiatives, policies and procedures, and availability of pediatric equipment. The authors note that the questionnaire also collected information on hospital demographics, including ED configuration, and annual overall and pediatric patient volume.

Of 5017 ED nurse managers contacted, 4137 (82.5%) responded, representing about 24 million annual pediatric ED visits. Of those who responded, 1966 (47.5%) reported having a physician pediatric emergency care coordinator (PECC), 2455 (59.3%) reported a nurse PECC, and 1737 (42%) reported having both. "With a large number of EDs responding, our sample provides more complete data on the presence and impact of PECCs and quantifies efforts by national stakeholders to improve the presence of PECCs in EDs," the authors write.

The overall median weighted pediatric readiness score was 68.9 out of 100, and there was a trend for increased score with increased pediatric patient volume. Specifically, the weighted pediatric readiness score of low, medium, medium to high, and high-volume EDs was 61.4, 69.3, 74.8, and 89.8, respectively. The overall median represents an improvement from a previously reported weighted pediatric readiness score of 55, the authors write.

Readiness scores related to staffing were also volume-dependent, with lower-volume hospitals reporting a higher percentage of family medicine-trained physicians caring for children (78.9%) compared with high-volume hospitals (32.1%). In contrast, in high-volume hospitals, most physicians who cared for children were trained in emergency medicine (88.6%) or pediatric emergency medicine (55.4%).

The assessment showed that 99.5% of the EDs reported that their staff was trained in the location of pediatric equipment, but only 45.1% reported having a quality improvement plan addressing the needs of children, and only 46.8% reported having a disaster plan that addresses children, according to the study.

Of the responding nurse managers, the majority (80.8%) reported barriers to implementing readiness guidelines, including the cost of training (54.4%) and a lack of educational resources (49.0%). Many respondents (80.8%) reported barriers to implementing readiness guidelines that may be targeted for future initiatives, the authors note.

The publication of the "National Assessment of Pediatric Readiness of Emergency Departments" represents a "huge step forward in the further definition of the path forward to optimal care for children in the emergency care setting," Evaline A. Alessandrini, MD, MSCE, from Cincinnati Children's Hospital Medical Center in Ohio, and Joseph L. Wright, MD, MPH, from Howard University College of Medicine in Washington, DC, write in an accompanying editorial. The high response rate to the assessment indicates "enthusiasm and accountability for pediatric readiness in ED settings, and their results demonstrate a real improvement in readiness scores over prior assessments," they write.

Although the report represents a critical foundational step, the editorialists stress that "the work does not associate better readiness scores with improved outcomes of pediatric emergency care." This limitation should be addressed as the researchers and national coalition "go beyond ensuring day-to-day pediatric readiness to ensuring best possible outcomes for children in our nation's EDs."

This project is supported by grants from the Emergency Medical Service for Children network development and the Emergency Medical Service for Children National Resource Center from the Health Resources and Services Administration of the US Department of Health and Human Services. The authors and editorialists have disclosed no relevant financial relationships.

JAMA Pediatr. Published online April 13, 2015. Article abstract, Editorial extract

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