Overcrowding crisis in our nation's emergency departments: is our safety net unraveling?

Emergency departments (EDs) are a vital component in our health care safety net, available 24 hours a day, 7 days a week, for all who require care. There has been a steady increase in the volume and acuity of patient visits to EDs, now with well over 100 million Americans (30 million children) receiving emergency care annually. This rise in ED utilization has effectively saturated the capacity of EDs and emergency medical services in many communities. The resulting phenomenon, commonly referred to as ED overcrowding, now threatens access to emergency services for those who need them the most. As managers of the pediatric medical home and advocates for children and optimal pediatric health care, there is a very important role for pediatricians and the American Academy of Pediatrics in guiding health policy decision-makers toward effective solutions that promote the medical home and timely access to emergency care.     

Consent for emergency medical services for children and adolescents

Pediatric patients frequently seek medical treatment in the emergency department (ED) unaccompanied by a legal guardian. Current state and federal laws and medical ethics recommendations support the ED treatment of minors with an identified emergency medical condition, regardless of consent issues. Financial reimbursement should not limit the minor patient's access to emergency medical care or result in a breach of patient confidentiality. Every clinic, office practice, and ED should develop policies and guidelines regarding consent for the treatment of minors. The physician should document all discussions of consent and attempt to seek consent for treatment from the family or legal guardian and assent from the pediatric patient. Appropriate medical care for the pediatric patient with an urgent or emergent condition should never be withheld or delayed because of problems with obtaining consent. This statement has been endorsed by the American College of Surgeons, the Society of Pediatric Nurses, the Society of Critical Care Medicine, the American College of Emergency Physicians, the Emergency Nurses Association, and the National Association of EMS Physicians.     

Care of children in the emergency department: guidelines for preparedness

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.     

Showing (motor vehicle) restraint: a primer for emergency physicians

In 2000, 1,668 child occupants under the age of 14 died in motor vehicle crashes and nearly 250,000 children were injured. When used correctly, child safety seats can dramatically reduce a child’s risk of death and serious injury in a motor vehicle crash. Emergency physicians have a unique opportunity to counsel parents and caregivers and provide recommendations on the appropriate restraint for their children as the majority of children in crashes who seek care are treated in emergency departments. The recommendations for child occupant protection are updated regularly. This paper will provide an overview of the current recommendations for restraining children in motor vehicles and identify sources for up to date information for physicians and families.     

Pediatric and adolescent mental health emergencies in the emergency medical services system

Emergency department (ED) health care professionals often care for patients with previously diagnosed psychiatric illnesses who are ill, injured, or having a behavioral crisis. In addition, ED personnel encounter children with psychiatric illnesses who may not present to the ED with overt mental health symptoms. Staff education and training regarding identification and management of pediatric mental health illness can help EDs overcome the perceived limitations of the setting that influence timely and comprehensive evaluation. In addition, ED physicians can inform and advocate for policy changes at local, state, and national levels that are needed to ensure comprehensive care of children with mental health illnesses. This report addresses the roles that the ED and ED health care professionals play in emergency mental health care of children and adolescents in the United States, which includes the stabilization and management of patients in mental health crisis, the discovery of mental illnesses and suicidal ideation in ED patients, and approaches to advocating for improved recognition and treatment of mental illnesses in children. The report also addresses special issues related to mental illness in the ED, such as minority populations, children with special health care needs, and children's mental health during and after disasters and trauma.     

Medical emergencies occurring at school

Children and adults might experience medical emergency situations because of injuries, complications of chronic health conditions, or unexpected major illnesses that occur in schools. In February 2001, the American Academy of Pediatrics issued a policy statement titled "Guidelines for Emergency Medical Care in Schools" (available at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;107/2/435). Since the release of that statement, the spectrum of potential individual student emergencies has changed significantly. The increase in the number of children with special health care needs and chronic medical conditions attending schools and the challenges associated with ensuring that schools have access to on-site licensed health care professionals on an ongoing basis have added to increasing the risks of medical emergencies in schools. The goal of this statement is to increase pediatricians' awareness of schools' roles in preparing for individual student emergencies and to provide recommendations for primary care and school physicians on how to assist and support school personnel.     

Dispensing medications at the hospital upon discharge from an emergency department

Although most health care services can and should be provided by their medical home, children will be referred or require visits to the emergency department (ED) for emergent clinical conditions or injuries. Continuation of medical care after discharge from an ED is dependent on parents or caregivers' understanding of and compliance with follow-up instructions and on adherence to medication recommendations. ED visits often occur at times when the majority of pharmacies are not open and caregivers are concerned with getting their ill or injured child directly home. Approximately one-third of patients fail to obtain priority medications from a pharmacy after discharge from an ED. The option of judiciously dispensing ED discharge medications from the ED's outpatient pharmacy within the facility is a major convenience that overcomes this obstacle, improving the likelihood of medication adherence. Emergency care encounters should be routinely followed up with primary care provider medical homes to ensure complete and comprehensive care.     

Patient safety in the pediatric emergency care setting

Patient safety is a priority for all health care professionals, including those who work in emergency care. Unique aspects of pediatric care may increase the risk of medical error and harm to patients, especially in the emergency care setting. Although errors can happen despite the best human efforts, given the right set of circumstances, health care professionals must work proactively to improve safety in the pediatric emergency care system. Specific recommendations to improve pediatric patient safety in the emergency department are provided in this policy statement.     

Emergency physician perspectives on child passenger safety: a national survey of attitudes and practices

ObjectiveTo understand attitudes and self-reported practices of pediatric and general emergency physicians regarding child passenger safety.MethodsWe conducted a cross-sectional mailed national survey of 600 pediatric emergency medicine (PEM) physicians and 600 emergency medicine (EM) physicians who provide clinical care in the United States randomly sampled from the American Medical Association Physician Masterfile. Survey questions explored attitudes related to the role of the physician and the emergency department (ED) in child passenger safety and self-reported frequency of performing specific child passenger safety practices.ResultsResponses were received from 638 of 1000 (64%) eligible physicians with a valid mailing address. Surveys were completed by 367 PEM and 271 EM physicians. Regardless of their training background, emergency physicians overwhelmingly agreed that it is their role to educate parents about child passenger safety (95% PEM vs 82% EM) and that they can make a difference in how parents restrain their child (92% PEM vs 93% EM). Physicians were similar in their views that the most appropriate person to provide child passenger safety information in their ED was a nurse/midlevel provider followed by a physician. Self-report of child passenger safety practices in response to 2 hypothetical scenarios showed physicians infrequently provide best-practice safety recommendations to families.ConclusionsEmergency physicians are supportive of the ED as a setting to promote child passenger safety, yet do not consistently promote child passenger safety themselves. Differences between PEM and EM physicians’ attitudes toward child passenger safety may necessitate different approaches on injury prevention in general and pediatric EDs.     

American Academy of Pediatrics: Falls from heights: windows, roofs, and balconies

Falls of all kinds represent an important cause of child injury and death. In the United States, approximately 140 deaths from falls occur annually in children younger than 15 years. Three million children require emergency department care for fall-related injuries. This policy statement examines the epidemiology of falls from heights and recommends preventive strategies for pediatricians and other child health care professionals. Such strategies involve parent counseling, community programs, building code changes, legislation, and environmental modification, such as the installation of window guards and balcony railings.     

Patient- and family-centered care of children in the emergency department

Patient- and family-centered care is an innovative approach to the planning, delivery, and evaluation of health care that is grounded in a mutually beneficial partnership among patients, families, and health care professionals. Providing patient- and family-centered care to children in the emergency department setting presents many opportunities and challenges. This technical report draws on previously published policy statements and reports, reviews the current literature, and describes the present state of practice and research regarding patient- and family-centered care for children in the emergency department setting as well as some of the complexities of providing such care. This technical report has been endorsed by the Academic Pediatric Association (formerly the Ambulatory Pediatric Association), the American College of Osteopathic Emergency Physicians, the National Association of Emergency Medical Technicians, the Institute for Family-Centered Care, and the American College of Emergency Physicians. This report is also supported by the Emergency Nurses Association.     

Pediatric Asthma in the Community Emergency Department: Room for Improvement and Aligned Incentives

Asthma is a common reason for emergency department (ED) visits in children. Over 80% of children who visit an ED go to a general, not a pediatric-specific, ED. The treatment children with asthma receive in general EDs is not as compliant with national guidelines as is treatment in pediatric-specific centers. Several studies document improvements in pediatric asthma care through quality improvement initiatives, but few address the emergency care of pediatric asthma in the community setting. National programs such as Pathways for Improving Pediatric Asthma and Translating Emergency Knowledge for Kids provide resources to community EDs for improving pediatric asthma care. More research is needed to determine if programs such as these, as well as partnerships at the local level, can have a positive impact on the emergency care of pediatric asthma. It is essential that we bridge the gaps in care between community and pediatric-specific EDs to improve the quality of emergency care for the over 7 million children in the US with asthma.     

Emergency department utilization by children in foster care.

OBJECTIVE: To examine emergency department (ED) utilization of children in foster care using nationally representative data. METHODS: Cross-sectional analysis of the National Survey of Child and Adolescent Well-Being, Wave 1, which provided data for children ages 1 to 14 years in foster care for 1 year between October 1999 and December 2000. We identified children as having used the ED based upon foster parent responses to the question, "In the last 12 months, has your child gone to an emergency room or urgent care center (UCC) for an illness or injury?" We examined child and family demographic variables that were associated with having used the ED. RESULTS: The sample included 559 children in foster care. Thirty-one percent (95% confidence interval = 26%, 36%) of foster children had visited the ED or UCC in the past 12 months. Multivariate logistic regression analysis revealed that out of all children in foster care, children who had a chronic condition, children of younger age, and children with younger foster caregivers were significantly more likely to have used the ED. CONCLUSION: A sizeable proportion of children in foster care use the ED, and subgroups of these children have particularly high rates of ED use. An important component of providing a medical home for children in foster care should involve coordination of care around ED visits for this vulnerable group of children.     

Emergency Care of the Technology-Assisted Child

As more special needs children reside in community settings, emergency physicians will continue to play an important role in the overall care of these children. To this end, emergency medical services providers and ED physicians should have a familiarity in recognizing and managing acute complications of chronic disease states and in troubleshooting equipment problems. In addition to assisting with acute crises, the emergency provider can be instrumental in helping families with CSHCN integrate successfully into the community by reminding families of important measures that they should take to optimize their child's medical care. In particular, families should be encouraged to have medical summary information and go-bags wherever they travel and to develop written emergency care plans in concert with their primary care provider. The Emergency Information Form co-developed by the American Academy of Pediatrics and the American College of Emergency Physicians is an excellent resource for families with CSHCN [45]. In addition, it is important for families of chronically ill and technology-assisted children to notify community emergency medical services departments and local utility companies of their residence [5]. Together, the medical community and families can partner to ensure optimal medical care and community integration of special needs children.     

End-of-life issues in the pediatric emergency department

The death of a child is one of the most tragic and stressful times in the life of a parent or caretaker. The natural order seems contradicted. Countless and unforeseen problems and challenges exist for the family of the child who died. Physicians, however, are also greatly affected by the death of a patient. In Western society, death has become institutionalized and secularized, and there are fewer societal support systems to facilitate bereavement. Physicians may find themselves in the unexpected role of providing these services at the time of death. Despite or perhaps because of these challenges, there are many appropriate and well-received interventions for bereaved families. The emergency department (ED) is a place where many lives are saved and a few lost. Most ED deaths are unexpected and are usually caused by trauma or acute infections. But many children with terminal diseases, chronic illnesses, and technological dependence are now living at home, and may present to the ED with complications leading to death. This article will address many of the procedural and ethical issues surrounding end-of-life care for children in the ED.     

Fatal child abuse: a two-decade review

The purpose of the present study was to identify demographic variables and medical causes of death associated with child deaths, secondary to abuse, at one pediatric hospital. Abuse and neglect reporting forms, social service records, and autopsy reports were reviewed. A total of 72 known deaths occurred between 1965 and 1984. The majority of children were under two years of age, and the most common cause of death was head trauma. Less than one half of the children who died presented to the emergency department with visible signs of injury. Male abusers outnumbered females; boyfriends of the victims' mothers were the most frequent perpetrators. Emergency department personnel should have a high index of suspicion about abuse in cases of inadequately explained conditions in children. All cases of children who die unexpectedly, or from inadequately explained conditions, should be referred to the coroner, and autopsies should be performed.     

Selecting and using the most appropriate car safety seats for growing children: guidelines for counseling parents

Despite the existence of laws in all 50 states requiring the use of car safety seats or child restraint devices for young children, more children are still killed as passengers in car crashes than from any other type of injury. Pediatricians and other health care professionals need to provide up-to-date, appropriate information for parents regarding car safety seat choices and proper use. Although the American Academy of Pediatrics is not a testing or standard-setting organization, this policy statement discusses the Academy's current recommendations based on the peer-reviewed literature available at the time of publication and sets forth some of the factors that parents should consider before selecting and using a car safety seat.     

Nondiscrimination in pediatric health care

This policy statement is a revision of a 2001 statement and articulates the positions of the American Academy of Pediatrics on nondiscrimination in pediatric health care. It addresses both pediatricians who provide health care and the infants, children, adolescents, and young adults whom they serve.     

Emergency department utilization patterns and health care needs assessment among parents of Chinese American children in New York City

A limited number of publications have addressed the health care needs of Chinese American children of recently immigrated parents. We administered a Chinese-language survey to parents presenting to an urban pediatric emergency department (PED) in New York City and at community venues. The survey assessed demographics, access to health care, and utilization/expectations of the PED. Emergency Severity Index scores were recorded for emergency department patients. Three hundred fifteen families (54% in the PED) completed the survey. Of those completed in the PED, 79% sought emergency services because of pediatric referral or because their pediatrician's office was closed. Of our sickest patients with an Emergency Severity Index score of 3 or less, 28% of parents felt that the child was somewhat sick or not sick at all. Although the majority of our Chinese American families utilize the emergency department appropriately, 28% of the parents of our sickest patients did not appreciate the degree of illness of their children.     

Principles of child health care financing. American Academy of Pediatrics Committee on Child Health Financing

Child health care financing must maximize access to quality, comprehensive pediatric and prenatal health care. This policy statement replaces the 1998 policy statement by the same title. Changes reflect recent state and federal legislation that affect child health care financing. The principles outlined in the statement will be used to evaluate the changing structure of child health care financing.