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.     

National Pediatric Readiness Project: Making a Difference Through Collaboration,Simulation, and Measurement of the Quality of Pediatric Emergency Care

The National Pediatric Readiness Project is a national quality initiative sponsored by the American College of Emergency Physicians, the American Academy of Pediatrics, and the Emergency Nurses Association. Multiple efforts across numerous states are in process to optimize pediatric readiness of emergency departments. This article describes past, current, and future efforts to ensure pediatric readiness of our nations' emergency departments and to understand the relationship between pediatric readiness and quality of pediatric emergency care.     

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.     

Management of pediatric trauma

Injury is the number 1 killer of children in the United States. In 2004, injury accounted for 59.5% of all deaths in children younger than 18 years. The financial burden to society of children who survive childhood injury with disability continues to be enormous. The entire process of managing childhood injury is complex and varies by region. Only the comprehensive cooperation of a broadly diverse group of people will have a significant effect on improving the care and outcome of injured children. This statement has been endorsed by the American Association of Critical-Care Nurses, American College of Emergency Physicians, American College of Surgeons, American Pediatric Surgical Association, National Association of Children's Hospitals and Related Institutions, National Association of State EMS Officials, and Society of Critical Care Medicine.     

Consent for emergency medical services for children and adolescents

Parental consent generally is required for the medical evaluation and treatment of minor children. However, children and adolescents might require evaluation of and treatment for emergency medical conditions in situations in which a parent or legal guardian is not available to provide consent or conditions under which an adolescent patient might possess the legal authority to provide consent. In general, a medical screening examination and any medical care necessary and likely to prevent imminent and significant harm to the pediatric patient with an emergency medical condition should not be withheld or delayed because of problems obtaining consent. The purpose of this policy statement is to provide guidance in those situations in which parental consent is not readily available, in which parental consent is not necessary, or in which parental refusal of consent places a child at risk of significant harm.     

Nurses Are Integral to the Success of EMS for Children

Nurses, particularly emergency nurses, have long been involved with Emergency Medical Services for Children (EMSC) at the local, state, and national level. Partnerships with several professional nursing associations, including the Emergency Nurses Association, have championed the mission of EMSC. These partnerships have been essential to ensuring pediatric emergency readiness, disaster preparedness, and education across the Health Resources and Services EMSC program. Emergency nurses are actively engaged in quality improvement work with the Facility Recognition Collaborative and the Pediatric Readiness Quality Collaborative with their EMSC partners, as well as research through the Pediatric Emergency Care Applied Research Network. In the future, continuing to leverage and expand partnerships with professional nurses and nursing organizations is an important component to the success and growth of EMSC.     

Diagnosis of an intraventricular hemorrhage by a pediatric emergency medicine attending using point-of-care ultrasound: a case report

For the past 2 decades, point-of-care ultrasound (POCU) has been increasingly performed in adult emergency medicine for a variety of indications. However, the incorporation of POCU into pediatric emergency medicine has been much slower. Cranial ultrasound is an integral part in neonatology and is routinely used to diagnose intraventricular hemorrhage (IVH). Although cranial ultrasound is not considered a core emergency ultrasound application in the 2008 American College of Emergency Physicians ultrasound guidelines, this novel approach may prove beneficial in the emergency department (ED) setting. We report a case of a 16-day-old male that presented to the pediatric ED with fussiness and found to be anemic. An IVH was diagnosed for the first time using POCU by a pediatric ED attending. Sonographic characteristics of an IVH may be helpful in the prompt diagnosis of this condition, thereby reducing morbidity and mortality and improving the final outcome.     

Pediatric mental health emergencies in the emergency medical services system

Emergency departments are vital in the management of pediatric patients with mental health emergencies. Pediatric mental health emergencies are an increasing part of emergency medical practice because emergency departments have become the safety net for a fragmented mental health infrastructure that is experiencing critical shortages in services in all sectors. Emergency departments must safely, humanely, and in a culturally and developmentally appropriate manner manage pediatric patients with undiagnosed and known mental illnesses, including those with mental retardation, autistic spectrum disorders, and attention-deficit/hyperactivity disorder and those experiencing a behavioral crisis. Emergency departments also manage patients with suicidal ideation, depression, escalating aggression, substance abuse, posttraumatic stress disorder, and maltreatment and those exposed to violence and unexpected deaths. Emergency departments must address not only the physical but also the mental health needs of patients during and after mass-casualty incidents and disasters. The American Academy of Pediatrics and the American College of Emergency Physicians support advocacy for increased mental health resources, including improved pediatric mental health tools for the emergency department, increased mental health insurance coverage, and adequate reimbursement at all levels; acknowledgment of the importance of the child's medical home; and promotion of education and research for mental health emergencies.     

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.     

Death of a child in the emergency department

Of the estimated 40000 American children < or =14 years old who die each year, approximately 20% die or are pronounced dead in outpatient sites, primarily the emergency department (ED). The ED is distinguishable from other sites at which children die, because the death is often sudden, unexpected, and without a previously established physician-patient care relationship. Despite these difficult circumstances and potentially limited professional experience with the death of a child, the emergency physician must be prepared to respond to the emotional, cultural, procedural, and legal issues that are an inevitable part of caring for ill and injured children who die. All of this must be accomplished while supporting a grieving family. There is also a responsibility to inform the child's pediatrician of the death, who in turn also must be prepared to counsel and support bereaved families. The American Academy of Pediatrics and American College of Emergency Physicians collaborated on the joint policy statement, "Death of a Child in the Emergency Department," agreeing on recommendations on the principles of care after the death of a child in the ED. This technical report provides the background information, consensus opinion, and evidence, where available, used to support the recommendations found in the policy statement. Important among these are the pediatrician's role as an advocate to advise in the formulation of ED policy and procedure that facilitate identification and management of medical examiners' cases, identification and reporting of child maltreatment, requests for postmortem examinations, and procurement of organ donations.     

Emergency Care of Pediatric Asylum Seekers in the United States

There has been a significant increase in the number of asylum-seekers entering the United States in recent years, including children and unaccompanied minors. Upon arrival to the country, these young patients may seek care in an emergency department for acute medical issues related to their journey or chronic conditions that were undiagnosed or inadequately treated in their country of origin. The purpose of this article is to familiarize emergency department clinicians with the common medical conditions seen in pediatric asylum-seekers and outline the ethical and legal issues that may arise when caring for this vulnerable patient population.     

Patient- and family-centered care and the role of the emergency physician providing care to a child in the emergency department

Patient- and family-centered care is an approach to health care that recognizes the role of the family in providing medical care; encourages collaboration between the patient, family, and health care professionals; and honors individual and family strengths, cultures, traditions, and expertise. Although there are many opportunities for providing patient- and family-centered care in the emergency department, there are also challenges to doing so. The American Academy of Pediatrics and the American College of Emergency Physicians support promoting patient dignity, comfort, and autonomy; recognizing the patient and family as key decision-makers in the patient's medical care; recognizing the patient's experience and perspective in a culturally sensitive manner; acknowledging the interdependence of child and parent as well as the pediatric patient's evolving independence; encouraging family-member presence; providing information to the family during interventions; encouraging collaboration with other health care professionals; acknowledging the importance of the patient's medical home; and encouraging institutional policies for patient- and family-centered care.     

Pediatric triage: a 2-tier, 5-level system in the United States

Emergency care continues to be a challenge for the pediatric population. Pediatric emergency department (ED) visits have escalated to over 12.5 million/y. To provide quality care, the provider must strive to meet ED efficiency, patient safety, and federal regulations. One of the most critical and challenging areas is pediatric triage. International healthcare systems in Canada and Australia have designed national triage systems to address the needs of patient acuity, improve patient safety, and enhance customer satisfaction. The United States continues to have various triage systems that include 3-level, 4-level, and 5-level systems in a variety of ED settings. This paper describes a pediatric triage system in the United States with a 2-tier process for high volume and 5 levels of acuity for time to treatment with over 30,000 ED visits per year.     

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.     

Consent by proxy for nonurgent pediatric care

Minor-aged patients are often brought to the pediatrician for nonurgent acute medical care or health supervision visits by someone other than their custodial parent or guardian. These surrogates can be members of the child's extended family, such as a grandparent or aunt. In cases of divorce and remarriage, a noncustodial parent or stepparent may accompany the patient. Sometimes, children are brought for care by adults living in the home who are not biologically or legally related to the child. In some instances, a child care professional (eg, au pair, nanny) brings the pediatric patient for medical care. This report identifies common situations in which pediatricians may encounter "consent by proxy" for nonurgent medical care for minors and explains the potential for liability exposure associated with these circumstances. The report suggests practical steps that balance the need to minimize the physician's liability exposure with the patient's access to health care. Key issues to be considered when creating or updating office policies for obtaining and documenting consent by proxy are offered.     

Legal regulations to protect under-aged donors issued by E.U. Member Countries. Analysis of the present situation and proposals

Allogeneic bone marrow transplantation in the E.U. is a routine treatment which requires specific legal procedures to protect under-aged donors. The European Council (5/29/1978) decreed the guidelines concerning organ transplantation for the Member Countries. These guidelines included obtaining written consent from the donor or his/her guardian. The International Convention on children s rights (New York 11/20/1989, art. 12) stated that the minor has the right to give his/her opinion, which must be taken into consideration. Currently, though legal guidelines vary among Member Countries, all require the parents or guardian s written consent. In France, an ethics committee (L. 76-1181/1976) must inform the minor about the consequences of the procedure, respect his/her will and obtain consent. In Luxembourg, the Department of Health requires written consent as well as authorization by three experts, including two physicians. In Spain an ethics committee must obtain the minor s consent which is then approved by a government authority and counter-signed by a physician. In UK an N.H.S. directive (1st Aug. 1993) states that as of 16 years of age donors must give consent. In Germany minors over 14 are allowed to give consent. A legal guarantee is required when the recipient is a parent to avoid conflict of interest. In Belgium minors between 15 and 18 require witnessed written consent, counter-signed by the guardian and approved by a physician. Married donors below 21 need the consenting adult s approval. In Portugal verbal consent by the minor and the guardian is sufficient. In Denmark the guardian s written consent is needed. In Italy a law is being prepared to best protect minors. In conclusion it would be useful for the European Council to decree the detailed legal guidelines and require greater uniformity among the E.U. Countries.     

Standards for clinical evaluation and documentation by the emergency medicine provider

Pediatric emergency medicine is full of challenges. When a pediatric patient has a poor outcome after treatment in an emergency department (ED), a malpractice lawsuit is likely to result. Pediatric emergency medicine (PEM) physicians might sometimes alter their medical care and practice "defensive medicine" in hopes of avoiding a malpractice lawsuit. Radiographs and other diagnostic studies might be ordered without true indications to "completely rule out" a diagnosis. This can result in excess radiation for a child. On the other hand, failure to order the appropriate study or misinterpretation of a radiographic study by a radiologist or an emergency physician can result in a malpractice lawsuit. PEM physicians must work cooperatively with radiologists to improve the care for children in the ED. Together these specialists can decide on appropriate studies for children in the ED, keep radiation exposure to a minimum and ensure proper management based on these studies.     

Treating minors without their parents

Minors frequently present to the ED for treatment without their legal guardians. In most such situations, it is best to contact the parents to obtain consent for treatment and to inform them about their child's problem. However, in some emergency situations or problems involving adolescent health, it may be impractical or damaging to contact the parents. In these situations, the law is sufficiently vague to protect the well-meaning physician who gives care to consenting minors for their own benefit. Of course, if problems result from the care which is rendered, the usual malpractice law will apply, and the physician will try to demonstrate that his treatment fit into one of the legal exceptions to the general rule.     

Who is responsible for pediatric triage decisions in Australian emergency departments: a description of the educational and experiential preparation of general and pediatric emergency nurses

BACKGROUND: Pediatric presentations to the emergency department (ED) account for approximately one third of ED presentations. Triage is the process employed by the ED to prioritize presenting patients, including children, on the basis of clinical urgency. This role is undertaken by emergency nurses, and a range of recommendations are available regarding the level of experience and education required by the nurse responsible for pediatric triage decisions. However, little is known about the actual education and experience of nurses undertaking pediatric triage. OBJECTIVES: To describe the level of experiential and educational preparation of emergency nurses responsible for pediatric triage decisions in pediatric and adult and pediatric population EDs. METHODS: An anonymous survey of emergency nurses responsible for pediatric triage decisions in a number of specialist and mixed EDs was conducted. RESULTS: Education and experience varies widely among nurses responsible for pediatric triage decisions. Many nurses practicing pediatric triage do not meet recognized guidelines for the levels of education and experience required to undertake pediatric triage. Nurses practicing in mixed population EDs were less likely to meet the recommended educational requirements than pediatric emergency nurses and yet reported no difference in their level of confidence in undertaking pediatric triage. CONCLUSIONS: Educationalists and managers must make a commitment to pediatric triage preparation for nurses in EDs providing pediatric services. In particular, emphasis must be placed on providing pediatric continuing education for nurses practicing in mixed population EDs. However, it is also essential that the impact of education and experience on patient outcomes be investigated before an attempt is made to influence the preparation of nurses for triage.     

The Pediatric Emergency Care Applied Research Network (PECARN): rationale,development, and first steps

Since its formal recognition as a medical specialty, the field of pediatric emergency medicine has made substantial advances with respect to its scope and sophistication. These advances have occurred in clinical practice as well as in the research base to improve clinical practice. There remain, however, many areas in emergency medical services for children (EMSC) in the out-of-hospital, emergency department (ED), and hospital settings that suffer from a lack of data to guide practice. In an effort to expand the quality and quantity of research in pediatric emergency care, the Pediatric Emergency Care Applied Research Network (PECARN) was created in October of 2001. PECARN is the first federally funded national network for research in EMSC and is the result of cooperative agreement grants funded through the Health Resources and Services Administration with the purpose of developing an infrastructure capable of overcoming inherent barriers to EMSC research. Among these recognized barriers are low incidence rates of serious pediatric emergency events, the need for large numbers of children from varied backgrounds to achieve broadly representative study samples, lack of an infrastructure to test the efficacy of pediatric emergency care, and the need for a mechanism to translate study results into clinical practice. PECARN will serve as a national platform for collaborative research involving the continuum of care within the EMSC system, including out-of-hospital care, patient transport, ED and in-hospital care, and rehabilitation. This article describes the history of EMSC, the need for a national collaborative research network in EMSC, the organization and development of PECARN, and the work plan for the network.