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.     

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.     

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.     

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.     

Patient- and family-centered care and the pediatrician's role

Drawing on several decades of work with families, pediatricians, other health care professionals, and policy makers, the American Academy of Pediatrics provides a definition of patient- and family-centered care. In pediatrics, patient- and family-centered care is based on the understanding that the family is the child's primary source of strength and support. Further, this approach to care recognizes that the perspectives and information provided by families, children, and young adults are essential components of high-quality clinical decision-making, and that patients and family are integral partners with the health care team. This policy statement outlines the core principles of patient- and family-centered care, summarizes some of the recent literature linking patient- and family-centered care to improved health outcomes, and lists various other benefits to be expected when engaging in patient- and family-centered pediatric practice. The statement concludes with specific recommendations for how pediatricians can integrate patient- and family-centered care in hospitals, clinics, and community settings, and in broader systems of care, as well.     

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.     

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.     

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.     

Metered-dose inhaler: the emergency department orphan.

OBJECTIVE: Physicians providing emergency department care to children primarily use nebulizers for the delivery of bronchodilators and these physicians have misconceptions regarding the advantages and disadvantages of using metered-dose inhalers (MDIs) with a spacer (MDI + S) for acute asthma exacerbations. DESIGN: Self-administered mail survey. SETTING: Emergency department. PARTICIPANTS: Emergency medicine section members of the American Academy of Pediatrics and Canadian Pediatric Society. INTERVENTIONS: Bronchodilator delivery methods in acute pediatric asthma. MAIN OUTCOME MEASURES: The 2 principal outcomes for bivariate analysis were self-reported nebulizer use in all patients and MDI + S use in patients with mild acute asthma. RESULTS: Of eligible physicians, 333 (51%) of 567 responded. The majority were dual trained in pediatrics and pediatric emergency medicine (72%) and practiced full time (83%) in an urban (83%) pediatric emergency department (80%). The most commonly cited advantages of MDIs were their cost (33%) and speed of use (28%). The most commonly cited disadvantages were patient or parent dissatisfaction (24%) and relative ease of nebulizer use (23%). Only 10% to 21% of participants used MDIs in the emergency department and reserved this delivery method for children with mild asthma exacerbations. There were no significant associations between selected respondent demographic variables and the use of MDIs. CONCLUSIONS: Misconceptions regarding the efficacy and safety of MDI + S for the treatment of acute asthma exacerbations exist but are limited to a minority of surveyed emergency medicine physicians caring for children. Nebulizers remain the preferred method of routine bronchodilator delivery by physicians providing care to pediatric asthmatics in the emergency department.     

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 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.     

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.     

Utilization of emergency services among patients of a pediatric group practice

Pediatric group practices in university hospitals provide primary care to children who are often from indigent families. Those practices that attempt to provide care in a continuous way often encounter difficulty in attempting to change their patients' patterns of emergency department utilization. This study attempts to define the relationship between patient characteristics such as access to a telephone and inappropriate utilization of the emergency department. A university hospital database was reviewed to identify all patients of the pediatric group practice. Emergency department records over a six-month period were reviewed to identify all visits of group practice patients to the emergency department. Patients without access to a telephone were more likely to inappropriately access care in the emergency department than were patients with phone access. However, within the cohort of emergency department utilizers, phone access was not a predictor of use. Of those who used the emergency department, babies and young children and those of indigent status were more likely to inappropriately access care than were older children and those at a higher socioeconomic level. We conclude that the demographic information of clients in a pediatric group practice can be utilized to predict inappropriate utilization of emergency department services and that this information can be used to implement programs to help foster continuity of care.     

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.     

Pediatric observation units

Pediatric observation units (OUs) are hospital areas used to provide medical evaluation and/or management for health-related conditions in children, typically for a well-defined, brief period. Pediatric OUs represent an emerging alternative site of care for selected groups of children who historically may have received their treatment in an ambulatory setting, emergency department, or hospital-based inpatient unit. This clinical report provides an overview of pediatric OUs, including the definitions and operating characteristics of different types of OUs, quality considerations and coding for observation services, and the effect of OUs on inpatient hospital utilization.     

¿Deberían estar presentes los padres durante los procedimientos invasivos en urgencias?

Over the last decades, health care has been moving away from the paternalistic model, to one of family-centered care. In the pediatric emergency department, this new trend has led to parents playing a larger role in the health care of children, particularly during invasive procedures and/or resuscitation. Despite the increased attention to family presence, it remains a controversial topic, especially among emergency medical staff. Several studies have been performed that look at the advantages and disadvantages of this new way of conceiving child health care. To our knowledge, there is only one Spanish article on this topic, which is the reason why we performed a literature review on family presence in the emergency department.     

Parent perspectives on pain management, coping, and family functioning in pediatric sickle cell disease

Pediatric sickle cell disease is a chronic illness for which recurrent pain is a ubiquitous experience. This study used quantitative and qualitative methods to examine relationships between patient and family coping and health care utilization in children with sickle cell disease and to assess parents' recommendations for ensuring patient and family-centered care. Participants were 53 parents of children aged 7 to 13 with sickle cell disease across three large urban children's hospitals. Data showed that positive patient coping was related to positive family functioning and lower health utilization. In addition, parents report the need for comprehensive health care approaches that meet the physical and psychologic needs of patients and families.     

The APA and the rise of pediatric generalist network research

The Academic Pediatric Association (APA, formerly the Ambulatory Pediatric Association) first encouraged multi-institutional collaborative research among its members over 30 years ago. Individual APA members subsequently went on to figure prominently in establishing formal research networks. These enduring collaborations have been established to conduct investigations in a variety of generalist contexts. At present, 4 generalist networks--Pediatric Research in Office Settings (PROS), the Pediatric Emergency Care Applied Research Network (PECARN), the COntinuity Research NETwork (CORNET), and Pediatric Research in Inpatient Settings (PRIS)--have a track record of extensive achievement in generating new knowledge aimed at improving the health and health care of children. This review details the history, accomplishments, and future directions of these networks and summarizes the common themes, strengths, challenges, and opportunities inherent in pediatric generalist network research.     

Updated American College of Critical Care Medicine--pediatric advanced life support guidelines for management of pediatric and neonatal septic shock: relevance to the emergency care clinician

Shock is a major preventable cause of morbidity and mortality in children referred to emergency care. The recently updated American College of Critical Care Medicine guidelines for the management of newborns and children with septic shock emphasize the role of emergency care in improving survival and functional outcomes. Implementation of these guidelines of stepwise use of fluids, antibiotics, and, if necessary, inotropes within the first hour of admission to the emergency department can reduce mortality and neurological morbidity risks 2-fold. Therapies should be goal directed to maintain age-specific threshold heart rates and blood pressure as well as a capillary refill of less than 3 seconds or 2 seconds or less. Inotropes should be delivered through peripheral intravenous or intraosseous access when central access is unavailable because delay in inotrope delivery can greatly increase mortality risks. Emergency care systems should be organized to facilitate recognition, triage, and treatment of shock in the first hour. Emergency departments should be stocked with ready access to antibiotics, fluids, and inotrope infusions, and clinicians should be trained in the delivery of goal-directed fluid, antibiotics, and inotrope therapies in the first hour of resuscitation. For newborns, in addition to fluids, antibiotics, and inotropes, a prostaglandin infusion should be available within 10 minutes if duct-dependent congenital heart disease is a possibility.