Few ERs Are Equipped to Care for Children

Sept. 21, 2009 — -- As the flu season nears, hospital emergency departments are bracing for a fresh onslaught of patients. But research shows that the majority of EDs lack the special equipment, supplies, and expertise needed to treat children.

Out of almost 4,000 EDs in the U.S., only 6 percent are fully prepared to properly care for pediatric patients, according to a new joint policy statement from the American Academy of Pediatrics (AAP), the American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA), published today in the journal Pediatrics.

Experts said the guidelines for pediatric ED preparedness in the joint policy statement, which updates the 2006 guidelines from the Institute of Medicine (IOM), will spotlight the need for better pediatric care in hospitals and provide a tool to help lagging EDs get on par with their better-prepared counterparts.

"The original [2006] guidelines had 162 items in it, including various sizes of [equipment]," said Dr. Marianne Gausche-Hill, a professor of medicine at the David Geffen School of Medicine at the University of California at Los Angeles and one of the lead authors of the joint statement.

"Of all these items, only 6 percent [of EDs] had all these items," she said. "On the flip side, around 80 percent have about 90 percent of the equipment... but there are surprising deficiencies, and I think smaller hospitals need help getting these resources."

Children Require Different Equipment, Expertise

Treating children can require a variety of specialized equipment -- smaller blood pressure cuffs or narrower tubing, for example. Radiation and medication dosages need to be adjusted for children. Rectal thermometers should be available for infants.

"People think that pediatric patients are just small adults and they can [treat them] without special equipment or skill sets when, in fact, they need specialized care," said Dr. Michael Kim, head of the Pediatric Emergency Department at the American Family Children's Hospital in Madison, Wis. "If you don't have a champion in the department, these things can get overlooked."

Training Trumps Equipment in Many Cases

According to 2006 data from the IOM, children accounted for 20 percent of the 119 million ED visits.

Still, there are several reasons a hospital may not invest in a full complement of pediatric equipment. Small or rural hospitals may not see enough pediatric patients to recognize a need for special treatment. A lack of funding and space could result in neglected pediatric emergency facilities. Pediatric patients are not always in need of critical emergency care that requires special equipment.

And according to the joint statement, only 56 percent of emergency care directors were aware that guidelines for pediatric emergency care were available.

But doctors point out that training is just as important, if not more so, than facilities for a pediatric ED.

"The level of expertise among providers, even more than the equipment available, represents a major barrier to optimal care delivery," said Dr. David Cornfield, chief of pulmonary, allergy, and immunology at Lucille Packard Children's Hospital in Palo Alto, Calif.

Better Expertise Necessary for Pediatric EDs

And pediatric emergency medicine is a relatively new specialty, although it is poised for rapid growth, according to data from the Association of American Medical Colleges. Currently, there are 758 active pediatric ED doctors. Almost 100 additional doctors entered training for the specialty in 2008.

Without trained pediatric emergency physicians, patients are subject to delays as equipment is gathered or as they are stabilized for transfer to a different facility.

"It is crucial that emergency departments of all types be fully capable of handling whatever comes their way," said Dr. Robert Field, professor of Health Management and Policy at the Drexel University School of Public Health in Philadelphia, Pa. "It's not like deciding between supermarkets. In a state of crisis, most people will go wherever is closest, or wherever the ambulance takes them. They should not have to second-guess whether that is a wise choice."

Although doctors agree that expertise is paramount, some are not convinced that acquiring a cache of pediatric equipment is the best course of action for every ED.

Physician Coordinators Could Assist EDs

"It depends how you set up the criteria. If one missing minor piece of equipment is the way you "fail" the test, well then that does not mean you can't treat children," said Dr. Richard O'Brien, an emergency physician at Moses Taylor Hospital in Scranton, Pa. "Only by going piece by piece -- and person by person -- can any one department come up with a consensus about [the report's] applicability in a single hospital... I suspect it will be a help, as such, to many EDs."

But with children at increased risk for the novel H1N1 influenza virus, EDs may be more inclined to embrace guidelines that will help them prepare for a potential influx of pediatric patients.

"Since the ratio of kids infected with H1N1 is higher than other age groups, and the severity of the strain is still unknown, it is important for emergency facilities treating pediatric patients to be well prepared," said Dr. Alison Tothy, medical director of pediatric emergency medicine at the University of Chicago Medical Center.

Tothy pointed out that the number of pediatric ER patients at the University of Chicago's Comer Children's hospital rose 150 percent over a two-week period during the spring H1N1 outbreak. She added they expect another significant increase in pediatric patients due to H1N1, seasonal flu, and other winter respiratory viral outbreaks in the coming months.

More Leadership Crucial for Upgrading EDs

"We shouldn't wait for H1N1 flu, or a similar disaster, to teach us the importance of uniform quality emergency care," Field said.

According to the joint report, fewer than 20 percent of EDs appoint either a physician or a nurse coordinator for pediatric emergency care, but those EDs tend to show more compliance with pediatric care guidelines established by the ACEP and the American Academy of Pediatrics.

Increased trained leadership in pediatric emergency care to oversee general treatment and safety for patients, disaster preparedness, acquiring proper equipment and continuing education for staff, among other responsibilities, is one of the primary recommendations from the ACEP and ENA joint report.

"Probably the most important thing that we recommended now is a physician coordinator," Gausche-Hill said. "There has been an intense effort by professional organizations in the last five years to improve awareness of EDs of the need to have these [resources], especially in light of... infectious disesases like H1N1 and the influenza outbreaks and acts of terrorists. Not only do we need these things every day, if we don't have them for every day, we certainly won't have them for natural or manmade disasters."