Are emergency departments ready to treat their youngest patients

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The difference between life and death for a child who arrives in an emergency room often depends on medical preparations that go largely unseen and rarely used. Consider the 2-year-old who was rushed into the Kaiser Permanente Vacaville Medical Center in California with a head bleed after being hit by a car.

The medical team was confident that it had the skills and supplies it needed, as summarized by Mildred McGillvray-Hill, RN, the center's senior clinical practice nurse leader: a blood warmer for transfusion (because children lose heat faster than adults), intubation tools that fit a child, small cervical collars (all the way down to size zero) to stabilize the spine, a history of continuous staff training overseen by pediatric emergency care coordinators (PECCs), and more.

They saved the child.

Such preparation is critical for successfully treating children in emergency departments (EDs).

"The care that they get in the first hour - this is the space where we have the greatest opportunity to save kids," says Aaron Jensen, MD, MEd, a pediatric and trauma surgeon at the University of California San Francisco's Benioff Children's Hospitals.

Yet many EDs (especially those that are not part of children's hospitals) are not fully prepared. From 2013 to 2021, the proportion of children with timely access to an ED rated as highly ready by the National Pediatric Readiness Project (NPRP) decreased from 70.2% to 66.7%. Today, the pressure on EDs in some areas is increasing, partly because of measles outbreaks and an increase in the number of parents forgoing vaccinations for their children. Adding to the challenge is that from 2008 to 2022, the United States lost 30% of its dedicated pediatric inpatient units (from 1,749 to 1,226), as hospitals shifted more children's care to large pediatric centers, leaving EDs at those hospitals with less pediatric expertise.

Health leaders are working to help EDs improve their readiness for pediatric care. In January, the NPRP - a group of professional societies representing ED physicians, along with nurses, pediatricians, and trauma surgeons - released new standards for what every ED needs to be fully ready to treat children. The standards cover equipment and procedures customized for the sizes and ages of children, as well as staff training and responsibilities. The standards update recommendations released in 2009 and 2018 and are being followed by a survey of EDs nationwide to gauge their pediatric readiness.

About 30 million children receive care in emergency departments each year, according to the NPRP. But they do not usually get care that's optimized for children.

"More than 80 percent of children who come to an ED go to a general community hospital, not a children's hospital," said Kate Remick, MD, co-director of the NPRP and lead author of the updated standards, in a statement.

At most of those EDs, the vast majority of patients are adults. Speaking of ED staff in general, Cindy Chang, MD, MEd, assistant professor of emergency medicine and pediatrics at the University Cincinnati College of Medicine, notes, "We don't see as many children in the general ER [emergency room], and when we do, it can be stressful for everyone."

That's why it's important for institutions to assess themselves according to child readiness standards, say Chang and other ED leaders. "Every ED should be fully prepared for kids," Remick says. "These recommendations [from the NPRP] save lives."

The need

A child arrives at an ED regardless of whether anyone there is ready for the child.

"A family suddenly brings in a critically ill child," Remick says. "There's no time to prep. It stresses an already stressed system."

"They get carried in by their mom and dad," McGillvray-Hill says, recounting a common occurrence. "They [the parents] don't know the difference between a pediatric trauma center and a regular ED. They just see 'emergency department' and bring them in. You have to be ready."

Those children pose specific challenges. "Children have unique physical and psychosocial needs that are heightened in the setting of serious or life-threatening emergencies," the NPRP statement notes.

Among other factors, their size and biological responses require adjustments from adult care, to everything from blood infusion and drug dosages to the size of medical devices and conversations with the patient.

"You've never given a kid a lot of blood," Jensen says, thinking of an ED doctor faced with an injured child. "You need to have a way to dose that blood infusion" to the size of the child.

In addition, "if you're giving large volumes of blood to any patient, you need to have it warmed," notes Jean Hoffman, MD, medical director of the ED at UCHealth University of Colorado Hospital. "It's even more important in children because they can't regulate their body temperature" as well as adults.

Treating that critically injured child "might be a once-in-a-career experience" for an ED physician, Jensen says. "That once-in-a-career experience might save a kid's life."

Because most EDs treat adults far more than they treat children, "children are not on hospitals' radar screens on a day-to-day basis," says Marianne Gausche-Hill, MD, emeritus professor of clinical emergency medicine and pediatrics at the University of California, Los Angeles, David Geffen School of Medicine (DGSOM). The low number of pediatric cases "doesn't stimulate hospitals to take action to ensure pediatric readiness."

Readiness can take the form of specific medical items, such as child-sized McGill forceps, which are angled, steel airway tools used to remove airway blockages. "Although it's not common to have full obstruction with choking," Gausche-Hill says, by having them on hand, "we've saved lives."

On the other hand, the items can be as simple as clothing. Hoffman recalls a case:

"We had a child who came in, and we needed to examine them, and we didn't have a gown [that fit]. You want to reassure a parent that you're competent to care for their child and have all the small things that convey competence, like gowns and diapers. We needed a crib. If you don't have a crib, somebody has to sit with that infant who's on a hospital stretcher, because they can fall through the sides."

"Every ED should have all size equipment for any kid, from a newborn to an adolescent," Gausche-Hill says. "That's just the cost of doing business."

Solutions

Readiness isn't only about equipment. Perhaps even more importantly, it's about people: leaders committed to allocating time and finance resources, continuously trained staff, and people designated to own the responsibility.

One of the core elements in the NPRP statement is assigning PECCs to promote adequate pediatric skills and knowledge among ED staff. The critical element is that this position is always maintained (even as designated PECCs leave and are replaced by new staff) and that the person has authority to ensure that training is carried out, supplies are in place, procedures are established, and staff know how to access all of that in a pediatric emergency.

"Periodically check the bins to make sure that you have all the sizes of tubes that you're supposed to have," Jensen says of the role. "Periodically check the policies and protocols to make sure that they're up to date. In some centers, it can be a one-day-a-week job."

Gausche-Hill defines the PECC as "someone who is minding the store."

The PECC also has to ensure that staff will work across teams within the hospital. At DGSOM, Gausche-Hill says, "no matter what the injury is on a kid, we bring pharmacy [staff] down to help make sure that medication doses are appropriate."

One effective practice has been running ED staff through simulations of pediatric emergencies. These are often done in partnership with regional children's hospitals. In Cincinnati, for example, the Children's Hospital Medical Center conducts simulations with EDs at area hospitals, Chang says.

The NPRP recommendations also include more focus on pediatric mental health, such as suicide screening in teens; the inclusion of portable, weight-based pediatric resuscitation carts; and preparation to care for children during disasters.

Results

Research shows that critically ill and injured children treated in EDs in the top 25% of readiness nationwide are up to 76% less likely to die compared to children treated in EDs in the lowest quartile, according to the NPRP.

As for cost: the price of reaching the top 25% of EDs in terms of readiness stands between $4 to $48 per pediatric patient, depending on patient volume, according to NPRP calculation.

"There are ways to do this without spending a lot of money," Jensen says. "Making sure that they [hospitals] have baseline competency and assessment practices is an investment.

"Optimizing pediatric readiness is dirt cheap."