Most hospitals are not set up as Pediatric Trauma Centers; however, all hospitals will face pediatric emergencies frequently, as children account for one-quarter of Emergency Department (ED) patients. Hospitals, clinics, and doctors’ rooms must be set up correctly for pediatric emergencies, as transferring them in time to a designated center is not always an option. A well set up medical workstation on wheels, or two, with all the essential items to deal with a pediatric emergency, is the ideal solution.
Pediatric Emergency Care
ED’s serve as a gateway to definitive care – here, patients are triaged, assessed and stabilized before being transferred to the most appropriate resource, which could be in the current hospital or one better equipped to deal with the emergency.
The pediatric patient has unique physiological, emotional, and psychosocial needs, which makes the provision of emergency care extremely complex, and the requirements differ depending on age. They present for different reasons than adults, and those with chronic diseases will present more frequently.
Children and emergency care:
- 27% of the U.S. population.
- Approximately 20% of all hospital ED visits.
- Described as ‘portable’ (presenting by private car, being brought in by a parent and not by ambulance).
- 90% of emergency pediatric visits take place in a local general hospital rather than a pediatric specialization facility.
- Pediatric emergency care is uneven due to the inequity of available pediatric care resources.
- 5% of all hospitals are specialty pediatric hospitals or children’s hospitals.
- Do not exist in every community or every state.
- Transfer of the pediatric ED patient to specialty facilities for children is common.
The Institute of Medicine reported in 2006 that even though children make up more than 20% of ED patients, many of them lack pediatric-specific equipment, supplies as well as specialty personnel.
The Federal EMS for Children Program, set up in 1984, has partnered with many federal and medical professional organizations to promote the needs of children in the broader emergency care system.
National and regional guidelines for pediatric readiness has been implemented in some states. The EMS for Children State Partnership Program facilitates the integration of pediatric readiness via ten core performance measures and has provided grants to most states for implementation.
The HRSA requires grantees to report on performance measures (71-80) to verify the effectiveness of the use of grant money and are part of the Government Performance Results Act (GPRA).
Ten Core Performance Measures to report on:
- The percent of prehospital provider agencies in the state or territory that have on-line pediatric medical direction available from dispatch through patient transport to a definitive care facility.
- The percent of prehospital provider agencies in the state/territory that have off-line pediatric medical direction available from dispatch through patient transport to a definitive care facility.
- The percent of patient care units in the state or territory that have essential pediatric equipment and supplies, as outlined in national guidelines.
- The percent of hospitals recognized through a statewide, territorial, or regional standardized system that is able to stabilize or manage pediatric medical emergencies.
- The percent of hospitals recognized through a statewide, territorial, or regional standardized system that is able to stabilize and manage pediatric traumatic emergencies.
- The percentage of hospitals in the state/territory that has written interfacility transfer guidelines that cover pediatric patients and that include pre-defined components of transfer.
- The percent of hospitals in the state/territory that has written interfacility transfer agreements that cover pediatric patients.
- The adoption of requirements by the state/territory for pediatric emergency education for license/certification renewal of BLS/ALS providers.
- The degree to which state/territories have established the permanence of EMSC in the state/territory EMS system by establishing an EMSC Advisory Committee, incorporating pediatric representation on the EMS Board, and hiring a full-time EMSC manager.
- The degree to which state/territories have established permanence of EMSC in the state/territory EMS system by integrating EMSC priorities into statutes/regulations.
Joint Policy Statement—Guidelines for Care of Children in the Emergency Department
Published in 2009, the statement outlines the necessary resources to ensure that EDs are ready to deal with children of all ages, from neonates through to adolescents, and was endorsed by over twenty medical and quality professional organizations. The full set informs the term ‘pediatric readiness’ of elements outlined in the joint policy statement. The requirements include having the correct pediatric equipment, pediatric policies, ongoing pediatric education for staff, pediatric policies. It also requires the identification of a pediatric medical director and a pediatric liaison nurse who is responsible for pediatric-specific quality improvement efforts.
Emergency Department Readiness Project
Over 5,000 EDs were offered pediatric readiness assessments based on six topics published in the national guidelines in a quality improvement project in 2013. This was a joint effort by the American College of Emergency Physicians, the Emergency Nurses Association, and the EMSC.
Hospital Pediatric Guidelines for Disasters
Issued by the Centers for Bioterrorism Preparedness Planning Pediatric Task Force Initiative in 2005, they cover the critical areas that health care facilities need to prepare for to deal with pediatric emergencies, in the event of mass casualties, where critically ill or injuries children will be sent to the nearest healthcare facility regardless of its status.
Regardless of the size of the facility, any healthcare facility must have at least one medical workstation on wheels kitted out according to the national guidelines to cope with a pediatric emergency should the need arise. Larger facilities will need to calculate the number of workstations and medication carts required to deal with daily pediatric patient demand as well as mass casualty surge.
In a study to assess pediatric readiness in California EDs, only 69% reported having the recommended equipment and supplies (at least 90%). Even though pediatric sized equipment was generally available, items that were found commonly missing included end-tidal carbon dioxide monitoring, umbilical venous catheters, central venous catheters 4-7F, tracheostomy tubes 2.5-4, laryngeal mask airways 1-3 as well as a pediatric difficult airway kit. Policies were mostly in place.
Tips to Being Prepared for Pediatric Emergencies
1. National Guidelines
Incorporate the National Guidelines for pediatric emergencies into the facility’s quality improvement and management processes and keep updated on current research and changes.
2. Audit
Set up a review and audit process for pediatric readiness and conduct regular self-audits.
3. Pediatric MD
Appoint a Pediatric MD or a physician coordinator for pediatric emergency medicine that is either qualified or competent in the care of children in emergency settings. In small or rural facilities, they may work under the auspices of a remotely qualified mentor from a bigger facility.
To take responsibility for review of policies and procedures, standards, disaster preparedness, audit results, education, and training of staff in pediatric readiness, quality improvement, and clinical care. Act as liaison for referrals or other integrated services.
4. Nursing coordinator
Appoint a nursing coordinator for pediatric emergency care, qualified or skilled in pediatric care. The nursing coordinator is to work closely with the Pediatric MD in fulfilling the duties assigned to the pair for planning, standards, quality management as well as nurse training and promotion of patient and family training.
5. Clinical staff
Appoint physicians, nurses, and other ED healthcare providers that have the necessary skill, knowledge, and training in providing emergency care to children, or provide additional training and CME to strengthen knowledge and skills. Swapping programs to give staff exposure to pediatric centers are a good option. Perform baseline and regular competency evaluations for each category of children.
6. Patient care-review
Incorporate pediatric patient care-reviews into the hospital QI program as well as specific clinical outcome indicators.
7. Monitor professional performance
Develop mechanisms to monitor professional performance, credentialing, continuing education, and clinical competencies, including the integration of findings from QI audits and case reviews.
8. Improve pediatric patient safety
Pediatric patients have unique safety concerns which should be accommodated:
- Weight in kilograms, display prominently.
- In emergency resuscitation use a length-based system to estimate weight.
- Full sets of vital signs – have ranges available for urgent notification.
- Safe medication storage – medication carts must be lockable and have facilities for delivery systems used for children.
- Prescribing and delivery – precalculated dosing guidelines.
- Patient-identification policies.
- Support patient and family-centered care.
- Culturally and linguistically appropriate.
- Isolation facilities as required.
- Infection-control policies.
- Event disclosure policies.
9. Policies, procedures, and protocols
Establish policies, procedures, and protocols for all aspects of pediatric care and emergencies, educate, monitor, and review frequently. Should include triage, clinical care, emergency protocols, imaging, and diagnostic procedures, consent, mandated reporting, restraint, death, transfers, and transportation, referrals, safety, medication protocols, disaster management, decontamination, evacuation, mental and social health and special needs children, to name but a few.
10. Support services
Set up appropriate support services and ensure timely delivery of results.
11. Equipment, supplies, and medication
Pediatric equipment, supplies, and medications must be appropriate for children.
- Easily accessible
- Clearly labeled
- Safely and logically organized
Custom medical carts and a specially prepared medical workstation on wheels are recommended to ease access to required items for emergencies.
A mobile pediatric crash cart is strongly recommended to house resuscitation equipment and supplies.
Pediatric medication should be kept in a lockable, mobile medicine cart, with the appropriate tools to ensure proper dosing such as a medication chart, length-based tape, or medical software.
Daily verification of all items should be mandatory, and ongoing education for staff on the use of these items.
12. Improve clinical and professional competency
It is difficult to keep skills honed when clinical emergencies are few and far between, and mechanisms for continuing medical education and resuscitation skills should be practiced.
13. Provision of the equipment and supplies as per the guidelines
Equipment and supplies should be neatly organized in medical carts or medical workstation on wheels, as appropriate.
General equipment:
- Patient warming device.
- Intravenous blood/fluid warmer.
- Restraint device.
- Weight scale, in kilograms only (not pounds), for infants and children.
- Tool or chart that incorporates both weight (in kilograms) and length to assist physicians and nurses in determining equipment size and correct drug dosing (by weight and total volume), such as a length-based resuscitation tape.
- Pain-scale–assessment tools appropriate for age.
Monitoring equipment:
- Blood pressure cuffs (neonatal, infant, child, adult-arm, and thigh).
- Doppler ultrasonography devices.
- Electrocardiography monitor/defibrillator with pediatric and adult capabilities, including pediatric-sized pads/paddles.
- Hypothermia thermometer.
- Pulse oximeter with pediatric and adult probes.
- Continuous end-tidal CO2 monitoring device.
Respiratory equipment and supplies:
- Endotracheal tubes.
- Uncuffed: 2.5 and 3.0 mm.
- Cuffed or uncuffed: 3.5, 4.0, 4.5, 5.0, and 5.5 mm.
- Cuffed: 6.0, 6.5, 7.0, 7.5, and 8.0 mm.
- Feeding tubes (5F and 8F).
- Laryngoscope blades (curved: 2 and 3; straight: 0, 1, 2, and 3).
- Laryngoscope handle.
- Magill forceps (pediatric and adult).
- Nasopharyngeal airways (infant, child, and adult).
- Oropharyngeal airways (sizes 0–5).
- Stylets for endotracheal tubes (pediatric and adult).
- Suction catheters (infant, child, and adult).
- Tracheostomy tubes (sizes 2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5 mm).
- Yankauer suction tip.
- Bag-mask device (manual resuscitator), self-inflating (infant size: 450 mL; adult size: 1000 mL).
- Clear oxygen masks (standard and nonrebreathing) for an infant, child, and adult.
- Masks to fit bag-mask device adaptor (neonatal, infant, child, and adult sizes).
- Nasal cannulas (infant, child, and adult).
- Nasogastric tubes (sump tubes): infant (8F), child (10F), and adult (14F–18F).
- Laryngeal mask airway† (sizes 1, 1.5, 2, 2.5, 3, 4, and 5).
Vascular access supplies and equipment:
- Arm boards (infant, child, and adult sizes).
- Catheter-over-the-needle device (14–24 gauge).
- Intraosseous needles or device (pediatric and adult sizes).
- Intravenous catheter–administration sets with calibrated chambers and extension tubing and infusion devices with the ability to regulate rate and volume of infusate.
- Umbilical vein catheters (3.5F and 5.0F).
- Central venous catheters (4.0F–7.0F).
- Intravenous solutions to include normal saline; dextrose 5% in normal saline; and dextrose 10% in water.
Fracture-management devices:
- Extremity splints, including femur splints (pediatric and adult sizes).
- Spine-stabilization method/devices appropriate for children of all ages.
Specialized pediatric trays or kits:
- Lumbar-puncture tray including infant (22-gauge), pediatric (22-gauge), and adult (18- to 21-gauge) lumbar-puncture needles.
- Supplies/kit for patients with difficult airway conditions (to include but not limited to supraglottic airways of all sizes, such as the laryngeal mask airway, 2 needle cricothyrotomy supplies, surgical cricothyrotomy kit).
- Tube thoracostomy tray.
- Chest tubes to include infant, child, and adult sizes (infant: 10F–12F; child, 16F–24F; adult, 28F–40F).
- Newborn delivery kit (including equipment for initial resuscitation of a newborn infant: umbilical clamp, scissors, bulb syringe, and towel).
- Urinary catheterization kits and urinary (indwelling) catheters (6F–22F).
Use of Medical Carts
Medical carts and medical workstation on wheels are hospital devices used to organize, store and create ease of access of equipment, tools, supplies, and medications used in the care of patients, and keep them in the hands of authorized users. They are designed to be stabilized, easy to clean and disinfect, with drawers that open and close smoothly and lock when necessary. Smooth-rolling casters allow for excellent mobility, and they are particularly useful for the emergency treatment of pediatric patients.
Scott-Clark Medical manufactures a range of state-of-the-art mobile medical carts that can be custom fitted for your needs.