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Emergency Care for Children: Growing Pains (2007)

Chapter: 5 Improving the Quality of Pediatric Emergency Care

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Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
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5
Improving the Quality of Pediatric Emergency Care

Providing high-quality emergency care services to children requires an infrastructure designed to support care for pediatric patients. In Chapter 2 the committee discussed how many provider organizations, both emergency medical services (EMS) agencies and hospitals, lack recommended pediatric equipment and supplies for children. Addressing these basic deficiencies is an important first step. As technology improves and knowledge of quality in health care expands, however, expectations for provider preparedness extend well beyond simply having the right-sized equipment and appropriately labeled medications. We expect provider organizations to have safeguards in place to protect pediatric patients from the hazards of EMS and emergency department (ED) environments. We expect that advances in technology and information systems adopted by provider organizations will be appropriate for children as well as adults. And we expect care to be provided in a way that is evidence based, protocol driven, and respectful to children and their parents or guardians.

This chapter begins with an overview of the threats to patient safety in the EMS and ED environments and the implications for care, with a focus on pediatric patients. The committee believes emergency care provider organizations—both EMS agencies and hospitals—must take active steps to address these threats to reduce the burden of illness and injury to all patients, including children. To this end, the chapter presents the committee’s recommendations for improving the safety of emergency care for pediatric patients. Finally, the chapter addresses the important topic of how to make emergency care for children more family-centered.

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
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PATIENT SAFETY IN THE EMERGENCY CARE SETTING

Challenges of the Emergency Care Environment

Emergency care services are delivered in an environment where the need for haste, the distraction of frequent interruptions, and clinical uncertainty abound, thus potentially exposing patients to a number of threats to safety. Children are, of course, at particular risk under these circumstances because of their physical and developmental vulnerabilities and their inability to describe their symptoms and past medical history accurately, and because they may require care from providers who are not accustomed to treating pediatric patients (see Chapter 4).

EDs are high-risk environments for medical care for patients of all ages. The nature of their mission and the multiple challenges they confront increase the risk of medical errors and adverse events (Leape et al., 1991; IOM, 2000; Vinen, 2000; Weingart et al., 2000). In their study of admissions to hospitals in Colorado and Utah, Thomas and colleagues (2000) found the ED to be the hospital department with the highest proportion of negligent adverse events (52.6 percent). An earlier study by Trautlein and colleagues (1984) found that 15 to 20 percent of hospital malpractice claims were a result of errors in the ED, most of which involved serious injury or death (Trautlein et al., 1984).

There are several reasons why the ED is an area of high risk for errors. First, many EDs face excessive crowding, resulting in a noisy, even chaotic environment with frequent workflow interruptions. The large volume of patients results in many being evaluated, treated, and housed in the ED hallways, creating situations fraught with opportunities for error (Cosby, 2003; Selbst et al., 2004; Weiss et al., 2004). Moreover, ED patients do not arrive on a scheduled basis. Therefore, ED volumes can fluctuate a great deal, which makes it difficult to make staffing adjustments to meet sudden shifts in demand (Chamberlain et al., 2004).

Second, ED personnel often work under a great deal of stress. They are required to see a broad case mix of patients and make rapid clinical decisions with little time and often without sufficient patient information (Selbst et al., 2004). Most physicians manage one patient at a time (in the operating room, clinic, diagnostic suite, or outpatient surgical center); emergency physicians, by contrast, are often responsible for the simultaneous management of 10 to 20 patients or more with a variety of problems and different levels of acuity. This is such an intrinsic part of emergency medical practice that the oral board exam administered by the American Board of Emergency Medicine (ABEM) requires examinees to properly handle three hypothetical cases simultaneously. No other specialty incorporates multiple patient encounters in its board certification examination process.

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
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In addition to caring for multiple patients, emergency care providers often face competing demands on their time; along with examining patients and providing treatment, they may have to handle EMS calls, help manage patient flow, listen to patients’ and family members’ complaints about waiting times and delays in care, track down missing laboratory or radiology results, and the like. ED physicians are frequently interrupted while working. In many cases, these interruptions result in a break in the physician’s focus on his or her primary task (Chisholm et al., 2001).

In contrast to outpatient clinics and doctors’ offices, EDs operate 24 hours a day. The social and circadian stresses involved in consistently staffing the ED on a round-the-clock basis make ED physicians, nurses, and support staff particularly subject to fatigue, further increasing opportunities for mental errors (Vinen, 2000; Weinger and Ancoli-Israel, 2002; Chamberlain et al., 2004; Selbst et al., 2004). A study of the effect of sleep deprivation on experienced emergency physicians revealed that physicians working night shifts demonstrated a decrease in the speed of intubation and subjective alertness as compared with their day-shift work (Smith-Coggins et al., 1997).

Patient hand-offs from one provider to another midtreatment can result in loss or distortion of important clinical information, thus providing increased opportunities for errors (Croskerry, 2000; Stiell et al., 2003; Chamberlain et al., 2004; Selbst et al., 2004). Physicians, nurses, and other clinicians working on the same shift often fail to communicate effectively, further increasing chances for errors to occur (Risser et al., 1999; Croskerry, 2000; Cosby, 2003; Selbst et al., 2004; White et al., 2004). In fact, poor communication and teamwork failures are a significant problem in the ED. White and colleagues (2004) noted that communication issues were associated with 30 percent of the ED risk management files they studied, and appeared to contribute directly to adverse medical outcomes in 20 percent of those cases. In addition, a 1999 study of the contribution of teamwork failures to clinical errors found that 8 of 12 deaths reviewed could have been prevented if appropriate teamwork action had been taken (Risser et al., 1999). The study authors noted that the most frequently cited primary contributor to clinical error in the ED (35 percent) was the failure to cross-monitor the actions of team members.

Another problem faced by clinicians in the ED is lack of access to complete and accurate medical histories for the patients they are treating (Schenkel, 2000; Cosby, 2003; Chamberlain et al., 2004; Selbst et al., 2004; White et al., 2004). In most cases, ED physicians lack access to a patient’s medical record or even to records of previous visits to that or other area EDs. This problem can be compounded by poor information flow from patient to provider due to the patient’s age, mental health status, use of de-

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
×

bilitating drugs or alcohol, language, culture, or apprehension and anxiety about the need for emergency care.

Less research has been conducted on threats to patient safety in the EMS environment (O’Connor et al., 2002), although that environment is similar to the ED in many ways (Fairbanks, 2004): the fast-paced nature of the work, the stressful environment for providers, and the shift work and round-the-clock coverage that contribute to provider fatigue. EMTs also lack complete and/or accurate medical histories of patients. However, EMS personnel must also contend with a different set of challenges. They often have to provide patient care in unusual locations, such as on the side of a road or highway or close to a crash scene. EMS personnel also have fewer options for backup. Many EDs have physicians to make diagnosis and develop treatment plans, nurses to start intravenous (IV) treatment and administer medications, technicians to take patients’ blood pressure and pulse, social workers to talk with families, a secretary to complete billing information, and specialists that can be called in to assist with complex interventions. EMTs and paramedics in the field, by contrast, have no backup, other than perhaps the muscle and moral support of first-responding firefighters or other rescue personnel. Sometimes EMTs perform all of these tasks alone as a first responder or in the back of an ambulance. Thus the EMS environment lacks even the meager redundancies and system protections found in the ED that occur with a team approach to patient care. Additionally, much of the equipment used by EMTs was designed for in-hospital use and has not been well adapted for the EMS environment (Fairbanks, 2004).

Additional Challenges for Pediatric Emergency Care

Most of the above challenges contribute to a potentially unsafe emergency care environment for all patients, not just children. However, other factors complicate care for children more than that for adults. First, some children are preverbal and cannot self-report their symptoms. Many have multiple caregivers, which increases the likelihood that providers will be given an incomplete or inaccurate medical and medication history. Also, children are likely to be accompanied by parents or guardians suffering from great anxiety, which requires staff to attend to them while also staying focused on the patient (Chamberlain et al., 2004). Young children, particularly those who are frightened or in pain, are unable to cooperate with the examiner or understand the process of care, and may actively resist the performance of painful or uncomfortable procedures. As a result, pediatric providers must use a variety of tactics, including use of short-acting sedatives and other hazardous drugs, to complete treatment successfully.

Timeliness represents another important challenge for pediatric patients in the emergency care setting. The emergency care system must be

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
×

organized to eliminate unnecessary delays in triage and treatment. Because of their unique anatomical and physiological differences, children can get into trouble physiologically much more rapidly than adults. If children do not receive effective emergency care in a timely manner, certain illnesses and injuries can lead to serious consequences, even death, relatively quickly. For example, an infant or young child’s thermoregulatory system is less capable of cooling the body; body temperature can rise 3 to 5 times faster than occurs with adults, making infants and young children more susceptible to heat stroke (Null, 2006). An infant left in an enclosed automobile in hot weather, for example, will become hyperthermic very quickly. If not quickly diagnosed, hyperthermia in infants and young children leads to problems with resuscitation (ACEP and AAP, 2006). Hypothermia also occurs very quickly in children because they have thin skin, less insulating body fat, and a high ratio of body surface area to mass.

Meningococcemia, or blood stream infection, is a potentially life-threatening illness that occurs abruptly and progresses rapidly. Cases are rare, but occur most often in children younger than age 5 (Kapes, 2005). Meningococcemia can lead to death more quickly than any other infectious disease, so early recognition is critical to providing prompt therapy and supportive care. Treatment must begin quickly because irreversible shock and death may occur within hours of the onset of symptoms of the disease (Tanzi and Silverberg, 2005). However, symptoms (fever, chills, sore throat) often resemble those of other conditions. Approximately 20 percent of children who develop meningococcemia do not survive (Children’s Hospital Boston, 2005b).

Another example is shock. Pediatric practitioners treating acutely ill children, from neonates to young adults, are faced with multiple causes of shock (e.g., trauma, infection, anaphylaxis). Hypovolemic shock results from a deficiency of blood volume and is a leading cause of pediatric mortality in the United States. Whereas an adult can lose 500 cubic centimeters (cc) of blood without much effect, losing only half this amount of blood will result in death in infants. Delay in recognizing and quickly treating a state of shock can lead to widespread multiple system organ failure and death in pediatric patients (Schwarz, 2006). In a study of nearly 100 patients over a 10-year period, researchers were able to determine that when community hospitals, primary care physicians, and families recognized and treated children for shock before bringing them to the hospital, the mortality rate decreased dramatically. However, shock tends to be underrecognized and undertreated by emergency providers (Han et al., 2003).

Children are also more susceptible to smoke inhalation and carbon monoxide toxicity than adults because of their higher metabolic rates and smaller volume of distribution for the carbon monoxide they ingest (ACEP and AAP, 2006). They experience symptoms more quickly then adults, but

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
×

carbon monoxide poisoning is often treated improperly in children because its symptoms are similar to those associated with the flu (without the fever) and food poisoning (Children’s Hospital Boston, 2005a). A child’s continued exposure to carbon monoxide can lead to neurological disorders, cardiac arrest, and death.

As another example, vomiting is rather common in children. Vomiting may be caused by gastroenteritis, which is generally less serious, or by many life-threatening conditions, such as meningitis, encephalitis, intussusception, or other conditions that can result in significant morbidity or mortality if not evaluated and managed quickly (D’Agostino, 2002; Fleisher et al., 2006).

Although these are but a few of the pediatric conditions that require prompt identification and treatment, one thing common to many of these examples is that diagnosis may be delayed if symptoms resemble those of other, more common problems. Because children can maintain normal physiology using compensatory mechanisms until they can no longer compensate, at which time they deteriorate quickly, they are particularly vulnerable if treatment is not started promptly. For example, infants and children may have normal blood pressure and be in compensated shock. Their bodies compensate by increasing the heart rate and clamping down on extremity arteries to shunt blood to central circulation. Therefore, subtle signs, such as an increase in heart rate and cool extremities, must be recognized promptly.

However, parents, guardians, and primary care physicians may not recognize the need for immediate emergency care for pediatric patients, and emergency care providers may not be able to determine the severity of illness or injury quickly. In fact, at least one study has shown that the level of agreement in triage assignment for pediatric patients in the ED is not high, and varies based on the level of pediatric training (Maldonado and Avner, 2004).

Another pediatric concern related to timeliness has to do with the often long wait times associated with ED visits. As discussed in Chapter 2, ED crowding has become a daily occurrence in many hospitals. National Hospital Ambulatory Medical Care Survey (NHAMCS) data indicate that in 2003, the average waiting time for all patients (children and adults) to see a physician in the ED was 46 minutes (McCaig and Burt, 2005). Data for 2000 demonstrate the differences in wait time according to patient acuity. On average, patients waited 24 minutes for a visit classified as “emergent,” 38 minutes for an “urgent” visit, 56 minutes for a “semiurgent” visit, and 67 minutes for a “nonurgent” visit (McCaig and Ly, 2002). Prolonged wait times may result in protracted pain for all patients (Derlet and Richards, 2000; Derlet et al., 2001), but for pediatric patients there is another concern. In busy EDs that serve both adults and children, children may be exposed

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
×

to inappropriate and frightening scenes, such as violence, severe injury, and threatening language. Adult EDs are generally not well suited to providing a comforting or reassuring environment for children.

Evidence of Compromised Safety for Pediatric Patients

Given this potentially perilous emergency care environment, how often do medical errors occur among pediatric patients? Surprisingly, the answer to that question is unknown. In fact, there is little high-quality data on the epidemiology of medical errors in children, particularly within the emergency care system. Instead, there are a few, typically small studies demonstrating that care is compromised during several different stages of an ED visit. For example, providers often triage patients inaccurately (Selbst et al., 2004). Errors in specimen collection methods (Walsh-Kelly et al., 1997) and interpretation of radiographs are also a concern (Walsh-Kelly et al., 1995). As might be expected, children with special medical needs or those who are dependent on technology are significantly more likely to experience a medical error than other children (Slonim et al., 2003).

One of the most telling studies on the quality of pediatric care comes from a recent drill conducted in 35 EDs (including 5 trauma centers) in North Carolina. Using life-size child manakins, researchers staged “mock codes” and presented each team with a vignette describing patients’ symptoms. Nearly all of the EDs failed to stabilize seriously injured children properly during trauma simulations. Thirty-four hospitals failed to administer dextrose properly to a child in hypoglycemic shock (a life-threatening drop in blood sugar); 34 failed to warm a hypothermic child correctly; 31 failed to order proper administration of IV fluids; 24 failed to attempt or succeed at accessing a child’s bloodstream through a bone (a critical alternative for delivering fluids and medicines rapidly to sick children); and 23 failed to provide appropriate medications, monitoring equipment, and personnel needed to transport a child safely within the hospital. On the other hand, many hospitals were successful at calling appropriate individuals for assistance, performing initial airway assessment and initial bag-mask ventililation, ordering appropriate imaging tests, and conducting initial assessment of vital signs (Hunt et al., 2006).

There have been few published studies describing the nature or extent of medical errors in the EMS environment. In one research effort, however, 15 paramedics were interviewed about adverse events and near misses; all had multiple events to report. In sum, 61 events were described, 23 percent of which involved a child. The major types of errors were mistakes in clinical judgment (54 percent), errors in skill performance (21 percent), and medication errors (15 percent). Only one-third of the errors had been reported

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
×

to anyone (Fairbanks and Crittenden, 2006). In another small study, which tested the ability of 14 paramedics to use a manual defibrillator, several paramedics defibrillated when they intended to cardiovert. This is a potentially fatal error, and in some cases, participants were not aware they had made the mistake. The researchers attributed the error to the defibrillators’ poor interface design (Fairbanks, 2004; Fairbanks et al., 2004).

However, the best evidence of medical errors and compromised safety concerns medication errors and adverse drug events in children. Prescribing errors occur more frequently in the ED than in any other part of the hospital and more frequently in the care of children than in that of adults. Medication errors were the most commonly reported type of error at one pediatric ED (Selbst et al., 1999). In a retrospective study of more than 1,500 charts of children treated in a pediatric ED, prescribing errors were identified in 10 percent of the charts (Kozer et al., 2002). These errors occurred more frequently during overnight hours (8:00 PM to 4:00 AM) and on weekends and were made most often by trainees. Another study evaluated medication errors with respect to antipyretics and found that 22 percent of acetaminophen doses ordered were outside the recommended 10–15 mg/kg/dose (Losek, 2004). Another study of medication errors among acutely ill and injured children presenting to rural EDs revealed errors in 48 percent of patient charts (Marcin et al., 2005). More seriously ill children are more likely to experience a prescribing error than those with less serious illnesses or injuries (Kozer et al., 2002).

Not surprisingly, the limited evidence available also indicates that medication errors occur frequently in the EMS environment. In a study that assessed the medication calculation skills of 109 paramedics, overall performance was found to be poor. On average, the paramedics answered 51 percent of the test questions correctly. Medication infusions were calculated incorrectly in one-third of cases (Hubble and Paschal, 2000; Fairbanks, 2004).

Challenges Associated with Prescribing and Administering Medications to Children in an Emergency Setting

Perhaps the foremost problem associated with providing medications to children is that many medications are frequently prescribed for children “off label,” meaning they have not been approved for pediatric use by the Food and Drug Administration (FDA). Once a drug has been approved for use by the FDA, further studies to determine its safety and efficacy in infants and children are rarely conducted for the majority of drugs (Rapkin, 1999). The result is that emergency providers must prescribe medications to children without a full understanding of the risks, benefits, or implications.

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
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One example is the use of medications to treat depression in children. Data indicate that psychiatric emergencies are on the rise for children and adolescents, yet there is only one medication, fluoxetine, approved for pediatric use. Still, others are frequently prescribed. The dosages, efficacy, and safety of these medications have not been well established for pediatric patients. Although there is some evidence that one of those drugs, paroxetine, may lead to an increased risk of suicide, the research is thin, and it is unclear why there is a greater risk associated with this and other drugs in comparison with fluoxetine.

Medications designed for adults may not be suitable for children because of differences in pharmacokinetics (what the body does to a drug) and pharmacodynamics (what a drug does to the body). Children’s bodies absorb, distribute, metabolize, and eliminate medications differently from those of adults. But pharmacokinetics and pharmacodynamics also differ as children develop, so the needs of a premature infant, full-term infant, child, and adolescent can vary greatly. A good example is morphine. To achieve a morphine steady-state serum concentration of 10 nanograms (ng)/ml, the infusion rate in micrograms (µg)/kg/hr is 5 for neonates, 8.5 at 1 month of age, 13.5 at 3 months, 18 at 1 year, and 16 at ages 1–3 after noncardiac surgery in an intensive care unit (ICU) (Bouwmeester et al., 2004).

Currently, emergency care professionals have little by way of evidence-based guidelines and information to assist them with the prescribing of medications for infants, children, and adolescents (Mace et al., 2004). For example, there is currently no consensus on optimal guidelines for medications for pediatric sedation; in fact, sometimes these medications are given to children in combination with other drugs. Adverse drug events are common, particularly for antibiotics (e.g., ceftriaxone, clindamycin, amoxicillin), opioids (e.g., morphine, hydromorphone, acetaminophen with codeine), and anticonvulsants (e.g., phenytoin, phenobarbital, valproic acid); drugs in these classes are commonly prescribed to children in an emergency setting. Because of the startling knowledge gap and the frequent use of medications in children in the emergency setting, the committee recommends that the Department of Health and Human Services fund studies of the efficacy, safety, and health outcomes of medications used for infants, children, and adolescents in emergency care settings in order to improve patient safety (5.1). A number of different agencies within the Department of Health and Human Services (DHHS) could lead this effort, including the FDA, the Health Resources and Services Administration (HRSA), and the Agency for Healthcare Research and Quality (AHRQ). Congress has already taken some action in this area by passing two laws that provide incentives for or require drug manufacturers to conduct studies on the effects of drugs when used for pediatric patients—the Best Pharmaceuticals for Children Act of

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
×

2002 (BPCA) and the Pediatric Research Equity Act of 2003 (PREA), respectively. Under BCPA, the manufacturer takes the initiative in conducting pediatric studies and requests 6-month patent extensions from the FDA; however, this may not occur for drugs with limited market potential. PREA applies only to new molecular entities or new drugs, for which the FDA can require that the manufacturer conduct pediatric studies unless exceptions are granted. There is currently no regulation providing incentives for or requiring manufacturers to perform pediatric studies for the vast majority of drugs on the market in the generic forms used for pediatric patients.

Even for the small group of medications for which pediatric guidelines are available, a number of pitfalls exist at the prescribing, dispensing, administration, and monitoring stages that can result in medication errors and adverse drug events. Most adverse drug events for pediatric patients are a result of errors that occur at the prescribing stage, and they often involve incorrect dosing (IOM, 2000; Kaushal et al., 2001; Selbst et al., 2004; Chamberlain et al., 2004). Doses for pediatric patients must be calculated based on the patient’s weight and therefore must be determined specifically for each patient. But the calculations needed to develop the dosing are complicated, and errors are common (Selbst et al., 2004). Patient weight can be and often is obtained or recorded incorrectly (Selbst et al., 1999). Among the most serious dosing errors are 10-fold errors that occur when a decimal point is missing or misread. There have been several examples of children receiving 10 or 100 times the intended dose of a medication and dying as a result. In one case, a baby was given 15 milligrams of morphine instead of the intended 0.15 milligrams—a 100-fold difference in dosing (Goldstein, 2001).

Other dosing errors can occur if there is confusion between milligrams (mg) and micrograms (µg) or mg and milliliters (ml). Additionally, errors are common with combinations of products, for example, Tylenol with codeine; it may be unclear whether the dosage is for the Tylenol or the codeine. Finally, dosage errors may occur when a product is prepared in two different ways and the concentrations are different. For example, Tylenol comes in a syrup and a drop, but the concentrations differ.

The process of dispensing and administering medications for children, compared with that for adults, relies much more heavily on manual compounding of liquid medications and administration to patients who are unable to perform their own medication safety checks. This may well make the dispensing and administering of medications for children more prone to error. Additionally, errors can occur during the dispensing stage if drugs that look or sound alike are confused, for example, Zantac and Zyrtec or Tobrex and Tobradex. Additionally, the packaging of two medications may look alike, contributing to errors at the dispensing stage (Levine et al., 2001;

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
×

Selbst et al., 2004). Most EDs do not have a pharmacist on staff to review orders or assist with medication use (Selbst et al., 2004). At the administration phase, a drug may be delivered twice if the first dosing is not promptly recorded in the medical record.

To reduce the high frequency of medication errors that occur in pediatric emergency care, the committee recommends that the Department of Health and Human Services and the National Highway Traffic Safety Administration fund the development of medication dosage guidelines, formulations, labeling guidelines, and administration techniques for the emergency care setting to maximize effectiveness and safety for infants, children, and adolescents. Emergency medical services agencies and hospitals should incorporate these guidelines, formulations, and techniques into practice (5.2). Agencies could commission research studies and/or convene a panel of experts to carry out these tasks. The Office of Emergency Medical Services within the National Highway Traffic Safety Administration (NHTSA) is a natural leader for this effort; within DHHS, a number of agencies could lead the effort, including the FDA, HRSA, and AHRQ. Implementing the proposed guidelines would not only improve patient safety, but also potentially reduce providers’ liability claims since medication errors have been shown to be the second most frequent and second most expensive reason for such claims (Physician Insurers Association of America, 1993).

IMPROVING SAFETY FOR PEDIATRIC PATIENTS

The task of ED and EMS providers—to care for patients of all types, often with limited patient information and in a difficult, crowded environment—is enormous, and many providers and organizations are up to that task. However, there is enough evidence to suggest the need for action to improve the safety of emergency care, including that provided to pediatric patients. The committee therefore recommends that hospitals and emergency medical services agencies implement evidence-based approaches to reducing errors in emergency and trauma care for children (5.3). Those organizations that give guidance to providers, such as government agencies and professional organizations, should encourage providers to implement measures designed to protect patient safety. Continued research is needed to determine the best strategies for improving patient safety in prehospital and ED care; however, these strategies should focus on the factors that contribute to the deterioration of performance, such as crowding, problems with communication and information, and lack of provider resources.

Various hospitals and EMS agencies have tried several promising strategies with some success that could be replicated in other organizations. These initiatives have the potential to help all patients, not just children. Below we

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
×

classify the strategies into three groups: provider policies, provider training, and technologies. Ideally, organizations would adopt all three of these strategies. A few examples of each type are given here.

Provider Policies

One of the problems associated with reducing the incidence of medical errors is that the frequency of errors and their most important triggers are unknown. Provider initiatives aimed at raising awareness of medical errors have shown some potential, although such programs must be coupled with limits on provider liability to encourage participation. For example, one hospital created and implemented the Good Catch Reporting Program. Under this program, all staff are required to report suspected and identified medical errors and near misses without fear of reprisal. Senior hospital leadership appointed a patient safety manager who reports to the chief nurse and reviews all errors and near misses. This information is used to develop system improvements for patient safety. Within the first 3 months of the program, reporting of near misses doubled (Salisbury, 2005). This approach could also be applied to the EMS environment.

EMS and hospital administrators have a number of opportunities to examine and specifically develop policies to address areas in which they believe shortcomings in patient safety exist. One hospital created the Look Alike/Sound Alike Project, in which a second person is required to verify all medications prior to their administration to a patient. Additionally, a pharmacist separated all look alike/sound alike medications in the pharmacy and clinics. Since the project was implemented, no look alike/sound alike medication errors have been identified (Salisbury, 2005).

Provider Training

Energized by successes in the aviation industry, where teamwork training has led to reductions in errors and improved performance (Risser et al., 1999; Sprague, 1999), several organizations have promoted the concept of teamwork training for health professionals. The similarities between pilots and doctors—highly trained technically, accustomed to viewing themselves as bearers of ultimate authority and responsibility, independent yet increasingly dependent on others of varying skill levels—suggest that teamwork training may be influential in reducing errors in the medical field (Sprague, 1999). Research on the impact of teamwork training in the ED is limited but promising. MedTeams, a Department of Defense (DoD) project that introduced teamwork training to health care, developed an Emergency Team Coordination Course (ETCC), an 8-hour didactic course for physicians, nurses, technicians, and support personnel. An evaluation of the course re-

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
×

vealed considerable success. EDs using the ETCC experienced a 67 percent increase in error-averting behavior and a 58 percent reduction in observable errors (Risser et al., 1999; Shapiro et al., 2004).

Training initiatives that use simulation exercises have been shown to improve performance (Chorpra et al., 1994; Shapiro et al., 2004). Simulation training involves giving emergency care providers practice in performing tasks in lifelike circumstances using human models or virtual reality, with feedback from skilled observers, other team members, and video cameras. Some hospitals and academic medical centers use robotic human simulators (for example, an infant patient simulator used to train providers for intubation) so providers can experience high-risk, low-frequency events. These human simulators, analogous to the flight simulators used by pilots, allow providers to manage a wide range of clinical scenarios and learn from mistakes without harming a real patient (ECRI, 2005). The modern human patient simulator is extremely realistic, with anatomically correct clinical signs and the ability to communicate (Reznek et al., 2002).

Pediatric human simulators are in use in a limited number of hospitals. For example, at the University of Michigan, simulation is used to train EMTs and pediatric residents in standardized pediatric resuscitation courses. An attending physician developed the Pediatric Mock Code Program, in which the pediatric human patient simulator is used during actual pediatric code activations. Evaluation and training are provided to pediatric residents as well as other code team members, including nurses, pharmacists, and respiratory therapists. The program evaluates resuscitation skills, team interaction, and team leadership skills using a variety of scenarios representing the critically ill or injured child in the arrest and prearrest state (University of Michigan Health System, 2005).

Evidence for the effectiveness of simulation-based training is limited and has focused primarily on adult patient settings. However, use of and testing with pediatric human patient simulators could be a promising approach to pediatric training, particularly since many providers encounter critically ill or injured patients infrequently in practice; use of a simulator could help these providers maintain pediatric skills. However, there is presently limited access to simulation training technologies in hospitals, and even more so in EMS environments. Mobile simulation apparatus will be needed to bring this training to providers in the field, particularly those in rural areas (NHTSA, 2002).

Technologies

To further promote safety, attention has recently focused on identifying medications, patients, and providers with bar codes. Using technology that reads these bar codes, a computer system can confirm that the right medication is being given to the right patient at the right time and warn the

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
×

provider of any safety issues. But progress on this technology remains stalled as the pharmaceutical industry tries to find a standard method of identifying medications (Kaushal and Bates, 2002). A review of the available controlled studies shows time savings and error reduction with the use of bar codes; however, further study is needed (Oren et al., 2003). There is also hope that the increased use of electronic health records, computerized physician order entry, decision-support systems, and the like will help improve patient safety, making it easier for emergency care providers to determine correct diagnoses and provide proper treatment to their patients (Cosby, 2003). Indeed, all of these technologies have been shown to be effective in reducing errors in small evaluations involving patients of all ages (Hunt et al., 1998; Bates et al., 1999; Bizovi et al., 2002; Buller-Close et al., 2003), although results have not been universally positive (Han et al., 2005). The next section describes some of these technologies and addresses the need to design them for use with pediatric patients.

ADVANCES IN TECHNOLOGY AND INFORMATION SYSTEMS

Technology is also likely to advance the way care is delivered in the prehospital and ED settings. New technologies designed to accelerate diagnosis and workflow (advanced imaging modalities, rapid diagnostic tests, laboratory automation, EMS technologies, patient tracking tools, and new triage models) and improve treatment (ultrasonography, tympanocentesis, needleless drug administration, and innovations in procedural sedation) are likely to be adopted. As these new technologies are introduced, it will be critical to consider how they help (and whether they may bring harm to) pediatric patients. While this appears to be a rather obvious consideration, history is filled with examples of medical technologies originally developed for adults and used on children with unintended consequences. Devices are typically developed for adults because they constitute a much larger share of the market for medical services than children. For similar reasons, post-market surveillance of medical devices is focused on adults, especially older adults, rather than children. Also, regulation and patient safety efforts for medical products tend to focus more on pharmaceuticals than on medical devices (IOM, 2005).

When detrimental effects on children are discovered postmarket, adjustments are eventually made to technologies, making them safer for pediatric use. One example is the infusion pump, introduced more than 30 years ago, which delivers medications and fluids intravenously. As originally designed, the devices had a wide range of acceptable programming parameters. For example, they could be programmed to deliver a drop or two every hour or a liter or more in an hour. They were designed for maximum flexibility; they could be used on an adult ICU patient one day and on a premature infant the

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
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next. Because the technology relied on human intelligence for programming, errors naturally occurred. In a neonatal ICU, for example, an infusion rate was programmed to 304 ml/hr when the physician intended the rate to be 3.4 ml/hr. In many cases, critical errors were made because a single wrong button was pressed (Reves, 2003).

Advances in infusion technology led to the introduction of “smart pumps,” which are widely used today. Smart pumps utilize software that checks programmed doses. The software contains information on drugs, their usual concentrations, dosing units, and dosing limits. When the practitioner uses the pump, he or she programs it for use in a designated area (e.g., adult ICU, neonatal ICU), and the pump is automatically configured for use on adults or children. Additional safeguards are also built into the pumps, for example, alerting the user if the dosage exceeds the hospital’s established limit and not allowing the user to base the dose on the patient’s weight if the drug is not dosed on that basis (Reves, 2003).

A market for pediatric technologies, equipment, and supplies must be stimulated so that products will be designed initially to meet the needs of pediatric patients, instead of being adapted from products originally designed and intended for use with adult patients. The market for pediatric-designed products has not been well developed in part because providers have not been compelled to purchase pediatric-specific products. To stimulate demand for such products, emergency providers should be made aware of the potential shortcomings of products designed for adults and adapted for children. To advance this effort, the committee recommends that federal agencies and private industry fund research on pediatric-specific technologies and equipment for use by emergency and trauma care personnel (5.4).

This is not the first recommendation of its kind. The 2005 Institute of Medicine (IOM) report Safe Medical Devices for Children emphasized the need for the FDA, the National Institutes of Health (NIH), and AHRQ to define a research agenda and priorities for evaluation of the short- and long-term safety and effectiveness of medical devices for children (IOM, 2005). The report also called for the FDA to work with industry and others to focus more attention on adverse events involving the use of medical devices for children and to update product labeling promptly to reflect safety-related findings. Emergency providers should be able to take comfort in knowing that the equipment they are using on pediatric patients is safe and effective. Development and testing of new products are needed to give providers this assurance.

Federal agencies and private industry also need to take a careful look at the technologies already in place and available for use with infants, children, and adolescents. For a number of devices and technologies being used on pediatric patients, it is unclear whether they ultimately do children more good than harm. One example is the growing use of pediatric computed tomog-

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
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raphy (CT), a tool that assists ED providers in diagnosing illness and injury in children. Annually, 2–3 million CT scans are performed on children—a seven-fold increase in the past 10 years (Doheny, 2003), much of which is due to the technology’s increased availability. One problem with the use of CT is radiation exposure. Children are more sensitive to radiation than adults, and they have longer life expectancy and therefore a greater opportunity to develop cancer in their lifetime. The same radiation dose when given to a neonate is several times more likely to produce cancer over the child’s lifetime than when given to a 40-year-old adult (National Cancer Institute and Society for Pediatric Radiology, 2002). Indeed, research indicates that pediatric CT scans are used too liberally in the ED, frequently to appease parents or guardians who request them (Doheny, 2003). Additionally, practitioners often fail to adjust the exposure parameters when administering a CT scan to a pediatric patient. As a result, in 2002 the National Cancer Institute and the Society for Pediatric Radiology issued a guide to physicians instructing them in how to minimize children’s exposure to radiation. They recommended performing CT scans only when necessary, limiting the region of the body scanned, adjusting exposure parameters based on the child’s size and weight, and minimizing the use of multiple scans (National Cancer Institute and Society for Pediatric Radiology, 2002). Children scanned at adult hospitals may receive a higher dose of radiation than those scanned at children’s hospitals because at the former, the machine is kept on default settings typically intended for adult patients.

Another technology that is already in use with unclear implications for children is the automated external defibrillator (AED), often used by first responders in public settings. AEDs are programmed to deliver adult-dose shocks to individuals in ventricular fibrillation (VF) cardiac arrest. None of the AEDs introduced in office buildings, airports, and other public places were designed for use in children under age 8, and none were cleared by the FDA for use in children. Additionally, there were no data regarding the safety and efficacy of AEDs in children. However, new AEDs with pediatric cables and pads have been designed to direct some of the current away so the pediatric patient receives a lower level of energy (Brown et al., 2004). The American Heart Association (AHA) and the National Association of EMS Physicians (NAEMSP) have stated that AEDs may be used together with cardiopulmonary resuscitation (CPR) in children aged 1 to 8 in cardiac arrest (Markenson and Domeier, 2003; Samson et al., 2003), and the AHA recommends the use of the two together for treatment of cardiac arrest in children above age 8 (Atkins et al., 1998). The FDA has cleared the way for the marketing of specially modified AEDs for use on infants and children younger than age 8 (Automated Defibrillator Cleared, 2001).

Today there remains uncertainty about the appropriate use of AEDs in children, however. According to a recent advisory statement from the

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
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International Liaison Committee on Resuscitation, newer AED models with pediatric capabilities can be used on children over age 1, but only a limited number of studies have looked at the impact of AEDs on children. Although the incidence of sudden cardiac arrest among children is rare, it is estimated that AEDs could assist approximately 15 high school students with the condition per year if placed in schools (Brown et al., 2004). In 2004, a number of organizations, including the AHA, NAEMSP, the American Academy of Pediatrics (AAP), and the American College of Emergency Physicians (ACEP), developed a joint statement that outlines recommendations for the use of AEDs in schools (Hazinski et al., 2004).

One thing common to all of the examples in this section is that the technologies were not originally designed for use in children, but were used on children in practice. In the absence of pediatric-specific technologies, providers may be compelled to use adult technologies on children thinking that the benefits outweigh the risks; certainly in many cases, use of the adult technology may be better than foregoing treatment for the pediatric patient altogether (National Cancer Institute and Society for Pediatric Radiology, 2002). However, encouraging the development and testing of pediatric-specific technologies is key to ensuring that children receive the best treatment for their conditions.

A similar issue exists with the development of information technology (IT) systems. Hospitals, EMS systems, and government entities are beginning to make substantial investments in health IT systems that may improve the quality and efficiency of emergency care delivery for all patients, but there are benefits specific to pediatric patients as well. IT systems that make immunization records of children available to emergency care providers have the potential to greatly improve the efficiency and effectiveness of care. Additionally, some children with special health care needs have sizable medical records, whose details could be made available to emergency care providers with certain IT systems.

Because of the unique nature of pediatric relative to adult emergency care, specific consideration of children’s needs during the design of systems is critical to ensure that the systems will be appropriate for the pediatric patient. For example, clinical decision-support systems must incorporate the various threats to children’s health and diseases common to children; systems designed for adult care currently do not do so. The lack of uniform agreement on standard pediatric doses is at least part of the reason for the usual absence of pediatric-specific dosing tables powering most commercially available computerized physician order entry tools. Without standard pediatric doses and requirements for building these dosage rules into computerized prescribing tools, children will fail to fully reap the benefits of IT in the medication delivery process. Also, electronic health records must be designed to allow providers to record measurements on a sufficiently

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
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granular scale appropriate for newborns and infants (e.g., rounding to the nearest tenth of a kilogram or recording age by month rather than year) (Shiffman et al., 2001).

While studies indicate great benefits of advances in information systems, the safety, impacts, and risks of these systems for pediatric patients have received little attention (Lehmann, 2003). Pediatric experts need to be involved in the design of these products, not only to ensure that the data collected and produced by the systems are appropriate for children, but also to ensure that the systems are designed suitably for the input of data by providers of care to pediatric patients. Pediatric performance measures should be monitored before and after the implementation of new information systems. For example, at least one study revealed an increase in pediatric mortality after the implementation of a computerized physician order entry system, which was expected to reduce errors in the care of pediatric patients (Han et al., 2005).

The committee’s companion report on hospital-based emergency care addresses advances in health IT in greater depth, including the need for systems to be designed appropriately for patients of all ages.

THE IMPORTANCE OF FAMILY-CENTERED CARE

One of the six aims for quality health care identified by the IOM in its seminal report Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001) is patient-centeredness. This means that care should encompass the qualities of compassion, empathy, and responsiveness to the needs, values, and preferences of the individual patient. In the case of pediatric patients, parents or guardians are recognized as the child’s primary source of strength and support and play an integral role in the child’s health and well-being. The aim of patient-centered care recognizes that parents and guardians must collaborate with providers in decision making regarding their child’s care (Lewandowski and Tesler, 2003). Increasing recognition of the importance of meeting the psychosocial and developmental needs of children and of fostering the role of families in promoting the health and well-being of their children has led to the concept of “family-centered care” (Eichner et al., 2003). This section describes the concept of family-centered care and its benefits. Unfortunately, few EMS agencies or EDs have written policies or guidelines for family-centered care in place, and few providers are trained in offering such care (Loyacono, 2001; MacLean et al., 2003). Because the family-centered approach to care can mutually benefit the patient, family, and provider, the committee supports its widespread adoption by the emergency care system, including EMS agencies and hospitals. The committee recommends that emergency medical services agencies and hospitals integrate family-centered care into emergency care practice (5.5).

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
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Entities that offer guidance to providers, such as government agencies and professional organizations, should demonstrate leadership in this area by promoting the use of family-centered guidelines.

The concept of family-centered care evolved between 1980 and 1990 under the leadership of parent advisory groups, health professionals, the Maternal and Child Health Bureau, and the Office of the Surgeon General. The concept contrasts with the more traditional medical model of health care, which is oriented toward disease and disability, the notion that health providers know best how to treat problems, and the view that family members should comply with treatment recommendations (Baren, 2001). There are several definitions of family-centered care, but they all essentially recognize that providers should acknowledge and use the family’s knowledge of their child’s condition and the family’s skills and presence when caring for a child (Boudreaux et al., 2002). The core principles of family-centered care include the following (ENA et al., 2000):

  • Treatment of patients and families with dignity and respect

  • Communication of unbiased information

  • Patient and family participation in experiences that enhance control and independence and build on their strengths

  • Collaboration in the delivery of care, policy and program development, and professional education

Family-centered care is supported by a growing body of research showing the need to ensure the involvement of patients and families in their own health care decisions, to better inform families of treatment options, and to improve access to information by patient and families (Eichner et al., 2003). A number of studies have found some evidence of improved health outcomes, patient and family satisfaction, and provider satisfaction with the introduction of family-centered care (Meyers et al., 1998, 2000; Boie et al., 1999; Boudreaux et al., 2002; Saunders et al., 2003; Moreland, 2005). The approach is especially important when emergency providers have a pediatric patient with special health care needs; because of their frequent interactions with medical providers and deep familiarity with their child’s condition, parents of such patients may be in a better position than emergency care providers to diagnose the problem. The development and implementation of family-centered care encompass multiple components of care delivery, policies and procedures, the care environment, and personnel practices.

Collaboration with Families in the EMS and ED Environments

Often a parent or guardian is present when emergency medical technicians (EMTs) arrive on scene or a child arrives at the ED. Emergency

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
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providers encounter families at a highly stressful time. The family-centered approach to care revolves around collaborating with families, keeping them informed about the child’s condition, prognosis, and treatment (National Association of Emergency Medical Technicians, 2000a). For EMTs, simply explaining the function of equipment, procedures being performed, and their effects is important so that family members can be better prepared to make decisions about care, such as termination of resuscitation. Potential benefits include decreased patient and family anxiety and combativeness, decreased liability issues if parents/guardians are involved in decision making, and easing of the consent process for organ donation if parents/guardians are aware of everything that has been done (National Association of Emergency Medical Technicians, 2000b).

The family-centered approach to emergency services also includes giving families the option of being present during invasive procedures as long as the safety of the patient and medical providers is not compromised. Family members have traditionally been excluded at such times because of concerns that they could lose emotional control and interrupt care, a lack of staff to meet family needs, insufficient room at the bedside, increased risk of litigation, family-imposed limitations on the training of medical residents, and the potential that providers’ skills could be affected by discomfort with the family’s presence. But heightened awareness and new research have revealed that these concerns are overstated and that there are multiple benefits to the presence of family members: their presence removes doubt about what is happening to the child and reinforces that everything possible has been done, it reduces anxiety and fear (Wolfram and Turner, 1996; Wolfram et al., 1997), it engenders feelings of supporting and helping the patient, it sustains patient–family connectedness, it engenders feelings of being helpful to the health care staff, and it facilitates the grieving process (Doyle et al., 1987; MacLean et al., 2003). In addition, the existing literature indicates that family presence does not negatively impact the ability of providers to perform invasive procedures or exacerbate clinician anxiety (Bauchner and Vinci, 1996; Wolfram and Turner, 1996; Sacchetti et al., 2005), although at least one study showed that family members’ presence during resuscitation was occasionally stressful and anxiety provoking for providers (Hanson and Strawser, 1992).

Research on this issue suggests that families want to be given the option to be present during invasive procedures and resuscitations, and when given the option often take it (Bauchner et al., 1991; Haimi-Cohen et al., 1996; Sacchetti et al., 1996; Boie et al., 1999; Boudreaux et al., 2002). Family members who were present for a procedure report favorable experiences and believe their presence benefited the patient and their own emotional response to the incident (Boudreaux et al., 2002).

While families overwhelmingly support family-centered policies, pro-

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
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viders have mixed opinions about family presence. Often inclusion of parents or guardians goes against the culture of emergency care providers. An example is Children’s Hospital of Philadelphia’s pediatric/neonatal ground transport team, which historically had a policy of excluding parents from the transport of a child in a ground ambulance. The transport team cited a number of reasons for the policy: difficulty caring for the patient if the parent needed attention, potential trouble in dealing with a belligerent or hysterical parent, difficulty controlling the child if a parent was present, and the transport team’s anxiety about performing medical interventions while being watched by a parent. In 1995, the transport team explored the idea of allowing parents to ride in ground ambulances and surveyed parents who were and were not allowed to do so. Overwhelmingly, results showed that parents preferred to accompany their child during transport. The research team also surveyed pediatric transport team managers from a number of different children’s hospitals. They found diverse opinions and practices regarding parental accompaniment during transport (Woodward and Fleegler, 2000, 2001).

Provider opinions regarding family presence vary with the invasiveness of the procedure and the provider’s experience. A recent survey of ED faculty, nurses, and pediatric residents at an urban children’s hospital found that ED staff generally supported the presence of family members during minor procedures, but expressed concern regarding the effects on the family and the success of the procedure. Most attending physicians and nurses supported the family’s presence during highly invasive procedures, but most residents did not (Fein et al., 2004). This study and others have shown that more experienced practitioners tend to be more comfortable than those with less experience with regard to allowing families to be present during procedures (Mitchell and Lynch, 1997; Meyers et al., 2000; O’Brien et al., 2002; Fein et al., 2004).

Studies also indicate that nurses are more likely than physicians to support family presence policies (Chalk, 1995; Helmer et al., 2000; Fein et al., 2004). In 1994, the Emergency Nurses Association (ENA) passed a resolution supporting the presence of family members at the bedside during invasive procedures and/or resuscitations. Other organizations that explicitly support family-centered care, including the Emergency Medical Services for Children (EMS-C) program, ACEP, and the American Association for the Surgery of Trauma (AAST), have not developed official resolutions on parental presence during invasive procedures (Boudreaux et al., 2002). A 2002 survey of critical care and emergency care nurses revealed that, despite the frequency of requests from family members to be present during invasive procedures, nearly all EDs lack written policies or guidelines for family presence (MacLean et al., 2003).

A few studies of family-centered care have found evidence of improvements in staff satisfaction, but most have focused on primary care delivery

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
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or inpatient care (Eichner et al., 2003). The exception is a 2001 study that found that when family-centered care was the cornerstone of culture in a pediatric ED, staff members had more positive feelings about their work than staff members in an ED where emotional support for families was not emphasized (Hemmelgarn et al., 2001).

The family-centered approach requires a shift in thinking for emergency providers typically trained to rapidly assess, treat, and/or transport patients (National Association of Emergency Medical Technicians, 2000b). A lack of training in why and how to communicate with families can be a barrier to the adoption of family-centered care. The committee recognizes the value of family-centered pediatric emergency care and encourages provider organizations to take steps to educate practitioners in and develop protocols for adopting this approach. Family members’ presence during invasive procedures and resuscitations remains controversial (Sacchetti et al., 2005), but institutions should consider such policies. Family presence for more minor procedures, such as wound repair, is overwhelmingly supported by both patients and providers and should be reflected in providers’ treatment protocols.

Resources exist to help guide EMS agencies and hospitals in the implementation of family-centered practices. For example, On the Same Team is a training tool for EMTs designed to assist them in becoming more proficient in engaging family members in the care of their loved ones. In 1997, the EMS-C National Resource Center, in collaboration with the Institute for Family-Centered Care (IFCC), developed an assessment tool for evaluating family-centered practices. There are separate tools for prehospital emergency care and care in the ED. More recently, the IFCC partnered with the AHA to produce a resource for practitioners wishing to advance the practice of family-centered care (AHA, 2005). The provision of family-centered care is also advanced in the Pediatric Advanced Life Support (PALS) manual, Advanced Pediatric Life Support (APLS): Pediatric Emergency Medicine Resource, and the AHA’s guidelines for CPR (Knapp and Mulligan-Smith, 2005). Guidelines for implementing family-centered care were also provided in a report of the National Consensus Conference on Family Presence during Pediatric Cardiopulmonary Resuscitation and Procedures (Henderson and Knapp, 2005).

A Family-Centered ED Environment

Another important component of family-centered care is creating an environment in the ED that is both family- and child-friendly. However, a minority of hospitals have separate pediatric EDs (Gausche-Hill et al., 2004). The majority of hospitals treat both children and adults in the same

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
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area, creating an uncomfortable environment for parents or guardians and a frightening one for children if they are in the waiting room with bleeding or intoxicated adults.

Attention to creating a family-centered environment has grown in recent years. The 2001 EMS-C Program Guide for Improving Family-Centered Care contains a framework for improving the environment and design of EDs for children and their families. The guide encourages EDs to reflect on whether their environment is family-centered by answering a number of questions, such as the following: Is the waiting area large enough, with enough comfortable seating available, for all children and adults who may be waiting, even if several adults and children accompany one child? Are examination, treatment, and procedure rooms designed to accommodate parents or guardians who wish to remain with their child? Can families easily find their way from the ED to other areas of the hospital, including radiology, laboratories, pharmacy, admitting office, patient care units, and cafeteria?

Because of the emotional impact an ED visit can have on a patient and parent/guardian, the exterior and interior of the ED should be inviting and make the patient and family feel comfortable. Working with hospital staff, patients, and parents, designers of pediatric EDs have formulated advice for designing the interior of a pediatric ED. First, the normal environment for children does not include bright primary colors; it is often better to create a calming environment than a stimulating one. Second, lighting that is appropriate for an exam is not helpful to parents’ or guardians’ frayed nerves. Distractions such as a television or radio are welcome to families that are waiting. Third, children should feel that they can master an environment and not be overwhelmed or intimidated by it. One means to this end is to design the room to the scale of a child. Examples include wall sconces 24 inches above the floor and a rail system detailed to accommodate the sightline of a 4-year old. Lower ceilings may also be appropriate (Pence, 2000; Hanson, 2001).

Many hospital inpatient units, particularly in pediatric centers, use child life programs and specialists to address the psychosocial aspects of hospitalization for the pediatric patient and parents or caregivers (AAP, 2000). These programs and services help reduce emotional disturbances in children and help them anticipate and make it through difficult procedures. Evidence has shown that these programs can reduce stress and aid recovery (Wolfer et al., 1998). It is unclear how prevalent these programs are in EDs, although a mid-1990s survey of large children’s hospitals found that 6 of 44 EDs had at least one full-time child life specialist on staff (Krebel et al., 1996). Evidence is limited as to the impact of having child life services available in the ED setting, though the practice appears to have potential.

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
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Cultural Competency

Another component of family-centered care is cultural competency. According to the EMS-C program, “cultural competence includes possessing the appropriate knowledge, skills, and capacity to provide emergency services to children in a manner that demonstrates respect, sensitivity, and understanding of the unique cultural differences within, among, and between groups” (EMS-C National Resource Center, 1999).

Only a few studies have been able to draw a direct link between cultural competence and health care improvement, although expert opinion strongly suggests a connection among cultural competence, quality of care, and reduced racial and ethnic disparities (Betancourt et al., 2002). These studies are not specific to pediatric patients, but cultural competency is an important issue for the emergency care system in general, not just services for children, particularly because the racial/ethnic distribution of emergency care providers is not well matched to the racial/ethnic distribution of the population, and is even less well matched to the population that uses emergency services most frequently. This disparity can only be expected to increase as the U.S. population continues to diversify at a much faster rate than most health professions and occupations (Heron and Haley, 2001; Cone et al., 2003).

One of the biggest challenges for emergency care providers is language barriers. Professional interpreters are often not available in the field or at an ED. Indeed, interpreters are frequently not used in the ED, even when thought necessary by a patient or provider (Baker et al., 1996). When providers cannot obtain adequate information from a patient interview, they tend to use more resources, such as laboratory and radiographic investigations. One study of language barriers in a pediatric ED revealed that a physician–family language barrier was associated with a higher rate of resource utilization for diagnostic studies and increased ED visit times (Hampers et al., 1999).

One special concern is the use of children as interpreters for their own care or the care of their parents/guardians when they speak English but their parents/guardians do not. Use of children as medical interpreters is common practice in many areas with large immigrant populations (Burke, 2005); often, however, the information that needs to be interpreted is beyond children’s comprehension and may be inappropriate for them (Yee, 2005). Children assuming this role take on a heavy emotional responsibility. Additionally, use of an untrained interpreter can lead to medical errors. In one study, the error rate was highest for the youngest interpreter, an 11-year-old (Flores et al., 2003). Some states have regulations that prevent children from serving as medical interpreters for their parents/guardians, but these rules may not apply in emergency situations. The traditional subordinate role of children can be reversed when they are used as interpreters, and in some

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
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cultures, their assumption of this role can be seen as a threat to parental authority and therefore serve as a barrier to care (National Association of Emergency Medical Technicians, 2000b).

The challenge goes beyond language barriers, however. Providers need to be aware of the various cultures residing in their catchment area so as to be prepared to serve them. Also, understanding different family structures can help avoid hostile reactions resulting from inadvertent disrespect toward families (National Association of Emergency Medical Technicians, 2000b). Providers’ actions can affect patient perceptions of care. A survey of adult patients presenting to an ED with one of six chief complaints found that non–English speakers were less satisfied with their care in the ED, were less willing to return to the same ED if they had a problem they felt required emergency care, and reported more problems with emergency care (Carrasquillo et al., 1999).

Failure to appreciate the importance of culture and language during pediatric emergencies can result in multiple adverse consequences, including difficulties with informed consent; miscommunication; inadequate understanding of diagnosis and treatment by families; dissatisfaction with care; preventable morbidity and mortality; unnecessary child abuse evaluations; lower-quality care; clinician bias; and ethnic disparities in prescriptions, analgesia, test ordering, and diagnostic evaluation (Flores et al., 2002). The National Association of Emergency Medical Technicians emphasizes the use of communication strategies to combat some of the cultural barriers to care that may arise. Examples of these strategies include identifying providers to the patient and family members, identifying a team member to interact with the family members on each call, asking how the patient and family would like to be addressed, using courtesy titles, and watching for verbal and nonverbal cues from families about the amount of information they want and whether they understand what is being explained to them (National Association of Emergency Medical Technicians, 2000b).

Care of Adolescents

Less research on patient- and family-centered care has been conducted for adolescents than for younger children. In fact, relatively little is known about adolescents’ health care preferences or expectations (Britto et al., 2004). Results of a study of adolescents with chronic illness suggest that aspects of interpersonal care are most important to their judgment of quality. Physicians’ honesty and attention to pain are deemed of critical importance. Adolescents also want to participate in their own care and have their views taken seriously by providers (Britto et al., 2004).

Adolescents tend to find the ED a fast-paced, confusing, and frightening place according to results from a focus group of teens in four cities.

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
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Respondents reacted negatively to the idea of emergency care personnel approaching them at the hospital and engaging them in discussions of violence or personal safety (Dowd et al., 2000). This finding presents a real challenge to emergency care providers since teens often present with conditions resulting from violence or alcohol or drug use. Most EDs do not provide preventive screenings or counseling for adolescents (Wilson and Klein, 2000). Physicians tend to find adolescent patients “frustrating,” and according to one study, adolescents receive less-than-optimal care in the emergency room (March and Jay, 1993). Yet brief interventional counseling for adolescents may be of value. A prevention effort at one ED targeting injured adolescents resulted in greater use of seat belts and bicycle helmets (Johnston et al., 2002).

Certainly more research is necessary to provide adolescents with emergency services in a way that is both patient-centered and effective. Clearly, however, an understanding of the psychosocial and developmental issues that characterize adolescence may help staff respond more effectively to adolescent patients (March and Jay, 1993).

SUMMARY OF RECOMMENDATIONS

5.1 The Department of Health and Human Services should fund studies of the efficacy, safety, and health outcomes of medications used for infants, children, and adolescents in emergency care settings in order to improve patient safety.


5.2 The Department of Health and Human Services and the National Highway Traffic Safety Administration should fund the development of medication dosage guidelines, formulations, labeling guidelines, and administration techniques for the emergency care setting to maximize effectiveness and safety for infants, children, and adolescents. Emergency medical services agencies and hospitals should incorporate these guidelines, formulations, and techniques into practice.


5.3 Hospitals and emergency medical services agencies should implement evidence-based approaches to reducing errors in emergency and trauma care for children.


5.4 Federal agencies and private industry should fund research on pediatric-specific technologies and equipment for use by emergency and trauma care personnel.


5.5 Emergency medical services agencies and hospitals should integrate family-centered care into emergency care practice.

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
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REFERENCES

AAP (American Academy of Pediatrics). 2000. Access to pediatric emergency medical care. Pediatrics 105(3 Pt. 1):647–649.

ACEP, AAP (American College of Emergency Physicians, American Academy of Pediatrics). 2006. APLS: The Pediatric Emergency Medicine Resource (4th edition). Elk Grove Village, IL/Dallas, TX: ACEP and AAP.

AHA (American Hospital Association). 2005. Strategies for Leadership: Patient-and Family-Centered Care. [Online]. Available: http://www.aha.org/aha/key_issues/patient_safety/resources/patientcenteredcare.html [accessed January 25, 2006].

Atkins DL, Hartley LL, York DK. 1998. Accurate recognition and effective treatment of ventricular fibrillation by automated external defibrillators in adolescents. Pediatrics 101(3 Pt. 1):393–397.

Automated defibrillator cleared for use in infants and children. 2001. FDA Consumer 35(4):4.

Baker DW, Parker RM, Williams MV, Coates WC, Pitkin K. 1996. Use and effectiveness of interpreters in an emergency department. Journal of the American Medical Association 275(10):783–788.

Baren JM. 2001. Rising to the challenge of family-centered care in emergency medicine. Academic Emergency Medicine 8(12):1182–1185.

Bates DW, Teich JM, Lee J, Seger D, Kuperman GJ, Ma’Luf N, Boyle D, Leape L. 1999. The impact of computerized physician order entry on medication error prevention. Journal of the American Medical Informatics Association 6(4):313–321.

Bauchner H, Vinci R. 1996. Parents and procedures: A randomized controlled trial. Pediatrics 861.

Bauchner H, Waring C, Vinci R. 1991. Parental presence during procedures in an emergency room: Results from 50 observations. Pediatrics 87(4):544–548.

Betancourt JR, Green AR, Emilio Carillo J. 2002. Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches. Field Report. New York: The Commonwealth Foundation.

Bizovi KE, Beckley BE, McDade MC, Adams AL, Lowe RA, Zechnich AD, Hedges JR. 2002. The effect of computer-assisted prescription writing on emergency department prescription errors. Academic Emergency Medicine 9(11):1168-1175.

Boie ET, Moore GP, Brummett C, Nelson DR. 1999. Do parents want to be present during invasive procedures performed on their children in the emergency department? A survey of 400 parents. Annals of Emergency Medicine 34(1):70–74.

Boudreaux E, Francis J, Loyacono T. 2002. Family presence during invasive procedures and resuscitations in the emergency department: A critical review and suggestions for future research. Annals of Emergency Medicine 40(2):193–205.

Bouwmeester NJ, Anderson BJ, Tibboel D, Holford NHG. 2004. Developmental pharmacokinetics of morphine and its metabolites in neonates, infants and young children. British Journal of Anaesthesia 92(2):208–217.

Britto MT, DeVellis RF, Hornung RW, DeFriese GH, Atherton HD, Slap GB. 2004. Health care preferences and priorities of adolescents with chronic illnesses. Pediatrics 114(5):1272–1280.

Brown L, Dietrich AM, Hostetler MA, Goldman RD, Barata IA, Higginbotham E, Finkler JH. 2004. Automated External Defibrillators (AEDs) and Pediatric Patients. Dallas, TX: ACEP.

Buller-Close K, Schriger DL, Baraff LJ. 2003. Heterogeneous effect of an emergency department expert charting system. Annals of Emergency Medicine 41(5):644–652.

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
×

Burke G. 2005, October 21. Children speaking for their parents? Sacramento Union. [Online]. Available: http://www.sacunion.com/pages/california/articles/6612/ [accessed January 31, 2007].

Carrasquillo O, Orav EJ, Brennan TA, Burstin HR. 1999. Impact of language barriers on patient satisfaction in an emergency department. Journal of General Internal Medicine 14(2):82–87.

Chalk A. 1995. Should relatives be present in the resuscitation room? Accident and Emergency Nursing 3(2):58–61.

Chamberlain J, Slonim A, Joseph J. 2004. Reducing errors and promoting safety in pediatric emergency care. Ambulatory Pediatrics 4(1):55–63.

Children’s Hospital Boston. 2005a. Carbon Monoxide Poisoning. [Online]. Available: http://www.childrenshospital.org/az/Site649/mainpageS649P0.html [accessed April 4, 2006].

Children’s Hospital Boston. 2005b. Meningococcal Infections. [Online]. Available: http://www.childrenshospital.org/az/Site1291/printerfriendlypageS1291PO.html [accessed April 4, 2006].

Chisholm CD, Dornfeld AM, Nelson DR, Cordell WH. 2001. Work interrupted: A comparison of workplace interruptions in emergency departments and primary care offices. Annals of Emergency Medicine 38(2):146–151.

Chorpra V, Gesnik BJ, de Jong J, Boville JG. 1994. Does training on an anesthesia simulator lead to improvement in performance? British Journal of Anaesthesia 73:293–297.

Cone DC, Richardson LD, Knox HT, Betancourt JR, Lowe RA. 2003. Health care disparities in emergency medicine. Academic Emergency Medicine 10(11):1176–1183.

Cosby KS. 2003. A framework for classifying factors that contribute to error in the emergency department. Annals of Emergency Medicine 42(6):815–823.

Croskerry P. 2000. The feedback sanction. Academic Emergency Medicine 7(11):1232–1238.

D’Agostino J. 2002. Common abdominal emergencies in children. Emergency Medical Clinics of North America 20(1):139–153.

Derlet RW, Richards JR. 2000. Overcrowding in the nation’s emergency departments: Complex causes and disturbing effects. Annals of Emergency Medicine 35(1): 63–68.

Derlet RW, Richards JR, Kravitz R. 2001. Frequent overcrowding in U.S. emergency departments. Academic Emergency Medicine 8(2):151–155.

Doheny K. 2003, April 5. CT scans for kids: Not every bump warrants an X-ray. HON News. [Online]. Available: http://www.hon.ch/News/HSN/512003.html [accessed October, 2005].

Dowd MD, Seidel JS, Sheehan K, Barlow B, Bradbard SL. 2000. Teenagers’ perceptions of personal safety and the role of the emergency health care provider. Annals of Emergency Medicine 36(4):346–350.

Doyle CJ, Post H, Burney RE, Maino J, Keefe M, Rhee KJ. 1987. Family participation during resuscitation: An option. Annals of Emergency Medicine 16(6):673–675.

ECRI (Emergency Care Research Institute). 2005, February. Teamwork takes hold to improve patient safety. The Risk Management Reporter 24(1):1–7.

Eichner JM, Neff JM, Hardy DR, Klein M, Percelay JM, Sigrest T, Stucky ER, Dull S, Perkins MT, Wilson JM, Corden TE, Ostric EJ, Mucha S, Johnson BH, Ahmann E, Crocker E, DiVenere N, MacKean G, Schwab WE. 2003. Family-centered care and the pediatrician’s role. Pediatrics 691–696.

EMS-C National Resource Center (Emergency Medical Services for Children National Resource Center). 1999. EMSC and Cultural Competence. Washington, DC: EMS-C National Resource Center.

ENA, HRSA, EMSC (Emergency Nurses Association, Health Resources and Services Administration, Emergency Medical Services Cooperation). 2000. Assessment of Family-Centered Care in the Emergency Department. Des Plaines, IL: ENA.

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
×

Fairbanks RG, Crittenden CN. 2006. The Nature of Adult and Pediatric Adverse Events. Unpublished report. [Online]. Available: http://www.thefederationonline.org/PowerPoint/TerryFairbanks.pdf [accessed February 2006].

Fairbanks RJ, Caplan S, Shah MN, Marks A, Bishop P. 2004. Defibrillator usability study among paramedics. Human Factors and Ergonomics Society Meeting. [Online.} Available: http://www.thefederationonline.org/PowerPoint/TerryFairbanks.pdf [accessed September 2005].

Fairbanks T. 2004. Human Factors and Patient Safety in Emergency Medical Services. Science Forum on Patient Safety and Human Factors Research. Rochester, NY: University of Rochester.

Fein JA, Ganesh J, Alpern ER. 2004. Medical staff attitudes toward family presence during pediatric procedures. Pediatric Emergency Care 20(4):224–227.

Fleisher GR, Ludwig S, Henretig FM, Ruddy RM, Silverman BK. 2006. Textbook of Pediatric Emergency Medicine. Philadelphia, PA: Lippincott Williams and Wilkins.

Flores G, Rabke-Verani J, Pine W, Sabharwal A. 2002. The importance of cultural and linguistic issues in the emergency care of children. Pediatric Emergency Care 18(4):271–284.

Flores G, Laws MB, Mayo SJ, Zuckerman B, Abreu M, Medina L, Hardt EJ. 2003. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics 111(1):6–14.

Gausche-Hill M, Lewis R, Schmitz C. 2004. Survey of US Emergency Departments for Pediatric Preparedness––Implementation and Evaluation of Care of Children in the Emergency Department: Guidelines for Preparedness. Emergency Medical Services for Children Partnership for Information and Communication Grant #IU93 MC 00184. Unpublished results.

Goldstein A. 2001, April 20. Overdose kills girl at Children’s Hospital. The Washington Post. p. B1.

Haimi-Cohen Y, Amir J, Harel L, Straussberg R, Varsano Y. 1996. Parental presence during lumbar puncture: Anxiety and attitude toward the procedure. Clinical Pediatrics 35(1):2–4.

Hampers LC, Cha S, Gutglass DJ, Binns HJ, Krug SE. 1999. Language barriers and resource utilization in a pediatric emergency department. Pediatrics 103(6):1253–1256.

Han YY, Carcillo JA, Dragotta MA, Bills DM, Watson RS, Westerman ME, Orr RA. 2003. Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome. Pediatrics 112(4):793–799.

Han YY, Carcillo JA, Venkataraman ST, Clark RS, Watson RS, Nguyen TC, Bayir H, Orr RA. 2005. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics 116(6):1506–1512.

Hanson C, Strawser D. 1992. Family presence during cardiopulmonary resuscitation: Foote Hospital emergency department’s nine-year perspective. Journal of Emergency Nursing 18(2):104–106.

Hanson T. 2001. Pediatric design––put yourself in some small shoes––design perspectives. Healthcare Review.

Hazinski MF, Markenson D, Neish S, Gerardi M, Hootman J, Nichol G, Taras H, Hickey R, O’Connor R, Potts J, van der Jagt E, Berger S, Schexnayder S, Garson A Jr, Doherty A, Smith S. 2004. Response to cardiac arrest and selected life-threatening medical emergencies: The medical emergency response plan for schools––a statement for healthcare providers, policymakers, school administrators, and community leaders. Annals of Emergency Medicine 43(1):83–99.

Helmer SD, Smith RS, Dort JM, Shapiro WM, Katan BS. 2000. Family presence during trauma resuscitation: A survey of American Association for the Surgery of Trauma and Emergency Nurses Association members. The Journal of Trauma 48(6):1015–1022; discussion 1023–1024.

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
×

Hemmelgarn A, Glisson C, Dukes D. 2001. Emergency room culture and the emotional support component of family-centered care. Childrens Health Care 30(2):93–110.

Henderson DP, Knapp JF. 2005. Report of the national consensus conference on family presence during pediatric cardiopulmonary resuscitation and procedures. Pediatric Emergency Care 21(11):787–791.

Heron S, Haley L Jr. 2001. Diversity in emergency medicine: A model program. Academic Emergency Medicine 8(2):192–195.

Hubble MW, Paschal KR. 2000. Medication calculation skills of practicing paramedics. Prehospital Emergency Care 4(3):253–260.

Hunt DL, Haynes RB, Hayward RS, Pim MA, Horsman J. 1998. Patient-specific evidence-based care recommendations for diabetes mellitus: Development and initial clinic experience with a computerized decision support system. International Journal of Medical Informatics 51(2–3):127–135.

Hunt EA, Hohenhaus SM, Luo X, Frush KS. 2006. Simulation of pediatric trauma stabilization in 35 North Carolina emergency departments: Identification of targets for performance improvement. Pediatrics 117(3):641–648.

IOM (Institute of Medicine). 2000. To Err Is Human: Building a Safer Health System. LT Kohn, JM Corrigan, MS Donaldson, eds. Washington, DC: National Academy Press.

IOM. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press.

IOM. 2005. Safe Medical Devices for Children. Washington, DC: The National Academies Press.

Johnston BD, Rivara FP, Droesch RM, Dunn C, Copass MK. 2002. Behavior change counseling in the emergency department to reduce injury risk: A randomized, controlled trial. Pediatrics 110(2 Pt. 1):267–274.

Kapes B. 2005, April 1. Accurate, timely diagnosis of dermatoses in children critical. Dermatology Times. [Online]. Available: http://www.highbeam.com/doc/1G1-135648502.html [accessed September, 2005].

Kaushal R, Bates DW. 2002. Information technology and medication safety: What is the benefit? Quality & Safety in Health Care 11(3):261–265.

Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, Goldmann DA. 2001. Medication errors and adverse drug events in pediatric inpatients. Journal of the American Medical Association 285(16):2114–2120.

Knapp J, Mulligan-Smith D. 2005. Death of a child in the emergency department. Pediatrics 115(5):1432–1437.

Kozer E, Scolnik D, Macpherson A, Keays T, Shi K, Luk T, Koren G. 2002. Variables associated with medication errors in pediatric emergency medicine. Pediatrics 110(4):737–742.

Krebel MS, Clayton C, Graham C. 1996. Child life programs in the pediatric emergency department. Pediatric Emergency Care 12(1):13–15.

Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H. 1991. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. New England Journal of Medicine 324(6):377–384.

Lehmann CU. 2003. Medical information systems in pediatrics. Pediatrics 111(3):679.

Levine SR, Cohen RM, Blanchard NR, Frederico F, Magelli M, Lomax C, Greiner G, Poole RL, Lee CKK, Lesko A. 2001. Guidelines for preventing medication errors in pediatrics. Journal of Pediatric Pharmacological Therapy 6:426–442.

Lewandowski LA, Tesler MD, eds. 2003. Family Centered Care: Putting it into Action: The SPN/ANA Guide to Family-Centered Care. Washington, DC: SPN and ANA.

Losek JD. 2004. Acetaminophen dose accuracy and pediatric emergency care. Pediatric Emergency Care 20(5):285–288.

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
×

Loyacono TR. 2001. Family-centered prehospital care. Emergency Medical Services 30(6):83.

Mace SE, Barata IA, Cravero JP, Dalsey WC, Godwin SA, Kennedy RM, Malley KC, Moss RL, Sacchetti AD, Warden CR, Wears RL. 2004. Clinical policy: Evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department. Journal of Pediatric Surgery 39(10):1472–1484.

MacLean S, Guzzetta C, White C, Fontaine D, Eichhorn D, Meyers T, Desy P. 2003. Family presence during cardiopulmonary resuscitation and invasive procedures: Practices of critical care and emergency nurses. Journal of Emergency Nursing 29(3):208–221.

Maldonado T, Avner J. 2004. Triage of the pediatric patient in the emergency department: Are we all in agreement? Pediatrics 114(2):356–360.

March CA, Jay MS. 1993. Adolescents in the emergency department: An overview. Adolescent Medicine 4(1):1–10.

Marcin JP, Seifert S, Cho M, Cole SL, Romano PS. 2005, May 16. Medication errors among acutely ill and injured children presenting to rural emergency departments. Presentation to the Pediatric Academic Societies Meeting. Washington, DC.

Markenson DS, Domeier RM. 2003. The use of automated external defibrillators in children. Prehospital Emergency Care 7(2):258–264.

McCaig LF, Burt CW. 2005. National Hospital Ambulatory Medical Care Survey: 2003 Emergency Department Summary. Hyattsville, MD: National Center for Health Statistics.

McCaig LF, Ly N. 2002. National Hospital Ambulatory Medical Care Survey: 2000 Emergency Department Summary. Advance Data from Vital and Health Statistics; No. 326. Hyattsville, MD: National Center for Health Statistics.

Meyers TA, Eichhorn DJ, Guzzetta CE. 1998. Do families want to be present during CPR? A retrospective survey. Journal of Emergency Nursing 24(5):400–405.

Meyers TA, Eichhorn DJ, Guzzetta CE, Clark AP, Klein JD, Taliaferro E, Calvin A. 2000. Family presence during invasive procedures and resuscitation. American Journal of Nursing 100(2):32–42; quiz 43.

Mitchell MH, Lynch MB. 1997. Should relatives be allowed in the resuscitation room? Journal of Accident & Emergency Medicine 14(6):366–369; discussion 370.

Moreland P. 2005. Family presence during invasive procedures and resuscitation in the emergency department: A review of the literature. Journal of Emergency Nursing 31(1):58–72; quiz 119.

National Association of Emergency Medical Technicians. 2000a. Family-Centered Prehospital Care: Partnering with Families to Improve Care. Fact Sheet. Washington, DC: National Association of Emergency Medical Technicians.

National Association of Emergency Medical Technicians. 2000b. Guidelines for Providing Family-Centered Prehospital Care. Rockville, MD: HRSA.

National Cancer Institute and Society for Pediatric Radiology. 2002. Radiation and Pediatric Computed Technology. Rockville, MD: National Cancer Institute.

NHTSA (National Highway Traffic Safety Administration). 2002. Patient Safety in Emergency Medical Services. Washington, DC: NHTSA.

Null J. 2006. Hyperthermia Deaths of Children in Hot Vehicles. Unpublished report. [Online]. Available: http://funnel.sfsu.edu:16080/courses/metr100.2/null%20hyperthermia.ppt [accessed March 2006].

O’Brien MM, Creamer KM, Hill EE, Welham J. 2002. Tolerance of family presence during pediatric cardiopulmonary resuscitation: A snapshot of military and civilian pediatricians, nurses, and residents. Pediatric Emergency Care 18(6):409–413.

O’Connor RE, Slovis CM, Hunt RC, Pirrallo RG, Savre MR. 2002. Eliminating errors in emergency medical services: Realities and recommendations. Prehospital Emergency Care 6(1):107–113.

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
×

Oren E, Shaffer ER, Guglielmo BJ. 2003. Impact of emerging technologies on medication errors and adverse drug events. American Journal of Health-System Pharmacy 60(14):1447–1458.

Pence K. 2000. Pediatric design: Beyond big bird murals—design perspectives—design options for pediatric hospitals and clinics. Healthcare Review.

Physician Insurers Association of America. 1993. Medication Error Study. Washington, DC: Physician Insurers Association of America.

Rapkin K. 1999. Pediatric “off-label” prescribing: What every APN should know. The Internet Journal of Advanced Nurse Practice 3(1).

Reves JG. 2003. “Smart pump” technology reduces errors. Anesthesia Patient Safety Foundation 18(1).

Reznek M, Harter P, Krummel T. 2002. Virtual reality and simulation: Training the future emergency physician. Academic Emergency Medicine 9(1):78–87.

Risser DT, Rice MM, Salisbury ML, Simon R, Jay GD, Berns SD. 1999. The potential for improved teamwork to reduce medical errors in the emergency department. The MedTeams Research Consortium. Annals of Emergency Medicine 34(3):373–383.

Sacchetti A, Lichenstein R, Carraccio CA, Harris RH. 1996. Family member presence during pediatric emergency department procedures. Pediatric Emergency Care 12(4):268–271.

Sacchetti A, Paston C, Carraccio C. 2005. Family members do not disrupt care when present during invasive procedures. Academic Emergency Medicine 12(5):477–479.

Salisbury ML. 2005. *LLINK Upload: All Abstracts. Patient Safety Award Submissions, 2004. Falls Church, VA: Department of Defense Patient Safety Program.

Samson RA, Berg RA, Bingham R. 2003. Use of automated external defibrillators for children: An update––an advisory statement from the Pediatric Advanced Life Support Task Force, International Liaison Committee on Resuscitation. Pediatrics 112(1 Pt. 1):163–168.

Saunders RP, Abraham MR, Crosby MJ, Thomas K, Edwards WH. 2003. Evaluation and development of potentially better practices for improving family-centered care in neonatal intensive care units. Pediatrics 111(4):e437–e499.

Schenkel S. 2000. Promoting patient safety and preventing medical error in emergency departments. Academic Emergency Medicine 7(11):1204–1222.

Schwarz A. 2006. Shock. Emedicine. [Online]. Available: http://www.emedicine.com/PED/topic3047.htm [accessed March 2006].

Selbst SM, Fein JA, Osterhoudt K, Ho W. 1999. Medication errors in a pediatric emergency department. Pediatric Emergency Care 15(1):1–4.

Selbst SM, Levine S, Mull C, Bradford K, Friedman M. 2004. Preventing medical errors in pediatric emergency medicine. Pediatric Emergency Care 20(10):702–709.

Shapiro MJ, Morey JC, Small SD, Langford V, Kaylor CJ, Jagminas L, Suner S, Salisbury ML, Simon R, Jay GD. 2004. Simulation based teamwork training for emergency department staff: Does it improve clinical team performance when added to an existing didactic teamwork curriculum? Quality & Safety in Health Care 13(6):417–421.

Shiffman RN, Spooner AS, Kwiatkowski K, Flatley Brennan P. 2001. Information technology for children’s health and health care: Report on the information technology in children’s health care expert meeting, September 21–22, 2000. Journal of the American Medical Informatics Association 8(6):546–551.

Slonim AD, LaFleur BJ, Ahmed W, Joseph JG. 2003. Hospital-reported medical errors in children. Pediatrics 111(3):617–621.

Smith-Coggins R, Rosekind MR, Buccino KR, Dinges DF, Moser RP. 1997. Rotating shiftwork schedules: Can we enhance physician adaptation to night shifts? Academic Emergency Medicine 4(10):951–961.

Sprague L. 1999. Reducing Medical Error: Can You Be as Safe in a Hospital as You Are in a Jet? (Issue Brief No. 740). Washington, DC: National Health Policy Forum.

Suggested Citation:"5 Improving the Quality of Pediatric Emergency Care." Institute of Medicine. 2007. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. doi: 10.17226/11655.
×

Stiell A, Forster AJ, Stiell IG, van Walraven C. 2003. Prevalence of information gaps in the emergency department and the effect on patient outcomes. Canadian Medical Association Journal 169(10):1023–1028.

Tanzi E, Silverberg N. 2005, June 14. Meningococcemia. Emedicine. [Online]. Available: http://www.emedicine.com/DERM/topic261.htm [accessed January 2006].

Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ, Howard KM, Weiler PC, Brennan TA. 2000. Incidence and types of adverse events and negligent care in Utah and Colorado. Medical Care 38(3):261–271.

Trautlein JJ, Lambert RL, Miller J. 1984. Malpractice in the emergency department: Review of 200 cases. Annals of Emergency Medicine 13(9 Pt. 1):709–711.

University of Michigan Health System. 2005. Pediatric Human Patient Simulator. [Online]. Available: http://www.med.umich.edu/em/children/edu/pedshumansim.htm [accessed January 25, 2006].

Vinen J. 2000. Incident monitoring in emergency departments: An Australian model. Academic Emergency Medicine 7(11):1290–1297.

Walsh-Kelly CM, Melzer-Lange MD, Hennes HM, Lye P, Hegenbarth M, Sty J, Starshak R. 1995. Clinical impact of radiograph misinterpretation in a pediatric ED and the effect of physician training level. American Journal of Emergency Medicine 13(3):262–264.

Walsh-Kelly CM, Hennes HM, Melzer-Lange MD. 1997. False-positive preliminary radiograph interpretations in a pediatric emergency department: Clinical and economic impact. American Journal of Emergency Medicine 15(4):354–356.

Weingart SN, Wilson RM, Gibberd RW, Harrison B. 2000. Epidemiology of medical error. British Medical Journal 320(7237):774–777.

Weinger MB, Ancoli-Israel S. 2002. Sleep deprivation and clinical performance. Journal of the American Medical Association 287(8):955–957.

Weiss SJ, Derlet R, Arndahl J, Ernst AA, Richards J, Fernandez-Frackelton M, Schwab R, Stair TO, Vicellio P, Levy D, Brautigan M, Johnson A, Nick TG, Fernandez-Frankelton M. 2004. Estimating the degree of emergency department overcrowding in academic medical centers: Results of the national ED overcrowding study (NEDOCS). Academic Emergency Medicine 11(4):408.

White AA, Wright SW, Blanco R, Lemonds B, Sisco J, Bledsoe S, Irwin C, Isenhour J, Pichert JW. 2004. Cause-and-effect analysis of risk management files to assess patient care in the emergency department. Academic Emergency Medicine 11(10):1035–1041.

Wilson KM, Klein JD. 2000. Adolescents who use the emergency department as their usual source of care. Archives of Pediatrics & Adolescent Medicine 154(4):361–365.

Wolfer J, Gaynard L, Goldberger J, Laidley LN, Thompson R. 1998. An experimental evaluation of a model child life program. Child Health Care 16(4):244–254.

Wolfram RW, Turner ED. 1996. Effects of parental presence during children’s venipuncture. Academic Emergency Medicine 3(1):58–64.

Wolfram RW, Turner ED, Philput C. 1997. Effects of parental presence during young children’s venipuncture. Pediatric Emergency Care 13(5):325–328.

Woodward GA, Fleegler EW. 2000. Should parents accompany pediatric interfacility ground ambulance transports? The parent’s perspective. Pediatric Emergency Care 16(6):383–390.

Woodward GA, Fleegler EW. 2001. Should parents accompany pediatric interfacility ground ambulance transports? Results of a national survey of pediatric transport team managers. Pediatric Emergency Care 17(1):22–27.

Yee LY. 2005. AB 775 Fact Sheet. [Online]. Available: http://www.anacalifornia.org/B%20775%20Fact%20Sheet.pdf [accessed January 2006].

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Next: 6 Improving Emergency Preparedness and Response for Children Involved in Disasters »
Emergency Care for Children: Growing Pains Get This Book
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Children represent a special challenge for emergency care providers, because they have unique medical needs in comparison to adults. For decades, policy makers and providers have recognized the special needs of children, but the system has been slow to develop an adequate response to their needs. This is in part due to inadequacies within the broader emergency care system. Emergency Care for Children examines the challenges associated with the provision of emergency services to children and families and evaluates progress since the publication of the Institute of Medicine report Emergency Medical Services for Children (1993), the first comprehensive look at pediatric emergency care in the United States. This new book offers an analysis of:

• The role of pediatric emergency services as an integrated component of the overall health system.

• System-wide pediatric emergency care planning, preparedness, coordination, and funding.

• Pediatric training in professional education.

• Research in pediatric emergency care.

Emergency Care for Children is one of three books in the Future of Emergency Care series. This book will be of particular interest to emergency health care providers, professional organizations, and policy makers looking to address the pediatric deficiencies within their emergency care systems.

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