Follow new pediatric guidelines or risk inappropriate care, liability
Follow new pediatric guidelines or risk inappropriate care, liability
Many emergency departments are not in compliance
A child comes to the ED with abdominal pain and bruises on the legs and buttocks. A CT scan of the abdomen is negative for appendicitis, and his white blood cell count is normal. Child abuse is suspected immediately, and the boy is taken into protective custody.
The child is later found to have Henoch-Schonlein purpura, which is seen only in children between 4 and 10 years old, says Barbara Weintraub, RN, MPH, MSN, pediatric critical care nurse practitioner at Northwest Community Hospital in Arlington Heights, IL. "These children can go on to have nephritis, nephrotic syndrome, and renal failure if the condition is not recognized and treated appropriately," she adds.
To avoid scenarios like this, you’ll need to comply with new guidelines for pediatric care. Care of Children in the Emergency Department: Guidelines for Preparedness was jointly published by the Dallas-based American College of Emergency Physicians (ACEP) and the Elk Grove Village, IL-based American Academy of Pediatrics (AAP). (For information on obtaining a complete copy of the guidelines, see "Resources," at the end of this article.)
If you don’t follow the guidelines, you face potential risk management problems, warns Marianne Gausche-Hill, MD, FACEP, FAAP, director of emergency medical services at Harbor-University of California at Los Angeles Medical Center in Torrance. "Certainly, not abiding by published guidelines creates potential liability," Gausche-Hill says. "For example, there would be no defense for not having the equipment necessary to care for children of all ages."
When national organizations publish guidelines, they tend to be interpreted in legal circles as standards, explains Weintraub. "You need to sit up and take notice of these guidelines," she urges. "Unfortunately, quality-of-care issues become litigation issues when the outcome is not good."
Following the guidelines will improve patient satisfaction and decrease poor outcomes, adds Weintraub. "This can help ensure consistent, quality, family- centered care for our smallest, most vulnerable patients," she says. "Parents expect that the care we give them will be specific to their child’s needs, and this is often not the case today."
Even if there is no adverse outcome, parents will not be happy if pediatric care is lacking in your ED, stresses Weintraub. She offers the following example: An 11-year-old boy presents with chest tightness. "This is a red flag for cardiac disease in the adult world, so he receives a chest X-ray and an ECG, both of which are read as normal, and the child is discharged," she says.
However, chest tightness in a child is more commonly respiratory-related, says Weintraub. "When the child returns later that afternoon to a pediatric ED with continued chest tightness, it is recognized that although wheezing couldn’t be heard, it was most likely due to decreased air entry," she says.
He receives an albuterol nebulizer treatment, with immediate relief of the chest tightness. "Although the parents are delighted that their child is better, they perceive that they wouldn’t have needed two visits had the ED staff at the first visit known kids better," she says.
Here are ways to comply with the guidelines:
— Find out if transport services are trained adequately.
Identifying the transport services with pediatric training is essential before you transfer seriously/ critically ill and injured children, warns Nancy Eckle, RN, MSN, program manager for emergency services at Children’s Hospital in Columbus, OH. You may be tempted to send a child with the first available transport service, she explains. "However, if the transport team is not trained in the care of children, changes in condition and needed interventions may not be recognized," Eckle says.
When assessing the team’s training, Eckle recommends asking the following questions:
- What pediatric competency has been established for the team members?
- What is the experience/background of the team?
- Do team members have pediatric specific training and ongoing education?
- What pediatric courses are taken by the team?
- Are team members all verified in pediatric life support courses?
— Designate a "coordinator" for pediatric emergency care.
The guidelines recommend that you have physician and nursing coordinators who will ensure that appropriate policies and procedures are in place, equipment and supplies appropriate for children are available, and a quality or performance improvement plan is in place. (See "Guidelines for administration and coordination of the ED for the care of children" and "Facility recognition criteria for the emergency department approved for pediatrics," in this issue.)
The "coordinator" role can be a separate position or it can be an added role for a nurse manager or medical director, says Gausche-Hill. (See "Job description for coordinator of pediatric emergency services," in this issue.) "These individuals ensure that the recommendations made in the guidelines would be appropriately addressed in the ED’s policies and procedures manual," she explains.
This recommendation, when followed, ensures that there is an identified person with a pediatric focus and expertise who can evaluate care issues, says Eckle. "That person is focused on the needs of pediatric patients in the ED, including staff education needs, equipment needs, and quality improvement," she adds.
At Northwest Community Hospital, the nursing coordinator recommends equipment and training needs, conducts inservices, and monitors pediatric quality improvement activities, Weintraub reports. "This individual ensures that the nursing care received by a pediatric patient anywhere within the emergency care continuum is research-based and family-centered," she says.
— Ensure that all staff members have appropriate pediatric training.
All emergency care providers must be able to evaluate and intervene for a child with an emergent condition, stresses Eckle. "Not being able to recognize an emergency condition and take the appropriate steps to stabilize the patient can cost the child his/her life," she warns. Age-specific competencies should include neonates, infants, children, and adolescents, she urges. (See table, below.)
| Guidelines for Physicians and Other Practitioners Staffing the ED | |
| • | Physicians staffing the ED have the necessary skill, knowledge, and training to provide emergency evaluation and treatment of children of all ages who may be brought to the ED, consistent with the services provided by the hospital. |
| • | Nurses and other practitioners have the necessary skill, knowledge, and training to provide nursing care to children of all ages who may be brought to the ED, consistent with the services offered by the hospital. |
| • | Competency evaluations completed by the staff are age-specific and include neonates, infants, children, and adolescents. |
| Source: American College of Emergency Physicians and the American Academy of Pediatrics. Excerpt of Care of Children in the Emergency Department: Guidelines for Preparedness. Ann Emerg Med 2001; 37:423-427. | |
A report from Illinois Emergency Medical Services for Children (EMS-C) found that while 91% of ED physicians had taken an Advanced Cardiac Life Support (ACLS) course for adult resuscitation, only 63% had completed a pediatric equivalent such as Pediatric Advanced Life Support (PALS) or Advanced Pediatric Life Support (APLS). Similarly, 90% of ED nurses had completed an ACLS course, but only 35% had completed a formal pediatric resuscitation course.1 EMS-C is a Washington, DC-based national program to ensure that state-of-the-art emergency medical care is available for ill or injured children.
Weintraub recommends the Emergency Nursing Pediatric Course (ENPC) from the Des Plaines, IL-based Emergency Nurses Association as the "baseline" course for nurses. "It covers assessment, triage, and specific pediatric emergency conditions, as well as treatment of these conditions," she says. "It also addresses grieving, transport of ill children, trauma, and child abuse." (See "Resources," at the end of this article, for information about pediatric courses.) Weintraub also recommends that ED nurses take PALS, but notes that this course is more focused on the resuscitative aspect of pediatric care.
Research shows that in the vast majority of pediatric cases, if the assessment and treatment follow established guidelines, resuscitative measures will not be needed, she says. "Research also indicates that when children do require full resuscitation, the outcomes are even more dismal than for adults," she adds.2
All ED physicians should be PALS-certified and also should consider a neonatal resuscitation program (NRP) certification, offered jointly by the AAP and the Dallas-based American Heart Association, adds Weintraub. At Northwest’s ED, nurses are required to take ENPC, PALS, the Emergency Nurses Association’s Trauma Nursing Core Course (TNCC), and 20 hours of pediatric-specific continuing education per year, says Weintraub. "We also offer a pediatric-specific IV skills lecture," she notes. "Even veteran ED nurses have indicated that this lecture has taught them new strategies."
References
1. Illinois Department of Public Health. Illinois EMSC Needs Assessment Summary 1994-1995. Springfield, IL; 1996.
2. American College of Emergency Physicians and the American Academy of Pediatrics. Care of children in the emergency department: guidelines for preparedness. Ann Emerg Med 2001; 37:423-427.
Resources
The American College of Emergency Physicians (ACEP)/ American Academy of Pediatrics (AAP) policy statement, "Care of Children in the Emergency Department: Guidelines for Preparedness" (published in the April 2001 issues of Pediatrics and Annals of Emergency Medicine), is among the AAP policy statements that can be downloaded free from the web site: www.aap.org. (Click on "Policy Statements." Under heading "C," click on "Care of children in the emergency department: Guidelines for preparedness.") The policy statement also can be purchased for $1.95 per copy, including shipping and handling. To order, contact:
• AAP Publications Department, P.O. Box 747, Elk Grove Village, IL 60009-0747. Telephone: (800) 433-9016 Ext. 4776 or (847) 981-7924. Fax: (847) 228-1281. E-mail: [email protected].
The Emergency Nursing Pediatric Course (ENPC) is a 16-hour course. For a list of ENPC courses in your area, go to the ENA web site (www.ena.org), click consecutively on "Programs and Meetings," "Continuing Education," and "ENPC Schedule." For more information, contact:
• ENA, Department of Trauma and Pediatric Services, 915 Lee St., Des Plaines, IL 60016. Telephone: (800) 900-9659. E-mail: [email protected].
A Pediatric Advanced Life Support Course (PALS) is offered by the American Heart Association (AHA). The course focuses on advanced medical assessment and interventions used to treat pediatric victims of respiratory and/or cardiovascular emergency and stroke.
• To contact AHA staff at a local level, call (888) 352-3824 or send an e-mail to [email protected]. For more information about the course, go to the AHA site for Emergency Cardiovascular Care Programs (www.cpr-ecc.org). Click on "About Courses," "Healthcare Provider Course Descriptions," and then "PALS provider."
The Advanced Pediatric Life Support Course (APLS) is offered by ACEP and the AAP. To find a course in your area, go to the AAP web site (www.aap.org). Click consecutively on "Professional Education," "Life Support Programs," "APLS: The Pediatric Emergency Medicine Course," and then "Find an APLS Course or Course Director." Or contact:
• American Academy of Pediatrics, 141 N.W. Point Blvd., Elk Grove Village, IL 60007-1098. Telephone: (847) 434-4000 ext. 4795. Fax: (847) 228-1350. E-mail: [email protected].
• A free Pediatric Resource Kit available from Emergency Medical Services for Children covers illness and injury prevention, patient care training and safety, equipment guidelines, public policy, and special populations. The kit can be downloaded from the EMS-C web site (www.ems-c.org) by clicking on "Products and Resources" and then "EMS-C Resources." A free CD-ROM version is available by contacting EMS-C Clearinghouse at (703) 902-1203 or send an e-mail to [email protected].
For more information about the guidelines, contact:
• Nancy Eckle, RN, MSN, Emergency Services, Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205. Telephone: (614) 722-4353. Fax: (614) 722-6890. E-mail: [email protected].
• Marianne Gausche-Hill, MD, FACEP, FAAP, Harbor-UCLA Medical Center, 1000 W. Carson St., Box 21, Torrance, CA 90509. Telephone: (310) 222-3501. Fax: (310) 782-1763. E-mail: [email protected].
• Barbara Weintraub, RN, MPH, MSN, Northwest Community Hospital, 800 W. Central Road, Arlington Heights, IL 60005. Telephone: (847) 618-5432. Fax: (847) 618-4169. E-mail: [email protected].
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