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Is Your Trauma Center Peds Ready?

      If a 1-year-old child with a viral illness presents to a community emergency department in a remote or rural area, chances are that they will still receive appropriate care for their condition, even if that emergency department rarely cares for children. But what if that 1-year-old child has instead been critically injured in a motor vehicle crash? Will their needs be met? Will the team who typically cares for adults recognize altered mental status in the young, nonverbal child? Will the department have a pediatric intraosseous device to use to provide life-saving fluids or blood if intravenous access attempts are unsuccessful? Will the nurse who must draw up weight-based medications during resuscitation have access to the necessary tools to help prevent the medication errors that can be so easy to make in stressful, unexpected situations, especially when caring for patients who are much smaller than the patients typically treated?
      The purpose of this editorial is to update readers regarding the results of some of the most recent data regarding the links between pediatric readiness and pediatric morbidity and mortality in United States emergency departments. A secondary goal is to introduce the readers to some of the major resources and tools available thanks to the National Pediatric Readiness Project (NPRP). Taking advantage of these resources can not only improve an emergency department’s readiness to care for ill and injured children, but can also help prepare an emergency department for regulatory and accreditation visits.

      National Pediatric Readiness Quality Initiative. About us. Accessed November 15, 2021. https://sites.utexas.edu/nprqi/home/about-nprqi/

      Linking Pediatric Readiness to Pediatric Outcomes: What the Data Tell Us

      Being prepared for pediatric emergencies can be very challenging when you have very limited exposure to pediatric patients. Nevertheless, emergency departments and emergency professionals have both a professional and ethical duty to be prepared to deliver life- and limb-saving care to pediatric patients just as they do for adults.

      Snow S, Stone E; ENA Position Statement Committee. The emergency nurse's role in supporting pediatric readiness in the emergency department. Published 2019. Accessed October 15, 2021. https://enau.ena.org/Users/ChefViewCatalog.aspx?Criteria=23

      The reality is that the vast majority of critically ill and injured children are initially brought to community emergency departments for stabilizing care rather than to a facility with pediatric specialization or expertise.

      Emergency Medical Services for Children Innovation and Improvement Center. Accessed November 15, 2021. https://emscimprovement.center/

      This underscores the importance of having standardized national guidelines for pediatric preparedness. A study published in 2019 by Ames et al
      • Ames S.G.
      • Davis B.S.
      • Marin J.R.
      • et al.
      Emergency department pediatric readiness and mortality in critically ill children. Pediatrics. 2019;144(3):e20190568.
      sought to link pediatric preparedness to outcomes. This study was based on the 2013 NPRP Assessment and examined outcomes for over 20 000 critically ill children who presented to 426 US hospitals. Results confirmed that after adjusting for age, chronic complex conditions, and illness severity, presentation to a hospital in the highest NPRP pediatric readiness quartile was associated with decreased odds of in-hospital mortality (adjusted odds ratio compared with the lowest quartile: 0.25; 95% confidence interval: 0.18-0.37; P <.001).
      Injury remains the leading cause of death for children age 1 to 18 years, yet the initial care of most injured children also takes place in emergency departments primarily designed and equipped to treat adults.

      Genovese TJ, Roberts-Santana C, Wills H. Pediatric trauma readiness: a trauma-specific assessment to complement the National Pediatric Readiness Project. Pediatr Emerg Care. Accessed November 15, 2021. doi: 10.1097/PEC.0000000000002144

      The results of recent studies have shown that even trauma centers are inconsistent in their level of readiness to care for children.
      • Remick K.
      • Gaines B.
      • Ely M.
      • Richards R.
      • Fendya D.
      • Edgerton E.
      Pediatric emergency department readiness among US trauma hospitals.
      ,
      • Newgard C.D.
      • Lin A.
      • Olson L.M.
      • et al.
      Evaluation of emergency department pediatric readiness and outcomes among US trauma centers.
      For example, while the majority of trauma centers have a tool to use for precalculated pediatric drug dosing, many lack other important parameters such as recording pediatric weights in kilograms only and the presence of a quality improvement process that includes pediatric-specific metrics.
      • Remick K.
      • Gaines B.
      • Ely M.
      • Richards R.
      • Fendya D.
      • Edgerton E.
      Pediatric emergency department readiness among US trauma hospitals.
      A recently published study of injured children brought to 832 emergency departments in US trauma centers was the first to dig deeper and evaluate the association between pediatric readiness of emergency departments verified as trauma centers (as per the 2013 NPRP nationwide assessment), in-hospital mortality, and in-hospital complications.
      • Newgard C.D.
      • Lin A.
      • Olson L.M.
      • et al.
      Evaluation of emergency department pediatric readiness and outcomes among US trauma centers.
      In the study of over 372 000 injured children, receiving initial care in an emergency department that had a pediatric readiness score within the highest quartile of readiness was associated with 42% lower odds of death. The authors concluded that if all the children included in the study had been treated in emergency departments in the highest quartile of readiness, an additional 126 lives (95% confidence interval 97-154 lives) might have been saved in each of the 6 years for which data were collected.
      • Newgard C.D.
      • Lin A.
      • Olson L.M.
      • et al.
      Evaluation of emergency department pediatric readiness and outcomes among US trauma centers.
      That is over 700 children’s lives that might have been saved if the trauma centers had all invested the time and resources required to better prepare for stabilizing pediatric emergency care! On the basis of the results of the 2013 NPRP national assessment survey, we learned that many US emergency departments were not adequately prepared to quickly stabilize critically ill or injured children.
      • Remick K.E.
      The time is now: uncovering the value of pediatric readiness in emergency departments.
      Now we also know that just because an emergency department is a verified trauma center doesn’t mean that it is adequately prepared to stabilize critically ill and injured children. Not surprisingly, we’ve learned through our professional networks that leaders in several states are considering incorporating the NPRP assessment or significant NPRP criteria as they revise their trauma rules used for verification.
      Even in the absence of pediatric specialists, general or mixed age emergency departments, including low patient volume departments in remote or rural areas, can help ensure more equitable care for ill and injured children by taking advantage of the many resources that have been created by the NPRP. Recommended measures include establishing a nurse and physician pediatric emergency care coordinator (PECC), being proactive in providing pediatric emergency nursing education, stocking specific, potentially life-saving pediatric equipment, and participating in pediatric-specific quality improvement initiatives.
      • Remick K.
      • Gausche-Hill M.
      • Joseph M.M.
      • et al.
      Pediatric readiness in the emergency department.
      What role can emergency nurses play? Perhaps one of the most important ones. The presence of a PECC has been identified as the single most important factor that influences the readiness of any emergency department that cares for pediatric patients.
      • Abulebda K.
      • Lutfi R.
      • Petras E.A.
      • et al.
      Evaluation of a nurse pediatric emergency care coordinator-facilitated program on pediatric readiness and process of care in community emergency departments after collaboration with a pediatric academic medical center.
      The 2018 American Academy of Pediatrics Committee on Pediatric Emergency Medicine and Section on Surgery, American College of Emergency Physicians Pediatric Emergency Medicine Committee, and Emergency Nurses Association Pediatric Committee Joint Policy Statement, “Pediatric Readiness in the Emergency Department,”
      • Remick K.
      • Gausche-Hill M.
      • Joseph M.M.
      • et al.
      Pediatric readiness in the emergency department.
      identified the presence of 2 PECCs, one a physician and one a nurse, as central to the readiness of any emergency department that cares for children. Guidance for the recommended qualifications and responsibilities of PECCs are included in this joint statement. An Internet link for this Joint Statement can be found in the resource list for this article. Depending on an emergency department’s pediatric volume, a PECC may not require a full-time equivalent and may even be shared through formal agreements with other emergency departments.

      Navigating the NPRP Resources

      In case you have not discovered them yet or, like me, you sometimes find all the acronyms associated with the NPRP a bit confusing, let me recommend 2 valuable, free resources available to all emergency departments. The NPRP ED checklist, a tool that can be used for improving your emergency department’s pediatric preparedness, and the National Pediatric Readiness Quality Initiative platform (NPRQI) can be found at the corresponding Internet link in the reference list.

      National Pediatric Readiness Quality Initiative. About us. Accessed November 15, 2021. https://sites.utexas.edu/nprqi/home/about-nprqi/

      Emergency Medical Services for Children Innovation and Improvement Center. ED readiness checklist. Accessed October 15, 2021. https://emscimprovement.center/domains/pediatric-readiness-project/readiness-toolkit/readiness-ED-checklist/

      See the Box for additional resources. The NPRQI was created with a focus on community and rural emergency departments. It represents the implementation arm of the NPRP and is designed to allow individual emergency departments, regardless of size, to participate in larger quality improvement initiatives with evidence-based pediatric-specific metrics. Emergency departments that participate in the NPRQI can enjoy many benefits, including the following:
      • Assessment of current pediatric emergency care delivery and tracking performance over time
      • Ability to assess performance across 28 standardized pediatric quality measures (system and clinical conditions)
      • Benchmarking performance with similar hospitals
      • Optimization of care on the basis of current available resources
      • Annual reports to share with hospital/ED leadership regarding quality, patient safety, and risk mitigation
      • Fulfilling requirements for Pediatric Medical Recognition in your state/territory
      • Accreditation by state/regulatory agencies
      • Value-based care reimbursement and reporting

        National Pediatric Readiness Quality Initiative. About us. Accessed November 15, 2021. https://sites.utexas.edu/nprqi/home/about-nprqi/

      A Shout Out for Pediatric Preparedness During the Pandemic

      Being prepared for pediatric patients can be challenging, but it becomes an even greater challenge when faced with a global pandemic. I would like to give kudos to emergency departments such as the one at Boston Children’s Hospital for their excellent work to meet the unique needs of their pediatric patients and staff during the coronavirus disease 2019 (COVID-19) pandemic. The more prepared an emergency department is at usual or normal operational levels (if there is such a thing), the more prepared they will be when the unexpected occurs, whether that be a natural disaster, a school shooting, or a global pandemic. “Implementing a Novel Nursing Site Manager Role in the Pediatric Emergency Department for Patient and Staff Safety during the COVID-19 Pandemic,”
      • Schmid A.
      • Downey D.
      Implementing a novel nursing site manager role in the pediatric emergency department for patient and staff safety during the COVID-19 pandemic.
      published in this current issue of the Journal of Emergency Nursing (JEN) described the way the Boston Children’s Hospital emergency department pivoted quickly at the onset of the pandemic to meet the specialized needs of their multidisciplinary staff during this time, while ultimately also benefiting their pediatric patients.
      Many infants and young children will not tolerate a face mask and will touch everything in reach, regardless of whether they are sick or not. To put it mildly, young children rarely understand, care about, or cooperate with infection control, and during the pandemic, everyone, of every age, was suddenly a possible vector for COVID-19. Developmentally appropriate behavior as an infection control risk represented major challenges to emergency departments that cared for pediatric patients during the pandemic, when having patients wear masks and cleaning all surfaces well between patients became higher priorities for all patients (not just those on isolation) than in any other time in recent history. This emergency department, already well-prepared to care for pediatric patients in normal noncrisis operations, was able to focus their attention and resources on meeting the educational, safety-related, and psychosocial needs of their staff during this unique time. This is exceptional as many emergency departments were in full crisis mode, forgoing any quality improvement initiatives. Schmid and Downey’s
      • Schmid A.
      • Downey D.
      Implementing a novel nursing site manager role in the pediatric emergency department for patient and staff safety during the COVID-19 pandemic.
      results demonstrated an instance wherein caring for staff was also doing what was best for patients. It ultimately resulted in more effective, patient-centered, and safe patient care during an unprecedented time in health care.

      Closing Thoughts

      Widely adopted standards for stroke and ST-segment elevation myocardial infarction care have decreased morbidity and mortality for those conditions, just as the development of trauma centers has significantly reduced preventable deaths caused by injury.
      • Remick K.E.
      The time is now: uncovering the value of pediatric readiness in emergency departments.
      Unfortunately, national standards do not exist for pediatric emergency care, and pediatric preparedness among US emergency departments is uneven as a result. Because injury is the leading cause of death for children aged 1 to 18 years, increasing the pediatric readiness of our nation’s trauma centers can play a major role in the effort to improve the outcomes of injured pediatric patients. The infographic included within this editorial (Appendix), “Improve Your ED’s Readiness to Care for Children,” was developed by the Emergency Nurses Association to serve as a visual summarizing key points for emergency departments that seek to ensure that they are prepared for children regardless of how infrequently those children present for care and regardless of where they are located.

      Resources

      Tabled 1
      • Remick K, Gausche-Hill M, Joseph MM, et al. Pediatric readiness in the emergency department. J Emerg Nurs. 2019;45(1):e3-e18. Published correction appears in J Emerg Nurs. 2019;45(1):3. https://doi.org/10.1016/j.jen.2018.10.003

      Appendix

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      References

      1. National Pediatric Readiness Quality Initiative. About us. Accessed November 15, 2021. https://sites.utexas.edu/nprqi/home/about-nprqi/

      2. Snow S, Stone E; ENA Position Statement Committee. The emergency nurse's role in supporting pediatric readiness in the emergency department. Published 2019. Accessed October 15, 2021. https://enau.ena.org/Users/ChefViewCatalog.aspx?Criteria=23

      3. Emergency Medical Services for Children Innovation and Improvement Center. Accessed November 15, 2021. https://emscimprovement.center/

        • Ames S.G.
        • Davis B.S.
        • Marin J.R.
        • et al.
        Emergency department pediatric readiness and mortality in critically ill children. Pediatrics. 2019;144(3):e20190568.
        Pediatrics. 2020; 145e20200542https://doi.org/10.1542/peds.2020-0542
      4. Genovese TJ, Roberts-Santana C, Wills H. Pediatric trauma readiness: a trauma-specific assessment to complement the National Pediatric Readiness Project. Pediatr Emerg Care. Accessed November 15, 2021. doi: 10.1097/PEC.0000000000002144

        • Remick K.
        • Gaines B.
        • Ely M.
        • Richards R.
        • Fendya D.
        • Edgerton E.
        Pediatric emergency department readiness among US trauma hospitals.
        J Trauma Acute Care Surg. 2019; 86: 803-809https://doi.org/10.1097/TA.0000000000002172
        • Newgard C.D.
        • Lin A.
        • Olson L.M.
        • et al.
        Evaluation of emergency department pediatric readiness and outcomes among US trauma centers.
        JAMA Pediatr. 2021; 175: 947-956https://doi.org/10.1001/jamapediatrics.2021.1319
        • Remick K.E.
        The time is now: uncovering the value of pediatric readiness in emergency departments.
        Pediatrics. 2019; 144e20191636https://doi.org/10.1542/peds.2019-1636
        • Remick K.
        • Gausche-Hill M.
        • Joseph M.M.
        • et al.
        Pediatric readiness in the emergency department.
        J Emerg Nurs. 2019; 45: e3-e18https://doi.org/10.1016/j.jen.2018.10.003
        • Abulebda K.
        • Lutfi R.
        • Petras E.A.
        • et al.
        Evaluation of a nurse pediatric emergency care coordinator-facilitated program on pediatric readiness and process of care in community emergency departments after collaboration with a pediatric academic medical center.
        J Emerg Nurs. 2021; 47: 167-180https://doi.org/10.1016/j.jen.2020.06.006
      5. Emergency Medical Services for Children Innovation and Improvement Center. ED readiness checklist. Accessed October 15, 2021. https://emscimprovement.center/domains/pediatric-readiness-project/readiness-toolkit/readiness-ED-checklist/

        • Schmid A.
        • Downey D.
        Implementing a novel nursing site manager role in the pediatric emergency department for patient and staff safety during the COVID-19 pandemic.
        J Emerg Nurs. 2022; 48: 13-21

      Biography

      Elizabeth L. Stone, Member, North Carolina ENA Cardinal Chapter, is a Co-section Editor, Pediatric Update, 2021 ENA Liaison to the American Academy of Pediatrics’ Committee on Pediatric Emergency Medicine (COPEM), Itasca, IL; 2021 Chair, ENA Position Statement Committee, Schaumburg, IL; 2021 Advisory Board Member, Emergency Medical Services for Children Innovation and Improvement Center (EIIC), Austin, TX; Clinical Assistant Professor, School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC; and a Pediatric Emergency Nurse, WakeMed Health and Hospitals, Raleigh, NC. Twitter: @ElizStone70. ORCID identifier: https://orcid.org/0000-0003-1144-5681.