Patient Flow E-Newsletter
Volume 4, Issue 2
May/June 2007
Special Focus Issue-Putting Kids First

Perspectives
Leadership Needed: Hospitals Must Work Together to Improve Pediatric Emergency Care

Although any emergency medical situation can be challenging, nearly every emergency physician understands that cases involving children can be amongst the trickiest. Children are not simply small adults and certainly cannot be treated as such. They are typically more fearful than adult patients and their treatment often requires proficiency in the use of smaller-sized equipment, knowledge of weight-based medication administration, and familiarity with the nuances of child development from infancy through adolescence.

While we know that treating kids is a unique skill - and that children are heavy users of the nation's emergency medical system - most emergency care systems are not prepared to manage the full range of pediatric emergencies that they might face. An Institute of Medicine (IOM) study released last year, "The Future of Emergency Medicine in the United States Health System," reported that even though children make up 27 percent of all emergency department (ED) visits in this country, just 6 percent of America's EDs are fully equipped to treat every child who comes through the door. Many hospitals lack the equipment, depth of supplies or personnel resources necessary to initiate the care and stabilization of a seriously ill or injured child.

Communities across the country are already grappling with how to coordinate emergency care for kids. They realize that while providing consistent, quality pediatric emergency care may not be an easy goal to achieve, it is a realistic and necessary one. Having spent my career in emergency and prehospital pediatrics, I believe the solution lies in a regionalized approach to service delivery, the development of standards for pediatric emergency care and healthcare leaders willing to advocate on behalf of the needs of children to help improve the systems that care for them.

With the relative scarcity of widely dispersed resources, combined with a workforce concentration of pediatric emergency specialists skewed towards population hubs and academic centers, emergency services for children are ideally suited for delivery through regionalization. A coordinated, regionalized approach allows communities which do not have proximate access to specialized children's services, or hospitals with fully-capable pediatric EDs, to expediently triage and transfer, as needed, pediatric patients to the most appropriate level of care. This may require bypassing closer, local EDs in order to transport children to more distant facilities in an exclusive model where care for the most seriously ill or injured children is limited to a restricted number of centers. This model has been successfully implemented in many parts of the country in the provision of pediatric trauma care utilizing a trauma center verification and designation system.

However, the application of such an approach to medical and non-trauma pediatric emergency care is more complex and will require a great deal of collaborative effort in order to develop. Communities and the EDs that serve them must therefore critically examine the emergency medical care systems in which they operate - from the pre-hospital capabilities through ED preparedness to in-house critical care expertise - in order to assess and accurately determine which facilities in a given catchment area are fully capable of taking care of kids in an emergency. With that knowledge, hospital and regional resources can be coordinated to provide the most appropriate and timely pediatric emergency services for a given community.

In addition to regional solutions, America needs national standards for pediatric emergency care. Without an objectively determined consensus on appropriate pediatric readiness standards for EDs across the nation, there will always be disparities in the quality of care available to children. Most parents expect, and probably assume, that a certain level of care will be provided when walking into an ED with their child. However, until a "floor" of preparedness and treatment expectation is established upon which escalating capabilities can be built, uniformity in the emergency care of children will remain subject to geography and the sophistication of regionalized approaches to obviate shortcomings. Further, in national policy development debate and dialogue, the unique needs of children cannot be overlooked and cannot be an afterthought; pediatric emergency care experts must be at the table and included as primary thought leaders and participants.

If we are ever going to see a coordinated system of regionalized, high-quality care for pediatric emergencies with national standards to guide us, we are going to need to do a better job of being champions for kids. Identifying local leaders who are committed to pediatric readiness in every ED - and who can bring stakeholders together to discuss planning approaches - is critical to improving pediatric care. Without such leadership, we will never be able to encourage the large-scale systemic changes that are needed to ensure that children receive the best emergency care possible. Consistent with the IOM recommendations, I firmly believe that every hospital in this nation needs to identify accountable ED leaders responsible for assessing and developing processes to improve emergency care for kids; this needs to occur for both nurses and physicians, and in liaison with pre-hospital professionals. Only through strong leadership can small improvements grow and develop into a healthy, well-coordinated system of care.

All of us say that children are our future, our most precious and valuable resource, which is why we must work together to be able to confidently offer them the highest quality emergency care in the world. Preparing for the challenges of pediatric emergencies is not beyond the capabilities of our nation's emergency systems. It simply requires hospitals and EDs to recognize their shortcomings, assess their capabilities and work together to establish a safe and effective pediatric emergency care continuum. Failure to act now will almost assuredly result in widening care disparities for the most vulnerable members of our society.

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Joseph L. Wright, M.D., M.P.H.
Executive Director, Child Health Advocacy Institute
Professor of Pediatrics and Emergency Medicine
Children's National Medical Center
Washington, D.C.