DALLAS – Emergency departments have substantially improved their readiness to receive pediatric patients since a 2009 multispecialty call to action was triggered by documented major deficiencies in preparedness, the results of a comprehensive new survey indicate.
"We’ve seen significant improvement in all ED patient volume classes in terms of median pediatric readiness scores. The data are pretty exciting. It says we’re moving in the right direction," Dr. Marianne Gausche-Hill said in presenting the survey findings at the annual meeting of the Society for Academic Emergency Medicine.
The key outcome measure in the national survey was a weighted ED pediatric readiness score based upon the extent to which an ED was compliant with the major recommendations of the 2009 joint American Academy of Pediatrics/American College of Emergency Physicians/Emergency Nurses Association guidelines for the care of children in EDs (Pediatrics 2009;124:1233-44.
The guidelines lay out in concrete terms what ED pediatric readiness entails in terms of specialized equipment, medications, policies and protocols, safety issues, staff, and professional education.
Lack of recommended equipment needed to handle pediatric emergencies, such as laryngeal mask airways for children, was a major problem identified in the first survey. Indeed, at that time only 6% of EDs had all the recommended equipment and supplies. In contrast, the new survey showed that today EDs have a median of 91% of all recommended equipment; in higher-volume EDs that figure rises to virtually 100%, according to Dr. Gausche-Hill.
Overall, the median ED pediatric readiness score in the new survey was 69 on a 0-100 scale, up sharply from a median of 55 in an earlier nationwide survey, conducted in 2003 and published in 2007, for which Dr. Gausche-Hill also was the lead author (Pediatrics 2007;120:1229-37).
A test score of 55 gets a big red F in any classroom not grading on the curve. So this disappointing performance was an impetus for the 2009 joint guidelines, of which Dr. Gausche-Hill was a lead coauthor. The guidelines were endorsed by nearly two dozen organizations, including the American Academy of Family Physicians and the American College of Surgeons.
A theme emphasized in the joint guidelines is that all EDs need to be prepared to meet the unique needs of pediatric patients; 90% of all ED visits by patients under age 15 are to nonchildren’s hospitals, and roughly one-third of these visits are to EDs in rural and remote areas, which generally scored poorly in the initial national survey.
Another impetus for issuing the guidelines was recognition that pediatric ED visits are increasing even as the number of EDs nationwide is declining, worsening overcrowding, explained Dr. Gausche-Hill, professor of emergency medicine at the University of California, Los Angeles, and director of emergency medical services at Harbor-UCLA Medical Center.
She and her coinvestigators in the large coalition known as the National Pediatric Readiness Project sent the survey to more than 5,000 U.S. EDs. The response rate was an impressive 83%, despite the fact that the 55-question survey addressed 189 items and took a full hour to complete. Dr. Gausche-Hill attributed this remarkable response rate to on-site advocates’ passion for improved ED pediatric preparedness. Another factor: survey respondents received immediate feedback about how their hospital’s ED score compared with the average score of other hospitals with similar patient volume, as well as information about the top three things their hospital needs to do to reach a preparedness score of at least 80, which is the coalition’s short-term goal.
Dr. Marianne Gausche-Hill
In analyzing the ED scores, the single most effective way most hospitals can improve their ED pediatric readiness score is for the hospital ED medical director to appoint a physician and/or a nurse pediatric emergency care coordinator. Hospitals with a coordinator scored higher, and the 42% of hospitals with both a physician and a nurse pediatric emergency care coordinator scored highest of all. Hospitals with at least one pediatric emergency care coordinator were more than fivefold more likely to have a quality improvement plan in place for ED pediatric patients, as recommended in a 2006 Institute of Medicine report that described the nation’s ED pediatric readiness as uneven.
In the new survey, 82% of EDs reported one or more barriers to compliance with the pediatric readiness guidelines. These barriers will be the focus of future quality improvement initiatives.
What’s next? Dr. Gausche-Hill said the coalition is reaching out to health care corporate groups in an effort to convince them to make changes in their hospitals.
"We’ve seen the Hospital Corporation of America make a huge initiative and change their average readiness score from 66 to 91 in the intervention hospitals. Also, Kaiser Permanente has initiated a readiness initiative," she said.