Pediatric Corner
Improve care of children with special needs
When a child with severe mental retardation and cerebral palsy was brought to the ED for increased seizures, the physician was initially alarmed at the nonresponsiveness of the child. But after ED staff were able to review a summary that explained the child’s condition, the child was treated and released instead of admitted, says Anita Somplasky, RN, project coordinator for EPIC Medical Home Initiative in Rosemont, PA, which works to improve care of children with special needs. "The parent later admitted that she was so used to the child’s [nonresponsive] status that she did not think to specifically tell the physician," she adds.
This scenario underscores the importance of planning ahead to manage children with special health care needs in the ED, she emphasizes. Here are ways to improve care:
• Give parents a "portable care plan." One of the biggest frustrations that parents report is having to explain the child’s entire medical history repeatedly, says Somplasky. To address this, she developed a "portable care plan" for parents to share with ED staff. By using this tool, a parent of a child with multiple anomalies and respiratory difficulties was able to reduce the time spent in the ED, and time to admission because she didn’t have to repeat information to the triage nurse and resident, she reports. (See Medical Summary: click here.)
Somplansky adds that when a child became ill with a strep infection while on vacation, the parents had the summary with them to facilitate care. "The ED had access to all of the background on medications and chronic conditions that they needed to treat the child, so the visit was expedited," she says.
• Develop a "frequent-flyer" file. Somplasky recommends having a file of "frequent flyers" for children who are frequently in the ED and often require admission. "Again, it eliminates the need for repeating information over and over again," she says.
As a pediatric liaison nurse for the ED at Long Beach Memorial Medical Center, Valerie Lancer, RN, created a "pink file" so information is immediately available when a special-needs child presents. For every special-needs child, a face sheet lists the physician and caregiver information along with the insurance status. "It enables us to give care without delay," says Lancer. "Also, the child’s physician may be contacted to discuss treatment."
"If the child has been admitted at some point, chances are that a dictated report would be available on the computer," she adds.
The problem is that these children, although "repeat-ers" to the ED, are often treated in clinics, says Lancer. "There was no interface with other computers to give us information on the specific health problem of this child, the primary caregiver, or insurance status." Sometimes, caregivers are unable to explain the scope of the child’s medical needs and history, adds Lancer. "Many times they will say, Oh, it’s just a cold,’ yet you see a trach in place, with the child’s eyes rolled back."
Since many of these children presented when medical records were minimally staffed, the ED needed a system to allow immediate access to the records, explains Lancer. Lancer says she has spent many hours finding the needed information for each child in the file. "An advantage is that it is not necessary to make changes to the original material, since the problems remains the same, although the primary care physician may change."
"Originally, I thought we would have about 50 children in the file, yet when I resigned from the position, we had almost 600," she says. If you don’t have the history on file, Lancer suggests contacting the child’s physician instead of relying solely on the parent.
On one visit to the ED, a nurse called the ear, nose, and throat physician to get a history of a 2-year-old girl born with meconium aspiration, which was a relief for Marlene Carbullido, RN, the child’s mother and a nurse with the department of public health in Guam. "That way, I did not have to fill her in on all the treatments and surgeries she has had. I was also relieved to know that the ED nurse had access to her records as a former inpatient," she says.
• Ask for the caregiver’s input. You should listen to the history provided by the caregiver about the child’s normal breathing, behavior, or appearance, and use this in your nursing assessment to determine if an emergency actually exists, says Carbullido. She recalls taking her 1-year-old daughter to the ED after a light fixture fell on her head. "Instead of paying attention to that, the nurse/physician was more interested in her breathing pattern," she says.
Carbullido explains that her daughter, who was diagnosed with bilateral vocal cord paralysis, normally has a stridorous upper airway sound. "The physician subjected her to a needless X-ray only to find out her lungs were clear," she says. Don’t assume you know more about the child’s health condition than the caregiver, she says, adding, "You may know the textbook well enough, but the family lives with the condition daily."
Sources and resource
For more information on improving care of special needs children, contact:
• Marlene Carbullido, RN, 557 Chalan Macajna, Agana Heights, Guam 96910. E-mail: [email protected].
• Valerie Lancer, RN, Emergency Department, Long Beach Memorial Medical Center, 2801 Atlantic Ave., Long Beach, CA 90806-1737. Telephone: (562) 933-1400. Fax: (562) 933-2053. E-mail: [email protected].
• Anita Somplasky, RN, Project Coordinator, EPIC Medical Home Initiative, 919 Conestoga Road, Building 2, Suite 307, Rosemont, PA 19010. Telephone: (610) 520-3653. Fax: (610) 520-9177. E-mail: [email protected]. Web: www.paaap.org.
A variety of resources pertaining to children with special needs are available on the Emergency Medical Services for Children (EMSC) web site (www.ems-c.org). Click on "Rehabilitation and Children with Special Needs." Children with Special Health Care Needs: Technology-Assisted Children (TAC) (Product ID No. 000700) is a spiral-bound book that covers airways, breathing, circulation assessment, and interventions, with special attention to tracheotomies, mechanical ventilators, central intravenous catheters, feeding tubes, cerebrospinal shunts, and artificial pacemakers. The cost is $5, including shipping. A fact sheet, Emergency Care Plans for Children with Special Health Care Needs (Product ID No. 000717) can be downloaded at no charge. (Click on the publication title). Or, single paper copies are available at no charge by contacting:
• EMSC Clearinghouse, 2070 Chain Bridge Road, Suite 450, Vienna, VA 22182. Telephone: (703) 902-1203. Fax: (703) 821-2098. E-mail: [email protected]. Orders also can be placed on-line at www.ems-c.org/cfusion/OnlineOrder.cfm.
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