Cater to children in your ED
There are many ways to send the message that children are a priority in your ED, says Larry B. Mellick, MD, MS, FAAP, FACEP, chair and professor in the department of emergency medicine and director of pediatric emergency medicine at Medical College of Georgia in Augusta. "You can have a separate pediatric ED or carve out space within your general ED by designating one or two rooms for children," he suggests. "Even if space doesn't allow for either of those options, there may be significant planning in policies and procedures to maximize the care of children."
Supply and demand issues dictate that general EDs must focus on pediatric patients, says Mellick. "There are some 120 children's hospitals in the United States, and not all of them have pediatric EDs," he notes. "Twenty million ED visits from children are expected for 1998. The majority of those children are going to go to general EDs, so you need to take steps to provide maximum quality care for these kids."
When integrating pediatric services, care should be the foremost priority, says Mark S. Mannenbach, MD, section head of pediatric emergency services at the Mayo Clinic in Rochester, MN. "The major goals and challenges of integrating pediatric services into a 'general ED' are ensuring timely and appropriate care for the pediatric patient," he stresses.
That goal sounds simple, but it presents a considerable challenge, Mannenbach states. "In a time when the emphasis by many in healthcare seems to be cost containment, the philosophy of 'getting along with who we have' may be more of a reality," he says.
Integrating pediatric services results in better care, says Michael Altieri, MD, FACEP, section chief for pediatric emergency medicine at Inova Fairfax Hospital in Falls Church, VA. "In a system like ours, which is integrated, the whole level of care for a child has risen above what you normally get in a general ED. That's due to the coexistence of pediatric and emergency physicians."
Catering to children also makes good business sense, says Mellick. "Along with every pediatric patient comes two potential patients-the child's parents," he notes. "If the experience goes well, parents will come back again and again over the years. There is evidence that a successful pediatric program increases overall business."
Patient satisfaction is clearly increased, says Mellick. "Parents are protective of their children and don't want them exposed to offensive conditions," he stresses. "They also want them cared for by people who are experts in the field of pediatric emergency medicine. A hospital recognized for its pediatric expertise is elevated to a special status in the community."
Children have a major effect on the culture of an ED, says Mellick. "In some ways, they up the emotional ante of a department," he notes. "The image of a dying child strikes to the very core of a clinician. Pediatric resuscitations are clearly remembered months or years later."
Improving clinical care of children is part of raising the "clinical bar," says Mellick. "Up until the last 10 years, it was one of the last areas people paid attention to, but that has changed dramatically," he notes. (For information about pediatrics guidelines established in California's Riverside County, see ED Management 1996;8:91-93.)
Here are some things to consider when integrating pediatric and adult services:
Recognize patients are less willing to wait. "You need to recognize that children and their parents are different from the general population," says Carol Steltonkamp, MD, FAAP, assistant professor of pediatrics at University of Kentucky Medical Center in Lexington. "An adult tends to be much more patient when it's their own injury than their child's. When a 10-month old is screaming and crying and has a temperature of 104°F, it's much more difficult to sit and wait."
Staff should be understanding with parents who seem impatient. "Yes, this mother may not be particularly friendly because she is so stressed out, but be empathetic to that," says Steltonkamp. "Acknowledge that this is stressful, that they are distraught, and you will get to them as soon as possible. This is something we all tend to do if somebody is injured seriously, but we need to recognize that parents are just as upset when they bring in a sick baby."
Ask primary care physicians for input. Pediatricians can give valuable feedback about the needs of pediatric patients and their families. "Get in touch with them and ask 'What can be done for you and your patients?'" suggests Steltonkamp.
Ask families for their suggestions. Hold focus groups with parents and children to obtain valuable input and suggestions, says Alan Vierling, RN, CEN, director of emergency services at Carilion Radford Community Hospital (VA). "We set up an advisory group to focus on pediatric care hospital-wide," he reports. "At monthly meetings, we ask kids what they liked and didn't like about the ED, if anything scared them, and what they thought about the room they were treated in."
Ensure staff are adequately trained. Staff need to be kept up to date on advanced pediatric life support and neonatal resuscitation, says Steltonkamp. "They all take ACLS in a heartbeat-that's a given. But to lend some credence to your ability to care for pediatric patients, even if you donsee that many of them, make it mandatory for staff to be trained," she advises.
If that is cost prohibitive, there should be at least one member of every shift who is certified. "This sends a message that you recognize children are not small adults," says Steltonkamp.
Have physicians report to same leadership. When Fairfax integrated the practice of emergency medicine with pediatrics, it was determined that pediatric ED physicians needed a close alliance with the ED leadership. "That means that pediatric emergency services needs to be part of the department of emergency medicine," says Altieri. "The physicians working shoulder to shoulder need to be marching to the same drummer, not having allegiances to different leaderships."
Still, the pediatric ED physicians needed a close alliance with the department of pediatrics. "The pediatricians feel, rightly so, that they set the standard for pediatric care," says Altieri. "So, they need to be closely tied to the department of pediatrics and they need to be approved of and respected by pediatricians."
Maximize use of pediatric physicians. "Our pediatric emergency physicians will also see appropriate adults, so we don't have anybody sitting there just to see kids," says Altieri. "When volume is low, it isn't cost effective to have somebody doing nothing."
Fairfax's ED has 11 pediatric emergency physicians out of a group of 35, but several are board certified in both emergency medicine and pediatrics. "They can work both pediatric or adult shifts," says Altieri. "So even though a child may come in at 5 a.m., they still may see a pediatric emergency physician who happens to be doing an adult shift."
Track pediatric volume to determine staffing. "We looked at the way kids flowed into our department and tracked visits by age and time of visit," says Altieri. "We found that if we have a pediatric emergency physician on duty from noon until 3 a.m., we will see 85-90% of kids that way."
In the remaining hours between 3 a.m. and noon, there is a much lower pediatric volume. "So the cost effectiveness of having a pediatric emergency physician available really drops off after those hours," notes Altieri.
The ED is split into two sides, one monitored and the other non-monitored, which also has pediatrics. "One hallway is mainly adults and the other hallway is mainly pediatrics," says Altieri. "We try to keep kids on that side, but we wouldn't keep a bed empty because it's a pediatric bed or adult bed." At 3 a.m., when the pediatric volume drops down, the ED operates out of the acute side so sick children can be monitored, he explains.
Train clinicians in pediatrics. Healthcare providers who see pediatric patients on a regular basis in an emergency setting should be appropriately trained and/or supervised by someone with adequate pediatric training, says Mannenbach. "If you don't feel prepared for pediatric emergencies either because of lack of training, ancillary support, or appropriate equipment/facilities, I feel you need to re-evaluate the type of care you are providing," says Mannenbach.
ED physicians, nurses, prehospital care providers, physician assistants, nurse practitioners, and ancillary staff need to be competent in the care that they provide to children, Mannenbach advises. "Not just anyone can appropriately care for emergent pediatric problems, just as not just anyone can care for the adult patients," he says. "I would not feel qualified or comfortable with treating the adult patient with acute chest pain or a geriatric patient with altered mental status."
Don't depend on an on-call system. An "on-call" system in the emergency setting is fraught with potential time delays and oversights, especially in EDs with a large volume of pediatric patients, says Mannenbach. "To call someone in for help, the problems must first be appropriately identified, and interventions must be made concurrently and not in sequence."
Clinicians in the ED must be prepared to deal with pediatric emergencies, says Mannenbach. "Those on the front lines need to be competent to avoid a hectic and confusing approach to emergent pediatric problems," he stresses. "In other words, too many cooks with limited training or experience may cause more harm than good."
Separate children physically. Physical separation of pediatric patients from the traumatically injured or combative patient must be attempted at all costs, stresses Mannenbach. "This may mean creating a separate entrance, hallway, or waiting area for the pediatric patient and the family," he says.
Failing to separate adults from children can increase anxiety of both clinicians and patients. "I was caring for an infant with status epilepticus when an adult patient who was intoxicated, combative, and belligerent was brought into across the hall that was separated only by a curtain and about 30 feet of space," Mannenbach recalls. "That situation made me uncomfortable and distracted. I was embarrassed to care for the infant and her family in that setting."
Without separation, it's difficult to shield children from traumatic sights and sounds. "The seriously injured patient requires close monitoring with a devoted group of care providers; there is little time available to spend worrying about the effect on other patients," says Mannenbach. "The adult patient may need to have a separate entrance or area of the ED for their care, especially if the volume of pediatric patients prohibits exam rooms devoted to children specifically."
The reverse scenario may also be true. "The crying, scared child can be disturbing to the adult patient population in the ED as well and is another reason for physical separation of these patients," says Mannenbach. Security measures must also be maintained to ensure the safety of all patients and their families, he advises.
Register children at the bedside. "Getting the patient directly to his or her exam room is best with the registration process being handled there rather than in the waiting area or registration area," says Mannenbach. Eliminating the registration booth area creates more physical space for a separate pediatric care area with private exam rooms or a separate pediatric waiting area, he adds.
Consider needs of older children. The "pediatric" patient ranges from infants to young adults, notes Mannenbach. "Cute cartoon characters may appeal to the toddler but be very uncomfortable for the teenager," he says. "Decor that is age-appropriate or more colorful is helpful."
Exam rooms used specifically for procedures will allow for age-appropriate measures to be brought into the room without offending the teenaged patient, says Mannenbach. "For example, mobiles or appropriate videotapes or music can be brought into the room to provide distraction during painful procedures or testing. A separate room for blood draws, LP's, urinary catherization, etc., could be used temporarily to allow for comfort measures of the patient, family, and other patients as well."
Take advantage of remodeling. "When planning a remodeling or renovation of the ED, consider needs of children. If the ED is physically attached to a children's hospital or a pediatric floor, a common decor or theme could be employed to provide the idea of continuity of care for the patient and the family," suggests Mannenbach.
Implement vertical integration of personnel with pediatric hospital/wing. "The skills and interests of nurses, respiratory therapists, and lab personnel who care for children should be utilized to their fullest extent," says Mannenbach. "If personnel in the ED don't feel comfortable caring for children or lack appropriate training in pediatric issues/procedures, those in the pediatric intensive care unit or pediatric inpatient facilities may be more appropriate to care for the pediatric patient in the ER."
Vertical integration of ED and inpatient pediatric staff improves communication, notes Mannenbach. "This integration also breaks down some of the "us vs. them" mentality often found between those working in the ED and the inpatient unit or between those working in the ED and the pediatric units," he says.
Editor's Note: A publication entitled Working with Families to Enhance Emergency Medical Services for Children is available. For more information, contact EMSC National Resource Center, 111 Michigan Avenue NW, Washington DC 20010. Telephone: (202) 884-4927. Fax: (301) 650-8045. Email: [email protected] For more information about building a family-centered system of care and in identifying families to serve as advisors, contact the Institute for Family Centered Care, 7900 Wisconsin Avenue, Suite 405, Bethesda, MD 20814. Telephone: (301) 652-0281. Fax: (301) 652-0186. Internet: http://www.familycenteredcare.org
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