Pediatric cases may test your EDs cost-vs.-quality priorities
Veteran pediatric specialists urge giving managed care concerns less importance
In 1993, the Institute of Medicine in Chigaco, IL, issued a report urging hospital emergency departments (EDs) to maintain a minimum level of equipment and supplies to meet the needs of pediatric patients.
The report had a far-reaching effect on hospitals. But prior to and since the report's publication, emergency providers have not been able to agree on what constitutes minimum levels of pediatric emergency equipment and supplies.
The same can be said of the degree of emergency services that should be rendered to a pediatric population in an emergency setting, according to some specialists. While clinical best practices have existed for years covering specific childhood conditions, emergency providers appear to lack any comprehensive protocols regarding how to treat children as a separate patient population from adults.
Yet, emergency physicians believe there is a great deal known anecdotally about what distinguishes pediatric emergency cases from the mainstream population. "Unlike adult patients, children presenting with what would be considered routine illnesses in adults pose a particular challenge for emergency physicians who normally don't see a large number of pediatric cases," observes Mark A. Del Beccaro, MD. Del Beccaro is acting chief of emergency medical services at Children's Hospital and Medical Center in Seattle, WA.
Risk of under-treatment outweighs the cost
The problem becomes complicated by the fact that children are measurably more susceptible to orthopedic injuries, bacterial infections, and routine illnesses than the general adult population.
"Most of the kids we see [at Children's Hospital] really need to be seen. The percentage we admit is also much higher [than at other hospitals], and the ones who are discharged home get a fairly high level of treatment before they leave," says Del Beccaro.
But the higher level of resource use at Children's Hospital isn't linked to chance but to a combination of formal clinical knowledge and practical experience gathered from intensively working with a pediatric population.
Based on a consensus gleaned from physicians and nurses and documented in recent literature, physicians are being advised by pediatric specialists to consider the risks of under-treatment more than the cost of going to extremes in working with a pediatric population. The advice stems partly from a lack of consensus on what constitutes appropriate levels of medical care.
Emergency physicians, especially those who lack extensive experience in treating children, should be less concerned about over-utilizing clinical resources than in delivering what they consider to be the most appropriate care at the time, says Richard P. Shugerman, MD, a colleague of Del Beccaro at Children's Hospital.
But how much care is an appropriate level of care at a particular time? The answer depends on the actual level of experience of individual physicians, according to veteran pediatric emergency providers.
The question of how much care is too much care may be important in relation to the financial priorities of managed care, but children pose a different set of clinical considerations independent of managed care concerns, Del Beccaro states.
Individually, physicians at mainstream community hospitals generally don't see sufficient numbers of pediatric cases to develop a comfort-zone in working with childhood conditions, Del Beccaro states. That level of assurance changes with years in practice. But the number of physicians exposed to pediatric emergency cases is variable, according to some experts.
Physicians lack strong experience with pediatric cases
In a 1997 survey of pediatric residents conducted by Del Beccaro and Shugerman, the researchers found that over a three-year period, medical residents training at an unidentified children's hospital did not see sufficient numbers of individual illnesses to be judged competent based on their typical rotations in the ED.1
Part of the reason for this was that the number and type of patients seen by individual residents in the study showed significant variation. The result was that residents were found in the survey to lack "significant clinical experience with a surprising number of important pediatric illnesses." They also lacked experience with common ED procedures such as intubation, thoracentesis, or bladder tap.
"Even when studied for the entire three years of training, residents were unlikely to experience sufficient clinical contact in the ED to ensure competence solely on the basis of their experience with [cases] as common and important as febrile seizures, croup, or diabetic ketoacidosis," the study reports stated.
However, Del Beccaro and Shugerman qualified their findings in their report by stating at the conclusion that their result may be biased. "For any ED attending physician with years of accumulated exposure, it is easy to develop unrealistic expectations of what residents may see during a series of sporadic ED rotations," the authors wrote.
Actually, managed care has helped physicians by educating parents and creating a pre-hospital screening system that has reduced the problem of over-use and unnecessary care. Telephone triage and stronger patient education delivered by pediatricians and family physicians have helped reduce the number of unanticipated midnight visits to the ED. That has only happened in high managed care areas, according to Steven Weber, RN, EMT, manager of the children's emergency department at WakeMED, a regional hospital in Raleigh, NC.
Latest efforts have focused on equipment and supplies
The system is still laden with excess, Weber says. Providers acknowledge that some 25% of pediatric emergency cases do not need to be seen. Nevertheless, physicians and telephone triage nurses refuse to take chances of postponing or redirecting these patients before the visit. But they are working toward reducing those numbers through patient education.
Simultaneously, researchers and specialty societies have tried to establish norms for properly equipping hospitals to at least provide an optimum level of medical care even in the absence of uniform, comprehensive guidelines for physicians.
In 1995, the American Academy of Pediatrics in Elk Grove Village, IL, published a set of standards for designated pediatric emergency care facilities. Although the guidelines focused on life-threatening pediatric illnesses and injuries, they offered concrete recommendations for a variety of emergency settings from simple standby pediatric facilities to larger comprehensive regional emergency centers.
Likewise, earlier this year an ad hoc committee of pediatric and emergency medicine specialists published a set of guidelines for pediatric equipment and supplies recommended for use in EDs. However, the guidelines admittedly excluded mention of routine equipment and supplies already found at most hospitals, and limited the number of drugs in deference to individual physicians' scope of practice.2 (For a sample listing of items from the guidelines, see table on this page.)
If anything, some specialists acknowledge that managed care has helped reveal certain deficiencies in treating specific patient populations, including children and the elderly, in the emergency setting. Now providers will have to find answers to difficult questions regarding appropriate levels of care. "There may be no answers to these questions because there are no easy answers," says Del Beccaro.
References
1. Del Beccaro MA, Shugerman RP. Pediatric residents in the emergency department: What is their experience? Ann Emerg Med 1998;31:43-53.
2. Committee on Pediatric Equipment and Supplies for Emergency Departments. Guidelines for pediatric equipment and supplies for emergency departments. Ann Emerg Med 1998; 31:54-57.
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