By Dorothy Brooks
While there is some good news coming from the latest assessment of pediatric readiness in U.S. EDs, the 2021 assessment still shows many departments are not meeting national guidelines for the provision of pediatric emergency care.
Considering the latest assessment was completed in the midst of the COVID-19 pandemic, researchers observed it is notable that EDs showed improvement on five of the six domains evaluated in the survey-based assessment, completed by the National Pediatric Readiness Project (NPRP). These domains covered personnel, quality improvement, patient safety, policies and procedures, and equipment/supplies.
However, there was a significant decline from the 2013 assessment regarding administration and coordination, a heavily weighted domain that indicates whether EDs employ a designated physician and/or nurse pediatric emergency care coordinators (PECC) — a position strongly linked to pediatric readiness.
Specifically, 37.3% of respondents reported their departments had designated a physician PECC in the 2021 assessment, down by more than 10% from the 2013 assessment. Similarly, 37.4% of EDs reported they had designated a nurse PECC, down from 59% in the 2013 assessment.1
As a result of the decline in designated PECCs, the overall adjusted median pediatric readiness score on the 2021 assessment was 69.5, a 1.6-point decline from the median pediatric readiness score from 2013. Researchers noted the minimum score associated with marked improvement in survival is 88.
Why is the PECC designation so important? Katherine Remick, MD, FAAP, FACEP, FAEMS, executive director of the National Pediatric Readiness Quality Initiative and the lead author of the 2021 pediatric readiness assessment, says it is a key administrative role akin to employing a trauma program director or a stroke program director.
“Children have not gotten a fair shake when it comes to emergency care. Without someone to champion that work locally, it’s impossible to ensure the system is ready for them,” Remick says.
Remick notes PECCs orient ED staff to ensure they are aware of all the elements in place to meet the needs of children.
“They’re writing policies and protocols, and implementing them into practice locally,” she says. “They’re also overseeing local quality improvement efforts, or at least delegating that work to someone to ensure that quality improvement mechanisms are in place to identify what kind of care is being provided to children.”
Remick adds PECCs ensure safety protocols are in place, and that staff are appropriately credentialed to maintain pediatric competencies.
“They [PECCs] are really making sure that the entire system is ready. Without someone doing that, unfortunately, children are just not on the radar,” Remick says.
Indeed, Remick reports most EDs surveyed in the readiness assessment see only a few pediatric patients. “In most of these EDs, 80% of their patients are adults. Because of that, they don’t see critically ill and injured children every single day,” Remick observes.
Thus, pediatric care competency and quality may not be receiving the attention they deserve, allowing pediatric readiness to fall through the cracks, Remick offers.
Marianne Gausche-Hill, MD, FACEP, FAAP, co-director of the NPRP and a co-author of the readiness assessment study, agrees on the importance of designating a PECC in every ED. However, she also believes the decline in PECC positions on the 2021 assessment was, at least in part, because of the pandemic-related workforce tumult.
“What happened during COVID is that people in nonclinical roles got recruited back to clinical care during surges [and] when there was a huge workforce change, [such as] people retiring or leaving the healthcare workforce. Also, there was a lack of people coming up and training for positions in healthcare during COVID,” Gausche-Hill explains. “All of those things had negative consequences that led to a diminution in our healthcare workforce, and we’re still experiencing that. It has gotten better, but our assessment data definitely reflect that diminution in the workforce.”
Nonetheless, the assessment showed designating a PECC improves pediatric readiness. It is an issue Gausche-Hill intends to elevate in the coming years.
For instance, she would like to see both payors and accreditors prioritize the position. Gausche-Hill also intends to work with her colleagues to ensure hospital leaders understand the importance of designated PECCs.
“Having a PECC improves pediatric readiness and decreases mortality pretty significantly, but that hasn’t been communicated to leadership as well as we could,” she admits.
In addition to designated PECCs, the 2021 assessment showed two other factors were strongly associated with pediatric readiness: staffing with board-certified emergency physicians or pediatric emergency physicians and maintaining a pediatric-specific quality improvement (QI) plan.
When asked how to go about establishing an effective QI plan, Gausche-Hill says during the first pediatric readiness assessment, many respondents stopped taking the survey when they were asked how many children they see in their ED every year. Thus, it is important to collect some basic data on a range of pediatric-specific metrics.
“You want to understand when variance occurs. [Find out] how many children you see, how many children are admitted, and how many children get transferred because you don’t have services within your organization,” Gausche-Hill explains. “Then, take a deeper dive when there are issues of care that are recognized to have a whole process for evaluating quality.”
For example, if the chief complaint that results in admission is asthma in a particular ED, department leaders might want to focus on recognizing and treating that condition, and whether the care that is provided aligns with national guidelines. The bottom line is to create a process to collect data, find variances, implement QI efforts aimed at addressing those variances, and re-evaluate.
“It’s not that complicated, but you do have to include children in these efforts — not only in your data collection and your search for variances, but also when coming up with a plan to address any opportunities for improvement that you are seeing,” Gausche-Hill stresses.
The 2021 assessment data pointed to other areas where children need to be included. For instance, fewer than half of the 3,647 ED leaders who responded to the survey indicated they included pediatric components in their disaster plans. Remick observes this reveals an enormous gap that needs to be closed.
“Children are disproportionately impacted in the case of disasters because of their [in]ability to communicate, and because their physiology puts them at more risk for things like respiratory distress and exposure to toxins,” she explains. “If we are not planning to take care of children [in these scenarios], then we put them at grave risk.”
Fortunately, this is one area pediatric leaders are working to highlight and improve. Remick explains the Health Resources and Services Administration has funded an organization called the Pediatric Pandemic Network. (Editor’s Note: Learn more about this organization at this link: pedspandemicnetwork.org/.) This group of 10 children’s hospitals across the United States is working to create a more robust disaster response plan that is particularly focused on including children. “We know there is a tremendous amount of work to do here, especially as our environment becomes less predictable, and as mental illness continues to be on the rise,” Remick notes.
On the positive side, Remick observes the 2021 assessment showed most EDs have acquired most of the equipment needed to take care of pediatric patients. Here, too, is room for improvement. “Pieces of equipment that are most commonly missing are those for the very, very young. When those children present, [the proper equipment] is a critical factor in terms of intervention,” Remick shares. “Respiratory failure is the leading cause of cardiac arrest in the pediatric population.2 If we can’t manage that effectively, then we’re in trouble.”
Another finding from the assessment indicated 62% of respondents had created a triage policy that addresses children. This is a concern, according to Remick, because children present differently from adults on a range of measures, including on routine vital sign measurements, such as blood pressure and heart rate. “An adult should have a heart rate between 60 and 100, but if we saw a five-year-old with a heart rate of 60, we might be concerned because that is quite low, and we would expect it to be closer to 120,” she explains. “A pediatric triage tool is necessary because it highlights the differences in physiology of the pediatric population, without which we can’t determine the severity of illness or the rapidity with which we need to respond to that child.”
As a partner in the NPRP, the Emergency Nurses Association (ENA) regularly offers an emergency nursing pediatric course (ENPC) to ensure members are well-versed in how to care for sick children who present to the ED, explains Terry Foster, MSN, RN, CEN, CEN, CPEN, CCRN, TCRN, FAEN, president of ENA, and one of the people who teaches this two-day course.
He also notes all EDs require their nurses to receive pediatric advanced life support (PALS) training. “That’s a great requirement, and that’s for a child in respiratory or cardiac arrest,” he explains.
In contrast, Foster notes the ENPC course is focused on the wide range of other issues with which children may present in a busy ED. “For instance, a child can decompensate very, very quickly. I’ve seen that happen a lot,” Foster shares. “[It is important] to have that awareness that sometimes a child may seem OK when they first present, but then 10 minutes later they may have a seizure or something like that. Things can change very quickly.”
That is just one of the many reasons why it is important for emergency nurses to maintain their skills in pediatric care, according to Foster, who also notes the latest pediatric readiness assessment underscores the point that emergency nurses need to advocate for their young patients, too.
“Children in our care deserve better, and we really need to have increased ... readiness for any pediatric situation that presents,” Foster says. “We need to keep that front and center because we are always going to have these pediatric cases, such as a child who has been hit by a car or a child who is crashing, who we need to take care of [in the ED].”
Foster says there is nothing worse than a seriously ill or injured child presenting to the ED, the resources needed to care for that child quickly and appropriately are unavailable.
“That strikes fear into my heart, and it should,” he says. “When you grab a child and run back into a trauma room ... you hope and pray that you have all the resources required and everything is ready for what that child needs.”
Remick observes that while the 2021 readiness assessment highlighted many areas of progress, the fact that there was not significant overall improvement speaks to an ongoing lack of prioritization of children within the emergency care system.
“We could be doing better, and I do believe that children are likely dying needlessly every day because our system is not ready to meet their critical needs,” she says. “This assessment was done during COVID, and our healthcare system was strained, but it is often the case that when it comes to children, they are the lowest on the list of priorities.”
Remick points to the significant loss of PECCs in the latest assessment. “There were some very slight differences between the 2013 assessment and the 2021 assessment, which makes them not 100% comparable, but the two assessments are quite similar,” she says.
Remick is hopeful that awareness of the shortcomings highlighted in the 2021 assessment will serve as a call to action. “A median overall score of 69 is simply not sufficient,” she says. “We need to figure out a sustainable way to ensure that our emergency care systems are ready for children.”
Gausche-Hill agrees, but she is nonetheless gratified that so many EDs responded to the survey, even amid the severe workforce shortages.
“The big surges of 2020 were over, but we had huge workforce issues,” she recalls. “To have 71% of the EDs in the country respond to this assessment is a real success.”
Further, Gausche-Hill is hopeful that improvement will be evident in the next national pediatric readiness assessment, which could happen as soon as 2026.
REFERENCES
1. Remick KE, Hewes HA, Ely M, et al. National assessment of pediatric readiness of US emergency departments during the COVID-19 pandemic. JAMA Netw Open 2023;6:e2323707.
2. Society for Academic Emergency Medicine. Cardiac arrest.
EDs showed improvement on five of the six domains evaluated in the survey-based assessment, completed by the National Pediatric Readiness Project. However, there was a significant decline from the 2013 assessment regarding administration and coordination, a heavily weighted domain.
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