1. Summary of Guidelines for Care of Children in the Emergency Department
American Academy of Pediatrics
American College of Emergency Physicians
Emergency Nurses Association
AMERICAN ACADEMY OF PEDIATRICS COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE; AMERICAN COLLEGE OF EMERGENCY PHYSICIANS PEDIATRIC COMMITTEE; EMERGENCY NURSES ASSOCIATION PEDIATRIC COMMITTEE. Joint Policy Statement--Guidelines for Care of Children in the Emergency Department. Pediatrics. 2009; 124 (4):
AMERICAN ACADEMY OF PEDIATRICS COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE; AMERICAN COLLEGE OF EMERGENCY PHYSICIANS PEDIATRIC COMMITTEE;

2. AAP/ACEP, 2001; McCaig, 2006; Burt, 2006; Pitts 2008; Middleton, 2006
Background
Approximately 3833 emergency departments (EDs) in the United States (2006)
119 million ED visits in 2006
Almost 20% visits by children
2001: Joint guideline from AAP/ACEP regarding ED preparedness for children
McCraig LF, Nawar EW. National hospital ambulatory medical care survey: 2004 emergency department summary. Adv Data. 2006; (372): 1-29.
Burt CW, McCaig LF. Staffing, capacity, and ambulance diversion in emergency departments: United States Adv Data. 2006; (376): 1-23.
Pitts SR, Niska RW, Xu J, Burt CW. National hospital ambulatory medical care survey: 2006 emergency department summary. Natl Health Stat Rep. 2008; 7:1-39.
Middleton KR, Burt CW. Availability of pediatric services and equipment in emergency departments: United States, Advance data from vital and health statistics; no. 367.Hyattsville, MD: National Center for Health Statistics, 2006.
AAP/ACEP, 2001; McCaig, 2006; Burt, 2006; Pitts 2008; Middleton, 2006

3. Barriers to Optimal Emergency Care for Children
Lack of equipment availability
Lack of appropriately trained staff
Absence of policies and procedures to ensure timely transfer to definitive care
American Academy of Pediatrics, Committee on Pediatric Emergency Medicine. Access to optimal emergency care for children. Pediatrics. 2007;119 (1):161 –164
AAP, 2007.

4. Guideline Objectives
Purpose: To delineate the resources necessary to prepare hospital emergency departments to serve pediatric patients
Adoption of these guidelines should facilitate the delivery of emergency care for children of all ages, and when appropriate, timely transfer to a facility with specialized pediatric services

5. Guidelines for Administration and Coordination for the Care of Children

6. Physician Coordinator Qualifications
Specialist in emergency medicine (EM) or pediatric emergency medicine (PEM)
May be a staff physician currently assigned to other roles in the ED, or may be a physician shared through agreements with outside hospitals
Special interest, knowledge, and skill in emergency care of children as demonstrated by training, clinical experience or focused CME

7. Physician Coordinator Responsibilities
Promote/verify skill and knowledge of emergency providers
Oversee pediatric quality improvement (QI), performance improvement (PI), patient safety, injury/illness prevention, and clinical activities
Development and review of policies, procedures and standards for pediatric medications, equipment, and supplies
Liaison/coordinator to in-hospital and out-of-hospital pediatric care committees

8. Nursing Coordinator Qualifications
Registered nurse with special interest, knowledge, and skill in pediatric emergency care
May be a staff nurse currently assigned to other roles in the ED, or may be a nurse shared through formal consultation agreements with outside hospitals
Registered nurse with special interest, knowledge, and skill in emergency care of children as demonstrated by training, clinical experience, or focused CE

9. Nursing Coordinator Responsibilities
Facilitate ED pediatric QI/PI activities
Serve as a liaison to in-hospital and out-of-hospital pediatric care committees
Facilitate ED nursing continuing education
Ensure nursing competency evaluations are pertinent to all children
Assure availability of pediatric equipment, medications, staffing ,and other resources

10. Physicians, Nurses, and Other Health Care Providers Staffing the ED

11. ED Providers
Physicians, nurses and other health care providers staffing the ED have the necessary skill, knowledge, and training in the emergency evaluation and treatment of children of all ages who may be brought to the ED, consistent with the services provided by the hospital

12. Provider Competency Evaluation
Baseline and periodic competency evaluations completed for all ED clinical staff are age specific and include neonates, infants, children, adolescents, and children with special health care needs

13. Guidelines for Quality Improvement/Performance Improvement in the ED

14. Pediatric Patient Care Review Process
Interfaces with out-of-hospital and in-hospital QI/PI activities
Includes pediatric specific indicators
Requires pediatric clinical competency evaluations
Mechanisms for monitoring professional performance, credentialing, continuing education and clinical competencies

15. Guidelines to Improve Patient Safety

16. Specific Guidelines All children should be weighed in kilograms
For children requiring emergency stabilization, a standard method for estimating weight in kilograms should be used
All children should have a full set of vital signs, including temperature, heart rate, and respiratory rate
Blood pressure and pulse oximetry monitoring should be available for all children
Process should be in place to identify abnormal vital signs by age and to notify the physician of these abnormalities

17. Specific Guidelines
Processes for safe medication storage, prescribing and delivery should be established
Should include pre-calculated dosing guidelines
Implementation of infection control practices
Implementation of patient identification policies
Implementation of policies for reporting and evaluation of safety events and for the disclosure of errors or unanticipated outcomes

18. Specific Guidelines
Emergency services should be culturally and linguistically appropriate
The ED should provide an environment that is child-safe and supports patient and family-centered care

19. Guidelines for Policies, Procedures, and Protocols for the ED
Development and implementation of policies, procedures and protocols pertaining to the following topics:
Triage
Pediatric patient assessment
Documentation of vital signs, abnormal vitals signs and actions to be taken for abnormal vital signs
Immunization assessment and management of the under-immunized patient
Sedation and analgesia

20. Guidelines for Policies, Procedures, and Protocols for the ED
Development and implementation of policies, procedures and protocols pertaining to the following topics:
Consent
Social and mental health issues
Physical or chemical restraint of patients
Child maltreatment mandated reporting
Death of a child
Do not resuscitate orders

21. Guidelines for Policies, Procedures, and Protocols for the ED
Development and implementation of policies, procedures and protocols pertaining to the following topics:
Family centered care, including:
Involving families in patient care decision-making and in safety processes
Family presence during all aspects of emergency care
Education of the patient, family, and regular caregivers
Discharge planning and instruction
Bereavement counseling

22. Guidelines for Policies, Procedures, and Protocols for the ED
Development and implementation of policies, procedures and protocols pertaining to the following topics
Communication with patient’s medical home or primary health care provider
Medical imaging policies which address age- or weight-appropriate dose reductions for children

23. Guidelines for Policies, Procedures, and Protocols for the ED
Policies, procedures and protocols for emergency care of children should be developed and implemented pertaining to the following topics:
All-hazard disaster preparedness plan addressing the following pediatric issues:
Availability of medications, vaccines, equipment, and appropriately trained providers
Surge capacity for both injured and non-injured children
Decontamination, isolation and quarantine of families and children
Minimizing parent-child separation and improved methods for reuniting separated children with their families

24. Guidelines for Policies, Procedures, and Protocols for the ED
Policies, procedures and protocols for emergency care of children should be developed and implemented pertaining to the following topics:
All-hazard disaster preparedness plan addressing the following pediatric issues:
Access to specific medical and mental health therapies, as well as social services
Disaster drills that include a pediatric mass casualty incident at least once every two years
Care of children with special health care needs
Evacuation of pediatric units and pediatric specialty units

25. Pediatric Interfacility Transfer Procedures
Process for initiation of transfer
Transport plan to deliver children safely and in a timely manner to the appropriate facility
Process for selecting the appropriate care facility for pediatric specialty services not available at the hospital
Process for selecting the appropriate care facility for pediatric specialty services not available at the hospital. These services include medical subspecialty and surgical specialty care, critical care, reimplantation (replacement of severed digits of limbs), trauma and burn care, psychiatric emergencies, obstetrics and perinatal emergencies, child maltreatment (physical and sexual abuse and assault), rehabilitation for recovery from critical medical or traumatic conditiosn.

26. Pediatric Interfacility Transfer Procedures
Process for selecting the appropriate transport service to match the patient’s acuity level
Process for patient transfer
Plan for transfer of patient information, belongings, and provision of directions and referral institution information to family
Process for return transfer of the pediatric patient to the referring facility as appropriate

27. Guidelines for ED Support Services: Radiology
The radiology department should have the skills and capability to provide imaging studies of children
Guidelines to reduce radiation exposure
The hospital’s radiology capability must meet the needs of the children in the community it serves
Process for the referral to appropriate facilities for procedures which exceed the capability of the hospital
Process for the timely interpretation and reporting of radiologic studies by a qualified radiologist

28. Guidelines for ED Support Services: Laboratory
The laboratory should have the skills and capability to perform laboratory tests for all children
The laboratory capability must meet the needs of the children in the community it serves
There should be a clear understanding of laboratory capability for any given community and definitive plans for referring children to the appropriate facility

29. Guidelines for Equipment, Supplies and Medications for the Care of Pediatric Patients

30. Guidelines for Equipment, Supplies and Medications for the Care of Pediatric Patients
Pediatric equipment, supplies, and medications shall be easily accessible, labeled, safely, and logically organized
ED staff should know the location of all items
Resuscitation equipment and supplies shall be located in the ED
Other items may be housed in other departments as long as the items are immediately accessible
A mobile pediatric crash cart is strongly recommended

31. Guidelines for Equipment, Supplies and Medications for the Care of Pediatric Patients
The ED shall have a method of daily verification of proper location and function of equipment and supplies
A medication chart, length-based tape, medical software, or another system shall be readily available to ED staff to assure proper sizing of resuscitation equipment and proper dosing of medication

32. Clinical and Professional Competency
Potential areas for development of pediatric competency and professional performance evaluations may include:
Triage
Illness and injury assessment and management
Pain assessment and treatment, including sedation and analgesia
Airway management
Vascular access
Critical care monitoring
Neonatal and pediatric resuscitation

33. Clinical and Professional Competency
Potential areas for development of pediatric competency and professional performance evaluations may include:
Trauma care
Burn care
Mass casualty events
Patient and family centered care
Medication delivery, and device/equipment safety
Team training and effective communication

34. Summary
All EDs must be prepared to receive, assess, and at a minimum, stabilize and transfer acutely ill and injured children
Strong foundation for pediatric emergency and all-hazard preparedness provided by:
Recognition of unique needs of ill and/or injured children
Commitment to better meeting those needs through adoption of these guidelines
Ongoing commitment to evaluating care quality and safety and maintaining pediatric care competencies

35. Appendices Guidelines for medications for pediatric patients in the ED
Guidelines for equipment and supplies for pediatric patients in the ED