1. Hospital Pediatric
Emergency Care Readiness
“Children’s Project”
Small Rural Hospital Conference
Williamsburg, Virginia
April 13, 2010
David P. Edwards, MBA
Virginia EMS for Children Coordinator
(804) 888-7527 (office)
david.edwards@vdh.virginia.gov

2. Where did this come from?
 Institute of Medicine (IOM) report summary
recommendations -- “Emergency Care for
Children: Growing Pains‖ (Committee on
the Future of Emergency Care in the United
States Health System)
 EMS for Children (EMSC) Program --
National Performance Measures (HRSA:
Maternal & Child Health Bureau)
 Various Homeland Defense initiatives
dealing with pediatric disaster
preparedness, hospital surge capacity &
emergency planning, etc.

3. ―Emergency Care for Children:
Growing Pains‖
 This section will introduce the problems
inherent in treating children in an
emergency setting, and
 Discuss some of the Summary
Recommendations of this important IOM
report.

4. Special Challenges
 Children represent a special challenge for
emergency and trauma care providers, in
large part because they have unique
medical needs in comparison with adults.

6. Why Children are Different
 Vital sign measurements change as children
mature (RR, HR, BP)
 Normal for adults may signal distress in a
child
 Airway anatomy differs
 Needed interventions require special care
and appropriate equipment sizes
(Example: shorter trachea, higher larynx)

7. Why Children are Different
 Medication dosages
 Emotional reactions
 Ability to communicate
 Triage more difficult

8. Studies identified
that children had
higher mortality
rates
than adults in similar
emergency situations

9. Provider Stress
 It is not surprising, then, that many
emergency providers feel stress and
anxiety when caring for pediatric patients

10. Provider Stress

11. System Slow to Respond
 For a long time, special needs of children
have been acknowledged, but…
 Emergency and trauma care system has
been slow to develop adequate response
 In part, this is probably due to flaws in the
―broader‖ system.

12. Contributing Factors
 Emergency and trauma care system is
highly fragmented
 Little coordination exists between
prehospital, hospital and public health
 While ED usage is increasing, ED closings
are also increasing, and hospital staffing is
problematic
 ED‘s that remain open are chronically in a
crowded condition

13. Contributing Factors
 Ambulance ―diversion‖ practices have been
increasing
 Key physician specialists (emergency and
trauma) are harder to find and keep
 Longer waits in ED
 More distant prehospital transport for
critically injured patients.

14. Contributing Factors
 ―Safety Net‖ patients with intractable
social problems
– Compensation for care of these folks is
poor or non-existent
– Tremendous financial pressures on
safety net hospitals
 Some have closed
 Some are in danger of closing

15. Care of Children is Challenging
 Problems faced by children in current
emergency care system are even more
daunting.
 Children represent 27 percent of all ED
visits, yet many hospitals are not well
prepared to handle pediatric patients

16. Example: ED Readiness
 Only 6% of ED‘s in the U.S. have on hand
all of the supplies deemed essential for
managing pediatric emergencies
 Only half of hospitals have at least 85% of
those supplies

17. Essential Pediatric Equipment & Supplies in
Hospital Emergency Departments
More than 85% of essential
equipment & supplies (44%
of EDs) Less than 85% of essential
equipment & supplies (50%
44% of EDs)
50%
6%
100% of essential equipment
& supplies (6% of EDs)

18. Example: Skills Degradement
 Pediatric skills deteriorate quickly
 Continuing education in pediatric care is
– Not required, or
– Extremely limited for many prehospital
emergency medical technicians (EMT‘s)

19. Example: Medications
 Many medications prescribed for
children are ―off label*‖
*not adequately tested or approved by the U.S. Food
and Drug Administration (FDA) for use in pediatric
populations

20. Example: Disaster Preparedness
 Disaster preparedness plans often
overlook the needs of children, even
though their needs during a disaster
differ from those of adults

21. Disaster Preparedness Challenges
Examples:
 Minimizing parent-child separation
 Reuniting separated children with families
 Pediatric expertise for DMAT teams
 Pediatric surge capacity (injured/non-injured)
 Availability of/access to specific medical/mental
health therapies and social services for children
 Disaster drills seldom involve pediatric mass
casualty events

22. Example: Variation in Treatment
Patterns
 Pediatric treatment patterns vary widely
 Many emergency care providers still…
– Do not properly stabilize seriously injured
or ill children
– Under-treat children in comparison with
adults
– Fail to recognize and/or report cases of
child abuse

23. Example: Rural Setting Worse
 Shortcomings often exacerbated in rural
areas
 Less availability of specialized pediatric
training and resources that many take for
granted—despite dedicated rural providers

24. Achieving the Vision of a 21st
Century Emergency Care System
 Three Goals:
– Coordination
– Regionalization
– Accountability

25. Coordination (currently)
 Fragmentation of EMS, hospital, trauma
center and public health efforts
 Public safety and EMS often lack common
radio frequencies & protocols
 Care providers lack access to patient
medical histories
 Only half of hospitals have pediatric inter-
facility transfer agreements

26. Coordination (vision)
 Dispatch, EMS, ED providers, public
safety, and public health should be fully
interconnected and united in an effort to
ensure that each patient receives the
appropriate care, at the optimal location,
with the minimum delay

27. Coordination (vision cont.)
 Delivery of emergency care services (from
the standpoint of the patient and parents)
should be seamless
 Inclusion of pediatric concerns during
planning can help the system meet the
needs of children to the best of its ability

28. Regionalization
 Because not all hospitals within a
community have the personnel and
resources to support the delivery of high-
level emergency care, critically ill and
injured patients should be directed
specifically to those facilities with such
capabilities*
*Substantial evidence exists proving improvement of
outcomes, cost reductions across a range of high-risk
conditions and procedures.

29. Recommendation (3.1)
 “That the Department of Health and Human
Services and the National Highway Traffic Safety
Administration, in partnership with professional
organizations, convene a panel of individuals with
multidisciplinary expertise to develop evidence-
based categorization systems for emergency
medical services, emergency departments, and
trauma centers based on adult and pediatric service
capabilities.”

30. Recommendation (3.2)
 “That the National Highway Traffic Safety
Administration, in partnership with professional
organizations, convene a panel of individuals with
multidisciplinary expertise to develop evidence-
based model prehospital care protocols for the
treatment, triage, and transport of patients,
including children.”

31. Accountability
 Without accountability, participants in the
emergency care system need not accept
responsibility for failures and can avoid
making changes to improve the delivery of
care…
 Accountability has failed to take hold in
emergency care to date because
responsibility is dispersed across many
different components of the system, so it is
difficult even for policy makers to determine
where system breakdowns occur and how they
can subsequently be addressed

32. Accountability (cont.)
 When hospitals lack pediatric transfer
agreements, when providers receive no
continuing education pediatric education,
and when pediatric specialists and on-call
specialists are not available, no one party
is to blame—it is a system failure

33. Recommendation (3.3)
 “That the Department of Health and Human
Services convene a panel of individuals with
emergency and trauma care expertise to develop
evidence-based indicators of emergency and
trauma care system performance, including the
performance of pediatric emergency care.”

34. Achieving the Vision
 States and regions face a variety of different
situations with respect to emergency and trauma
care:
– Level of development of adult and pediatric trauma systems.
– Effectiveness of state EMS offices/regional EMS councils.
– Degree of coordination among fire departments, EMS,
hospitals, trauma centers, and emergency management.
 No single approach to enhancing emergency care
systems will accomplish the three goals outlined
above, and it will be necessary to explore and
evaluate a number of difference avenues for
achieving the committee‘s vision

35. Recommendation: (3.4)
 “That Congress establish a demonstration program,
administered by the Health Resources and Services
Administration, promote coordinated, regionalized,
and accountable emergency care systems
throughout the country, and appropriate $88 million
over 5 years to this program.”

36. Recommendation: (3.6)
 “That Congress establish a lead agency for
emergency and trauma care within 2 years of the
release of this report. The lead agency should be
housed in the Department of Health and Human
Services, and should have primary programmatic
responsibility for the full continuum of emergency
medical services and emergency and trauma care
for adults and children, including medical 9-1-1 and
emergency medical dispatch, prehospital
emergency medical services (both ground and air),
hospital-based emergency and trauma care, and
medical-related disaster preparedness.”

37. Recommendation: (3.6 cont.)
 “Congress should establish a working group to
make recommendations regarding the structure,
funding, and responsibilities of the new agency, and
develop and monitor the transition.
 The working group should have representation from
federal and state agencies and professional
disciplines involved in emergency and trauma care.”

38. Addressing Specific
Pediatric Concerns
 Strengthening the workforce
 Improving patient safety
 Exploiting advances in medical and
information technology
 Fostering family-centered care
 Enhancing disaster preparedness
 Improving the evidence base
 Funding the EMS for Children Program

39. Strengthening the Workforce
 Residency programs, medical school,
nursing school, states, EMS agencies, and
hospitals have varying requirements for
initial and continuing pediatric emergency
care education and training
 Of particular concern are providers who
rarely encounter pediatric patients, making
it difficult for them to maintain pediatric
skills—this is a long-standing problem that
has improved somewhat over time

40. Recommendation (4.1)
 “That every pediatric- and emergency-care related
health professional credentialing and certification
body define pediatric emergency care
competencies and require practitioners to receive
the level of initial and continuing education
necessary to achieve and maintain those
competencies.”

41. Recommendation (4.2)
 “That the Department of Health and Human
Services collaborate with professional organizations
to convene a panel of individuals with multi-
disciplinary expertise to develop, evaluate, and
update clinical practice guidelines and standards of
care for pediatric emergency care.”

42. Recommendation (4.3)
 “That emergency medical services agencies appoint
a pediatric emergency coordinator, and that
hospitals appoint two pediatric emergency
coordinators—one a physician—to provide pediatric
leadership for the organization.”

43. Improving Patient Safety
 Emergency care services are delivered in an
environment where the need for haste, the
distraction of frequent interruptions, and
clinical uncertainty abound, thus posing a
number of potential threats to patient safety
 Children are, of course, at great risk under
these circumstances because of their physical
and developmental vulnerabilities, as well as
their need for care that may be atypical for
providers used to treating adult patients

44. Recommendation (5.1)
 “That the Department of Health and Human
Services fund studies of the efficacy, safety, and
health outcomes of medications used for infants,
children, and adolescents in emergency care
settings in order to improve patient safety”.

45. Recommendation (5.2)
 “That the Department of Health and Human
Services and the National Highway Traffic Safety
Administration fund the development of medication
dosage guidelines, formulations, labeling
guidelines, and administration techniques for the
emergency care setting to maximize effectiveness
and safety for infants, children and adolescents.
 Emergency medical services agencies and
hospitals should incorporate these guidelines,
formulations, and techniques into practice.”

46. Recommendation (5.3)
 “That hospitals and emergency medical services
agencies implement evidence-based approaches to
reducing errors in emergency and trauma care for
children.”

47. Exploiting Advances in Medical
and Information Technology
 Technology is likely to advance the way
care is delivered in the prehospital and ED
settings.
 New technologies designed to accelerate
diagnosis and workflow—advanced imaging
modalities, rapid diagnostic tests,
laboratory automation, EMS technologies,
patient tracking tools, and new triage
models—are likely to be adopted.

48. Exploiting Advances in Medical and
Information Technology (cont.)
 As these new technologies are introduced, it
is critical to consider how they can help (and
whether they may bring harm to) pediatric
patients.
 While this may appear to be an obvious
consideration, there have been many examples
of medical technologies originally developed
for adults but used on children with
unintended consequences.
 A market for products designed specifically for
pediatric patients has not been well developed.

49. Recommendation (5.4)
 “That federal agencies and private industry fund
research on pediatric-specific technologies and
equipment for use by emergency and trauma care
personnel”

50. Fostering Family-Centered Care
 Parents are recognized as a pediatric
patient‘s primary source of strength and
support and play an integral role in the
child‘s health and well-being.
 Increasing recognition of both the
importance of meeting the psychosocial
and developmental needs of children and
the role of families in promoting the
health and well-being of their children has
led to the concept of family-centered
care.

51. Fostering Family-Centered Care
(cont.)
 Providers should acknowledge and make use of
the family‘s presence, skills, and knowledge of
their child‘s condition when caring for the child.
 Few EMS agencies and ED‘s have written
policies or guidelines for family-centered care
in place, and few providers are trained in
family-centered approaches (despite a growing
body of research demonstrating its importance
in improving health outcomes).
 Such approaches to care can mutually benefit
the patient, family, and provider.

52. Recommendation: (5.5)
 “That emergency medical services agencies and
hospitals integrate family-centered care into
emergency care practice.

54. Enhancing Disaster Preparedness
 Children are more generally more vulnerable
than adults in the event of a disaster.
 They require specialized equipment and
different approaches to treatment during
such an event (decontamination equipment
units adjustments, etc.).
 Children require difference antibiotics, and
different dosages to counter many chemical
and biological agents.
 A 1997 FEMA survey found that none of the
states had incorporated pediatric components
into their disaster plans.

55. Recommendation (6.1)
 “That federal agencies (the Department of Health
and Human Services, the National Highway Traffic
Safety Administration, and the Department of
Homeland Security), in partnership with state and
regional planning bodies and emergency care
providers, convene a panel with multidisciplinary
expertise to develop strategies for addressing
pediatric needs in the event of a disaster.
 This effort should encompass the following:”

56. Recommendation (6.1 cont.)
 “Development of strategies to minimize parent-child
separation and improved methods for reuniting separated
children with their families.
 Development of strategies to improve the level of pediatric
expertise on Disaster Medical Assistance Teams and other
organized disaster response teams.
 Development of disaster plans that address pediatric surge
capacity for both injured and non-injured children.
 Development of and improved access to specific medical
and mental health therapies, as well as social services, for
children in the event of a disaster.
 Development of policies to ensure that disaster drills
include a pediatric mass casualty incident at least once
every 2 years.”

57. Improving the Evidence Base
 A significant information gap exists in
pediatric research related to emergency
care; basic questions about the structure
of the pediatric emergency care system
and patient outcomes remains unanswered.
 Many of the treatments and management
strategies that are widely practiced today
are not supported by scientific evidence.

58. Improving the Evidence Base
(cont.)
 The use of data networks (such as
PECARN), in which researchers from
difference institutions pool data, has
proven to be successful in addressing such
challenges--but it is has been difficult to
obtain training grants from the ‗siloed‘
funding structure of the NIH (the largest
single source of support for biomedical
research in the world

59. Recommendation (7.1)
 “That the Secretary of Health and Human Services conduct a
study to examine the gaps and opportunities in emergency care
research, including pediatric emergency care, and recommend a
strategy for the optimal organization and funding of the research
effort.
 This study should include consideration of the training of new
investigators, development of multi-center research networks,
involvement of emergency and trauma care researchers in the
grant review and research advisory process, and improved
research coordination through a dedicated center or institute.
 Congress and federal agencies involved in emergency and trauma
care research (including the Dept. of Transportation, the Dept. of
Health and Human Services, the Dept. of Homeland Security, and
the Dept. of Defense) should implement the study’s
recommendations.”

60. Recommendation (7.2)
 “That administrators of state and national trauma
registries include standard pediatric-specific data
elements and provide the data to the National
Trauma Data Bank.
 Additionally, the American College of Surgeons
should establish a multidisciplinary pediatric
specialty committee to continuously evaluate
pediatric-specific data elements for the National
Trauma Data Bank and identify areas for pediatric
research.”

61. Funding the
―EMS for Children‖ Program
 Despite modest annual appropriations, the
EMS-C program boasts many accomplishments
– Initiation of hundreds of injury prevention
programs
– Providing thousands of hours of training to EMT‘s,
paramedics, and other emergency medical care
providers
– Development of educational materials covering
every aspect of pediatric emergency care
– Establishment of a pediatric research network

62. Recommendation (3.7)
 “That Congress appropriate $37.5 million per year
for the next five years to the Emergency Medical
Services for Children program.”
 NOTE: Current funding for EMSC under the Health
Care Reform Act recently passed was approved at
21.5 million for this year; EMSC as a federal
program (HRSA) was “re-authorized” for an
additional 5 years.

63. Concluding IOM Remarks
 The quality of the U.S. emergency care
system is of critical importance
 Though the current system operates
poorly in many respects, a more reliable
system is achievable
 Change must be stimulated quickly,
however, as millions of Americans continue
to access this flawed system each week

64. Concluding IOM Remarks (cont.)
 As reforms to the broader emergency care
system are accomplished, policy makers at
the federal, state, and local levels must
not repeat mistakes made in previous
decades by neglecting the special needs of
pediatric patients
 Consideration of those needs must be fully
integrated into all aspects of emergency
care planning

65. Concluding IOM Remarks (cont.)
 Individual providers (physicians, nurses,
EMT‘s, and others), as well as provider
organizations, also have an important role
to play in stimulating improvements in
pediatric emergency care
 Indeed, they have a responsibility to
ensure that care delivered to children
meets the highest possible standards of
quality

66. What about Virginia?
 EMSC has been around in various forms
for about 12 years
 When federal grant funding became
available, the program was based in the
Department of Pediatrics at Virginia
Commonwealth University
 In 2007, collaboration between VCU and
the Department of Health resulted in
transitioning the EMSC program into the
Office of EMS (Department of Health)

67. Virginia Department of Health
Karen Remley, MD, Commissioner
EMS Advisory Board Office of Emergency Medical Services
(reports to Board of Health) Gary Brown, Director
Division of Trauma & Critical Care
Paul Sharpe, RN, Program Manager
EMSC Committee EMS for Children Program
(reports to EMS Advisory Board) David P. Edwards, MBA, EMSC Coordinator
Medical Director
--Theresa Guins, MD, FACEP
-- Theresa Guins, MD, FACEP
Family Representative
--Petra M. Connell, PhD
-- Petra M. Connell, PhD

68. HRSA Federal Funding
 In 2007 HRSA (Health Resource Services
Administration) awarded the VA Office of
EMS an EMSC State Partnership Grant;
every state has one of these grants and
participates in the program
 One significant focus nationally is to
gather data in regard to a number of
―performance measures‖ inspired and
supported by this IOM report

69. Performance Measures
 The performance measures have
accompanying measurable goals, which are
being pursued at the same time the
measures are being assessed
 Data is being gathered by all fifty states
and 6 U.S. protectorates to establish a
baseline with which to create goals and
evaluate program effectiveness

70. Performance Measure 71
 The percentage of agencies in the
State/Territory that have on-line
pediatric medical direction available from
dispatch through patient transport to a
definitive care facility.
2007-2008 Data Collection: (2009 not collected)
 BLS on-line pediatric medical direction: 42.9%.
 ALS on-line pediatric medical direction: 58.7%.

71. Performance Measure 72
 The percentage of agencies in the
State/Territory that have off-line
pediatric medical direction available from
dispatch through patient transport to a
definitive care facility.
2007-2008 Data Collection: (2009 not collected)
 BLS off-line medical direction: 85.7%.
 ALS off-line medical direction: 82.6%.

72. Performance Measure 73
 The percentage of patient care units in the
state/territory that have essential
pediatric equipment and supplies as
outlined in national guidelines.
2007-2008 Data Collection: (2009 not collected)
 BLS patient care units: 62.2% comply.
 ALS patient care units: 39.0% comply.

73. Performance Measure 74
 The percent of hospitals recognized
through a statewide, territorial, or
regional standardized system that are able
to stabilize and/or manage pediatric
medical emergencies.
 THIS is where the voluntary facility
recognition program comes in… which will
be based on the 3 categorization levels
now being determined.

74. Performance Measure 75
 The percent of hospitals recognized
through a statewide, territorial, or
regional standardized system that are able
to stabilize and/or manage pediatric
trauma emergencies.
 This Performance Measure data will be
extrapolated from current trauma center
designation information.

75. Performance Measure 76
 The percentage of hospitals in the
State/Territory that have written
interfacility transfer guidelines that cover
pediatric patients and that include certain
predefined components of transfer:

76. Performance Measure 76 (cont.)
 Defined process for initiation of transfer, including the
roles and responsibilities of the referring facility and
referral center (including responsibilities for requesting
transfer and communication)
 Process for selecting the appropriate care facility
 Process for selecting the appropriately staffed transport
service to match the patient’s acuity level (level of care
required by patient, equipment needed in transport, etc.)
 Process for patient transfer (including obtaining informed
consent)
 Plan for transfer of patient information (e.g. medical
record, copy of signed transport consent), personal
belongings of the patient, and provision of directions and
referral institution information to family

77. Performance Measure 76 (cont.)
2007-2008 Data Collection:
•Only 14.7% had written transfer
interfacility guidelines that covered
pediatric patients and included all the pre-
defined components of transfer (before the
2009 revision of the definition).
•47% had some kind of written transfer
guidelines, but did not include all of the
pre-defined components of transfer.

78. Performance Measure 77
 The percentage of hospitals in the
State/Territory that have written pediatric
inter-facility transfer agreements that cover
pediatric patients.
2007-2008 Data Collection:
 41.2% of reporting hospitals had written
transfer agreements that cover pediatric
patients.

79. Performance Measure 78
 The adoption of requirements by the
state/territory for pediatric emergency
education for license/certification renewal
of BLS/ALS providers.
 Virginia currently requires both ALS (16 hours) and
BLS (2 hours) personnel to have a minimum number of
pediatric training/education hours to qualify for
certification/renewal.
 Virginia is assessing final national EMS Education
Agenda requirements (and our EMS system‘s
response) before reassessing the appropriate number
of future pediatric focus hours for certification/
renewal.

80. Performance Measure 79
 The degree to which state/territories
have established permanence of EMSC in
the state/territory EMS system by
– establishing an EMSC Advisory Committee
– incorporating pediatric representation on the
EMS Board
– hiring a full-time EMSC Manager
*Virginia has achieved this measure

81. Performance Measure 80
 The degree to which state/territories
have established permanence of EMSC in
the state/territory EMS system by
integrating EMSC priorities into
statutes/regulations.
*6 priorities are detailed, which are included
within the other Performance Measures

82. Number of Hospitals
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83. Article (Richmond Times-Dispatch)

84. Article Continued

85. Current Issues in VA EMSC
 Addition of EMS personnel as mandated
reporters of child abuse—the new law went
into effect July 31, 2009
 Establishing ―best practices‖ for using child
restraints (during ambulance transport)
 Inhalant abuse by children/adolescents
 Increasing access to pediatric training
 Hospital ED pediatric care—medical and
trauma (recognition and categorization)
 Pediatric disaster preparedness

86. Pediatric Facility Recognition
Process to identify
the readiness and
capability of a
hospital and its
staff to provide
optimal pediatric
emergency and
critical care

87. Facility Recognition Development
 EMSC Committee (VA EMS Advisory Board)
 Trauma Systems Oversight & Management
Committee (VA EMS Advisory Board)
 Virginia EMS for Children (EMSC) Program
 Virginia Hospital & Healthcare Association
 VA Chapter, American Academy of Pediatrics
 VA College of Emergency Physicians
 VA Emergency Nurses Association
 ED Nurse, ED Physician, EMS Coordinator,
Pediatric Nurse Practitioner, Pediatric
Physician, Pediatric Nurse Manager, Trauma
Coordinator, and _________

88. Pediatric Facility Recognition Levels (DRAFT)
SEDP EDAP PCCC
 Standby or Basic ED  Comprehensive ED •Comprehensive ED
 Typically does not have  24 hour ED that is an EDAP
inpatient pediatric physician coverage •Dedicated PICU
capabilities •Range of pediatric
 Able to provide
 Criteria aims to assure specialty services
capabilities to initially more specialized
pediatric services and inpatient
manage/resuscitate resources
patient  May have inpatient
•Have transfer
 Transfer agreements pediatric agreements with
with tertiary care capabilities
centers and referral facilities
 Transfer •Transport team or
mechanisms to transfer
child to a more definitive agreements affiliation with
level of care as transport system
appropriate

89. Physician Qualifications/Requirements
 EDAP - One MD per shift with Board
Certification
– ABEM, AOBEM, ABP, AOBP, ABFP, AOBFP
 Current PALS/APLS for the physicians above who are not emergency
medicine board certified
– Waiver option
 SEDP - Licensed MD
– Training in care of pediatric patients thru residency training,
clinical training or practice
– Current PALS/APLS
 EDAP/SEDP
– 16 hrs CME in pediatric emergency topics every two years
– Availability of pediatric telephone consultation capabilities
– ED Back-up physician within 1 hour for increased surge
– Response time protocols for on-call physicians

90. Physician Qualifications/Requirements
 PCCC
– PICU Medical Director
1. Board Certified in Pediatrics by ABP or AOBP, and Board
Certified or in the process of certification in Pediatric Critical
Care Medicine by ABP or Pediatric Intensive Care by AOBP; or
2. Board Certified in Pediatrics by ABP or AOBP and Board
certified in a pediatric subspecialty with at least 50% practice
in pediatric critical care; or
3. Board Certified in Anesthesiology by ABA or AOBA, with
practice limited to infants and children and with a
subspecialty Certification in Critical Care Medicine;
4. Board Certified in Pediatric Surgery by ABS with a
subspecialty Certification in Surgical Critical Care Medicine by
ABS.
NOTE: In situations 2, 3 & 4 above, a Board Certified Pediatric
Intensivist, certified by ABP, shall be appointed as Co-
Director.

91. Physician Qualifications/Requirements
 PCCC – The PICU shall have 24 hour in-hospital coverage
by:
– A Board Certified Pediatric Intensivist, certified by ABP or AOBP, or
in the process of certification by ABP or AOBP, who is available
within 30 minutes in-house after determination is made that they are
needed and who is responsible for the supervision of those listed
below. When the intensivist is not in-house, one of the following must
be in-house:
 Board Certified Pediatrician, certified by ABP or AOBP or in the process of
board certification;
 A resident of PGY-2 or greater under the auspices of a Pediatric Training shall
be in the unit, with a PGY-3 in-house.
– All of the physicians listed above shall successfully complete and
maintain current recognition in PALS or APLS
– Availability of physician specialists
 Pediatric Unit Hospitalists – Maintain APLS or PALS

92. Mid-Level Provider Qualifications
Nurse Practitioners/Physician Assistants
EDAP/SEDP
 Credentialing reflects orientation, ongoing training, specific
competencies in the care of the pediatric emergency patient
 Current recognition in APLS, ENPC or PALS
 Nurse Practitioner
– Emergency NP; or
– Pediatric NP; or
– Family Practice NP; or
– Waiver option (2000 hours of hospital-based ED or acute care as
a nurse practitioner over the last 24 month period that includes
pediatric patients)
 16 hours CEU/CME in pediatric emergency topics every two
years

93. Mid-Level Provider Qualifications
Nurse Practitioners/Physician Assistants
PCCC
 PICU Nurse Practitioner – completion of a Pediatric Nurse
Practitioner program or Pediatric Critical Care Nurse
Practitioner Program. Certification as an Acute Care Nurse
Pediatric Practitioner
 PICU Physician Assistant – Current Virginia Physician
Assistant licensure
 NP & PA – Completion of a documented, precepted, post
graduate clinical experience, in the management of
critically ill pediatric patients
 NP & PA - 50 hours CEU/CME in pediatric critical care
topics every two years

94. Staff Nursing Qualifications
 One RN per shift responsible for the direct care of the
child in the ED with current recognition in:
– APLS, or
– ENPC, or
– PALS
 All ED nurses need to maintain recognition in APLS,
ENPC or PALS within 2 years of hire
 EDAP - 8 hours of pediatric emergency/critical care CE
every two years for all nurses
 SEDP - 8 hours of pediatric emergency/critical care CE
every two years for one nurse per shift

95. Staff Nursing Qualifications
PCCC
 PICU Nurse Manager
– 3 years of clinical critical care experience with a minimum of one year in
clinical pediatric care
– Maintains APLS, ENPC or PALS recognition
 Pediatric Unit Nurse Manager
– 3 years pediatric experience
– Maintains APLS, ENPC or PALS recognition
 Advanced Practice Nurse (CNS/NP)
– Completion of a documented, precepted, post graduate clinical
experience, in the management of critically ill pediatric patients
– 50 hours CEU/CME in pediatric critical care topics/two years
 Staff Nurse
– Maintains APLS, ENPC or PALS recognition
– 16 hours of pediatric emergency/critical care CE every two years for PICU
and pediatric unit nurses

96. Policies and Procedures
 EDAP/SEDP
– Interfacility Transfer Policy
– Interfacility Transfer Agreements
– Suspected Child Abuse Policy
– Latex-Allergy Policy
– Pediatric Treatment Guidelines
 Requirement currently reads as “The facility shall have
protocols addressing appropriate stabilization measures in
response to critically ill or injured pediatric patients”
 Submitted change to EMS Rules “The facility shall have
guidelines or policies addressing initial response and
assessment for the high volume/high risk pediatric population
(ie fever, trauma, respiratory distress, seizures)”
 Encourage to link newly developed guidelines with CQI
monitoring

97. Policies and Procedures
 PCCC
– Admission/discharge criteria policy
– Nursing staffing policy based on patient acuity
– Managing psychiatric/psychosocial needs of the PICU
patient
– Protocols/order sets/guidelines for management of
high/low frequency diagnoses
– Others

98. Quality Improvement
Emergency Department
 Multidisciplinary CQI process with documented monitors
addressing pediatric care
 Must minimally address all pediatric ED deaths, resuscitations
and interfacility transfers
 Designation of a pediatric CQI Liaison who is responsible to:
– Assure documentation of pediatric continuing education
requirements
– Coordinate pediatric focused CQI activities
– Participate along with other hospital CQI Liaisons within your region
in Regional CQI Subcommittee meetings and conduct regional
quality improvement activities
– One CQI Liaison designated per region to report on Regional CQI
Subcommittee activities to Regional EMS Advisory Board

99. Quality Improvement
PCCC - PICU/Inpatient Pediatric Unit
 Multidisciplinary Pediatric CQI Committee
 Focused outcome analyses of PICU services,
including:
– Pediatric deaths
– Pediatric interfacility transfers
– Pediatric morbidities or negative outcomes as a result of
treatment rendered/omitted
– Pediatric audit filters
– Child abuse cases (unless performed by another
hospital committee)
– Readmissions within 48 hours of being discharged from
the ED or inpatient that result in admission to the PICU
– All potential and unanticipated adverse outcomes

100. CQI Goal/Objectives
Improve overall pediatric emergency/critical care
• Enhance individual emergency department pediatric quality
improvement activities
• Bring together hospitals within a region
• Networking
• Mentoring
• Sharing of resources/experiences
• Monitors
• Standards
• Education
• Develop targeted regional ED/EMS quality improvement initiatives
• Demonstrated improvements (some have shown statistical
significant improvements)
• Plans to develop QI process among PCCC’s

101. Equipment/Supplies/
Medications
• Various equipment items, supplies and medications
• Dosing device (length or weight based system for dosing
and equipment)
• Access to the 1-800-222-1222 Virginia Poison Center
helpline
• Latex-free policy that identifies access to latex supplies
• Equipment/Supplies/Medications requirements include all of
the items listed in the AAP/ACEP Care of Children in the
Emergency Department: Guidelines for Preparedness

102. Facility Recognition
Addresses Healthy People 2010, Objective 1-14b
“Increase the number of States and the District of Columbia that
have adopted and disseminated pediatric guidelines that
categorize acute care facilities with the equipment, drugs, trained
personnel and other resources necessary to provide varying
levels of pediatric emergency and critical care.”
Addresses EMSC Five Year Plan, Objective A-3
“Increase to 56, the number of States, Tribal Reservations,or
Federal Territories that have adopted and disseminated pediatric
guidelines that categorize acute care facilities with the
equipment, drugs, trained personnel and facilities necessary to
provide varying levels of pediatric emergency and critical care.”

103. Facility Recognition
Addresses National EMSC Performance
Measures
 PM 74: The percentage of hospitals with an
emergency department (ED) recognized
through a statewide, territorial, or regional
standardized system that are able to stabilize
and/or manage pediatric medical emergencies.
 PM 75: The percentage of hospitals with an
emergency department (ED) recognized
through a statewide, territorial, or regional
standardized system that are able to stabilize
and/or manage pediatric traumatic
emergencies.

104. Facility Recognition
National EMSC Performance Measures Addressed
 PM 76: The percentage of hospitals with an ED in the state/territory
that have written interfacility transfer guidelines that cover pediatric
patients and that contain the following components of transfer:
– Defined process for initiation of transfer, including the roles and responsibilities of the
referring facility and referral center (Including responsibilities for requesting transfer and
communication)
– Process for selecting the appropriate care facility
– Process for selecting the appropriately staffed transport service to match the patient’s
acuity level (level of care required by patient, equipment needed in transport, etc.)
– Process for patient transfer (including obtaining informed consent)
– Plan for transfer of patient information (e.g. medical record, copy of signed transport
consent), personal belongings of the patient, and provision of direction and referral
institution information to family

105. Facility Recognition
Helps to Address 2006 JCAHO Survey Focus
on Emergency Management and Preparation
for Special Populations (i.e. pediatric
population)

106. Guidelines for Care of Children
in the Emergency Department
--October 2009
 Consensus document that was jointly
developed by the American Academy of
Pediatrics (AAP), the American College of
Emergency Physicians (ACEP) and Emergency
Nurses Association
 Defines minimal guidelines/”standards” for
ED’s to assure appropriate tools are in place to
care for the pediatric patient

107. Endorsed By…
 Academic Pediatric  National Association of
Association Children‘s Hospitals and
 American Academy of Family Related Institutions
Physicians  National Association of EMS
 American Academy of Physicians
Physician Assistants  National Association of
 American College of Emergency Medical
Osteopathic Emergency Technicians
Physicians  National Association of State
 American College of Surgeons EMS Officials
 American Heart Association  National Committee for
 American Medical Association
Quality Assurance
 American Pediatric Surgical
 National PTA
Association  Safe Kids USA
 Brain Injury Association of  Society of Trauma Nurses
America  Society for Academic
 Child Health Corporation of Emergency Medicine
America  The Joint Commission
 Children‘s National Medical  Pediatrics 2009;124:1233-
Center 1243
 Family Voices

108. Implementation Forthcoming…
 To date, _0_ hospitals within the state are
recognized as a PCCC, EDAP or SEDP
 List of recognized hospitals will eventually be
accessible on Virginia EMSC & Virginia
Department of Health websites
– www.vdh.state.va.us/OEMS
– www.vdh.state.va.us
 Also an initial step in pediatric disaster/terrorism
preparedness

109. Site Survey Issues
 Education
– Physician non-compliance with pediatric CME
requirements
 Ongoing pediatric continuing education is essential
for ALL practitioners who encounter children
 On-line CME is available and easy to access
– Non-American Heart Assn sponsored PALS courses
(needs to include both cognitive and skills evaluation –
some online PALS course do not meet this)
– Conduction of pediatric mock codes
 PALS scenarios can be used as a resource
 Multidisciplinary; incorporate utilization of crash cart

110. Site Survey Issues (cont.)
 Policies/Documentation
– Outdated written interfacility transfer agreements
– Lack of pediatric treatment guidelines or lack of
protocols/guidelines that address high volume or low
volume/high risk diagnoses
– Pediatric guidelines containing outdated information
(i.e. IO access only in kids < 5y/o) or treatment
modalities not consistent with current practice
standards (i.e. use of Demerol in young children, use
of rotating tourniquets)
– Pediatric pain scale addressing the infant and non-
verbal child
 Most ED’s using Wong-Baker FACES scale (appropriate for
age 3 and older)
 Need scales based on physiologic criteria for younger
children, ie FLACC, NIPS

111. Site Survey Issues (cont.)
Equipment/Supplies
– Old Poison Center phone # posted (new National
Poison Hotline 1-800-222-1222)
– Outdated Broselow tape (2007 is the latest version)
– Expired drugs/equipment trays
– Stocking of medications that are no longer
recommended, i.e. Ipecac
– Missing smaller airway supplies, i.e. nasal cannula,
nasal airways, pediatric magill forceps

112. Site Survey Issues (cont.)
– Pediatric crash cart issues
 Poor organization or difficulty finding items
 Lack of first-line resuscitation drugs stocked in
crash cart
 Broselow cart stocking that is not consistent with
the color coded tape
 Cart check system not consistently documented
 Crash cart not locked
 Pediatric crash carts not standardized within the
institution

113. Site Survey Issues (cont.)
Quality Improvement
– Inconsistent or lack of attendance at regional CQI meetings
– CQI documentation doesn’t include thorough follow-thru or
loop closure
– Need to build on current pediatric QI efforts
Other
– Lack of administrator or designee during site survey. Difficult
to determine administrative support
– Lack of awareness of physician waiver availability
– Need to begin incorporating pediatric components in disaster
planning

114. Facility Recognition Goal
To decrease childhood morbidity
and mortality by ensuring the
availability of appropriate
emergency department
resources and capabilities in
order to effectively manage
the critically ill and injured
child.

115. The Need for EMSC
“While I was U.S. Surgeon General, the United States
Congress passed legislation to improve emergency
medical services for children. It received my full support,
because critically ill and injured children were not
receiving the same high quality of emergency health care
we provided for adults. But this is not unusual;
throughout history, children have not been our first
priority.”
- C. Everett Koop, MD

117. Hospital Surveys
 I need help! I need a contact person to
fill out a short SIMPLE survey regarding
written pediatric emergency transfer
GUIDELINES and AGREEMENTS.
 I need more than 80% of hospitals to fill
out this survey to remain in good graces
for funding through HRSA for equipment,
supplies and training for hospital and EMS
personnel.

119. Questions?

120. Thanks for your attention
This has been
Hospital Pediatric
Emergency Care Readiness
“Children’s Project”
Small Rural Hospital Conference
Williamsburg, Virginia
April 13, 2010
David P. Edwards, MBA
Virginia EMS for Children Coordinator
David.Edwards@vdh.virginia.gov

121. Tashkent, Uzbekistan, 1999