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Edwards Edwards Presentation Transcript

  • 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
  • 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.
  • ―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.
  • 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.
  • 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)
  • Why Children are Different  Medication dosages  Emotional reactions  Ability to communicate  Triage more difficult
  • Studies identified that children had higher mortality rates than adults in similar emergency situations
  • Provider Stress  It is not surprising, then, that many emergency providers feel stress and anxiety when caring for pediatric patients
  • Provider Stress
  • 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.
  • 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
  • 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.
  • 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
  • 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
  • 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
  • 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)
  • 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)
  • 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
  • Example: Disaster Preparedness  Disaster preparedness plans often overlook the needs of children, even though their needs during a disaster differ from those of adults
  • 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
  • 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
  • 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
  • Achieving the Vision of a 21st Century Emergency Care System  Three Goals: – Coordination – Regionalization – Accountability
  • 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
  • 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
  • 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
  • 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.
  • 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.”
  • 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.”
  • 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
  • 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
  • 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.”
  • 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
  • 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.”
  • 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.”
  • 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.”
  • 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
  • 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
  • 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.”
  • 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.”
  • 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.”
  • 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
  • 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”.
  • 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.”
  • Recommendation (5.3)  “That hospitals and emergency medical services agencies implement evidence-based approaches to reducing errors in emergency and trauma care for children.”
  • 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.
  • 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.
  • 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”
  • 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.
  • 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.
  • Recommendation: (5.5)  “That emergency medical services agencies and hospitals integrate family-centered care into emergency care practice.
  • 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.
  • 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:”
  • 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.”
  • 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.
  • 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
  • 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.”
  • 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.”
  • 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
  • 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.
  • 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
  • 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
  • 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
  • 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)
  • 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
  • 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
  • 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
  • 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%.
  • 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%.
  • 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.
  • 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.
  • 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.
  • 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:
  • 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
  • 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.
  • 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.
  • 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.
  • 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
  • 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
  • Number of Hospitals B lu 0 2 4 6 8 10 12 14 C e R 16 en id tr a lS ge 2 he na nd oa h Lo 5 rd Fa N irf ax or th er 4 n Vi rg in O ia ld D 9 om in i on Pe 16 nn in s ul R a ap 6 pa ha So nn u o ck th Hospitals by EMS Region w es 3 tV irg in ia 12 Ti de Th w at om er as 11 Je ffe W rs es on te 2 rn Vi rg in ia 13
  • Article (Richmond Times-Dispatch)
  • Article Continued
  • 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
  • Pediatric Facility Recognition Process to identify the readiness and capability of a hospital and its staff to provide optimal pediatric emergency and critical care
  • 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 _________
  • 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
  • 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
  • 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.
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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.”
  • 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.
  • 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
  • Facility Recognition Helps to Address 2006 JCAHO Survey Focus on Emergency Management and Preparation for Special Populations (i.e. pediatric population)
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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.
  • 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
  • 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.
  • Questions?
  • 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
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