Pediatric Emergencies

(1)

0

American Medical Association Commission on Emergency Medical

Services

Pediatric

Emergencies

An excerpt from “Guidelines for the Categorization of Hospital Emergency Capabilities.”

Endorsed by the American Academy of Pediatrics

PREAMBLE

The purpose of these guidelines for the classifi-cation of pediatric emergency services is (a) to allow

any given community to identify the level of care available for the critically injured or ill pediatric patient, and (b) provide guidance to hospitals and EMS systems as to the resources necessary to pro-vide optimal care to these children. This is a nec-essary step in the development of EMS systems that meet the needs of the pediatric patient.

These systems require (1) patient and parent 0 recognition of when to access the system and

knowledge of how to access the system; (2) prehos-pital care providers with appropriate expertise in the assessment and treatment of infants, children, and adolescents; (3) regional networking of

hospi-. tals at varying levels of pediatric sophistication

with transport systems to ensure that the critically ill or injured child is promptly identified, stabilized,

; and brought to the tertiary pediatric center; (4) primary and secondary centers that have the level of expertise to care for the bulk of pediatric pa-tients; (5) the development ofpediatric tertiary care facilities with pediatric subspecialist availability for the complex patients; (6) pediatric rehabilitation and long term care programs; and (7) audit and quality assurance programs to review the care ren-dered.

This document only addresses one part of a sys-tern, the classification of hospital capabilities. The

systems implementation process involves a tn-phasic approach:

1. The identification of the capabilities of an

Received for publication Jan 23, 1990; accepted Jan 26, 1990

0 Reprint requests to American Medical Association, 535 N Dear-born, Chicago, IL 60610.

Chap-institution by that institution which will provide

information on its compliance with the guidelines.

2. Verification of a given hospital’s compliance or noncompliance with the guidelines by outside, noninvolved individuals, the verification site re-view.

3. Designation of the hospital, a political govern-mental process by which a legally empowered agency designates the level of care a given hospital can provide, based on the above verification proc-ess.

This process should not be viewed as an isolated event, but always kept in the context of creating an appropriate and optimal system of pediatric care. Thus, these guidelines describe institutions with three different levels of pediatric sophistication. The Level III primary care hospital has minimal pediatric resources but has the ability to stabilize seriously ill and injured children before transport. The Level II hospital has significant pediatric re-sources but lacks comprehensive subspecialty ex-pertise. The Level I hospital has comprehensive pediatric resources available to provide definitive care for the most complex problems.

(2)

0

Guidelines Levels

(E = essential;

D = desirable)

I II III

I. Hospital organization

All physician/staff members listed shall be either Board Certi-fled or Board Eligible and actively seeking certification. This standard includes subspecialty Boards/Certificates where appli-cable. Each member of the institution’s medical staff shall be credentialed by the facility for the appropriate specialty, includ-ing trauma care where applicable. More than one area of practice in the surgical specialties may be covered by one individual with appropriate training and experience.

880 PEDIATRIC EMERGENCIES

The exact interplay of these institutions will vary from state to state and region to region, as will available resources. In regions with limited pediat-nc resources, the concentration of specialists in a comprehensive center will be important to avoid the fragmentation and dilution of care to children. The Level I center outlined in these guidelines describes the requirements for such a comprehen-sive center capable of bringing pediatric medical and surgical expertise to the bedside of acutely ill or traumatized children. This comprehensive ap-proach is important because of the multispecialty teams required to care for these complex patients.

Institutions may choose to develop expertise in certain areas and not others. In some areas such as large metropolitan communities, there may be ad-equate pediatric resources so that multiple centers will coexist. Alternatively, pediatric expertise may be divided so that different institutions elect to concentrate on specific missions, e.g., pediatric traumatic or pediatric medical emergencies. In such settings, these guidelines can be used to define the personnel, facilities, and equipment requirements necessary to meet the institution’s mission. If a regional EMS system only defines, for example, the subset of capabilities for the traumatized child; the critically ill children, representing up to 80% of the patient pool requiring critical care, will be under-served. Great care must be exercised in the desig-nation process to avoid neglecting the needs of major groups of pediatric patients.

Thus, it is important that these guidelines be utilized synergistically to ensure that pediatric trauma is an integral part of an overall system to provide care for traumatized patients while simul-taneously an integrated approach to all pediatric patients exists within an overall EMS system. Where a comprehensive effort in meeting the needs of children has not been undertaken, these young patients are deprived of the benefits that an orga-nized EMS system brings to adult patients. Where

such an effort is made, the outcome for children can be significantly improved.

Each region will have its own unique

character-istics with varying resources for pediatric care. The major factor that must be considered by all regions is the identifiable measure of the commitment. This commitment entails not just the determination that patients with severe trauma on life-threatening medical illness be tniaged to the appropriate facility, but perhaps as importantly, this commitment should entail a constant effective integration of all the specialities dedicated to the improvement of care for children.

CLASSIFICATION: PEDIATRICS

Level I

An institution capable of providing comprehen-sive, specialized pediatric care to any acutely ill or injured child. Usually a children’s hospital or a large general hospital with a pediatric division providing comprehensive subspecialty pediatric medical and surgical services.

Level II

A hospital with a pediatric service capable of caring for the majority of pediatric patients, but with limited pediatric critical care and subspecialty expertise.

Level III

A

hospital with a functioning Emergency De-partment capable of evaluation, stabilization, and transfer of seriously ill and injured pediatric pa-tients. Such facilities should have formalized trans-fer agreements to higher levels of pediatric care. They should provide a vital service in stabilization and transfer in areas where level I and level II facilities are not readily accessible.

0

at Viet Nam:AAP Sponsored on September 7, 2020

www.aappublications.org/news

(3)

Guidelines (E essential;

D = desirable)

I II III

0

E E E E E E E E E E E E E E E E

D

D D

D

E D E

D

E E E In-house 24 Hours per Day

On Call and Promptly Available

1. Department of Pediatrics Chairman Emergency Medicin& Critical Care Cardiology Neurology Pulmonology Allergy/Immunology Gastroenterology Hematology/Oncology Nephrology Endocrinology General Pediatrics Infectious Diseases

2. Department of Surgery General Surgery Pediatric Surgery Cardiac Surgery

Pediatric Cardiac Surgery Neurologic Surgery

Pediatric Neurologic Surgery Urologic Surgery

Pediatric Urologic Surgery Gynecologic Surgery Orthopedic Surgery

Pediatric Orthopedic Surgery Plastic and Maxillofacial Surgery Oral Surgery

Ophthalmologic Surgery

Pediatric Ophthalmologic Surgery Pedodontics

Otorhinolaryngology Thoracic Surgery

3. Department of Anesthesia Pediatric Anesthesia

4. Emergency Department 5. Pediatric Trauma Service 6. Radiology Department

Pediatric Radiology 7. Specialist Availability

(4)

Levels

Guidelines (E = essential;

D = desirable)

I II III

Neurology Pediatric Neurology Pulmonology Pediatric Pulmonology Allergy/Immunology Pediatric Allergy/Immunology Gastroenterology Pediatric Gastroenterology Hematology/Oncology Pediatric Hematology/Oncology Nephrology Pediatric Nephrology Endocrinology Pediatric Endocrinology General Pediatrics Radiology Pediatric Radiology Infectious Disease

Pediatric Infectious Disease Family Medicine (or Pediatrics) Anesthesia

Neurosurgery Pathology

Pediatric Pathology

Physical Medicine and Rehabilitation Psychiatry

Pediatric Psychiatry

Orthopedic Surgery

Pediatric Orthopedic Surgery Microsurgery

Cardiac Surgery

Pediatric Cardiac Surgery Gynecologic Surgery Otorhinolaryngolic Surgery Plastic and Maxillofacial Surgery Oral Surgery

Pedodontics

Ophthalmologic Surgery

Pediatric Ophthalmologic Surgery Hand Surgery

Urologic Surgery

Pediatric Urologic Surgery General Surgery

Vascular Surgery Thoracic Surgery 8. Department of Nursing

Director of Nursing

Manager, Pediatric Nursing

Pediatric Head Nurse, General Pediatrics

Pediatric Clinical Specialist: ED, OR, ICU, PACU

0 D E E

D

0

D D

D

E E

0

D

882

PEDIATRIC

EMERGENCIES

E E E E E E E E E E E E E E E E E E E E E E E E E E E E D D D D D D D D D D D

D

E E

D

D E E E D E D E D

D

D D D E

D

D D E

D

E

D

E D D E E E D

(5)

D

= desirable)

I

II

III

E E E

E6 E6

E2 E E

E6

E D

E

E7

E

E#{176}

E8 E E E E4 E

E

D

E D

E E9 E9

E E D

E D

E E D

E E E

0

Pediatric Nurse Education Trauma Nurse Coordinator

II.

Facilities/Resources/Capabilities 1. Emergency Department

A. Personnel

1. Designated Physician Director

2. Physician with a commitment to the care of the critically ill or injured child present in E.D. 24 hours per day

3. Pediatric consultant readily available

4. Pediatric trauma team

Immediately Available

a. Trauma team leader as designated by the chief of trauma service

b. 2 additional MD members of trauma team c. Neurologic Surgery

d. Emergency Nurses e. Respiratory Therapist f. Laboratory Technician g. Radiology Technician h. Anesthesia

i. Orthopedics

0 Promptly Available

a. Licensed/certified clinical social worker, as a member of an interdisciplinary team, shall provide families with psychotherapeutic serv-ices, which may include, but are not limited to, crisis intervention, grief counseling, advo-cacy, etc.

5. Nursing Staff

a. Designated Pediatric Nursing Director b. Designated E.D. Nursing Director c. Pediatric Clinical Nurse Specialists

d. General Staff experienced in pediatric emer-gency nursing care

e. Staff Educator in Pediatrics

6. Dedicated Pediatric Emergency Area

7. Designated resuscitation area equipped for the resuscitation and stabilization of neonatal,

pedi-atnic/adolescent patients and of adequate size to

accommodate a full resuscitation team, including trauma

B. Equipment

1. Communication equipment with EMS system 2. Airway control and ventilation equipment

a. Laryngoscopes: sizes 0, 1, 2, 3, straight and curved

(6)

0

Levels

D = desirable)

I II III

c. Endotracheal tubes cuffed and uncuffed: 2.5- E E E

9.0 (2.5-6.0 uncuffed)

d. Suction and appropriate size catheters, 5-12 E E E

fr, yankauer

e. Airways E E E

f. Oxygen E E E

g. Tracheostomy and thoracostomy trays with E E E

tracheostomy tubes: size 0-3; chest tubes: size 16-28 fr

h. Thoracotomy tray E E

3. Cardiopulmonary monitors with pediatric capa- E E E

bility;

Monitors with at least two pressure capability E D

4. Catheters for intravenous and intraarterial lines E E E

(3-8 fr, 16-24 gauge, intraosseous needles)

5. Monitor-defibrillator with pediatric paddies 0- E E E

400 watt/sec capability

6. Trays for venisection suturing, plastics E E E

7. Pediatric splints, casts, traction including equip- E E E

ment for cervical spine stabilization

8. NG tubes: #10-36 fr, 3 and 5 fr feeding tubes E E E

9. Foley catheters #8-14 E E E

10. Dialysis catheters: infant, pediatric and adult E E E

1 1. Medications in pediatric concentrations E E E

12. IV solutions with both microdrip and high volume E E E

infusion sets

13. Pediatric LP and subdural trays E E E

14. Burr-hole/ICP monitor tray E

15. Blood pressure cuffs: premie, infant, child, adult, E E E

thigh

16. Doppler for blood pressure monitoring E E E

17. Non-invasive blood pressure monitor E E E

18. Pulse oximeter E E E

19. MAST suits: adult, adolescent, child E E E

20. Infusion pumps with fractional cc infusion capa- E E E

bility

21. Pediatric scales for weight measurement E E E

22. Temperature control devices for patient, IV E E E

fluids, and blood

23. Printed pediatric drug dosage reference material E E E

readily available

24. Thermometer with range 28#{176}-42#{176}C E E E

25.OBtray E E E

C. Support Services

In-house 24 hours per day

1. Laboratory with micro capability and blood gas E E D

analysis, blood bank capabilities

2. X-ray availability E E D

3. Respiratory Therapy E E D

(7)

D

= desirable)

I

II

III

0

D. On Call and Promptly Available

1. Clinical social worker, as a member of an inter- E E E

disciplinary team, shall provide families with psy-chotherapeutic services, which may include, but are not limited to, crisis intervention, grief coun-seling and advocacy, as well as physical and sex-ual abuse protocols.

2. Pastoral Care E E E

3. Child Life Therapist E D

2. Intensive Care Unit

A. Separate Pediatric Unit E D

B.

Designated Pediatric Medical Director E D

C. Pediatric ICU physician present in hospital 24 hours E#{176} D per day

D. Designated Pediatric Nursing Unit Manager E D

E. Pediatric Nurse Specialists E D

F. Equipment

1. Invasive monitoring venous, arterial E E

2. Invasive monitoring capabilities: cardiac output, E D pulmonary artery, ICP monitoring

3. Cardiopulmonary monitors with E E

at least 3 pressures

4. Capnography E D

5. Pulse oximeter E E

6. Noninvasive blood pressure monitoring E E

7. Pacemaker capability, including temporary E

transvenous pacemaker

8. Pediatric ventilators E E

9. Airway control equipment as listed in ED E E

10. Appropriate emergency surgical trays, i.e., cut- E E

down, thoracotomy, ventniculostomy

11. Pulmonary function measuring devices E D

3. Operating Room

A. Readily available and adequately staffed 24 hours per E E D

day

B.

Nursing Unit Manager E E E

C. Scrub and circulating nurse readily available E E D

D.

Post Anesthesia Care Unit (may be PICU) staffed 24 E D D

hours per day E. Equipment

1. Cardiopulmonary bypass E

2. Operating microscope E D

3. Thermal control for patient, room and blood E E E

4. X-ray capability including C-arm E D

5. Cardiopulmonary monitoring with E E E

at least 3 pressures E D

6. Endoscopes and bronchoscopes E E

7. Craniotome E E

(8)

0

886 PEDIATRIC EMERGENCIES

Levels

D

= desirable)

I II III

9. Pediatric anesthesia equipment E E D

10. Noninvasive blood pressure monitoring E E D

11. Pulse oximeter E E E

12. Cardiac output equipment E D

13. Pediatric instruments and equipment E E D

4. Clinical Laboratory

Available 24 hours per day: E E E

1. Chemistry E E E

2. Hematology E E E

3. Serology E E D

4. Blood bank E E E

5. Blood gases E E E

6. Microbiology E E D

7. Toxicology E E D

8. Drug levels E E D

9. Micro capability E E D

5. Hemodialysis Capability/Transfer Agreement E E

6. Burn Unit Availability/Transfer Agreement E E E

7. Pediatric Medical/Surgical Units

A.

Separate pediatric unit E E

B. Pediatric Unit Nursing Director E E

C.

Pediatric nurses in appropriate staffing E E

D.

Equipment

1. Airway equipment as in ED E E

2. Oxygen, air, and suction E E

3. EKG monitor/defibrillator E E

4. Standard pediatric IV solutions, drugs and sup- E E

plies 8. Radiology

A.

Immediately Available

1. Routines 24 hours per

day

E

B.

Promptly Available

1. Angiography 24 hours per day E D

2. Ultrasound 24 hours per day E D

3. CT scan 24 hours per day E D

4. Nuclear Medicine E D

5. MRI scan D D

9. Rehabilitation Medicine/Transfer Agreement

A.

Medical Director E D

B.

Properly trained staff to provide comprehensive ap- E D

proach

10. Acute Spinal Cord Injury Management Capability/Trans- E E E

fer Agreement

11. Helipad E E E

12. Transport Protocols and Transfer Agreement for Critically E E E

Ill and Injured Pediatric Patients

13. Participation in Regional Interhospital Transfer Program, E E E

Including Transfer Agreements

14. Pharmacy Staffed by Licensed Pharmacist

A.

In-house 24 hours per day E D

B.

Promptly available E D

(9)

0 D

= desirable)

I

II

III

15. Organ Procurement Program and Agreement E E E

III. Quality Assurance

1. Structured program E E E

2. Review of all pediatric deaths E E E

3. Review of all incident reports E E E

4. Multidisciplinary pediatric trauma and resuscitation con- E E E

ferences

5. Maintain pediatric trauma registry E D

6. Participate in pediatric trauma registry E E E

7. Pediatric Nursing Audit E E E

8. Review of all E.D. 7-day neadmits E E E

9. E.D. physician audit of pediatric patients E E E

10. Review of pediatric transports and pre-hospital care E E E

1 1. Review of regional systems of pediatric care E E E

12. Participate in medical direction of EMS systems E E E

IV.

Community Programs

1. Consultations with physicians and referral institutions E E E

2. Public Education E E E

3. Continuing Education Program for professional staff E E E

4. Pre-hospital Care Providers Education E D D

5. Outreach program to referral institutions E D

V. Research

1. Pediatric Trauma E D

2. Pediatric Critical Care E D

3. Pediatric Emergency Medicine institutions E D

NOTES: PEDIATRIC EMERGENCIES

1. Requirements may be met by a Pediatric Emergency De-partment in a Department of Pediatrics or by a recognized administrative component of Pediatric Emergency Medicine within a Department of Emergency Medicine.

2. This requirement may be fulfilled by a physician (1) who is board certified/board eligible in pediatrics or board certi-fled/board prepared in emergency medicine and (2) who demonstrates his/her commitment by engaging in the exclu-sive practice of pediatric emergency medicine a minimum of 100 hours per month, or has an additional one year of training in pediatric emergency medicine.

3. When a resident or other physician is utilized to fulfill this requirement the chief of the respective specialty service shall designate residents at the appropriate level of training who can provide the indicated treatment. Staff specialist shall be physically present within 30 minutes.

4. Requirements may be fulfilled by an anesthesiology resident and/or CRNA designated by the Chief of Anesthesia as capable of assessing emergent situations in pediatric pa-tients and providing any indicated treatment. Where no facility in a region can provide in-house anesthesia coverage, this requirement may be met by an attending level pediatric critical care or pediatric emergency medicine physician

des-0

ignated as above by the ChiefofAnesthesia. A staff specialist in pediatric anesthesia must be available promptly within 30 minutes. (In Level II facilities a staff specialist in anes-thesia must be available within 30 minutes.)

5. A physician capable of pediatric airway management must be present in the hospital 24 hours/day. This could be a pediatrician, emergency medicine physician, anesthesiolo-gist or surgeon.

6. In institutions that do not provide an organized trauma service, these criteria do not apply.

7. A staff level surgical team leader must be in-house within 30 minutes if a surgical resident is fulfilling this require-ment. The staff surgeon will assume the team leader role on arrival. In the interim, leadership of the trauma team must be defined clearly by pne-established protocols. Such proto-cols should ensure that an attending level physician is physically present during the initial resuscitation.

8. If the Emergency Department is not always staffed to pro-vide an adequate number of trauma nurses, nurses in the hospital with special training in pediatric trauma must be on call as members of the trauma team. At least two nurses per shift must have completed a pediatric trauma nurse

course. These nurses may come from a Pediatric Unit. 9. There must be one nurse on each shift who has extra

(10)

1990;85;879

Pediatrics

Pediatric Emergencies

Services

Updated Information &

http://pediatrics.aappublications.org/content/85/5/879

including high resolution figures, can be found at:

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtml

entirety can be found online at:

Information about reproducing this article in parts (figures, tables) or in its

Reprints

http://www.aappublications.org/site/misc/reprints.xhtml

Information about ordering reprints can be found online:

(11)