by Allee
Mead
If a sick or injured child comes into your emergency
department, do you know what to do? Do you use
age-appropriate pain scales? Do you have child-sized
blood pressure cuffs and automated external defibrillator
pads? Is this equipment in a central location so staff
can find it quickly? Do you have policies and trainings
so the staff know how to assess, treat, and transfer
pediatric patients?
Pediatric readiness is an emergency department’s or
emergency medical services agency’s ability to provide
quality care for children. EDs and EMS can improve their
pediatric readiness by making sure they have
pediatric-specific equipment and policies in place and
train their staff on how to care for their youngest
patients. In an emergency situation, that preparation can
mean the difference between life and death for a child.
Dr. Sanya Desai.
According to the
National Pediatric Readiness Project (NPRP), when
hospitals are highly pediatric ready, there is a 76%
lower mortality rate for ill children and a 60% lower
mortality rate for injured children. An estimated 2,143
children’s lives may be saved every year if every ED in
the United States achieved high pediatric readiness.
But rural EDs and EMS tend to have fewer resources and
see fewer pediatric patients than urban facilities. Rural
facilities also face the challenges of “competing
priorities, turnover, and the lack of time” in becoming
pediatric ready, Dr. Sanya Desai said. Desai works with
the National
Pediatric Readiness Quality Initiative (NPRQI)
Collaborative, which helps EDs, including small and
low-resourced ones, engage in quality improvement (QI) to
improve pediatric readiness.
History of the NPRP
NPRP and NPRQI are initiatives under the EMSC Innovation and
Improvement Center (EIIC). The EIIC is funded by the
Emergency Medical Services for Children (EMSC)
program from the Health Resources and Services
Administration Maternal and Child Health Bureau. EIIC
furthers the EMSC’s work through QI, education, and
communication.
Dr. Marianne Gausche-Hill is a co-lead for the NPRP. In
2012, Gausche-Hill became involved with establishing the
NPRP, after success with a similar program she started in
California. In 2013, the NPRP launched its first national
assessment to measure emergency departments’ readiness to
treat pediatric patients.
We wanted every emergency department in the United States
to be able to meet these guidelines.
When the EIIC first developed pediatric readiness
criteria, the organization reached out to rural
facilities for input. “We wanted every emergency
department in the United States to be able to meet these
guidelines,” Gausche-Hill said. “You didn’t want it just
for high-resourced children’s hospitals.”
“Every emergency clinician who goes to work wants to do
the best job possible. The key was how do we empower them
and help them optimize their working environment and the
infrastructure in order to be able to do that,”
Gausche-Hill said. “Now, we can’t build a PICU [pediatric
intensive care unit] in every hospital and staff it;
that’s just not going to happen.”
Instead, the NPRP helps EDs put pediatric-specific
policies in place and provides a list of equipment needed
for pediatric emergencies, guidelines, clinical pathways,
and checklists. The EIIC has
toolkits for EDs and EMS and
modules for pediatric emergency care coordinators
(PECCs) — champions who promote pediatric
readiness at their facilities and agencies.
“Assigning this role [of PECC] is important for children,
almost more so than any other patient population, just
because they can’t truly advocate for themselves,”
Gausche-Hill said. She added that, based on national
assessments of pediatric readiness, assigning the role of
a physician and nurse PECC is the single most important
intervention needed to achieve and sustain pediatric
readiness.
Starting the pediatric readiness journey
Heather Casebeer, RN, is the PECC at Permian Regional
Medical Center in Andrews, Texas. About two and a
half years ago, Casebeer’s then-director brought up the
topic of pediatric readiness, and Casebeer volunteered to
lead that effort.
“At the time, I was very uncomfortable taking care of
pediatric patients. And one of my mentors as a nurse told
me that’s the thing you need to jump into when you’re
uncomfortable,” Casebeer said. “I thought this would be
perfect to help me get over my fear of taking care of
children if I just dive right into this.”
Casebeer took the NPRP assessment, which showed Permian
Regional Medical Center’s gaps in pediatric readiness and
its score compared to other hospitals. She said the
assessment was “very overwhelming in the beginning…It’s
like over a hundred questions, asking: Do you have all
this equipment? Do you have these policies? Do you have
this stuff set up for charting?”
It wasn’t that we were not taking care of children. It
was just very under-recognized.
Casebeer said one step in the pediatric readiness
assessment is to estimate how many pediatric patients the
ED sees in a year. “We assumed we were seeing less than
1,500. That very first year that I actually kept
track…our census was over 2,500. Last year we saw over
3,000,” she said. “It wasn’t that we were not taking care
of children. It was just very under-recognized.”
Casebeer said the pediatric readiness assessment does not
have deadlines for facilities to meet, which can help the
process seem less daunting and more attainable for
facilities with “competing priorities.”
Andrew Appleby, RN, is the PECC at South Lincoln
Hospital District (SLHD), a Critical Access Hospital
in rural Kemmerer, Wyoming. In 2021, SLHD completed the
NPRP assessment, and “it was relatively low scoring,”
Appleby said. SLHD had pediatric equipment but no central
location to keep it, and the hospital did not have many
pediatric-specific policies in place.
We’re not the only ones in the nation that have this
issue and this is maybe a fairly common population
segment that is underserved.
In 2022, Appleby became the hospital’s trauma
coordinator. The following year, SLHD completed a trauma
site survey that the state of Wyoming was conducting.
Appleby got involved with the NPRQI Collaborative and
“quickly realized that this is a very important thing and
that we’re not isolated to this.” He added, “We’re not
the only ones in the nation that have this issue and this
is maybe a fairly common population segment that is
underserved.”
Rewriting policies and making other changes
Appleby said it took “a good six-ish months” to become
pediatric ready. Creating new policies or taking other
facilities’ existing pediatric-specific policies and
tailoring them to fit SLHD took time, he said, as well as
receiving approval for the new policies from medical
staff and administration. He said the whole process was
“a little time consuming, but well worth it.”
Like Appleby, Casebeer in Texas realized her facility did
not have policies that specifically addressed pediatric
care. With some policies, she was able to add a new
pediatric-specific section. With others, she had to
completely rewrite the policy.
Permian Regional Medical Center emergency nurses and
local EMS partners use a mannequin during training.
Casebeer also organized training simulations for the ED
and other departments. “When we have a code or trauma
activation…we have everybody coming to help because there
are not very many hands in our ER.” In addition, she
began including EMS personnel in the simulations, which
take place quarterly.
Casebeer also began chart reviews, which offer feedback
to staff. Before, she said, “there wasn’t any
follow-through. After the chart was done, no one ever
looked at it again.” Through QI initiatives, staff
learned they did well assessing and reassessing
high-acuity pediatric patients but not with other
pediatric patients. They also did not have a pain score
that was appropriate for children.
“We didn’t have the tools, but we didn’t know we didn’t
have them until somebody gets in there and starts digging
around,” Casebeer said.
Trainings and other resources
In October 2019, the Georgia Office of Emergency Medical
Services and the
Georgia State Office of Rural Health (SORH) began
discussing pediatric needs. In February 2020, the state
EMSC program director assembled a 12-person committee to
define criteria for a state pediatric readiness
designation as well as identify hospitals to participate
in a pilot program.
Two healthcare professionals from rural Georgia
hospitals complete training on a pediatric mannequin.
The Georgia SORH created two grant-funded initiatives to
encourage participation in the pilot program and provide
continuing education opportunities. The first program is
a five-year grant awarded to Georgia Southern University
to collect county-level data and complete needs
assessments.
Eight rural counties participate each year, and
university personnel meet with the hospital leaders to
discuss the findings and the possibility of pursuing the
pediatric readiness designation. “I’ll be honest, we’re
almost finished with the reports, and all of them
recommend that the hospitals should pursue pediatric
readiness,” said Nita Ham, Georgia SORH Executive
Director, “because every rural community can certainly
benefit from that.”
The second program is a four-year grant awarded to the
Georgia Trauma Foundation to deliver free continuing
education programs at rural hospitals. “Those nationally
recognized classes…are difficult for rural hospital staff
to attend,” Ham said. “They cost money and there’s
typically travel time involved. You have to be off shift
and the hospital has to backfill…so we decided we wanted
to take the classes directly to our rural communities.”
A Georgia program provides free continuing education
programs at rural hospitals.
The program sends instructors and equipment to rural
hospitals, specifically facilities that have enough room
for neighboring hospitals’ staff to also participate in
the training. “Not only do we deliver quality classes,”
Ham said, “but this allows the clinical staff to be in
their own environment where they feel more comfortable
and they can train in the same environment where they
will be delivering care.”
Not only do we deliver quality classes, but this allows
the clinical staff to be in their own environment where
they feel more comfortable and they can train in the same
environment where they will be delivering care.
“We lovingly referred to it as the Traveling Training
Show,” Ham said.
Online, nationally available resources include
NPRQI, a free web-based platform to help frontline
staff conduct QI. Desai said the platform helps ED teams
make small, meaningful changes without needing to be
experts in QI or technology. The NPRQI team guides ED
teams through the QI process. The platform is designed to
“take stuff off your plate,” she said. “We’re taking the
data burden away from them and allowing them to really
focus on making the changes.”
NPRQI has 28 pediatric quality metrics for EDs, and they
were designed with “EDs with low resources and low
pediatric volume” in mind, Desai said. Participating EDs
sample their pediatric patient encounters over two or
three months and enter the data into the platform. NPRQI
provides one-on-one coaching in data interpretation and
QI methodology.
The current EMSC-NPRQI Collaborative cohort has 141
participants. Each participant chooses a focus area,
completes monthly sessions, and learns from other
participants and subject matter experts.
EDs that engage in QI have a 26-point increase in their
pediatric readiness score.
“EDs that engage in QI have a 26-point increase in their
pediatric readiness score,” Desai said. “But based on the
last NPRP assessment, we saw that only about half of EDs
that we surveyed did any QI.”
All the EMSC resources have been absolutely amazing,”
Casebeer from Texas said. She uses the free SimBox
simulations for training staff.
Improvements in care, confidence, and community
perceptions
Since taking the first assessment, Permian Regional
Medical Center’s score has gone up about 22 points,
Casebeer estimated. She has also seen an emotional change
in her coworkers: “I love seeing the confidence and the
enthusiasm in the staff.”
“We see a lot of engagement from rural sites,” Desai
said. She remembered a PECC from a different rural Texas
hospital whose work “was above and beyond the national
performance on almost all of the core NPRQI metrics.”
When the PECC asked for guidance on what to work on next,
Desai encouraged her to look at advanced measures but
also to share her “incredible work” with hospital
leadership.
Appleby in Wyoming said community members used to say
that SLHD was unable to take care of patients, constantly
transferring them to larger facilities. Now, he said, he
and his coworkers “don’t hear that anymore.”
“I think that was probably the biggest benefit, how our
image transformed to the community,” Appleby said.
The Wyoming
Hospital Pediatric Readiness Project, through the
Wyoming EMSC Program, has recognized 10 emergency
departments in the state as pediatric ready, including
SLHD in 2024.
Georgia currently has ten pediatric ready hospitals, two
of which are rural. The SORH’s needs assessment program
has produced 40 reports so far, and its continuing
education program has completed “a total of 85 classes,
with over 900 students participating in over 10,000
classroom hours of instruction delivered,” Ham said.
Gausche-Hill said 4,593 EDs, or 82.6% of all EDs in the
United States, responded to the most recent NPRP survey.
“This is the largest number of hospitals that have ever
responded,” she said.
Partnerships, protected time, and other steps to success
Gausche-Hill said it is important for rural EDs to
establish guidelines, build relationships with larger
neighboring hospitals, and practice stabilizing children
and preparing them for transport if needed. “You want to
do it before the child hits the door,” she said.
In Wyoming, SLHD often works with Intermountain Primary
Children’s Hospital in Salt Lake City, Utah — a
two-hour drive away. The children’s hospital provides
training, telehealth, and consultations and often
receives pediatric patients that SLHD needs to transfer.
Appleby called the children’s hospital team “wonderful to
work with.” He added, “I wish we could get them here more
often” for training, which currently happens
semi-annually.
Ham praised the Georgia SORH’s close working relationship
with other state agencies. “The partnerships with these
organizations are what really make this work,” she said.
Gausche-Hill also recommended pre-calculating drug dosing
— instead of trying to determine the correct
dosage during an emergency — and said that
rural hospitals can reach out to local pharmacists at
larger facilities that have already done that work. “You
don’t always have to reinvent the wheel,” she said. “You
can borrow from others.”
Heather Casebeer (left) and Permian Regional Medical
Center’s trauma registrar show off the bands used for
high-acuity pediatric patients. Each band matches a
color on the pediatric resuscitation cart, allowing any
team caring for the child to immediately know which
drawer to use should the need arise.
Desai clarified who should be a PECC: “What is sometimes
misunderstood is that this is going to be that nurse or
physician that likes seeing kids, and so they should see
every kid that comes in the ED.” She said a PECC is an
administrative role to make sure the ED team is prepared
to treat children.
Desai also recommended that PECCs “have protected time to
do this work” and have that work built into their salary.
When Casebeer in Texas first started this journey, the
hospital blocked off time during her regular shift for
her to focus on pediatric readiness.
Casebeer also serves as the Pediatric Readiness
Improvement and Simulation Mentor (PRISM) in her region
of Texas and answers neighboring facilities’ questions.
“Children don’t pick where they get sick or injured,”
Casebeer said. “I think that they deserve the best care
they can get regardless of where they are.”
