The URL can be used to link to this page

Home My WebLink Aboutjoint-policy-statement-peds-edJoint Policy Statement—Guidelines for Care of Children in the Emergency Department abstract Children who require emergency care have unique needs, especially when emergencies are serious or life-threatening. The majority of ill and injured children are brought to community hospital emergency departments (EDs) by virtue of their geography within communities. Similarly, emer- gency medical services (EMS) agencies provide the bulk of out-of-hospital emergency care to children. It is imperative, therefore, that all hospital EDs have the appropriate resources (medications, equipment, policies, and education) and staff to provide effective emergency care for children. This statement outlines resources necessary to ensure that hospital EDs stand ready to care for children of all ages, from neonates to adolescents. These guidelines are consistent with the recommendations of the Institute of Medicine’s report on the future of emergency care in the United States health system. Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that hospital ED staff and administrators and EMS systems’ administrators and medical directors seek to meet or exceed these guidelines in efforts to optimize the emergency care of children they serve. This statement has been endorsed by the Academic Pediatric Association, American Academy of Family Phy- sicians, American Academy of Physician Assistants, American College of Osteopathic Emergency Physicians, American College of Surgeons, Ameri- can Heart Association, American Medical Association, American Pediatric Surgical Association, Brain Injury Association of America, Child Health Cor- poration of America, Children’s National Medical Center, Family Voices, National Association of Children’s Hospitals and Related Institutions, Na- tional Association of EMS Physicians, National Association of Emergency Medical Technicians, National Association of State EMS Ofﬁcials, National Committee for Quality Assurance, National PTA, Safe Kids USA, Society of Trauma Nurses, Society for Academic Emergency Medicine, and The Joint Commission.Pediatrics 2009;124:1233–1243 INTRODUCTION This policy statement delineates guidelines and the resources neces- sary to prepare hospital emergency departments (EDs) to serve pedi- atric patients. Adoption of these guidelines should facilitate the deliv- ery of emergency care for children of all ages and, when appropriate, timely transfer to a facility with specialized pediatric services. This policy is an update of previously published guidelines.1,2 This statement has been endorsed by the Academic Pediatric Associa- tion, American Academy of Family Physicians, American Academy of Physician Assistants, American College of Osteopathic Emergency Phy- AMERICAN ACADEMY OF PEDIATRICS COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE AMERICAN COLLEGE OF EMERGENCY PHYSICIANS PEDIATRIC COMMITTEE EMERGENCY NURSES ASSOCIATION PEDIATRIC COMMITTEE KEY WORD pediatric emergency preparedness ABBREVIATIONS ED—emergency department EMS—emergency medical services EMSC—emergency medical services for children QI—quality improvement PI—performance improvement This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have ﬁled conﬂict-of-interest statements with the American Academy of Pediatrics. Any conﬂicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. www.pediatrics.org/cgi/doi/10.1542/peds.2009-1807 doi:10.1542/peds.2009-1807 All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reafﬁrmed, revised, or retired at or before that time. PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2009 by the American Academy of Pediatrics FROM THE AMERICAN ACADEMY OF PEDIATRICS Organizational Principles to Guide and Deﬁne the Child Health Care System and/or Improve the Health of all Children PEDIATRICS Volume 124, Number 4, October 2009 1233 sicians, American College of Surgeons, American Heart Association, American Medical Association, American Pediat- ric Surgical Association, Brain Injury Association of America, Child Health Corporation of America, Children’s Na- tional Medical Center, Family Voices, National Association of Children’s Hos- pitals and Related Institutions, Na- tional Association of EMS Physicians, National Association of Emergency Medical Technicians, National Associa- tion of State EMS Ofﬁcials, National Committee for Quality Assurance, Na- tional PTA, Safe Kids USA, Society of Trauma Nurses, Society for Academic Emergency Medicine, and The Joint Commission. BACKGROUND The National Hospital Ambulatory Med- ical Care Survey reported that in 2006, there were approximately 3833 EDs in the United States. Most of these EDs routinely care for patients of all ages.3–6 Of the 119 million ED visits in the United States in 2006, almost 20% were for children.5,6 In 1993, after nearly a decade of efforts to integrate the needs of children into emergency medical services (EMS) systems, the Institute of Medicine was asked to provide an independent re- view of emergency medical services for children (EMSC) and report to the nation on the state of the continuum of care for children within the EMS system.7 Summary recommendations of that report concluded that all agencies with jurisdiction over hos- pitals “require that hospital emer- gency departments . . . have available and maintain equipment and supplies appropriate for the emergency care of children” and that they “address the issues of categorization and regional- ization in overseeing and development of EMSC and its integration into state and regional EMS systems.” Published data have suggested that compliance with national guidelines is low and that many EDs in the United States and Canada still do not have some of the basic equipment and supplies needed to care for children of all ages.8–10 Middleton and Burt,6 in the emergency pediatric services and equipment supplement of the 2002–2003 National Hospital Ambula- tory Medical Care Survey, reported that only 6% of US EDs have all of the recommended pediatric supplies and equipment as outlined in previously published national guidelines. Gausche- Hill et al10 reported similar results in a nationwide survey of EDs in the United States and cited reasons for the lack of equipment availability in many EDs (in- cluding lack of awareness, with only 59% of ED managers being aware of the published guidelines) and relative lack of pediatric experience among the workforce, with limited exposure to critically ill or injured pediatric pa- tients at many US hospitals. In fact, 50% of EDs care for fewer than 10 pe- diatric patients per day; therefore, pe- diatric planning by these facilities is crucial.10 Access to optimal emergency care for children is affected by the lack of avail- ability of equipment, appropriately trained staff to care for children, and policies and procedures that ensure timely transfer to deﬁnitive care.11 Al- though advances have been made that promote access to emergency care for children, improved awareness of the pediatric resources available to hospitals, in addition to the develop- ment of regionalized and coordi- nated emergency and trauma care systems, may optimize access and outcomes for many acutely ill and in- jured children.12,13 The Institute of Medicine, in a compre- hensive report on the state of emer- gency care in the United States in 2006, made a strong recommendation for regionalized systems of care and fur- ther recommended that hospitals and EMS systems appoint qualiﬁed coordi- nators for pediatric emergency care.12 Only 18% of EDs in the United States currently appoint a physician coordi- nator, and 12% appoint a nursing coor- dinator for pediatric emergency care. EDs that do appoint these positions tend to be more prepared as mea- sured by compliance with guidelines on the care of children in the ED pub- lished by the American College of Emergency Physicians and American Academy of Pediatrics.10 The Health Resources and Services Administration-EMSC program has also advocated for such regionalized systems, and in response to the need to document outcomes of the pro- gram’s activities, performance mea- sures for states and territories were outlined in 2009.14 These performance measures call for the existence of a statewide, territorial, or regional stan- dardized system that recognizes hos- pitals that are able to stabilize and/or manage pediatric medical emergen- cies and trauma. Target dates have been set for states to comply with these performance measures. Clearly, much work is left to be done to pro- mote and measure pediatric pre- paredness in all EDs in the United States and for emergency and trauma care systems to be ready to meet the needs of children in disasters. The following guidelines are intended for all hospital EDs that provide emer- gency care 24 hours a day, 7 days a week that are continuously staffed by a physician. Children may be cared for in other emergency settings, such as freestanding EDs or urgent care cen- ters, critical access hospitals15 or stand-by emergency facilities, retail- based clinics, and primary care ofﬁce practices. These care settings are not addressed in this document, but ad- ministrators, physicians, nurses, and other health care providers who staff 1234 FROM THE AMERICAN ACADEMY OF PEDIATRICS these settings should ensure that these facilities maintain the neces- sary equipment, medications, and supplies and are staffed appropri- ately to care for pediatric patients. Pediatric emergency-preparedness guidelines have been created for ur- gent care centers as well as for ofﬁces of primary care providers.16,17 These guidelines provide current in- formation on equipment, medications, supplies, and personnel considered essential for managing pediatric emergencies in EDs. This statement also offers guidelines for the adminis- tration and coordination of pediatric care in the ED; pediatric emergency care quality improvement (QI), perfor- mance improvement (PI), and patient safety activities; policies, procedures, and protocols for pediatric care; and key ED support services. It is expected that all EDs in the United States that are staffed by a physician 24 hours a day, 7 days a week can meet or exceed these guidelines and that some hospi- tals, such as pediatric critical care centers or children’s hospitals with greater resources, will develop and implement even more comprehensive guidelines and share their expertise with their local and regional communi- ties. New technology and research will require that such emergency drug, equipment, and supply lists be kept current and that updated recommen- dations be readily available to hospi- tals that provide emergency care to children. I. GUIDELINES FOR ADMINISTRATION AND COORDINATION OF THE ED FOR THE CARE OF CHILDREN A. A physician coordinator for pediat- ric emergency medicine is ap- pointed by the ED medical director. 1. The physician coordinator has the following qualiﬁcations: a. Meets the qualiﬁcations for credentialing by the hospital as a specialist in emergency medicine or pediatric emer- gency medicine. It is recog- nized that physicians in these specialties may not always be available in some communi- ties; in these areas, the physi- cian coordinator must meet the qualiﬁcations for creden- tialing by the hospital as a specialist in pediatrics or family medicine and demon- strate, through experience or continuing education, compe- tence in the care of children in emergency settings, in- cluding resuscitation. b. Has special interest, knowl- edge, and skill in emergency medical care of children as demonstrated by training, clinical experience, or fo- cused continuing medical education. c. Maintains competency in pe- diatric emergency care (see “III. GUIDELINES FOR QI/PI IN THE ED”). d. May be a staff physician who is currently assigned other roles in the ED or may be shared through formal con- sultation agreements with professional resources from a hospital that is capable of providing deﬁnitive pediatric care. 2. The physician coordinator is re- sponsible for the following: a. Promoting and verifying ade- quate skill and knowledge of ED staff physicians and other ED health care providers (ie, physician assistants and ad- vanced practice nurses) in the emergency care and re- suscitation of infants and children. b. Overseeing ED pediatric QI, PI, patient safety, injury and ill- ness prevention, and clinical care activities. c. Assisting with development and periodic review of ED pol- icies and procedures and standards for medications, equipment, and supplies to ensure adequate resources for children of all ages. d. Serving as liaison/coordina- tor to appropriate in-hospital and out-of-hospital pediatric care committees in the com- munity (if they exist). e. Serving as liaison/coordina- tor to a deﬁnitive care hospi- tal (such as a regional pediat- ric referral hospital and trauma center), EMS agen- cies, primary care providers, health insurers, and any other medical resources needed to integrate services for the con- tinuum of care of the pediatric patient. f. Facilitating pediatric emer- gency education for ED health care providers and out-of- hospital providers afﬁliated with the ED. g. Ensuring that competency evaluations completed by the staff are pertinent to children of all ages. h. Ensuring that pediatric needs are addressed in hos- pital disaster/emergency- preparedness plans. i. Collaborating with the nurs- ing coordinator to ensure ad- equate stafﬁng, medications, equipment, supplies, and other resources for children in the ED. B. A nursing coordinator for pediatric emergency care is appointed by the ED nursing director. FROM THE AMERICAN ACADEMY OF PEDIATRICS PEDIATRICS Volume 124, Number 4, October 2009 1235 1. The nursing coordinator has the following qualiﬁcations: a. Is a registered nurse (RN) who possesses special inter- est, knowledge, and skill in the emergency medical care of children as demonstrated by training, clinical experi- ence, or focused continuing nursing education. b. Maintains competency in pe- diatric emergency care (see “III. GUIDELINES FOR QI/PI IN THE ED”). c. Is credentialed and has com- petency veriﬁcation per the hospital policies and guide- lines to provide care to chil- dren of all ages. d. May be a staff nurse who is currently assigned other roles in the ED, such as clinical nurse specialist, or may be shared through formal con- sultation agreements with pro- fessional resources from a hospital that is capable of providing deﬁnitive pediatric care. 2. The nursing coordinator is re- sponsible for the following: a. Facilitating ED pediatric QI/PI activities. b. Serving as liaison to appro- priate in-hospital and out- of-hospital pediatric care committees. c. Serving as liaison to inpatient nursing as well as to a deﬁni- tive care hospital, a regional pediatric referral hospital and trauma center, EMS agencies, primary care pro- viders, health insurers, and any other medical resources needed to integrate services for the continuum of care of the pediatric patient. d. Facilitating,alongwithhospital- based educational activities, ED nursing continuing educa- tion in pediatrics and ensur- ing that pediatric-speciﬁc elements are included in orientation for new staff members. e. Ensuring that initial and an- nual competency evaluations completed by the ED nursing staff are pertinent to children of all ages. f. Promoting pediatric disas- ter preparedness for the ED and participating in hospi- tal disaster-preparedness activities. g. Promoting patient and family education in illness and in- jury prevention. h. Providing assistance and support for pediatric educa- tion of out-of-hospital provid- ers who are afﬁliated with the ED. i. Working with clinical leader- ship to ensure the availability of pediatric equipment, medi- cations, stafﬁng, and other resources through the devel- opment and periodic review of ED standards, policies, and procedures. j. Collaborating with the physi- cian coordinator to ensure that the ED is prepared to care for children of all ages, including children with spe- cial health care needs. II. PHYSICIANS, NURSES, AND OTHER HEALTH CARE PROVIDERS WHO STAFF THE ED A. Physicians who staff the ED have the necessary skill, knowledge, and training in the emergency evalua- tion and treatment of children of all ages who may be brought to the ED, consistent with the services pro- vided by the hospital. B. Nurses and other ED health care providers have the necessary skill, knowledge, and training in provid- ing emergency care to children of all ages who may be brought to the ED, consistent with the services of- fered by the hospital. C. Baseline and periodic competency evaluations completed for all ED clinical staff, including physicians, are age speciﬁc and include evalu- ation of skills related to neonates, infants, children, adolescents, and children with special health care needs. Competencies are deter- mined by each institution’s medical staff privileges policy. III. GUIDELINES FOR QI/PI IN THE ED A pediatric patient care-review pro- cess is integrated into the QI/PI plan of the ED according to the following guidelines: A. Components of the process interface with out-of-hospital, ED, trauma, inpa- tient pediatric, pediatric critical care, and hospital-wide QI or PI activities. B. The QI/PI plan of the ED shall include pediatric-speciﬁc indicators. Mini- mum components of the QI/PI pro- cess should include collecting and analyzing data to discover vari- ances, deﬁning a plan for improve- ment, and evaluating the success of the QI/PI plan with measures that are outcome based. C. Pediatric clinical-competency eval- uations should be developed as a part of the local credentialing pro- cess for all licensed ED staff (eg, sedation and analgesia, airway management [Appendix 1]). Compe- tencies should be age speciﬁc and include those for neonates, infants, children, adolescents, and children with special health care needs. 1236 FROM THE AMERICAN ACADEMY OF PEDIATRICS D. Mechanisms should be in place to monitor professional performance, credentialing, continuing educa- tion, and clinical competencies, in- cluding integration of ﬁndings from QI audits and case reviews. IV. GUIDELINES FOR IMPROVING PEDIATRIC PATIENT SAFETY IN THE ED The delivery of pediatric care should reﬂect an awareness of unique pediat- ric patient safety concerns18,19 and should include the following policies or practices: A. Children should be weighed in kilo- grams, with the exception of chil- dren who require emergent stabili- zation, and the weight should be recorded in a prominent place on the medical record, such as with the vital signs. 1. For children who require resus- citation or emergency stabiliza- tion, a standard method for estimating weight in kilograms should be used (eg, length-based system). B. Infants and children should have a full set of vital signs recorded to in- clude temperature, heart rate, and respiratory rate. Blood pressure and pulse oximetry monitoring should be available for children of all ages on the basis of illness and injury severity. C. A process should be in place for identifying abnormal vital signs ac- cording to the age of the patient and for notifying the physician of abnor- mal values obtained. D. Processes for safe medication storage, prescribing, and delivery should be established20,21 and should include the use of precalcu- lated dosing guidelines for children of all ages. E. Infection-control practices, includ- ing hand hygiene and use of per- sonal protective equipment, should be implemented and monitored. F. Pediatric emergency services should be culturally and linguistically ap- propriate,22 and the ED should pro- vide an environment that is safe for children and supports patient- and family-centered care.23 G. Patient-identiﬁcation policies, consis- tent with the Joint Commission na- tional patient safety goals, should be implemented and monitored.24 H. Policies for the timely reporting and evaluation of patient safety events and for the disclosure of medical errors or unanticipated outcomes should be implemented and moni- tored, and education and training in disclosure should be available to care providers who are assigned this responsibility.18,19 V. GUIDELINES FOR POLICIES, PROCEDURES, AND PROTOCOLS FOR THE ED A. Policies, procedures, and protocols for the emergency care of children are developed and implemented; staff should be educated according- ly; and they should be monitored for compliance and periodically up- dated. These resources should in- clude, but are not limited to, the fol- lowing: 1. Illness and injury triage. 2. Pediatric patient assessment and reassessment. 3. Documentation of pediatric vital signs, abnormal vital signs, and actions to be taken for abnormal vital signs. 4. Immunization assessment and management of the underimmu- nized patient.25 5. Sedation and analgesia for procedures, including medical imaging.26,27 6. Consent (including situations in which a parent is not immedi- ately available).28 7. Social and mental health issues. 8. Physical or chemical restraint of patients. 9. Child maltreatment (physical and sexual abuse, sexual as- sault, and neglect) and domes- tic violence mandated report- ing criteria, requirements, and processes. 10. Death of the child in the ED.29,30 11. Do-not-resuscitate orders. 12. Family-centered care,31–35 including: a. Involving families in patient care decision-making and in medication safety processes. b. Family presence during all as- pects of emergency care, in- cluding resuscitation.35,36 c. Education of the patient, fam- ily, and regular caregivers. d. Discharge planning and instruction. e. Bereavement counseling. 13. Communication with the pa- tient’s medical home or primary health care provider.37 14. Medical imaging policies that ad- dress age- or weight-appropriate dosing for children receiving studies that impart ionizing radi- ation, consistent with as-low-as- reasonably-achievable (ALARA) principles.38 15. All-hazard disaster-preparedness plan that addresses the follow- ing pediatric issues12,39–41: a. Availability of medications, vaccines, equipment, and ap- propriately trained providers for children in disasters. b. Pediatric surge capacity for both injured and noninjured children. c. Decontamination, isolation, and FROM THE AMERICAN ACADEMY OF PEDIATRICS PEDIATRICS Volume 124, Number 4, October 2009 1237 quarantine of families and children of all ages. d. A plan that minimizes parent- child separation and includes system tracking of pediatric patients, allowing for the timely reuniﬁcation of sepa- rated children with their families. e. Access to speciﬁc medical and mental health therapies, as well as social services, for children in the event of a disaster. f. Disaster drills, which should include a pediatric mass- casualty incident at least ev- ery 2 years. g. Care of children with special health care needs. h. A plan that includes evacua- tion of pediatric units and pe- diatric specialty units. B. Hospitals should have written pedi- atric interfacility transfer proce- dures that include the following pe- diatric components of transfer42: 1. Deﬁned process for initiation of transfer, including the roles and responsibilities of the re- ferring facility and referral center (including responsibili- ties for requesting transfer and communication). 2. Transport plan for delivering children safely and in a timely manner to the appropriate facil- ity that is capable of providing deﬁnitive care. 3. Process for selecting the appro- priate care facility for pediatric specialty services not available at the hospital. These specialty services may include: a. Medical subspecialty and sur- gical specialty care. b. Critical care. c. Reimplantation (replacement of severed digits or limbs). d. Trauma and burn care. e. Psychiatric emergencies. f. Obstetric and perinatal emergencies. g. Child maltreatment (physi- cal and sexual abuse and assault). h. Rehabilitation for recovery from critical medical or trau- matic conditions. 4. Process for selecting the appro- priately staffed transport ser- vice to match the patient’s acuity level (eg, level of care required by patient, equipment needed in transport) and appropriate for children with special health care needs. 5. Process for patient transfer (including obtaining informed consent). 6. Plan for transfer of patient infor- mation (eg, medical record and copy of signed transport con- sent), personal belongings of the patient, and provision of direc- tions and referral institution in- formation to family. 7. Process for return transfer of the pediatric patient to the refer- ring facility as appropriate. VI. GUIDELINES FOR ED SUPPORT SERVICES A. The radiology department should have the skills and capability to pro- vide imaging studies of children and have the equipment necessary to do so and must have guidelines for reducing radiation exposure that are age and size speciﬁc.38 1. The radiology capability of hospi- tals may vary from 1 institution to another; however, the radiol- ogy capability of a hospital must meet the needs of the children in the community it serves. 2. A process should be established for the referral of children to ap- propriate facilities for radiologic procedures that exceed the ca- pability of the hospital. 3. A process should be in place for the timely review, interpretation, and reporting by a qualiﬁed radi- ologist for medical imaging studies. B. The laboratory should have the skills and capability to perform lab- oratory tests for children of all ages, including obtaining samples, and should have the availability of microtechnique for small or limited sample size. 1. The clinical laboratory capability must meet the needs of the chil- dren in the community it serves. 2. There should be a clear under- standing of what the labora- tory capability is for any given community and deﬁnitive plans for referring children to the ap- propriate facility for labora- tory studies should be in place. VII. GUIDELINES FOR EQUIPMENT, SUPPLIES, AND MEDICATIONS FOR THE CARE OF PEDIATRIC PATIENTS IN THE ED A. Pediatric equipment, supplies, and medications should be appropriate for children of all ages and sizes and shall be easily accessible, clearly labeled, and safely and logi- cally organized. B. Resuscitation equipment and sup- plies shall be located in the ED; trays and other items may be housed in other departments (such as the newborn nursery or central supply) as long as the items are immediately accessible to the ED staff. A mobile pedi- 1238 FROM THE AMERICAN ACADEMY OF PEDIATRICS atric crash cart is strongly recommended. C. ED staff shall be appropriately edu- cated on the location of all items. D. Each ED shall have a method of daily veriﬁcation of proper loca- tion and function of equipment and supplies. E. Medication chart, length-based tape, medical software, or other systems shall be readily available to ED staff to ensure proper sizing of resuscitation equipment and proper dosing of medications. F. Table 1 and Appendix 2 outline med- ications, equipment, and supplies that are necessary for the care of children in the ED. SUMMARY The 2006 Institute of Medicine report Emergency Care for Children: Grow- ing Pains uses the word “uneven” to describe the current status of pedi- atric emergency care in the United States.12 Although programs such as EMSC have led toward improvement in the level of pediatric emergency readiness in many communities,43 there remains a signiﬁcant opportu- nity for further progress nationwide. The updated guidelines offered in this policy statement are intended to serve as a resource for clinical and administrative leadership of hospi- tal EDs as they endeavor to improve their readiness for children of all ages. An important ﬁrst step in en- suring readiness is the identiﬁcation of both a physician and a nurse co- ordinator for pediatric emergency care. All hospital EDs must be continually prepared to receive, accurately as- sess, and, at a minimum, stabilize and safely transfer acutely ill or injured children, which is necessary even for hospitals located in communities with readily accessible pediatric tertiary care centers and regionalized systems for pediatric trauma and critical care. The vast majority of children who re- quire emergency services in the United States receive this care in a non– children’s hospital ED, with 50% of EDs providing care for fewer than 10 chil- dren per day.10 This relatively infre- quent exposure of hospital-based emergency care professionals to seri- ously ill or injured children represents a substantial barrier to the mainte- nance of essential skills and clinical competency. Recognition of the unique needs of the ill and/or injured children served by a hospital, including chil- dren with special health care needs; the commitment to better meeting those needs through adoption of these guidelines; and the ongoing commit- ment to evaluating care quality and safety and maintaining pediatric emer- gency care competencies should pro- vide a strong foundation for pediatric emergency and all-hazard disaster readiness. APPENDIX 1: CLINICAL AND PROFESSIONAL COMPETENCY Demonstration and maintenance of pediatric clinical competency may be achieved through a number of continuing education mechanisms in- cluding participation in local educa- tional programs, professional organi- zation conferences, and national life- support programs (ie, Pediatric Advanced Life Support [PALS], Ad- vanced Pediatric Life Support [APLS]: The Pediatric Emergency Medicine Course, Emergency Nursing Pediat- ric Course [ENPC]) or through sched- uled mock codes or patient simula- tion, team training exercises, or experiences in other clinical settings such as the operating room (ie, air- way management). Potential areas for the development of pediatric competency and profes- sional performance evaluations may include but should not be limited to: 1. Triage 2. Illness and injury assessment and management 3. Pain assessment and treatment, including sedation and analgesia 4. Airway management 5. Vascular access 6. Critical care monitoring 7. Neonatal and pediatric resuscitation 8. Trauma care 9. Burn care 10. Mass-casualty events 11. Patient- and family-centered care TABLE 1 Guidelines for Medications for Use in Pediatric Patients in EDs Resuscitation Medications Other Drug Groups Atropine Activated charcoal Adenosine Topical, oral, and parenteral analgesics Amiodarone Antimicrobial agents (parenteral and oral) Antiemetic agents Anticonvulsant medications Calcium chloride Antidotes (common antidotes should be accessible to the ED)a Dextrose (D10W, D50W) Antipyretic drugs Epinephrine (1:1000; 1:10 000 solutions) Bronchodilators Lidocaine Corticosteroids Magnesium sulfate Inotropic agents Naloxone hydrochloride Neuromuscular blockers Procainamide Sedatives Sodium bicarbonate (4.2%, 8.4%) Vaccines Vasopressor agents For a more complete list of medications used in a pediatric ED, see ref.44 D10W indicates dextrose 10% in water; D50W, dextrose 50% in water. a For less frequently used antidotes, a procedure for obtaining them should be in place. FROM THE AMERICAN ACADEMY OF PEDIATRICS PEDIATRICS Volume 124, Number 4, October 2009 1239 12. Medication delivery and device/ equipment safety 13. Team training and effective communication APPENDIX 2: GUIDELINES FOR EQUIPMENT AND SUPPLIES FOR USE IN PEDIATRIC PATIENTS IN THE ED General Equipment ●Patient warming device ●Intravenous blood/ﬂuid warmer ●Restraint device ●Weight scale, in kilograms only (not pounds), for infants and children ●Tool or chart that incorporates both weight (in kilograms) and length to assist physicians and nurses in de- termining equipment size and cor- rect drug dosing (by weight and to- tal volume), such as a length-based resuscitation tape ●Pain-scale–assessment tools ap- propriate for age Monitoring Equipment ●Blood pressure cuffs (neonatal, in- fant, child, adult-arm and thigh) ●Doppler ultrasonography devices ●Electrocardiography monitor/deﬁ- brillator with pediatric and adult ca- pabilities including pediatric-sized pads/paddles ●Hypothermia thermometer ●Pulse oximeter with pediatric and adult probes ●Continuous end-tidal CO2 monitor- ing device* Respiratory Equipment and Supplies ●Endotracheal tubes ●Uncuffed: 2.5 and 3.0 mm ●Cuffed or uncuffed: 3.5, 4.0, 4.5, 5.0, and 5.5 mm ●Cuffed: 6.0, 6.5, 7.0, 7.5, and 8.0 mm ●Feeding tubes (5F and 8F) ●Laryngoscope blades (curved: 2 and 3; straight: 0, 1, 2, and 3) ●Laryngoscope handle ●Magill forceps (pediatric and adult) ●Nasopharyngeal airways (infant, child, and adult) ●Oropharyngeal airways (sizes 0–5) ●Stylets for endotracheal tubes (pe- diatric and adult) ●Suction catheters (infant, child, and adult) ●Tracheostomy tubes (sizes 2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5 mm) ●Yankauer suction tip ●Bag-mask device (manual resusci- tator), self-inﬂating (infant size: 450 mL; adult size: 1000 mL) ●Clear oxygen masks (standard and nonrebreathing) for an infant, child, and adult ●Masks to ﬁt bag-mask device adap- tor (neonatal, infant, child, and adult sizes) ●Nasal cannulas (infant, child, and adult) ●Nasogastric tubes (sump tubes): in- fant (8F), child (10F), and adult (14F–18F) ●Laryngeal mask airway† (sizes 1, 1.5, 2, 2.5, 3, 4, and 5) Vascular Access Supplies and Equipment ●Arm boards (infant, child, and adult sizes) ●Catheter-over-the-needle device (14–24 gauge) ●Intraosseous needles or device (pe- diatric and adult sizes) ●Intravenous catheter–administration sets with calibrated chambers and extension tubing and/or infusion de- vices with ability to regulate rate and volume of infusate ●Umbilical vein catheters (3.5F and 5.0F)‡ ●Central venous catheters (4.0F– 7.0F) ●Intravenous solutions to include: normal saline; dextrose 5% in nor- mal saline; and dextrose 10% in water Fracture-Management Devices ●Extremity splints, including femur splints (pediatric and adult sizes) ●Spine-stabilization method/devices appropriate for children of all ages§ Specialized Pediatric Trays or Kits ●Lumbar-puncture tray including infant (22-gauge), pediatric (22- gauge), and adult (18- to 21-gauge) lumbar-puncture needles ●Supplies/kit for patients with difﬁ- cult airway conditions (to include but not limited to supraglottic airways of all sizes, such as the la- ryngeal mask airway,2 needle crico- thyrotomy supplies, surgical crico- thyrotomy kit) ●Tube thoracostomy tray *End-tidal CO2 monitoring is considered the opti- mal method of assessing for and monitoring of endotracheal tube placement in the trachea; however, for low-volume hospitals, adult and pe- diatric CO2 colorimetric detector devices could be substituted. Clinical assessment alone is not appropriate. †Laryngeal mask airways could be shared with an- esthesia but must be immediately accessible to the ED. ‡Feeding tubes (size 5F) may be used as umbilical venous catheters but are not ideal. A method for securing the umbilical catheter, such as an umbil- ical tie, should also be available. §A spinal stabilization device should be a device that can also stabilize the neck of an infant, child, or adolescent in a neutral position. 1240 FROM THE AMERICAN ACADEMY OF PEDIATRICS ●Chest tubes to include infant, child, and adult sizes (infant: 10F–12F; child, 16F–24F; adult, 28F–40F) ●Newborn delivery kit (including equipment for initial resuscitation of a newborn infant: umbilical clamp, scissors, bulb syringe, and towel) ●Urinary catheterization kits and urinary (indwelling) catheters (6F–22F) ACKNOWLEDGMENTS Development of this statement was supported by the US Department of Health and Human Services, Health Re- sources and Services Administration’s Maternal and Child Health Bureau, Partnership for Information and Com- munication Project (U93MC00184) and the Emergency Medical Services for Children National Resource Center at Children’s National Medical Center (U07MC09174). The statement is also consistent with recommendations of the Institute of Medicine’s report on the future of emergency care in the US health system. AMERICAN ACADEMY OF PEDIATRICS, COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE, 2007–2008 *Steven E. Krug, MD, Chairperson Thomas Bojko, MD, MS Joel A. Fein, MD, MPH Laura S. Fitzmaurice, MD Karen S. Frush, MD Louis C. Hampers, MD, MBA Patricia J. O’Malley, MD Robert E. Sapien, MD Paul E. Sirbaugh, DO Milton Tenenbein, MD Loren G. Yamamoto, MD, MPH, MBA LIAISONS Kathleen Brown, MD – American College of Emergency Physicians Kim Bullock, MD – American Academy of Family Physicians Andrew Garrett, MD, MPH – National Association of EMS Physicians Dan Kavanaugh, MSW – Maternal and Child Health Bureau Cindy Pellegrini – AAP Department of Federal Affairs Tasmeen Singh Weik, DrPH, NREMT-P – EMSC National Resource Center Sally K. Snow, RN, BSN – Emergency Nurses Association David W. Tuggle, MD – American College of Surgeons Tina Turgel, BSN, RN-C – Maternal and Child Health Bureau Joseph L. Wright, MD, MPH – EMSC National Resource Center CONTRIBUTORS Alice D. Ackerman, MD, MBA Kathy N. Shaw, MD, MSCE STAFF Sue Tellez AMERICAN COLLEGE OF EMERGENCY PHYSICIANS, PEDIATRIC COMMITTEE 2007–2008 Kathleen Brown, MD Ramon W. Johnson, MD Isabel A. Barata, MD Lee S. Benjamin, MD Lisa Bundy, MD James M. Callahan, MD Richard M. Cantor, MD James E. Colletti, MD Randolph J. Cordle, MD Ann Marie Dietrich, MD Martin I. Herman, MD Douglas K. Holtzman, MD Mark A. Hostetler, MD Paul Ishimine, MD Madeline Joseph, MD John M. Litell, DO David S. Markenson, MD Sanjay Mehta, MD Antonio E. Muniz, MD Aderonke Ojo, MD, MBBS Malford T. Pillow, MD Gerald R. Schwartz, MD Ghazala Q. Sharieff, MD STAFF Nancy B. Medina, CAE Stephanie Wauson 2006–2007 Ghazala Q. Sharieff, MD Ramon W. Johnson, MD Isabel A. Barata, MD Lee S. Benjamin, MD Kathleen Brown, MD Lance A. Brown, MD, MPH David B. Burbulys, MD James M. Callahan, MD Cindy Chan, MD James E. Colletti, MD Randolph J. Cordle, MD Joseph H. Finkler, MD Martin I. Herman, MD Douglas K. Holtzman, MD Dennis A. Hernandez, MD Mark A. Hostetler, MD Paul Ishimine, MD Sharon E. Mace, MD Maureen D. McCollough, MD Alfred D. Sacchetti, MD Gerald R. Schwartz, MD STAFF Nancy B. Medina, CAE Tracy Napper EMERGENCY NURSES ASSOCIATION, PEDIATRIC COMMITTEE, 2008–2009 Beth N. Bolick, RN, DNP, PNP-BC, CPNP-AC, Chairperson Liesel Caten, RN, BSN Kathleen Lozano, RN, BSN Christine Marshall, RN, MSN Nancy Stevens, RN, MSN, FNP AnnMarie Papa, RN, MSN, Board Liaison STAFF Claudia Jorgenson, RN, MSN Altair Juarez, MPH Tracy Lloyd, RN, MPH Leslie Gates AMERICAN ACADEMY OF PEDIATRICS, EMERGENCY DEPARTMENT PREPAREDNESS GUIDELINES ADVISORY COUNCIL *Marianne Gausche-Hill, MD, Co-chairperson – American College of Emergency Physicians *Steven E. Krug, MD, Co-chairperson – American Academy of Pediatrics Frederick Blum, MD, Board Liaison – American College of Emergency Physicians Kim Bullock, MD – American Academy of Family Physicians Catherine W. Burt, PhD – Centers for Disease Control James Chamberlain, MD – American Academy of Pediatrics George L. Foltin, MD – American Academy of Pediatrics Karen Frush, MD – American Academy of Pediatrics Ramon Johnson, MD, Board Liaison– American College of Emergency Physicians Dan Kavanaugh, MSW – Maternal and Child Health Bureau Kimberly Middleton, MPH – Centers for Disease Control Ghazala Sharieff, MD– American College of Emergency Physicians Al Sacchetti, MD – American College of Emergency Physicians Sally K. Snow, RN, BSN – Emergency Nurses Association Robert A. Wiebe, MD – American Academy of Pediatrics Joseph L. Wright, MD, MPH – EMSC National Resource Center STAFF Sue Tellez stellez@aap.org *Lead authors FROM THE AMERICAN ACADEMY OF PEDIATRICS PEDIATRICS Volume 124, Number 4, October 2009 1241 REFERENCES 1. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine; American College of Emergency Physicians, Pediatric Committee. Care of children in the emergency department: guidelines for preparedness.Pediatrics.2001;107(4):777–781 2. American College of Emergency Physicians, Pediatric Committee; American Academy of Pediat- rics, Committee on Pediatric Emergency Medicine. Guidelines for preparedness of emergency departments that care for children: a call to action.Ann Emerg Med.2001;37(4):389–391 3. Pitts SR, Niska RW, Xu J, Burt CW. National Hospital Ambulatory Medical Care Survey: 2006 emer- gency department summary.Natl Health Stat Rep.2008;(7):1–39 4. Burt CW, McCaig LF. Stafﬁng, capacity, and ambulance diversion in emergency departments: United States 2003–2004.Adv Data.2006;(376):1–23 5. McCaig LF, Nawar EW. National Hospital Ambulatory Medical Care Survey: 2004 emergency depart- ment summary.Adv Data.2006;(372):1–29 6. Middleton KR, Burt CW. Availability of pediatric services and equipment in emergency departments: United States, 2002–2003.Adv Data.2006;(367):1–16 7. Institute of Medicine, Committee on Pediatric Emergency Medical Services.Institute of Medicine Report: Emergency Medical Services for Children.Durch JS, Lohr KN, eds. Washington, DC: Na- tional Academies Press; 1993 8. McGillivray D, Nijssen-Jordan C, Kramer MS, Yang H, Platt R. Critical pediatric equipment avail- ability in Canadian hospital emergency departments.Ann Emerg Med.2001;37(4):371–376 9. Athey J, Dean JM, Ball J, Wiebe R, Melese d’Hospital I. Ability of hospitals to care for pediatric emergency patients.Pediatr Emerg Care.2001;17(3):170–174 10. Gausche-Hill M, Schmitz C, Lewis RJ. Pediatric preparedness of United States emergency departments: a 2003 survey.Pediatrics.2007;120(6):1229–1237 11. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine. Access to optimal emergency care for children.Pediatrics.2007;119(1):161–164 12. Institute of Medicine, Committee of the Future of Emergency Care in the US Health System. Emergency Care for Children: Growing Pains. Washington, DC: National Academies Press; 2006 13. Tuggle DW, Krug SE; American Academy of Pediatrics, Section on Orthopedics, Committee on Pediatric Emergency Medicine, Section on Critical Care, Section on Surgery, and Section on Transport Medicine. Management of pediatric trauma.Pediatrics.2008;121(4):849–854 14. Weik T, Fendya D, Hulbert J, Morrison-Quinata T. Emergency Medical Services for Children Program: Implementation Manual for EMSC State Partnership Performance Measures. Washington, DC: Emergency Medical Services for Children National Resource Center; 2009. Available at: www.childrensnational.org/emsc. Accessed August 20, 2009 15. Centers for Medicare and Medicaid Services, US Department of Health and Human Services. Appendix W: survey protocol, regulations and interpretive guidelines for critical access hospitals (CAHs) and swing-beds in CAHs. In:State Operations Manual.Baltimore, MD: Centers for Medicare and Medicaid Services; 2008. Available at: http://cms.hhs.gov/manuals/Downloads/ som107ap_w_cah.pdf. Accessed December 15, 2008 16. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine. Pediatric care recommendations for freestanding urgent care centers.Pediatrics.2005;116(1):258–260 17. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine. Preparation for emergencies in the ofﬁces of pediatricians and pediatric primary care providers.Pediatrics. 2007;120(1):200–212 18. American Academy of Pediatrics, National Initiative for Children’s Health Care Quality Project Advisory Committee. Principles of patient safety in pediatrics.Pediatrics.2001;107(6): 1473–1475 19. Frush K, Krug SE; American Academy of Pediatrics, Committee on Pediatric Emergency Medicine. Patient safety in the pediatric emergency care setting.Pediatrics.2007;120(6):1367–1375 20. American Academy of Pediatrics, Committee on Drugs and Committee on Hospital Care. Preven- tion of medication errors in the pediatric inpatient setting.Pediatrics.2003;112(2):431–436 21. Lesar TS, Mitchell A, Sommo P. Medication safety in critically ill children.Clin Pediatr Emerg Med. 2006;7(4):215–225 22. Taveras EM, Flores G. Why culture and language matter: the clinical consequences of providing culturally and linguistically appropriate services to children in the emergency department.Clin Pediatr Emerg Med.2004;5(2):76–84 23. Sadler BL, Joseph A.Evidence for Innovation: Transforming Children’s Health Through the Physical Environment. Alexandria, VA: National Association of Children’s Hospitals and Related Institutions; 2008 1242 FROM THE AMERICAN ACADEMY OF PEDIATRICS 24. Joint Commission.2008 National Patient Safety Goals: Hospital Program. Oakbrook Terrace, IL: Joint Commission; 2008. Available at: www.jointcommission.org/PatientSafety/ NationalPatientSafetyGoals/08_hap_npsgs.htm. Accessed December 15, 2008 25. American College of Emergency Physicians, Pediatric Committee. Immunization of adults and children in the emergency department.Ann Emerg Med.2008;51(5):695 26. Cote´ CJ, Wilson S; American Academy of Pediatrics and American Academy of Pediatric Dentistry Work Group on Sedation. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update.Pediatrics.2006;118(6): 2587–2602 27. Mace SE, Brown LA, Francis L, et al; EMSC Panel (Writing Committee) on Critical Issues in the Sedation of Pediatric Patients in the Emergency Department. Clinical policy: critical issues in the sedation of pediatric patients in the emergency department.Ann Emerg Med.2008;51(4): 378 –399 28. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine. Consent for emer- gency medical services for children and adolescents.Pediatrics.2003;111(3):703–706 29. Knapp J, Mulligan-Smith D; American Academy of Pediatrics, Committee on Pediatric Emergency Medicine. Death of a child in the emergency department.Pediatrics.2005;115(5):1432–1437 30. Knazik SR, Gausche-Hill M, Dietrich AM, et al. The death of a child in the emergency department. Ann Emerg Med.2003;42(4):519–529 31. American Academy of Pediatrics, Committee on Hospital Care. Family-centered care and the pediatrician’s role.Pediatrics.2003;112(3 pt 1):691–697 32. American Academy of Pediatrics, Committee on Emergency Medicine; American College of Emer- gency Physicians, Pediatric Committee. Patient- and family-centered care and the role of the emergency physician providing care to a child in the emergency department.Ann Emerg Med. 2006;48(5):643–645 33. American Academy of Pediatrics, Committee on Emergency Medicine; American College of Emer- gency Physicians, Pediatric Committee. Patient- and family-centered care and the role of the emergency physician providing care to a child in the emergency department.Pediatrics.2006; 118(5):2242–2244 34. Emergency Nurses Association.ENA Position Statement: Care of the Pediatric Patient in the Emergency Care Setting. Des Plaines, IL: Emergency Nurses Association; 2007. Available at: www.ena.org/about/ position/position/Pediatric_Patient_in_the_Emergency_Setting_-_ENA_PS.pdf. Accessed December 16, 2008 35. Guzzetta CE, Clark AP, Wright JL. Family presence in emergency medical services for children.Clin Pediatr Emerg Med.2006;7(1):15–24 36. Emergency Nurses Association.ENA Position Statement: Family Presence at the Bedside During Inva- sive Procedures and Cardiopulmonary Resuscitation. Des Plaines, IL: Emergency Nurses Association; 2005. Available at: www.ena.org/about/position/position/Family_Presence_-_ENA_PS.pdf. Accessed December 16, 2008 37. American Academy of Pediatrics, Medical Home Initiatives for Children With Special Health Care Needs. The medical home.Pediatrics.2002;110(1 pt 1):184–186 38. Brody AS, Frush DP, Huda W, Brent RL; American Academy of Pediatrics, Section on Radiology. Radiation risk to children from computed tomography.Pediatrics.2007;120(3):677–682 39. Centers for Bioterrorism Task Force.Hospital Guidelines for Pediatrics in Disasters. 2nd ed. New York, NY: New York City Department of Health and Mental Hygiene; 2006. Available at: www.nyc.gov/ html/doh/downloads/word/bhpp/bhpp-focus-ped-toolkit.doc. Accessed December 15, 2008 40. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, Committee on Medical Liability, and Task Force on Terrorism. The pediatrician and disaster preparedness. Pediatrics.2006;117(2):560–565 41. Markenson D, Reynolds S; American Academy of Pediatrics, Committee on Pediatric Emergency Medicine and Task Force on Terrorism. The pediatrician and disaster preparedness.Pediatrics. 2006;117(2). Available at: www.pediatrics.org/cgi/content/full/117/2/e340 42. Teshome G, Closson FT. Emergency Medical Treatment and Labor Act: the basics and other med- icolegal concerns.Pediatr Clin North Am.2006;53(1):139–155 43. Ball JW, Liao E, Kavanaugh D, Turgel C. The emergency medical services for children program: accomplishments and contributions.Clin Pediatr Emerg Med.2006;7(1):6–14 44. Hegenbarth MA; American Academy of Pediatrics, Committee on Drugs. Preparing for pediatric emergencies: drugs to consider.Pediatrics.2008;121(2):433–443 FROM THE AMERICAN ACADEMY OF PEDIATRICS PEDIATRICS Volume 124, Number 4, October 2009 1243