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Petrack E, Perry LS, Vehar K.
 Integration of pharmacologic and non pharmacologic techniques to enhance pediatric minor procedures.
Jrnl Urgent Care Med. 2008 Feb; 2(5):11-16.
Children frequently require minor procedures, such as blood draws, IV catheter placement, suturing, and abscess drainage. Although "minor," these procedures can highlight safety concerns and create significant anxiety for the child, family and even staff. This article discusses how to gain trust, and give children and families a sense of control. Specific techniques are offered to position children for procedures to maximize safety and reduce restraint. The authors discuss how to use appropriate language, prepare, and then distract children during the procedure. The integration of pharmacologic and non-pharmacologic techniques is emphasized.
Zisk RY, Grey M, Medoff-Cooper B, MacLaren JE, Kain ZN.
The squeaky wheel gets the grease: parental pain management of children treated for bone fractures.
Pediatr Emerg Care. 2008 Feb;24(2):89-96.
This study looked at parental attitudes towards pharmacologic and non-pharmacologic pain management after extremity fractures. Fifty parents of children 5-10 years old with extremity fractures were studied. On the day following the fracture, 20% received no analgesia, and 44% received only 1 dose. Most children received analgesia based on active, loud behaviors such as crying; yet, children exhibited quiet behaviors more frequently than crying. Although this is a small number of patients, the authors raise the concern that recognizing behaviors that correlate with pain is difficult, and that quiet behaviors may also reflect pain and need for analgesia.
Kanter, R. K.Moran, J. R.
Pediatric preparedness of US emergency departments: a 2003 survey.
Pediatrics. 2007 Dec;120(6):1229-1237.
These authors sent a survey to assess pediatric preparedness to all US emergency departments in 2003. A total of 1,489 useable surveys (29%) were received for analysis. 89% of pediatric ED visits occurred in non-children's hospitals, with 26% occurring in rural or remote facilities. Of note, 75% of respondents saw less than 7,000 children annually. Only 6% of EDs had all recommended equipment and supplies, with neonatal or infant equipment frequently lacking. The authors conclude that there is significant opportunity for improvement in pediatric preparedness. While this study has led to some controversy, it supports concerns raised by the Institute of Medicine regarding preparedness for pediatric emergency care in our nation's emergency departments.
Krug, S. E.Frush, K.
Patient safety in the pediatric emergency care setting.
Pediatrics. 2007 Dec;120:1367-1375.
This policy statement from the American Academy of Pediatrics focuses on patient safety in the emergency department. It delineates specific suggestions and guidelines for reducing medication errors and enhancing patient safety for children. These include practices such as time-outs before procedures, mock codes, teamwork training, use of clinical tools to aid medication dosing and administration, integrating family-centered care into the ED, and supporting Institute of Medicine recommendations.
Dingeman, R. S., Mitchell, E. A., Meyer, E. C., et al.
Parent presence during complex invasive procedures and cardiopulmonary resuscitation: a systematic review of the literature.
Pediatrics. 2007 Oct;120:842-854.
This article is a systematic review of 15 studies on parent presence during invasive pediatric procedures or resuscitation. The data support recommendations by the American Academy of Pediatrics and Society of Critical Care Medicine that parents be offered the option to be with their children during this difficult period. It is noted that there remains significant controversy among clinicians concerning this practice, and few institutions have developed guidelines.
Burt C.W., Middleton K.R.
Factors associated with ability to treat pediatric emergencies in US hospitals.
Ped Emerg Care. 2007 Oct;23:681-689.
These authors sought to understand factors associated with the availability of pediatric services and expertise in US hospitals for treating pediatric emergencies. They used data from the 2002-2003 NHAMCS survey, compared with guidelines developed by the American Academy of Pediatrics and American College of Emergency Physicians. Pediatric volume, teaching hospital status, geographic region, and per capita income of the community were strongly related to better preparedness on each of their measures. Many hospitals that did not offer specialized pediatric care lacked transfer agreements with hospitals offering such care.
Hsiao, A. L., Santucci, K. A., Dziura, J., et al.
A randomized trial to assess the efficacy of point-of-care testing in decreasing length of stay in a pediatric emergency department.
Pediatr Emerg Care. 2007 Jul;23:457-462.
Point of care (POC) laboratory testing is one enhancement that emergency departments use to reduce throughput times. This is a prospective, randomized, controlled trial of pediatric patients requiring blood work. Of 225 patients, 114 were randomized to the POC testing group, and 111 to the routine blood testing group. Significantly less time was required for results to become available with POC vs. routine testing (5 vs 70 minutes; p<0.001). A significant decrease of 38.5 minutes (p<0.001) in length of stay was also noted. The authors conclude that POC testing is effective in improving throughput time and improving patient flow.
Brousseau, D. C., Hoffmann, R. G., Nattinger, A. B., et al.
Quality of primary care and subsequent pediatric emergency department utilization.
Pediatrics. 2007 Jun;119:1131-1138.
The relationship between access to primary care and emergency department utilization remains controversial. This study sought to determine if parent-reported, high quality primary care was associated with decreased pediatric nonurgent emergency department utilization. The authors did a retrospective analysis of 8,823 children, using 2000-2002 data from the Medical Expenditure Panel Survey. They found that high quality family-centeredness was associated with a 42% reduction in nonurgent ED visits for publicly insured children and a 49% reduction for children ? 2 years old. Greater realized access was associated with a 44% reduction in nonurgent visits for children 3-11 years old, and a 56% reduction for children ? 12 years old. They conclude that parental perception of high quality care and realized access to primary care were associated with decreased nonurgent ED use for children.
Bourgeois, F. T.Shannon, M. W.
Emergency care for children in pediatric and general emergency departments.
Pediatr Emerg Care. 2007 Feb;23:94-102.
Using the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1995-2002, these authors reviewed differences in pediatric care between pediatric and general emergency departments. They found that pediatric EDs saw more medical problems, while general EDs saw more injuries. Visits to pediatric EDs were associated with longer wait times to see a physician, and longer stays in the ED. There were no differences in the ordering frequency of common diagnostic studies, such as CBC, urinalysis, and chest radiograph. Not surprisingly, children in pediatric EDs seemed to be sicker. The authors note that these data provide the first glimpse of pediatric health care in EDs nationally.
Committee on Pediatric Emergency Medicine, American Academy of Pediatrics
Access to optimal emergency care for children
Pediatrics. 2007 Jan;119:161-164.
This policy statement from the American Academy of Pediatrics highlights the problems surround the provision of emergency care for children, along with specific recommendations.
Committee on Pediatric Emergency Medicine, American Academy of Pediatrics
Patient- and family- centered care and the role of the emergency physician providing care to a child in the emergency department.
Pediatrics. 2006 Nov;118:2242-2244.
This is a joint Policy Statement from the American Academy of Pediatrics and the American College of Emergency Physicians. It emphasizes the important role the family plays in optimizing medical care for children. It also highlights some of the challenges related to providing family- centered care in emergency settings.
Child Life Council, Committee on Hospital Care, American Academy of Pediatrics
Child Life Services
Pediatrics. 2006 Oct;118:1757-1763.
This policy statement from the American Academy of Pediatrics is an excellent overview of the value child life specialists bring to enhancing family-centered care in healthcare settings. It discusses their function in emergency departments, and comments on some of the challenges related to justifying the cost of child life services. They offer specific recommendations, beginning with a statement that child life services should be considered an essential component of quality pediatric health care and noting that these services are integral to family-centered care and best-practice models for pediatric services.
Rogers AJ, Greenwald MH, DeGuzman MA et al.
A randomized, controlled trial of sucrose analgesia in infants younger than 90 days of age who require bladder catheterization in the pediatric emergency department.
Acad Emerg Med. 2006 June;13:617-622.
In this randomized, double-blinded study to assess the analgesic effect of sucrose solution for infants ? 90 days of age requiring bladder catheterization, infants were given 2 ml of sucrose or water 2 minutes prior to the procedure. Forty patients were randomized to each group. In the overall analysis, sucrose did not provide significant analgesia. However, in the subgroup of infants less than 30 days of age, sucrose did provide significant analgesia, with a smaller change in pain scores, infants less likely to cry, and more rapid return to baseline after catheter removal. It appears that sucrose solution provides effective analgesia for infants under 30 days of age. I have seen catheterizations and IV placements in these young patients using sucrose solution, and it clearly works well for at least some young infants.
Drendel AL, Brousseau DC, Gorelick MH.
Pain assessment for pediatric patients in the emergency department.
Pediatrics 2006 May;117:1511-1518.
These authors examined the association between patient visit characteristics, pain score documentation, and analgesic use. Their data is based on the NHAMCS national survey (1997-2000), and included 24,707 visits. Younger age, self-pay, visits to pediatric facilities and non-injury visits were associated with decreased pain score documentation. Importantly, they found that documentation of pain score was associated with increased odds of analgesic (in particular, opioid) use. Overall, they conclude that infants and toddlers are at higher risk for not having pain score documentation, and that decreased documentation is associated with decreased analgesic use.
Sinha M, Christopher NC, Fenn R et al.
Evaluation of nonpharmacologic methods of pain and anxiety management for laceration repair in the pediatric emergency department.
Pediatrics. 2006 April;117:1162-1168.
This is the first controlled study to evaluate the effect of distraction techniques on children requiring laceration repair. While there are some limitations to this study, the authors found that distraction techniques reduced self-reported anxiety (but not pain) in older children and lowered parental perception of pain distress in younger children. It appears that the non pharmacologic techniques offered by child-life specialists and nurses may have an important role in this setting.
Hunt EA, Hohenhaus SM, Luo X
Simulation of pediatric trauma stabilization in 35 North Carolina emergency departments: identification of targets for performance improvement.
Pediatrics. 2006 Mar;117(3):641-648.
This prospective, observational study looked at pediatric trauma mock codes at 35 North Carolina EDs, scoring each code on 44 stabilization tasks. While the median number of tasks that needed improvement was 25 (57%), some common critical tasks, such as warming measures, ordering IV fluids and preparing for intraosseous needle insertion, were missed by the vast majority. Their conclusion suggests that mistakes in handling pediatric trauma are very common and that additional training is needed to enhance outcomes for pediatric patients.
 Availability of pediatric services and equipment in emergency departments: United States, 2002-03
Vital and Health Statistics, U.S. Department of Health and Human Services, February 2006.
This report provides some detailed data on the availability of pediatric care in U.S. emergency departments. 23% of EDs had 24 hour access to a board-certified pediatric emergency physician. Only 5.5% had all recommended pediatric supplies, although overall, hospitals had 83% of the recommended supplies. This report, a supplement to the large, national NHAMCS database, is worth a look.
Stevenson MD, Bivins CM, O’Brien K et al.
Child life intervention during angiocatheter insertion in the pediatric
emergency department.
Ped Emerg Care. 2005 Nov;21:712-718.
There are very few studies which evaluate the role of child life specialists in the emergency department. This study focused
on children 2- 16 years of age, randomly assigning 149 children to a child life intervention or standard care. 121 of 149
patients (81%) required only one attempt at angiocatheter insertion, and in this group, there was a significant decrease in
behavioral distress, especially in children 4-7 years of age. This study supports the role of child life specialists in
preparing children for procedures.
Child life services can provide competitive edge
ED Management, October 2004
Magaret ND, Clark TA, Warden CR, Magnusson AR, Hedges JR.
Patient satisfaction in the emergency department--a survey of pediatric patients and their parents.
Acad Emerg Med. 2002 Dec;9(12):1379-88.
Shows that both parental and child satisfaction with emergency department visits are associated with the quality of the provider-patient interaction and the adequacy of information provided
Thomas DO.
Special considerations for pediatric triage in the emergency department.
Nurs Clin North Am. 2002 Mar;37(1):145-59, viii.
Emphasizes the importance of pediatric triage skills in the emergency department.
Athey J, Dean JM, Ball J, Wiebe R, Melese-d'Hospital I.
Ability of hospitals to care for pediatric emergency patients.
Ped Emerg Care 2001;17:170-174.
Examines ability of U.S. hospital emergency departments to meet the needs of children, suggesting that there are concerns with both pediatric emergency equipment and expertise to meet children's emergency needs
McGillivray D, Nijssen-Jordan C, Kramer MS, Yang H, Platt R.
Critical pediatric equipment availability in Canadian hospital emergency departments.
Ann Emerg Med. 2001 Apr;37(4):371-6.
Demonstrates significant deficiencies with pediatric emergency equipment in Canadian emergency departments
Gausche M, Rutherford M, Lewis RL.
Emergency department quality assurance/improvement practices for the pediatric patient.
Ann Emerg Med. 1995 Jun;25(6):804-8.
Outlines need for separate QI program for children in general emergency departments.
Alcock DS, Feldman W, Goodman JT, McGrath PJ, Park JM.
Evaluation of child life intervention in emergency department suturing.
Pediatr Emerg Care. 1985 Sep;1(3):111-5.
Highlights the role of child- life services in reducing anxiety and enhancing patient satisfaction.
Note: my experience is that a child-life program is a major differentiator of excellence in pediatric emergency care in the market place, and can be implemented with existing staff in a cost-effective manner.
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