5
Improving the Quality of Pediatric Emergency Care

Providing high-quality emergency care services to children requires an infrastructure designed to support care for pediatric patients. In Chapter 2 the committee discussed how many provider organizations, both emergency medical services (EMS) agencies and hospitals, lack recommended pediatric equipment and supplies for children. Addressing these basic deficiencies is an important first step. As technology improves and knowledge of quality in health care expands, however, expectations for provider preparedness extend well beyond simply having the right-sized equipment and appropriately labeled medications. We expect provider organizations to have safeguards in place to protect pediatric patients from the hazards of EMS and emergency department (ED) environments. We expect that advances in technology and information systems adopted by provider organizations will be appropriate for children as well as adults. And we expect care to be provided in a way that is evidence based, protocol driven, and respectful to children and their parents or guardians.

This chapter begins with an overview of the threats to patient safety in the EMS and ED environments and the implications for care, with a focus on pediatric patients. The committee believes emergency care provider organizations—both EMS agencies and hospitals—must take active steps to address these threats to reduce the burden of illness and injury to all patients, including children. To this end, the chapter presents the committee’s recommendations for improving the safety of emergency care for pediatric patients. Finally, the chapter addresses the important topic of how to make emergency care for children more family-centered.



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Emergency Care for Children: Growing Pains 5 Improving the Quality of Pediatric Emergency Care Providing high-quality emergency care services to children requires an infrastructure designed to support care for pediatric patients. In Chapter 2 the committee discussed how many provider organizations, both emergency medical services (EMS) agencies and hospitals, lack recommended pediatric equipment and supplies for children. Addressing these basic deficiencies is an important first step. As technology improves and knowledge of quality in health care expands, however, expectations for provider preparedness extend well beyond simply having the right-sized equipment and appropriately labeled medications. We expect provider organizations to have safeguards in place to protect pediatric patients from the hazards of EMS and emergency department (ED) environments. We expect that advances in technology and information systems adopted by provider organizations will be appropriate for children as well as adults. And we expect care to be provided in a way that is evidence based, protocol driven, and respectful to children and their parents or guardians. This chapter begins with an overview of the threats to patient safety in the EMS and ED environments and the implications for care, with a focus on pediatric patients. The committee believes emergency care provider organizations—both EMS agencies and hospitals—must take active steps to address these threats to reduce the burden of illness and injury to all patients, including children. To this end, the chapter presents the committee’s recommendations for improving the safety of emergency care for pediatric patients. Finally, the chapter addresses the important topic of how to make emergency care for children more family-centered.

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Emergency Care for Children: Growing Pains PATIENT SAFETY IN THE EMERGENCY CARE SETTING Challenges of the Emergency Care Environment Emergency care services are delivered in an environment where the need for haste, the distraction of frequent interruptions, and clinical uncertainty abound, thus potentially exposing patients to a number of threats to safety. Children are, of course, at particular risk under these circumstances because of their physical and developmental vulnerabilities and their inability to describe their symptoms and past medical history accurately, and because they may require care from providers who are not accustomed to treating pediatric patients (see Chapter 4). EDs are high-risk environments for medical care for patients of all ages. The nature of their mission and the multiple challenges they confront increase the risk of medical errors and adverse events (Leape et al., 1991; IOM, 2000; Vinen, 2000; Weingart et al., 2000). In their study of admissions to hospitals in Colorado and Utah, Thomas and colleagues (2000) found the ED to be the hospital department with the highest proportion of negligent adverse events (52.6 percent). An earlier study by Trautlein and colleagues (1984) found that 15 to 20 percent of hospital malpractice claims were a result of errors in the ED, most of which involved serious injury or death (Trautlein et al., 1984). There are several reasons why the ED is an area of high risk for errors. First, many EDs face excessive crowding, resulting in a noisy, even chaotic environment with frequent workflow interruptions. The large volume of patients results in many being evaluated, treated, and housed in the ED hallways, creating situations fraught with opportunities for error (Cosby, 2003; Selbst et al., 2004; Weiss et al., 2004). Moreover, ED patients do not arrive on a scheduled basis. Therefore, ED volumes can fluctuate a great deal, which makes it difficult to make staffing adjustments to meet sudden shifts in demand (Chamberlain et al., 2004). Second, ED personnel often work under a great deal of stress. They are required to see a broad case mix of patients and make rapid clinical decisions with little time and often without sufficient patient information (Selbst et al., 2004). Most physicians manage one patient at a time (in the operating room, clinic, diagnostic suite, or outpatient surgical center); emergency physicians, by contrast, are often responsible for the simultaneous management of 10 to 20 patients or more with a variety of problems and different levels of acuity. This is such an intrinsic part of emergency medical practice that the oral board exam administered by the American Board of Emergency Medicine (ABEM) requires examinees to properly handle three hypothetical cases simultaneously. No other specialty incorporates multiple patient encounters in its board certification examination process.

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Emergency Care for Children: Growing Pains In addition to caring for multiple patients, emergency care providers often face competing demands on their time; along with examining patients and providing treatment, they may have to handle EMS calls, help manage patient flow, listen to patients’ and family members’ complaints about waiting times and delays in care, track down missing laboratory or radiology results, and the like. ED physicians are frequently interrupted while working. In many cases, these interruptions result in a break in the physician’s focus on his or her primary task (Chisholm et al., 2001). In contrast to outpatient clinics and doctors’ offices, EDs operate 24 hours a day. The social and circadian stresses involved in consistently staffing the ED on a round-the-clock basis make ED physicians, nurses, and support staff particularly subject to fatigue, further increasing opportunities for mental errors (Vinen, 2000; Weinger and Ancoli-Israel, 2002; Chamberlain et al., 2004; Selbst et al., 2004). A study of the effect of sleep deprivation on experienced emergency physicians revealed that physicians working night shifts demonstrated a decrease in the speed of intubation and subjective alertness as compared with their day-shift work (Smith-Coggins et al., 1997). Patient hand-offs from one provider to another midtreatment can result in loss or distortion of important clinical information, thus providing increased opportunities for errors (Croskerry, 2000; Stiell et al., 2003; Chamberlain et al., 2004; Selbst et al., 2004). Physicians, nurses, and other clinicians working on the same shift often fail to communicate effectively, further increasing chances for errors to occur (Risser et al., 1999; Croskerry, 2000; Cosby, 2003; Selbst et al., 2004; White et al., 2004). In fact, poor communication and teamwork failures are a significant problem in the ED. White and colleagues (2004) noted that communication issues were associated with 30 percent of the ED risk management files they studied, and appeared to contribute directly to adverse medical outcomes in 20 percent of those cases. In addition, a 1999 study of the contribution of teamwork failures to clinical errors found that 8 of 12 deaths reviewed could have been prevented if appropriate teamwork action had been taken (Risser et al., 1999). The study authors noted that the most frequently cited primary contributor to clinical error in the ED (35 percent) was the failure to cross-monitor the actions of team members. Another problem faced by clinicians in the ED is lack of access to complete and accurate medical histories for the patients they are treating (Schenkel, 2000; Cosby, 2003; Chamberlain et al., 2004; Selbst et al., 2004; White et al., 2004). In most cases, ED physicians lack access to a patient’s medical record or even to records of previous visits to that or other area EDs. This problem can be compounded by poor information flow from patient to provider due to the patient’s age, mental health status, use of de-

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Emergency Care for Children: Growing Pains bilitating drugs or alcohol, language, culture, or apprehension and anxiety about the need for emergency care. Less research has been conducted on threats to patient safety in the EMS environment (O’Connor et al., 2002), although that environment is similar to the ED in many ways (Fairbanks, 2004): the fast-paced nature of the work, the stressful environment for providers, and the shift work and round-the-clock coverage that contribute to provider fatigue. EMTs also lack complete and/or accurate medical histories of patients. However, EMS personnel must also contend with a different set of challenges. They often have to provide patient care in unusual locations, such as on the side of a road or highway or close to a crash scene. EMS personnel also have fewer options for backup. Many EDs have physicians to make diagnosis and develop treatment plans, nurses to start intravenous (IV) treatment and administer medications, technicians to take patients’ blood pressure and pulse, social workers to talk with families, a secretary to complete billing information, and specialists that can be called in to assist with complex interventions. EMTs and paramedics in the field, by contrast, have no backup, other than perhaps the muscle and moral support of first-responding firefighters or other rescue personnel. Sometimes EMTs perform all of these tasks alone as a first responder or in the back of an ambulance. Thus the EMS environment lacks even the meager redundancies and system protections found in the ED that occur with a team approach to patient care. Additionally, much of the equipment used by EMTs was designed for in-hospital use and has not been well adapted for the EMS environment (Fairbanks, 2004). Additional Challenges for Pediatric Emergency Care Most of the above challenges contribute to a potentially unsafe emergency care environment for all patients, not just children. However, other factors complicate care for children more than that for adults. First, some children are preverbal and cannot self-report their symptoms. Many have multiple caregivers, which increases the likelihood that providers will be given an incomplete or inaccurate medical and medication history. Also, children are likely to be accompanied by parents or guardians suffering from great anxiety, which requires staff to attend to them while also staying focused on the patient (Chamberlain et al., 2004). Young children, particularly those who are frightened or in pain, are unable to cooperate with the examiner or understand the process of care, and may actively resist the performance of painful or uncomfortable procedures. As a result, pediatric providers must use a variety of tactics, including use of short-acting sedatives and other hazardous drugs, to complete treatment successfully. Timeliness represents another important challenge for pediatric patients in the emergency care setting. The emergency care system must be

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Emergency Care for Children: Growing Pains organized to eliminate unnecessary delays in triage and treatment. Because of their unique anatomical and physiological differences, children can get into trouble physiologically much more rapidly than adults. If children do not receive effective emergency care in a timely manner, certain illnesses and injuries can lead to serious consequences, even death, relatively quickly. For example, an infant or young child’s thermoregulatory system is less capable of cooling the body; body temperature can rise 3 to 5 times faster than occurs with adults, making infants and young children more susceptible to heat stroke (Null, 2006). An infant left in an enclosed automobile in hot weather, for example, will become hyperthermic very quickly. If not quickly diagnosed, hyperthermia in infants and young children leads to problems with resuscitation (ACEP and AAP, 2006). Hypothermia also occurs very quickly in children because they have thin skin, less insulating body fat, and a high ratio of body surface area to mass. Meningococcemia, or blood stream infection, is a potentially life-threatening illness that occurs abruptly and progresses rapidly. Cases are rare, but occur most often in children younger than age 5 (Kapes, 2005). Meningococcemia can lead to death more quickly than any other infectious disease, so early recognition is critical to providing prompt therapy and supportive care. Treatment must begin quickly because irreversible shock and death may occur within hours of the onset of symptoms of the disease (Tanzi and Silverberg, 2005). However, symptoms (fever, chills, sore throat) often resemble those of other conditions. Approximately 20 percent of children who develop meningococcemia do not survive (Children’s Hospital Boston, 2005b). Another example is shock. Pediatric practitioners treating acutely ill children, from neonates to young adults, are faced with multiple causes of shock (e.g., trauma, infection, anaphylaxis). Hypovolemic shock results from a deficiency of blood volume and is a leading cause of pediatric mortality in the United States. Whereas an adult can lose 500 cubic centimeters (cc) of blood without much effect, losing only half this amount of blood will result in death in infants. Delay in recognizing and quickly treating a state of shock can lead to widespread multiple system organ failure and death in pediatric patients (Schwarz, 2006). In a study of nearly 100 patients over a 10-year period, researchers were able to determine that when community hospitals, primary care physicians, and families recognized and treated children for shock before bringing them to the hospital, the mortality rate decreased dramatically. However, shock tends to be underrecognized and undertreated by emergency providers (Han et al., 2003). Children are also more susceptible to smoke inhalation and carbon monoxide toxicity than adults because of their higher metabolic rates and smaller volume of distribution for the carbon monoxide they ingest (ACEP and AAP, 2006). They experience symptoms more quickly then adults, but

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Emergency Care for Children: Growing Pains carbon monoxide poisoning is often treated improperly in children because its symptoms are similar to those associated with the flu (without the fever) and food poisoning (Children’s Hospital Boston, 2005a). A child’s continued exposure to carbon monoxide can lead to neurological disorders, cardiac arrest, and death. As another example, vomiting is rather common in children. Vomiting may be caused by gastroenteritis, which is generally less serious, or by many life-threatening conditions, such as meningitis, encephalitis, intussusception, or other conditions that can result in significant morbidity or mortality if not evaluated and managed quickly (D’Agostino, 2002; Fleisher et al., 2006). Although these are but a few of the pediatric conditions that require prompt identification and treatment, one thing common to many of these examples is that diagnosis may be delayed if symptoms resemble those of other, more common problems. Because children can maintain normal physiology using compensatory mechanisms until they can no longer compensate, at which time they deteriorate quickly, they are particularly vulnerable if treatment is not started promptly. For example, infants and children may have normal blood pressure and be in compensated shock. Their bodies compensate by increasing the heart rate and clamping down on extremity arteries to shunt blood to central circulation. Therefore, subtle signs, such as an increase in heart rate and cool extremities, must be recognized promptly. However, parents, guardians, and primary care physicians may not recognize the need for immediate emergency care for pediatric patients, and emergency care providers may not be able to determine the severity of illness or injury quickly. In fact, at least one study has shown that the level of agreement in triage assignment for pediatric patients in the ED is not high, and varies based on the level of pediatric training (Maldonado and Avner, 2004). Another pediatric concern related to timeliness has to do with the often long wait times associated with ED visits. As discussed in Chapter 2, ED crowding has become a daily occurrence in many hospitals. National Hospital Ambulatory Medical Care Survey (NHAMCS) data indicate that in 2003, the average waiting time for all patients (children and adults) to see a physician in the ED was 46 minutes (McCaig and Burt, 2005). Data for 2000 demonstrate the differences in wait time according to patient acuity. On average, patients waited 24 minutes for a visit classified as “emergent,” 38 minutes for an “urgent” visit, 56 minutes for a “semiurgent” visit, and 67 minutes for a “nonurgent” visit (McCaig and Ly, 2002). Prolonged wait times may result in protracted pain for all patients (Derlet and Richards, 2000; Derlet et al., 2001), but for pediatric patients there is another concern. In busy EDs that serve both adults and children, children may be exposed

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Emergency Care for Children: Growing Pains to inappropriate and frightening scenes, such as violence, severe injury, and threatening language. Adult EDs are generally not well suited to providing a comforting or reassuring environment for children. Evidence of Compromised Safety for Pediatric Patients Given this potentially perilous emergency care environment, how often do medical errors occur among pediatric patients? Surprisingly, the answer to that question is unknown. In fact, there is little high-quality data on the epidemiology of medical errors in children, particularly within the emergency care system. Instead, there are a few, typically small studies demonstrating that care is compromised during several different stages of an ED visit. For example, providers often triage patients inaccurately (Selbst et al., 2004). Errors in specimen collection methods (Walsh-Kelly et al., 1997) and interpretation of radiographs are also a concern (Walsh-Kelly et al., 1995). As might be expected, children with special medical needs or those who are dependent on technology are significantly more likely to experience a medical error than other children (Slonim et al., 2003). One of the most telling studies on the quality of pediatric care comes from a recent drill conducted in 35 EDs (including 5 trauma centers) in North Carolina. Using life-size child manakins, researchers staged “mock codes” and presented each team with a vignette describing patients’ symptoms. Nearly all of the EDs failed to stabilize seriously injured children properly during trauma simulations. Thirty-four hospitals failed to administer dextrose properly to a child in hypoglycemic shock (a life-threatening drop in blood sugar); 34 failed to warm a hypothermic child correctly; 31 failed to order proper administration of IV fluids; 24 failed to attempt or succeed at accessing a child’s bloodstream through a bone (a critical alternative for delivering fluids and medicines rapidly to sick children); and 23 failed to provide appropriate medications, monitoring equipment, and personnel needed to transport a child safely within the hospital. On the other hand, many hospitals were successful at calling appropriate individuals for assistance, performing initial airway assessment and initial bag-mask ventililation, ordering appropriate imaging tests, and conducting initial assessment of vital signs (Hunt et al., 2006). There have been few published studies describing the nature or extent of medical errors in the EMS environment. In one research effort, however, 15 paramedics were interviewed about adverse events and near misses; all had multiple events to report. In sum, 61 events were described, 23 percent of which involved a child. The major types of errors were mistakes in clinical judgment (54 percent), errors in skill performance (21 percent), and medication errors (15 percent). Only one-third of the errors had been reported

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Emergency Care for Children: Growing Pains to anyone (Fairbanks and Crittenden, 2006). In another small study, which tested the ability of 14 paramedics to use a manual defibrillator, several paramedics defibrillated when they intended to cardiovert. This is a potentially fatal error, and in some cases, participants were not aware they had made the mistake. The researchers attributed the error to the defibrillators’ poor interface design (Fairbanks, 2004; Fairbanks et al., 2004). However, the best evidence of medical errors and compromised safety concerns medication errors and adverse drug events in children. Prescribing errors occur more frequently in the ED than in any other part of the hospital and more frequently in the care of children than in that of adults. Medication errors were the most commonly reported type of error at one pediatric ED (Selbst et al., 1999). In a retrospective study of more than 1,500 charts of children treated in a pediatric ED, prescribing errors were identified in 10 percent of the charts (Kozer et al., 2002). These errors occurred more frequently during overnight hours (8:00 PM to 4:00 AM) and on weekends and were made most often by trainees. Another study evaluated medication errors with respect to antipyretics and found that 22 percent of acetaminophen doses ordered were outside the recommended 10–15 mg/kg/dose (Losek, 2004). Another study of medication errors among acutely ill and injured children presenting to rural EDs revealed errors in 48 percent of patient charts (Marcin et al., 2005). More seriously ill children are more likely to experience a prescribing error than those with less serious illnesses or injuries (Kozer et al., 2002). Not surprisingly, the limited evidence available also indicates that medication errors occur frequently in the EMS environment. In a study that assessed the medication calculation skills of 109 paramedics, overall performance was found to be poor. On average, the paramedics answered 51 percent of the test questions correctly. Medication infusions were calculated incorrectly in one-third of cases (Hubble and Paschal, 2000; Fairbanks, 2004). Challenges Associated with Prescribing and Administering Medications to Children in an Emergency Setting Perhaps the foremost problem associated with providing medications to children is that many medications are frequently prescribed for children “off label,” meaning they have not been approved for pediatric use by the Food and Drug Administration (FDA). Once a drug has been approved for use by the FDA, further studies to determine its safety and efficacy in infants and children are rarely conducted for the majority of drugs (Rapkin, 1999). The result is that emergency providers must prescribe medications to children without a full understanding of the risks, benefits, or implications.

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Emergency Care for Children: Growing Pains One example is the use of medications to treat depression in children. Data indicate that psychiatric emergencies are on the rise for children and adolescents, yet there is only one medication, fluoxetine, approved for pediatric use. Still, others are frequently prescribed. The dosages, efficacy, and safety of these medications have not been well established for pediatric patients. Although there is some evidence that one of those drugs, paroxetine, may lead to an increased risk of suicide, the research is thin, and it is unclear why there is a greater risk associated with this and other drugs in comparison with fluoxetine. Medications designed for adults may not be suitable for children because of differences in pharmacokinetics (what the body does to a drug) and pharmacodynamics (what a drug does to the body). Children’s bodies absorb, distribute, metabolize, and eliminate medications differently from those of adults. But pharmacokinetics and pharmacodynamics also differ as children develop, so the needs of a premature infant, full-term infant, child, and adolescent can vary greatly. A good example is morphine. To achieve a morphine steady-state serum concentration of 10 nanograms (ng)/ml, the infusion rate in micrograms (µg)/kg/hr is 5 for neonates, 8.5 at 1 month of age, 13.5 at 3 months, 18 at 1 year, and 16 at ages 1–3 after noncardiac surgery in an intensive care unit (ICU) (Bouwmeester et al., 2004). Currently, emergency care professionals have little by way of evidence-based guidelines and information to assist them with the prescribing of medications for infants, children, and adolescents (Mace et al., 2004). For example, there is currently no consensus on optimal guidelines for medications for pediatric sedation; in fact, sometimes these medications are given to children in combination with other drugs. Adverse drug events are common, particularly for antibiotics (e.g., ceftriaxone, clindamycin, amoxicillin), opioids (e.g., morphine, hydromorphone, acetaminophen with codeine), and anticonvulsants (e.g., phenytoin, phenobarbital, valproic acid); drugs in these classes are commonly prescribed to children in an emergency setting. Because of the startling knowledge gap and the frequent use of medications in children in the emergency setting, the committee recommends that the Department of Health and Human Services fund studies of the efficacy, safety, and health outcomes of medications used for infants, children, and adolescents in emergency care settings in order to improve patient safety (5.1). A number of different agencies within the Department of Health and Human Services (DHHS) could lead this effort, including the FDA, the Health Resources and Services Administration (HRSA), and the Agency for Healthcare Research and Quality (AHRQ). Congress has already taken some action in this area by passing two laws that provide incentives for or require drug manufacturers to conduct studies on the effects of drugs when used for pediatric patients—the Best Pharmaceuticals for Children Act of

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Emergency Care for Children: Growing Pains 2002 (BPCA) and the Pediatric Research Equity Act of 2003 (PREA), respectively. Under BCPA, the manufacturer takes the initiative in conducting pediatric studies and requests 6-month patent extensions from the FDA; however, this may not occur for drugs with limited market potential. PREA applies only to new molecular entities or new drugs, for which the FDA can require that the manufacturer conduct pediatric studies unless exceptions are granted. There is currently no regulation providing incentives for or requiring manufacturers to perform pediatric studies for the vast majority of drugs on the market in the generic forms used for pediatric patients. Even for the small group of medications for which pediatric guidelines are available, a number of pitfalls exist at the prescribing, dispensing, administration, and monitoring stages that can result in medication errors and adverse drug events. Most adverse drug events for pediatric patients are a result of errors that occur at the prescribing stage, and they often involve incorrect dosing (IOM, 2000; Kaushal et al., 2001; Selbst et al., 2004; Chamberlain et al., 2004). Doses for pediatric patients must be calculated based on the patient’s weight and therefore must be determined specifically for each patient. But the calculations needed to develop the dosing are complicated, and errors are common (Selbst et al., 2004). Patient weight can be and often is obtained or recorded incorrectly (Selbst et al., 1999). Among the most serious dosing errors are 10-fold errors that occur when a decimal point is missing or misread. There have been several examples of children receiving 10 or 100 times the intended dose of a medication and dying as a result. In one case, a baby was given 15 milligrams of morphine instead of the intended 0.15 milligrams—a 100-fold difference in dosing (Goldstein, 2001). Other dosing errors can occur if there is confusion between milligrams (mg) and micrograms (µg) or mg and milliliters (ml). Additionally, errors are common with combinations of products, for example, Tylenol with codeine; it may be unclear whether the dosage is for the Tylenol or the codeine. Finally, dosage errors may occur when a product is prepared in two different ways and the concentrations are different. For example, Tylenol comes in a syrup and a drop, but the concentrations differ. The process of dispensing and administering medications for children, compared with that for adults, relies much more heavily on manual compounding of liquid medications and administration to patients who are unable to perform their own medication safety checks. This may well make the dispensing and administering of medications for children more prone to error. Additionally, errors can occur during the dispensing stage if drugs that look or sound alike are confused, for example, Zantac and Zyrtec or Tobrex and Tobradex. Additionally, the packaging of two medications may look alike, contributing to errors at the dispensing stage (Levine et al., 2001;

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Emergency Care for Children: Growing Pains Selbst et al., 2004). Most EDs do not have a pharmacist on staff to review orders or assist with medication use (Selbst et al., 2004). At the administration phase, a drug may be delivered twice if the first dosing is not promptly recorded in the medical record. To reduce the high frequency of medication errors that occur in pediatric emergency care, the committee recommends that the Department of Health and Human Services and the National Highway Traffic Safety Administration fund the development of medication dosage guidelines, formulations, labeling guidelines, and administration techniques for the emergency care setting to maximize effectiveness and safety for infants, children, and adolescents. Emergency medical services agencies and hospitals should incorporate these guidelines, formulations, and techniques into practice (5.2). Agencies could commission research studies and/or convene a panel of experts to carry out these tasks. The Office of Emergency Medical Services within the National Highway Traffic Safety Administration (NHTSA) is a natural leader for this effort; within DHHS, a number of agencies could lead the effort, including the FDA, HRSA, and AHRQ. Implementing the proposed guidelines would not only improve patient safety, but also potentially reduce providers’ liability claims since medication errors have been shown to be the second most frequent and second most expensive reason for such claims (Physician Insurers Association of America, 1993). IMPROVING SAFETY FOR PEDIATRIC PATIENTS The task of ED and EMS providers—to care for patients of all types, often with limited patient information and in a difficult, crowded environment—is enormous, and many providers and organizations are up to that task. However, there is enough evidence to suggest the need for action to improve the safety of emergency care, including that provided to pediatric patients. The committee therefore recommends that hospitals and emergency medical services agencies implement evidence-based approaches to reducing errors in emergency and trauma care for children (5.3). Those organizations that give guidance to providers, such as government agencies and professional organizations, should encourage providers to implement measures designed to protect patient safety. Continued research is needed to determine the best strategies for improving patient safety in prehospital and ED care; however, these strategies should focus on the factors that contribute to the deterioration of performance, such as crowding, problems with communication and information, and lack of provider resources. Various hospitals and EMS agencies have tried several promising strategies with some success that could be replicated in other organizations. These initiatives have the potential to help all patients, not just children. Below we

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Emergency Care for Children: Growing Pains Cultural Competency Another component of family-centered care is cultural competency. According to the EMS-C program, “cultural competence includes possessing the appropriate knowledge, skills, and capacity to provide emergency services to children in a manner that demonstrates respect, sensitivity, and understanding of the unique cultural differences within, among, and between groups” (EMS-C National Resource Center, 1999). Only a few studies have been able to draw a direct link between cultural competence and health care improvement, although expert opinion strongly suggests a connection among cultural competence, quality of care, and reduced racial and ethnic disparities (Betancourt et al., 2002). These studies are not specific to pediatric patients, but cultural competency is an important issue for the emergency care system in general, not just services for children, particularly because the racial/ethnic distribution of emergency care providers is not well matched to the racial/ethnic distribution of the population, and is even less well matched to the population that uses emergency services most frequently. This disparity can only be expected to increase as the U.S. population continues to diversify at a much faster rate than most health professions and occupations (Heron and Haley, 2001; Cone et al., 2003). One of the biggest challenges for emergency care providers is language barriers. Professional interpreters are often not available in the field or at an ED. Indeed, interpreters are frequently not used in the ED, even when thought necessary by a patient or provider (Baker et al., 1996). When providers cannot obtain adequate information from a patient interview, they tend to use more resources, such as laboratory and radiographic investigations. One study of language barriers in a pediatric ED revealed that a physician–family language barrier was associated with a higher rate of resource utilization for diagnostic studies and increased ED visit times (Hampers et al., 1999). One special concern is the use of children as interpreters for their own care or the care of their parents/guardians when they speak English but their parents/guardians do not. Use of children as medical interpreters is common practice in many areas with large immigrant populations (Burke, 2005); often, however, the information that needs to be interpreted is beyond children’s comprehension and may be inappropriate for them (Yee, 2005). Children assuming this role take on a heavy emotional responsibility. Additionally, use of an untrained interpreter can lead to medical errors. In one study, the error rate was highest for the youngest interpreter, an 11-year-old (Flores et al., 2003). Some states have regulations that prevent children from serving as medical interpreters for their parents/guardians, but these rules may not apply in emergency situations. The traditional subordinate role of children can be reversed when they are used as interpreters, and in some

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Emergency Care for Children: Growing Pains cultures, their assumption of this role can be seen as a threat to parental authority and therefore serve as a barrier to care (National Association of Emergency Medical Technicians, 2000b). The challenge goes beyond language barriers, however. Providers need to be aware of the various cultures residing in their catchment area so as to be prepared to serve them. Also, understanding different family structures can help avoid hostile reactions resulting from inadvertent disrespect toward families (National Association of Emergency Medical Technicians, 2000b). Providers’ actions can affect patient perceptions of care. A survey of adult patients presenting to an ED with one of six chief complaints found that non–English speakers were less satisfied with their care in the ED, were less willing to return to the same ED if they had a problem they felt required emergency care, and reported more problems with emergency care (Carrasquillo et al., 1999). Failure to appreciate the importance of culture and language during pediatric emergencies can result in multiple adverse consequences, including difficulties with informed consent; miscommunication; inadequate understanding of diagnosis and treatment by families; dissatisfaction with care; preventable morbidity and mortality; unnecessary child abuse evaluations; lower-quality care; clinician bias; and ethnic disparities in prescriptions, analgesia, test ordering, and diagnostic evaluation (Flores et al., 2002). The National Association of Emergency Medical Technicians emphasizes the use of communication strategies to combat some of the cultural barriers to care that may arise. Examples of these strategies include identifying providers to the patient and family members, identifying a team member to interact with the family members on each call, asking how the patient and family would like to be addressed, using courtesy titles, and watching for verbal and nonverbal cues from families about the amount of information they want and whether they understand what is being explained to them (National Association of Emergency Medical Technicians, 2000b). Care of Adolescents Less research on patient- and family-centered care has been conducted for adolescents than for younger children. In fact, relatively little is known about adolescents’ health care preferences or expectations (Britto et al., 2004). Results of a study of adolescents with chronic illness suggest that aspects of interpersonal care are most important to their judgment of quality. Physicians’ honesty and attention to pain are deemed of critical importance. Adolescents also want to participate in their own care and have their views taken seriously by providers (Britto et al., 2004). Adolescents tend to find the ED a fast-paced, confusing, and frightening place according to results from a focus group of teens in four cities.

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Emergency Care for Children: Growing Pains Respondents reacted negatively to the idea of emergency care personnel approaching them at the hospital and engaging them in discussions of violence or personal safety (Dowd et al., 2000). This finding presents a real challenge to emergency care providers since teens often present with conditions resulting from violence or alcohol or drug use. Most EDs do not provide preventive screenings or counseling for adolescents (Wilson and Klein, 2000). Physicians tend to find adolescent patients “frustrating,” and according to one study, adolescents receive less-than-optimal care in the emergency room (March and Jay, 1993). Yet brief interventional counseling for adolescents may be of value. A prevention effort at one ED targeting injured adolescents resulted in greater use of seat belts and bicycle helmets (Johnston et al., 2002). Certainly more research is necessary to provide adolescents with emergency services in a way that is both patient-centered and effective. Clearly, however, an understanding of the psychosocial and developmental issues that characterize adolescence may help staff respond more effectively to adolescent patients (March and Jay, 1993). SUMMARY OF RECOMMENDATIONS 5.1 The Department of Health and Human Services should fund studies of the efficacy, safety, and health outcomes of medications used for infants, children, and adolescents in emergency care settings in order to improve patient safety. 5.2 The Department of Health and Human Services and the National Highway Traffic Safety Administration should fund the development of medication dosage guidelines, formulations, labeling guidelines, and administration techniques for the emergency care setting to maximize effectiveness and safety for infants, children, and adolescents. Emergency medical services agencies and hospitals should incorporate these guidelines, formulations, and techniques into practice. 5.3 Hospitals and emergency medical services agencies should implement evidence-based approaches to reducing errors in emergency and trauma care for children. 5.4 Federal agencies and private industry should fund research on pediatric-specific technologies and equipment for use by emergency and trauma care personnel. 5.5 Emergency medical services agencies and hospitals should integrate family-centered care into emergency care practice.

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