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.
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.
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-
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
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
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
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
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.
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
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;
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
classify the strategies into three groups: provider policies, provider training, and technologies. Ideally, organizations would adopt all three of these strategies. A few examples of each type are given here.
One of the problems associated with reducing the incidence of medical errors is that the frequency of errors and their most important triggers are unknown. Provider initiatives aimed at raising awareness of medical errors have shown some potential, although such programs must be coupled with limits on provider liability to encourage participation. For example, one hospital created and implemented the Good Catch Reporting Program. Under this program, all staff are required to report suspected and identified medical errors and near misses without fear of reprisal. Senior hospital leadership appointed a patient safety manager who reports to the chief nurse and reviews all errors and near misses. This information is used to develop system improvements for patient safety. Within the first 3 months of the program, reporting of near misses doubled (Salisbury, 2005). This approach could also be applied to the EMS environment.
EMS and hospital administrators have a number of opportunities to examine and specifically develop policies to address areas in which they believe shortcomings in patient safety exist. One hospital created the Look Alike/Sound Alike Project, in which a second person is required to verify all medications prior to their administration to a patient. Additionally, a pharmacist separated all look alike/sound alike medications in the pharmacy and clinics. Since the project was implemented, no look alike/sound alike medication errors have been identified (Salisbury, 2005).
Energized by successes in the aviation industry, where teamwork training has led to reductions in errors and improved performance (Risser et al., 1999; Sprague, 1999), several organizations have promoted the concept of teamwork training for health professionals. The similarities between pilots and doctors—highly trained technically, accustomed to viewing themselves as bearers of ultimate authority and responsibility, independent yet increasingly dependent on others of varying skill levels—suggest that teamwork training may be influential in reducing errors in the medical field (Sprague, 1999). Research on the impact of teamwork training in the ED is limited but promising. MedTeams, a Department of Defense (DoD) project that introduced teamwork training to health care, developed an Emergency Team Coordination Course (ETCC), an 8-hour didactic course for physicians, nurses, technicians, and support personnel. An evaluation of the course re-
vealed considerable success. EDs using the ETCC experienced a 67 percent increase in error-averting behavior and a 58 percent reduction in observable errors (Risser et al., 1999; Shapiro et al., 2004).
Training initiatives that use simulation exercises have been shown to improve performance (Chorpra et al., 1994; Shapiro et al., 2004). Simulation training involves giving emergency care providers practice in performing tasks in lifelike circumstances using human models or virtual reality, with feedback from skilled observers, other team members, and video cameras. Some hospitals and academic medical centers use robotic human simulators (for example, an infant patient simulator used to train providers for intubation) so providers can experience high-risk, low-frequency events. These human simulators, analogous to the flight simulators used by pilots, allow providers to manage a wide range of clinical scenarios and learn from mistakes without harming a real patient (ECRI, 2005). The modern human patient simulator is extremely realistic, with anatomically correct clinical signs and the ability to communicate (Reznek et al., 2002).
Pediatric human simulators are in use in a limited number of hospitals. For example, at the University of Michigan, simulation is used to train EMTs and pediatric residents in standardized pediatric resuscitation courses. An attending physician developed the Pediatric Mock Code Program, in which the pediatric human patient simulator is used during actual pediatric code activations. Evaluation and training are provided to pediatric residents as well as other code team members, including nurses, pharmacists, and respiratory therapists. The program evaluates resuscitation skills, team interaction, and team leadership skills using a variety of scenarios representing the critically ill or injured child in the arrest and prearrest state (University of Michigan Health System, 2005).
Evidence for the effectiveness of simulation-based training is limited and has focused primarily on adult patient settings. However, use of and testing with pediatric human patient simulators could be a promising approach to pediatric training, particularly since many providers encounter critically ill or injured patients infrequently in practice; use of a simulator could help these providers maintain pediatric skills. However, there is presently limited access to simulation training technologies in hospitals, and even more so in EMS environments. Mobile simulation apparatus will be needed to bring this training to providers in the field, particularly those in rural areas (NHTSA, 2002).
To further promote safety, attention has recently focused on identifying medications, patients, and providers with bar codes. Using technology that reads these bar codes, a computer system can confirm that the right medication is being given to the right patient at the right time and warn the
provider of any safety issues. But progress on this technology remains stalled as the pharmaceutical industry tries to find a standard method of identifying medications (Kaushal and Bates, 2002). A review of the available controlled studies shows time savings and error reduction with the use of bar codes; however, further study is needed (Oren et al., 2003). There is also hope that the increased use of electronic health records, computerized physician order entry, decision-support systems, and the like will help improve patient safety, making it easier for emergency care providers to determine correct diagnoses and provide proper treatment to their patients (Cosby, 2003). Indeed, all of these technologies have been shown to be effective in reducing errors in small evaluations involving patients of all ages (Hunt et al., 1998; Bates et al., 1999; Bizovi et al., 2002; Buller-Close et al., 2003), although results have not been universally positive (Han et al., 2005). The next section describes some of these technologies and addresses the need to design them for use with pediatric patients.
ADVANCES IN TECHNOLOGY AND INFORMATION SYSTEMS
Technology is also likely to advance the way care is delivered in the prehospital and ED settings. New technologies designed to accelerate diagnosis and workflow (advanced imaging modalities, rapid diagnostic tests, laboratory automation, EMS technologies, patient tracking tools, and new triage models) and improve treatment (ultrasonography, tympanocentesis, needleless drug administration, and innovations in procedural sedation) are likely to be adopted. As these new technologies are introduced, it will be critical to consider how they help (and whether they may bring harm to) pediatric patients. While this appears to be a rather obvious consideration, history is filled with examples of medical technologies originally developed for adults and used on children with unintended consequences. Devices are typically developed for adults because they constitute a much larger share of the market for medical services than children. For similar reasons, post-market surveillance of medical devices is focused on adults, especially older adults, rather than children. Also, regulation and patient safety efforts for medical products tend to focus more on pharmaceuticals than on medical devices (IOM, 2005).
When detrimental effects on children are discovered postmarket, adjustments are eventually made to technologies, making them safer for pediatric use. One example is the infusion pump, introduced more than 30 years ago, which delivers medications and fluids intravenously. As originally designed, the devices had a wide range of acceptable programming parameters. For example, they could be programmed to deliver a drop or two every hour or a liter or more in an hour. They were designed for maximum flexibility; they could be used on an adult ICU patient one day and on a premature infant the
next. Because the technology relied on human intelligence for programming, errors naturally occurred. In a neonatal ICU, for example, an infusion rate was programmed to 304 ml/hr when the physician intended the rate to be 3.4 ml/hr. In many cases, critical errors were made because a single wrong button was pressed (Reves, 2003).
Advances in infusion technology led to the introduction of “smart pumps,” which are widely used today. Smart pumps utilize software that checks programmed doses. The software contains information on drugs, their usual concentrations, dosing units, and dosing limits. When the practitioner uses the pump, he or she programs it for use in a designated area (e.g., adult ICU, neonatal ICU), and the pump is automatically configured for use on adults or children. Additional safeguards are also built into the pumps, for example, alerting the user if the dosage exceeds the hospital’s established limit and not allowing the user to base the dose on the patient’s weight if the drug is not dosed on that basis (Reves, 2003).
A market for pediatric technologies, equipment, and supplies must be stimulated so that products will be designed initially to meet the needs of pediatric patients, instead of being adapted from products originally designed and intended for use with adult patients. The market for pediatric-designed products has not been well developed in part because providers have not been compelled to purchase pediatric-specific products. To stimulate demand for such products, emergency providers should be made aware of the potential shortcomings of products designed for adults and adapted for children. To advance this effort, the committee recommends that federal agencies and private industry fund research on pediatric-specific technologies and equipment for use by emergency and trauma care personnel (5.4).
This is not the first recommendation of its kind. The 2005 Institute of Medicine (IOM) report Safe Medical Devices for Children emphasized the need for the FDA, the National Institutes of Health (NIH), and AHRQ to define a research agenda and priorities for evaluation of the short- and long-term safety and effectiveness of medical devices for children (IOM, 2005). The report also called for the FDA to work with industry and others to focus more attention on adverse events involving the use of medical devices for children and to update product labeling promptly to reflect safety-related findings. Emergency providers should be able to take comfort in knowing that the equipment they are using on pediatric patients is safe and effective. Development and testing of new products are needed to give providers this assurance.
Federal agencies and private industry also need to take a careful look at the technologies already in place and available for use with infants, children, and adolescents. For a number of devices and technologies being used on pediatric patients, it is unclear whether they ultimately do children more good than harm. One example is the growing use of pediatric computed tomog-
raphy (CT), a tool that assists ED providers in diagnosing illness and injury in children. Annually, 2–3 million CT scans are performed on children—a seven-fold increase in the past 10 years (Doheny, 2003), much of which is due to the technology’s increased availability. One problem with the use of CT is radiation exposure. Children are more sensitive to radiation than adults, and they have longer life expectancy and therefore a greater opportunity to develop cancer in their lifetime. The same radiation dose when given to a neonate is several times more likely to produce cancer over the child’s lifetime than when given to a 40-year-old adult (National Cancer Institute and Society for Pediatric Radiology, 2002). Indeed, research indicates that pediatric CT scans are used too liberally in the ED, frequently to appease parents or guardians who request them (Doheny, 2003). Additionally, practitioners often fail to adjust the exposure parameters when administering a CT scan to a pediatric patient. As a result, in 2002 the National Cancer Institute and the Society for Pediatric Radiology issued a guide to physicians instructing them in how to minimize children’s exposure to radiation. They recommended performing CT scans only when necessary, limiting the region of the body scanned, adjusting exposure parameters based on the child’s size and weight, and minimizing the use of multiple scans (National Cancer Institute and Society for Pediatric Radiology, 2002). Children scanned at adult hospitals may receive a higher dose of radiation than those scanned at children’s hospitals because at the former, the machine is kept on default settings typically intended for adult patients.
Another technology that is already in use with unclear implications for children is the automated external defibrillator (AED), often used by first responders in public settings. AEDs are programmed to deliver adult-dose shocks to individuals in ventricular fibrillation (VF) cardiac arrest. None of the AEDs introduced in office buildings, airports, and other public places were designed for use in children under age 8, and none were cleared by the FDA for use in children. Additionally, there were no data regarding the safety and efficacy of AEDs in children. However, new AEDs with pediatric cables and pads have been designed to direct some of the current away so the pediatric patient receives a lower level of energy (Brown et al., 2004). The American Heart Association (AHA) and the National Association of EMS Physicians (NAEMSP) have stated that AEDs may be used together with cardiopulmonary resuscitation (CPR) in children aged 1 to 8 in cardiac arrest (Markenson and Domeier, 2003; Samson et al., 2003), and the AHA recommends the use of the two together for treatment of cardiac arrest in children above age 8 (Atkins et al., 1998). The FDA has cleared the way for the marketing of specially modified AEDs for use on infants and children younger than age 8 (Automated Defibrillator Cleared, 2001).
Today there remains uncertainty about the appropriate use of AEDs in children, however. According to a recent advisory statement from the
International Liaison Committee on Resuscitation, newer AED models with pediatric capabilities can be used on children over age 1, but only a limited number of studies have looked at the impact of AEDs on children. Although the incidence of sudden cardiac arrest among children is rare, it is estimated that AEDs could assist approximately 15 high school students with the condition per year if placed in schools (Brown et al., 2004). In 2004, a number of organizations, including the AHA, NAEMSP, the American Academy of Pediatrics (AAP), and the American College of Emergency Physicians (ACEP), developed a joint statement that outlines recommendations for the use of AEDs in schools (Hazinski et al., 2004).
One thing common to all of the examples in this section is that the technologies were not originally designed for use in children, but were used on children in practice. In the absence of pediatric-specific technologies, providers may be compelled to use adult technologies on children thinking that the benefits outweigh the risks; certainly in many cases, use of the adult technology may be better than foregoing treatment for the pediatric patient altogether (National Cancer Institute and Society for Pediatric Radiology, 2002). However, encouraging the development and testing of pediatric-specific technologies is key to ensuring that children receive the best treatment for their conditions.
A similar issue exists with the development of information technology (IT) systems. Hospitals, EMS systems, and government entities are beginning to make substantial investments in health IT systems that may improve the quality and efficiency of emergency care delivery for all patients, but there are benefits specific to pediatric patients as well. IT systems that make immunization records of children available to emergency care providers have the potential to greatly improve the efficiency and effectiveness of care. Additionally, some children with special health care needs have sizable medical records, whose details could be made available to emergency care providers with certain IT systems.
Because of the unique nature of pediatric relative to adult emergency care, specific consideration of children’s needs during the design of systems is critical to ensure that the systems will be appropriate for the pediatric patient. For example, clinical decision-support systems must incorporate the various threats to children’s health and diseases common to children; systems designed for adult care currently do not do so. The lack of uniform agreement on standard pediatric doses is at least part of the reason for the usual absence of pediatric-specific dosing tables powering most commercially available computerized physician order entry tools. Without standard pediatric doses and requirements for building these dosage rules into computerized prescribing tools, children will fail to fully reap the benefits of IT in the medication delivery process. Also, electronic health records must be designed to allow providers to record measurements on a sufficiently
granular scale appropriate for newborns and infants (e.g., rounding to the nearest tenth of a kilogram or recording age by month rather than year) (Shiffman et al., 2001).
While studies indicate great benefits of advances in information systems, the safety, impacts, and risks of these systems for pediatric patients have received little attention (Lehmann, 2003). Pediatric experts need to be involved in the design of these products, not only to ensure that the data collected and produced by the systems are appropriate for children, but also to ensure that the systems are designed suitably for the input of data by providers of care to pediatric patients. Pediatric performance measures should be monitored before and after the implementation of new information systems. For example, at least one study revealed an increase in pediatric mortality after the implementation of a computerized physician order entry system, which was expected to reduce errors in the care of pediatric patients (Han et al., 2005).
The committee’s companion report on hospital-based emergency care addresses advances in health IT in greater depth, including the need for systems to be designed appropriately for patients of all ages.
THE IMPORTANCE OF FAMILY-CENTERED CARE
One of the six aims for quality health care identified by the IOM in its seminal report Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001) is patient-centeredness. This means that care should encompass the qualities of compassion, empathy, and responsiveness to the needs, values, and preferences of the individual patient. In the case of pediatric patients, parents or guardians are recognized as the child’s primary source of strength and support and play an integral role in the child’s health and well-being. The aim of patient-centered care recognizes that parents and guardians must collaborate with providers in decision making regarding their child’s care (Lewandowski and Tesler, 2003). Increasing recognition of the importance of meeting the psychosocial and developmental needs of children and of fostering the role of families in promoting the health and well-being of their children has led to the concept of “family-centered care” (Eichner et al., 2003). This section describes the concept of family-centered care and its benefits. Unfortunately, few EMS agencies or EDs have written policies or guidelines for family-centered care in place, and few providers are trained in offering such care (Loyacono, 2001; MacLean et al., 2003). Because the family-centered approach to care can mutually benefit the patient, family, and provider, the committee supports its widespread adoption by the emergency care system, including EMS agencies and hospitals. The committee recommends that emergency medical services agencies and hospitals integrate family-centered care into emergency care practice (5.5).
Entities that offer guidance to providers, such as government agencies and professional organizations, should demonstrate leadership in this area by promoting the use of family-centered guidelines.
The concept of family-centered care evolved between 1980 and 1990 under the leadership of parent advisory groups, health professionals, the Maternal and Child Health Bureau, and the Office of the Surgeon General. The concept contrasts with the more traditional medical model of health care, which is oriented toward disease and disability, the notion that health providers know best how to treat problems, and the view that family members should comply with treatment recommendations (Baren, 2001). There are several definitions of family-centered care, but they all essentially recognize that providers should acknowledge and use the family’s knowledge of their child’s condition and the family’s skills and presence when caring for a child (Boudreaux et al., 2002). The core principles of family-centered care include the following (ENA et al., 2000):
Treatment of patients and families with dignity and respect
Communication of unbiased information
Patient and family participation in experiences that enhance control and independence and build on their strengths
Collaboration in the delivery of care, policy and program development, and professional education
Family-centered care is supported by a growing body of research showing the need to ensure the involvement of patients and families in their own health care decisions, to better inform families of treatment options, and to improve access to information by patient and families (Eichner et al., 2003). A number of studies have found some evidence of improved health outcomes, patient and family satisfaction, and provider satisfaction with the introduction of family-centered care (Meyers et al., 1998, 2000; Boie et al., 1999; Boudreaux et al., 2002; Saunders et al., 2003; Moreland, 2005). The approach is especially important when emergency providers have a pediatric patient with special health care needs; because of their frequent interactions with medical providers and deep familiarity with their child’s condition, parents of such patients may be in a better position than emergency care providers to diagnose the problem. The development and implementation of family-centered care encompass multiple components of care delivery, policies and procedures, the care environment, and personnel practices.
Collaboration with Families in the EMS and ED Environments
Often a parent or guardian is present when emergency medical technicians (EMTs) arrive on scene or a child arrives at the ED. Emergency
providers encounter families at a highly stressful time. The family-centered approach to care revolves around collaborating with families, keeping them informed about the child’s condition, prognosis, and treatment (National Association of Emergency Medical Technicians, 2000a). For EMTs, simply explaining the function of equipment, procedures being performed, and their effects is important so that family members can be better prepared to make decisions about care, such as termination of resuscitation. Potential benefits include decreased patient and family anxiety and combativeness, decreased liability issues if parents/guardians are involved in decision making, and easing of the consent process for organ donation if parents/guardians are aware of everything that has been done (National Association of Emergency Medical Technicians, 2000b).
The family-centered approach to emergency services also includes giving families the option of being present during invasive procedures as long as the safety of the patient and medical providers is not compromised. Family members have traditionally been excluded at such times because of concerns that they could lose emotional control and interrupt care, a lack of staff to meet family needs, insufficient room at the bedside, increased risk of litigation, family-imposed limitations on the training of medical residents, and the potential that providers’ skills could be affected by discomfort with the family’s presence. But heightened awareness and new research have revealed that these concerns are overstated and that there are multiple benefits to the presence of family members: their presence removes doubt about what is happening to the child and reinforces that everything possible has been done, it reduces anxiety and fear (Wolfram and Turner, 1996; Wolfram et al., 1997), it engenders feelings of supporting and helping the patient, it sustains patient–family connectedness, it engenders feelings of being helpful to the health care staff, and it facilitates the grieving process (Doyle et al., 1987; MacLean et al., 2003). In addition, the existing literature indicates that family presence does not negatively impact the ability of providers to perform invasive procedures or exacerbate clinician anxiety (Bauchner and Vinci, 1996; Wolfram and Turner, 1996; Sacchetti et al., 2005), although at least one study showed that family members’ presence during resuscitation was occasionally stressful and anxiety provoking for providers (Hanson and Strawser, 1992).
Research on this issue suggests that families want to be given the option to be present during invasive procedures and resuscitations, and when given the option often take it (Bauchner et al., 1991; Haimi-Cohen et al., 1996; Sacchetti et al., 1996; Boie et al., 1999; Boudreaux et al., 2002). Family members who were present for a procedure report favorable experiences and believe their presence benefited the patient and their own emotional response to the incident (Boudreaux et al., 2002).
While families overwhelmingly support family-centered policies, pro-
viders have mixed opinions about family presence. Often inclusion of parents or guardians goes against the culture of emergency care providers. An example is Children’s Hospital of Philadelphia’s pediatric/neonatal ground transport team, which historically had a policy of excluding parents from the transport of a child in a ground ambulance. The transport team cited a number of reasons for the policy: difficulty caring for the patient if the parent needed attention, potential trouble in dealing with a belligerent or hysterical parent, difficulty controlling the child if a parent was present, and the transport team’s anxiety about performing medical interventions while being watched by a parent. In 1995, the transport team explored the idea of allowing parents to ride in ground ambulances and surveyed parents who were and were not allowed to do so. Overwhelmingly, results showed that parents preferred to accompany their child during transport. The research team also surveyed pediatric transport team managers from a number of different children’s hospitals. They found diverse opinions and practices regarding parental accompaniment during transport (Woodward and Fleegler, 2000, 2001).
Provider opinions regarding family presence vary with the invasiveness of the procedure and the provider’s experience. A recent survey of ED faculty, nurses, and pediatric residents at an urban children’s hospital found that ED staff generally supported the presence of family members during minor procedures, but expressed concern regarding the effects on the family and the success of the procedure. Most attending physicians and nurses supported the family’s presence during highly invasive procedures, but most residents did not (Fein et al., 2004). This study and others have shown that more experienced practitioners tend to be more comfortable than those with less experience with regard to allowing families to be present during procedures (Mitchell and Lynch, 1997; Meyers et al., 2000; O’Brien et al., 2002; Fein et al., 2004).
Studies also indicate that nurses are more likely than physicians to support family presence policies (Chalk, 1995; Helmer et al., 2000; Fein et al., 2004). In 1994, the Emergency Nurses Association (ENA) passed a resolution supporting the presence of family members at the bedside during invasive procedures and/or resuscitations. Other organizations that explicitly support family-centered care, including the Emergency Medical Services for Children (EMS-C) program, ACEP, and the American Association for the Surgery of Trauma (AAST), have not developed official resolutions on parental presence during invasive procedures (Boudreaux et al., 2002). A 2002 survey of critical care and emergency care nurses revealed that, despite the frequency of requests from family members to be present during invasive procedures, nearly all EDs lack written policies or guidelines for family presence (MacLean et al., 2003).
A few studies of family-centered care have found evidence of improvements in staff satisfaction, but most have focused on primary care delivery
or inpatient care (Eichner et al., 2003). The exception is a 2001 study that found that when family-centered care was the cornerstone of culture in a pediatric ED, staff members had more positive feelings about their work than staff members in an ED where emotional support for families was not emphasized (Hemmelgarn et al., 2001).
The family-centered approach requires a shift in thinking for emergency providers typically trained to rapidly assess, treat, and/or transport patients (National Association of Emergency Medical Technicians, 2000b). A lack of training in why and how to communicate with families can be a barrier to the adoption of family-centered care. The committee recognizes the value of family-centered pediatric emergency care and encourages provider organizations to take steps to educate practitioners in and develop protocols for adopting this approach. Family members’ presence during invasive procedures and resuscitations remains controversial (Sacchetti et al., 2005), but institutions should consider such policies. Family presence for more minor procedures, such as wound repair, is overwhelmingly supported by both patients and providers and should be reflected in providers’ treatment protocols.
Resources exist to help guide EMS agencies and hospitals in the implementation of family-centered practices. For example, On the Same Team is a training tool for EMTs designed to assist them in becoming more proficient in engaging family members in the care of their loved ones. In 1997, the EMS-C National Resource Center, in collaboration with the Institute for Family-Centered Care (IFCC), developed an assessment tool for evaluating family-centered practices. There are separate tools for prehospital emergency care and care in the ED. More recently, the IFCC partnered with the AHA to produce a resource for practitioners wishing to advance the practice of family-centered care (AHA, 2005). The provision of family-centered care is also advanced in the Pediatric Advanced Life Support (PALS) manual, Advanced Pediatric Life Support (APLS): Pediatric Emergency Medicine Resource, and the AHA’s guidelines for CPR (Knapp and Mulligan-Smith, 2005). Guidelines for implementing family-centered care were also provided in a report of the National Consensus Conference on Family Presence during Pediatric Cardiopulmonary Resuscitation and Procedures (Henderson and Knapp, 2005).
A Family-Centered ED Environment
Another important component of family-centered care is creating an environment in the ED that is both family- and child-friendly. However, a minority of hospitals have separate pediatric EDs (Gausche-Hill et al., 2004). The majority of hospitals treat both children and adults in the same
area, creating an uncomfortable environment for parents or guardians and a frightening one for children if they are in the waiting room with bleeding or intoxicated adults.
Attention to creating a family-centered environment has grown in recent years. The 2001 EMS-C Program Guide for Improving Family-Centered Care contains a framework for improving the environment and design of EDs for children and their families. The guide encourages EDs to reflect on whether their environment is family-centered by answering a number of questions, such as the following: Is the waiting area large enough, with enough comfortable seating available, for all children and adults who may be waiting, even if several adults and children accompany one child? Are examination, treatment, and procedure rooms designed to accommodate parents or guardians who wish to remain with their child? Can families easily find their way from the ED to other areas of the hospital, including radiology, laboratories, pharmacy, admitting office, patient care units, and cafeteria?
Because of the emotional impact an ED visit can have on a patient and parent/guardian, the exterior and interior of the ED should be inviting and make the patient and family feel comfortable. Working with hospital staff, patients, and parents, designers of pediatric EDs have formulated advice for designing the interior of a pediatric ED. First, the normal environment for children does not include bright primary colors; it is often better to create a calming environment than a stimulating one. Second, lighting that is appropriate for an exam is not helpful to parents’ or guardians’ frayed nerves. Distractions such as a television or radio are welcome to families that are waiting. Third, children should feel that they can master an environment and not be overwhelmed or intimidated by it. One means to this end is to design the room to the scale of a child. Examples include wall sconces 24 inches above the floor and a rail system detailed to accommodate the sightline of a 4-year old. Lower ceilings may also be appropriate (Pence, 2000; Hanson, 2001).
Many hospital inpatient units, particularly in pediatric centers, use child life programs and specialists to address the psychosocial aspects of hospitalization for the pediatric patient and parents or caregivers (AAP, 2000). These programs and services help reduce emotional disturbances in children and help them anticipate and make it through difficult procedures. Evidence has shown that these programs can reduce stress and aid recovery (Wolfer et al., 1998). It is unclear how prevalent these programs are in EDs, although a mid-1990s survey of large children’s hospitals found that 6 of 44 EDs had at least one full-time child life specialist on staff (Krebel et al., 1996). Evidence is limited as to the impact of having child life services available in the ED setting, though the practice appears to have potential.
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
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.
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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