Children's Program

Children constitute nearly one-third of all ED visits. A large proportion of adverse events occur in children, and in many cases they are the most vulnerable to long-term disability. EDs are ill-prepared to care for children; compounded by the fact that hospital facilities rarely have a designated pediatric emergency care. This program focuses on the needs of children to address special circumstances that arise when children are treated in the ED.

Children in the ED

The needs of children in emergency situations differ from those of adults and require special attention. Infants and children suffer from a different spectrum of diseases and are less reliable historians making accurate diagnosis more difficult. Providers require specific training and understanding of these differences. In addition there are individual and equipment requirements for pediatric care. The current health care system, especially smaller, front-line hospitals, are ill-equipped to meet these needs. Pediatric care is perceived as the Achilles Heel of many front-line ED services as the following facts demonstrate:

Utilization

• 31.5 million infants, children, and adolescents visit EDs every year, this corresponds to 30% of all ED visits while they represent only 20% of the U.S. population (Child Health USA 2000 – HRSA, 2000 U.S. census).
• Of these, 12.5 million infants, children, and adolescents use EDs for urgent or emergent problems annually and 1.9 million of these visits result in hospital admission or transfer to a subsequent facility, suggesting severe illness or injury.
• The ED is the primary care facility for children of the underserved and socioeconomically handicapped. Unfortunately, the lack of continuity in their care after an acute episode poses life threatening risk.

Hospital Profile

• It is estimated that there are only 50 freestanding pediatric hospitals in the U.S. (Pediatric Emer., June 2001) and only 7% of U.S. hospitals have a Pediatric ED. Just 33% of hospitals have a separate pediatric ward or department, this ratio is lower still in smaller and rural hospitals because of infrastructure and funding issues.
• Approximately 76% of U.S. hospitals care for pediatric emergencies in an adult/pediatric combined ED and 18% in the adult ED.
• It is estimated that 25% of hospitals without pediatric trauma services still admit critically injured children to their own facilities and 9% of hospitals without pediatric intensive care facilities admit critically injured children to their own facilities.
• 7% of hospitals routinely admit children to their adult intensive care units rather than transferring the patient to a facility with pediatric intensive care facilities.

Staffing

• Small and front-line emergency departments rarely have a pediatrician on staff at the facility on a 24-hour basis. A recent study shows that only 66% of hospital have 24-hour access to emergency medicine-trained physicians (either in-house or on call) and only 23% of hospitals have a Pediatric emergency physician available in-house or on call 24 hours a day.
• Pediatricians are available in 64% of EDs, but few hospitals have protocols for obtaining consultation on pediatric emergencies.

ED Adverse Events in Children

• Currently, there is no broad study that documents the incidence of ED-related adverse events in children. However, several studies in specific areas clearly indicate that children are at greater risk for harm because of increased ED utilization compared to adults.
• A study by Esposito et al.(J Trauma 1999) showed that frequent errors occur in the management of Pediatric Trauma leading to approximately 9% preventable trauma mortality. Also, the study showed a 64% error rate in management of pediatric patients, including gross violations of basic trauma care. Additionally, the study reported that inaccurate care was more prevalent in patients less than 14 years old.
• Potentially harmful medication errors occur three times more often among hospitalized children than adults according to a recently published article in JAMA (April 2001). The most common error in pediatric emergency departments is incorrect dose of medication (35%) or incorrect medication given (30%). In one-third of the cases, the family was not made aware of the error. In 12%, patients required additional treatment and required admission to the hospital.
• Another study on ED return visits found that 1.9% of patients returned to the ED within 72 hours and 7.8% were due to a medical error. Using these incidence rates, it can be estimated that 45,300 children return to the ED annually because of medical errors. As many as 3,540 of these children may die as the result of ED-related adverse events (UTCO 2000, Liaw 1999).
• Most errors occur on the evening and night shifts. In rural areas, difficult access to the ED results in pediatricians treating pediatric emergencies in their office many times without the necessary support of a hospital infrastructure. One-fourth to one-third of the U.S. population resides in rural areas.

CEHI Program Curriculum

• Fully one-third of our curriculum will specifically address the unique needs of children.
• Our faculty include world-class pediatric specialists focused on practical challenges at front-line institutions and best practices for treatment of children will be a major development focus.
• Due to the relative isolation of small community and front-line ED teams; both geographically and by virtue of 24-hour operation and lack of interaction with other medical colleagues in the middle of the night, there will be a focus on decision support knowledge that could help with critical care issues.
• Unfortunately, certain extremely common conditions that can harm children are not well understood by a majority of care providers.
  
• Kernicterus, is an example of such a condition that can lead to severely debilitating disabilities. Kernicterus is a type of brain damage that causes athetoid cerebral palsy and hearing loss in children. It also causes problems with vision and teeth and can cause mental retardation. In some newborn babies, the liver makes too much yellow pigment called bilirubin. When too much bilirubin builds up in a new baby's body, the skin and whites of the eyes turn yellow. Click here to read more about this condition.
  
• This yellow coloring is called jaundice. Jaundice is very common in newborn babies and usually goes away by itself. A little jaundice is not a problem, but a few babies have too much jaundice. If left untreated, high levels of bilirubin can damage the brain.
• It has been recently recognized that kernicterus is much more common than we realize. Our program will address such conditions and the best practices that are necessary to prevent it.
• This initiative will work with consumer groups and associations to make sure that illnesses and preventable conditions such as kernicterus are addressed in the program. Click here to read more about this initiative.