Quality Pediatric Emergency Care: Everywhere, All the Time
Article Outline
Thousands of infants, children, adolescents, and young adults are cared for every day in emergency departments in the United States. Emergency care is delivered by a variety of providers in different hospital settings, with and without the availability of the full spectrum of pediatric-appropriate medical equipment. Previous studies have addressed the potential for such care to be uneven, uncoordinated, unsafe, and of poor quality.1, 2 But despite these challenges, much progress has occurred in the care of pediatric emergency department patients over the last 20 years, as the speciality of emergency medicine and subspecialty of pediatric emergency medicine have evolved. The most recent data show that more than 23 million pediatric patients are treated annually in emergency departments, that more than 90% of these departments have appropriate pediatric equipment, and that more than 1000 subspecialty-trained pediatric emergency medicine providers are currently practicing. The American College of Emergency Physicians and the American Academy of Pediatrics have jointly produced and promulgated guidelines for the care of children in the emergency department. Educational programs specific to pediatric emergency medicine (eg, PALS, APLS) are common.
See related article, p 783
It seems intuitive that where a patient goes for care and the training of the provider who provides that care will affect the quality of the care that that patient receives. If this is in fact true, then the important question is: How can we ensure that appropriate quality care is always provided for every patient?
In this issue of The Journal, Dharmar et al ask: “Does the quality of pediatric emergency department care vary with hospital setting and the credentials of the physician provider?”3 This is not an easy question to answer. Evaluating the quality of care for sick children is always difficult, given the low incidence of severe illness and injury in the pediatric emergency department. What constitutes quality pediatric emergency medical care is difficult to define.4 Does it relate to the absence of medical errors? Does it relate to the absence of adverse events (ie, death or readmissions), which are quite rare? Does it relate to making a proper diagnosis and/or providing safe care? Who determines quality of care? Finally, what standard of care should be used? Should the same expectations hold regardless of practice location, hospital type, or patient volume?
To address the question that they pose, Dharmar et al use a tool they developed and validated in a previous study,5 a 7-point structured implicit review instrument that assesses care across 5 domains and assigns scores of 5 to 35. The tool is easy to use and can easily differentiate acceptable and unacceptable care. It was derived from a small sample (178 patients), validated through the identification of medication administration errors in this group (34 patients), and was studied only in patients in rural hospital emergency departments.
Dharmar et al describe some limitations of their tool. It was tested only in the most ill children and only in rural emergency departments. The reviewers were limited to 2 pediatric emergency medicine physicians. The retrospective review was limited by the quality and quantity of the medical record documentation. Dharmar et al concede that medication error was a “less than ideal validation measure,” and that there was only “fair” interrelator reliability in their initial assessment of the tool.
Despite these limitations, however, this tool is central to the authors' current study, which they undertook to examine differences in quality of care between hospital settings and physician providers. The study involved emergency department care in 4 rural community hospitals and 1 urban emergency department. Four pediatric emergency medicine physicians reviewed the care of 325 patients. An overall quality of care score of 5 to 35 was assigned to the care provided for each patient.
Dharmar et al used powerful statistical methods to review the data and make comparisons across a number of variables. The obvious conclusions from their study include the following:
The authors' findings, although interesting and seemingly obvious, require a reality check. Using the authors' data (see their Table II), no matter how it is sliced (eg, provider training, hospital site, time of day, patient injury), the mean quality scores are always >27 (on a scale of 5 to 35). The authors previously used a score >20 to indicate “acceptable” quality of care. In the current study, differences between groups across different variables are in the range of 3 points or less. This difference can be accounted for by moving a score from “extremely appropriate” to “very appropriate” in 3 of the 5 categories. It is not clear that this truly represents a “move to a lower quality,” especially when average scores are all well within the range of appropriate care. The authors have perhaps statistically and numerically proven that care in the rural setting provided by nonpediatric emergency physicians is inferior. Whether this is clinically relevant is less clear, and the findings do not resolve the dilemma that much pediatric emergency care will continue to be provided in rural and community emergency departments rather than in academic centers and specialized children's hospital emergency departments. Sick child events will continue to be infrequent, and most of the care for such critically ill and injured children will still, at least initially, be delivered in general emergency departments by a range of providers.
So what are we to do with the results of Dharmar et al? First, it would seem that we can assume that differences exist and that care is “acceptable” in nearly all settings, and work to make improvements from this starting point. Providers who care for the rare seriously ill child must obtain continuing training and reinforcement of the skills and competencies necessary to provide optimal outcomes. Patient simulation can make critical care events, resuscitation, and critical procedures common occurrences for these providers.6 Simulation also provides an opportunity to train an emergency department team, an important step to ensure safe care. As specialties, emergency medicine and pediatrics should encourage the continued expansion of pediatric emergency medicine training programs to increase their attractiveness for both emergency medicine and pediatric residency graduates. The combined training of emergency medicine/pediatric emergency medicine has been undersubscribed by emergency medicine residency graduates. This is the pathway that can have greatest influence on the overall quality of pediatric emergency department care, because such individuals will be more likely to be employed as emergency physicians in smaller, more rural, and general community hospitals. Leaders at every level (speciality, physician group, hospital) must work to promote a safe, collaborative team environment in the emergency department.7 Activities to promote safe emergency department environments for children include safety rounds, voluntary reporting systems for near-miss events, reporting and remediation of medication errors, use of the SBAR (situation-background-assessment-recommendation) tool, development of practice guidelines, and implementation of such clinical tools as medication dosing tapes and computerized physician order entry systems. Physician competencies necessary to practice safe and efficient quality pediatric emergency care must be incorporated into the maintenance of certification program of both the American Board of Emergency Medicine and the American Board of Pediatrics, as well as into the emerging programs for maintenance of licensure. The practice improvement programs of both boards, as part of maintenance of certification, must encourage self-evaluation of critical competencies for providers who care for infrequent but life-threatening events in the most seriously ill and injured children. Efforts should continue to improve emergency medical system and 911 responsiveness for pediatric patients. Rural hospitals that see ill pediatric patients only infrequently should have transfer agreements with academic or children's hospitals. Children's hospitals and academic centers that have the luxury of pediatric emergency medicine trained specialists should make available (in real time) educational assistance, consultation, and transfer assistance. Research in emergency medicine and pediatrics should continue to develop and refine appropriate tools that can provide meaningful evaluation of quality of care across ages, diseases, and illness severity. These tools must be linked to identifiable patient outcomes that provide useful information about the quality of care. The existing road maps from The Institute of Medicine's 2006 report and the joint position paper on the care of children in the emergency department from the American College of Emergency Physicians and American Academy of Pediatrics should be followed closely.8, 9
The study of Dharmar et al reminds us that all is not perfect. Pediatric emergency medicine is vastly different today than 20 years ago, yet there remain quality gaps and areas for improvement. Improving the quality of care for every emergency department patient remains a complex work in progress.
References
- . Ability of hospitals to care for pediatric emergency patients. Pediatr Emerg Care. 2001;17:170–174
- . Analysis of preventable pediatric trauma deaths and inappropriate trauma care in Montana. J Trauma. 1999;47:243–251
- Quality of care of children in the emergency department: association with hospital setting and physician training. J Pediatr. 2008;153:783–789
- . Emergency department quality assurance/improvement practices for the pediatric patient. Ann Emerg Med. 1995;25:804–808
- A new implicit review instrument for measuring quality of care delivered to pediatric patients in the emergency department. BMC Emerg Med. 2007;7:13
- . Simulation of pediatric trauma stabilization in 35 North Carolina emergency departments: identification of targets for performance improvement. Pediatrics. 2006;117:641–648
- Patient safety in the pediatric emergency care setting (Policy statement, American Academy of Pediatrics). Pediatrics. 2007;120:1367–1375
- . Emergency Care for Children: Growing Pains. Washington DC: National Academic Press; 2006;
- Care of children in the emergency department: guidelines for preparedness (Position paper, American College of Emergency Physicians/American Academy of Pediatrics). Pediatrics. 2001;107:777–781
PII: S0022-3476(08)00574-X
doi:10.1016/j.jpeds.2008.07.001
© 2008 Mosby, Inc. All rights reserved.
Refers to article:
- Quality of Care of Children in the Emergency Department: Association with Hospital Setting and Physician Training , 11 July 2008
