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526 PEDIATRICS Vol. 96 No. 3 September 1995
AMERICAN ACADEMY OF PEDIATRICS
Guidelines for Pediatric Emergency Care Facilities
Committee on Pediatric Emergency Medicine
Emergency care for life-threatening pediatric ill-ness and injury requires specialized resources in-
cluding equipment, drugs, trained personnel, andfacilities. The American Medical Association Com-mission on Emergency Medical Services has pro-
vided guidelines for the categorization of hospitalpediatric emergency facilities that have been en-
dorsed by the American Academy of Pediatrics(AAP).’ This document was used as the basis forthese revised guidelines, which define:
I . The desirable characteristics of a system of Emen-
gency Medical Services for Children (EMSC) thatmay help achieve a reduction in mortality andmorbidity, including long-term disability.
2. The role of health care facilities in identifying andorganizing the resources necessary to provide the
best possible pediatric emergency care within aregion.
3. An integrated system of facilities that provides
timely access and appropriate levels of care for allcritically ill or injured children.
4. The responsibility of the health cane facility for
support of medical control of pre-hospital activi-ties and the pediatric emergency cane and educa-tion of pre-hospital providers, nurses, and physi-
cians.5. The role of pediatric centers in providing out-
reach education and consultation to community
facilities.6. The role of health cane facilities for maintaining
communication with the medical home of thepatient.
Children have their emergency cane needs met in avariety of settings, from small community hospitals
to large medical centers. Resources available to thesehealth cane sites vary, and they may not always havethe necessary equipment, supplies, and trained per-sonnel required to meet the special needs of pediatric
patients during emergency situations.Timely, effective pediatric emergency care de-
pends on a network of pre-hospital and hospitalmedical and administrative resources. For a system
of pediatric emergency cane to be developed, thecapabilities of the emergency care facility for pediat-tic treatment must be categorized. Once health care
The recommendations in this statement do not indicate an exclusive course
of treatment or procedure to be followed. Variations, taking into account
individual circumstances, may be appropriate.
PEDIATRICS (ISSN 0031 4005). Copyright © 1995 by the American Acad-
emy of Pediatrics.
facilities are categorized according to their emer-
gency capabilities, a network must be developedwithin a region that assures access to specialized
cane, avoids duplication of services, and assures that
services are available to all infants and children. Thisprocess of categorization and regionalization of pe-
diatnic emergency facilities requires the cooperation
of hospitals and emergency medical services (EMS)systems within a region.
These guidelines are designed to assist health care
facilities within a region to meet the emergency careneeds of children. A framework is offered that inte-grates the resources of facilities to assure access to
appropriate levels of care, including specialized ser-vices for children wherever the entry point into the
system.Many children access emergency care at commu-
nity hospitals that must take responsibility for the
triage and stabilization of critically ill or injured pe-
diatric patients. Most hospitals provide basic pediat-nc emergency services. However, a system that as-
sures comprehensive care is often not available. Thedevelopment of a regionalized cooperative network
of EMS-EMSC allows rural and community hospitalsaccess to a system that assures integration with morespecialized facilities.
Each state, region, or local area has different ad-ministrative structures and organizations responsi-
ble for the administration of an EMS-EMSC system.Each hospital within the system is a component of
EMSC. Pre-hospital care is often not the direct ne-
sponsibility of a health care facility, but each facilitymust support and cooperate with their pre-hospital
system to assure a functioning pediatric emergencycare network. This cooperation may include assisting
pre-hospital care providers and services with educa-tion, training, and consultation. Every health care
facility that is a component of EMSC has a responsi-
bility to accept appropriate patients, provide pre-
hospital guidance when necessary, stabilize pediatric
emergencies, and, when appropriate, transport pa-
tients to a definitive cane facility.
Small community facilities (such as standby orbasic) within an EMS-EMSC system are responsiblefor accepting critically ill and/or injured childrenwho do not have immediate access to definitive careresources because of geographical restrictions, and
they must have the equipment and skilled personnelnecessary to recognize, stabilize, and support the
timely transport of pediatric patients to a prear-ranged definitive care resource.
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Pediatric Surgeon
General Surgeon
Hospital
Emergency Department
ICU
Trauma Service
Trauma Team
E
D
D
Source: Resources for Optimal Care of the Injured Patient, American College of Surgeons Committee on Trauma.4
Abbreviations: E, essential; D, desirable.
* A pediatric surgeon credentialed in trauma care will be promptly available. This responsible pediatric surgeon will be present in the
operating room for any and all operative procedures. A general surgical resident at a minimum PGY-4 level may initiate resuscitative care
until the attending pediatric surgeon arrives.
t The trauma surgeon available for pediatric trauma care must have special interest in and commitment to care of the injured child. This
should be demonstrated by documented continuing medical education.
TABLE 1. Resources Necessary for the Optimal Care of the Injured Child
AMERICAN ACADEMY OF PEDIATRICS 527
Regional Pediatric Trauma Center
Children’s hospital or general hospital
with a separate pediatric department
Pediatric emergency department with
appropriate personnel, equipment,and facilities
Pediatric Intensive Care Unit (ICU) with
pediatric surgery and other surgical, medical,
and nursing personnel and equipment needed
to care for the injured child
Pediatric trauma service organized and
run by a pediatric surgeon
1. Pediatric Surgeon
2. Pediatric Orthopaedist
3. Pediatric Neurosurgeon
4. Pediatric Anesthesiologist
5. Pediatric Intensivist
6. Pediatric Emergency Physicians
7. Pediatric Radiologists
8. Other Pediatric Surgical Specialists
9. Other Medical Pediatric Specialists
10. Pediatric Trauma Coordinator
11. Pediatric Trauma Nurse
E
E
E
Pediatric Trauma Quality Improvement
Psychosocial Services
Rehabilitation
Trauma Center With Pediatric
Commitment
D
Et
General hospital with an organized
pediatric service
Pediatric capabilities in an
emergency department equipped
and staffed by personnel trained
to care for pediatric trauma victims
ICU with personnel and equipment
appropriate for care of the injured child
Pediatric trauma program administered
by a surgeont
1 . Pediatric Surgeon (D)
2. General Surgeon
3. Orthopaedist
4. Neurosurgeon
5. Surgical Critical Care Specialists
6. Emergency Physician
7. Radiologists8. Trauma Coordinator
9. Pediatric-trained Trauma Nurses
Between the small community hospital and thecomprehensive regional pediatric center (CRPC) area number of hospitals that have the capability ofproviding some, but not all, of the resources needed
for definitive care of critical pediatric emergencies.The goals are provided here for such hospitals to
facilitate the implementation of a regionalized EMS-EMSC system and assist in organizing a network of
pediatric emergency care.The CRPC has the most available resources and
must have a major role in organizing and imple-menting a regional EMSC system. The CRPC mustprovide pediatric consultation and support asneeded to hospitals and EMS agencies within the
region, including systems development, transport,quality review, education, research, and datamaintenance.
Because areas will exist where access to a CRPC isimpeded by geographical or political boundaries,physicians and health planners in all regions mustreview the capabilities of their institutions, iden-tify areas of concern, and seek solutions either by
developing the requisite resources or by identify-ing resource centers that will accept their patients.A comprehensive approach is necessary with clear
expectations that high acuity patients will be trans-ferred to an appropriate CRPC to prevent avoid-able morbidity and mortality.2’3 For example, com-prehensive pediatric trauma centers meeting therequirements of a CRPC can provide the major
trauma pediatric patient access to specialized pe-diatnic care including surgery, critical cane, andpediatric medical and surgical subspecialties. Suchcenters afford this subset of pediatric patients thebest opportunity for maximum functional recov-ery. Trauma care for children may not be equiva-lent between adult and pediatric trauma centers
even though mortality statistics may be similar.Trauma centers that do not meet these pediatricguidelines for a CRPC should, when possible, di-vent high acuity pediatric patients to a CRPC. In
areas where an adult center must assume nespon-sibility for the initial care of children, clear guide-lines must be in place for the transfer of critical
patients to a regional center for pediatric traumaand critical care.5 Circumstances may dictate thatadult trauma centers with a commitment to chil-dren provide definitive care for children. Studiesof treatment outcome should be in place to assurethat the standard of cane is equivalent to that of aCRPC. Table I contains program qualifications for
pediatric trauma cane as defined by the American
College of Surgeons for comparison.These guidelines are designed to assist hospitals in
defining their pediatric emergency capabilities and
are intended to assist communities in reducing mor-bidity, mortality, and disability. The six areas ofemergency care for review include: 1) facilities;2) personnel; 3) equipment and supplies; 4) access,triage, transfer, and transport; 5) education, training,
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528 GUIDELINES FOR PEDIATRIC EMERGENCY CARE FACILITIES
research, and quality assessment; and 6) administna-tive support and hospital commitment.
PEDIATRIC EMERGENCY CARE FACILITY
CAPABILITIES
Standby Pediatric Emergency Facility
A standby pediatric emergency service is:
. Capable of identifying critically ill on injured on
potentially critically ill or injured patients.. Capable of stabilizing the pediatric patient, includ-
ing the management of airway, breathing, andcirculation.
. Responsible for assuring timely access to a defin-
itive cane facility.
. Staffed by a registered nurse (RN) on physician’sassistant who works under the direct supervision
of a physician with pediatric experience. Supenvi-sion may be by protocols, standing orders, and/on
telephone access, but the physician must bepromptly available to respond to emergencies.
Basic Pediatric Emergency Facility
A basic facility in a system:
. Provides appropriate identification, stabilization,
and transport as described for the standby facility.. Has a physician in-house 24 hours a day, 7 days a
week for emergency cane.S Has limited wand capabilities for the management
of minor pediatric inpatient problems.. Is willing to accept the transfer of appropriate
pediatric patients from a standby facility when nofacility with more comprehensive capabilities isavailable within a region.
General Pediatric Emergency Facility
A general facility in a system:
. Has a defined separate pediatric inpatient service.
. Has a department of pediatrics within the medical
staff structure.. Accepts referrals of appropriate pediatric patients
from standby and basic hospitals as a pant of pre-
arranged triage, transfer, and transport agree-
ments.
Comprehensive Regional Pediatric Center (CRPC)
The regional center:
. Is capable of providing comprehensive specialized
pediatric medical and surgical cane to all acutely illand injured children, on in special circumstancesproviding safe and timely transfer of children to
other resources for specialized care.. Is responsible for serving as a regional referral center
for the specialized cane of pediatric patients.. Actively supports systems development, includ-
ing:1 . assistance and support of education for pre-
hospital personnel.2. education and training for all levels of hospital-
based health care providers.
3. provision of transport services or assurance thatappropriate transport services are available for
the transfer of critically ill on injured pediatricpatients.
4. provision of comprehensive pediatric subspe-
cialty medical and surgical consultation to healthcane facilities and providers within a region.
5. a commitment to research, systems develop-
ment, quality assessment and improvement,
data collection and analysis, and injury preven-tion.
6. assurance of available rehabilitation services forchildren.
Emergency staff in all facilities must be able toprovide information on patient encounters to thepatient’s medical home. This may be through tele-phone contact with the primary cane provider atthe time of encounter, faxing on mailing the med-ical record, on providing patients with a copy ofthe medical record to bring to their physician.Follow-up visits should be arranged or necom-
mended with the primary care provider whenevernecessary.
Table 2 provides a summary of the guidelines for
emergency cane facilities for each level of pediatrichealth cane. Personnel, equipment, and issues that
are essential at each level are described as eitherbeing essential in the emergency department(EED), essential within the hospital (EH), orpromptly available (EP). An optional but strongly
encouraged category (SE) is used to describe per-sonnel, activities, on issues that may be essential tonetwork a comprehensive negionalized EMS-EMSC system in rural areas. Although these arenot generally required of a specific hospital, they
are strongly encouraged if such services are notavailable within a reasonable distance. Specialistconsultants should be board certified or board pre-
pared and actively seeking certification in disci-plines in which a specialty exists. A CRPC shouldbe staffed with specialist consultants with pediat-
nc subspecialty training. The following narrative isprovided to clarify issues that are difficult to in-dude in a table form. Issues highlighted by anasterisk in the table are explained in the text.
GUIDELINES FOR A STANDBY PEDIATRIC
EMERGENCY FACILITY
Personnel
At least one RN on physician’s assistant must bephysically present 24 hours per day, 7 days per week,
and capable of recognizing and managing shock andrespiratory failure and stabilizing pediatric traumapatients, including early recognition and stabiliza-tion of problems that may lead to shock and respi-ratory failure. Successful completion of courses such
as the American Heart Association Pediatric Ad-vanced Life Support (PALS) on the EmergencyNurses Association Emergency Nursing PediatricCourse (ENPC) can be utilized to demonstrate thisclinical capability.
An on-call physician must be promptly available
and provide supervision and direction for the in-
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TABLE 2. Guidelines for Emergency Pediatric Care Facilities
Facility Levels
CRPC General Basic Standby
Personnel
Physician with pediatric emergency care experience* EED EED EED EP
RN with pediatric training* EED EED EED EED
Respiratory therapist EH EH EH
Trauma coordinator E E
Nurse educator E E
Trauma team* E E SE
Specialist consultants*
Pediatrics EH EP EP SE
Radiology EP EP EP SE
Anesthesiology* EH EH EP SE
Cardiology EP
Critical Care EH EP
Nephrology EP
Hematology/oncology EP
Endocrinology EP
Gastroenterology EP
Allergy EP
Neurology EP
Pulmonology EP
Psychiatry EP
Infectious Disease EP
Surgical specialists*
General surgeon EH EP SEPediatric surgeon EH SE
Neurosurgery EP EP
Orthopedics EP EP EP
Otolaryngology EP
Urology EP
Plastic surgery EP
Oral/maxillofacial EP
Gynecology EP
Microvascular surgery EP
Hand surgery EP
Ophthalmology EP
Cardiac surgery EP
Equipment and SuppliesEMS communication equipment* E E E E
Organized emergency cart* EED EED EED EED
Printed, drug doses/tape EED EED EED EED
Monitoring devices
ECG monitor/defibrillator with pediatric paddles 0-400 joules and hard EED EED EH EHcopy capabilities
Pulse oximeter (adult/pediatric probes) EED EED EH EH
Blood pressure cuffs (infant, child, adult, thigh) EED EED EED EEDRectal thermometer probe (28#{176}-42#{176}C) EED EED EH EH
Otoscope, ophthalmoscope, stethoscope EED EED EED EED
Cardiopulmonary monitor with pediatric capability EED EED EED EH
Doppler and noninvasive blood pressure monitoring (infant, child, adult EED EED EH
cuffs)
Apnea/respiratory monitor EED EED SE
End tidal CO2. monitor EED EH SE
Monitor for central venous pressure, arterial lines EED EH SE
Airway control/ventilation equipment
Bag-valve-mask device: pediatric (450 mL), and adult (1000 mL) with oxygen EED EED EED EED
reservoir and without pop-off valve. Infant, child, and adult masks
Oxygen delivery device with flow meter EED EED EED EED
Cleap oxygen masks, standard and non-rebreathing (neonatal, infant, child, EED EED EED EED
adult)
Nasal cannula (infant, child, adult) EED EED EED EED
Suction devices-catheters 6-14 fr, yankauer-tip EED EED EED EED
Oral airways (sizes 0-5) EED EED EED EED
Abbreviations: E, essential; EED, essential in emergency department (ED); EH, essential in hospital; EP, promptly available (within 20-30
min when possible); SE, strongly encouraged if such services are not available within a reasonable distance. �, See text for further
definition�
AMERICAN ACADEMY OF PEDIATRICS 529
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Facility
CRPC General
Levels
Basic Standby
Vascular access supplies
Arm boards (infant, child, and adult sizes)
Butterflies (19-25 gauge)
Catheters for intravenous lines (16-24 gauge)
Needles (18-27 gauge)
Intraosseous needles
Umbilical vessel catheters (3,5 fr)
IV administration sets and extension tubing with calibrated chambers
Extension tubing, stopcocks, T-connectors
Infusion device with the ability to regulate rate and volume of infusate
Isotonic balanced salt solution and D5 0.5 normal saline
Central venous access utilizing Seldinger technique (4-7 fr)
IV fluid/blood warmer
Blood gas kit
Rapid infusion pumps and fluid warmers
Medications-unit dose, prepackagedActivated charcoal EED EED EED EED
Adenosine EED EED EED EED
Atropine EED EED EED EED
Beta-agonist for inhalation EED EED EED EED
Bretylium EED EED EHCalcium chloride EED EED EED EED
Corticosteroids (dexamethasone, methylprednisolone) EED EED EED EED
Cyanide kit and pediatric doses EED EED EED
Dextrose-25% and 50% EED EED EED EED
Digitalis antibody EH EH EH
Diphenhydramine EED EED EED EED
Dobutamine EED EED EHDopamine EED EED EH
Epinephrine (1:1000, 1:10 000) EED EED EED EED
Factor VIII, IX concentrates, DDAVP EH EH EH
Flumazenil EH EH EH EH
TABLE 2. Continued
530 GUIDELINES FOR PEDIATRIC EMERGENCY CARE FACILITIES
Nasal airways (infant, child, adult)
Nasogastric tubes (sizes 6-16 fr)
Laryngoscope handle and blades:
- curved 2,3
- straight or Miller 0,1,2,3
Endotracheal tubes:
- uncuffed (2.5-5.5)
- cuffed (6.0-9.0)
Stylets for endotracheal tubes (pediatric, adult)
Lubricant, water soluble
Magill forceps (pediatric, adult)
Tracheostomy tubes (shiley sizes 0-6)
Oxygen blender
Pediatric endoscopes and bronchoscopes available
Pediatric ventilators
Specialized pediatric trays
Lumbar puncture
Urinary catheterization: Foley 8-14 fr
Newborn kit/obstetric pack
Venous cutdown
Umbilical vessel cannulation
Thoracostomy tray with chest tube sizes 10-28 fr
Peritoneal lavage tray
Needle cricothyroidotomy setIntracranial pressure monitor tray
Subdural tray
Tracheostomy tray
Fracture management devices
Cervical immobilization equipment suitable for pediatric patients
Spine board (child/adult)
Extremity splints
Femur splint; child, adult
EED EED EED EED
EED EED EED EED
EED EED EED EED
EED EED EED EED
EED EED EED EED
EED EED EED EED
EED EED EED EED
EED EED EED EED
EED EED EED EED
EED EH EH
EED EED EED EED
EH EH
EH EH
EED EED EED EED
EED EED EED EED
EED EED EED EED
EED EED EED EED
EED EED EED EEDEED EED EED EED
EED EED EED EED
EED EED EED EEDEED EED EED EED
EED EED EED EED
EED EED EED
EED EED EH
EED EED EH
EED EED SE
EED EED EED EH
EED EED EED EH
EED EED EED EED
EED EED EH EHEED EED EH EH
EED EED SE
EED EED SE
EED EED EED
EED SE
EED SE SEEED EED SE
EED EED EED EED
EED EED EED EED
EED EED EED EED
EED EED EED EED
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TABLE 2. Continued
Facility
CRPC General
Levels
Basic Standby
Furosemide EED EED EED EED
Glucagon EED EED EED
Insulin EH EH EH
Ipecac EED EED EED EEDKayexalate EH EH EH
Ketamine EED EH EHLidocaine-1% EED EED EED EED
Mannitol-20% EED EED EED EED
Methylene blue EH EH EH EH
N-acetyl cysteine EH EH EH
Naloxone EED EED EED EED
Potassium chloride EED EED EED
Prostaglandin E1 EH EH
Sodium bicarbonate 7.5% and 4.2% EED EED EED EED
Succinylcholine EED EED EH
Thiopental EED EH EH
Whole bowel irrigation solution EH EH EH
Drug classes
Analgesics EED EED EH EH
Antibiotics EED EED EED EED
Anticonvulsants EED EED EED EED
Antihypertensive agents EED EED EH EH
Antipyretics EED EED EED EED
Chelating agents for heavy metal poisonings EH EH EH
Nondepolarizing neuromuscular blocking agents EED EED EED
Miscellaneous
Resuscitation board EED EED EED EED
Infant scale EED EED EED EEDHeating source (for infant warming) EED EED EED EED
Precakulated drug sheets or length-based tape EED EED EED EED
Pediatric restraint equipment (to use for painful or difficult procedures) EED EED EED
Portable radiography EED EH EH
Slit lamp EH EH EH
Pacemaker capability (ie, temporary transcutaneous and transvenous EH EH
pacemaker with pediatric capability)Thermal control for patient and/or resuscitation room EED EED EED
FacilitiesEmergency Area
Open 24 hours per day E E E E
Well-lighted emergency entrance with ambulance access E E E E
Separate pediatric resuscitation area E ESeparate pediatric EAccess to helicopter landing site E E E E
Hospital support services
Pediatric ward for inpatient care E EPediatric intensive care unit (AAP/SCCM standards)*
Level I ELevel II E
Child abuse team EP EP
Child life support EH
Operating room staffed 24 hours per day E E SEAnesthesia and surgical suite promptly available E E SE
Laboratory servicesHematology E E E E
Chemistry E E E E
Microbiology E E E SE
Microcapabilities E E
Blood bank E E SE
Drug levels/toxicology E SE SE
Blood gases E E E
Radiology services (on-call)Routine services 24 hours per day E E E EComputed tomography scan 24 hours per day E E SEUltrasound 24 hours per day E E SE
Magiietic resonance imaging availability/transfer E E
AMERICAN ACADEMY OF PEDIATRICS 531
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Access, Triage, Transfer, and TransportSupport of medical control*
Accept call-ahead ambulance information
Transfer agreements for:
In-patient pediatric care
ICU pediatric careMajor trauma care
Burn care
Hemodialysis
Spinal injury care
Rehabilitation care
Accept all critically ill patients from lower-level hospitals within a region
Access to transport services appropriate for pediatrics
Provide 24-hour consultation to lower-level facilities
Consultation agreements with CRPC
E SEE E SE
E SE
E E SEE E SE
E E E E
E E EE E SE
E E SE
E E SE
E E SE SEE E E E
E EE E EE E E
E E E
E E EE E E
E E E
E SE SEE E E E
E
E E
E E SE SEE E E EE SE SE SEE SE
E E E E
E E SEE
E E E E
E E E E
E SE SEE E E EE E E E
E E E EE SE SE SEE SE SE SE
E E E EE E E EE E E E
EH EHEP EPE
E SE SE SEEED EH EH
E
TABLE 2. Continued
532 GUIDELINES FOR PEDIATRIC EMERGENCY CARE FACILITIES
Facility
CRPC General
Levels
Basic Standby
Nuclear medicine
Fluoroscopy/contrast studies 24 hours per day
Angiography 24 hours per day
Echocardiography
Electroencephalography
Access to
Regional poison control center
Hemodialysis capability/transfer agreement
Rehabilitation medicine/ transfer agreement
Acute spinal cord injury management capability/transfer agreement
Hyperbaric oxygen chamber availability/transfer agreement when
appropriate
Education, Training, Research, and Quality Assessment and Improvement*
Education and Training
Public education, injury prevention
Assure staff training in resuscitation and stabilization
Assist with pre-hospital education
Network educational resources for training all levels of health professionals
Research
Support state EMSC and CRPC research efforts and data collection
Participate in and/or maintain trauma registry
Organized research program
Quality Assessment and Improvement
Structured QA/QI program with indicators and periodic review
Participate in regional quality review by CRPC and/or local EMS authority
Administrative Support and Hospital Commitment*Make available clinical resources for training pre-hospital personnel
Assure properly trained ED staff
Assure availability of all necessary
equipment/supplies/protocols/agreements/policies
Provide emergency care and stabilization for all pediatric patients
Support networking education/training for all health care professionals
Assure appropriate medical control and input to ED management and
pediatric care
Participate in networking pediatric emergency care within a region
Assure transport services and agreements are available
Assure resources available for data collection
Assure availability of:
Social services
Child abuse support services
Child life support
On-line pre-hospital control
Respiratory care
Child development services
Abbreviations: RN, registered nurse; EMS, emergency medical services; ECG, electrocardiogram; CO2. carbon dioxide; IV, intravenous;
ED, emergency department; AAP, American Academy of Pediatrics; SCCM, Society of Critical Care Medicine; ICU, intensive care unit;CRPC,comprehensive regional pediatric center; EMSC, emergency medical services for children.
house nursing staff. The physician must be compe-tent in the care of pediatric emergencies including
the recognition and management of shock and nespi-ratory failure, the stabilization of pediatric trauma
patients, advanced airway skills (intubation, needlethoracostomy), vascular access skills (including in-traosseous needle insertion), and be able to performa thorough screening neurologic assessment and to
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AMERICAN ACADEMY OF PEDIATRICS 533
interpret physical signs and laboratory values in anage-appropriate manner. Successful completion of
courses such as PALS and the American Academy ofPediatrics and American College of Emergency Phy-
sician’s Advanced Pediatric Life Support (APLS) canbe utilized to demonstrate this clinical capability.
An on-call system is necessary for access to physi-
cians who have advanced airway and vascular accessskills as well as for general surgery and pediatricspecialty consultation. There should be one addi-tional call-in RN available for emergencies.
Equipment and Supplies
Equipment for communication with EMS is essen-tial if there is no higher-level facility capable of re-
ceiving ambulances or there are no resources forproviding medical control to the pre-hospital system.
An emergency cart or other system to organize sup-
plies induding resuscitation equipment, drugs, printed
ped iatric drug doses, and pediatric reference materialsmust be readily available. Equipment, supplies, trays,
and medications should be easily accessible, labeled,and logically organized. Antidotes necessary for a spe-cific geographic area should be determined through
consultation with a poison control center.
Facilities
See Table 2.
Access, Triage, Transfer, and Transport
A standby facility needs to be capable of providingresuscitation, stabilization, and timely triage for all pe-
diatric patients, and, when appropriate, transfer of pa-tients to a higher-level facility. Necessary triage andtransfer agreements depend on available communityresources and are listed in Table 2. A standby facility isresponsible for having appropriate transfer agreementsto assure that all pediatric patients receive timely emer-
gency care at the most appropriate pediatric facility
available � to a specific region. This facifity must belinked with a CRPC for pediatric consultation.
Education, Training, Research, and Quality Assessmentand Improvement
A standby facility must:
. Provide public education regarding access to pe-diatric emergency care.
. Provide patient data and information in support ofregional and state EMS-EMSC data collection ef-
fonts.. Organize a structured quality assurance and im-
provement program that reviews the following
issues and indicators:1) pediatric deaths.2) incident reports.
3) transfers.4) child abuse cases.
5) cardiopulmonary on respiratory arrests.6) admissions within 48 hours of an emergency
department (ED) visit.7) surgery after being discharged from an ED
within 48 hours.
8) quality indicators requested by the CRPC orstate/local EMSC authority regarding nursing
care, physician care, pre-hospital cane, and themedical direction for pre-hospital providers ofEMS systems.
Administrative Support and Hospital Commitment
A standby facility must have the hospital admin-istrative support to:
. Assure that properly trained and adequate pen-
sonnel provide the emergency services expected atthat level of facility.
S Assure that financial resources are available toprovide the ED with the equipment necessary forthe level of facility as described in these guide-lines.
. Assure that facilities are designed for easy accessand are appropriate for the care of pediatric pa-tients as described in these guidelines.
I Provide access to emergency care for all urgentand emergent pediatric patients.
. Participate in developing a network of pediatric
emergency care within a region by linking thefacility with a regional referral center to:1) guarantee transfer and transport agreements.2) refer serious and critically ill patients and spe-
cial problem patients to an appropriate facility.. Work collaboratively with the regional EMS-
EMSC authority to support educational programsfor pre-hospital personnel, nurses, and physicians.
. Work collaboratively with the CRPC and regionalEMS-EMSC authority to assure that the data col-
lection and quality indicators established by thestate/local EMS-EMSC agency are monitored andavailable.
. Assure linkage with pre-hospital care and trans-port.Assure that the ED has a:1) medical director.2) physician coordinator for pediatric emergency
cane with experience as defined in the Person-nel section of the guidelines for a standby pe-diatric emergency facility.
3) Nursing coordinator for pediatric emergencycare.
. Establish policies, procedures, on protocols for pe-diatric emergency patients to include:
1) medical triage.2) general assessment.
3) safety.4) child abuse and neglect.
5) consent.6) transfers.7) do-not-resuscitate orders.
8) death in the ED (including sudden infantdeath syndrome) and the cane of the grieving
family.
9) conscious sedation.
GUIDELINES FOR A BASIC PEDIATRIC
EMERGENCY FACILITY
Guidelines include all of the activities and issuesdescribed under standby facilities in addition to thefollowing:
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534 GUIDELINES FOR PEDIATRIC EMERGENCY CARE FACILITIES
Personnel
A basic pediatric facility requires the presence of
an emergency physician in-house 24 hours pen day, 7days pen week. A pediatrician, general surgeon withtrauma experience, anesthesiologist, and radiologistmust be promptly available 24 hours pen day.
Equipment and Supplies
See Table 2.
Facilities
See Table 2.
Access, Triage, Transfer, and Transport
A basic facility must support standby facilities
within a region when necessary by having triage andtransfer agreements to receive appropriate patientsas a part of a regional pediatric care network.
Education, Training, Research, and Quality Assessment
and Improvement
A basic facility must:
. Participate in a network of public education that
addresses:1) access to pediatric emergency cane.2) injury prevention.3) first aid and cardiopulmonary resuscitation.
S Organize a quality assurance and improvementprogram that reviews the issues described underthe standby facilities in addition to:I ) a review of pediatric transports to and from the
facility.2) a review of pediatric inpatient illness and injury
outcome data.
Administrative Support and Hospital Commitment
A basic facility must provide administrative sup-
port to:
. Assure that properly trained and adequate pen-sonnel provide the emergency services expected atthat level of facility.
. Assure that financial resources are available toprovide the ED with the equipment necessary forthe level of facility as described in these guide-lines.
. Assure that facilities are designed for easy access
and are appropriate for the cane of pediatric pa-tients as described in these guidelines.
. Provide access to emergency care for all urgent
and emergent pediatric patients regardless of fi-nancial status.
S Participate in developing a network of pediatricemergency care within a region by linking thefacility with a regional referral center to:
1) guarantee transfer and transport agreements.2) refer serious and critically ill patients and spe-
cial problem patients to an appropriate facility.
3) assure the support of agreements to receiveappropriate patients from lower-level facilities.
. Assure that the necessary education and trainingare available for health cane staff as described in
these guidelines.. Work collaboratively with the EMS-EMSC system
to provide education to pre-hospital personnel,
nurses, and physicians.. Actively participate in data collection to assure
that the quality indicators established by the re-gional resource center are monitored, and makedata available to the regional resource center on a
central data monitoring agency.. Assure the facility is linked with pre-hospital cane
and transport.
. Provide access to social services and child abusesupport services.
GUIDELINES FOR A GENERAL PEDIATRIC
EMERGENCY FACILITY
For large metropolitan or regional hospitals with
significant pediatric patient volumes, a separate pe-diatric emergency area is strongly recommended.This area should be staffed by pediatricians or emen-
gency physicians who are committed to pediatricemergency care.
Guidelines include all activities and issues underthe basic facilities in addition to the following:
Personnel
Physician Coverage
Pediatricians or emergency physicians with the
skills, knowledge, and commitment to cane forcritically ill on injured children are present in theED 24 hours per day (pediatric emergency physi-cian, pediatrician, or emergency physician).
Pediatric Trauma Team
. A pediatrician, emergency physician, on pediatric
emergency physician.I A trauma surgeon with pediatric trauma expeni-
ence and training.. Three RNs with emergency, critical care, pediatric,
on surgical experience.. A neurosurgeon who is promptly available.I An orthopedic surgeon who is promptly available.. An anesthesia resident or certified nurse anesthe-
tist, both with pediatric experience, may be in-house with an anesthesiologist promptly avail-
able.. A respiratory therapist, laboratory technician, na-
diology technician, and social worker readily
available.. A trauma coordinator who is responsible for data
collection, quality assurance, and education.
Nursing Staff
S At least one nurse pen shift with pediatric emen-gency nursing experience (PALS, ENPC, or equiv-alent)
. A pediatric nurse educator.
Equipment and Supplies
See Table 2.
Facilities
A general facility must have access to a Pediatric
Intensive Care Unit (level I or 2 per AAP/SCCM
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AMERICAN ACADEMY OF PEDIATRICS 535
standards).4 This requirement may be fulfilled byhaving transfer and transport agreements available
for moving critically ill or injured patients to a CRPC.
Access, Triage, Transfer, and Transport
See Table 2.
Education, Training, Research, and Quality Assessment
and Improvement
When a CRPC is not available to a region, a gen-
eral facility must:
. Assist the state/local EMS-EMSC authority in or-ganizing a network of public education with thebasic and standby EDs as resources for the dissem-ination of information.
. Assist the state/local EMS-EMSC authority in pro-viding support for the education, skills training,and dissemination of new information to pre-hos-pital care providers utilizing the resources of basicand standby hospitals.
A general facility must:
. Collaborate and work closely with a CRPC to as-sure that health cane workers in the facility andregion have access to continuing education in on-den to maintain and update their skills for necog-nizing and stabilizing pediatric emergencies.
. Collaborate with the CRPC to organize regionalresearch and assist the state/local EMS-EMSC au-thonity with data collection and maintenance.
. Collaborate with the CRPC and the state/local
EMS-EMSC authority to organize the quality mdi-
cators appropriate for regional periodic review ofparticipating health care facilities.
. Participate in a pediatric trauma registry.
Administrative Support and Hospital Commitment
A general facility must:
. Assure that properly trained and adequate pen-
sonnel provide emergency services.. Assure that financial resources are available to
provide the ED with the equipment necessary forthe level of facility as described in these guide-lines.
. Assure that facilities are designed for easy accessand are appropriate for the cane of pediatric pa-tients as described in these guidelines.
. Provide access to emergency care for all urgentand emergent pediatric patients.
S Participate in developing a network of pediatricemergency care within a region by linking thefacility with a regional referral center to:1) guarantee transfer and transport agreements.2) refer serious and critically ill patients and spe-
cial problem patients to an appropriate facility.3) assure support of agreements to receive appro-
pniate patients from lower-level facilities.S Assure that the necessary education and training
are available for the health care staff as describedin these guidelines.
. Work collaboratively with the CRPC to supporteducation for pre-hospital personnel, nurses, and
physicians.
. Actively participate in data collection to assurethat quality indicators are monitored.
. Assure that the facility is linked with pre-hospital
care and transport.. Have a physician director of the ED who is board
certified/prepared in emergency medicine or pe-diatric emergency medicine.
. Have an ED nursing director.
. Develop and monitor pediatric emergency andcritical care protocols, policies, and quality im-provement and management programs with
the formal involvement of the Department ofPediatrics.
COMPREHENSIVE REGIONAL PEDIATRIC CENTER
Guidelines for a comprehensive regional pediatric
center include all of the activities and issues undergeneral facilities in addition to the following:
Personnel
Physician Coverage
. Twenty-four-hour ED coverage by physicians who
are board certified, board eligible, or fellows (sec-ond-year level on above) in pediatric emergencymedicine.
Pediatric Trauma Team
I A pediatric emergency physician.. A pediatric trauma surgeon (a PGY-4 or greater
surgical resident in-house with a pediatric sun-geon promptly available).
. One additional MD team member (a surgery or
pediatric resident).. Three RNs with pediatric emergency, pediatric
critical care, on pediatric surgical experience aswell as training in trauma care.
. A neurosurgeon who is promptly available.
. An orthopedic surgeon who is promptly available.
. A nurse anesthetist or anesthesia resident in-house, both with pediatric experience, with ananesthesiologist who is promptly available.
. A pediatric respiratory therapist, laboratory tech-nician, and radiology technician.
. A computed tomography technician in-house. Thetechnician may be on-call and promptly available
if the specific clinical needs of the hospital makethis necessary and it does not have an adverseimpact on patient care.
. Social services that are promptly available.
. A pediatric trauma coordinator who is responsiblefor data collection, quality improvement, and ed-ucation, and may include case management.
Nursing Staff
. A pediatric ED nursing director.
S An RN responsible for ongoing staff education.I General staff experienced in pediatric emergency
and trauma nursing care.
See Table 2 for on-call pediatric specialists andsurgical support.
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Equipment assures dissemination of new information, main-
536 GUIDELINES FOR PEDIATRIC EMERGENCY CARE FACILITIES
See Table 2.
Facilities
A CRPC emergency department must have geo-
graphically separate and distinct pediatric medical/trauma areas that have all the staff, equipment, and
skills necessary fon comprehensive pediatric emen-gency cane. Separate fully equipped pediatric nesusci-tation rooms must be available and capable of support-
ing at least two simultaneous resuscitations. A level 1
(pen AAP/SCCM standards)4 pediatric intensive care
unit must be available within the institution.
Access, Triage, Transfer, and Transport
A CRPC must:
. Assist with the provision of regional pre-hospitaldirect medical control for pediatric patients.
. Promote a regional network of direct medical con-
trol by lower-level hospitals within the region byworking closely with the regional EMS medicaldirector to assure:
1) standards for pre-hospital cane.2) triage and transfer guidelines.
3) quality indicators for pre-hospital care.S Accept all patients from a defined region who
require specialized care not available at lower-level hospitals within the region.1) have prearranged transfer agreements that net-
work hospitals within a region to assure appro-
pniate intra-emengency department triage andtransfer to assure optimum care for seriously
and critically ill or injured pediatric patients.2) have prearranged transfer agreements for pedi-
atnic patients needing specialized cane not avail-able at the CRPC (eg, burn specialty unit, spinalcord injury unit, on rehabilitation facility).
. Assure a pediatric transport service that:1) is available to all regional participating hospi-
tals.2) provides a network for transport of appropriate
patients from all regional hospitals to theCRPC, on to an alternative facility when neces-sany.
. Provide 24-hour consultation to all lower-level fa-cilities for issues regarding:1) emergency care and stabilization.
2) triage and transfer.
3) transport.
Education, Training, Prevention, Research, and Quality
Assessment and Improvement
A CRPC must support all the issues and activities
under general facilities in addition to the following:
. Organize a network for public education regard-ing issues of pediatric emergency access, care, andinjury prevention utilizing the resources ofstandby, basic, and general EDs within a region.
. Support EMS agencies and EMS directors in main-taming a regional network of pne-hospital pro-vider education and training that utilizes the ne-
sources of standby, basic, and general EDs and
tenance of pediatric emergency skills, and updatesstandards of cane and protocols.
. Assure that a network of pediatric emergency care
education is available to all health care workersutilizing the resources of standby, basic, and gen-enal facilities within the region.
. Organize a structured quality assurance and im-provement program with the assistance and sup-port of local/state EMS-EMSC agencies that al-lows ongoing review and:I ) reviews all issues and indicators described un-
den standby, basic, and general EDs.2) provides feedback, quality review, and infor-
mation to all participating hospitals, EMS
and transport systems, and appropriate stateagencies.
3) develops quality indicators for the review ofpediatric cane given that are linked to periodiccontinuing education and reviewed at all pan-ticipating institutions.
. Assists in organizing and providing support forregional, state, and national data collection efforts
for EMSC that include:1) trauma registry.2) injury and illness epidemiology.3) pediatric specific quality indicators.
. Has an organized program for research in pediat-ric trauma, emergency care, critical care, and in-jury prevention.
Administrative Support and Hospital Commitment
A CRPC must have administrative support to:
. Assure an adequate staff that is properly trained.
. Assure that financial resources are available to
provide necessary equipment for emergency andtransport care.
S Assure that facilities are designed for easy access
and appropriate for the care of pediatric patientsas described in these guidelines.
. Provide access to emergency care for all urgentand emergent pediatric patients.
. Assure available support services to the ED in-
cluding:1) Social services.2) Child life.
3) Child/sexual abuse support.4) Respiratory care.
. Assist local and state agencies for EMS-EMSC in
organizing and implementing a network for pro-viding pediatric emergency cane within a definedregion that:1) provides transfer and transport agreements
with lower-level facilities.2) provides transport services when needed for
receiving critically ill or injured patients withinthe regional network.
3) provides necessary consultation to participat-ing network hospitals.
4) provides indirect (off-line) consultation, sup-port, and education to regional pre-hospitalsystems and supports the efforts of regionaland state pre-hospital committees.
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AMERICAN ACADEMY OF PEDIATRICS 537
5) provides medical support to assure quality di-rect (on-line) medical control for all pre-hospi-
tal systems within the region.
. Organize and implement a network of educationalsupport to all regional hospitals that:1) trains instructors to teach pediatric pre-hospital,
nursing, and physician-level emergency care.2) assures that training courses are available to all
hospitals and health care providers within theregion.
. Provide support for a regional data system that:1) defines the population served.
2) maintains and monitors specific quality indica-tors.
3) is � adaptable to answer questions for clinicalresearch.
. Support active institutional and collaborative ne-gional research.
. Have a physician director of the pediatric ED who
is board certified/prepared in pediatric emer-
gency medicine.
COMMII-rEE ON PEDIATRIC EMERGENCY MEDICINE, 1994 TO
1995
Joseph A. Weinberg, MD, ChairpersonBarbara Barlow, MDGeorge L. Foltin, MDJer#{224}meA. Hirschfeld, MDDee Hodge III, MDJane Knapp, MDWilliam J. Lewander, MDKarin A. McCloskey, MDRobert A. Wiebe, MD
LiAISON REPRESENTATIVES
Jean Athey, PhDMaternal and Child Health BureauMax L. Ramenofsky, MDAmerican College of SurgeonsRobert W. Schafermeyer, MDAmerican College of Emergency Physicians
AAP SEcrI0N LIAisoNS
Patricia J. Davidson, MDSection on AnesthesiologyMichele Moss, MDSection on Critical CareJames O’Neill, MDSection on Surgery
CONSULTANTS
1. Alexander Hailer, Jr. MDJames S. Seidel, MD, PhDCalvin C. J. Sia, MDDennis W. Vane, MD
REFERENCES
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Washington, DC: National Academy Press; 1993
3. Pollack MM, Alexander SR. Clarke N, Ruttimann UE, Tesselaar HM,
Bachulis AC. Improved outcomes from tertiary center pediatric inten-
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4. Committee on Trauma, American College of Surgeons. Resources for
Optimal Care of the Injured Patient: 1993. Chicago, IL: American College
of Surgeons; 1993
5. American Academy of Pediatrics, Committee on Hospital Care, and Sod-
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1995;96;526Pediatrics Committee on Pediatric Emergency Medicine
Guidelines for Pediatric Emergency Care Facilities
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