Pediatric Emergency Department Considerations

Emergency Department Capabilities

It is estimated that fewer than 10% of hospitals in the United States have dedicated pediatric emergency departments (EDs), but almost 20% of all ED visits are for children.

Trauma Centers

Trauma is the leading cause of death for children between the ages of 6 months and 14 years; consequently, the interfacility transport of critically injured children is an essential component of a quality system for pediat­ric trauma care. It is essential that pediatric transport staff be familiar with the trauma capabilities of receiving institutions. The American College of Surgeons Committee on Trauma (ACSCOT) classifies trauma center levels on the basis of predefined criteria for staffing, facilities, and other resources and confirms their presence through a voluntary verification visit. Guidelines for transport destination based on trauma center level typically are deter­mined by state or regional protocols. Pediatric trauma patients may or may not be given special consideration within a state's trauma system, depending on the availability and accessibility of pediatric trauma centers in the region.

The ACSCOT criteria for trauma center levels are included in Table

20.1. Most trauma centers undergo biannual surveys to maintain verification. Trauma centers are classified as trauma centers, level I, II, or III (formerly adult trauma centers), or pediatric trauma centers, level I or II.

Most pediatric trauma patients have blunt injuries and are managed nonsurgically. Trauma resuscitation focuses on airway management, ven­tilatory support, and restoration of intravascular volume. Approximately 3% to 5% of children will undergo surgery within the first 24 hours after injury, the majority for stabilization of orthopedic injuries. An even smaller number will require emergency surgical procedures on arrival to a trauma center, such as patients with an expanding epidural hematoma or penetrat­ing thoracic trauma. In these cases, it is important that transport programs work with receiving hospitals to develop procedures for expedited transfer of selected patients to the operating room (OR) or other appropriate assessment or interventional location. Components of a “direct to the OR” protocol include a communication system to notify the appropriate surgical service(s) and essential personnel (eg, anesthesia, OR nursing, blood bank, radiology). In addition, the option for preregistration is important so that all required

Table 20.1: American College of Surgeons Criteria for Pediatric Trauma Centers

materials and medications are available and consents can be obtained before or immediately on patient arrival. In most cases, patients transported directly to the OR already have a secure airway, and will have completed any imaging that would be essential before surgery (eg, computed tomography scan).

Accidental Hypothermia

Another emergency situation that requires rapid mobilization of the receiv­ing hospital’s resources is the management of pulseless patients with severe hypothermia from exposure or cold-water drowning. Pediatric patients with core temperatures less than 30°C and no pulse are unlikely to respond to efforts at rewarming without the use of extracorporeal life support (ECLS). Referring institutions should be advised to avoid delays for efforts at less effective types of rewarming therapy in place of rapid transfer to a center that can provide pediatric cardiopulmonary bypass or extracorporeal mem­brane oxygenation (ECMO). In general, ECLS is not indicated for patients with documented submersion of >2 hours or those with a core temperature and alternates responsible for site safety and health

• Safety, health, and other hazards present on the site

• Use of personal protective equipment (PPE)

• Work practices by which the employee can minimize risks from hazards

• Medical surveillance requirements, including recognition of symptoms and signs that might indicate exposure to hazards

• Specific contents of the site safety and health plan, including decon­tamination procedures, PPE, confined space entry procedures, and spill­containment program

The requirements for emergency providers are much less stringent than for personnel involved in clean-up operations and include an “initial briefing at the site prior to their participation in any emergency response. The initial briefing shall include instruction in the wearing of appropriate personal protective equipment (PPE), what chemical hazards are involved, and what duties are to be performed.” OSHA has published a document titled, “Best Practices for Protecting EMS Responders during Treatment and Transport of Victims of Hazardous Substance Releases” with recommenda­tions for training, PPE, and decontamination of personnel and ambulances.

The AAP (http://www.aap.org) also has published guidelines for the isolation and treatment of children exposed to bioterrorism or chemical hazards.

Infection Control

Similar to other health care providers, transport team members may be exposed to patients or family members with contagious diseases. In general, transport personnel always should use standard precautions, including gloves and frequent hand washing, as their primary means to avoid disease trans­mission. The availability of alcohol-based hand washes and gels eliminates the need for a source of running water, making it more practical for transport team members to maintain hand hygiene in a mobile environment. When transporting a patient with a suspected contagious disease, the transport team should communicate with the receiving facility so that the patient can be tri­aged to an appropriate point of entry and/or an isolation area, as indicated.

Certain patient conditions require additional measures to protect health care providers and/or prevent disease transmission to other patients. For example, when treating patients who are colonized or infected with multi­drug-resistant organisms, such as methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE), transport team mem­bers should wear disposable gowns over their clothes or uniforms to avoid contact. Patients may have known or suspected infectious conditions that are transmitted by respiratory secretions or droplets, such as meningococcal disease and varicella, necessitating the use of masks to prevent transmission. When highly virulent diseases are suspected, such as severe acute respiratory syndrome (SARS), the use of disposable high-filtration respirators is indi­cated. Information on specific diseases and recommendations for health care providers can be found on the Centers for Disease Control and Prevention Web site at http://www.cdc.gov.

Transport team members should consider obtaining available immu­nizations for certain contagious diseases to which they may be exposed. Vaccinations are available against hepatitis A and B, influenza, mumps, measles, rubella, Meningococcus species (certain strains), varicella, polio, tetanus, diphtheria, and pertussis. People who are not vaccinated or naturally immune also can receive postexposure passive immunization for hepatitis A, hepatitis B, tetanus, and varicella. Antibiotic prophylaxis may be indi­cated after a significant exposure to a patient with meningococcal disease. Transport team members should undergo OSHA-approved training regard­ing prevention and management of exposure to blood and body fluids. Health care workers should be familiar with institutional procedures in the event of an accidental needlestick or blood or body fluid exposure because of the potential indication for passive immunization against tetanus or hepa­titis B or postexposure prophylaxis against human immunodeficiency virus.