Young people who are sick or injured and require immediate care have unique medical needs, but many emergency departments (EDs) aren't fully prepared to care for pediatric emergencies. The past decades have seen significant improvement, including better trauma care, better resident training, and more attention to pain management. Yet there is still room for improvement.

To strengthen pediatric emergency care, hospitals around the country are investing in customized facilities and equipment, hiring ED physicians and nurses with pediatric experience, and retraining other staff. Some are even creating kids-only emergency departments. While most hospitals can't afford separate departments, there are simple steps all hospitals can take to prepare for pediatric emergencies. Better management of pediatric emergencies could help EDs alleviate overcrowding and improve patient flow by effectively treating these patients in a timely manner.

Customized Facilities, Movies on Demand
Lucile Packard Children's Hospital at Stanford, serving Bay Area residents, decided to build a separate pediatric emergency facility after hearing complaints from families about long waits and an unwelcoming environment in the general ED. Members of the community created an endowment that enabled the hiring of key members of a pediatric emergency team. Then Lucile Packard and Stanford University Hospital joined forces and designed and built a state of the art Pediatric ED. After a year and a half of development, the new facility opened in December 2005.

Today, after being triaged in the main emergency department, children and their families follow a blue "river" pattern on the floor leading to the pediatric ED. The waiting room there is filled with toys and video games to entertain children and help to alleviate their stress (there is also free wireless access for their parents). The walls are decorated with colorful artwork taken from familiar children's books. Thanks to community donors, the exam rooms are equipped with iMac computers and wireless Internet access, so that patients can watch movies or listen to music while they are being examined.

The ED has special pediatric emergency equipment, including child-size gastric tubes, airway kits, and special medications. Monitors in every exam room are linked to the central nursing station to enable observation of patients' vital signs. In addition, two of the eight exam rooms function as isolation rooms, since many pediatric patients have infectious conditions or are immunocompromised.

A Pediatric Emergency Team
The pediatric ED is directed by Bernard Dannenberg, M.D., one of a handful of U.S. physicians with dual training in pediatrics and emergency medicine. Dannenberg says that the hospital aims to teach staff that they are "treating the entire family when they have a pediatric patient." Staff is encouraged to consult with parents, keep them informed of steps they are taking, and solicit their input in decision-making.

Nurses have been a key part of the changes to workflow. To enable them to develop expertise in caring for both adult and pediatric patients, they shift between Stanford's ED and the pediatric ED. Paula Miller, R.N., an experienced pediatric ICU nurse and educator, is helping to train the nurses to tailor their care to younger patients. They undergo initial training in pediatric emergency care, and have annual skills days focused on particular topics, such as use of ventilators.

"A lot of the staff training focused on communication with families. Nurses had to learn that sometimes they need to give up control," Miller explains. "If a mother with a disabled child comes to the ED, sometimes it's best to let the mother perform some of the procedures since she does it everyday and she knows her child's body so well. This is a difficult mentality for nurses to learn, because they are used to running the show."

Attending to Pain and Trauma
According to the American Medical Association, children are often given minimal or no analgesia for procedures that would routinely be treated aggressively in adults. In recent years, however, researchers have produced new sedation techniques and topical creams to blunt the discomfort of procedures such as injections or IV tubing. Stanford aims to take advantage of these developments to create what Dannenberg calls an "ouchless ED," focused on pediatric pain management.

Stanford has also hired a "child life specialist," Colleen O'Connor, to comfort children during procedures and serve as a liaison between providers and families. The concept of a child life specialist evolved from the discipline of recreation therapy, which seeks to reduce the stress of illness or injury and the strangeness of hospital environments. O'Connor, who has a background in both theater and applied developmental psychology, brings a sense of play to the healing process. She might blow bubbles to break a child's tension, read a book to distract a child during a delicate procedure, or use a mini-CT scanner to demonstrate to a child what the machine looks like and what they will go through during the examination.

Results
Since opening the pediatric emergency department, Stanford has seen a significant increase in patient volume--more than 23 percent from January 2005 to January 2006. Patients' satisfaction scores have been rising, and Press Ganey scores rating the hospital environment are in the highest percentile. The overall assessment score for the pediatric ED increased from 71.8 points to 79.3 points.

"We realized up front that we had to tailor care to be competitive," Dannenberg says. "Much of the parent and child's anxiety has been eliminated by creating this child-friendly atmosphere."

Work remains to be done to reduce waiting times, which Dannenberg hopes to accomplish in part through investment in information technology to speed the transfer of medical information. He also plans to focus on the rate of patients leaving without being seen, which has not changed due to the increased volume. Eventually, he hopes to establish a research fellowship in pediatric emergency medicine to train the next generation of specialists and conduct long-term studies on strategies for improving patient care and family services.

Advice for Hospitals
To strengthen pediatric care and create safe and comfortable environments for families, all hospitals can take a few key steps.

• Designate a physician and nurse to pediatric emergency care.
• Make sure you have the right equipment. The AAP and ACEP have published guidelines for equipping a pediatric area in a community hospital (see Innovations section of this issue). For example, the guidelines suggest the use of systems for easy identification of appropriate medication dosages, such as stocking medical carts with supplies that are color-coded for children of different sizes.
• Train staff in the specific procedures for pediatric emergency care. Pediatric Advanced Life Support (PALS) courses are widely available.
• Seek to manage pain and reduce stress. Take advantage of new techniques for safely and effectively managing children's pain.
• Create child- and family-friendly environments. Simple steps, such as offering private family bathrooms or books and toys in the waiting rooms, can go a long way toward making families feel welcome.
• Advocate for improvements in the network of pediatric care. Many children end up within the ED because they don't have access to regular preventive care. Some hospitals are testing strategies to link families with primary care providers in an effort to reduce non-urgent ED visits and improve patient flow.

About Stanford Hospital
Lucile Packard Children's Hospital and Stanford Hospital and Clinics are joint facilities, and they share the pediatric emergency department.
Staffed Pediatric Emergency Department Beds: 8
Hospital Type: Not-for-profit
Patient Volume: Over 42,000 emergency visits a year to Stanford Hospital and Clinics; almost 12,000 pediatric visits in 2006.

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Bernard Dannenberg, MD, FAAP, FACEP
Director, Pediatric Emergency Medicine
Division of Emergency Medicine
Department of Surgery
Stanford University School of Medicine
Lucile Packard Children's Hospital

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Paula Miller RN, CCRN
Educator/Coordinator for Pediatric Services
Emergency Department
Stanford Hospital and Clinics
Lucile Packard Children's Hospital