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Trauma Triage Journal Scan

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Articles related to optimizing care for critically ill children in general emergency departments.

Reviewed by Melanie Stroud, RN, BSN, MBA, Pediatric Trauma Program Manager, Lucile Packard Children's Hospital- Stanford Children’s Health

Why are these articles relevant?
We often wonder if the feedback we are giving to general emergency departments is of value, and what else might be needed. Views of front line providers is very important to understand as they are part of the continuum of care and ultimately contribute to patient outcomes. Environmental constraints, and unanticipated knowledge gaps regarding pediatric practice and guidelines are a known issue when providing care to children in general emergency departments.

The National Pediatric Readiness Project is a multi-phase quality improvement initiative to ensure that all U.S. emergency departments have the essential guidelines and resources in place to provide effective emergency care to children. Approximately 90% of pediatric emergency care is provided in community emergency departments (CEDs) that care for both adults and children. Paradoxically, the majority of pediatric emergency medicine knowledge generation, quality improvement work, and clinical training occurs in children’s hospitals.

In 2013, more than 4,100 emergency departments (ED) across the nation voluntarily participated in an assessment to determine their readiness to care for a sick or injured child. 83% of the approximately 5,000 hospitals nationwide participated in the assessment and indicated their widespread interest in improving care for children. The national overall hospital Pediatric Readiness score is 69%. Though this score is a marked improvement from an earlier assessment of pediatric readiness conducted in 2003, when the score was found to be 55%, there is still much work to be done. Only 47% of responding facilities had included pediatric specific considerations into their hospital disaster plans. Even those facilities where children are frequently cared for had opportunities to improve their disaster preparedness. Only 45% of hospital EDs reported having a pediatric care review process and only 58% of respondents had defined pediatric quality indicators. The presence of a physician and nurse pediatric emergency care coordinator (PECC) was associated with a higher adjusted median Pediatric Readiness score compare with no PECC. Several recent articles have been written to attempt to quantify the needs of the General Emergency Department, and are being reviewed in this journal scan in attempt to assist us in understanding the needs of the general emergency departments.

ARTICLE # 1: Query, L & Olson K., et Al. (2018) Minding the gap: A qualitative study of provider experience to optimize care for critically ill children in general emergency departments.

Type of Article: Qualitative Study

Level of Evidence: Level VI –Single descriptive or qualitative study

Discussion: Pediatric emergency care provision in the U.S. is uneven. Little is understood about the frontline providers and the lived experiences of emergency medicine caring for acutely ill children in the general emergency department. Theoretical sampling was used to enroll EM physicians and advanced practice providers from 25 Wisconsin General emergency departments. Participants completed 0ne-on-one, semi structured interviews. This study is a comprehensive qualitative exploration of the issues encountered during the provision of emergency medical care to critically ill children. General emergency department providers endorsed that they seldom encounter children needing critical care in their practice. This lack of exposure impacts their experiences because they cannot anticipate their pediatric –specific knowledge gaps, resulting in heightened anxiety. They then seek to find emergent guidance and exhibit a forced approach to pediatric emergency care. There was a desire to have a proactive, multi-faceted approach to enhancing patient care through provider focused interventions.

Conclusions: In summary, the lived experiences of emergency department physicians and advanced practice providers is challenging and complex. The results showed barriers to general ED providers maintaining their pediatric competencies. This lack of knowledge results in a fragmented medical network with limitations in resources, knowledge transfer, and guidance. Looped feedback about care provided & patient outcomes was expressed as needed from tertiary pediatric facilities to which they transfer patients. Embedding Pediatric Emergency department education using well utilized learning modalities would be useful. Networking to facilitate guidance of in-the-moment consultation with the pediatric experts was seen as very important.

PTS Summary: The continues heightened attention should be brought on behalf of the educational needs for General Emergency Departments with regard to pediatric readiness. Trauma has been seen as a leader in providing loop closure feedback and education to general emergency departments. This should be continued as best practice, and ways to enhance this should be sought.

ARTICLE # 2: Goldman, M & Wong, A. et. Al (2018) Providers’ perceptions of caring for pediatric patients in community hospital emergency departments: A mixed- method analysis

Type of Article: Mixed Method Analysis

Level of Evidence: Level V, Evidenced from systematic reviews of descriptive and qualitative studies, multicenter

Discussion: The objective of the article was to explore interprofessional Community Hospital ED providers’ perceptions of caring for pediatric patients. Participants given a preparticipation survey collected data on demographics, experience, and comfort in caring for children. Pediatric simulations were then utilized to prime interprofessional teams for debriefings. The discussions underwent qualitative analysis by three blinded authors who coded transcripts into themes. 171 community hospital providers from 6 community ED’s participated. (49% nurse, 22% physicians, & 23% technicians) The majority were PALS trained (70%) and experienced fewer than 5 pediatric resuscitations in their career. (61%) Following the debriefings, three major themed challenges prevailed: 1. knowledge & skills limitations attributed to infrequency of training & actual clinical events. 2. The emotional toll of caring for a sick child 3. Acknowledgement of pediatric specific quality and safety deficits.

Conclusions: Through preintervention surveys and a qualitative analysis of the debriefings from a series of simulation primed experiences, they offered themes to help other centers with hypothesis on future pediatric-specific interventions to improve community ED pediatric care. Their strategies included in-situ simulation and other training, sharing of coping skills, sharing updated cognitive aides, patient follow up and feedback, adopting clinical care guidelines, and telemedicine opportunities.

PTS Summary- Very well done qualitative study, which could be duplicated in a multicenter approach. This information could be used to guide the development of community ED pediatric improvement strategies in trauma centers and beyond. Continuing to partner with Level 1 Pediatric Trauma Centers to lead the care and collaboration efforts is imperative.

ARTICLE # 3: Gangadharan, S. & Tiyyagura, G., et. Al (2018) A grounded theory qualitative analysis of interprofessional providers’ perceptions on caring for critically ill infants and children in pediatric & general emergency departments

Type of Article: Qualitative Methods

Level of Evidence: Level V, Qualitative study, multicenter

Discussion: The objective of this study was to explore pediatric emergency department and general emergency department providers’ perceptions on caring for critically ill infants & children. A total of 188 simulation debriefings were recorded in 24 departments, wit 15 teams participating from 8 Pediatric EDs and 32 teams from 16 General EDs. Four themes emerged: 1. General EDs provider comfort with algorithm-based pediatric care and overall comfort with pediatric care in Pediatric emergency departments. 2. General ED provider reliance on cognitive aids versus experience-based recall by Pediatric ED providers. 3. General ED provider discomfort with located and determining size or dose of pediatric specific equipment and medications 4. Pediatric ED provider reliance on larger team size and challenges with multitasking during resuscitation.

Conclusions: After looking at the quantitative information delivered by teams during the simulation, qualitative themes were also examined such as attitudinal differences and self-perceptions in caring for acutely ill children. Suggestions included to strengthen relationships between General EDs and Pediatric EDs with the assistance of tools such as in situ simulation, dissemination of pathways and protocols, and telemedicine.

PTS Summary- There is significant value in this information so that designing effective care delivery systems across the continuum care and partnering with the General EDs by the children’s hospital and pediatric trauma centers is important. Educational opportunities to improve the quality of emergency care for children is imperative, regardless of where they receive care.

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