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Peds guidelines include appointment of ED nurse, physician coordinators
Coordinators would handle many duties normally left to managers
Recognizing and re-emphasizing the fact that children are a distinct population of patients in the ED, the American Academy of Pediatrics, the American College of Emergency Physicians (ACEP), and the Emergency Nurses Association (ENA) have released a joint policy statement that includes guidelines for the care of children in EDs. The statement was published online in the journal Pediatrics.1
"We wanted to draw attention to the role that children play in the overall scheme of the ED," says Alfred Sacchetti, MD, FACEP, chief of emergency services at Our Lady of Lourdes Medical Center, Camden, NJ, a spokesman for ACEP, and a member of the committee that developed the guidelines. "The Centers for Medicare & Medicaid Services, The Joint Commission, and others have been establishing sets of standards for adult patients, and part of this effort was to say that we also want to have the same attention focused on the children — in other words, don't let the kids get lost in the overall avalanches of protocols being launched by other organizations."
The guidelines should be particularly helpful for EDs in community hospitals, adds AnnMarie Papa, MSN, RN, CEN, FAEN, president-elect of ENA for 2010. "When you think about pediatric care, most children's care for emergencies is done in community emergency facilities," Papa says. In light of the fact that the Institute of Medicine has called care of children "uneven," "We wanted to address that," she says. "Hopefully our statement provides a good overview about what a basic community hospital needs."
Well-known children's hospitals in major metropolitan areas might not need these guidelines as much, "but most children in the country do not get their care there," Papa says.
Creating new positions
While the guidelines do not hold many surprises, one of the more creative proposals involves the establishment of two new positions in the ED: A physician coordinator and a nurse coordinator. "This allows you to say that this is the one person in the department who will have an area of interest in the care of kids," Sacchetti explains.
The physician coordinator should be chosen by the ED medical director, and the nursing coordinator should be selected by the nurse manager, he says. However, Papa takes a different approach. "I see both the physician coordinator and nurse coordinator being appointed jointly by the medical director and nursing director," she says. "In my experience, I worked collaboratively with the medical director."
The selection process should not be a difficult one, Sacchetti says. "It's almost a natural choice in any department," he explains. "In any ED, you have someone who's really into cardiology, or toxicology, and the same is true for pediatrics."
They might not have done fellowships in the area, says Sacchetti, but they will have demonstrated an interest in pediatrics. "You will almost always have someone who follows the pediatrics literature a little more closely than anyone else," he observes. "They come to doctors' meetings, or nurses' meetings, and say, 'Did you know that they changed the definition of 'X,' or there's a new drug for 'Y'?" The bottom line, he says, is that "You should take advantage of that one individual in your department."
The medical director and nursing director should not only understand pediatrics, but they also should have great communication skills, Papa says. "That's because they have to be the liaison to the rest of the hospital, so that surgery, respiratory therapy, and other departments understand the unique needs of the child," she says. In other words, Papa envisions those people facilitating hospitalwide programs.
Sacchetti says, "They would certainly be responsible for ongoing performance improvement activities that address pediatrics." To address the joint guideline that covers support services for the ED, the ED manager, nurse coordinator, or physician coordinator — or all three — will need to sit down, for example, with radiology managers to discuss implementation of the recommendations, he says.
The coordinators also should be responsible for the pediatric aspects of surge management and disaster planning, says Papa. "It's much more difficult than it is for adults, especially if they are separated from their parents," she explains.
Does the creation of these new positions require additional staffing? "There could be a number of ways to do it, depending on your budget," says Papa. "Most people will identify someone in the department who has those skills and then take them off the clinical side for a certain number of hours."
Depending on the ED's volume, "that could be anywhere from 20% to 40% of the time that the person would be doing administrative work," she says. For the nursing coordinator, most often that time would be spent doing data collection, while the doctors would be spending more time on analysis, Papa says.
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Staff competencies are a key concern
Joint guidelines from the American Academy of Pediatrics, the American College of Emergency Physicians (ACEP), and the Emergency Nurses Association (ENA) cover several major areas including staff competencies; improving patient safety; policies, procedures, and protocols; transfer agreements; support services; and equipment, supplies, and medications.
Satisfying nearly all of these guidelines requires an ED staff that is competent in the specialized care children need. What core competencies should be required? "The ED manager has to work in cooperation with the pediatric coordinators to identify them," says AnnMarie Papa, MSN, RN, CEN, FAEN, president-elect of ENA for 2010. "Typically what you do when you develop competencies is you look at things like the population base, as well as the types of injuries that are common in your area, since they're all different."
However, there are some common considerations that must be taken into account, Papa says. "Number one is safety," she says. "That includes airway management, and recognizing a child is sick before they start getting sicker, because kids can go downhill real fast."
For nurses, there are some important certifications, such as pediatric advanced life support (PALS), Papa says. "Also, ENA has an emergency nursing pediatrics course, or ENPC, that nurses have to take every four years," she says. "It covers airway management, identifying burns, resuscitation, dehydration, and sepsis." Any nurse that cares for a child should have this course, Papa says. "Some think PALS is enough, but that only addresses airway management," she adds.
In addition, she says, it's important to have the ability to bond with parents and to listen to them. "If a parent says their kid is sick, then they are sick until proven otherwise — and you have to have people who are sensitive to that," Papa says. "You need to partner with them and trust the parent to tell you what has worked in the past, say, for Tommy's asthma."
There is no substitute for this relationship with the parents, she emphasizes. "You can have every certification, have every piece of equipment you need, and be a top clinical nurse, but if you can't develop trust and bond with the parents in the first two minutes, it'll be all downhill," Papa warns.
The pediatrics coordinator should handle all of the competency training or train the trainers, she says. "That gives nurses in the department to opportunity to grow," Papa says. The coordinator also should handle competency evaluations, she adds.
It's important when training your staff to advise them against becoming intimidated by caring for children, notes Alfred Sacchetti, MD, FACEP, chief of emergency services at Our Lady of Lourdes Medical Center, Camden, NJ, a spokesman for the American College of Emergency Physicians (ACEP), and a member of the committee that developed the guidelines. "Overall, we tend to underestimate the quality [of care we provide], and as a result, these people tend to be intimidated by children when they shouldn't be," he says. "Once you become intimidated, you basically back away from doing the right thing, and inappropriate intimidation in itself may lead to suboptimal care."