Emergency Department Recognition Program for Pediatric Services Does It Make a Difference?

Objective: This study aimed to determine if a pediatric emergency care facility recognition (PECFR) program improved care processes for injured children younger than 15 years. Methods: A controlled pre-post study design was used. Emergency department (ED) medical records were abstracted from 8 Delaware hospitals and 13 comparison hospitals in North Carolina in 2009 and again in 2013, 1 year after PECFR implementation. Data collected focused on pediatric processes of care, including vital sign assessment, pain assessment and management, treatment procedures, and diagnostic radiation. Results: A majority of 1737 children (97%) had an Injury Severity Score of 9 or lower. Both hospital cohorts significantly increased initial pain assessment documentation over time (P < 0001). For children with extremity immobilization and a pain score of 5 or greater, the interval between pain assessment and pain management was significantly shorter in the Delaware hospitals (P < 0.01) compared with hospitals from North Carolina. A significant reduction in radiation use (flat film and computed tomographic imaging) was also found in Delaware hospitals (P < 0001) compared with the hospitals in North Carolina. Conclusions: Improvements in care to injured children associated with the PECFR program were limited to the interval between pain assessment and pain medication for children with extremity immobilization and to radiation use 1 year after the implementation of the PECFR program. Key Words: Emergency Medical Services for Children, department approved for pediatrics, research (Pediatr Emer Care 2014;30: 00-00) C hildren and youth receive a substantial amount of care for acute illnesses and injuries in emergency departments (EDs). In 2010, children younger than 15 years accounted for 19.6% of all ED visits, and approximately 5% of these visits by children resulted in hospitalization. Of all ED patients with an injury diagnosis, children younger than 15 years accounted for 21.4% of all patient visits, with most injured children between 5 and 14 years of age. The Emergency Medical Services for Children (EMSC) program promotes a more uniform approach to improve statewide pediatric emergency care. State funding from EMSC supports initiatives to improve the quality of pediatric emergency care. One specific performance measure for EMSC state partnership grants is: • The percentage of hospitals recognized as part of a statewide, territorial, or regional standardized system that are able to stabilize and/or manage pediatric traumatic emergencies. 2 This performance measure calls for a pediatric emergency department designation program that is expected to improve the quality of care for injured children. A similar performance measure addresses the care of children with medical emergencies. These performance measures were developed in response to findings that EDs were not well equipped or staffed to manage pediatric emergencies. 5,6 The higher designation level is usually awarded to a hospital with pediatric critical care capability. The lowest designation level requires the hospital ED to have the resources for basic assessment and stabilization and to transfer children with serious health conditions needing more advanced care. Many hospitals seek trauma center verification using criteria developed by the American College of Surgeons Committee on Trauma (ACS-COT). These criteria describe the specific personnel, resources, and quality improvement requirements for each level of verification, including requirements of pediatric trauma care. 7 States also designate trauma centers, and designation is often based on the ACS-COT criteria or trauma center verification by the ACS-COT. Most states have established trauma systems to improve the trauma care access for all residents. Studies have documented that organized systems of trauma care for critically injured pediatric patients improve outcomes, and some sources indicate that pediatric trauma centers produce better outcomes for injured children. 8-10 Importance In recent years, many states have initiated a pediatric ED designation process to meet EMSC program performance measure requirements, but the degree to which such a designation process improves care of injured children is unknown. In 2009, the State of Delaware began developing criteria for the Pediatric Emergency Care Facility Recognition (PECFR) program and planned statewide voluntary implementation. The PECFR program standards identified 4 pediatric capability levels that addressed personnel; equipment, medication, and supplies; physician and nurse coordinators for pediatric emergency care; continuing education; and participation in a pediatric ED quality improvement program supported by the state. The levels of ED preparedness for pediatric care include the following: From the *Committee on Trauma, †American College of Surgeons