Should pediatric emergency physicians be decentralized in the medical community?

Emergency Department Arrival Modes: Time for Mandatory Pediatric Readiness

INTRODUCTION

Because small children can be transported by private vehicles, many children seek emergency care outside of Emergency Medical Services (EMS). Such transports may access the closest emergency departments (EDs) without knowledge of their pediatric competence. This study quantifies this practice and the concept of mandatory pediatric readiness.

METHODS

The electronic health records of 3 general EDs and 2 pediatric EDs were queried for all pediatric and young adult visits for the year 2022. Data collected included patient age, ED type, arrival mode (EMS/police or private mode), and disposition (admission/transfer or discharge). Study patients were categorized as "small children" if aged younger than 10 years, "large children" if 10 to 18 years, and "young adult" if 19 to 40 years. Associations between mode of arrival, ED type, and disposition were analyzed through χ 2 and analysis of variance.

RESULTS

The study population included 37,866 small children, 19,108 large children, and 68,293 young adults. When compared with EMS/police transports, a private arrival mode was selected by 96.1% of small children, 90.0% of large children, and 85.4% of young adults ( P < 0.0001). For the admission/transfer patients, private transportation was selected by 87.4% of small children, 73.8% of large children, and 78.8% of young adults ( P < 0.0001). For admitted/transferred children, the private mode was used by 80.4% of those in the general ED and 81.9% in the pediatric ED ( P > 0.41).

CONCLUSIONS

Pediatric patients seeking ED care overwhelmingly arrive through a private mode regardless of the severity of their problem or type of ED in which treated. Emergency Medical Services programs and state hospital regulatory agencies need to recognize this practice and assure the pediatric competence of every ED within their system.

Heat stroke: knowledge and practices of medical professionals in pediatric emergency medicine departments - a survey study

Background and importance

Heat stroke is a life-threatening condition affecting children worldwide. Rapid cooling remains the most important feature of emergency management. The accepted preferred method of evaporative cooling in the ED as listed by the reference text book endorsed by the Israeli Society of Pediatric Emergency Medicine (PEMI), is actively cooling the patient by spraying him with water and positioning fans to blow air across the body.

Objective

This study aimed to assess Israeli health care workers (HCWs) medical professionals’ knowledge and preparedness of treating heat stroke and recommend policy changes to ensure better treatment based on survey results.

Design, settings and participants

A cross-sectional survey of all HCWs working in an ED that accepts children was conducted. An online questionnaire was utilized to assess heat stroke management practices and available resources in all Israeli pediatric emergency departments (PEDs).

Main results

Data from 208 health care workers was analyzed. Only 30% of the participants reported ever treating a patient with exertional heat stroke. Two scenarios were presented to the participants: motor vehicle-related child hyperthermia (MVRCH) in an infant and an adolescent with exertional heat stroke. One hundred twenty-five (60%) and 83 (40%) participants, respectively, listed cool water with a fan as the primary mode of cooling, which is considered the appropriate preferred method of evaporative cooling in the PED. Certificated pediatric emergency medicine (PEM) physicians answered significantly more correctly regarding both scenarios’ management (P < 0.001). Participants who were trained via simulation in the past, answered significantly more correctly regarding the exertional heat stroke scenario (P < 0.01), however no difference was found regarding the MVRCH case.

Conclusions: The present study exposes weaknesses in HCW knowledge, PED resources, and published PED policies for appropriate management of children following heat stroke. Our finding emphasizes the importance of both certificated PEM physicians attendance and simulation performance for implementing proper management of patients with heat stroke. A policy change should be performed among the Israeli PED community, with respect to establishing and implementing guidelines for treatment of exertional heat stroke. A future study, following an interventional simulation program is planned to be performed.

Optimizing the workforce: a proposal to improve regionalization of care and emergency preparedness by broader integration of pediatric emergency physicians certified by the American Board of Pediatrics

BACKGROUND

Emergency care in the United States faces notable challenges with regard to children. In some jurisdictions, available resources are not sufficient to meet local needs. Physicians with specialty training in pediatric emergency care are largely concentrated in children's medical centers within larger urban areas. Rural emergency facilities, which are more likely to face ongoing staffing shortages in all specialties, are particularly deficient in pediatric emergency medicine (PEM) physicians. This paper addresses challenges in distribution of pediatric emergency care specialists into suburban and rural health care facilities, and proposes potential local and regional solutions to improve pediatric emergency care capabilities as well as to enhance disaster response in children.

OBJECTIVES

The American College of Emergency Physicians (ACEP) committee on PEM generated the objective to study and explore methods and strategies to address current challenges and shortcomings in the distribution of pediatric emergency physicians and to develop recommendations to improve access to emergency pediatric expertise in all care settings. A sub-committee was formed to generate a written report followed by full committee input. The content was reviewed by the ACEP Board of Directors.

DISCUSSION

Pediatric emergency physicians are certified either by the American Board of Emergency Medicine or the American Board of Pediatrics (ABP) depending on whether their training occurred through the emergency medicine or a pediatric residency program. ABP-certified PEM that account for the majority of PEM physicians, remain largely concentrated in urban tertiary pediatric care centers, primarily children's hospitals. By contrast to the resources, the majority of pediatric patients receive emergency care in emergency departments (EDs) outside this setting. The goal of our recommendations is to help regionalize PEM expertise, allowing sharing of such resources with facilities that have traditionally not had access to PEM expertise. Financial or low number of pediatric cases likely contributed to lack of PEM resources in suburban and rural EDs, although a significant factor for lack of access to ABP-certified PEM physicians may be local privilege and practice restrictions. Expanding the scope of practice for ABP-certified PEM physicians beyond traditionally assigned arbitrary age limits to include selective adult patients has the potential to alleviate credentialing barriers and offset the financial and volume concerns while enhancing preparedness efforts, resource utilization, and access to specialized pediatric emergency care.

CONCLUSION

Recognition that the training of ABP-certified PEM physicians allows for these individuals to safely care for selective adult patients with common disease patterns that extend beyond traditionally assigned arbitrary pediatric age limits has the potential to improve resource dissemination and utilization, allowing for greater access to pediatric emergency physicians in currently underserved settings.

Sources of Variability in Pediatric Head Computed Tomography Use Among Emergency Departments in New Jersey

OBJECTIVE

Published guidelines have been developed to limit ionizing radiation exposure in children related to diagnostic computed tomography (CT). This study examines the sources of variability in head CT use in children in emergency departments (EDs) in New Jersey despite the presence of such consensus recommendations.

METHODS

The New Jersey Hospital Association (NJHA) Clinical Repository was queried for study data on all patients younger than 18 years discharged from the ED over a 1-year period. Patient information collected included: treating hospital, patient age, discharge diagnosis, use of head CT, children's hospital (CH) certification, presence of licensed in-patient pediatric beds, association with a hospital system and hospital annual pediatric ED volume. A potential diagnosis requiring a head CT (PDRCT) was defined as one of the following discharge diagnoses: Head Injury, Seizure, Syncope or Headache. Analysis of CT use per 10,000 ED visits was performed through ANOVA, analysis of means for variances, and χ.

RESULTS

A total of 735,866 ED visits were examined with 16,942 (2.3%) undergoing head CTs. Mean Pediatric Head CT use per 10,000 ED visits for the state was 275 (±16; range, 27-640). During the study period 47,169 (6.4%) ED visits met the PDRCT criteria, 11,495 (27%) of which underwent head CTs. Mean Pediatric Head CT use in this group per 10,000 PDRCT visits was 2948 (±152; range, 728-5806). Characteristics associated with lowest use of head CTs in the PDRCT group included: ED census greater than 10,000 visits per year, CH designation, and younger patient. The presence of in-patient pediatric beds and association with a hospital system with or without an in system CH were not associated with lower head CT use.

CONCLUSIONS

Despite existing recommendation regarding head CTs in children, there exists a large degree of variability in use of this diagnostic study in EDs in New Jersey.

A Roadmap for the Student Pursuing a Career in Pediatric Emergency Medicine

Introduction

Three pathways are available to students considering a pediatric emergency medicine (PEM) career: pediatric residency followed by PEM fellowship (Peds-PEM); emergency medicine residency followed by PEM fellowship (EM-PEM); and combined EM and pediatrics residency (EM&Peds). Questions regarding differences between the training pathways are common among medical students. We present a comparative analysis of training pathways highlighting major curricular differences to aid in students’ understanding of these training options.

Methods

All currently credentialed training programs for each pathway with curricula published on their websites were included. We analyzed dedicated educational units (EU) core to all three pathways: emergency department (ED), pediatric-only ED, critical care, and research. Minimum requirements for primary residencies were assumed for fellowship trainees.

Results

Of the 75 Peds-PEM, 34 EM-PEM, and 4 EM&Peds programs screened, 85% of Peds-PEM and EM-PEM and all EM&Peds program curricula were available for analysis. Average Peds-PEM EUs were 20.4 EM, 20.1 pediatric-only EM, 5.8 critical care, and 9.0 research. Average EM-PEM EUs were 33.2 EM, 18.3 pediatric-only EM, 6.5 critical care, and 3.3 research. Average EM&Peds EUs were 26.1 EM, 8.0 pediatric-only EM, 10.0 critical care, and 0.3 research.

Conclusion

All three pathways exceed pediatric-focused training required for EM or pediatric residency. Peds-PEM has the most research EUs, EM-PEM the most EM EUs, and EM&Peds the most critical care EUs. All prepare graduates for a pediatric emergency medicine career. Understanding the difference in emphasis between pathways can inform students to select the best pathway for their own careers.

2018 Academic Emergency Medicine Consensus Conference: A Workforce Development Research Agenda for Pediatric Care in the Emergency Department

Each year, more than 30 million children visit U.S. emergency departments (EDs). Although the number of pediatric emergency medicine specialists continues to rise, the vast majority of children are cared for in general EDs outside of children's hospitals. The diverse workforce of care providers for children must possess the knowledge, experience, skills, and systemic support necessary to deliver excellent pediatric emergency care. There is a crucial need to understand the factors that drive the professional development and support systems of this diverse workforce. Through the iterative process culminating with the 2018 Academic Emergency Medicine consensus conference, we have identified five key research themes and prioritized a specific research agenda. These themes represent critical gaps in our understanding of the development and maintenance of the pediatric emergency care workforce and allow for a prioritization of future research efforts. Only by more fully understanding the gaps in workforce needs, and the necessary steps to address these gaps, can outcomes be optimized for children in need of emergency care.

A Research Agenda to Advance Pediatric Emergency Care Through Enhanced Collaboration Across Emergency Departments

In 2018, the Society for Academic Emergency Medicine and the journal Academic Emergency Medicine (AEM) convened a consensus conference entitled, "Academic Emergency Medicine Consensus Conference: Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps." This article is the product of the breakout session, "Emergency Department Collaboration-Pediatric Emergency Medicine in Non-Children's Hospital"). This subcommittee consisting of emergency medicine, pediatric emergency medicine, and quality improvement (QI) experts, as well as a patient advocate, identified main outcome gaps in the care of children in the emergency departments (EDs) in the following areas: variations in pediatric care and outcomes, pediatric readiness, and gaps in knowledge translation. The goal for this session was to create a research agenda that facilitates collaboration and partnering of diverse stakeholders to develop a system of care across all ED settings with the aim of improving quality and increasing safe medical care for children. The following recommended research strategies emerged: explore the use of technology as well as collaborative networks for education, research, and advocacy to develop and implement patient care guidelines, pediatric knowledge generation and dissemination, and pediatric QI and prepare all EDs to care for the acutely ill and injured pediatric patients. In conclusion, collaboration between general EDs and academic pediatric centers on research, dissemination, and implementation of evidence into clinical practice is a solution to improving the quality of pediatric care across the continuum.