Tag Archives: emergency department

Performance Improvement

The Implications Of A High Pediatric Readiness Score

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In my last post, I described the Pediatric Readiness Score and its components. Today, I’ll explain why maintaining a high score may benefit your trauma center and what it costs to do so.

Research groups at the Oregon Health Sciences University and the University of Utah combined multiple data sources to estimate current levels of ED pediatric readiness, the cost to achieve it, the number of pediatric deaths in emergency departments, and the number of potential lives saved if readiness is maintained.

As you can imagine, this was an extensive data set suffering from the usual glitches. The authors either excluded incomplete data or managed it with sophisticated statistical methods. Data was included from 4,840 emergency departments in all 50 states and the District of Columbia.

Here are the factoids:

  • The authors estimated that nearly 670,000 children receive care in the emergency departments each year
  • Only 15% (842 EDs) had high readiness. The range was 2.9% in Arkansas to 100% in Delaware.
  • The annual cost to achieve high pediatric readiness nationwide was approximately $210 million
  • The annual cost per child to achieve high readiness ranged from $0 in Delaware to $11.84 in North Dakota
  • It was estimated that about 28% of the 7619 childhood deaths each year could be prevented if the treating ED had high pediatric readiness

Bottom line: This paper has a lot of information to digest. Please remember that these are not precisely measured numbers but estimates based on statistical models. So, minor inaccuracies in those models could change these results.

Nonetheless, the data demonstrate the importance of maintaining high pediatric readiness in your emergency department.  Don’t let the total cost of readiness frighten you. Spread evenly across all the EDs studied, this amounts to only about $43,000 annually.

I urge all trauma centers to measure their pediatric readiness score. Then, dedicate the resources your hospital can afford to improve it as much as possible/practical. The number of potential pediatric lives saved is substantial and meaningful.

Reference: State and National Estimates of the Cost of Emergency Department Pediatric Readiness and Lives Saved. JAMA Netw Open. 2024;7(11):e2442154.

Performance Improvement

Why Is Your Hospital’s Pediatric Readiness Score Important?

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The Pediatric Readiness Score (PRS) is a new(er) metric that is now required for all US trauma centers verified by the American College Surgeons. There is no specific threshold that must be met, but the value must be reported for review at the time of the site visit.

What is the PRS? It is a measure introduced by the National Pediatric Readiness Project. This is a quality initiative that was developed by the Emergency Medical Services for Children program (EMS-C), which partnered with the American College of Emergency Physicians, the Emergency Nurses Association, and the American Academy of Pediatrics. The goal was to improve hospitals’ pediatric readiness through a self-administered survey. It was believed that by quantifying readiness, the hospitals would be better able to improve their scores via simple and, hopefully, inexpensive changes.

Each hospital completes a comprehensive assessment online (the paper version is 19 pages long). It solicits information on the following topics

  • presence of a physician pediatric care coordinator
  • presence of an ED nurse pediatric emergency care coordinator
  • pediatric training and education of any health professionals taking care of children
  • existence of an ED performance improvement plan for pediatric patients
  • details of monitoring and care of children in the ED
  • presence of social services and transfer guidelines for children
  • existence of policies for family-centered care in the ED
  • disaster planning polices including children
  • presence of pediatric equipment, supplies, and resuscitation equipment in the ED

The scores provided by this assessment provide a standardized measure of pediatric readiness, ranging from 0 to 100. Scores can be improved relatively easily by ensuring that appropriate pediatric equipment is available in the ED, and ensuring that social services and transfer agreements include children and are up to date. Tasking a physician and nurse to oversee pediatric readiness is not necessarily as easy, but many are more than willing to step in to improve pediatric care at their hospital.

The biggest question I have when any major assessment / intervention is rolled out is, does it do what it is intended to do? In my next post, I’ll review a paper published last week that looks at the real-world implications of pediatric readiness vs. the lack thereof. This is of significance to both trauma and non-trauma hospitals.

References:

  1. The National Pediatric Readiness Project website (pedsready.org)
  2. Download a copy of the assessment
General

Extubating Trauma Patients In The ED

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Many patients are intubated in the emergency department who need brief control of their airway or behavior. In some cases, the condition requiring intubation resolves while they are still in the department. Most of the time these patients are admitted, typically to an ICU bed, for extubation. This is expensive and uses valuable resources. Is it possible to safely extubate these patients and possibly send them home?

Maryland Shock Trauma and Mount Sinai Medical Center looked at their experience in extubating selected patients in the ED. They looked at a series of 50 patients who were intubated for combativeness, sedation, or seizures. A specific protocol was followed to gauge whether or not extubation should be attempted.

None of the patients who were extubated per protocol required unplanned reintubation. One patient underwent planned reintubation when taken to the OR for an orthopedic procedure. 16% of patients were able to be discharged home from the ED.

Bottom line: A subset of patients who are intubated in the emergency department can be extubated once the inciting factor has resolved. These factors include sedation for painful procedures and combativeness. Following this protocol can reduce admission rates and reduce the use of scarce intensive care unit resources.

Click here to download a copy of the ED extubation protocol.

Related post: Trauma 20 years ago: ED intubation for head injury

Reference: Trauma patients can be safely extubated in the emergency department. J Emerg Med 40(2):235-239, 2011.

NOTE: The EMCrit blog, written by Scott Weingart, covered this topic in November 2010. He is the first author on the paper and has created a nice podcast on the topic. You can find his blog here, and you can download the podcast here.

General

Extubation in the Emergency Department

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Many patients are intubated in the emergency department who need brief control of their airway or behavior. In some cases, the condition requiring intubation resolves while they are still in the department. Most of the time these patients are admitted, typically to an ICU bed, for extubation. This is expensive and uses valuable resources. Is it possible to safely extubate these patients and possibly send them home?

Maryland Shock Trauma and Mount Sinai Medical Center looked at their experience in extubating selected patients in the ED. They looked at a series of 50 patients who were intubated for combativeness, sedation, or seizures. A specific protocol was followed to gauge whether or not extubation should be attempted.

None of the patients who were extubated per protocol required unplanned reintubation. One patient underwent planned reintubation when taken to the OR for an orthopedic procedure. 16% of patients were able to be discharged home from the ED.

Bottom line: A subset of patients who are intubated in the emergency department can be extubated once the inciting factor has resolved. These factors include sedation for painful procedures and combativeness. Following this protocol can reduce admission rates and reduce the use of scarce intensive care unit resources.

Click here to download a copy of the ED extubation protocol.

Related post: Trauma 20 years ago: ED intubation for head injury

Reference: Trauma patients can be safely extubated in the emergency department. J Emerg Med 40(2):235-239, 2011.

NOTE: The EMCrit blog, written by Scott Weingart, covered this topic last November. He is the first author on the paper and has created a nice podcast on the topic. You can find his blog here, and you can download the podcast here.

General

Frequent Flyers in the Emergency Department

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We’re all aware of the patients that are seen in the ED so frequently that the ER staff know their names, medical histories, and sometimes family members very well. They are the so-called “frequent flyers.” These patients have been characterized as uninsured and on occasion, undesirable.

A recent study analyzed 25 studies done in the last decade detailing the characteristics of these patients. As usual, reality is different that perception.

The study examined data from a variety of sources. The bulk of these studies examined patients being treated at university of public hospitals. Some highlights:

  • 1 in 20 ED patients were “frequent fliers”, and they accounted for more than a quarter of all ED visits. Many go on to become a frequent flyer the following year, too.
  • Half of frequent flyers presented to multiple EDs
  • The majority (60%) were middle-aged and white
  • Almost two-thirds had Medicare or Medicaid coverage. Only 15% were uninsured.
  • Frequent users were more likely to have seen a primary care physician in the year before their visits. They were also 6 times more likely to have been hospitalized after a visit.
  • Use of ambulances was more frequent, and mortality was higher.
  • Children were frequent flyers, too. Parents stated that access to a pediatrician was the major factor, but 95% of kids had a primary care provider.

Hopefully, this study will stimulate more scrutiny of this patient group. The research may give some insight into some of the unintended consequences of healthcare reform.

Reference: LaCalle, Rabin. Frequent Users of Emergency Departments: The Myths, the Data, and the Policy Implications. Ann Emerg Med, in press, March 2010.