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526 PEDIATRICS Vol. 96 No. 3 September 1995

AMERICAN ACADEMY OF PEDIATRICS

Guidelines for Pediatric Emergency Care Facilities

Committee on Pediatric Emergency Medicine

Emergency care for life-threatening pediatric ill-ness and injury requires specialized resources in-

cluding equipment, drugs, trained personnel, andfacilities. The American Medical Association Com-mission on Emergency Medical Services has pro-

vided guidelines for the categorization of hospitalpediatric emergency facilities that have been en-

dorsed by the American Academy of Pediatrics(AAP).’ This document was used as the basis forthese revised guidelines, which define:

I . The desirable characteristics of a system of Emen-

gency Medical Services for Children (EMSC) thatmay help achieve a reduction in mortality andmorbidity, including long-term disability.

2. The role of health care facilities in identifying andorganizing the resources necessary to provide the

best possible pediatric emergency care within aregion.

3. An integrated system of facilities that provides

timely access and appropriate levels of care for allcritically ill or injured children.

4. The responsibility of the health cane facility for

support of medical control of pre-hospital activi-ties and the pediatric emergency cane and educa-tion of pre-hospital providers, nurses, and physi-

cians.5. The role of pediatric centers in providing out-

reach education and consultation to community

facilities.6. The role of health cane facilities for maintaining

communication with the medical home of thepatient.

Children have their emergency cane needs met in avariety of settings, from small community hospitals

to large medical centers. Resources available to thesehealth cane sites vary, and they may not always havethe necessary equipment, supplies, and trained per-sonnel required to meet the special needs of pediatric

patients during emergency situations.Timely, effective pediatric emergency care de-

pends on a network of pre-hospital and hospitalmedical and administrative resources. For a system

of pediatric emergency cane to be developed, thecapabilities of the emergency care facility for pediat-tic treatment must be categorized. Once health care

The recommendations in this statement do not indicate an exclusive course

of treatment or procedure to be followed. Variations, taking into account

individual circumstances, may be appropriate.

PEDIATRICS (ISSN 0031 4005). Copyright © 1995 by the American Acad-

emy of Pediatrics.

facilities are categorized according to their emer-

gency capabilities, a network must be developedwithin a region that assures access to specialized

cane, avoids duplication of services, and assures that

services are available to all infants and children. Thisprocess of categorization and regionalization of pe-

diatnic emergency facilities requires the cooperation

of hospitals and emergency medical services (EMS)systems within a region.

These guidelines are designed to assist health care

facilities within a region to meet the emergency careneeds of children. A framework is offered that inte-grates the resources of facilities to assure access to

appropriate levels of care, including specialized ser-vices for children wherever the entry point into the

system.Many children access emergency care at commu-

nity hospitals that must take responsibility for the

triage and stabilization of critically ill or injured pe-

diatric patients. Most hospitals provide basic pediat-nc emergency services. However, a system that as-

sures comprehensive care is often not available. Thedevelopment of a regionalized cooperative network

of EMS-EMSC allows rural and community hospitalsaccess to a system that assures integration with morespecialized facilities.

Each state, region, or local area has different ad-ministrative structures and organizations responsi-

ble for the administration of an EMS-EMSC system.Each hospital within the system is a component of

EMSC. Pre-hospital care is often not the direct ne-

sponsibility of a health care facility, but each facilitymust support and cooperate with their pre-hospital

system to assure a functioning pediatric emergencycare network. This cooperation may include assisting

pre-hospital care providers and services with educa-tion, training, and consultation. Every health care

facility that is a component of EMSC has a responsi-

bility to accept appropriate patients, provide pre-

hospital guidance when necessary, stabilize pediatric

emergencies, and, when appropriate, transport pa-

tients to a definitive cane facility.

Small community facilities (such as standby orbasic) within an EMS-EMSC system are responsiblefor accepting critically ill and/or injured childrenwho do not have immediate access to definitive careresources because of geographical restrictions, and

they must have the equipment and skilled personnelnecessary to recognize, stabilize, and support the

timely transport of pediatric patients to a prear-ranged definitive care resource.

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Pediatric Surgeon

General Surgeon

Hospital

Emergency Department

ICU

Trauma Service

Trauma Team

E

D

D

Source: Resources for Optimal Care of the Injured Patient, American College of Surgeons Committee on Trauma.4

Abbreviations: E, essential; D, desirable.

* A pediatric surgeon credentialed in trauma care will be promptly available. This responsible pediatric surgeon will be present in the

operating room for any and all operative procedures. A general surgical resident at a minimum PGY-4 level may initiate resuscitative care

until the attending pediatric surgeon arrives.

t The trauma surgeon available for pediatric trauma care must have special interest in and commitment to care of the injured child. This

should be demonstrated by documented continuing medical education.

TABLE 1. Resources Necessary for the Optimal Care of the Injured Child

AMERICAN ACADEMY OF PEDIATRICS 527

Regional Pediatric Trauma Center

Children’s hospital or general hospital

with a separate pediatric department

Pediatric emergency department with

appropriate personnel, equipment,and facilities

Pediatric Intensive Care Unit (ICU) with

pediatric surgery and other surgical, medical,

and nursing personnel and equipment needed

to care for the injured child

Pediatric trauma service organized and

run by a pediatric surgeon

1. Pediatric Surgeon

2. Pediatric Orthopaedist

3. Pediatric Neurosurgeon

4. Pediatric Anesthesiologist

5. Pediatric Intensivist

6. Pediatric Emergency Physicians

7. Pediatric Radiologists

8. Other Pediatric Surgical Specialists

9. Other Medical Pediatric Specialists

10. Pediatric Trauma Coordinator

11. Pediatric Trauma Nurse

E

E

E

Pediatric Trauma Quality Improvement

Psychosocial Services

Rehabilitation

Trauma Center With Pediatric

Commitment

D

Et

General hospital with an organized

pediatric service

Pediatric capabilities in an

emergency department equipped

and staffed by personnel trained

to care for pediatric trauma victims

ICU with personnel and equipment

appropriate for care of the injured child

Pediatric trauma program administered

by a surgeont

1 . Pediatric Surgeon (D)

2. General Surgeon

3. Orthopaedist

4. Neurosurgeon

5. Surgical Critical Care Specialists

6. Emergency Physician

7. Radiologists8. Trauma Coordinator

9. Pediatric-trained Trauma Nurses

Between the small community hospital and thecomprehensive regional pediatric center (CRPC) area number of hospitals that have the capability ofproviding some, but not all, of the resources needed

for definitive care of critical pediatric emergencies.The goals are provided here for such hospitals to

facilitate the implementation of a regionalized EMS-EMSC system and assist in organizing a network of

pediatric emergency care.The CRPC has the most available resources and

must have a major role in organizing and imple-menting a regional EMSC system. The CRPC mustprovide pediatric consultation and support asneeded to hospitals and EMS agencies within the

region, including systems development, transport,quality review, education, research, and datamaintenance.

Because areas will exist where access to a CRPC isimpeded by geographical or political boundaries,physicians and health planners in all regions mustreview the capabilities of their institutions, iden-tify areas of concern, and seek solutions either by

developing the requisite resources or by identify-ing resource centers that will accept their patients.A comprehensive approach is necessary with clear

expectations that high acuity patients will be trans-ferred to an appropriate CRPC to prevent avoid-able morbidity and mortality.2’3 For example, com-prehensive pediatric trauma centers meeting therequirements of a CRPC can provide the major

trauma pediatric patient access to specialized pe-diatnic care including surgery, critical cane, andpediatric medical and surgical subspecialties. Suchcenters afford this subset of pediatric patients thebest opportunity for maximum functional recov-ery. Trauma care for children may not be equiva-lent between adult and pediatric trauma centers

even though mortality statistics may be similar.Trauma centers that do not meet these pediatricguidelines for a CRPC should, when possible, di-vent high acuity pediatric patients to a CRPC. In

areas where an adult center must assume nespon-sibility for the initial care of children, clear guide-lines must be in place for the transfer of critical

patients to a regional center for pediatric traumaand critical care.5 Circumstances may dictate thatadult trauma centers with a commitment to chil-dren provide definitive care for children. Studiesof treatment outcome should be in place to assurethat the standard of cane is equivalent to that of aCRPC. Table I contains program qualifications for

pediatric trauma cane as defined by the American

College of Surgeons for comparison.These guidelines are designed to assist hospitals in

defining their pediatric emergency capabilities and

are intended to assist communities in reducing mor-bidity, mortality, and disability. The six areas ofemergency care for review include: 1) facilities;2) personnel; 3) equipment and supplies; 4) access,triage, transfer, and transport; 5) education, training,


528 GUIDELINES FOR PEDIATRIC EMERGENCY CARE FACILITIES

research, and quality assessment; and 6) administna-tive support and hospital commitment.

PEDIATRIC EMERGENCY CARE FACILITY

CAPABILITIES

Standby Pediatric Emergency Facility

A standby pediatric emergency service is:

. Capable of identifying critically ill on injured on

potentially critically ill or injured patients.. Capable of stabilizing the pediatric patient, includ-

ing the management of airway, breathing, andcirculation.

. Responsible for assuring timely access to a defin-

itive cane facility.

. Staffed by a registered nurse (RN) on physician’sassistant who works under the direct supervision

of a physician with pediatric experience. Supenvi-sion may be by protocols, standing orders, and/on

telephone access, but the physician must bepromptly available to respond to emergencies.

Basic Pediatric Emergency Facility

A basic facility in a system:

. Provides appropriate identification, stabilization,

and transport as described for the standby facility.. Has a physician in-house 24 hours a day, 7 days a

week for emergency cane.S Has limited wand capabilities for the management

of minor pediatric inpatient problems.. Is willing to accept the transfer of appropriate

pediatric patients from a standby facility when nofacility with more comprehensive capabilities isavailable within a region.

General Pediatric Emergency Facility

A general facility in a system:

. Has a defined separate pediatric inpatient service.

. Has a department of pediatrics within the medical

staff structure.. Accepts referrals of appropriate pediatric patients

from standby and basic hospitals as a pant of pre-

arranged triage, transfer, and transport agree-

ments.

Comprehensive Regional Pediatric Center (CRPC)

The regional center:

. Is capable of providing comprehensive specialized

pediatric medical and surgical cane to all acutely illand injured children, on in special circumstancesproviding safe and timely transfer of children to

other resources for specialized care.. Is responsible for serving as a regional referral center

for the specialized cane of pediatric patients.. Actively supports systems development, includ-

ing:1 . assistance and support of education for pre-

hospital personnel.2. education and training for all levels of hospital-

based health care providers.

3. provision of transport services or assurance thatappropriate transport services are available for

the transfer of critically ill on injured pediatricpatients.

4. provision of comprehensive pediatric subspe-

cialty medical and surgical consultation to healthcane facilities and providers within a region.

5. a commitment to research, systems develop-

ment, quality assessment and improvement,

data collection and analysis, and injury preven-tion.

6. assurance of available rehabilitation services forchildren.

Emergency staff in all facilities must be able toprovide information on patient encounters to thepatient’s medical home. This may be through tele-phone contact with the primary cane provider atthe time of encounter, faxing on mailing the med-ical record, on providing patients with a copy ofthe medical record to bring to their physician.Follow-up visits should be arranged or necom-

mended with the primary care provider whenevernecessary.

Table 2 provides a summary of the guidelines for

emergency cane facilities for each level of pediatrichealth cane. Personnel, equipment, and issues that

are essential at each level are described as eitherbeing essential in the emergency department(EED), essential within the hospital (EH), orpromptly available (EP). An optional but strongly

encouraged category (SE) is used to describe per-sonnel, activities, on issues that may be essential tonetwork a comprehensive negionalized EMS-EMSC system in rural areas. Although these arenot generally required of a specific hospital, they

are strongly encouraged if such services are notavailable within a reasonable distance. Specialistconsultants should be board certified or board pre-

pared and actively seeking certification in disci-plines in which a specialty exists. A CRPC shouldbe staffed with specialist consultants with pediat-

nc subspecialty training. The following narrative isprovided to clarify issues that are difficult to in-dude in a table form. Issues highlighted by anasterisk in the table are explained in the text.

GUIDELINES FOR A STANDBY PEDIATRIC

EMERGENCY FACILITY

Personnel

At least one RN on physician’s assistant must bephysically present 24 hours per day, 7 days per week,

and capable of recognizing and managing shock andrespiratory failure and stabilizing pediatric traumapatients, including early recognition and stabiliza-tion of problems that may lead to shock and respi-ratory failure. Successful completion of courses such

as the American Heart Association Pediatric Ad-vanced Life Support (PALS) on the EmergencyNurses Association Emergency Nursing PediatricCourse (ENPC) can be utilized to demonstrate thisclinical capability.

An on-call physician must be promptly available

and provide supervision and direction for the in-


TABLE 2. Guidelines for Emergency Pediatric Care Facilities

Facility Levels

CRPC General Basic Standby

Personnel

Physician with pediatric emergency care experience* EED EED EED EP

RN with pediatric training* EED EED EED EED

Respiratory therapist EH EH EH

Trauma coordinator E E

Nurse educator E E

Trauma team* E E SE

Specialist consultants*

Pediatrics EH EP EP SE

Radiology EP EP EP SE

Anesthesiology* EH EH EP SE

Cardiology EP

Critical Care EH EP

Nephrology EP

Hematology/oncology EP

Endocrinology EP

Gastroenterology EP

Allergy EP

Neurology EP

Pulmonology EP

Psychiatry EP

Infectious Disease EP

Surgical specialists*

General surgeon EH EP SEPediatric surgeon EH SE

Neurosurgery EP EP

Orthopedics EP EP EP

Otolaryngology EP

Urology EP

Plastic surgery EP

Oral/maxillofacial EP

Gynecology EP

Microvascular surgery EP

Hand surgery EP

Ophthalmology EP

Cardiac surgery EP

Equipment and SuppliesEMS communication equipment* E E E E

Organized emergency cart* EED EED EED EED

Printed, drug doses/tape EED EED EED EED

Monitoring devices

ECG monitor/defibrillator with pediatric paddles 0-400 joules and hard EED EED EH EHcopy capabilities

Pulse oximeter (adult/pediatric probes) EED EED EH EH

Blood pressure cuffs (infant, child, adult, thigh) EED EED EED EEDRectal thermometer probe (28#{176}-42#{176}C) EED EED EH EH

Otoscope, ophthalmoscope, stethoscope EED EED EED EED

Cardiopulmonary monitor with pediatric capability EED EED EED EH

Doppler and noninvasive blood pressure monitoring (infant, child, adult EED EED EH

cuffs)

Apnea/respiratory monitor EED EED SE

End tidal CO2. monitor EED EH SE

Monitor for central venous pressure, arterial lines EED EH SE

Airway control/ventilation equipment

Bag-valve-mask device: pediatric (450 mL), and adult (1000 mL) with oxygen EED EED EED EED

reservoir and without pop-off valve. Infant, child, and adult masks

Oxygen delivery device with flow meter EED EED EED EED

Cleap oxygen masks, standard and non-rebreathing (neonatal, infant, child, EED EED EED EED

adult)

Nasal cannula (infant, child, adult) EED EED EED EED

Suction devices-catheters 6-14 fr, yankauer-tip EED EED EED EED

Oral airways (sizes 0-5) EED EED EED EED

Abbreviations: E, essential; EED, essential in emergency department (ED); EH, essential in hospital; EP, promptly available (within 20-30

min when possible); SE, strongly encouraged if such services are not available within a reasonable distance. �, See text for further

definition�



Facility

CRPC General

Levels

Basic Standby

Vascular access supplies

Arm boards (infant, child, and adult sizes)

Butterflies (19-25 gauge)

Catheters for intravenous lines (16-24 gauge)

Needles (18-27 gauge)

Intraosseous needles

Umbilical vessel catheters (3,5 fr)

IV administration sets and extension tubing with calibrated chambers

Extension tubing, stopcocks, T-connectors

Infusion device with the ability to regulate rate and volume of infusate

Isotonic balanced salt solution and D5 0.5 normal saline

Central venous access utilizing Seldinger technique (4-7 fr)

IV fluid/blood warmer

Blood gas kit

Rapid infusion pumps and fluid warmers

Medications-unit dose, prepackagedActivated charcoal EED EED EED EED

Adenosine EED EED EED EED

Atropine EED EED EED EED

Beta-agonist for inhalation EED EED EED EED

Bretylium EED EED EHCalcium chloride EED EED EED EED

Corticosteroids (dexamethasone, methylprednisolone) EED EED EED EED

Cyanide kit and pediatric doses EED EED EED

Dextrose-25% and 50% EED EED EED EED

Digitalis antibody EH EH EH

Diphenhydramine EED EED EED EED

Dobutamine EED EED EHDopamine EED EED EH

Epinephrine (1:1000, 1:10 000) EED EED EED EED

Factor VIII, IX concentrates, DDAVP EH EH EH

Flumazenil EH EH EH EH

TABLE 2. Continued


Nasal airways (infant, child, adult)

Nasogastric tubes (sizes 6-16 fr)

Laryngoscope handle and blades:

- curved 2,3

- straight or Miller 0,1,2,3

Endotracheal tubes:

- uncuffed (2.5-5.5)

- cuffed (6.0-9.0)

Stylets for endotracheal tubes (pediatric, adult)

Lubricant, water soluble

Magill forceps (pediatric, adult)

Tracheostomy tubes (shiley sizes 0-6)

Oxygen blender

Pediatric endoscopes and bronchoscopes available

Pediatric ventilators

Specialized pediatric trays

Lumbar puncture

Urinary catheterization: Foley 8-14 fr

Newborn kit/obstetric pack

Venous cutdown

Umbilical vessel cannulation

Thoracostomy tray with chest tube sizes 10-28 fr

Peritoneal lavage tray

Needle cricothyroidotomy setIntracranial pressure monitor tray

Subdural tray

Tracheostomy tray

Fracture management devices

Cervical immobilization equipment suitable for pediatric patients

Spine board (child/adult)

Extremity splints

Femur splint; child, adult

EED EED EED EED

EED EED EED EED

EED EED EED EED

EED EED EED EED

EED EED EED EED

EED EED EED EED

EED EED EED EED

EED EED EED EED

EED EED EED EED

EED EH EH

EED EED EED EED

EH EH

EH EH

EED EED EED EED

EED EED EED EED

EED EED EED EED

EED EED EED EED

EED EED EED EEDEED EED EED EED

EED EED EED EED

EED EED EED EEDEED EED EED EED

EED EED EED EED

EED EED EED

EED EED EH

EED EED EH

EED EED SE

EED EED EED EH

EED EED EED EH

EED EED EED EED

EED EED EH EHEED EED EH EH

EED EED SE

EED EED SE

EED EED EED

EED SE

EED SE SEEED EED SE

EED EED EED EED

EED EED EED EED

EED EED EED EED

EED EED EED EED


TABLE 2. Continued

Facility

CRPC General

Levels

Basic Standby

Furosemide EED EED EED EED

Glucagon EED EED EED

Insulin EH EH EH

Ipecac EED EED EED EEDKayexalate EH EH EH

Ketamine EED EH EHLidocaine-1% EED EED EED EED

Mannitol-20% EED EED EED EED

Methylene blue EH EH EH EH

N-acetyl cysteine EH EH EH

Naloxone EED EED EED EED

Potassium chloride EED EED EED

Prostaglandin E1 EH EH

Sodium bicarbonate 7.5% and 4.2% EED EED EED EED

Succinylcholine EED EED EH

Thiopental EED EH EH

Whole bowel irrigation solution EH EH EH

Drug classes

Analgesics EED EED EH EH

Antibiotics EED EED EED EED

Anticonvulsants EED EED EED EED

Antihypertensive agents EED EED EH EH

Antipyretics EED EED EED EED

Chelating agents for heavy metal poisonings EH EH EH

Nondepolarizing neuromuscular blocking agents EED EED EED

Miscellaneous

Resuscitation board EED EED EED EED

Infant scale EED EED EED EEDHeating source (for infant warming) EED EED EED EED

Precakulated drug sheets or length-based tape EED EED EED EED

Pediatric restraint equipment (to use for painful or difficult procedures) EED EED EED

Portable radiography EED EH EH

Slit lamp EH EH EH

Pacemaker capability (ie, temporary transcutaneous and transvenous EH EH

pacemaker with pediatric capability)Thermal control for patient and/or resuscitation room EED EED EED

FacilitiesEmergency Area

Open 24 hours per day E E E E

Well-lighted emergency entrance with ambulance access E E E E

Separate pediatric resuscitation area E ESeparate pediatric EAccess to helicopter landing site E E E E

Hospital support services

Pediatric ward for inpatient care E EPediatric intensive care unit (AAP/SCCM standards)*

Level I ELevel II E

Child abuse team EP EP

Child life support EH

Operating room staffed 24 hours per day E E SEAnesthesia and surgical suite promptly available E E SE

Laboratory servicesHematology E E E E

Chemistry E E E E

Microbiology E E E SE

Microcapabilities E E

Blood bank E E SE

Drug levels/toxicology E SE SE

Blood gases E E E

Radiology services (on-call)Routine services 24 hours per day E E E EComputed tomography scan 24 hours per day E E SEUltrasound 24 hours per day E E SE

Magiietic resonance imaging availability/transfer E E



Access, Triage, Transfer, and TransportSupport of medical control*

Accept call-ahead ambulance information

Transfer agreements for:

In-patient pediatric care

ICU pediatric careMajor trauma care

Burn care

Hemodialysis

Spinal injury care

Rehabilitation care

Accept all critically ill patients from lower-level hospitals within a region

Access to transport services appropriate for pediatrics

Provide 24-hour consultation to lower-level facilities

Consultation agreements with CRPC

E SEE E SE

E SE

E E SEE E SE

E E E E

E E EE E SE

E E SE

E E SE

E E SE SEE E E E

E EE E EE E E

E E E

E E EE E E

E E E

E SE SEE E E E

E

E E

E E SE SEE E E EE SE SE SEE SE

E E E E

E E SEE

E E E E

E E E E

E SE SEE E E EE E E E

E E E EE SE SE SEE SE SE SE

E E E EE E E EE E E E

EH EHEP EPE

E SE SE SEEED EH EH

E

TABLE 2. Continued


Facility

CRPC General

Levels

Basic Standby

Nuclear medicine

Fluoroscopy/contrast studies 24 hours per day

Angiography 24 hours per day

Echocardiography

Electroencephalography

Access to

Regional poison control center

Hemodialysis capability/transfer agreement

Rehabilitation medicine/ transfer agreement

Acute spinal cord injury management capability/transfer agreement

Hyperbaric oxygen chamber availability/transfer agreement when

appropriate

Education, Training, Research, and Quality Assessment and Improvement*

Education and Training

Public education, injury prevention

Assure staff training in resuscitation and stabilization

Assist with pre-hospital education

Network educational resources for training all levels of health professionals

Research

Support state EMSC and CRPC research efforts and data collection

Participate in and/or maintain trauma registry

Organized research program

Quality Assessment and Improvement

Structured QA/QI program with indicators and periodic review

Participate in regional quality review by CRPC and/or local EMS authority

Administrative Support and Hospital Commitment*Make available clinical resources for training pre-hospital personnel

Assure properly trained ED staff

Assure availability of all necessary

equipment/supplies/protocols/agreements/policies

Provide emergency care and stabilization for all pediatric patients

Support networking education/training for all health care professionals

Assure appropriate medical control and input to ED management and

pediatric care

Participate in networking pediatric emergency care within a region

Assure transport services and agreements are available

Assure resources available for data collection

Assure availability of:

Social services

Child abuse support services

Child life support

On-line pre-hospital control

Respiratory care

Child development services

Abbreviations: RN, registered nurse; EMS, emergency medical services; ECG, electrocardiogram; CO2. carbon dioxide; IV, intravenous;

ED, emergency department; AAP, American Academy of Pediatrics; SCCM, Society of Critical Care Medicine; ICU, intensive care unit;CRPC,comprehensive regional pediatric center; EMSC, emergency medical services for children.

house nursing staff. The physician must be compe-tent in the care of pediatric emergencies including

the recognition and management of shock and nespi-ratory failure, the stabilization of pediatric trauma

patients, advanced airway skills (intubation, needlethoracostomy), vascular access skills (including in-traosseous needle insertion), and be able to performa thorough screening neurologic assessment and to



interpret physical signs and laboratory values in anage-appropriate manner. Successful completion of

courses such as PALS and the American Academy ofPediatrics and American College of Emergency Phy-

sician’s Advanced Pediatric Life Support (APLS) canbe utilized to demonstrate this clinical capability.

An on-call system is necessary for access to physi-

cians who have advanced airway and vascular accessskills as well as for general surgery and pediatricspecialty consultation. There should be one addi-tional call-in RN available for emergencies.

Equipment and Supplies

Equipment for communication with EMS is essen-tial if there is no higher-level facility capable of re-

ceiving ambulances or there are no resources forproviding medical control to the pre-hospital system.

An emergency cart or other system to organize sup-

plies induding resuscitation equipment, drugs, printed

ped iatric drug doses, and pediatric reference materialsmust be readily available. Equipment, supplies, trays,

and medications should be easily accessible, labeled,and logically organized. Antidotes necessary for a spe-cific geographic area should be determined through

consultation with a poison control center.

Facilities

See Table 2.

Access, Triage, Transfer, and Transport

A standby facility needs to be capable of providingresuscitation, stabilization, and timely triage for all pe-

diatric patients, and, when appropriate, transfer of pa-tients to a higher-level facility. Necessary triage andtransfer agreements depend on available communityresources and are listed in Table 2. A standby facility isresponsible for having appropriate transfer agreementsto assure that all pediatric patients receive timely emer-

gency care at the most appropriate pediatric facility

available � to a specific region. This facifity must belinked with a CRPC for pediatric consultation.

Education, Training, Research, and Quality Assessmentand Improvement

A standby facility must:

. Provide public education regarding access to pe-diatric emergency care.

. Provide patient data and information in support ofregional and state EMS-EMSC data collection ef-

fonts.. Organize a structured quality assurance and im-

provement program that reviews the following

issues and indicators:1) pediatric deaths.2) incident reports.

3) transfers.4) child abuse cases.

5) cardiopulmonary on respiratory arrests.6) admissions within 48 hours of an emergency

department (ED) visit.7) surgery after being discharged from an ED

within 48 hours.

8) quality indicators requested by the CRPC orstate/local EMSC authority regarding nursing

care, physician care, pre-hospital cane, and themedical direction for pre-hospital providers ofEMS systems.

Administrative Support and Hospital Commitment

A standby facility must have the hospital admin-istrative support to:

. Assure that properly trained and adequate pen-

sonnel provide the emergency services expected atthat level of facility.

S Assure that financial resources are available toprovide the ED with the equipment necessary forthe level of facility as described in these guide-lines.

. Assure that facilities are designed for easy accessand are appropriate for the care of pediatric pa-tients as described in these guidelines.

I Provide access to emergency care for all urgentand emergent pediatric patients.

. Participate in developing a network of pediatric

emergency care within a region by linking thefacility with a regional referral center to:1) guarantee transfer and transport agreements.2) refer serious and critically ill patients and spe-

cial problem patients to an appropriate facility.. Work collaboratively with the regional EMS-

EMSC authority to support educational programsfor pre-hospital personnel, nurses, and physicians.

. Work collaboratively with the CRPC and regionalEMS-EMSC authority to assure that the data col-

lection and quality indicators established by thestate/local EMS-EMSC agency are monitored andavailable.

. Assure linkage with pre-hospital care and trans-port.Assure that the ED has a:1) medical director.2) physician coordinator for pediatric emergency

cane with experience as defined in the Person-nel section of the guidelines for a standby pe-diatric emergency facility.

3) Nursing coordinator for pediatric emergencycare.

. Establish policies, procedures, on protocols for pe-diatric emergency patients to include:

1) medical triage.2) general assessment.

3) safety.4) child abuse and neglect.

5) consent.6) transfers.7) do-not-resuscitate orders.

8) death in the ED (including sudden infantdeath syndrome) and the cane of the grieving

family.

9) conscious sedation.

GUIDELINES FOR A BASIC PEDIATRIC

EMERGENCY FACILITY

Guidelines include all of the activities and issuesdescribed under standby facilities in addition to thefollowing:



Personnel

A basic pediatric facility requires the presence of

an emergency physician in-house 24 hours pen day, 7days pen week. A pediatrician, general surgeon withtrauma experience, anesthesiologist, and radiologistmust be promptly available 24 hours pen day.


See Table 2.

Facilities

See Table 2.


A basic facility must support standby facilities

within a region when necessary by having triage andtransfer agreements to receive appropriate patientsas a part of a regional pediatric care network.

Education, Training, Research, and Quality Assessment

and Improvement

A basic facility must:

. Participate in a network of public education that

addresses:1) access to pediatric emergency cane.2) injury prevention.3) first aid and cardiopulmonary resuscitation.

S Organize a quality assurance and improvementprogram that reviews the issues described underthe standby facilities in addition to:I ) a review of pediatric transports to and from the

facility.2) a review of pediatric inpatient illness and injury

outcome data.


A basic facility must provide administrative sup-

port to:

. Assure that properly trained and adequate pen-sonnel provide the emergency services expected atthat level of facility.

. Assure that financial resources are available toprovide the ED with the equipment necessary forthe level of facility as described in these guide-lines.

. Assure that facilities are designed for easy access

and are appropriate for the cane of pediatric pa-tients as described in these guidelines.

. Provide access to emergency care for all urgent

and emergent pediatric patients regardless of fi-nancial status.

S Participate in developing a network of pediatricemergency care within a region by linking thefacility with a regional referral center to:

1) guarantee transfer and transport agreements.2) refer serious and critically ill patients and spe-

cial problem patients to an appropriate facility.

3) assure the support of agreements to receiveappropriate patients from lower-level facilities.

. Assure that the necessary education and trainingare available for health cane staff as described in

these guidelines.. Work collaboratively with the EMS-EMSC system

to provide education to pre-hospital personnel,

nurses, and physicians.. Actively participate in data collection to assure

that the quality indicators established by the re-gional resource center are monitored, and makedata available to the regional resource center on a

central data monitoring agency.. Assure the facility is linked with pre-hospital cane

and transport.

. Provide access to social services and child abusesupport services.

GUIDELINES FOR A GENERAL PEDIATRIC

EMERGENCY FACILITY

For large metropolitan or regional hospitals with

significant pediatric patient volumes, a separate pe-diatric emergency area is strongly recommended.This area should be staffed by pediatricians or emen-

gency physicians who are committed to pediatricemergency care.

Guidelines include all activities and issues underthe basic facilities in addition to the following:

Personnel

Physician Coverage

Pediatricians or emergency physicians with the

skills, knowledge, and commitment to cane forcritically ill on injured children are present in theED 24 hours per day (pediatric emergency physi-cian, pediatrician, or emergency physician).

Pediatric Trauma Team

. A pediatrician, emergency physician, on pediatric

emergency physician.I A trauma surgeon with pediatric trauma expeni-

ence and training.. Three RNs with emergency, critical care, pediatric,

on surgical experience.. A neurosurgeon who is promptly available.I An orthopedic surgeon who is promptly available.. An anesthesia resident or certified nurse anesthe-

tist, both with pediatric experience, may be in-house with an anesthesiologist promptly avail-

able.. A respiratory therapist, laboratory technician, na-

diology technician, and social worker readily

available.. A trauma coordinator who is responsible for data

collection, quality assurance, and education.

Nursing Staff

S At least one nurse pen shift with pediatric emen-gency nursing experience (PALS, ENPC, or equiv-alent)

. A pediatric nurse educator.


See Table 2.

Facilities

A general facility must have access to a Pediatric

Intensive Care Unit (level I or 2 per AAP/SCCM



standards).4 This requirement may be fulfilled byhaving transfer and transport agreements available

for moving critically ill or injured patients to a CRPC.


See Table 2.

Education, Training, Research, and Quality Assessment

and Improvement

When a CRPC is not available to a region, a gen-

eral facility must:

. Assist the state/local EMS-EMSC authority in or-ganizing a network of public education with thebasic and standby EDs as resources for the dissem-ination of information.

. Assist the state/local EMS-EMSC authority in pro-viding support for the education, skills training,and dissemination of new information to pre-hos-pital care providers utilizing the resources of basicand standby hospitals.

A general facility must:

. Collaborate and work closely with a CRPC to as-sure that health cane workers in the facility andregion have access to continuing education in on-den to maintain and update their skills for necog-nizing and stabilizing pediatric emergencies.

. Collaborate with the CRPC to organize regionalresearch and assist the state/local EMS-EMSC au-thonity with data collection and maintenance.

. Collaborate with the CRPC and the state/local

EMS-EMSC authority to organize the quality mdi-

cators appropriate for regional periodic review ofparticipating health care facilities.

. Participate in a pediatric trauma registry.


A general facility must:

. Assure that properly trained and adequate pen-

sonnel provide emergency services.. Assure that financial resources are available to

provide the ED with the equipment necessary forthe level of facility as described in these guide-lines.

. Assure that facilities are designed for easy accessand are appropriate for the cane of pediatric pa-tients as described in these guidelines.

. Provide access to emergency care for all urgentand emergent pediatric patients.

S Participate in developing a network of pediatricemergency care within a region by linking thefacility with a regional referral center to:1) guarantee transfer and transport agreements.2) refer serious and critically ill patients and spe-

cial problem patients to an appropriate facility.3) assure support of agreements to receive appro-

pniate patients from lower-level facilities.S Assure that the necessary education and training

are available for the health care staff as describedin these guidelines.

. Work collaboratively with the CRPC to supporteducation for pre-hospital personnel, nurses, and

physicians.

. Actively participate in data collection to assurethat quality indicators are monitored.

. Assure that the facility is linked with pre-hospital

care and transport.. Have a physician director of the ED who is board

certified/prepared in emergency medicine or pe-diatric emergency medicine.

. Have an ED nursing director.

. Develop and monitor pediatric emergency andcritical care protocols, policies, and quality im-provement and management programs with

the formal involvement of the Department ofPediatrics.

COMPREHENSIVE REGIONAL PEDIATRIC CENTER

Guidelines for a comprehensive regional pediatric

center include all of the activities and issues undergeneral facilities in addition to the following:

Personnel

Physician Coverage

. Twenty-four-hour ED coverage by physicians who

are board certified, board eligible, or fellows (sec-ond-year level on above) in pediatric emergencymedicine.

Pediatric Trauma Team

I A pediatric emergency physician.. A pediatric trauma surgeon (a PGY-4 or greater

surgical resident in-house with a pediatric sun-geon promptly available).

. One additional MD team member (a surgery or

pediatric resident).. Three RNs with pediatric emergency, pediatric

critical care, on pediatric surgical experience aswell as training in trauma care.

. A neurosurgeon who is promptly available.

. An orthopedic surgeon who is promptly available.

. A nurse anesthetist or anesthesia resident in-house, both with pediatric experience, with ananesthesiologist who is promptly available.

. A pediatric respiratory therapist, laboratory tech-nician, and radiology technician.

. A computed tomography technician in-house. Thetechnician may be on-call and promptly available

if the specific clinical needs of the hospital makethis necessary and it does not have an adverseimpact on patient care.

. Social services that are promptly available.

. A pediatric trauma coordinator who is responsiblefor data collection, quality improvement, and ed-ucation, and may include case management.

Nursing Staff

. A pediatric ED nursing director.

S An RN responsible for ongoing staff education.I General staff experienced in pediatric emergency

and trauma nursing care.

See Table 2 for on-call pediatric specialists andsurgical support.


Equipment assures dissemination of new information, main-


See Table 2.

Facilities

A CRPC emergency department must have geo-

graphically separate and distinct pediatric medical/trauma areas that have all the staff, equipment, and

skills necessary fon comprehensive pediatric emen-gency cane. Separate fully equipped pediatric nesusci-tation rooms must be available and capable of support-

ing at least two simultaneous resuscitations. A level 1

(pen AAP/SCCM standards)4 pediatric intensive care

unit must be available within the institution.


A CRPC must:

. Assist with the provision of regional pre-hospitaldirect medical control for pediatric patients.

. Promote a regional network of direct medical con-

trol by lower-level hospitals within the region byworking closely with the regional EMS medicaldirector to assure:

1) standards for pre-hospital cane.2) triage and transfer guidelines.

3) quality indicators for pre-hospital care.S Accept all patients from a defined region who

require specialized care not available at lower-level hospitals within the region.1) have prearranged transfer agreements that net-

work hospitals within a region to assure appro-

pniate intra-emengency department triage andtransfer to assure optimum care for seriously

and critically ill or injured pediatric patients.2) have prearranged transfer agreements for pedi-

atnic patients needing specialized cane not avail-able at the CRPC (eg, burn specialty unit, spinalcord injury unit, on rehabilitation facility).

. Assure a pediatric transport service that:1) is available to all regional participating hospi-

tals.2) provides a network for transport of appropriate

patients from all regional hospitals to theCRPC, on to an alternative facility when neces-sany.

. Provide 24-hour consultation to all lower-level fa-cilities for issues regarding:1) emergency care and stabilization.

2) triage and transfer.

3) transport.

Education, Training, Prevention, Research, and Quality

Assessment and Improvement

A CRPC must support all the issues and activities

under general facilities in addition to the following:

. Organize a network for public education regard-ing issues of pediatric emergency access, care, andinjury prevention utilizing the resources ofstandby, basic, and general EDs within a region.

. Support EMS agencies and EMS directors in main-taming a regional network of pne-hospital pro-vider education and training that utilizes the ne-

sources of standby, basic, and general EDs and

tenance of pediatric emergency skills, and updatesstandards of cane and protocols.

. Assure that a network of pediatric emergency care

education is available to all health care workersutilizing the resources of standby, basic, and gen-enal facilities within the region.

. Organize a structured quality assurance and im-provement program with the assistance and sup-port of local/state EMS-EMSC agencies that al-lows ongoing review and:I ) reviews all issues and indicators described un-

den standby, basic, and general EDs.2) provides feedback, quality review, and infor-

mation to all participating hospitals, EMS

and transport systems, and appropriate stateagencies.

3) develops quality indicators for the review ofpediatric cane given that are linked to periodiccontinuing education and reviewed at all pan-ticipating institutions.

. Assists in organizing and providing support forregional, state, and national data collection efforts

for EMSC that include:1) trauma registry.2) injury and illness epidemiology.3) pediatric specific quality indicators.

. Has an organized program for research in pediat-ric trauma, emergency care, critical care, and in-jury prevention.


A CRPC must have administrative support to:

. Assure an adequate staff that is properly trained.

. Assure that financial resources are available to

provide necessary equipment for emergency andtransport care.

S Assure that facilities are designed for easy access

and appropriate for the care of pediatric patientsas described in these guidelines.

. Provide access to emergency care for all urgentand emergent pediatric patients.

. Assure available support services to the ED in-

cluding:1) Social services.2) Child life.

3) Child/sexual abuse support.4) Respiratory care.

. Assist local and state agencies for EMS-EMSC in

organizing and implementing a network for pro-viding pediatric emergency cane within a definedregion that:1) provides transfer and transport agreements

with lower-level facilities.2) provides transport services when needed for

receiving critically ill or injured patients withinthe regional network.

3) provides necessary consultation to participat-ing network hospitals.

4) provides indirect (off-line) consultation, sup-port, and education to regional pre-hospitalsystems and supports the efforts of regionaland state pre-hospital committees.



5) provides medical support to assure quality di-rect (on-line) medical control for all pre-hospi-

tal systems within the region.

. Organize and implement a network of educationalsupport to all regional hospitals that:1) trains instructors to teach pediatric pre-hospital,

nursing, and physician-level emergency care.2) assures that training courses are available to all

hospitals and health care providers within theregion.

. Provide support for a regional data system that:1) defines the population served.

2) maintains and monitors specific quality indica-tors.

3) is � adaptable to answer questions for clinicalresearch.

. Support active institutional and collaborative ne-gional research.

. Have a physician director of the pediatric ED who

is board certified/prepared in pediatric emer-

gency medicine.

COMMII-rEE ON PEDIATRIC EMERGENCY MEDICINE, 1994 TO

1995

Joseph A. Weinberg, MD, ChairpersonBarbara Barlow, MDGeorge L. Foltin, MDJer#{224}meA. Hirschfeld, MDDee Hodge III, MDJane Knapp, MDWilliam J. Lewander, MDKarin A. McCloskey, MDRobert A. Wiebe, MD

LiAISON REPRESENTATIVES

Jean Athey, PhDMaternal and Child Health BureauMax L. Ramenofsky, MDAmerican College of SurgeonsRobert W. Schafermeyer, MDAmerican College of Emergency Physicians

AAP SEcrI0N LIAisoNS

Patricia J. Davidson, MDSection on AnesthesiologyMichele Moss, MDSection on Critical CareJames O’Neill, MDSection on Surgery

CONSULTANTS

1. Alexander Hailer, Jr. MDJames S. Seidel, MD, PhDCalvin C. J. Sia, MDDennis W. Vane, MD

REFERENCES

1 . American Medical Association Commission on Emergency Medical

Services: pediatric emergencies. Pediatrics. 1990;85:879-887 (Excerpt

from Guidelines for Categorization of Hospital Emergency Capabilities)

2. Institute of Medicine, Committee on Pediatric Emergency Medical Ser-

vices. Durch JS, Lohr KN, eds. Emergency Medical Services for Children.

Washington, DC: National Academy Press; 1993

3. Pollack MM, Alexander SR. Clarke N, Ruttimann UE, Tesselaar HM,

Bachulis AC. Improved outcomes from tertiary center pediatric inten-

sive care: a statewide comparison of tertiary and nontertiary care facil-

ities. Crit Care Med. 1991;19:150-159

4. Committee on Trauma, American College of Surgeons. Resources for

Optimal Care of the Injured Patient: 1993. Chicago, IL: American College

of Surgeons; 1993

5. American Academy of Pediatrics, Committee on Hospital Care, and Sod-

ety of Critical Care Medicine, Pediatric Section. Guidelines and levels of

care for pediatric intensive care units. Pediatrics. 199392:166-175


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