Improving pediatric emergency care: ‘We need to do better’

When a critically ill child arrives in a hospital’s emergency department, even the most experienced nurse can feel a chill.

Terry Foster, the president of the Emergency Nurses Association, talks about the anxiety nurses feel when a child arrives in the hospital. Some parents don’t call an ambulance. They simply bring their children directly into the emergency room, and run straight toward a nurse.

“It stops your heart,” Foster says. “I'll never get used to that.”

“I've been a nurse for over 45 years,” he explains. “The number one fear of working emergency nurses is a critically ill child, or a child that, what we call crashes, it comes in, and looks like you're doing okay and deteriorates.

“And you better hope, as that emergency nurse, you've got the equipment there, you've got the other nurses trained, the docs, that kind of stuff, so that you can work and save that kid, and then obviously transfer them to a pediatric facility,” he says.

Hospitals are making strides in improving pediatric care for children, but there is room for improvement, according to the National Pediatric Readiness Project. The readiness project is a partnership of the Emergency Nurses Association, the American Academy of Pediatrics and the American College of Emergency Physicians. The findings of the study were published July 7 in Jama Network Open.

“Good signs of progress, but we need to do better,” Foster says. “And I feel like you can never sort of rest or sit back when there's a potential for a pediatric emergency patient coming into, especially an adult or community hospital or emergency department.

“Children's hospitals, pediatric hospitals are very well versed in taking care of those patients just fine,” he adds. “But when they come into a community hospital, you have to be on your game. And having the equipment and the training and the knowledge and the attitude with your staff to be able to take care of them means a whole lot.”

(See part of our conversation with Terry Foster. The story continues below.)

‘Need to be ready’

Children account for one in four emergency department visits, researchers found in the study. So even if a community hospital isn’t a designated pediatric hospital, some kids are coming through those doors.

As Foster says, “Hospitals need to be ready.”

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While hospitals have made progress in improving emergency care for pediatric patients, some gains were lost during the COVID-19 pandemic, the analysis suggests.

Many hospitals have struggled to recruit and retain nurses and other key healthcare workers since the beginning of the pandemic. Some hospitals have lost physicians and nurses assigned to coordinate pediatric emergency care.

Researchers found 28.5% of emergency departments said they had both physician and nurse pediatric emergency care coordinators in 2021, a 13.5% drop from 2013.

Foster stresses the key role of pediatric care coordinators in hospital emergency departments.

“I think they're vitally important,” he says, adding, “There's tons of them in pediatric hospitals, but in community hospitals, not so much.”

“We've seen a lot of turnover in emergency departments since COVID,” Foster continues.

Some nurses have left emergency departments for other nursing roles, and he says those pediatric care coordinator positions have been left vacant.

Pediatric care coordinators typically are up to speed on the latest training and equipment to treat children and teens in emergency departments, Foster says. And he says hospitals should work to have those pediatric coordinators in place.

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Regular training

Some hospitals have closed pediatric units in recent years.

Less than one-third of hospitals (30.8%) maintain pediatric inpatient ward beds, compared to 53.4% in 2013, according to the National Pediatric Readiness Project.

The number of hospitals reporting pediatric intensive care unit beds fell from 12.5% to 9.7% since the 2013 study.

For hospitals that don’t have their own units designed for children, Foster stresses the importance of regular training.

Foster, a critical-care clinical nurse specialist in the emergency departments at St. Elizabeth Healthcare in northern Kentucky, says his organization undergoes periodic training days. Some training will go over areas such as pediatric resuscitation.

“Every emergency department can get children,” he says. “That's a well known thing. It's how you handle that child.”

Many acute care hospitals are going to transfer children with critical needs to a pediatric hospital, and Foster notes that northern Kentucky hospitals transfer young patients to Cincinnati Children’s. But those hospitals still need the proper training and equipment before transferring a young patient.

Hospitals don’t want to hold a patient they aren’t truly equipped to treat.

“I think knowing what you can't handle is really, really important,” Foster says.

More hospitals should specifically include children in their triage policy, researchers with the readiness project found. Their study found only 62% of emergency departments said their triage policies specifically address children.

The Emergency Nurses Association offers training courses in pediatric care for those nurses and hospitals that are seeking more professional development, Foster notes.

With hospitals no longer dealing with the constant crisis of the most intense spread of the coronavirus, Foster is hopeful that more attention will be focused on improving pediatric emergency care.

“With COVID, there were so many changes, events moved so quickly, and you know, everything was kind of redone as far as emergency department care goes,” Foster says. “And we had tremendous peaks and valleys, obviously, with the pandemic. And I think now that that is leveling off, we're able to breathe a little bit.”

“I know a lot of them are, now that they've got some breathing room, looking at strategic planning, just kind of thinking things out, and again, looking at the whole picture a little bit more,” Foster says.