ORIGINAL CONTRIBUTION pediatric emergency medicine
P e d i a t r i c E m e r g e n c y M e d i c i n e -C u r r e n t S t a n d a r d s of Care: Results of a National Survey To assess current standards of care in pediatric emergency medicine, a questionnaire was mailed in May 1988 to the medical directors of all existing pediatric emergency medicine fellowship programs. Twenty-three programs (96%) oor~pleted this survey, which consisted of questions regarding census, staffing patterns, ancillary services, patient follow-up, and various clinical issues. The major deficiencies in pediatric emergency care identified by this survey concerned patient waiting time, weekend radiology coverage, patient follow-up, feedback to referring physicians, and feedback to emergency department housestaff on hospitalized patients. The data suggest that pediatric EDs associated with fellowship training programs are improving their quality of care, yet room for advancement in m a n y categories remains. [Isaacman D J: Pediatric emergency medicine Current standards of care: Results of a national survey. Ann Emerg Med May 1990;19:527-531.]
INTRODUCTION Pediatric emergency medicine is a new and evolving subspecialty whose practice, special knowledge, and skills have not yet been fully defined and formalized. Other subspecialties have passed through a similar period in their development before identifying patient problems, therapeutic interventions, conceptualizations, and specific information that distinguish the new subspeciahies from existing ones. Thus, new subspeciahies become defined both operationally and theoretically. Physicians who practice the new specialty provide operational definitions (ie, pediatric emergency medicine is what pediatricians or emergency medicine physicians practicing emergency medicine for children do). Theoretical definitions may come later as practitioners identify the concepts, knowledge base, and skills that they have used and that differ from those in other subspecialties. The survey reported here inquired about characteristics of pediatric emergency medicine programs with fellowship training components to determine whether similarities in patient problems, services provided, and management practices existed that define the subspecialty operationally and establish a baseline for present standards of care in the field.
Daniel J Isaacman, MD Pittsburgh, Pennsylvania Milwaukee, Wisconsin From the Department of Pediatrics, University of Pittsburgh School of Medicine, and Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; and the Department of Pediatrics, Medical College of Wisconsin, and Children's Hospital of Wisconsin, Milwaukee. Received for publication November 20, 1989. Accepted for publication December 21, 1989. Presented in part at the Annual Meeting of the American Academy of Pediatrics, Section on Emergency Medicine, in San Francisco, October 1988. Address for reprints: Daniel J Isaacman, MD, Department of Pediatrics, Children's Hospital of Wisconsin, Mail Station 756, PO Box 1997, Milwaukee, Wisconsin 53201.
METHODS A questionnaire covering the period of July 1, 1986, through June 30, 1987, was sent in May 1988 to the medical directors of the 24 existing pediatric emergency fellowship programs in the United States and Canada. Accompanying each survey was a cover letter explaining its purpose and a stamped, self-addressed return envelope. All medical directors were contacted by telephone before the initial mailing and recontacted three weeks after the mailing if the survey had not been returned. The survey design followed the "total design method" of Dillman et al, 1 which has demonstrated ability to increase respondent rate and validity of responses. The survey contained 38 questions about patient census, staffing patterns, ancillary services, patient follow-up, and residency training. These topics were selected as being important components of an academic pediatric emergency program. Question types included true-or-false (18), fill-in-theblank (12), and multiple-choice (eight). For certain questions, respondents were instructed to circle all appropriate answers, creating the possibility of
19:5 May 1990
Annals of Emergency Medicine
527/67
PEDIATRIC EMERGENCY MEDICINE Isaacman
FIGURE 1. Percentage of programs providing on-site attending or fellow coverage for the hours show~.
more than one answer per respondent. Completed surveys were reviewed by the author, and unusual responses were confirmed by telephone contact with the respondents. Occasionally, on multiple-choice questions, an answer that did not correspond precisely to one of the given choices was added (written in) by a respondent. These answers were categorized individually by the author and assigned to the answer category that corresponded most closely.
13%
22%
65%
RESULTS Of the 24 programs, 23 (96%) returned completed questionnaires, the majority of which were fully completed. Results are presented by category.
Staffing Sixty-five percent of the programs provided 24-hour coverage by staff physicians, and all provided at least ten hours of staff coverage per day (Figure 1). Fifteen programs (65%) used faculty to attend in the emergency d e p a r t m e n t on a p a r t - t i m e basis. Of the 101 full-time faculty representing the 23 responding programs, 92 (91%) were board certified in pediatrics, six (6%) were board certified in e m e r g e n c y medicine, 20 (20%) had c o m p l e t e d a p e d i a t r i c emergency fellowship, and 59 (58%) had m o r e t h a n four years' supervisory experience in pediatric emergency medicine. N i n e t e e n programs ( 8 3 % ) s t a t e d that residents from other training programs rotated through their ED. Four programs (17%) used physician assistants or nurse practitioners in their ED.
Patient Characteristics and Management All responding hospitals had triage systems in place, and 95% of programs stated that triage was done by nurses with specialized training in pediatrics. Fifty-nine percent of patients were classified as n o n u r g e n t ( p a t i e n t s deemed able to safely wait for the first physician available). Thirty-six percent of patients were classified as 68/528
•
24 hours
[]
16-18hours
]
< 16 hours N = 23
urgent (needing to be seen as soon as possible), and 5% of patients were classified as critical (unstable, needing to be seen immediately). Sixteen of the programs (70%) used a walk-in clinic to see nonurgent patients during certain hours. Directors were asked to estimate (to the nearest half hour) the average wait to be seen for nonurgent patients during the peak period of patient volume; the estimated wait was 1.25 (SD, 0.58) hours in the ED and 0.7 (SD, 0.33) hours in the walk-in clinics. Three fourths of programs provided t e l e p h o n e c o n s u l t a t i o n to parents from the community. The majority of these calls (57%) were handled by nurses, with the remainder (35% and 8%) handled by the attending pediatrician or the pediatric resident, respectively. Twelve programs (52%) stated that they provide medical c o m m a n d to incoming paramedic units. In six of these hospitals, only the attending or fellow gave the medical command, whereas in six programs, housestaff also gave command. Two programs stated that nurses could also give medical command.
Ancillary Services N i n e t e e n p r o g r a m s (83%) had a d e s i g n a t e d child abuse t e a m , 17 (74%) had a designated trauma team, and 16 (70%) had a social worker specifically working in the ED. Six proAnnals of Emergency Medicine
grams (26%) reported a radiography suite located in the ED, and three programs (13%) had a "star lab" located in the ED. Social work coverage varied widely between programs, with the majority of programs providing weekday ED c o v e r a g e b e t w e e n 8:00AM a n d 4:00 PM and about one half of the programs providing weekday coverage during the evening hours (Figure 2). Only one program currently reported having a social worker in the hospital between 12:00 midnight and 8:00 AM. Weekend coverage was less complete with approximately 25% of programs providing social workers in the hospital between 9:00 A.M. and 11:00 PM and, again, only one program with overnight coverage. Staff radiology coverage was similar a m o n g programs (Figure 3). All programs had weekday attending radiology coverage between "9:00 AM and 4:00 PM, whereas none of the programs had in-house attending rad i o l o g i s t s b e t w e e n 7:00PM and 7 : 0 0 AM. O n w e e k e n d s , a p p r o x imately 50% of programs had attending radiologists present during the morning hours. No program had staff (attending) radiologists present after 12:00 noon on the weekends.
Follow-up All programs provided p a t i e n t s with written discharge instructions for c o m m o n illnesses. Subjects for 19:5 May 1990
,oo
::[
FIGURE 2. Percentage of programs w i t h on-site social work coverage during the hours shown.
---;I
Peak Hours
K
80
FIGURE 3. Percentage of programs with on-site attending radiology coverage during the hours shown.
• Weekday
>m
[ ] Weekend 60
=
r-
services that had patients bypass the ED resident included neurosurgery (one) and dental (two). Only four programs (17%) had a formalized system for providing feedback to housestaff working in the ED about patients they admitted. The methods used for this feedback included c o n d u c t i n g w e e k l y conferences reviewing the admitted cases, conducting weekly floor rounds on admitted patients, or sending copies of the patient discharge summary to the admitting resident.
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3 which instructions were given included head trauma, wound and suture care, burn care, vomiting and diarrhea, fever, eczema, insect bites, poison ivy, scabies, constipation, asthma, conjunctivitis, croup, and varicella. Sixteen programs (70%) stated they had a formalized system for providing feedback to referring physicians. In 13 programs, the physician received a telephone call (either from a house officer or a nurse) in addition to a copy of the ED sheet, whereas in three cases, the ED sheet was the 19:5 May 1990
only source of follow-up for the referring physician. Twelve programs (57%)stated they had a formalized s y s t e m for telephone follow-up of patients of concern. Telephone follow-up was provided by either the staff physician who saw the patient (four), a designated house officer (four), or a designated nurse (five).
Residency Training Twenty programs (87%) stated that their residents saw all patients before referral to a subspecialty service. The Annals of
Emergency
Medicine
DISCUSSION Because the subspecialty of pediatric emergency medicine is seeking to define itself, it seemed timely to examine issues integral to the functioning of an academic pediatric ED (ie, staff qualifications, staffing patterns, ancillary services, patient follow-up, and educational issues). Previously reported surveys of pediatric EDs have concentrated mainly on staffing patterns, ~ a c a d e m i c salaries,3, 4 job opportunities and descriptions,3, 4 and appropriate patient use of emergency services, s This survey assessed the current practice of academic pediatric emergency medicine to define the subspecialty operationally and assess current standards of care in the field. These data may serve as a tool to describe what pediatric emergency physicians do as well as to monitor growth in the field. This study was meant as a pilot for an upcoming national survey of all accredited US and Canadian pediatric programs. A survey format was chosen to accomplish this task because it offered the most practical way to obtain information about programs across the nation, even though respondent bias and uncertainty regarding the v a l i d i t y of responses were acknowledged l i m i t a t i o n s of this method. A serious effort was made to avoid ambiguity in all questions and to accurately interpret all answers. The questions chosen for this sur529/69
PEDIATRIC EMERGENCY MEDICINE Isaacman
vey were based on the author's perception of desirable components of the ideal academic pediatric emergency service. This theoretical construct is presented below. The "ideal" academic ED would have a nurse trained in pediatrics to triage all patients. No patient would wait longer than ten minutes to be triaged or more than one hour to be seen by a physician. All critical patients would be seen immediately, and all urgent patients would be seen within minutes. A full-time attending physician would be present on a 24-hour basis to supervise all patients seen by housestaff. Attending physician qualifications would include board certification in pediatrics and/or emergency medicine with either practice experience or formal training in pediatric emergency medicine. Housestaff from other disciplines (including f a m i l y practice, adult emergency medicine, and child psychiatry) involved in the care of children would rotate through the department to gain experience in taking care of sick children. Pediatric housestaff would rotate through the department for several periods each year to gain familiarity with the seasonal changes in the spectrum of illness. Residents would see all patients presenting to the department before referral to a subspecialty service to get comprehensive exposure to the types of subspecialty problems that can occur. Residents would also be allowed to manage the CPR efforts in the department under the direct guidance of the attending physician. The ideal ancillary support would include a radiographic suite physically located in the ED with on-site radiology staff consultation available during daylight and peak hours. A laboratory dedicated to the ED would be present in or next to the departm e n t . Specialty t e a m s w o u l d be available on a 24-hour basis to handle child abuse and pediatric trauma. Two-way radio c o m m u n i c a t i o n would be present to gain information on incoming patients and give medical c o m m a n d as needed. A social worker specifically assigned to the ED would be available in the hospital during daytime and peak hours with on-call availability during the remainder of the day. To give comprehensive care, an ED should ensure patient understanding 70/530
of instructions given and must provide adequate follow-up of its patients. All patients of concern should be rechecked or at least recontacted by telephone, preferably by the physician who saw the patient. A system should be in place for reviewing all abnormal test results, radiographic reports, and positive culture results and for ensuring that appropriate care is then rendered. It is difficult to suggest an ideal means of handling outside telephone calls by parents in the c o m m u n i t y who have medical questions regarding their children because differing opinions exist as to the quality of advice given over the telephone. Some studies have questioned the usefulness of telephone advice,6, 7 pointing out many of the hazards implicit in telephone management of illness. At the same time, this service provides the only means of medical contact for many families who would otherwise have no access to medical advice. The detection of "deficiencies" by this survey a s s u m e s pre-existing standards for pediatric emergency care in the United States and Canada by which to judge the responses. In fact, no such standards are presently available. The American Academy of Pediatrics has recently established the Provisional Committee in Pediatric Emergency Medicine to set policies concerning the care of critically ill or injured children.S, 9 Pending specific r e c o m m e n d a t i o n s from this committee, the results of this survey were compared with the author's concept of an ideal ED. The following deficiencies were noted using this standard. First, the average wait for nonurgent cases to be seen in the ED often exceeded ideal standards. Curiously enough, the mean wait to be seen in walk-in clinics run by these same p r o g r a m s (mean wait, 0.7 hours; SD, 0.33 hours) was less than that for nonurgent cases seen in the ED (mean wait, 1.25 hours; SD, 0.58). Second, attending radiology coverage was limited on both evenings and weekends. In particular, the hours associated with the largest volume of patient visits (ie, 4:00 PM to 12:00 midnight) were generally not covered by attending radiologists. Third, in-house social work coverage was limited on the weekend and lacking during the peak hours. Annals of Emergency Medicine
Fourth, a relatively low percentage of programs ( 5 6 % ) p r o v i d e d telephone follow-up for patients of concern. In only 17% of cases did the physician who initially saw the patient provide the follow-up. Fifth, a very low percentage of hospitals (17%) had a formal mechanism for providing feedback to housestaff o n p a t i e n t s a d m i t t e d by t h e m through the ED. Finally, a finding of potential concern was the large number of programs (74%) that provided telephone consultation to parents in the community. The majority of these calls were handled by nurses. We did not determine the formal training of the responder or what backup was available for c o n s u l t a t i o n about these calls and are pursuing these issues in an ongoing study. Despite these deficiencies, m a n y hospitals possessed those qualities associated with state-of-the-art care: 24-hour attending or fellow coverage, well-qualified attending staff, trauma teams, child abuse teams, and specifically designated social workers. Some improvement in patient follow-up seems to be warranted. CONCLUSION Although pediatric EDs are currently setting high standards for patient care and resident education, areas n e e d i n g i m p r o v e m e n t have been identified. It will be important to evaluate and compare the practice of pediatric emergency medicine at a broader range of pediatric institutions to get a sense of the quality of care provided outside the fellowship institutions. The author thanks Holly Davis, MD, Raymond Karasic, MD, and Ken Rogers, MD, for extensive and invaluable help in survey and manuscript preparation.
REFERENCES
1. Dillman DA: Mail and Telephone Surveys: The Total Design Method. New York, John
Wiley & Sons, 1978, p 119-191. 2. Baker MD: Physician coveragein the pediatric emergencyroom. A m J Dis Child 1986; 140:755-757.
3. LosekJD, Walsh-KellyC, GlaeserP: Pediatric emergency departments. Pediatr Emerg Care 1986~2:215-217. 4. Li M, Baker MD, Ropp LJ: Pediatric emergency medicine: A developingsubspecialty. Pediatrics 1988;84:336-342. 5. DeAngelis C, Fossarelli P, Duggan AK: Use of the emergencydepartment by children en19:5 May 1990
rolled in a primary clinic. Pediatr Emerg Care 1985;1:61-65. 6. Selbst SM, Korin J: The telephone in pediatric emergency medicine. Pediatr Emerg Care 1985;1:108-110.
19:5 May 1990
7. Trautlein IJ, Lamber RL, Miller J: Malpractice in the emergency department - Review of 200 cases. Ann Emerg Med 1984;13:709-711. 8. American Academy of Pediatrics, Provisional Committee on Pediatric Emergency Medicine:
Annals of Emergency Medicine
Pediatrician's role i n emergency services for children. Pediatrics 1988;81:735. 9. Narkewicz RM: Role of pediatrician in pediatric emergency me di c a l services. Pediatrics 1988;81:730-731.
531/71
P e d i a t r i c E m e r g e n c y M e d i c i n e -C u r r e n t S t a n d a r d s of Care: Results of a National Survey To assess current standards of care in pediatric emergency medicine, a questionnaire was mailed in May 1988 to the medical directors of all existing pediatric emergency medicine fellowship programs. Twenty-three programs (96%) oor~pleted this survey, which consisted of questions regarding census, staffing patterns, ancillary services, patient follow-up, and various clinical issues. The major deficiencies in pediatric emergency care identified by this survey concerned patient waiting time, weekend radiology coverage, patient follow-up, feedback to referring physicians, and feedback to emergency department housestaff on hospitalized patients. The data suggest that pediatric EDs associated with fellowship training programs are improving their quality of care, yet room for advancement in m a n y categories remains. [Isaacman D J: Pediatric emergency medicine Current standards of care: Results of a national survey. Ann Emerg Med May 1990;19:527-531.]
INTRODUCTION Pediatric emergency medicine is a new and evolving subspecialty whose practice, special knowledge, and skills have not yet been fully defined and formalized. Other subspecialties have passed through a similar period in their development before identifying patient problems, therapeutic interventions, conceptualizations, and specific information that distinguish the new subspeciahies from existing ones. Thus, new subspeciahies become defined both operationally and theoretically. Physicians who practice the new specialty provide operational definitions (ie, pediatric emergency medicine is what pediatricians or emergency medicine physicians practicing emergency medicine for children do). Theoretical definitions may come later as practitioners identify the concepts, knowledge base, and skills that they have used and that differ from those in other subspecialties. The survey reported here inquired about characteristics of pediatric emergency medicine programs with fellowship training components to determine whether similarities in patient problems, services provided, and management practices existed that define the subspecialty operationally and establish a baseline for present standards of care in the field.
Daniel J Isaacman, MD Pittsburgh, Pennsylvania Milwaukee, Wisconsin From the Department of Pediatrics, University of Pittsburgh School of Medicine, and Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; and the Department of Pediatrics, Medical College of Wisconsin, and Children's Hospital of Wisconsin, Milwaukee. Received for publication November 20, 1989. Accepted for publication December 21, 1989. Presented in part at the Annual Meeting of the American Academy of Pediatrics, Section on Emergency Medicine, in San Francisco, October 1988. Address for reprints: Daniel J Isaacman, MD, Department of Pediatrics, Children's Hospital of Wisconsin, Mail Station 756, PO Box 1997, Milwaukee, Wisconsin 53201.
METHODS A questionnaire covering the period of July 1, 1986, through June 30, 1987, was sent in May 1988 to the medical directors of the 24 existing pediatric emergency fellowship programs in the United States and Canada. Accompanying each survey was a cover letter explaining its purpose and a stamped, self-addressed return envelope. All medical directors were contacted by telephone before the initial mailing and recontacted three weeks after the mailing if the survey had not been returned. The survey design followed the "total design method" of Dillman et al, 1 which has demonstrated ability to increase respondent rate and validity of responses. The survey contained 38 questions about patient census, staffing patterns, ancillary services, patient follow-up, and residency training. These topics were selected as being important components of an academic pediatric emergency program. Question types included true-or-false (18), fill-in-theblank (12), and multiple-choice (eight). For certain questions, respondents were instructed to circle all appropriate answers, creating the possibility of
19:5 May 1990
Annals of Emergency Medicine
527/67
PEDIATRIC EMERGENCY MEDICINE Isaacman
FIGURE 1. Percentage of programs providing on-site attending or fellow coverage for the hours show~.
more than one answer per respondent. Completed surveys were reviewed by the author, and unusual responses were confirmed by telephone contact with the respondents. Occasionally, on multiple-choice questions, an answer that did not correspond precisely to one of the given choices was added (written in) by a respondent. These answers were categorized individually by the author and assigned to the answer category that corresponded most closely.
13%
22%
65%
RESULTS Of the 24 programs, 23 (96%) returned completed questionnaires, the majority of which were fully completed. Results are presented by category.
Staffing Sixty-five percent of the programs provided 24-hour coverage by staff physicians, and all provided at least ten hours of staff coverage per day (Figure 1). Fifteen programs (65%) used faculty to attend in the emergency d e p a r t m e n t on a p a r t - t i m e basis. Of the 101 full-time faculty representing the 23 responding programs, 92 (91%) were board certified in pediatrics, six (6%) were board certified in e m e r g e n c y medicine, 20 (20%) had c o m p l e t e d a p e d i a t r i c emergency fellowship, and 59 (58%) had m o r e t h a n four years' supervisory experience in pediatric emergency medicine. N i n e t e e n programs ( 8 3 % ) s t a t e d that residents from other training programs rotated through their ED. Four programs (17%) used physician assistants or nurse practitioners in their ED.
Patient Characteristics and Management All responding hospitals had triage systems in place, and 95% of programs stated that triage was done by nurses with specialized training in pediatrics. Fifty-nine percent of patients were classified as n o n u r g e n t ( p a t i e n t s deemed able to safely wait for the first physician available). Thirty-six percent of patients were classified as 68/528
•
24 hours
[]
16-18hours
]
< 16 hours N = 23
urgent (needing to be seen as soon as possible), and 5% of patients were classified as critical (unstable, needing to be seen immediately). Sixteen of the programs (70%) used a walk-in clinic to see nonurgent patients during certain hours. Directors were asked to estimate (to the nearest half hour) the average wait to be seen for nonurgent patients during the peak period of patient volume; the estimated wait was 1.25 (SD, 0.58) hours in the ED and 0.7 (SD, 0.33) hours in the walk-in clinics. Three fourths of programs provided t e l e p h o n e c o n s u l t a t i o n to parents from the community. The majority of these calls (57%) were handled by nurses, with the remainder (35% and 8%) handled by the attending pediatrician or the pediatric resident, respectively. Twelve programs (52%) stated that they provide medical c o m m a n d to incoming paramedic units. In six of these hospitals, only the attending or fellow gave the medical command, whereas in six programs, housestaff also gave command. Two programs stated that nurses could also give medical command.
Ancillary Services N i n e t e e n p r o g r a m s (83%) had a d e s i g n a t e d child abuse t e a m , 17 (74%) had a designated trauma team, and 16 (70%) had a social worker specifically working in the ED. Six proAnnals of Emergency Medicine
grams (26%) reported a radiography suite located in the ED, and three programs (13%) had a "star lab" located in the ED. Social work coverage varied widely between programs, with the majority of programs providing weekday ED c o v e r a g e b e t w e e n 8:00AM a n d 4:00 PM and about one half of the programs providing weekday coverage during the evening hours (Figure 2). Only one program currently reported having a social worker in the hospital between 12:00 midnight and 8:00 AM. Weekend coverage was less complete with approximately 25% of programs providing social workers in the hospital between 9:00 A.M. and 11:00 PM and, again, only one program with overnight coverage. Staff radiology coverage was similar a m o n g programs (Figure 3). All programs had weekday attending radiology coverage between "9:00 AM and 4:00 PM, whereas none of the programs had in-house attending rad i o l o g i s t s b e t w e e n 7:00PM and 7 : 0 0 AM. O n w e e k e n d s , a p p r o x imately 50% of programs had attending radiologists present during the morning hours. No program had staff (attending) radiologists present after 12:00 noon on the weekends.
Follow-up All programs provided p a t i e n t s with written discharge instructions for c o m m o n illnesses. Subjects for 19:5 May 1990
,oo
::[
FIGURE 2. Percentage of programs w i t h on-site social work coverage during the hours shown.
---;I
Peak Hours
K
80
FIGURE 3. Percentage of programs with on-site attending radiology coverage during the hours shown.
• Weekday
>m
[ ] Weekend 60
=
r-
services that had patients bypass the ED resident included neurosurgery (one) and dental (two). Only four programs (17%) had a formalized system for providing feedback to housestaff working in the ED about patients they admitted. The methods used for this feedback included c o n d u c t i n g w e e k l y conferences reviewing the admitted cases, conducting weekly floor rounds on admitted patients, or sending copies of the patient discharge summary to the admitting resident.
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3 which instructions were given included head trauma, wound and suture care, burn care, vomiting and diarrhea, fever, eczema, insect bites, poison ivy, scabies, constipation, asthma, conjunctivitis, croup, and varicella. Sixteen programs (70%) stated they had a formalized system for providing feedback to referring physicians. In 13 programs, the physician received a telephone call (either from a house officer or a nurse) in addition to a copy of the ED sheet, whereas in three cases, the ED sheet was the 19:5 May 1990
only source of follow-up for the referring physician. Twelve programs (57%)stated they had a formalized s y s t e m for telephone follow-up of patients of concern. Telephone follow-up was provided by either the staff physician who saw the patient (four), a designated house officer (four), or a designated nurse (five).
Residency Training Twenty programs (87%) stated that their residents saw all patients before referral to a subspecialty service. The Annals of
Emergency
Medicine
DISCUSSION Because the subspecialty of pediatric emergency medicine is seeking to define itself, it seemed timely to examine issues integral to the functioning of an academic pediatric ED (ie, staff qualifications, staffing patterns, ancillary services, patient follow-up, and educational issues). Previously reported surveys of pediatric EDs have concentrated mainly on staffing patterns, ~ a c a d e m i c salaries,3, 4 job opportunities and descriptions,3, 4 and appropriate patient use of emergency services, s This survey assessed the current practice of academic pediatric emergency medicine to define the subspecialty operationally and assess current standards of care in the field. These data may serve as a tool to describe what pediatric emergency physicians do as well as to monitor growth in the field. This study was meant as a pilot for an upcoming national survey of all accredited US and Canadian pediatric programs. A survey format was chosen to accomplish this task because it offered the most practical way to obtain information about programs across the nation, even though respondent bias and uncertainty regarding the v a l i d i t y of responses were acknowledged l i m i t a t i o n s of this method. A serious effort was made to avoid ambiguity in all questions and to accurately interpret all answers. The questions chosen for this sur529/69
PEDIATRIC EMERGENCY MEDICINE Isaacman
vey were based on the author's perception of desirable components of the ideal academic pediatric emergency service. This theoretical construct is presented below. The "ideal" academic ED would have a nurse trained in pediatrics to triage all patients. No patient would wait longer than ten minutes to be triaged or more than one hour to be seen by a physician. All critical patients would be seen immediately, and all urgent patients would be seen within minutes. A full-time attending physician would be present on a 24-hour basis to supervise all patients seen by housestaff. Attending physician qualifications would include board certification in pediatrics and/or emergency medicine with either practice experience or formal training in pediatric emergency medicine. Housestaff from other disciplines (including f a m i l y practice, adult emergency medicine, and child psychiatry) involved in the care of children would rotate through the department to gain experience in taking care of sick children. Pediatric housestaff would rotate through the department for several periods each year to gain familiarity with the seasonal changes in the spectrum of illness. Residents would see all patients presenting to the department before referral to a subspecialty service to get comprehensive exposure to the types of subspecialty problems that can occur. Residents would also be allowed to manage the CPR efforts in the department under the direct guidance of the attending physician. The ideal ancillary support would include a radiographic suite physically located in the ED with on-site radiology staff consultation available during daylight and peak hours. A laboratory dedicated to the ED would be present in or next to the departm e n t . Specialty t e a m s w o u l d be available on a 24-hour basis to handle child abuse and pediatric trauma. Two-way radio c o m m u n i c a t i o n would be present to gain information on incoming patients and give medical c o m m a n d as needed. A social worker specifically assigned to the ED would be available in the hospital during daytime and peak hours with on-call availability during the remainder of the day. To give comprehensive care, an ED should ensure patient understanding 70/530
of instructions given and must provide adequate follow-up of its patients. All patients of concern should be rechecked or at least recontacted by telephone, preferably by the physician who saw the patient. A system should be in place for reviewing all abnormal test results, radiographic reports, and positive culture results and for ensuring that appropriate care is then rendered. It is difficult to suggest an ideal means of handling outside telephone calls by parents in the c o m m u n i t y who have medical questions regarding their children because differing opinions exist as to the quality of advice given over the telephone. Some studies have questioned the usefulness of telephone advice,6, 7 pointing out many of the hazards implicit in telephone management of illness. At the same time, this service provides the only means of medical contact for many families who would otherwise have no access to medical advice. The detection of "deficiencies" by this survey a s s u m e s pre-existing standards for pediatric emergency care in the United States and Canada by which to judge the responses. In fact, no such standards are presently available. The American Academy of Pediatrics has recently established the Provisional Committee in Pediatric Emergency Medicine to set policies concerning the care of critically ill or injured children.S, 9 Pending specific r e c o m m e n d a t i o n s from this committee, the results of this survey were compared with the author's concept of an ideal ED. The following deficiencies were noted using this standard. First, the average wait for nonurgent cases to be seen in the ED often exceeded ideal standards. Curiously enough, the mean wait to be seen in walk-in clinics run by these same p r o g r a m s (mean wait, 0.7 hours; SD, 0.33 hours) was less than that for nonurgent cases seen in the ED (mean wait, 1.25 hours; SD, 0.58). Second, attending radiology coverage was limited on both evenings and weekends. In particular, the hours associated with the largest volume of patient visits (ie, 4:00 PM to 12:00 midnight) were generally not covered by attending radiologists. Third, in-house social work coverage was limited on the weekend and lacking during the peak hours. Annals of Emergency Medicine
Fourth, a relatively low percentage of programs ( 5 6 % ) p r o v i d e d telephone follow-up for patients of concern. In only 17% of cases did the physician who initially saw the patient provide the follow-up. Fifth, a very low percentage of hospitals (17%) had a formal mechanism for providing feedback to housestaff o n p a t i e n t s a d m i t t e d by t h e m through the ED. Finally, a finding of potential concern was the large number of programs (74%) that provided telephone consultation to parents in the community. The majority of these calls were handled by nurses. We did not determine the formal training of the responder or what backup was available for c o n s u l t a t i o n about these calls and are pursuing these issues in an ongoing study. Despite these deficiencies, m a n y hospitals possessed those qualities associated with state-of-the-art care: 24-hour attending or fellow coverage, well-qualified attending staff, trauma teams, child abuse teams, and specifically designated social workers. Some improvement in patient follow-up seems to be warranted. CONCLUSION Although pediatric EDs are currently setting high standards for patient care and resident education, areas n e e d i n g i m p r o v e m e n t have been identified. It will be important to evaluate and compare the practice of pediatric emergency medicine at a broader range of pediatric institutions to get a sense of the quality of care provided outside the fellowship institutions. The author thanks Holly Davis, MD, Raymond Karasic, MD, and Ken Rogers, MD, for extensive and invaluable help in survey and manuscript preparation.
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