Patient safety is the foundation of high-quality health care and remains a critical priority for all clinicians caring for children. There are numerous aspects of pediatric care that increase the risk of patient harm, including but not limited to risk from medication errors attributable to weight-dependent dosing and need for appropriate equipment and training. Of note, the majority of children who are ill and injured are brought to community hospital emergency departments. It is, therefore, imperative that all emergency departments practice patient safety principles, support a culture of safety, and adopt best practices to improve safety for all children seeking emergency care. This technical report outlined the challenges and resources necessary to minimize pediatric medical errors and to provide safe medical care for children of all ages in emergency care settings.
Over the last decade, patient safety, which is defined as the prevention of harm to patients,1 has become a key priority for health care systems because of increased recognition of the risks of medical care. Since the publication of the 2000 report of the Institute of Medicine (now the National Academies of Sciences, Engineering, and Medicine) “To Err is Human: Building a Safer Health System,”1 there have been significant increases in research, education, collaboration among numerous organizations and development of outcome measures to promote safety in the medical care arena. Despite such progress, medical errors and harm to patients remain common.2,3
Caring for children in the emergency care setting can be prone to safety concerns because of a number of environmental and human factors. The emergency department (ED) environment has frequent workflow interruptions, multiple care transitions, and inherent barriers to effective communication. In addition, the ED’s high volume of patients, high decision density under time pressure, high levels of diagnostic uncertainty, and limited knowledge of patients’ history and preexisting conditions make the safe care of critically ill and injured patients even more challenging.4 It is imperative to look for best practices and provide strategies and recommendations to improve pediatric patient safety in the emergency care setting.
This document references several specific policies related to pediatric patient safety strategies that have been published in the last several years. This includes pediatric readiness in the ED, handoffs, patient- and family-centered care, and medication safety.5–8 In addition, this technical report expands on the principles in the American Academy of Pediatrics (AAP) policy statement “Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care”9 to address patient safety elements specific to caring for pediatric patients in the emergency care setting. This report is also intended for promoting pediatric safety in all emergency care settings, including general EDs caring for children and pediatric EDs.
One strategy to organize thinking about complicated health care systems is to categorize them into levels, such as micro, meso, and macro levels. This framework can provide understanding of the different points at which the patient interacts with the health care organization and highlight where potential safety measures can be effective. As such, the ED is considered a microsystem in which patients, families, and care teams meet and where quality and safe medical care is provided. On the other hand, the ED is part of multiple and interrelated microsystems (such as the laboratory and radiology departments), which is called the mesosystem, that could impact the quality and safety of medical care of ED patients. Such a system may be empowered and held accountable by the overarching macrosystem, such as a hospital or integrated health system safety policies.10
In the safety arena, most macrosystems aim to become high-reliability organizations (HROs), which are those that operate in a high-risk environment but maintain very low rates of injury or harm. The concept of an HRO is attractive for health care macrosystems because of the complexity of operations and the risk of significant and even potentially catastrophic consequences when failures occur. The 5 central principles of HROs are: (1) sensitivity to operations (ie, heightened awareness of the state of relevant systems and processes); (2) reluctance to simplify (ie, the acceptance that work is complex, with the potential to fail in new and unexpected ways); (3) preoccupation with failure (ie, to view near misses as opportunities to improve, rather than proof of success); (4) deference to expertise (ie, to value insights from staff with the most pertinent safety knowledge over those with greater seniority); and (5) practicing resilience (ie, to prioritize emergency training for many unlikely, but possible, system failures).11
High reliability means maintenance of consistent excellence in quality and safety across all services. The Joint Commission constructed a framework that health care organizations can use to accelerate their progress toward the ultimate goal of zero harm. The framework is organized around 3 major domains of change, including: (1) commitment of leadership to the goal of zero harm; (2) safety culture; and (3) empowerment of the workforce to employ robust process improvement tools to address the improvement opportunities they find and drive significant and lasting change.12 In addition, the Institute for Healthcare Improvement and Safe and Reliable Healthcare collaborated to develop the Framework for Safe, Reliable, and Effective Care. The framework consists of 2 foundational domains—culture and the learning system—along with 9 interrelated components, with engagement of patients and families at the core.13 The 9 components include leadership, 4 cultural components (psychological safety, accountability, teamwork and communication, and negotiation) and 4 components of the learning system (transparency, reliability, improvement and measurement, and continuous learning).13
This technical report addresses adopting The Joint Commission and Institute for Healthcare Improvement frameworks in the pediatric emergency care setting to promote patient safety.
LEADERSHIP COMMITMENT TO SAFETY THROUGH ADOPTING PEDIATRIC READINESS
Safety is a property of the clinical microsystem that can be achieved only through a systematic application of a broad array of process, equipment, organization, supervision, training, and teamwork changes. To achieve safety, hospital and ED leadership (macro- and microsystems) should set the stage for making safety a priority, not only for the organization, but also in the ED by supporting the ED to create innovative strategies for improvement and to achieve pediatric readiness to provide emergency care for children and adolescents.
The majority of children who are ill and injured are brought to community hospital EDs. To ensure safe and quality emergency care for children, it is imperative that hospitals or health care systems’ leadership ensure that all EDs have the appropriate resources (medications, age-appropriate equipment, policies, and education) and capable staff to provide such care. The joint policy statement from the AAP, American College of Emergency Physicians (ACEP), and Emergency Nurses Association (ENA) on pediatric readiness in the ED5 includes recommendations regarding current information on equipment, medications, supplies, and personnel that are considered critical for managing pediatric emergencies in EDs. That policy statement offered several recommendations that addressed safety and quality of pediatric emergency care, such as medication safety, guidelines to reduce radiation exposure that are age and size specific, and enhancing patient- and family-centered care.5,8,14 The recommendations also called for actively engaging patients and families in safety at all points of care, use of shared decision-making, and addressing issues of ethnic culture, literacy, and language by using trained language interpreter services rather than bilingual relatives.15
In a study by Gausche-Hill et al, hospital ED leaders in all US states and territories were asked to complete a comprehensive web-based assessment of their readiness to care for children. The response rate was 83% and represented more than 4000 EDs. Therefore, the data reveal a snapshot of the nation’s readiness to provide care to children in the ED as well as providing information on gaps in readiness at the state and national levels. One example of a potential safety concern was that a process to ensure that weights are measured and recorded in kilograms only was lacking in 32.3% of EDs completing the assessment.16 The data also revealed that only 45.1% of ED respondents reported having a quality improvement plan addressing the specific needs of children. Of those, 58.3% identified specific quality indicators for children; 88.1% collected and evaluated data, such as transfer, deaths, and return visits; 78.9% had a plan for addressing variances in care, such as the provision of education to staff; and 73.5% had evaluation and reevaluation processes for outcome-based measures, such as the relief of pain.16
Although much progress has been made for health care systems and hospitals’ leadership in improving pediatric readiness across communities, there remains a significant opportunity for further progress at the state and national levels. In a study by Shaw et al, a total of 1747 staff members (49%) responded to the survey on the climate of safety at 21 EDs. Of interest, there was a wide range (28% to 82%) in the proportion reporting a positive safety climate, and the rating was higher for physicians than those of nursing staff. Characteristics associated with an improved climate of safety were a lack of ED overcrowding, a sick call back-up plan for physicians, and the presence of an ED safety committee.17 Leadership’s commitment to ensuring that the ED is “pediatric ready” is essential to safe care of pediatric patients.
FACTORS INFLUENCING PATIENT SAFETY CULTURE IN THE ED
I. Factors That Influence People and Their Behavior
Patient- and Family-Centered Care
Providing safe care for pediatric patients in the ED is a shared responsibility between the patient (adolescent), the family, and health care personnel. Acknowledging the family’s role in the health of the patient is 1 of the core principles of patient- and family-centered care (PFCC). The health care team should engage in collaborative negotiation with patients and families to understand their priorities to be able to successfully achieve health goals.
It is critical to be inclusive of all types of families, including families with same or opposite sex married or unmarried partners, step-families, single-parent families, adoptive families, foster families, and families in which children are raised by their grandparents or other relatives. A technical report published by the AAP describes a number of important aspects of family-centered care in pediatric emergency care, including family presence, cultural sensitivity, communication, shared decision-making, coordination with the medical home, and discharge planning and instructions.7
A qualitative study involving focus groups with parents who accompanied their child to an ED identified dimensions of PFCC important to parents. The 8 dimensions included: (1) emotional support; (2) coordination; (3) elicit and respect preferences and involve the patient and family in care decisions; (4) timely and attentive care; (5) information, communication, and education; (6) pain management; (7) safe and child-focused environment; and (8) continuity and transition. These findings provide a framework for the development of such a measure needed to improve the quality of PFCC in the ED.20
PFCC contributes to safety in several ways. Despite the fact that the pediatric volume might not be sufficient in some general EDs to require a separate section, attention to the physical, emotional, and distinct medical needs of children is warranted for safer care. In a busy ED with critical patients, there is a need to access electrical plugs and to have containers for sharps readily available. It is important to mitigate the potential for injury by using new plugs with safety features and to keep sharp containers out of children’s reach. For children with special health care needs (autism spectrum disorder, sensory processing disorder, intellectual disabilities, nonverbal cerebral palsy, and deafness), an unexpected visit to the ED can be an overwhelming experience that creates intensifying behaviors and possibly an unsafe clinical interaction for the child and the medical team. The ED is a very stimulating environment with lights, noises, and many people, and some children with autism spectrum disorder, sensory processing disorder, and other special needs perceive stimuli at much different levels than neurotypical patients. Overstimulation in the ED can be minimized by having quiet or private rooms, especially in newly designed EDs, and providing noise-blocking headphones. Measures to keep headphones clean and secured for patient use are necessary.
In addition, adolescent patients value all aspects of privacy. Improving the care of adolescent patients requires clinicians to address not only informational but also psychological, social, and physical privacy of their patients. Confidentiality in the ED setting is also critical for the entire family.
The lack of an existing relationship with a given family and the acuity of the situation may make establishing a partnership for PFCC more difficult in the ED. Situations complicating this effort include pediatric patients arriving to the ED unaccompanied by a parent via ambulance from school or camp. Language and cultural barriers or inability to communicate with an uncooperative or nonverbal child further supports the need for PFCC to promote effective communication and safe care. The presence and expertise of a certified child life specialist in the ED that focuses on promoting effective coping skills in children during procedures like routine intravenous line insertion, wound repair, and other invasive and painful procedures can positively affect the experience for the child and caregiver and improve satisfaction with the ED visit. It also helps to decrease emotional distress in children during procedures.21–23
The use of virtual reality, internet technology, and electronic and digital devices as an effective means of distraction can reduce perception of pain. Distraction strategies are highly effective in reducing reported and observed pain and distress in children in the ED. Reducing the child’s distress and gaining cooperation lead to requiring fewer staff, facilitating safe and effective accomplishment of the medical procedure, decreasing parent anxiety, and increasing parent satisfaction.22
PFCC also supports family presence during procedures and resuscitation, promotes acceptance by the patient and family of resuscitation decisions, and does not interfere with care or increase risk for litigation. Family presence during resuscitation can also provide the ED team with pertinent information that might be critical for making the correct diagnosis and provide an appropriate treatment plan. Establishing a clear policy and procedure for family presence, supported by all levels of the hospital staff, including other subspecialties, might decrease family and staff anxiety when procedures and resuscitations are required.7,24,25
PFCC also encourages timely communication between the ED and the medical home, including access to electronic health records, which can facilitate understanding of the medical history and other vital sources of pertinent information regarding the patient, which help ED clinicians to provide quality and safe care. The Institute for Patient- and Family-Centered Care has many relevant resources, including a self-assessment inventory specific to the ED.26
In addition, PFCC is especially important for safe care in the ED for children and youth with special health care needs, such as children with intellectual disabilities, nonverbal cerebral palsy, and deafness. Specific components of dignity and respect (such as listening to families), participation, collaboration, and information are essential to enhance the family experience and patient safety. Other factors valued by parents included child-oriented resources, supports for families, and environmental resources (eg, conducive and welcoming waiting room design and wait-time strategies).27
Of importance, patients who become agitated or violent because of overstimulation, fear (eg, patients with autism spectrum disorder or sensory processing disorder), or other underlying medical or behavioral disorders can be a flight risk or risk of harm to other patients and the medical team. Safety measures can minimize the risk of harm to patients and staff. These measures include staff training in crisis intervention and safe de-escalation techniques; use of available safety resources, including hospital security; and checking the room, patient, and visitors for potentially dangerous items.
Cultural Competence, Cultural Humility
With the growing diversity in patient populations, especially children, across the United States, there is an increased risk for missed care opportunities and safety events. Explicit and implicit biases of health professionals can influence how they process information, which can affect diagnosis and treatment decisions and consequently lead to errors and health inequities.28 The fast pace and stressors in the ED environment can lead to cognitive shortcuts and greater use of stereotypes, which may exacerbate implicit biases in health care settings.28
Several recent studies in pediatric EDs have demonstrated racial and/or ethnic disparities in many aspects of emergency care, such as analgesic management for children presenting with acute abdominal pain, appendicitis, and fractures29–31 ; imaging,32 and antibiotic prescriptions in viral infections.33
In a study by Johnson et al, analysis of data from the National Hospital Ambulatory Medical Care Survey regarding 2298 visits by patients 21 years or younger who presented to EDs with abdominal pain was conducted to determine whether race and ethnicity-based differences existed in the management of such patients. Authors adjusted for confounders in the analysis, including clinical, system-level, and socioeconomic factors and found race and ethnicity-based differences in that non-Hispanic Black patients were less likely to receive any analgesic or a narcotic analgesic (even for severe pain) than non-Hispanic white patients and were more likely to have prolonged length of stay.29
Goyal et al conducted a retrospective cross-sectional study of children younger than 18 years with long-bone fractures using the Pediatric Emergency Care Applied Research Network Registry to measure the association between patient race and ethnicity and likelihood to receive analgesics or opioid analgesics and to achieve pain reduction.31 Authors found that non-Hispanic Black and Hispanic pediatric patients were more likely to receive analgesics and achieve a ≥2-point reduction in pain, but they were less likely to receive opioids and achieve optimal pain reduction.31
A large multicenter cross-sectional study of more than 13 million pediatric ED visits to 44 children’s hospitals demonstrated that non-Hispanic Black and Hispanic patients were less likely to undergo diagnostic imaging than were non-Hispanic white nonhospitalized patients across all insurances. The largest imaging differences were for conditions related to the male reproductive system, eye, and digestive conditions.32 There are many contributing factors, such as parent and guardian preferences, clinician biases, and structural factors. The differences in imaging could be attributable to underuse of imaging in non-Hispanic Black and Hispanic children, or alternatively, overuse in non-Hispanic white children, both of which can contribute to unsafe care. Overuse may expose children to unnecessary risks associated with imaging, and underuse may result in misdiagnoses, delay in diagnosis, and potentially worse clinical outcomes. Therefore, future work should target factors that contribute to enhancing the quality of care delivered and health outcomes for all children.32
A recent systematic review demonstrated a significant inverse relationship between the level of implicit bias and quality of care.34 Therefore, efforts to target implicit bias training and diversifying the ED workforce have the potential to close some of the gaps in heath disparities.
Cultural competency and humility are crucial to the delivery of optimal medical care. Overcoming cultural barriers is especially important in the ED setting because patients might use the ED as their first choice for health care. Education in health equity can improve clinicians’ cultural competency, humility, and awareness of their own implicit bias in pediatric ED settings.35
As our population becomes more diverse ethnically, racially, and linguistically, the challenge of providing safe and effective care becomes more evident. According to a report from the Agency for Healthcare Research and Quality, approximately 57 million people (20% of the US population) speak a language other than English at home, and approximately 25 million (8.6% of the United States population) are defined as having limited English proficiency.36 Language and cultural barriers have a great impact on health care delivery and patient safety because of higher rates of medical errors and worse clinical outcomes.37–43 In addition, language barriers may influence the evidence-based guideline management of children in the ED, which might not align with optimal and safe care. For an example, in a study by Zamor et al, of children presenting to the ED with acute bronchiolitis, children of non–English-speaking families were more likely to receive low-value testing (eg, chest radiography, laboratory tests) compared with English-speaking families.44 Another study suggested that patients with limited English proficiency are more likely to return to the ED for admission than English-speaking patients.43
Addressing language barriers involves providing professional language services and interpreters via phone or video 24/7, which is critical to provide safe care. Teleinterpreter services, including sign language, can also be used when needed. These services are used to obtain the correct information from patients and families as well as to explain and answer any questions patients might have regarding workup, procedures, and/or disposition.
When interpreters are not used to communicate with patients, the risk of adverse safety events increases.45 Clinicians with basic or intermediate foreign language skills often attempt to “make do” or “get by” without the use of a qualified interpreter. Clinicians’ assumptions that patients understand the information exchanged on the basis of nonverbal clues, such as nodding or smiling, is a major factor contributing to errors.45 Moreover, the use of family members and friends as interpreters is tempting, but the ability to accurately translate medical information is a skill that can be acquired only through training.45 Other recommendations in addition to hospital interpreters could include teleinterpreter services and include sign language.
Errors in Diagnosis in Pediatric Emergency Medicine
Errors in diagnosis can lead to inappropriate treatment, which can lead to patient harm. Diagnostic decision-making, a highly complex cognitive process, involves rapid information gathering and synthesis from history, physical examination, and laboratory or radiographic investigations. The diagnostic process is made under conditions of uncertainty, particularly in the ED setting, and thus, is highly susceptible to errors.46 Indeed, diagnostic errors are increasingly recognized as a major safety health concern. It is estimated that diagnostic errors occur as often as 1 in every 10 diagnoses, and such errors cause harm for 1 in every 100 ambulatory encounters.47
Diagnostic errors can result from breakdowns in the diagnostic process at any and/or all of the process’s domains. In addition, many factors contribute to diagnostic processes failures. Patient factors include language barriers, lower health literacy, and altered mentation. Clinician factors include overconfidence, cognitive biases, inadequate training, loss of skills or competencies, and drug use. Systems factors include, but are not limited to, lack of available resources and poorly designed electronic health systems. There are many safety concerns when clinicians in the ED might not have access to medical records of patients, particularly those with complex health conditions, to make clinical decision about care. Access to emergency information could be in different forms, such as electronic format, web-based, and paper-based forms. Access to emergency information can lead to more optimal care and improvement in patient safety. This includes a decrease in medical errors, reduced morbidity and mortality attributable to improved medical decision making, and more appropriate and timely delivery of therapeutic interventions.
In the diagnostic processes, information is processed via 2 systems, including pattern recognition and analytic thinking. Experts switch between the 2 processes but spend the bulk of their time in pattern recognition system.48 Pattern recognition allows clinicians to think more efficiently about common diagnoses and make rapid decisions, which is particularly salient in ED settings but places clinicians at risk for cognitive biases.49 Some common cognitive biases that can lead to diagnostic error are included in Table 1. Finally, there is an increased recognition of the impact of the system—ie, the context of care, the influence of the diagnostic team members, and the socioeconomic system (disparities attributable to insurance, race, language barriers, social determinants of health) in which the patient-provider interaction occurs that predisposes to diagnostic errors.47
Investigators have begun systematically addressing the issue of diagnostic errors in the pediatric population50–53 and in the pediatric emergency care setting.54–58 In a cohort study of patients in whom appendicitis was diagnosed, appendicitis was initially missed in 6.0% of adults and 4.4% of children in ED visits. Population-based estimates of the rates of potentially missed appendicitis reveal opportunities for improvement and identify factors that may mitigate the risk of a missed diagnosis.55
In a study by Sundberg et al, authors developed and applied a computerized tool to identify discordance between ED and hospital discharge diagnoses with potential for serious consequences.56 Discordance between ED and hospital discharge diagnoses occurred in 3.1% of cases, with the most common discordant diagnoses being Kawasaki disease and pancreatitis. Identifying such discordance may be valuable for improving ED diagnostic accuracy. On the other hand, final diagnosis might not be made in the ED, and the patient is admitted for further workup to make the diagnosis.
Shift Work, Burnout, and Wellness
It has long been recognized that clinician factors, such as physician burnout, have a significant influence on the health care system in terms of productivity, care quality, and patient safety.59–61 Burnout has led many physicians to consider reducing workload, retiring early, quitting, and even suicide.59–62 Clinicians’ mental health is also often affected by burnout.61
When measuring care quality in terms of patient safety, it is important to consider factors related to medical errors. These factors, which include diagnostic errors, incorrect medication orders, delayed care, and incorrect documentation, often have their roots in burnout.61 In a systematic review, authors found that poor well-being and moderate to high levels of burnout among staff are associated with poor patient safety outcomes, such as medical errors. Therefore, health care organizations might consider investing in improving employees’ mental health and work environments when planning interventions.63 Caring for the mental health and wellness of ED personnel may become more critical during disasters, such as during the coronavirus disease 2019 (COVID-19) pandemic because of the stressful work circumstances (lack of inpatient bed availability because of nursing shortage, leading to increase in ED on-boarding coupled with shortage of ED personnel, causing increase in their workload beyond capacity). In addition, there are concerns whether the medical profession will be able to attract sufficient numbers of nurses to care for populations into the future. Therefore, governments and health policy makers need to invest in the wellness of health care professionals, especially nursing, to ensure a healthy population.64,65
The 24-hour operation of the ED has created the need for shift work.66 When clinicians violate the normal circadian rhythm, this inevitably leads to sleep deprivation and chronic fatigue. In fact, “off hour” shift work including evenings, nights, weekends, and holidays, as well as changing shift assignments from day to night, has been associated with premature burnout as well as poor overall physical, cognitive, and mental health.63,66–69 Minimization of the short-term negative effects of a shifting sleep schedule can be accomplished with behavioral interventions such as light therapy, keeping a consistent shift, moderate caffeine consumption, and scheduled naps. Also, many of the risks of shift work of all ED staff are associated with metabolic syndrome and obesity. Therefore, keeping a healthy weight, exercising regularly, and adopting healthy eating habits might decrease such risks.
II. Managerial Factors
Psychological Safety and Reporting Close Calls
As part of the HRO, through the establishment of a reporting culture, everyone is empowered to identify and share patient care issues so that teams can take immediate action. The specific elements of psychological safety entail the following 4 attributes: (1) anyone can ask questions without looking stupid; (2) anyone can ask for feedback without looking incompetent; (3) anyone can be respectfully critical without appearing negative; and (4) anyone can suggest innovative ideas without being perceived as disruptive. An environment of psychological safety allows for appropriate communication reporting.70
Incident reporting can increase patient safety, and a proactive mindset can help contain and prevent errors. Therefore, patient safety can be enhanced using reports from front-line staff of close calls and unsafe conditions to identify latent safety events. In transparent organizations, it is clear how the entities make decisions and track performance, and they have the courage to display their work openly.
In a 1 year observational study of near-miss events and unsafe conditions among hospitals in the Pediatric Emergency Care Applied Research Network, Ruddy et al found that medications and process-related issues were important causes.71 Human factor issues were highly reported, and noncompliance with established procedures, calculation issues, communications (ie, handoffs), and clinical judgment were also reported. Such reporting is vital to continue to improve systems within the ED environment to ensure patient safety.
Of interest, families could be an underused source of data about errors, especially preventable adverse events. A study by Khan et al found that parents frequently reported errors and preventable adverse events, many of which were not documented anywhere in the medical record or event reporting. Of 383 parents surveyed (81% response rate), 34 parents (8.9%) reported 37 safety incidents. Two thirds of these errors were determined to be medical errors on physician review, with 30% of medical errors causing harm (ie, were preventable adverse events).72
Of importance, joint review and auditing of “close calls” among ED physicians and nursing staff might help in creating “just culture.” When the culture of an organization is just, it is expected that fair treatment will generate a sense of trust in the medical team. Perceptions of unfair treatment and blame suggest a possible reluctance among clinicians to report, or worse, to believe they should hide events. Therefore, open communication is critical to reporting from close calls.73 In addition, continuous learning requires feedback loops to provide data back into the various reporting systems to share information and generate insights to prompt action and learning.
ED Crowding and Patient Safety
ED crowding occurs when the need for emergency services exceeds the available resources in the ED and is detrimental to both public health and patient care quality and safety.74,75 The number of ED visits in the United States has shown continued growth, with an estimated 139 million ED visits in 2017, and 28 million of those ED visits were for children younger than 15 years.76 ED overcrowding occurs when there is a mismatch between the rising numbers of ED patients and availability of ED capacity or the increase in the ED on-boarding because of lack of inpatient bed or staff availability, as witnessed during the COVID-19 pandemic.
ED crowding threatens pediatric patient safety and poses an increased risk of medical errors.77 Studies have shown that crowding is associated with delays in antibiotic administration in febrile neonates,78 delays in analgesic administration in pediatric patients with sickle cell pain crisis,79 decreased timeliness and effectiveness of care for children with acute asthma exacerbation,80,81 and decreased timeliness and effectiveness of analgesia administration to children with fracture-associated pain.82 ED crowding has also been shown to be associated with prolonged wait times, which can lead to patient dissatisfaction83 and an increased rate of patients leaving without being seen and delaying care.76
Sustainable solutions to ED crowding are complex, resource-intensive, and involve input, throughput, and output factors.74,75,84 Solutions aimed at decreasing input by increasing primary care access through extended hours have helped reduce ED crowding.85,86
ACEP and the AAP highlight that ED throughput can be improved by implementing a 5-level triage system with nurse-initiated, evidence-based, standardized pathways and order sets at the point of initial triage.87–89 The use of clinical pathways has been shown to decrease variation, increase efficiency, and improve safety for pediatric patients.90–92 Hospital EDs can also focus on improving the efficiency of care provided to all acuity levels through the use of fast track and split flow on presentation.92,93 Innovative ED staffing models that adapt to growing patient needs and care utilization can also help improve throughput.94 Many EDs have developed observation units to further clarify which patient truly needs hospital admission. With these observation units, many patients avoid hospital admission even after initial treatment in the ED that would have led to hospitalization. Of note, the needs of each individual ED are unique. Therefore, the utilization and distribution of various staffing models utilizing physicians and other clinicians within the ED should be determined at the site level by local ED leadership.95
Increasing output through the introduction of active bed management to facilitate timely ED to inpatient bed transfer has been associated with decreased ED length of stay.96,97 Improvement of hospital inpatient discharge processes, such as timely room cleaning, streamlining the discharge process, and conducting early rounds to determine patients’ eligibility for discharge, can certainly facilitate early transfer of patients from ED to the inpatient unit. Further research, education, and collaboration are essential to developing and implementing sustainable solutions to prevent and manage ED crowding to improve patient quality and safety. Despite such efforts, boarding of admitted pediatric patients in the ED, particularly for mental and behavioral health emergencies, continue to occur because of the delay in transfer of care and limited availability of inpatient units.98 Early recognition of patients who are at high risk of harm to self or others and utilization of designated safe locations in the ED improves staff and patient safety (eg, quiet environment, safe shower facilities with no hanging cords for patient presenting with suicidal ideation or attempt). Utilizing a standardized handoff in boarded patients, who typically have their care handed off more often, is also critical in ensuring a safe and quality-driven transfer of care.
Disasters, such as the COVID-19, pandemic can create many factors that increased the frequency of emotional and behavioral health problems in children and adolescents, such as the duration of the crisis, conflicting and rapidly changing messages, need for quarantine and physical isolation, and uncertainty about the future.99 These factors were compounded with the interruption of routine health care services, school and other community supports. Black and Hispanic families have also suffered even worse mental health outcomes during the pandemic because of the increased burdens of grief, food insecurity, financial instability, and education interruption.100
The AAP recently joined the American Academy of Child and Adolescent Psychiatry and the Children’s Hospital Association to declare national state of emergency in children’s mental health. Of significance, pediatric mental health boarding may worsen during disasters such as in the COVID-19 pandemic because of the increase in frequency and severity of mental illnesses.101 In addition, there is a significant increase in length of stay (LOS) for mental health ED visits with great disparities for people of Hispanic ethnicity, which was associated with an almost threefold odds of LOS >12 hours. This finding could suggest worsening and inequitable access to definitive pediatric mental health care.102
Advocacy for systematic health care changes beyond the ED are necessary to increase access to early mental health illness identification and intervention, integrate mental health into pediatric primary care and in schools with appropriate increase insurance coverage and payment, and strengthen the child and adolescent mental health workforce. In addition, in a recent study by Das et al, authors found that increased continuity of mental health care at community health centers corresponded with a reduction in racial disparities in youth psychiatric ED visits.103
In addition, expansion of telehealth mental health care consults to be available to the ED has the potential to assist with safety planning and postdischarge mental health outreach, enabling ED personnel to provide timely evidence-based mental health treatments, and might help in reducing the burden for pediatric centers and pediatric psychiatric units.104
III. Organizational and Environmental Factors
Teamwork and Team Training
Highly trained individuals with different roles and responsibilities acting in the best interest of the pediatric patient are required to provide safe emergency care. Lack of situational awareness and failure to recognize barriers to communication among disciplines can lead to errors. Originally developed by the aviation industry, recognition of the need for teamwork training in health care has led to the application of teamwork principles. Although there is no single standardized program for teamwork training, it is recognized that all share similar key concepts.105–107 Training that teaches team members to crosscheck each other’s actions using easy-to-remember acronyms and mnemonics like those identified in the Children’s Hospital’s Solutions for Patient Safety-Zero Harm program decrease the possibility of errors.107
Team training creates a plan for review of errors that is nonjudgmental and provides feedback related to system errors as well as individual drift. ED team training via simulation enhances classroom education with specific scenarios to facilitate critical thinking skills, team interaction, and communication. Multidisciplinary teams benefit from preevent briefing, huddles, and postevent debriefing to help identify opportunities for improvement. Simulation of team interaction can be an effective quality assurance tool for improving patient safety.107 In a study by Patterson et al, the implementation of a multidisciplinary, simulation-based curriculum emphasizing teamwork and communication in a pediatric ED with a preintervention baseline of 2 to 3 patient safety events per year has resulted in more than 1000 days without a patient safety event.108 Therefore, simulation training is an effective tool to modify safety attitudes and teamwork behaviors in the ED setting. Sustaining cultural and behavioral changes requires repeated practice opportunities and accountability for all team members to complete the training.
Interprofessional education is fundamental for improved care coordination and enhanced patient safety. Team training can be effectively embedded in physician, nursing, and emergency medical service (EMS) training programs. The Agency for Healthcare Research and Quality provides information on several team-training programs with documented success in improving communication and teamwork, which is critical in emergency care settings.109
In addition, incorporation of a cultural broker, when available, who is the mediator between the traditional health beliefs and practices of a patient’s culture and the health care system, embraces the importance of cultural distinctions among patient groups.110 Typically, cultural brokers’ work goes beyond simply translating language and may support the team to effectively address cultural differences in their practices and subsequently promote health equity and safety.
Emergency Department Shift Huddles
Huddles support efforts to improve patient safety when they afford opportunities for heedful interactions to take place among all individuals caring for patients. Huddles create time and space for conversations geared toward care coordination. They enhance relationships and collaboration and strengthen a culture of safety, increasing in individual and collective accountability for patient safety.111–113 Team huddles consisting of nursing staff, physicians, respiratory therapists, and other personnel in the ED provide the right setting for discussion among the team regarding patient safety and goals of care.114
Safety huddles are also called daily safety briefings, daily check-ins, or daily safety calls. Huddles are recommended as a team-building tool in Team Strategies and Tools to Enhance Performance and Patient Safety, which is an evidence-based teamwork system aimed at optimizing patient outcomes and safety, to increase situational awareness.105
Many EDs experience communication breakdowns during shift changes. Short huddles before the start of a shift are a great way to promote teamwork by emphasizing the value of each coworker in contributing to the care to all patients and recognizing that patient safety is a shared responsibility. In addition, if time and circumstances allow, less formal “spot” meetings midshift to tackle any foreseeable concerns are encouraged.
Huddles can also improve the interprofessional and interdepartmental communication and collaboration between the ED and hospital units to improve patient flow from the ED to other units. Expedited patient admission from the ED to the appropriate unit where they can receive definitive care can potentially improve the quality and safety of patient care.115
Handoffs in the Emergency Department
Patients requiring emergency care often transition among multiple care areas, including the prehospital setting, the ED, inpatient units, and medical homes. During these transitions, multiple clinicians may care for a patient, and the responsibility of the patient’s care may transfer from one clinician to another. Multiple clinicians within the ED may also care for patients across shift changes. All of these transitions of care require handoffs to exchange mission-specific information, responsibility of care, and authority for treatment and procedures.6
It is important to recognize that miscommunication and misinformation that starts in the ED may affect a patient’s inpatient and outpatient care as well. These handoffs are a well-documented safety risk in the ED because of communication errors,118–121 cognitive biases,120 and environmental factors.6 As a result, the Accreditation Council for Graduate Medical Education122 and The Joint Commission123 highlight the importance of standardized processes to reduce handoff-related errors and recommend enhancing handoff processes to improve patient safety. The joint policy statement from the AAP, ACEP, and ENA on handoffs reviewed many recommendations to improve the safety practice in the ED setting.6
Unfortunately, structured handoffs occur in less than 20% of handoffs from ED to inpatient care.124,125 Numerous models have been implemented and studied to improve the quality of handoffs, including checklists,123,126 structured mnemonics,125,127,128 and handoff bundles.129,130 Examples of mnemonics include SBAR (situation, background, assessment, and recommendation),131 SOUND (synthesis, objective data, upcoming tasks, nursing input, and double check),125 ABC-SBAR (airway, breathing, circulation followed by situation, background, assessment, and recommendation),128 and I-PASS (illness severity, patient summary, action list, situation awareness and contingency planning, and synthesis by receiver).127 Quality improvement efforts designed to standardize handoffs can reduce care failures across multiple handoff types129 and reduce medical errors and preventable adverse events.130
It is critical to actively engage patients and families in safety at all points of care, use shared decision-making, and address issues of ethnic culture, literacy, and language by using trained language interpreter services rather than bilingual relatives.7,45 In addition to improving the quality and efficiency of handoffs, some pediatric EDs have developed novel and innovative physician staffing models to allow overlapping shifts to decrease the number of handoffs that occur.132
Special attention to identification and monitoring of patients in high-risk situations is warranted, in which key team members will visit such patients regularly to assess for change in clinical status. This situation would include handoff of an uncertain diagnosis or disposition, an unstable patient, a consultant-driven evaluation, a pending imaging study, deviations from a typical diagnosis or treatment plan, or a prolonged stay in the ED.133
Handoffs are a critical risk point for care failures, and further research comparing different handoff models in the ED setting are encouraged to determine their effects on patient harm and clinical outcomes. In addition, best practices for handoffs need to be derived and validated so they can be implemented to improve patient safety in the ED.
EMPOWERMENT OF THE WORK FORCE TO EMPLOY ROBUST PROCESS IMPROVEMENTS AND SAFETY STRATEGIES
It is critical for patient safety for staff to be empowered to do what is necessary for patients in a timely manner, keeping the best interest of the patient in mind. Such empowerment includes adapting to technology and developing and implementing strategies targeting providing safe and quality medical care. Staff members also need to build improvement capability and skills and receive coaching on applying these skills in their daily work.
In addition, information from front-line clinicians is critical to continue to improve any system process or strategies taken to increase patient safety.
The Role of Information Technology in Patient Safety
The widespread adoption of health information technology largely stems from recognition of the important role that it plays in improving health care safety and quality. In addition, technology plays a key role in modern health care including EDs, where the electronic health record (EHR) integrates bed management, patient flow, medications, abnormal study results, charting, changes in clinical status, and disposition planning.
The implementation of computerized physician order entry (CPOE) and clinical decision support (CDS) with electronic prescribing has reduced many ordering medication errors. Most CPOE systems obviate the need for simple dose calculation.134 A study by Sethuraman et al compared prescription error rates before and after introduction of CPOE with an electronic medication alert system in a pediatric ED.135 A CPOE with an electronic medication alert system was associated with a decrease in overall prescription errors. Alerts were generated for 29.6% of prescriptions, with 45% involving drug dose range checking. Prescribers modified 20% of these dosing alerts based on dosing alerts preventing the error from reaching the patient. However, 11% of true dosing alerts for medication errors were overridden by the prescribers: of these, 11.3% resulted in medication errors, and 88.6% were false-positive alerts. Therefore, system refinements are necessary to reduce the high false-positive alert rate, which could lead to alert fatigue.135 It is important to note that CPOE systems have not fully eliminated medication errors in children, because commercial or independently developed CPOE systems may fail to address critical unique pediatric dosing requirements.134
CDS tools are often integrated into EHRs to streamline workflows and take advantage of existing data sets. Many EDs are still facing challenges when it comes to creating user-friendly, and effective protocols for alarms, alerts, and decision-making pathways. An example of a guideline embedded within information systems to increase adherence to best practices is the successful CDS implementation in EHR of the 2 Pediatric Emergency Care Applied Research Network prediction rules to identify children at very low risk of clinically important traumatic brain injury.136 The authors implemented these prediction rules as decision support within the EHR to reduce computed tomography utilization. As a result, head computed tomography scan utilization rates decreased from 26.8% to 18.9%, with no increase in returns within 7 days and no significant missed diagnoses.
Other technological solutions to medical safety concerns include the use of electronic equipment (eg, programmable “smart” infusion pumps in neonates,137 barcoding to compare identification bands with medications), which has resulted in improved detection of medication calculations and administration errors.138
Other technological advances include telehealth use in the emergency care setting. Physicians in pediatric EDs can provide consultative services via telehealth to general EDs, urgent care centers, interfacility transport teams, EMS systems, primary care provider offices, and schools. These services could be critical to provide timely and safe care in rural and critical access areas.139 In addition, telehealth might promote safe and high-quality care by minimizing preventable transfers.140 This minimization of transfers is accomplished by allowing remote specialists or critical care specialists the opportunity to more effectively assess patients in the ED during consultations.141,142
Per a recent ACEP policy statement on telehealth, physicians are encouraged to clearly communicate treatment options, include patients and families in the decision-making process, and provide instructions on how to obtain higher-level care when needed.143 Of note, telehealth in the pediatric medical home can help eliminate access barriers, preserve the integrity of the pediatric medical home, and prevent the fragmentation of care common with standalone direct-to-consumer telehealth care providers. Medical home–based telehealth visits can also reduce ED visits for nonurgent care, thus preventing overcrowding and promoting patient safety.144
Because of factors such as the increased availability of health care data combined with the rapid evolution of analytics techniques, artificial intelligence (AI) is integrating the health care system. Applications based on AI have many implications for patient safety. Because the ED is where many diagnostic and treatment decisions must be made quickly and effectively, the ED and triage specifically have been a major focus for data scientists familiar with AI methods. Machine learning is an AI technique that utilizes statistical models to efficiently extract patterns and “learn” from both structured and unstructured data, including free text.145 After the model is “trained” with large volumes of existing data, it can be deployed into the clinical environment to help assist with clinical decision making. These methods enable real-time predictive analytics that can help monitor vulnerable populations,146 reduce human error, increase the accuracy of diagnostic and treatment decisions, and improve patient outcomes.147 In the ED, these methods have been used specifically to identify diseases such as sepsis, appendicitis, and bronchiolitis.147 AI methods have also been used to predict the need for admission or discharge, mortality, and triage acuity levels.147 These predictive analytics techniques can also be used to guide operational decisions, which have safety implications, such as assisting with “smart” data-based scheduling of both patients and clinicians.148
Strategies for Improving Medication Safety in the Emergency Care Setting
Medication errors are the most common type of medical error occurring in hospitalized patients, with rates being 3 times higher in pediatric versus adult patients.149,150 Medication error rates in pediatric EDs range from 10% to 31% and as high as 36% in rural EDs.151,152 Many factors contribute to the emergency care setting being at high risk for medication errors, particularly in children. These factors include lack of standard pediatric drug dosing and formulations, weight-based dosing, frequent interruptions, frequent transitions in care, and the lack of a pharmacist on the medical team. A summary of risk factors for medication errors during ordering, preparation, and administration and strategies for improvement is listed in Table 2. In addition, most children are cared for in EDs that treat a low number of pediatric patients, which can exacerbate such challenges.8 In a study by Alvarez et al, it was noted a high (90.6%) percentage of surveyed adult community hospitals regarding pediatric medication safety infrastructure used order sets or CPOE with pediatric weight-based dosing and 84.4% of respondents document weights only in the metric system (kilograms or grams) in the ED. On the other hand, only half had milligram-per-kilogram dosing required in the order. In addition, hospitals with greater than 300 beds had more resources and were likely to have a pediatric pharmacist than those with less than 300 beds (75% vs 44%, P ≤ .05).153
A joint policy statement from AAP, ACEP, and ENA on pediatric medication safety in the ED included many strategies for improvement.8 It is essential to use weight in kilogram as the base to calculate appropriate medication dosing, rather than pounds, to avoid inappropriate calculations, including tenfold-dosing errors.154 The development of a standard pediatric formulary can reduce opportunities for error by having standard concentrations and dosage of high-risk and frequently used medications, such as resuscitation medications, vasoactive infusions, narcotics, and antibiotics, as well as look-alike and sound-alike medications.8
Many organizations including ACEP and ENA support the integration of ED pharmacists with the ED team to verify the preparation, dosing, dispensing, and reconciliation of the many medications administered in the ED as well as drug education to the heath care team and patients.155–157 Having pharmacists in the ED directly, either on site or remotely (telepharmacy), has the potential to increase medication safety in the ED setting. Other strategies include the use of a distraction-free medication safety zone and implementation of an independent 2-provider check process158 for high-alert medications, as suggested by The Joint Commission and the Institute for Safe Medication Practices.159,160 Patient-identification policies, consistent with The Joint Commission’s National Patient Safety Goals, should be implemented and monitored.160
A recent collaborative effort of the AAP and the American Academy of Pediatric Dentistry has led to the publication of guidelines that offered health professionals updated information and guidance in delivering safe sedation to children.161
Developing policies and procedures for identifying, investigating, and disclosing adverse events related to medication errors to patients and families is important to help clinicians understand and navigate disclosure barriers. Honest and empathetic disclosure of error may reduce liability risk and litigation costs. The AAP policy statement on disclosure of adverse events in pediatrics includes clear delineation of disclosure barriers and ethical considerations in disclosure and provides practical disclosure skills.162
Pediatric Emergency Care Safety During Disasters
Optimal pediatric disaster preparedness is built on a foundation of emergency care systems that operate reliably, effectively, and safely on a day-to-day basis. Enhancing the abilities of EDs and health care systems to meet the needs of children and their families under normal operating conditions is a sensible tactic toward improving operational resiliency for large-scale or surge events that impact children.16 EDs that make the commitment toward becoming “pediatric ready” will be better prepared to safely and effectively respond to the needs of children during disasters. EDs resourced with a physician and nurse pediatric emergency care coordinators are likely to be best prepared.16
Children have unique physiologic, psychosocial, and psychological needs that differentiate them from adults; these differences and their care requirements may expand further during a public health emergency, especially under disaster conditions.163 Emergency and disaster readiness should consider the needs and relative vulnerabilities of the local community and the population of children served. Planning should consider children of all ages, including the special needs of pediatric patients with access and functional needs, who may have pre-existing conditions and physical, developmental, and psychosocial disabilities. Disaster planning must also take into consideration the risks and needs of children and families residing in marginalized communities.163
There are data indicating a steady increase in the occurrence and severity of natural disasters attributed by many to climate change. Disasters aside, climate change has had a profound impact on the health of children.164 Because of their location, some communities are exposed to naturally occurring disaster threats on an annual basis, whereas in many communities disasters represent a very low-frequency event. Regardless of location, all EDs should stand ready to respond to the needs of their entire community during a crisis, including children.164
Of note, a 2012 to 2013 national survey of ED readiness for pediatric care demonstrated that only 47% had any consideration for the needs of children in their disaster plan.16 The Emergency Medical Services for Children Improvement and Innovation Center has resources targeting important aspects of emergency care for children during disasters in a pediatric disaster preparedness toolkit based on a national multidisciplinary collaborative group.165 This toolkit includes many helpful resources, such as a checklist to help hospital administrators and leadership incorporate essential pediatric considerations into existing hospital disaster policies and resources essential to provide psychosocial support to children and families during and after disasters to ensure safety. It also provides resources to assist in the development of reunification planning elements that are inclusive, considering nonverbal children and children with disabilities and other access and functional needs, including hearing and visual impairments.
As already mentioned, readiness for the “disaster of one” on a day-to-day basis represents an important first step. Preparations for a surge event should include efforts to expand both care capacity (patient volume) and capabilities (scope of care provided) safely. Even in a children’s hospital setting, disaster care delivery will be of higher quality and safer if the institution engages in regular drills. For these exercises to be most useful, the scenario should include a number of children in excess of what might ordinarily be encountered. Hospitals will also need to consider providing levels of pediatric care not typically offered (eg, pediatric inpatients), because standard mechanisms for transfer may be disrupted and because there may be no availability of beds at the usual referral center.
There are many unique considerations in preparing to care for children safely during a disaster. Children spend an extraordinary amount of time outside their homes in school, camps, or child care programs. Affected children may, therefore, present to the ED without their parent or guardian. Infants, preschool-aged, and even some young school-aged children will be unable to fully self-identify. Hospitals must have the ability to safely track, identify, and protect unaccompanied children with a goal of accurate reunification with family or with the appropriate local agency.166,167 For children arriving with a family member, efforts must be taken to avoid the separation of the child from their family during treatment. The AAP has developed a hospital family reunification toolkit to highlight best practices for effective and safe family reunification.167
Certain disaster agents or pathogens require the use of personal protective equipment (PPE) in the delivery of care. ED and hospital staff should regularly practice the safe donning and doffing of PPE; this practice will promote patient and staff safety. Exercises should also allow for staff to practice emergency care delivery, including procedures while wearing PPE. Some disaster agents may require decontamination at the time of arrival to the ED. Reflecting on the unique characteristics of children, decontamination may require lower water pressure and warmer water temperature to avoid injury or hypothermia as well as consideration for the decontamination of the intact family.168
Because disasters will almost certainly continue, the ultimate goal for disaster readiness is community resiliency. Resiliency can be pursued via a whole community approach to planning, including the medical home and schools. As we are reminded by the COVID-19 pandemic and many other disasters, the largest impact on the health and well-being of children and their families has been within behavioral and mental health. It is reasonable to assume that every disaster will demonstrate a similar impact. Disaster recovery requires that plans be in place across the community and health care delivery system, including EDs, to address the increase in illness prevalence and gaps in available services.169,170
The AAP Council on Children and Disasters (previously the Disaster Preparedness Advisory Council) has developed and periodically updates resources relating to pediatric readiness.171 The AAP offers a Pediatric and Public Health Preparedness Exercise Resource Kit that provides tools and templates to make it easier for states, communities, hospitals, or health care coalitions to conduct a pediatric tabletop exercise.172 This kit was based on implementation of an AAP and Centers for Disease Control virtual exercise. A recent study was conducted to evaluate the effectiveness of virtual tabletop exercises in improving preparedness capabilities specific to children’s needs among pediatricians and public health practitioners. The study demonstrated that participants viewed virtual tabletop exercises positively and indicated increased pediatric emergency preparedness knowledge and confidence.173 Continued work is needed to address barriers to improving local pediatric emergency preparedness for providing safe care during disasters.
In the 2000 report, “To Err is Human: Building a Safer Health System,”1 the Institute of Medicine highlighted the need to build the infrastructure for providing quality and safe medical care. Although much progress has been made to improve pediatric patient safety, there remain significant opportunities for further progress in ensuring safety of pediatric patients in emergency care settings. Pediatric patient safety requires a multidisciplinary approach across the continuum of care starting from the prehospital setting, through the ED, to inpatient settings, and beyond. Key areas for pediatric patient safety specific to emergency care that warrant attention include hospital and ED leadership commitment to safety by ensuring that EDs have the appropriate resources and capable staff to provide emergency care for children per the AAP, ACEP, and ENA joint policy on pediatric readiness in the emergency department.5 In addition, recognition of implicit and cognitive biases on safety and quality of care is critical given that the fast pace of ED heightens such biases. Other important factors including teamwork, communications, and handoffs are also important in ensuring pediatric safety in emergency care settings.
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.
The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
Madeline M. Joseph, MD, FAAP, FACEP Prashant Mahajan, MD, MPH, MBA, FAAP Sally K. Snow, RN, BSN, CPEN, FAEN Brandon Ku, MD, FAAP Mohsen Saidinejad, MD, MS, MBA
AAP Committee on Pediatric Emergency Medicine, 2020–2021
Gregory P. Conners, MD, MPH, MBA, FAAP, Chairperson James Callahan, MD, FAAP Toni Gross, MD, MPH, FAAP Madeline Joseph, MD, FAAP Lois Lee, MD, MPH, FAAP Elizabeth Mack, MD, MS, FAAP Jennifer Marin, MD, MSc, FAAP Suzan Mazor, MD, FAAP Ronald Paul, MD, FAAP Nathan Timm, MD, FAAP
Mark Cicero, MD, FAAP – National Association of EMS Physicians Ann Dietrich, MD, FACEP – American College of Emergency Physicians Andrew Eisenberg, MD, MHA – American Academy of Family Physicians Mary Fallat, MD, FAAP – American College of Surgeons Patricia Fanflik, PhD, MFT, MS – Maternal and Child Health Bureau Cynthia Wright Johnson, MSN, RN – National Association of State EMS Officials Sara Kinsman, MD, PhD, FAAP – Maternal and Child Health Bureau Cynthiana Lightfoot, BFA, NRP – AAP Family Partnerships Network Charles Macias, MD, MPH, FAAP – EMSC Innovation and Improvement Center Diane Pilkey, RN, MPH – Maternal and Child Health Bureau Katherine Remick, MD, FAAP – National Association of Emergency Medical Technicians Sam Shahid, MBBS, MPH – American College of Emergency Physicians Elizabeth Stone, RN, PhD, CPEN – Emergency Nurses Association
Former Committee Members, 2018-2020
Joseph Wright, MD, MPH, FAAP, Chairperson (2016-2020) Javier Gonzalez del Rey, MD, MEd, FAAP
Former Liaisons, 2018-2020
Brian Moore, MD, FAAP – National Association of EMS Physicians Mohsen Saidinejad, MD, MBA, FAAP, FACEP – American College of Emergency Physicians Sally Snow, RN, BSN, CPEN, FAEN – Emergency Nurses Association
ACEP Pediatric Emergency Medicine Committee, 2020-2021
Ann M. Dietrich, MD, Chairperson Kiyetta H. Alade, MD Christopher S. Amato, MD, Zaza Atanelov, MD Marc Auerbach, MD Isabel A. Barata, MD, FACEP Lee S. Benjamin, MD, FACEP Kathleen T. Berg, MD Kathleen Brown, MD, FACEP Cindy Chang, MD Jessica Chow, MD Corrie E. Chumpitazi, MD, MS, FACEP Ilene A. Claudius, MD, FACEP Joshua Easter, MD Ashley Foster, MD Sean M. Fox, MD, FACEP Marianne Gausche-Hill, MD, FACEP Michael J. Gerardi, MD, FACEP Jeffrey M. Goodloe, MD, FACEP (Board Liaison) Melanie Heniff, MD, JD, FAAP, FACEP James (Jim) L. Homme, MD, FACEP Paul T. Ishimine, MD, FACEP Susan D. John, MD Madeline M. Joseph, MD, FACEP Samuel Hiu-Fung Lam, MD, MPH, RDMS, FACEP Simone L. Lawson, MD Moon O. Lee, MD, FACEP Joyce Li, MD Sophia D. Lin, MD Dyllon Ivy Martini, MD Larry Bruce Mellick, MD, FACEP Donna Mendez, MD Emory M. Petrack, MD, FACEP Lauren Rice, MD Emily A. Rose, MD, FACEP Timothy Ruttan, MD, FACEP Mohsen Saidinejad, MD, MBA, FACEP Genevieve Santillanes, MD, FACEP Joelle N. Simpson, MD, MPH, FACEP Shyam M. Sivasankar, MD Daniel Slubowski, MD Annalise Sorrentino, MD, FACEP Michael J. Stoner, MD, FACEP Carmen D. Sulton, MD, FACEP Jonathan H. Valente, MD, FACEP Samreen Vora, MD, FACEP Jessica J. Wall, MD Dina Wallin, MD, FACEP Theresa A. Walls, MD, MPH Muhammad Waseem, MD, MS, Dale P. Woolridge, MD, PhD, FACEP
Sam Shahid, MBBS, MPH
Marianne Gausche-Hill, MD, FACEP, FAAP, FAEMS
ENA Pediatric Committee, 2018–2019
2018 Pediatric Committee Members
Cam Brandt, MS, RN, CEN, CPEN, Chairperson Krisi M. Kult, BSN, RN, CPEN, CPN Justin J. Milici, MSN, RN, CEN, CPEN, CCRN, TCRN FAEN Nicholas A. Nelson, MS, RN, CEN, CPEN, CTRN, CCRN, NRP, TCRN Michele A. Redlo, MSN, MPA, RN, CPEN Maureen R. Curtis Cooper, BSN, RN, CEN, CPEN, FAEN, Board Liaison
2019 Pediatric Committee Members
Michele Redlo, MSN, MPA, BSN, RN, CPEN, Chairperson Krisi Kult, BSN, RN, CPEN, CPN Katherine Logee, MSN, RN, NP, CEN, CPEN, CFRN, CNE, FNP-BC, PNP-BC Dixie Elizabeth Bryant, MSN, RN, CEN, CPEN, NE-BC Maureen Curtis Cooper, BSN, RN, CEN, CPEN, FAEN Kristen Cline, BSN, RN, CEN, CPEN, CFRN, CTRN, TCRN, Board Liaison
Catherine Olson, MSN, RN Corresponding Author: Madeline M. Joseph, MD, FAAP, FACEP
Drs Joseph, Ku, Mahajan, and Saidinejad and Ms Ku were each responsible for all aspects of writing and editing the document and reviewing and responding to questions and comments from reviewers and the Board of Directors; and all authors approved the final manuscript as submitted.
Technical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, technical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.
The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
All technical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2022-059673.
American Academy of Pediatrics
American College of Emergency Physicians
clinical decision support
computerized physician order entry
Emergency Medical Services
Emergency Nurses Association
patient- and family-centered care