Advancing the Quality of Pediatric Emergency Medicine in Pediatrics

Commentary From the Section on Emergency Medicine and the Committee on Pediatric Emergency Medicine

The American Academy of Pediatrics (AAP) Section on Emergency Medicine (SOEM), founded in 1981, is among the AAP’s largest sections, and provides a forum for advocacy, education, and research on patient care in pediatric emergency medicine (PEM). The AAP Committee on PEM (COPEM), a national committee founded in 1985, is the principal author of PEM-related AAP policies.

Sixteen members of SOEM’s executive committee and COPEM reviewed every issue from the 75-year history of Pediatrics. Reviewers initially identified 81 highly regarded papers regarding the practice of PEM. A team of current and previous COPEM and SOEM leaders selected 12 landmark papers. Three of these, one published in each quarter century of Pediatrics, were selected as having advanced paradigms of PEM and pediatric prehospital care. They have continued to be influential since their publication. Taken together, these 3 papers provide an important backdrop for the development of PEM, from its early differentiation from general pediatrics to its current status as a well-established, evidence-based, quality-focused subspecialty advancing the care of sick and injured children.

Advancing the Quality of Pediatric Emergency Medicine in Pediatrics

Gregory P. Conners, MD, MPH, MBA, FAAP¹, Deborah C. Hsu, MD, MEd, FAAP², Ron L. Kaplan, MD, FAAP³, Jane F. Knapp, MD, FAAP⁴, Jennifer R. Marin, MD, MSc, FAAP⁵, Ronald I. Paul, MD, FAAP⁶

Affiliations: ¹Upstate Golisano Children’s Hospital, SUNY Upstate Medical University; ²Texas Children’s Hospital, Baylor College of Medicine; ³Seattle Children’s Hospital, University of Washington School of Medicine; ⁴Children’s Mercy Hospital, University of Missouri Kansas City School of Medicine; ⁵UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine; ⁶Norton Children’s Hospital, University of Louisville School of Medicine

First Quarter Century: 1948–October 1973

Highlighted Article From Pediatrics

• Haller JA. Newer concepts in emergency care of children with major injuries. Pediatrics. 1973;52(4): 485-487

In this 1973 article, Dr. Haller introduced the concept of the dedicated pediatric trauma center. At the time, major trauma was the leading cause of death in children, responsible for half of childhood deaths. Haller described the physical, as well as developmental and emotional differences between children and adults, and proposed the design of the children’s regional trauma center. Proposed essential features included prehospital care and transport capabilities; a specific resuscitation area within the trauma unit; core diagnostic facilities, including x-ray and laboratory; experienced physicians, nurses, and necessary consultants available 24 hours per day; adjacent pediatric intensive care units; and operating rooms that are immediately available. Since the development of this first pediatric trauma center at the Johns Hopkins Hospital, there are now 35 level I and 32 level II pediatric trauma centers in the United States verified by the American College of Surgeons Committee on Trauma. Many studies have documented the efficacy of trauma systems in reducing unnecessary mortality and disability.

Second Quarter Century: November 1973–October 1998

Highlighted Article From Pediatrics

• Seidel JS, Hornbein M, Yoshiyama K, et al. Emergency medical services and the pediatric patient: are the needs being met? Pediatrics. 1984;73(6):769-772

This landmark 1984 paper by Dr. Seidel and colleagues came at a time of increased organization of emergency medical services, which were largely focused on prehospital care of adults. The authors studied outcomes of pediatric patients managed by ambulance personnel in the Los Angeles, CA, area in 1980 and 1981, and compared them with adult patients. Children were noted to have specific patterns of illness and injury and were often transferred from initial hospitals to pediatric centers. Most importantly, they demonstrated that children had much higher fatality rates from traumatic injuries than did adults. They concluded that, despite representing 10% of patients managed by paramedics, “the needs of children in the prehospital setting are not being met,” and that “lack of timely transport to pediatric centers…may also play a role in prehospital and emergency department mortality.” They recommended a modest 6-item list of “pediatric paramedic equipment,” establishing management guidelines for pediatric prehospital care and regionalization of pediatric critical care services. This work, and others demonstrating similar results, were influential in the recognition of the importance of including pediatric considerations in emergency medical services systems, leading to the congressional Emergency Medical Services for Children legislation, first passed in 1984 and regularly renewed since then. This important legislation is widely credited with fundamentally improving emergency care of children in prehospital, emergency department, and critical care settings, saving lives and improving outcomes for countless children.

Third Quarter Century: November 1998 – present

Highlighted Article From Pediatrics

• Stang AS, Straus SE, Crotts J, Johnson DW, Guttmann A. Quality indicators for high acuity pediatric conditions. Pediatrics. 2013;132(4):752-762

In 2000 and 2001, the Institute of Medicine published the landmark reports “To Err is Human” and “Crossing the Quality Chasm,” respectively. These publications ushered in an age of quality. There was mounting evidence demonstrating that performance measurement improves health care outcomes. Emergency care for pediatric patients, as with other types of care delivery, was subject to significant practice variation with gaps between knowledge and practice in severely ill and injured children. The 2013 study by Dr. Stang and colleagues, “Quality Indicators for High Acuity Pediatric Conditions,” provided a systematic, evidence-based series of quality indicators for high-acuity pediatric conditions. Through a methodologically rigorous process, the authors developed 62 evidence- and consensus-based quality indicators for 6 high-acuity conditions treated in the emergency department setting (diabetic ketoacidosis, status asthmaticus, anaphylaxis, status epilepticus, severe head injury, and septic shock). This research provided tools to improve the quality of pediatric acute care for severely ill and injured children and served as a catalyst and model for the modern, quality-oriented practice of pediatric emergency medicine.

12 Landmark Articles Over 75 Years

1. Haller JA. Newer concepts in emergency care of children with major injuries. 1973;52(4): 485-487
2. Rumack BH, Peterson RG. Acetaminophen overdose: incidence, diagnosis, and management in 416 patients. Pediatrics. 1978;62(suppl 5):898-903
3. Seidel JS, Hornbein M, Yoshiyama K, et al. Emergency medical services and the pediatric patient: are the needs being met? Pediatrics. 1984;73(6):769-772
4. Baraff LJ, Schriger DL, Bass JW, et al. Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Pediatrics. 1993;92(1):1-12
5. Mower WR, Sachs C, Nicklin EL, Baraff LJ. Pulse oximetry as a fifth pediatric vital sign. 1997;99(5):681-686
6. Gorelick MH, Shaw KN, Murphy KO. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics. 1997;99(5):e6
7. Hoberman A, Wald ER, Hickey RW, et al. Oral versus initial intravenous therapy for urinary tract infections in young febrile children. Pediatrics. 1999;104(1):79-86
8. Viccellio P, Simon H, Pressman BD, et al. A prospective multicenter study of cervical spine injury in children. Pediatrics. 2001;108(2):e20
9. Reeves JJ, Shannon MW, Fleisher GR. Ondansetron decreases vomiting associated with acute gastroenteritis: a randomized, controlled trial. Pediatrics 2002;109(4):e62
10. Kimia AA, Capraro AJ, Hummel D, Johnston P, Harper MB. Utility of lumbar puncture for first simple febrile seizure among children 6 to 18 months of age. Pediatrics. 2009;123(1):6-12
11. Stang AS, Straus SE, Crotts J, Johnson DW, Guttmann A. Quality indicators for high acuity pediatric conditions. Pediatrics. 2013;132(4):752-762
12. Goyal MK, Badolato GM, Patel SJ, et al. State gun laws and pediatric firearm-related mortality. Pediatrics. 2019;144(2):e20183283