Emergency departments deal with a spectrum of sick, distressed, and critically ill patients. For many patients, especially children, experiencing an emergency department can be a traumatic experience in itself. One personal experience firmly etched in the principal author’s mind is of a mother in the emergency department desperately trying to cover her 5-year-old daughter’s eyes and ears to shield her from the screams of a nearby adult in pain, and the swearing of another disgruntled patient. Unfortunately, scenarios like these will inevitably arise in Canadian community hospital emergency departments, where children routinely share waiting and treatment areas with adult patients. We propose that a standardized Canadian guideline be developed to improve the environment and facilities provided to children in such combined emergency departments (cEDs). Such a guideline will hopefully improve the quality of health care for both pediatric and adult patients, while standardizing facilities available to children outside of specialized tertiary pediatric centres.
Currently, Canadian emergency departments are not required to meet standards that address the specific needs of their pediatric patients, leading to potentially harmful variations in the environment and services provided to children. International literature and guidelines have emphasized that implementing a child-friendly environment, appropriate prehospital assessment, and pediatric-appropriate hospital staff and training are the most important tenets for catering to children in cEDs. The International Federation of Emergency Medicine has also stressed that establishing standards or guidelines of care for pediatric patients “assists both managers and clinical staff to deliver improvements.” 1 Children represent a significant proportion of patients attending emergency departments; 30% in Canada, 22.1% in the United States, and 26.5% in the United Kingdom.Reference McGillivray, Nijssen-Jordan and Kramer 2 – 4 In the United States, only 7% of these patients will be treated in a space designed to accommodate pediatric patients.Reference Stone and Woodward 5 In Ontario, the number is slightly higher with 14.9% of children being treated in specialized pediatric facilities. 6 The remaining children will access cEDs within community hospitals. Ideally, a minimal standardized level of care should be provided to all children in Canada, irrespective of which hospital such children attend.
Currently, there are three national guidelines (United States, United Kingdom, and Australia), which address the care of children in cED; however, no comparable guidelines are available for Canadian cEDs. In the United States, The Joint Policy Statement: Guidelines for the Care of Children in Emergency Departments (2009) and The National Paediatric Readiness Project were implemented to improve pediatric care in cEDs. 7 , 8 In the United Kingdom, the Standards for Children and Young People in Emergency Care Settings 2012 outlines a standardized approach and also provides a framework to measure improvement. 9 In Australia, The Guidelines on Emergency Department design (2007) outline the importance of specific pediatric treatment areas and equipment. 10 We envision similar protocols for Canadian cEDs, incorporating aspects of the aforementioned international guidelines. However, we feel that such guidelines should be developed with a Canadian context in mind. Canada is a vast country with both urban and rural environments, incorporating a wide diversity of patient demographics. Our guidelines should accommodate the needs of our unique patients and should work in unison with our health care system. Although there are obvious practical and financial limitations to providing extensive pediatric facilities in every Canadian hospital, establishing standardized guidelines would allow us to prioritize the most vital features applicable to all community hospitals.
Based on a review of current existing guidelines, there are at least four areas that could be addressed in a Canadian guideline aimed at standardizing children’s care: triage, emergency department environment, equipment, and training.
Triage
Prehospital and emergency department triage are essential to optimal management of pediatric patients. Understandably, separate facilities and entrances for pediatric patients may not be logistically or financially feasible for every hospital. However, some hospitals may be able to arrange a separate pediatric entrance to the emergency department, where health care workers specifically trained to assess and treat pediatric patients can be placed. Children should be efficiently triaged using the pediatric Canadian Triage and Acuity Scale.Reference Warren, Jarvis, LeBlanc and Gravel 11 Standardized weight scales should be used to record the weight of every patient to facilitate weight-appropriate doses of medication and decrease the likelihood of dosing errors.Reference Stucky 12
Pain assessment
This can be a challenging aspect of triage in pediatric populations, because they may be at a pre-verbal state or have difficulty in verbalizing their symptoms. Standardized pediatric pain scales such as the Wong-Baker FACES pain scale, McGill pain questionnaire, or the visual analogue scale for measuring acute pain should be made available for triage staff.Reference Garra, Singer and Taira 13 – Reference Bijur, Silver and Gallager 15
Emergency Department Environment
The environment of an emergency department can have a direct influence on a child’s care and level of anxiety during his or her visit. Children experience a significant level of anxiety and distress when they visit a hospital, because they are concerned about unfamiliar health care professionals, procedures, and uncertainties regarding their outcome.Reference Coyne 16 It has been shown that it is more difficult to obtain a history and conduct an examination on an anxious child.Reference Athey, Dean and Ball 17 Environmental constraints can have potentially adverse outcomes, as highlighted in a Korean study, which showed a correlation between overcrowding in cEDs and increased mortality.Reference Cha, Shin and Cho 18
Separation from adults
The facilities in cEDs should ideally allow for separate waiting, treatment, and resuscitation areas for children. 19 In certain cases, having a specific pediatric resuscitation area is not feasible. In such cases, shared spaces should have ease of access to pediatric-appropriate equipment and resuscitation algorithms.Reference Stone and Woodward 5 Hospital environments that have specialized staff, equipment, and facilities that are geared toward children are most appropriate for treating pediatric patients under the age of 16. 20 Guidelines in the UK, for example, suggest that for every 5000 pediatric patients attending a cED, there should be a separate, secured child-friendly cubicle designed to meet their needs and to accommodate their caregivers. 9 Access to these areas should be controlled and secured from potentially aggressive adult patients. 1 Specialized pediatric observational areas or short stay units can help monitor unstable patients and better address their needs and avoid any unnecessary transfers. 1 However, if such transfers to tertiary or specialized centres are necessary, because many rural facilities lack extensive pediatric care, standardized patient criteria should be established to determine when such a transfer would be appropriate.
Physical environment
It is important to recognize that pediatric patients encompass a spectrum of developmental stages from infancy to adolescence and that each has unique requirements. Infants are highly dependent on their caregivers to meet their basic needs; therefore, provisions should be made for diaper changing and breastfeeding facilities.Reference McGillivray, Nijssen-Jordan and Kramer 2 Such initiatives have already begun to be implemented in Ontario hospitals via the Baby Friendly Initiative. 21 Toddlers will curiously explore their environment and therefore spaces should be void of potential hazards. Children’s spaces should be equipped with age-appropriate “toys and books that comply with health and safety regulations” and those that adhere to infectious disease guidelines. 9 For example, infectious disease guidelines recommend using germ-resistant fabrics that allow for easy disinfection. Therefore, any equipment or toys in child-friendly areas must be conducive to disinfection. Provisions for adolescent children should also be considered, and waiting areas should be equipped with health promotional material regarding issues such as sexual health, drugs, and smoking. 6 Internationally, the Patient-and-Family-Centered Care (PFCC) model is becoming more popular and has been shown to improve clinical outcomes.Reference Stone and Woodward 5 , 7 , 21 , Reference O’Malley, Brown and Krug 22 This model promotes family presence and involvement during critical periods of care to help alleviate anxiety relief and promotes patient autonomy.
Equipment
Pediatric training must also focus on familiarity and experience with pediatric-appropriate equipment, which is vital in emergency situations. Unique anatomical considerations in the pediatric population mandate accessibility to pediatric-appropriate equipment and training within cEDs.Reference Stone and Woodward 5 A Canadian study was conducted in order to determine the availability of pediatric equipment in cEDs across Canada and found alarming deficiencies in the availability of pediatric-appropriate equipment.Reference McGillivray, Nijssen-Jordan and Kramer 2 Because 5% of children presenting to cEDs are critically ill,Reference Schappert and Bhuiya 3 such deficiencies in equipment can seriously hamper treatment. As part of future research, we intend to assess the current level of availability of pediatric-appropriate equipment and help mitigate any potential deficiencies.
Training
Pediatric-appropriate training is a vital aspect in treating children in the emergency department. Health care professionals who deal with pediatric patients should have appropriate training in managing and communication to children and parents. 20 Having access to aptly skilled staff, resuscitation algorithms, and appropriate pediatric dosing in resuscitation situations has been shown to improve patient outcomes and reduce mortality.Reference Stone and Woodward 5 Hospitals should facilitate and promote adherence to refresher training courses such as paediatric advanced life support (PALS), advanced cardiac life support (ACLS), and neonatal resuscitation program (NRP) for emergency staff in order to keep up to date with current practices.
Access to pediatric-trained clinicians and health care workers are vital for managing children because they have unique presentations and conditions. U.S. surveys suggest that only 23% of the children attending the emergency department will be seen by pediatric emergency medicine physicians.Reference Stone and Woodward 5 For example, guidelines in the UK recommend that emergency departments that treat more than 16,000 pediatric patients annually should be permanently staffed by a pediatric emergency medicine physician. 9 Similarly, studies should be carried out in a Canadian context to establish a reasonable volume of pediatric patients treated at a facility, which would justify the presence of permanent pediatric staff in a community hospital. Integration of specialized staff, such as child-life specialists, can help reduce stress and promote the well-being of children under emergency circumstances.Reference Wilson 23 They can also be employed during unpleasant medical interventions to provide distraction. 1 Children and their caregivers should have access to pediatric social workers in cEDs to holistically address their needs.Reference Stone and Woodward 5
Canada has an exceptionally high standard of health care, and the care provided in most cED is exemplary. Nevertheless, emulating comparably developed countries by implementing standardized guidelines for the management of children in these settings would further improve the standard of care for pediatric emergency patients across the country. Children are the precious future of Canada. They deserve to be looked after in a cED that adheres to a minimum standard of practice enshrined in a Canadian-centric guideline ensuring child-appropriate triage, emergency department environment, equipment, and training.
Competing interests: None declared.
