Policy & Position Statement
The 2006 Institute of Medicine report found evidence that many emergency care providers feel stress and anxiety when caring for pediatric patients as compared to adults, and often undertreated or failed to properly stabilize seriously ill children. This is not surprising given the reality of pediatric emergencies: Most children who present to emergency departments in the United States are previously healthy, and come with acute complaints, such as fever or respiratory complaints, which usually reflect benign illness. Even if emergency medicine residency programs were to devote more time to pediatrics, the prevalence of both typical and atypical serious pediatric presentations (i.e.- sepsis, shock, myocarditis, etc.) to most emergency departments is so much lower as compared to adults, that the majority of residents would still not receive sufficient experience diagnosing and managing those conditions during residency training to feel entirely comfortable with them in practice. Since additional pediatric training is not a realistic solution to the dilemma of how to help EM physicians who staff non-pediatric community hospital emergency departments deal more adeptly with seriously ill and uncommon pediatric presentations, other more viable options must be sought.
As evidenced in the 2006 Institute of Medicine Report, emergency physicians possess keen self -awareness and recognize situations, including pediatric emergencies, which are beyond their comfort zone and expertise. A good working model for managing these types of situations already exists for other types of emergencies, such as poisonings and child abuse. While all emergency physicians receive extensive training and experience with toxicologic emergencies, serious poisonings may be uncommon. In these situations, EM physicians are never left to go it alone and always are able to consult with more expert toxicologists at a designated poison control center. These poison control centers have long established a user-friendly reputation among EM colleagues; in fact, many EM physicians will consult with them even in poisonings whose management they are familiar and experienced in, just to get a more expert opinion or updated management tips. Child Advocacy Centers represent a more recent but similar initiative, and have also met with great success. Child Abuse is a relatively new, challenging, and constantly evolving field of medical science. Previously, in the face of limited experience and a lack of available evidence to guide their decision-making, emergency physicians were burdened with the job of independently making on the- spot decisions in complicated cases of suspected abuse. Not surprisingly, often serious cases of abuse went undetected and many of these children suffered bad outcomes. With the recent advent of the medical subspecialty of Child Abuse and a corresponding proliferation of regional Child Advocacy Centers, experts in the field of abuse are often on-call by phone 24/7 to assist EM physicians with these cases.
In complicated or unusual pediatric cases, as in poisonings and suspected child abuse, the EM physician should be able to consult PEM experts by phone for help in diagnosis and management, and for transfer to a more tertiary setting when deemed necessary. In fact, the system for this is already in place. PEM-trained experts are already present 24/7 in tertiary pediatric emergency departments, and could easily fill this role.
To a limited extent, this arrangement already exists and works well for some tertiary pediatric emergency departments and those community hospital emergency departments that transfer children to them for admission or higher levels of care. However, the scope of this practice needs to be expanded to include ALL community hospital emergency departments. To work effectively, agreements and understanding between local community hospital emergency departments and their regional tertiary pediatric centers must be formalized, in order to both avoid concerns of malpractice risk by PEM physicians offering phone advice, and to prevent emergency physicians in the community from hesitating to consult their PEM colleagues by phone and seek support for their management decisions due to concerns the consultant on the other end of the line will not be receptive to their call. Again, both Poison Control and Child Advocacy centers are models of success for breaking through these barriers, and can provide guidance for Pediatric Emergency Departments who wish to implement similar consultation services for pediatric emergencies. As outlined above, The PEPNETWORK endorses an expanded role for pediatric tertiary hospital emergency departments; namely, to adopt a routine role as 24/7 phone consultants to community hospital EDs. As with other categories of emergencies, no emergency physicians should have to go it alone when faced with what they feel are unusual or major pediatric presentations, or when faced with pediatric management decisions they are unsure about. In fact, the resources and support to fix this problem are already in place; we are missing only the resolve to make it happen.