There's been a back and forth of views about the state of pediatric emergency medicine recently in the Wall St Journal.
Let me start first, actually, with the more recent statement, a rebuttal from Michael Gerardi M.D., FACEP, President of the American College of Emergency Physicians, in the form of a letter to the editor.
“Emergency care of children in the U.S. is the best in the world. Emergency physicians treat more than 22 million sick and injured children under age 15 each year, and the vast majority of them have good outcomes. If a child has a medical emergency, parents should get that child to the nearest emergency room and have confidence that they are receiving top-quality care in the right place from the right physicians.”
It's “the best in the world.” Is that an opinion? Where is the data to back that up?
Is the “nearest” emergency room always the right choice? That's a great question for an adult patient to ask, as well.
What does “a vast majority” mean? 80% What is a “good outcome?”
It's easy to tell people they should “have confidence,” but then again it's easy to say that “patient safety is our top priority.”
What did the original WSJ article say about the state of preparedness in hospital EDs? The headline is a bit damning:
Many Hospital ERs Aren't Ready to Treat Children
Hospitals aim to be prepared; many lack equipment and pediatric training for doctors and nurses
“When a child has a medical emergency, the first instinct is to rush to the nearest hospital ER. But, many emergency rooms are ill-equipped to treat infants and children and they are staffed with doctors and nurses who may not be trained in the specifics of pediatric care.”
What do the data suggest?
- 30 million American children end up in the E.D. for care, 90% of those are in general non-pediatric hospitals
“The ER staff often lack necessary emergency equipment, such as needles, catheters, breathing tubes and instruments designed and sized for different-aged children's unique anatomy. They also may lack a plan to deal with children in a mass casualty incident or natural disaster.”
- “the median readiness score was 69 on a scale of 100, up from 55 in 2003.”
The readiness survey is based on ACEP guidelines, which Dr. Gerardi (author of the letter to the editor) should be aware of. So they are making progress, but that's the patient impact of having a 69 readiness score instead of 95 or 100? I wish Dr. Gerardi had addressed what the gaps are and what they're doing about it instead of making a sweeping statement that says, basically, everything is OK.
“No problems is a problem,” as Toyota says.
But at least they're getting better… or are they?
“However, the authors cautioned that the review likely overestimated hospitals' readiness because there was no way to verify what hospitals reported about their status.”
That's the problem with self reporting… they might not want to admit that there's as much of a problem as there is.
“More than 15% are missing critical tools such as special forceps to remove objects obstructing a child's airways.”
And another statement of the problem:
“Parents are going to stop at the closest building with a big red emergency sign” says Alfred Sacchetti, chairman of the state's Emergency Medical Services for Children Advisory Council and chairman of the emergency department at Our Lady of Lourdes Medical Center in Camden, N.J. “That may not be the one that's going to fix the lacerated spleen, but they should be able to manage an airway, get an IV in and get the child expeditiously to the place with the expertise.”
So this seems like good advise, instead of assuming or trusting or being confident that all hospitals are equally good.
“Dr. Krug advises parents to ask their family doctor which hospital ER in their area is better prepared for children.”
If their family doctor knows… will that be based on opinions or facts?
Listen to Mark read this post (learn more) — more text after the audio:
Process Problems Can Harm Patients
One way that the lack of preparedness can hurt young patients is a lack of standardized work around expressing patient weights in pounds or kilograms.
“One area of concern when treating children: one-third of hospitals don't follow recommendations to record weight in kilograms rather than pounds. Medication doses are based on weight in kilograms, and mix-ups are a leading cause of medication errors, says Marianne Gausche-Hill, who led the readiness study and is chief of the division of pediatric emergency medicine at Harbor-UCLA Medical Center in Los Angeles.
One kilogram is equal to 2.2 lbs., so if a 30-lb child with a broken leg is mistakenly given morphine for pain based on a weight of 30 kilograms, “that is basically a double dose, which could make you stop breathing,” Dr. Hill says.”
Does your family physician know which hospitals do follow or don't follow that basic guideline?
We can admit there is opportunity for improvement, as one doctor quoted in the article says, or we can just pretend things are fine or scream of “yellow journalism” as one commenter did:
“Headline is baloney and smacks of yellow journalism. Not supported by the facts and not even by the content of the article.”
Calling something “baloney” — is that supported by facts?
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Once again, some members of the medical community have chosen to engage in defensive medicine rather than addressing the issues raised in the article. There are a number of common refrains: “We have the best healthcare system in the world” or “We provide the best (insert your medical specialty here) in the world.” I don’t disagree that the US has many shining examples of how to get health care right, but it often doesn’t take criticism well, which is an integral piece of understanding what’s wrong and working on fixes that make the system better and genuinely improve patient outcomes. Isn’t the first step to recovery (in this case, improvement), admitting that there’s a problem?
Thanks for the comment. I agree with you that there are many great things about American medicine. There’s a reason that people who can afford it travel from around the world to get complex specialty care here. That doesn’t mean that the health system serves every patient well every day in more mundane care.
“No problems is a problem” is a helpful mantra for Toyota or any organization. Recognizing we have a problem is the first step in solving it. I wish hospitals would read that report and then take action to close the gaps in their pediatric emergency preparedness.
I’m pretty critical of our health care system. My eyes have been opened quite a bit (and my jaw often drops). We need to do better.
The sad irony is that ambulatory surgery centers, where a hypothetically lower level of care is needed, who see children are required to stock and maintain a Broselow kit with all the necessary equipment and supplies, even if children only make up 5% of the ASC’s case mix.
Interesting, here in Utah I’ve found that our emergency rooms are fairly prepared for children and infants. I drove a neighbor to the hospital after her son took a nosedive on to the concrete and they showed us all of the child-sized tools and how they work.
OK, but what’s the definition of “fairly prepared” vs. “completed prepared” or even “adequately prepared?”
Children’s health or emergencies… that’s not an area to mess around.