2.3 Pediatric emergency care quality
2.3.1 Pediatric emergency care structure
Based on the literature review, 12 studies were concerned with the pediatric emergency care structure (Table 1). These studies were from the US (n=10), Australia (n=1), and Belgium (n=1). In the structure were categorized studies related to ED use (Marcin et al. 2018; Jaeger et al. 2015) and ED use by patients’ acuity (triage level) (Benagdemed et al. 2012; Kubisek et al. 2012).
Also, some studies were related to the emergency type being a general or pediatric emergency (Goldman et al. 2018; Hudgins et al. 2017; Peeler et al.
2016), staffing (Krinsky-Diener et al. 2017; Michelson et al. 2016), and ED facilities (Schroder et al. 2016; Gausche-Hill et al. 2015; Robison & Green 2015).
Pediatric emergency care facilities
Pediatric patients’ emergency care is organized either in general EDs or in dedicated PEDs (Goldman et al. 2018; Hudgins et al. 2017; Peeler et al. 2016).
In general EDs, pediatric patients receive care from a staff who care for patients of all ages, and the facilities of ED are the same for pediatric and adult patients. PEDs have facilities specifically for children that are staffed by
pediatric nurses and physicians. When comparing those two settings in the study (Hudgins et al. 2017) of the US, PEDs had a greater proportion of children under 1 year of age (18%), and PEDs had greater complexity and higher rates of hospitalization (10%) than general EDs (Hudgins et al. 2017).
Also, the patient volume has an impact on ED readiness for pediatric care patients. In the Gausche-Hill et al. study (2015), the pediatric readiness score means varied with a lower level at low-volume pediatric patients units and a higher level in high-volume pediatric units. The presence of pediatric
coordinators increased the likelihood of having all recommended components (Gausche-Hill et al. 2015).
The use of colorful lighting in the care environment has been found to be associated with children’s and their parents’ ED experiences. Children who received treatment in an ambient environment rated lower pain scores, and their caregivers experienced higher quality of care and the possibility of becoming better involved in their child’s care than in the traditional
environment. Parents in the traditional environment expected longer waiting times, felt more anxious, and were more scared than their parents in the ambient environment (Robinson & Green 2015).
Pediatric emergency patients
The number of PED patients has increased during the 21st century. In particular, this phenomenon has demonstrated an increased number of non-urgent visits (Doan et al. 2014.) In the literature, these PED patients are called either non-urgent patients or patients with ambulatory care service (ACS) conditions. According to a US study (Jaeger et al. 2015), of all ED visits in the US in 2010, 13% were patients with ACS conditions. Those patients presenting to the ED for ACS were related to have no insurance or to have public
insurance, lower household income, and younger age (Jaeger et al. 2015).
A study in Belgium (Benahmed et al. 2012) found that 40% of participants were considered low-acuity patients who do not need hospital-level care.
Factors related to low-acuity ED visits included the age of the child, the proximity of the ED location, the time of the visit being outside office hours, lacking a family doctor, the geographical location, parents’ perceptions of EDs’
high-quality care, and the convenience of using emergency services (Benahmed et al. 2012). In a survey study of caregivers/parents of non-urgent pediatric patients, nearly half of the annual incomes were less than $20,000, and 43%
did not have health insurance. Two out of three of them defined their child’s condition as acuity or high acuity, and half of them claimed that they had not previously received information about normal pediatric diseases (Kubisec et al.
2012). According to a previous study by Doan et al. (2014), from 2002 to 2011, the pediatric patient volume increased by 30%, and the hospitalization rate has remained at approximately 10% (Doan et al. 2014). This reflects the growing number of non-urgent patients, and it has led to the ED phenomenon called overcrowding. Related to the factors’ influence on care quality, it was found (Marcin et al. 2018) that patients’ age, sex, race/ethnicity, and payment source have not been related to care quality from the perspective of care process’
content. Instead, regarding pediatric patients’ chief complaints, fewer
respiratory symptoms have been found to be associated with lower care quality when assessed by the content of the care. (Marcin et al. 2018.)
Emergency department’s staffing
A limited number of studies have focused on PEDs’ staffing (Alessandrini et al.
2011). Pediatric emergency care staffing should be based on the number of patients. Among other things, planning of adequate staffing can be difficult because of patient flow’s fluctuating. A previous study (Krinsky-Diener 2017) addressed the holiday seasons, especially the summer season, and compared the lower number of patient visits with other holiday seasons. In addition, on Thanksgiving and Christmas Day, fewer patients visited the ED compared to non-holiday times, as well as other holidays, and fewer patients visited in the evenings in particular (Krinsky-Diener 2017). Limited staffing in the ED has been found to impact pediatric patients’ care process. A study aiming to test modeling that identifies the times of staffing limitations by provider types (physician, nurse), established space, and limited staffing times were associated with significantly longer LOS. (Michelsson et al 2016.)
Table 1. Summary of studies according to pediatric emergency care structure (n=12)
Author,
country Purpose Methods Results
Benahmed et
40% of patients were not assessed as requiring hospital-level care, and
factors related to this were child’s age, ED proximity, existence of a family doctor, visiting after
office time, and family’s living area. according to the volume of pediatric patients. In a
low patient volume, EDs’
readiness score mean was 68.9, and in a high patient volume, EDs’ mean score was 89.8. The presence of
a pediatric coordinator increased the likelihood of
having all recommended components.
Goldman et al.
that it was difficult to maintain competency due to fluctuations in pediatric patients’ numbers. Also,
they reported having difficulties regulating their
emotions when caring for sick children. The quality and safety of pediatric
patients' care were perceived as lacking.
Hudgins et al.
(2017) USA
To compare pediatric patients’
severity in the PED and general ED 169 million visits in
a general ED.
The PED had a greater proportion of children under 1 year (18%), and encounters in the PED had
greater complexity and patients presenting to the ED for ACS were assumed to have no insurance or to have public insurance,
To determine if it is possible to predict the patient
volume in a PED on holidays and to
determine if the
The smallest number of patient visits (median=74)
was in the summer; in other seasons, the median
was 89–91 visits per day.
Holidays, especially Thanksgiving and Christmas Day, saw fewer
visits than during other times.
Kubicek et al. children to EDs for
non-urgent
Of all caregivers, 49% of the annual incomes were less than $20,000, and 43% did not have health
insurance. 63% of participants described their child’s condition as urgent or very urgent, and
half of them reported not having information about basic childhood illness.
Reasons for ED visits included their perceptions
of high-quality care and convenience using the ED.
Marcin et al. payment source were not
related to the quality of care. Chief complaints and
fewer respiratory
Limited space and staffing times were associated from general ED to
PED. nursing staff and 8
The staff expressed fears regarding inadequate knowledge of pediatric
emergency care.
Training and clear communication supported
their transition in caring for pediatric patients in the new PED facilities.
members of the
In the ambient group, children rated lower pain
scores. In the ambient environment, caregivers
experienced a higher quality of care and the
possibility of involving themselves in their child’s
care better than in the traditional environment.
Caregivers in the traditional environment expected longer waiting times, felt more anxiety, and experienced more fear than caregivers in the
traditional environment. care quality in EDs.
In a survey of 42 EDs in America, 22
PEDs participated in the study.
Participated PEDs had a high quality of care when
measuring the structural elements of care.