Medico Legal, Risk Management Pitfalls, Pediatric EM

Readiness for Pediatric Patients in the Emergency Department

From the December 2013 issue of Pediatric Emergency Medicine Practice, “Emergency Department Readiness for Pediatric Illness and Injury.” Reprinted with permission. To access your EMRA member benefit of free online access to all EM Practice, Pediatric EM Practice, and EM Practice Guidelines Update issues, go to, call 1-800-249-5770, or send e-mail to


  1. “We do not see many pediatric patients, so we do not have a physician or nurse coordinator for pediatric emergency care.”
    All EDs have the responsibility to care for patients of any age who present for care and treatment. Designating someone to serve as a champion for pediatric emergency care issues ensures that the needs of children are being met, resulting in enhanced pediatric readiness. While high-volume facilities may choose to assign this role to a full-time position, smaller hospitals may choose a part-time or shared role.
  2.  “Our quality improvement plan does not address pediatric-specific metrics.”
    In order to ensure that the care received is as intended, quality improvement plans must be in place to identify and correct systems-based errors. While quality improvement plans may be broad, such plans must target all populations, including children.
  3. “Our patients' vital signs are easily visible on the chart. Therefore, there is no need to notify the physician specifically.”
    Prompt physician notification of the presence of abnormal vital signs leads to more rapid assessment and intervention. Failure to institute policies to notify physicians of abnormal vital signs may lead to delays in care and increase the potential for adverse outcomes.
  4. “We do not need a pediatric transfer plan or agreement because we rarely transfer pediatric patients.”
    While pediatric transfers may be rare occurrences for some facilities, it is important to have a transfer plan and agreement in place in order to expedite access to a higher level of care. Transfer plans may include mode of transport, communication elements, and other requirements. It is important to ensure all necessary communication and documentation is completed, as lack of agreements with outlying facilities may result in significant delays in care and a struggle to identify an appropriate receiving facility.
  5. “Our health care providers choose what CME they complete. We do not have any specific pediatric CME requirements.”
    Pediatric patients account for approximately 25% of ED visits. When a pediatric patient presents in extremis, it is critical that providers are prepared to manage the child effectively and efficiently. Given the relatively infrequent encounters with critically ill pediatric patients, pediatric-specific CME becomes even more important in order to maintain the skills needed to treat the pediatric population. All providers caring for children should be encouraged to complete pediatric-specific CME annually.
  6. “Our scale only weighs children in pounds.”
    Standard pediatric dosing is based on weight in kilograms. Weighing children in pounds requires the added step of converting weight to kilograms, which can create additional room for error. Also, using both pounds and kilograms may lead to errors in documentation. All children should be weighed only in kilograms, and weight should be recorded only in kilograms to avoid miscalculations.
  7.  ’“We do not require annual competency evaluations of our providers, as this is included in the certification process.”
    While recertification may test the current knowledge base, it is important that providers maintain pediatric-specific skills. This is particularly important when these skills are not practiced regularly. Annual competency evaluations provide a means for ensuring skills maintenance.
  8.  ““We do not use a validated pediatric triage tool.”
    The use of a validated pediatric triage tool is important to help predict resource use. Triage tools used for adults may under- or over-triage pediatric patients, leading to a mismatch in prioritization. A higher triage category alerts physicians to the need for rapid assessment or intervention. Particularly in the setting of overcrowding, failure to use a validated pediatric triage tool may result in delays in care and poor patient management.
  9.  ” “We have a hospital-wide disaster preparedness plan, but no separate plan or inclusive guidelines for children.”
    Children are disproportionately affected during disasters. In addition, children have special needs that are often not considered when managing adult patients in the setting of a disaster. Specific needs include pediatric triage, a pediatric approach to decontamination, surge capacity, reunification services, medications, and supplies. Pediatric-specific elements must be included in a hospital-wide disaster plan.
  10. “We have a calculator set up in the resuscitation bay for children.”
    When a child presents in extremis, the use of a calculator or other real-time dose calculation tools creates multiple opportunities for error. The likelihood of error may be increased during stressful situations such as resuscitations. While slight underdosing and overdosing may occur based on body habitus, the AHA recommends the use of a length-based tape or actual weight to eliminate unnecessary steps in calculation that may lead to significant dosing errors.