Blue Mountain Hospital, a critical access hospital in rural Utah, had not seen a child with a traumatic head injury in years. According to a nurse, the ED team was “rusty” before physicians from Primary Children’s Hospital visited to provide training on how to recognize vital sign changes associated with Cushing’s triad, a life-threating pressure in the brain, and how to an administer hypertonic saline, an essential medication.
A few days later, a child arrived at the hospital with a serious head trauma requiring resuscitation. The team recognized signs of Cushing’s triad and quickly gave the patient hypertonic saline, preventing permanent brain damage and potentially death.
“We felt so much more prepared to take care of that patient after the visit,” the Blue Mountain Hospital nurse said.
While rural emergency departments in the U.S. are readied for adults, most are not fully prepared to care for acutely ill and injured children, who require different care and equipment. In some EDs, kids in critical condition are four times more likely to die, according to an analysis that evaluated nearly 5,000 EDs in all 50 states.
“There's a huge difference in outcomes for some of these really critically ill and injured children depending on where they go,” said Hilary Hewes, a pediatric emergency medicine physician at Intermountain Health’s Primary Children's Hospital and professor of pediatrics at the University of Utah. “We know that a lot of the providers in rural and critical access hospitals don't get enough specific pediatric training, especially after residency, and a lot of the nurses don't come at this with a pediatric background.”
Though children’s hospitals are well-equipped to care for children in emergencies, only around 200 exist in the U.S. More than 80% of all ED visits happen at adult-focused hospitals.
Primary Children’s Hospital is helping improve readiness across a five-state, 600,000-mile region by training rural hospitals like Blue Mountain to handle common pediatric emergencies such as sepsis and seizures. “We have to empower our rural centers,” Hewes said. “It's our obligation as the children's hospital to do this.”
Getting hospitals ready
Primary Children’s Hospital’s efforts are guided by the National Pediatric Readiness Project (NPRP) assessment, which evaluates how ready hospitals are to care for children based on the latest national pediatric emergency care guidelines.
Along with a score based on a 100-point scale, hospitals that take the survey get a benchmark report comparing their scores to similar hospitals and a gap report showing areas for improvement. Hewes’ team uses the assessments and gap analysis to guide their training at rural hospitals where they provide emergency simulations, hands-on education, and plug-and-play protocols.
Trainings typically focus on common conditions with protocols hospitals can easily reference, like anaphylaxis, seizure, asthma, sepsis, and bronchiolitis.
“We don't want to pick something they might not have the resources for, like pediatric appendicitis that requires an ultrasound,” Hewes said. “We pick things with well-known, evidence-based practice you can do to intervene quickly and make a big difference.”
Though the clinical aspect is critical, so is simply knowing what and where the right piece of equipment is.
“A large part of the training is around operations and hands-on muscle memory,” Hewes said. “Where do you find your Ativan? Do you have a pediatric Broselow cart? Can you quickly pull out that Broselow tape and find the right sized equipment?”
After the visit, the Primary Children’s team leaves behind a binder replete with evidence-based pediatric protocols. The hospitals can access additional resources online, including educational videos and e-simulations. And when they need a consult, an ICU or ED physician at Primary Children’s is available 24/7 for phone or video calls.
“Our goal for every kid is to stay local and take that burden off the families. But if not, we speak the same language now. We know they've followed the protocol we would have followed, and so we know where they are in treatment. That’s a big benefit," Hewes said.
Hewes emphasized the importance of establishing a quality improvement process at each hospital. Her team reviews the charts to identify areas for improvement — such as patients requiring advanced airway or transfer to another hospital — and helps set up an improvement plan.
Some consistent gaps Hewes finds at rural hospitals are in disaster preparedness. If the hospital has a disaster plan at all, it often doesn’t account for pediatric components.
The national assessment also shows that hospital policies frequently leave out mental health screenings, social work, and family-centered care. “These common issues often take little to address and put policies in place. When they're resolved, pediatric readiness goes way up,” Hewes said.
Success is more likely at hospitals that have a pediatric emergency care coordinator (PECC), an understaffed position at most hospitals and a nonexistent one at many. “We really lean on PECCs to determine what each facility needs to focus on,” Hewes said.
After the first visit from Primary Children’s, the PECC ideally will lead additional simulations throughout the year, facilitate other readiness tasks, and serve as the point person with the children's hospital for any needs.
“I think the hardest thing is that PECC positions have historically not been supported with an FTE,” Hewes explained. “It needs to be an established position with a job description and some dedicated time recognized by the administration, just like a trauma manager and a STEMI person in adult hospitals.”
Making a difference
These interventions create a safer health care system for kids across Wyoming, Montana, Utah, Nevada, and Idaho. Most rural hospitals are eager to receive help, Hewes said.
“Everyone worries about pediatrics, especially in those rural areas where they don't have a lot of resources. They all feel emotional about kids and want to feel more prepared,” she said. “It's just a matter of finding the time and resources to do that.”
The matter of time and resources can be a significant barrier for rural and general hospitals who often struggle just to make ends meet. Many federally funded initiatives are addressing the issue with free resources and tools, such as the Pediatric Pandemic Network and the Emergency Medical Services for Children program (EMSC), which leads the National Pediatric Readiness Project.
One advantage of the national readiness approach is that most hospitals already have most of what they need to make significant improvements. With the help of Primary Children’s and targeted efforts of their own staff, the emergency room team at South Lincoln Hospital in rural Wyoming raised its score by 25 points in two years.
That’s only one example of many Hewes has witnessed over the past five years. The more hospitals involved in this work, the better outcomes for children across the country.
“There are many children’s hospitals making a difference in this area,” she said. “But I think every children's hospital should be involved in pediatric readiness.”
