CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Resources Recommended for the Care of Pediatric Patients in Hospitals Kimberly D. Ernst, MD, MSMI, FAAP, COMMITTEE ON HOSPITAL CARE

It is crucial that all children are provided with high-quality and safe health abstract care. Pediatric inpatient needs are unique in regard to policies, equipment, Section of Neonatal-Perinatal Medicine, Department of Pediatrics, facilities, and personnel. The intent of this clinical report is to provide College of Medicine, University of Oklahoma, Oklahoma City, Oklahoma recommendations for the resources necessary to provide high-quality and Dr Ernst was responsible for the literature review, writing the first safe pediatric inpatient medical care. draft, and revising the final draft with the input of all reviewers and approved the final manuscript as submitted.

Clinical reports from the American Academy of Pediatrics benefit from In 2016, there were 5.5 million hospitalizations of children 17 years and expertise and resources of liaisons and internal (AAP) and external 1 reviewers. However, clinical reports from the American Academy of younger, with a mean length of stay of 4.0 days. The primary indication Pediatrics may not reflect the views of the liaisons or the for inpatient pediatric hospitalizations is respiratory illness, including organizations or government agencies that they represent. 2 pneumonia, acute bronchiolitis, and asthma. Other common reasons for The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking pediatric hospital admissions include appendicitis, seizures, infections, into account individual circumstances, may be appropriate. and dehydration.2 Although many of these patients can be appropriately All clinical reports from the American Academy of Pediatrics cared for in community settings, there must be a balance between family automatically expire 5 years after publication unless reaffirmed, convenience, safe health care, and resource use. It is widely accepted that revised, or retired at or before that time. a minimum case volume is necessary to maintain competence and is This document is copyrighted and is property of the American associated with better outcomes; therefore, health care administrators and Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of professionals need to evaluate their ability to care for the unique needs of Pediatrics. Any conflicts have been resolved through a process the pediatric population and determine if they have the diagnostic and approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial treatment capabilities, as well as the equipment and staffing, to provide involvement in the development of the content of this publication. high-quality and safe health care for these patients. Hospitals need to DOI: https://doi.org/10.1542/peds.2020-0204 carefully evaluate their resources and may decide to be proactive in Address correspondence to Kimberly D. Ernst, MD, MSMI, FAAP. E-mail: stabilizing and then transferring pediatric patients to facilities with higher [email protected] pediatric inpatient volumes and more resources. PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). The intent of this clinical report is to provide recommendations for the Copyright © 2020 by the American Academy of Pediatrics resources (policies, equipment, facilities, and personnel) necessary to provide high-quality and safe pediatric inpatient medical care. Although all FINANCIAL DISCLOSURE: The author has indicated she has no financial relationships relevant to this article to disclose. hospitals are obligated to provide emergency stabilization for children of all ages, including newly born infants,3 this document’s intent is specificto FUNDING: No external funding. inpatient care after hospital admission, especially those hospitals with POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential conflicts of interest to disclose. lower pediatric volumes that may need additional guidance. For pediatric emergency care, the American Academy of Pediatrics (AAP) provides detailed information in “Joint Policy Statement--Guidelines for Care of To cite: Ernst KD, AAP COMMITTEE ON HOSPITAL CARE. Children in the Emergency Department,”4 and newborn care guidelines Resources Recommended for the Care of Pediatric Patients in Hospitals. Pediatrics. 2020;145(4):e20200204 can be found in Guidelines for Perinatal Care.5 For pediatric intensive care,

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 145, number 4, April 2020:e20200204 FROM THE AMERICAN ACADEMY OF PEDIATRICS the AAP and Society of Critical Care hospital-wide pediatric care and appropriate for their medical and Medicine provide resources in quality improvement efforts. psychosocial needs. “Criteria for Critical Care Infants and Children: PICU Admission, Regionalization and Interfacility Telehealth care may provide Discharge, and Triage Practice Transfer additional opportunities for collaboration between hospitals. In Statement and Levels of Care Hospitals and/or physicians ”6 addition to direct patient interactions Guidance. providing care for children need well- with pediatric medical subspecialists, established networks for timely tertiary centers may have outreach consultation by subspecialists with POLICIES, PROCEDURES, AND programs that can provide ongoing pediatric expertise and, when PROTOCOLS educational support for those necessary, for transfer of a patient to practicing in the community.12,13 One The care of the pediatric inpatient a facility that offers more advanced fi example of this model is Project population is suf ciently different levels of care. Guidance for ECHO (Extension for Community from that of the adult inpatient regionalization of care, the care of Healthcare Outcomes), population, and these differences pediatric trauma patients, the care of a telementoring program designed need to be taken into account when pediatric critical care patients, and to leverage widely available caring for this vulnerable patient transfer has been published videoconferencing technology, clinical population. Hospitals should by the AAP, the American College of management tools, and case-based electively admit only patients for Surgeons, the Society of Critical Care learning to increase workforce whom they have appropriate Medicine, and the Emergency Medical capacity by improving quality, resources, such as physical space, Services for Children (EMSC) – reducing variety, and standardizing size-appropriate equipment, and program.6 10 Formal written fi best practices within quali ed staff necessary for the interfacility transfer agreements a multidisciplinary, team-based unique needs of pediatric patients. should be in place for consultation approach.14 Establishing formalized In cases in which these resources are and transport of a pediatric patient to relationships in advance can benefit not available, policies to assist a facility with a higher level of care.10 both the referring hospital and the health care professionals with These include access to air and receiving tertiary care center by determining appropriate triage, ground transportation systems that creating joint quality improvement consultation, and referral decisions are responsive and appropriately teams to optimize patient care. are necessary. Hospitals that provide equipped and staffed on the basis of Comprehensive information pediatric inpatient or outpatient medical illness severity to care for regarding the use of telehealth services need both a plan in place children of all ages.11 It is important care can be found in “American (whether internally or through for these referral relationships to be Telemedicine Association Operating transport agreements) and developed proactively and for Procedures for Pediatric resources available to provide protocols to be standardized to Telehealth.”15 urgent and emergent transfer to facilitate safe and efficient transports. a facility with a higher level of care to best meet a patient’sneeds.These Regular multidisciplinary review of policies should address compliance children transferred out of the facility Patient Safety with the Emergency Medical as well as cases of deterioration can The provision of care for hospitalized Treatment and Labor Act be conducted to reevaluate the children should reflect an awareness 3 requirements. A board-certified hospital’s admission, discharge, and of the unique patient safety concerns general pediatrician or pediatric transfer criteria. Ideally, this review in the pediatric population: medical subspecialist is strongly would occur in collaboration with the  patient identification strategies recommended to provide regional referral facility. Such review that meet Joint Commission aleadershiproletoensureall may reveal minor modifications in standards16; hospital policies, procedures, and equipment or training that would  ’ protocols sufficiently address care allow the facility to safely care for the the child s current weight in for pediatric patients of all ages. If higher-acuity patients it has kilograms documented at a pediatrician is not available, then previously transferred out, or admission and at regular intervals; a physician board certified in family alternatively, it may identify high-risk  a full set of vital signs documented or emergency medicine with current diagnoses that warrant immediate in the medical record with pediatric expertise could fulfill that transfer on presentation. The goal is a process for reporting abnormal role. Ideally, this physician would to ensure that all children in the age-specific vital sign values to the also be active in the evaluation of facility receive the optimal care most child’s medical provider;

Downloaded from www.aappublications.org/news by guest on September 26, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS  all medication doses prescribed patients, families, and staff in cases of especially with younger children. and dispensed by using weight- active-shooter or other violent Ethical and legal guidelines for the 21 based dosing in kilograms with scenarios. care of adolescents need to be considered with regard to privacy checks to ensure doses do not Policies, procedures, and protocols and medical decision-making. Not exceed the expected maximum should also be developed and 17 only does consent need to be dosages ; implemented for all-hazards disaster addressed but also assent on the  precalculated medication dosages preparedness.4,22 Because of the basis of the child’sageand based on the child’s weight in complexities and need for advance developmental understanding.29,31 kilograms for common emergency planning, disaster preparedness is medications18; mentioned in this report to remind all Policies should be developed that  radiation safety procedures for facilities to address the issue. Hospital specify where children will be placed imaging by using as low as disaster plans are unique to each in the hospital once admitted. Single reasonably achievable ionizing facility and community depending on rooms provide better isolation for the 19 and shielding techniques ; and the patient populations served as well common infectious diseases for which as local, state, and regional resources  a rapid response team with at children are hospitalized and should and partners. The AAP has published least 1 person having expertise in also provide a space for caregivers to additional information in “Ensuring pediatric airway management as sleep and monitor care. If single the Health of Children in Disasters,”22 well as pediatric-specific criteria rooms are not available, guidelines and links to additional resources can leading to activation of the team.20 for appropriate age and sex cohorting be found on the AAP Disaster should be established, taking into Preparedness Advisory Council and The security of pediatric patients account adults who may be EMSC Web sites.23,24 The EMSC should be addressed within accompanying minors. Inviting program has prepared a checklist to individual facilities. The Joint families in the community to assist facilities in incorporating Commission standards require that participate in policy making or design pediatric preparedness into existing the facility identifies and implements of a facility remodel can be a valuable disaster policies.25 Information for security procedures to address resource for hospital leadership. handling an infant or child special populations, such as infants in abduction.21 For younger children, the NICU and children with special As the number of children with the use of security bracelets or health care needs, can be found in 26,27 chronic illnesses increases, hospitals umbilical cord tags provide one layer separate resources. may care for more pediatric patients of security, and locked units may with life-limiting illnesses, even if only provide security for older children. Family-Centered Care in an emergency situation. Processes A risk assessment should be Facilities striving to provide patient- should be in place for dealing with “do multidisciplinary, with each staff and family-centered care will include not resuscitate” or “allow natural member providing input in his or her active family involvement in death” orders with the understanding area of expertise to address actual decision-making, medication safety that individual situations require and potential risks.21 Not all pediatric processes, patient and family flexibility depending on the family and patients will have family supervision, education, and discharge child’s needs. The assessment and and the facility will be responsible for instruction.28 It is important to management of pain may be ensuring that children and address situations such as families challenging because of the adolescents do not leave the facility with limited English proficiency and/ developmental and individual unattended or with a noncustodial or low general literacy, especially differences in experiencing and parent or guardian. The physical with regard to informed consent and expressing pain. Several tools exist to layout, the number and arrangement family involvement and education.29 provide improved pain control of exits, the vulnerability of the Tailoring discussions with families assessment and management.32 The patient population, intended level of by using the principles of health AAP statement “Patient- and Family- guardian and/or visitor access, and literacy universal precautions is Centered Care and the Pediatrician’s community risk need to be addressed. critical for good communication.30 Role” can also act as a resource for Abduction and missing patient Religious and cultural considerations facilities as they design their policies exercises are effective means to may require adjustments to the and processes.28 validate pediatric security child’s care plan. Hospital policies effectiveness.21 Facilities will need to allowing at least 1 caregiver to Policies regarding personnel and address whole-hospital security remain with the child at all times training will be addressed later in this measures to provide safety to should be standard practice, report under Personnel and Training.

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 145, number 4, April 2020 3 EQUIPMENT ○ bag-valve masks and This equipment should account for the manometers; wide differences observed in the Emergency Resuscitation Equipment ○ suctioning equipment; pediatric population ranging from Essential equipment for care of the ○ laryngoscope blades; newborn infants to adolescents. The pediatric patient in hospitals includes following list supplements standard ○ oropharyngeal and resuscitation equipment for patients nasoharyngeal airways; adult equipment: whose status has deteriorated since ○  infant, standing, and bed scales to admission. All hospitals should be endotracheal tubes (laryngeal masks are beneficial for health measure patients in kilograms; prepared for the emergency occurring  in a pediatric patient, whether they care professionals who rarely appropriately sized respiratory routinely admit pediatric patients or have the opportunity to intubate equipment such as oxygen masks, not. A child who requires transfer to or rarely intubate children); nasal cannulas, bag-valve masks, a facility with a higher level of ○ feeding tubes to provide gastric artificial airways, and suctioning pediatric care should be stabilized decompression during supplies; while transport is being arranged. ventilation; and  supplemental oxygen delivery The AAP policy statement “Joint ○ chest tubes and large needles to systems, including low-flow Policy Statement--Guidelines for Care evacuate pneumothoraces; meters; of Children in the Emergency  vascular access devices and  oximeter monitoring supplies that ” fi Department provides speci c supplies: fit infants and small children; information for these situations.33 ○ skin preparation supplies and  nebulizers and metered-dose Separate pediatric emergency bandages; inhalers with masks and spacers; resuscitation carts are preferably ○ small needle sizes, including  “smart” infusion pumps designed located in or near areas such as the butterfly needles; for pediatric use with precise emergency department, pediatric ○ various sizes of syringes; administration of low infusion inpatient unit, labor and delivery rates with built-in libraries of the ○ umbilical line kits; and area, imaging area, and operating standard pediatric concentrations ○ room. Supplies recommended for intraosseous needles and drill; of medications;  these carts include the following: pediatric emergency medications,  heel warmers to improve fl  inventory checklist; including uids appropriate for peripheral blood flow for sampling pediatric patients (10% dextrose  standardized code sheets with the in infants; vials, 5% dextrose, and normal  medication dosages and Joules saline [NS] bags); and topical anesthetics for blood and precalculated on the basis of spinal fluid sampling34;  chemical mattress pads to provide weight in kilograms;  warmth for infants. pediatric lumbar puncture trays;  pediatric backboard;  sterile urine collection supplies in Maintaining a code sheet with the  personal protective equipment pediatric sizes; medication dosages and Joules (gloves, gowns, masks);  mercury-free thermometers with  precalculated on the basis of the sharps container; child’s actual weight in kilograms is measurements in Celsius;  cardiorespiratory and pulse desirable in the patient’s room (and,  pediatric-sized blood pressure cuffs; oximetry monitors with ideally, kept at all times with the  common pediatric fluids such as appropriate alarm limits for patient during transport between 10% dextrose vials, NS bags, 5% pediatric patients; departments or facilities). An dextrose with 1/2 normal saline fi  automated external defibrillators extensive checklist of more speci c (D5-1/2NS), and 5% dextrose capable of treating pediatric supply items can be found in the with normal saline (D5 NS); fi resources and toolkit section on the patients with cardiac de brillator  orogastric and nasogastric feeding EMSC Web site.18 paddles sized for infants and tubes in sizes to fit children from children; Routine Hospital Equipment newborn infants to adolescents;  airway management equipment  Essential equipment is necessary to common infant formula types and that fits children of all sizes provideforthemostcommon bottles with nipples; (newborn to adolescents): diagnoses seen in hospitals such as  pacifiers to provide newborn pain ○ oxygen tanks; respiratory illness, appendicitis, seizure analgesia or soothing for neonatal ○ pediatric oxygen masks; disorders, infections, and dehydration. abstinence;

Downloaded from www.aappublications.org/news by guest on September 26, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS  dedicated enteral pumps (these  ability to designate an milk as an additional layer of 40 provide safety because they indeterminate gender; security for error prevention ; prevent inadvertent  configuration of access to  discharge outpatient prescription administration of enteral products adolescent patient data based on prescribing with weight-based via the intravenous route); legal status and state dosing, including total metric dose,  electric breast pumps for mothers confidentiality laws37; as well as milliliters for liquid medications, name of medication, of young infants, including labels  ability to maintain continuity of for storage and accessible storage and reason for use; and access to health care information  facilities; in cases in which children are ability to provide family education  incubators and/or warmers for mobile between various legal or in their native language for infants and cribs with sleeping physical custodians, for example, medical issues as well as surfaces meeting safe-sleep the foster care system; medications. 35 guidelines ;  linking between infant and  Various sizes of diapers; maternal medical charts and FACILITIES  age-appropriate restraint devices, unlinking in cases of custodial loss Patient Care Area Facilities including soft wrist and leg or adoption; restraints and arm and/or wrist  management of immunization The Joint Commission provides the immobilizers, to help preserve data, including the ability to share Comprehensive Accreditation Manual life-saving equipment such as administration data with the for Hospitals that addresses the endotracheal tubes, feeding tubes, medical home and immunization standards of hospital facilities to 41 and intravenous lines; and registries; provide safe, quality health care. These standards generally address  wheelchairs, crutches, slings, and  management of age-specific data the physical space and the features splints in pediatric sizes. for handoff reports including the that protect patients, visitors, and transmission of the report to the Electronic Clinical Information staff. Caring for children requires medical home38,39; Systems additional considerations:  ability to manage newborn Electronic clinical information  screening and hearing screening single- or double-occupancy systems play an important role in rooms that comply with guidelines data; ensuring the safety and quality of  for prevention of hospital- pediatric care. A comprehensive AAP availability of age-appropriate acquired infections (grouping resource “Pediatric Aspects of normal values for laboratory test pediatric rooms allows for Inpatient Health Information results; efficient use of resources); ”  Technology Systems provides ability to document  pediatric beds allowing for bed guidance for facilities in developmental milestones; rails to be raised; understanding the unique aspects of  automated nutritional  rooms with enough space to safety, care, and documentation needs calculations; accommodate caregivers who stay with regard to pediatric patients.36  ability to manage the storage, with their children, including Although no dedicated pediatric tracking, and administration of a sleeping space for at least 1 inpatient clinical information system human milk; caregiver; exists, some unique pediatric needs  from this resource are highlighted electronic ordering of medications  adjustable privacy screens that below: and infusions with weight-based allow convenient observation and calculations and alerts specificto supervision of patients;  anthropometric measurements the pediatric population;  space to accommodate an (weight, length, head  circumference) in metric units ability to preadmit patients likely accompanying adult in elevators with automatic plotting on to be admitted (preterm infant and procedural rooms; appropriate growth charts based going to the NICU) so medications  a negative-pressure room for on sex and age; are readily available; children admitted with suspected   storage of age-specific data, such medication dosing and drug infectious illness that require that as Apgar scores, pediatric pain interactions relative to pediatric type of isolation; scales, neonatal abstinence scores, patients;  age-appropriate furniture, pediatric mortality prediction  barcode scanning capabilities for including cribs equipped with scores, and ages in hours or days; medications, blood, and human overhead safety devices and beds

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 145, number 4, April 2020 5 having covered mechanical or showers, etc) while they are ○ standard laboratory regulations electrical controls; staying with their children in the require appropriate critical reference values based on  high chairs for infant and toddler facility; and  patient age45; mealtimes; affordable or free parking for   bookshelves or other large or families with hospitalized children pharmacy services to provide age- and size-appropriate drug bulky furniture anchored to the to encourage family involvement. wall and that meet Consumer administration and dosing that Product Safety Commission Although interior design and decor is includes both a weight-based dose fi 46 standards with a process in place beyond the scope of this document, and a nal calculated amount : to monitor for product recalls42; additional information about child- ○ commonly used oral friendly, developmentally  specific safety products, such as suspensions, including oral appropriate environments may be electrical outlet covers, window sucrose solutions to use for obtained from the Institute for locks, cabinet door safety latches, analgesia with painful Patient- and Family-Centered Care procedures in young infants, padding for sharp corners and 44 Web site. 34 edges, and toilet latches, for quickly available ; spaces in children’s areas; ○ supplies and expertise to safely  create pediatric liquid cordless window coverings; Therapeutic and Diagnostic Facilities formulations at nationally  cordless phones;  The following therapeutic and accepted standard magnet-free status communication diagnostic facilities are necessary, and concentrations14; boards; 24-hour availability is strongly ○  orally administered liquid trash cans and sharps containers recommended: medications dispensed with out of reach of toddlers and small  routine radiographic imaging, metric dosing (milligrams, children; using techniques to reduce micrograms) on the label in  alcohol-containing hand sanitizer radiation exposure in children,19 small-volume milliliter-based dispensers not accessible to small with a radiologist skilled in dosing devices, such as children; pediatric assessment available syringes47;  age-appropriate spaces where either on-site or by teleradiology ○ doses of medications calculated children can feel safe from painful for interpreting images; by using computer programs or or scary medical procedures43;  clinical laboratory with services calculations based on  a separate treatment room for appropriate for infant and appropriate neonatal or procedures43; pediatric needs, including pediatric pharmacokinetic hematologic profiles, blood  entertainment consoles, models; and chemistries (including serum computers, as well as educational ○ medications for pediatrics bilirubin levels), blood gas and other age-appropriate stored in a separate location studies, microbiology studies, from adult formulations both activities help to keep children common locally used antibiotic within and outside of the distracted; all toys, equipment, levels, and standard urine pharmacy; and and play surfaces should be studies: regularly cleaned with appropriate  nutritional services to provide ○ equipment to process all germicidal solutions; child-friendly meals:  commonly ordered tests, such as an indoor and/or secure outdoor complete blood cell counts and ○ common infant and toddler playground area with equipment blood chemistry levels, by using formulas, pediatric nutritional that has accommodations for samples of less than 1 mL supplements, and rehydration those with impaired mobility; (“micro” samples); formulas stocked in pediatric  Internet access, with appropriate ○ serum drug concentrations for areas and readily retrieved for safeguards, available to all aminoglycoside antibiotics, for those in the emergency patients and families for example, known to cause department or other areas entertainment, work, and ototoxicity and nephrotoxicity, where children are treated; education; with results available in a timely ○ in cases in which the hospital  facilities for families to safely store manner; send-out testing may cafeteria does not remain open food and human milk and for not allow appropriate 24 hours, prepackaged meals personal hygiene (laundry, adjustments in dosing; and and patient nutritional supplies

Downloaded from www.aappublications.org/news by guest on September 26, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS stocked in the pediatric areas be licensed and have training in the complications. It is important to be before the cafeteria closes for care of hospitalized children either able to recognize the various levels of the night; through a formal training program sedation in addition to possessing the ○ nutritious meals and drinking and/or through supervised skills and age- and size-appropriate water readily available for experience consistent with the equipment necessary to provide ’ breastfeeding mothers; and individual facility s bylaws for appropriate monitoring as well as credentialing. Health care cardiopulmonary support if needed.50 ○ donor human milk, which is professionals need to maintain Because normal vital sign values becoming more widely available professional expertise through differ in younger age groups, and is a consideration for continuing education as well as instruction on the use of hospitals treating infants who maintenance of active life support cardiorespiratory monitors and their may benefit from this resource. credentials, including neonatal and alarms is necessary for all staff. pediatric advanced life support or Competencies and case volumes in PERSONNEL AND TRAINING equivalent training.48 Those who are pediatric sedation should be in charge of a pediatric patient’s care reviewed annually.50 Children Because respiratory illnesses are the may be either on-site or on-call, younger than 1 year are at a fourfold most common pediatric diagnoses depending on the severity of a child’s higher risk of anesthesia-related requiring inpatient admission, the illness, and policies may address an cardiac arrest than those between 1 need for health care facilities to have acceptable response time for on-call and 18 years of age.51 For this reason, ready access to personnel skilled in professionals. Children who require for children younger than 2 years or airway management as well as intermediate- or higher-level care older children with complex medical specialized equipment in sizes need a high-level health care diseases, it is preferred that board- appropriate for children from professional who is in-house and certified pediatric surgeons and newborn infants to adolescents is readily available to respond to the anesthesiologists supervise all imperative. Respiratory therapists patient immediately should the elective surgical procedures.51 The with pediatric expertise are especially child’s condition deteriorate.49 The AAP statement “Critical Elements important for providing safe pediatric AAP and Society of Critical Care for the Pediatric Perioperative care because pediatric patients tend Medicine publication “Criteria for Anesthesia Environment” has detailed to experience respiratory arrest Critical Care Infants and Children: information.50 rather than the cardiac arrest seen in PICU Admission, Discharge, and adults. Health care professionals with Triage Practice Statement and Levels Pediatric nursing experience and expertise in pediatric life support of Care Guidance” helps identify training is crucial in determining techniques should know the location resource needs in those settings.6 a facility’s ability to provide high- of carts and equipment for quality and safe pediatric medical cardiopulmonary resuscitation. Mock Facilities must have policies in place care. Because nurses spend more codes conducted on a regular basis so that the responsible health care face-to-face time with the patient with debriefings either by pediatric- professional is known to all personnel than any other member of the health trained internal staff or by using caring for the child, whether it be the care team, it is important that they personnel from tertiary centers are primary physician, on-call physician, are able to identify signs of strongly recommended. It is helpful if or an in-house emergency decompensation and are able to the multidisciplinary medical team department physician with abilities intervene in an emergency. They trains together during life support to care for pediatric patients. should understand that normal courses so that the team functions Procedures should be in place so that laboratory values may differ in optimally in times of emergency. This both families and the medical team pediatric patients. Nurses must training complements, but does not are able to easily identify this person. understand the behavioral differences replace, real-life experience in caring Because a child’s age, as well as that occur in children to modify their for hospitalized children. Education cognitive level, influences his or her care on the basis of the child’s sessions, clinical training ability to cooperate, sedation in understanding of the situation (eg, opportunities, and mock codes should children is often administered to the use of age-appropriate pediatric be documented for review by hospital relieve pain and anxiety as well as to pain scales)34 or developmental quality assurance committees and provide immobility to allow the safe differences in their ability to respond The Joint Commission. completion of a procedure. Health to a neurologic examination. Physicians and other health care care professionals should have an in- Adolescents require a fine balance professionals responsible for the care depth knowledge of the agents they between guidance and autonomy, and of inpatient pediatric patients should intend to use and their potential pediatric nurses need skill in

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 145, number 4, April 2020 7 recognizing signs of abuse or self- It is highly recommended that the tertiary hospital staff members. These harm. In cases in which nurses have following health care professionals be points of contact may provide regular relatively low skill in obtaining available on a routine basis to provide educational sessions, consultations intravenous access, it is preferable services to the inpatient pediatric for specific patients, and assistance that the most experienced staff patients: radiology technologists, with policy development.8,9 member attempt to obtain access to nutritionists, lactation specialists, decrease the child’s emotional and rehabilitation therapists, child life physical trauma. Although having specialists, mental health specialists, SPECIAL CONSIDERATIONS a pediatric nursing educator is ideal, social workers, and medical Although all health care professionals facilities lacking a pediatric educator interpreters. Professionals providing who provide care to pediatric should ensure they dedicate time these services should have adequate patients should be familiar with the to pediatric competencies. It is training and continuing education in unique and changing physical and important for hospitals to anticipate the pediatric applications of their psychosocial needs of children and pediatric personnel shortages or respective fields. Baseline and the core concepts of patient- and times of higher pediatric census by periodic competency evaluations family-centered care, having crosstraining nonpediatric staff, who should include competencies specific a child life specialist on staff is should only be used after successfully to the pediatric populations cared for recommended.28 If it is not feasible demonstrating the essential duties of in the individual facility. In many to maintain a dedicated child life nurses caring for pediatric inpatients. facilities, nurses often fill the role specialist, facilities should consult If skilled pediatric staff are not of providing lactation support to one at a tertiary center to assist with available, consideration should be mother-infant dyads with common ongoing education of the local given to transfer of children to lactation issues. Staff who are asked hospital staff in the provision of ’ a facility that can meet the patients to fill the gaps when other personnel psychosocial care and family- and needs. Baseline and annual are not available routinely should be child-friendly services.43 The fi evaluations that include age-speci c provided continuing education assessment of pain can be difficult in and psychosocial competencies as opportunities to ensure competence nonverbal children, and health care well as the performance of essential in the roles they are performing. It is professionals need training in how to pediatric skills should be verified by not acceptable to use family members use age-appropriate pediatric pain qualified personnel. as interpreters of health care scales appropriately. Staff may also information, and hospital staff should need training on how to support Similar to medical and nursing staff, practice health literacy universal children with intellectual disabilities pharmacists caring for pediatric or autism spectrum disorder, for patients need experience and specific precautions. Only 12% of US adults fl example, who present with a medical training in their roles. Pediatric are uent in the language of health care, and the ability to absorb and illness needing treatment. Training in patients are at higher risk for the physical as well as the emotional medication error and may experience use health information can be 30 components of end-of-life situations a more serious consequence should an compromised by stress. The Agency ’ and palliative care may be helpful for error occur.17 It is helpful for for Healthcare Research and Quality s AHRQ Health Literacy Universal staff because many find it difficult to pharmacists with pediatric experience deal with a child’s impending or Precautions Toolkit, Second Edition, to participate in prospective order actual death. review, safety and technology can help facilities increase patient committees, protocol development, and family understanding of health Hospitalized children, especially staff education, quality improvement, information and enhance support for those with hospital stays anticipated 30 and other high-impact patient care people of all health literacy levels. to last more than a week, need duties.52 Pharmacy technicians who Foreign and sign language assistance a designated hospital liaison (nurse, prepare pediatric medications, may be provided by a telephone or social worker, discharge planner, child including parenteral solutions, need to telehealth interpretive service, and life specialist) to partner with the maintain documented pediatric educational materials may be child’s school to ensure the pharmacy competencies. Not all translated by an off-site service if an hospitalization does not cause facilities will have a pediatric interpreter is not available in-house. interruption in the child’s education pharmacist on staff, and a liaison When it is not feasible to employ full- endeavors. In some cases, having pediatric pharmacist from a children’s time personnel or crosstrain staff access to videoconferencing or online hospital may be a beneficial resource because of financial or staffing issues, attendance at a child’s school can to assist in minimizing the possibility facilities should maintain appropriate keep the child from getting behind in of adverse consequences. consultative relationships with his or her studies.

Downloaded from www.aappublications.org/news by guest on September 26, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS Children may be seen in the CONCLUSIONS sb246-Geographic-Variation-Hospital- Stays.pdf. Accessed March 30, 2019 emergency department for medical Inpatient facilities caring for the disorders that can either present as or unique pediatric population should 2. Witt WP, Weiss AJ, Elixhauser A. coexist with psychiatric or behavioral be well resourced to provide high- Overview of Hospital Stays for Children disorders needing appropriate triage. quality and safe health care by in the United States, 2012. Statistical It is important to be sensitive to the providing the appropriate policies, Brief #187. Rockville, MD: Agency for Healthcare Research and Quality; 2014. needs of adolescent patients by asking equipment, facilities, and personnel Available at: https://www.hcup-us.ahrq. nonprejudiced questions in private as outlined in this clinical report. about sexual partners and substance gov/reports/statbriefs/sb187-Hospital- use. Although toxic ingestions in Stays-Children-2012.pdf. Accessed March 30, 2019 toddlers may be accidental, those in LEAD AUTHOR adolescents may be a sign of suicidal Kimberly D. Ernst, MD, MSMI, FAAP 3. Centers for Medicare and Medicaid intentions.53 Sixteen percent of Services. Emergency Medical Treatment adolescents have seriously COMMITTEE ON HOSPITAL CARE, 2018–2019 and Labor Act (EMTALA). 2012. Available at: www.cms.gov/Regulations-and- considered, and 8% have attempted, Daniel A. Rauch, MD, FAAP, Chairperson 54 Guidance/Legislation/EMTALA/. suicide in the past year. Certain Kimberly D. Ernst, MD, MSMI, FAAP Accessed March 30, 2019 ethnic groups, those with a family or Vanessa Lynn Hill, MD, FAAP personal history of suicide attempts Melissa Marie Mauro-Small, MD, FAAP 4. American Academy of Pediatrics, or behavioral disorders, and those Benson S. Hsu, MD, MBA, FAAP Committee on Pediatric Emergency Vinh Thuy Lam, MD, FAAP Medicine; American College of who identify as a sexual minority are Charles David Vinocur, MD, FAAP 55 Emergency Physicians, Pediatric at higher risk. Personnel should be Jennifer Ann Jewell, MD, FAAP, Former able to recognize these issues and be Chairperson Committee; Emergency Nurses Association, Pediatric Committee. Joint familiar with the hospital’s mental policy statement–Guidelines for care of health resources and policies for LIAISONS children in the emergency department. appropriate triage. Karen Castleberry – Family Liaison Pediatrics. 2009;124(4):1233–1243. Kristin Hittle Gigli, PhD, RN, CPNP-AC, Reaffirmed February 2016 Health care professionals responsible CCRN – National Association of Pediatric for the care of children should be Nurse Practitioners 5. American Academy of Pediatrics, trained in the recognition and initial Nancy Hanson – Children’s Hospital Committee on Fetus and Newborn; management of child abuse, Association American College of Obstetricians and – Gynecologists, Committee on Obstetric maltreatment, and neglect whether Michael S. Leonard, MD, MS, FAAP Representative to The Joint Commission Practice. Guidelines for Perinatal Care. physical, sexual, emotional, or medical. Barbara Romito, MA, CCLS – Association of In: Riley LE, Stark AR, eds. 7th ed. Elk They should be aware of the types of Child Life Professionals Grove Village, IL: American Academy of injuries that can occur at various ages Pediatrics and Washington, DC: and which ones are unlikely to have STAFF American College of Obstetricians and occurred in the manner in which they Gynecologists; 2012 S. Niccole Alexander, MPP are described by the child or 56,57 6. Frankel LR, Hsu BS, Yeh TS, et al; Voting accompanying adult. Children who Panel. Criteria for critical care infants have experienced physical or sexual ABBREVIATIONS and children: PICU admission, abuse, children who have experienced discharge, and triage practice violence in the home, or children who AAP: American Academy of statement and levels of care guidance. are diagnosed with a psychological Pediatrics Pediatr Crit Care Med. 2019;20(9): disorder should have timely EMSC: Emergency Medical 847–887 Services for Children intervention with a child maltreatment 7. American Academy of Pediatrics, team and/or mental health specialist. NS: normal saline Section on Transport Medicine. There should be policies in place to Guidelines for Air and Ground ensure proper reporting of allegations Transport of Neonatal and Pediatric to authorities for further investigation REFERENCES Patients. In: Insoft RM, ed. 4th ed. Elk as well as appropriate transfer to Grove Village, IL: American Academy of 1. Freeman WJ, Weiss AJ, Heslin KC. a facility with mental health services Pediatrics; 2016 Overview of U.S. Hospital Stays in 2016: with expertise in pediatric care if not Variation by Geographic Region. 8. American College of Surgeons, available locally. Guidance in the area Statistical Brief #246. Rockville, MD: Committee on Trauma. Resources for of child maltreatment can be found on Agency for Healthcare Research and Optimal Care of the Injured Patient. 6th the AAP Council on Child Abuse and Quality; 2018. Available at: https://www. ed. Chicago, IL: American College of Neglect Web site.58 hcup-us.ahrq.gov/reports/statbriefs/ Surgeons; 2014

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 145, number 4, April 2020 9 9. Committee on Pediatric Emergency 2015_NPSG_HAP.pdf. Accessed March Physicians; Emergency Nurses Medicine, Council on Injury; Violence, 30, 2019 Association. Checklist of Essential and Poison Prevention, Section on Pediatric Domains and Considerations 17. Levine SR, Cohen MR, Blanchard NR, Critical Care, Section on Orthopaedics, for Every Hospital’s Disaster et al. Guidelines for preventing medical Section on Surgery, Section on Preparedness Policies. Houston, TX: errors in pediatrics. J Pediatr Transport Medicine, Pediatric Trauma Emergency Medical Services for Pharmacol Ther. 2001;6:426–442 Society, and Society of Trauma Nurses Children Innovation and Improvement Pediatric Committee. Management of 18. Emergency Medical Services for Center; 2014. Available at: https://emsci pediatric trauma. Pediatrics. 2016; Children, Innovation and Improvement mprovement.center/documents/144/ 138(2):e20161569 Center. Pediatric Disaster Preparedness Checklist_HospitalDisasterPrepare Toolkit. 2009. Available at: https:// d2125.pdf. Accessed March 30, 2019 10. Emergency Nurses Association emscimprovement.center/resources/ Pediatric Committee; Society of Trauma 26. Barfield WD, Krug SE; Committee on publications/checklist-essential-for- Nurses Pediatric Special Interest Group. Fetus and Newborn; Disaster every-hospitals-disaster-preparedness- Inter Facility Transfer Tool Kit for the Preparedness Advisory Council. Disaster policies/. Accessed March 30, 2019 Pediatric Patient. Houston, TX: preparedness in neonatal intensive care Emergency Medical Services for 19. Image Gently. Interventional Radiology - units. Pediatrics. 2017;139(5):e20170507 Children Innovation and Improvement Step Lightly Resources. Available at: 27. American Academy of Pediatrics; Center; 2017. Available at: https:// https://www.imagegently.org/ Committee on Pediatric Emergency emscimprovement.center/resources/ Procedures/Interventional-Radiology/ Medicine and Council on Clinical toolboxes/interfacility-transfer-toolbox/. Image-Safely-Resources. Accessed Information Technology; American Accessed March 30, 2019 March 30, 2019 College of Emergency Physicians; 11. American Academy of Pediatrics; 20. Institute for Healthcare Improvement. Pediatric Emergency Medicine American College of Emergency Rapid response teams. Available at: Committee. Policy Physicians; American College of www.ihi.org/Topics/ statement–emergency information Surgeons Committee on Trauma; RapidResponseTeams/Pages/default. forms and emergency preparedness Emergency Medical Services for aspx. Accessed March 30, 2019 for children with special health care – Children; Emergency Nurses 21. US Department of Health and Human needs. Pediatrics. 2010;125(4):829 837. fi Association; National Association of Services, Office of the Assistant Reaf rmed October 2014 EMS Physicians; National Association of Secretary for Preparedness and 28. Committee on Hospital Care and State EMS Officials. Equipment for Response. Incorporating Active Shooter Institute for Patient- and Family- ground ambulances. Pediatrics. 2014; Incident Planning Into Health Care Centered Care. Patient- and family- 134(3). Available at: www.pediatrics. Facility Emergency Operations Plans. centered care and the pediatrician’s org/cgi/content/full/134/3/e919 Washington, DC: US Department of role. Pediatrics. 2012;129(2):394–404 12. Marcin JP, Rimsza ME, Moskowitz WB; Health and Human Services; 2014 29. Committee on Pediatric Emergency Committee on Pediatric Workforce. The 22. Disaster Preparedness Advisory Medicine; Committee on Bioethics. use of telemedicine to address access Council; Committee on Pediatric Consent for emergency medical and physician workforce shortages. Emergency Medicine. Ensuring the services for children and adolescents. Pediatrics. 2015;136(1):202–209 health of children in disasters. Pediatrics. 2011;128(2):427–433. 13. Burke BL Jr., Hall RW; Section on Pediatrics. 2015;136(5). Available at: Reaffirmed September 2015 Telehealth Care. Telemedicine: pediatric www.pediatrics.org/cgi/content/full/ 30. Agency for Healthcare Research and applications. Pediatrics. 2015;136(1): 136/5/e1407 Quality. AHRQ Health Literacy Universal e293–e308 23. American Academy of Pediatrics, Precautions Toolkit. Rockville, MD: 14. American Academy of Pediatrics. AAP Disaster Preparedness Advisory Agency for Healthcare Research and ECHO. Available at: www.aap.org/en-us/ Council. Children and disasters: Quality; 2018. Available at: www.ahrq.gov/ professional-resources/practice- disaster preparedness to meet professionals/quality-patient-safety/ transformation/echo/Pages/default. children’s needs. Available at: https:// quality-resources/tools/literacy-toolkit/ aspx. Accessed March 30, 2019 www.aap.org/en-us/advocacy-and- index.html. Accessed March 30, 2019 policy/aap-health-initiatives/Children- 15. McSwain SD, Bernard J, Burke BL Jr., 31. Committee on Bioethics. Informed and-Disasters/Pages/default.aspx. et al; American Telemedicine consent in decision-making in pediatric Accessed March 30, 2019 Association. American Telemedicine practice. Pediatrics. 2016;138(2):e20161484 Association operating procedures for 24. Emergency Medical Services for 32. American Academy of Pediatrics; pediatric telehealth. Telemed J E Health. Children Innovation and Improvement American College of Emergency 2017;23(9):699–706 Center. Education & resources. Available Physicians; Emergency Nurses at: https://emscimprovement.center/ 16. The Joint Commission. National Patient Association. Pediatric Pain Management resources/. Accessed March 30, 2019 Safety Goals. Oakbrook Terrace, IL: The Toolkit. Houston, TX: Emergency Medical Joint Commission; 2015. Available at: 25. American Academy of Pediatrics; Services for Children Innovation and www.jointcommission.org/assets/1/6/ American College of Emergency Improvement Center; 2017. Available at:

Downloaded from www.aappublications.org/news by guest on September 26, 2021 10 FROM THE AMERICAN ACADEMY OF PEDIATRICS https://emscimprovement.center/ www.pediatrics.org/cgi/content/full/ 52. Boucher EA, Burke MM, Johnson PN, resources/toolboxes/pediatric-pain- 133/5/e1471 Klein KC, Miller JL; Advocacy Committee management-toolbox/. Accessed March 44. Institute for Patient- and Family- for the Pediatric Pharmacy Advocacy 30, 2019 Centered Care. Resources. Available at: Group. Minimum requirements for core 33. Fleisher GR, Ludwig S. Textbook of http://ipfcc.org/resources/index.html. competency in pediatric pharmacy Pediatric Emergency Medicine. 6th ed. Accessed March 30, 2019 practice. J Pediatr Pharmacol Ther. 2015;20(6):481–484 Philadelphia, PA: Lippincott Williams & 45. Clinical and Laboratory Standards Wilkins; 2010 Institute. Defining, Establishing, and 53. Chun TH, Mace SE, Katz ER; American 34. Committee on Fetus and Newborn; Verifying Reference Intervals in the Academy of Pediatrics; Committee on Section on Anesthesiology and Pain Clinical Laboratory; Approved Guideline Pediatric Emergency Medicine; Medicine. Prevention and management of [CLSI Document EP28-A3c]. 3rd ed. American College of Emergency procedural pain in the neonate: an Wayne, PA: Clinical and Laboratory Physicians; Pediatric Emergency update. Pediatrics. 2016;137(2):e20154271 Standards Institute; 2008 Medicine Committee. Evaluation and management of children and adolescents 35. Task Force on Sudden Infant Death 46. American Society of Health-System with acute mental health or behavioral Syndrome. SIDS and other sleep-related Pharmacists. ASHP compounded oral problems. Part I: common clinical fi infant deaths: updated 2016 liquid version 1.01: nalized list July challenges of patients with mental health recommendations for a safe infant 2017. 2017. Available at: www.ashp. and/or behavioral emergencies. sleeping environment. Pediatrics. 2016; org/-/media/assets/pharmacy-practice/ Pediatrics. 2016;138(3):e20161570 138(5):e20162938 s4s/docs/s4s-ashp-oral-compound- 54. Shain B; Committee on Adolescence. 36. Lehmann CU; Council on Clinical liquids.ashx?la=en&hash= Suicide and suicide attempts in Information Technology. Pediatric 4C2E4F370B665C028981B61F62 adolescents. Pediatrics. 2016;138(1): aspects of inpatient health information 10335AD5D0D1D6. Accessed March 30, e20161420 technology systems. Pediatrics. 2015; 2019 135(3). Available at: www.pediatrics. 47. Committee on Drugs. Metric units and 55. Eaton DK, Kann L, Kinchen S, et al; org/cgi/content/full/135/3/e756 the preferred dosing of orally Centers for Disease Control and 37. Committee on Adolescence. Achieving administered liquid medications. Prevention (CDC). Youth Risk Behavior – quality health services for adolescents. Pediatrics. 2015;135(4):784 787 Surveillance - United States, 2011. – Pediatrics. 2016;138(2):e20161347 48. Lye PS; American Academy of MMWR Surveill Summ. 2012;61(4):1 162 38. Jewell JA; Committee on Hospital Care. Pediatrics. Committee on Hospital Care 56. Flaherty EG, Perez-Rossello JM, Levine Standardization of inpatient handoff and Section on Hospital Medicine. Clinical MA, Hennrikus WL; American Academy – ’ communication. Pediatrics. 2016;138(5): report physicians roles in coordinating of Pediatrics Committee on Child Abuse e2016281 care of hospitalized children. Pediatrics. and Neglect; Section on Radiology, 2010;126(4):829–832 American Academy of Pediatrics; 39. Kuo DZ, Houtrow AJ; Council on Children Section on Endocrinology, American with Disabilities. Recognition and 49. Jaimovich DG; American Academy of Academy of Pediatrics; Section on management of medical complexity. Pediatrics Committee on Hospital Care Orthopaedics, American Academy of Pediatrics. 2016;138(6):e20163021 and Section on Critical Care. Admission and discharge guidelines for the Pediatrics; Society for Pediatric Radiology. 40. Bates DW, Cohen M, Leape LL, Overhage pediatric patient requiring Evaluating children with fractures for JM, Shabot MM, Sheridan T. Reducing intermediate care. Pediatrics. 2004; child physical abuse. Pediatrics. 2014; the frequency of errors in medicine 113(5):1430–1433. Reaffirmed May 2017 133(2). Available at: www.pediatrics.org/ using information technology. J Am Med cgi/content/full/133/2/e477 Inform Assoc. 2001;8(4):299–308 50. Polaner DM, Houck CS; Section on Anesthesiology and Pain Medicine; 57. Christian CW; Committee on Child Abuse 41. The Joint Commission. Comprehensive American Academy of Pediatrics. and Neglect, American Academy of Accreditation Manual for Hospitals. Critical elements for the pediatric Pediatrics. The evaluation of suspected Oakbrook Terrace, IL: The Joint perioperative anesthesia environment. child physical abuse. Pediatrics. 2015; Commission; 2016 Pediatrics. 2015;136(6):1200–1205 135(5). Available at: www.pediatrics. org/cgi/content/full/135/5/e1337 42. US Consumer Product Safety 51. Society for Pediatric Anesthesia. Society Commission. Regulations, laws & for Pediatric Anesthesia Policy 58. Flaherty EG, Stirling J; American standards. Available at: www.cpsc.gov/ Statement on Provision of Pediatric Academy of Pediatrics, Committee on – Regulations-Laws Standards. Accessed Anesthesia Care. Richmond, VA: Society Child Abuse and Neglect. The March 30, 2019 for Pediatric Anesthesia; 2017. Available pediatrician’s role in child 43. Committee on Hospital Care and Child at: www.pedsanesthesia.org/about/ maltreatment prevention. Pediatrics. Life Council. Child life services. provision-of-pediatric-anesthesia-care/. 2010;126(4):833–841. Reaffirmed May Pediatrics. 2014;133(5). Available at: Accessed March 30, 2019 2014

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 145, number 4, April 2020 11 Resources Recommended for the Care of Pediatric Patients in Hospitals Kimberly D. Ernst and COMMITTEE ON HOSPITAL CARE Pediatrics originally published online March 23, 2020;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2020/03/19/peds.2 020-0204 References This article cites 26 articles, 19 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2020/03/19/peds.2 020-0204#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Current Policy http://www.aappublications.org/cgi/collection/current_policy Committee on Hospital Care http://www.aappublications.org/cgi/collection/committee_on_hospita l_care Hospital Medicine http://www.aappublications.org/cgi/collection/hospital_medicine_su b Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 26, 2021 Resources Recommended for the Care of Pediatric Patients in Hospitals Kimberly D. Ernst and COMMITTEE ON HOSPITAL CARE Pediatrics originally published online March 23, 2020;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2020/03/19/peds.2020-0204

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2020 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Downloaded from www.aappublications.org/news by guest on September 26, 2021