Results of the 2002 Emergency Pediatric Services and Equipment Supplement (EPSES) to the National Hospital Medical Care Survey (NHAMCS) Centers for Disease.

Results of the 2002 Emergency Results of the 2002 Emergency Pediatric Services and Equipment Pediatric Services and Equipment

Supplement (EPSES) to the Supplement (EPSES) to the National Hospital Medical Care National Hospital Medical Care

Survey (NHAMCS)Survey (NHAMCS)

Centers for Disease Control and PreventionNational Center for Health Statistics

Division of Health Care Statistics

Kimberly Middleton BSN MPH

OverviewOverview

BackgroundBackground

EPSES MethodologyEPSES Methodology

ResultsResults

Next StepsNext Steps

BackgroundBackground

American Academy of Pediatrics American Academy of Pediatrics RecommendationsRecommendations

A schedule of pediatricians on call to every A schedule of pediatricians on call to every EDED

All EDs to establish transfer agreements All EDs to establish transfer agreements with facilities with higher levels of pediatric with facilities with higher levels of pediatric care to ensure timely access to pediatric care to ensure timely access to pediatric emergency care for critically ill and injured emergency care for critically ill and injured childrenchildren

American Academy of Pediatrics American Academy of Pediatrics GuidelinesGuidelines

All equipment and supplies listed, All equipment and supplies listed, including age-appropriate and size-including age-appropriate and size-appropriate equipment for children of all appropriate equipment for children of all ages and sizes from premature infants ages and sizes from premature infants through adolescentsthrough adolescents

Each hospital must develop a method for Each hospital must develop a method for storage and provide accessibility of storage and provide accessibility of medications and equipment for childrenmedications and equipment for children

1998 NEISS Findings1998 NEISS Findings

Hospitals w/o pediatric dept, ward or trauma Hospitals w/o pediatric dept, ward or trauma service usually transfer critically injured pediatric service usually transfer critically injured pediatric trauma patientstrauma patients

Nearly 10% of hospitals w/o pediatric intensive Nearly 10% of hospitals w/o pediatric intensive care unit (PICU) admit critically injured pediatric care unit (PICU) admit critically injured pediatric trauma patientstrauma patients

7% of all hospitals admit pediatric patients 7% of all hospitals admit pediatric patients requiring intensive care to adult intensive care unit requiring intensive care to adult intensive care unit (ICU) instead of transferring to hospital with PICU(ICU) instead of transferring to hospital with PICU

1998 NEISS Findings cont’d1998 NEISS Findings cont’d

Few hospitals have protocols for obtaining Few hospitals have protocols for obtaining peds consultation for peds emergenciespeds consultation for peds emergencies

Appropriate sized equipment for infants and Appropriate sized equipment for infants and children was more likely to be missing than children was more likely to be missing than adult-sizesadult-sizes

A significant number of hospitals did not A significant number of hospitals did not have adequate equipment to care for have adequate equipment to care for newborn emergencies.newborn emergencies.

Emergency Pediatric Services Emergency Pediatric Services and Equipment Supplement and Equipment Supplement

(EPSES)(EPSES)

Funded by HRSA to replicate study of Funded by HRSA to replicate study of pediatric services done by NEISS in 1998.pediatric services done by NEISS in 1998.

Added as a supplement to the 2002-03 Added as a supplement to the 2002-03 NHAMCS. NHAMCS.

EPSES comparisonEPSES comparison

FindingsFindings: When compared to the NEISS : When compared to the NEISS study, the 2002 EPSES data study, the 2002 EPSES data did notdid not show show a difference in estimates. a difference in estimates.

ImplicationImplication: There has been : There has been nono increase in increase in the availability of pediatric emergency the availability of pediatric emergency services since 1998.services since 1998.

2002 NHAMCS/EPSES2002 NHAMCS/EPSESMethodologyMethodology

SurveySurvey Type of DataType of Data Years Years fieldedfielded

Current sample Current sample size size (approximate)(approximate)

National Hospital National Hospital Ambulatory Medical Ambulatory Medical Care Survey Care Survey (NHAMCS)(NHAMCS)

Visits to Visits to hospital hospital emergency emergency department department (ED) and (ED) and outpatient outpatient departments departments (OPD)(OPD)

1992-1992-presentpresent

480 hospitals480 hospitals

35,000 ED 35,000 ED visitsvisits

24,000 OPD 24,000 OPD visitsvisits

Characteristics of NHAMCS Characteristics of NHAMCS

NHAMCS MethodologyNHAMCS Methodology

National probability sampleNational probability sample Not Federal, military, or Veterans Not Federal, military, or Veterans

Administration facilitiesAdministration facilities Located in 50 states and D.C.Located in 50 states and D.C. 4 stage sample design4 stage sample design 4 week reporting period4 week reporting period Data collected by Bureau of CensusData collected by Bureau of Census

EPSES MethodologyEPSES Methodology

Short set of questions related to hospital Short set of questions related to hospital services followed by a listing of 131 pieces services followed by a listing of 131 pieces of AAP recommended pediatric of AAP recommended pediatric equipment.equipment.

Self-administered questionnaireSelf-administered questionnaire

EPSES ResponseEPSES Response

Raw number of hospitalsRaw number of hospitals: 480: 480 # of hospitals with no ED# of hospitals with no ED: 83 : 83 (17%)(17%) # of hospitals that refused# of hospitals that refused: 51 : 51 (13%)(13%) Number of participating hospitalsNumber of participating hospitals: 346 : 346 Response rate: 87%Response rate: 87%

EPSES concepts & measuresEPSES concepts & measures

Pediatric StructurePediatric Structure: : does not admit pediatric patientsdoes not admit pediatric patients admits pediatric patients, but has no admits pediatric patients, but has no

separate pediatric wardseparate pediatric ward admits pediatric patients and has a separate admits pediatric patients and has a separate

pediatric ward.pediatric ward.

EPSES concepts and measuresEPSES concepts and measures

ED Pediatric CaseloadED Pediatric Caseload: : Annual volume of ED cases by children under 18Annual volume of ED cases by children under 18 Percent of visits to an ED by children under 18 Percent of visits to an ED by children under 18

years of ageyears of age

Availability of Pediatric EquipmentAvailability of Pediatric Equipment Totally supplied-100% of recommended equipmentTotally supplied-100% of recommended equipment Percent available out of all recommended supplies Percent available out of all recommended supplies Adequately supplied- above the median in terms of Adequately supplied- above the median in terms of

available pediatric equipmentavailable pediatric equipment

ResultsResults StructureStructure ED caseloadED caseload ServicesServices ExpertiseExpertise EquipmentEquipment

Average Emergency DepartmentAverage Emergency DepartmentAnywhere, USAAnywhere, USA

Sees between Sees between 1500-75001500-7500 pediatric patients in a pediatric patients in a given year, which represents 20-30% of their ED given year, which represents 20-30% of their ED caseload.caseload.

Hospital is not likely to have a pediatric ward.Hospital is not likely to have a pediatric ward. Probably has a board certified emergency Probably has a board certified emergency

medicine attending, but unlikely to have a medicine attending, but unlikely to have a pediatricpediatric emergency medicine attending or emergency medicine attending or pediatric attending.pediatric attending.

Has about 80% of the recommended pediatric Has about 80% of the recommended pediatric supplies and 5% are fully supplied.supplies and 5% are fully supplied.

Average Pediatric VisitAverage Pediatric VisitAnywhere, USAAnywhere, USA

Average pediatric visit is to a hospital ED that Average pediatric visit is to a hospital ED that has a large pediatric volume (>7500)has a large pediatric volume (>7500)

Hospital is more likely to have a separate Hospital is more likely to have a separate pediatric ward and PICU (25%)pediatric ward and PICU (25%)

These EDs are more likely to have a board These EDs are more likely to have a board certified certified pediatricpediatric EM attending and a board EM attending and a board certified pediatric attending when compared to certified pediatric attending when compared to the average hospitalthe average hospital

Have 91% of recommended pediatric supplies Have 91% of recommended pediatric supplies and 20% of these EDs are fully supplied.and 20% of these EDs are fully supplied.

Pediatric StructurePediatric Structure

Among hospitals with 24hr EDs: Among hospitals with 24hr EDs:

10%10% do not admit pediatric patients do not admit pediatric patients

52%52% admit pediatric patients but do not admit pediatric patients but do not have a separate pediatric ward or have a separate pediatric ward or department, i.e., one intended for department, i.e., one intended for exclusively treating childrenexclusively treating children

38%38% admit pediatric patients admit pediatric patients andand have a have a separate pediatric ward or departmentseparate pediatric ward or department

Distribution of EDs by the relative size of the Distribution of EDs by the relative size of the pediatric ED patient mix and pediatric pediatric ED patient mix and pediatric

structure of the hospital: United States, 2002structure of the hospital: United States, 2002

0 5 10 15 20 25

01-45-9

10-1415-1920-2425-2930-3435-3940-4445-49

50+

Per

cen

t o

f E

D v

isit

s b

y ch

ildre

n

Percent of hospital EDs

No Peds admitted No Peds ward Peds ward

0

10

20

30

Percent of EDs

Not admit Peds

No Peds ward

Peds ward

ED Peds caseload

Inpatient pediatric structure

Distributution of EDs by annual size of ED pediatric caseload and inpatient pediatric structure

Not admit Peds 3.2 5.6 1.5

No Peds ward 19.9 27.3 4.3

Peds ward 1.2 18.1 18.8

<1,5001,500-7,500

>7,500

0

20

40

60

Percent of EDs

Not admit Peds

No Peds ward

Peds ward

ED Peds caseload

Inpatient pediatric structure

Distributution of pediatric ED visits by annual size of ED pediatric caseload and inpatient pediatric

structure

Not admit Peds 0.3 3.2 3.1

No Peds ward 2.2 15.4 9.5

Peds ward 0.2 13.4 52.7

<1,5001,500-7,500

>7,500

Pediatric ServicesPediatric Services

Services for critically injured Services for critically injured pediatric patientspediatric patients

37% 37% of all pediatric ED visits are for injuryof all pediatric ED visits are for injury

3%3% of EDs have a separate pediatric emergency of EDs have a separate pediatric emergency service area (ESA)service area (ESA)

18% 18% of hospitals with EDs,of hospitals with EDs, have a pediatric 23-have a pediatric 23-hour observation unithour observation unit

16%16% of hospitals with EDs, have a coordinated of hospitals with EDs, have a coordinated pediatric trauma servicepediatric trauma service

10% 10% of hospitals with EDs,of hospitals with EDs, have a PICUhave a PICU

Pyramid of pediatric ED casesPyramid of pediatric ED cases

350,000 transferred

1,400,000 admitted

or transferred

28,000,000 annual pediatric ED visits

5%

100%

1.25%

Pediatric transfersPediatric transfers

53% of hospitals had written transfer 53% of hospitals had written transfer agreements to facilities with a agreements to facilities with a pediatric pediatric trauma service.trauma service.

57% of hospitals had written transfer 57% of hospitals had written transfer agreements to facilities that have a agreements to facilities that have a pediatric intensive care unit.pediatric intensive care unit.

Among EDs w/o critical care services, percent with Among EDs w/o critical care services, percent with written transfer agreements by inpatient pediatric written transfer agreements by inpatient pediatric

structure, US 2002structure, US 2002

0

10

20

30

40

50

60

70

80

All EDs No admit peds No separate pedsward

Separate peds ward

Inpatient pediatric structure

Pe

rce

nt

of

ED

s

Hospitals w/o peds trauma service Hospitals w/o PICU

Pediatric Transfers for Critically Pediatric Transfers for Critically Injured Trauma PatientsInjured Trauma Patients

Percent of hospitals w/o peds trauma Percent of hospitals w/o peds trauma service that transfer to another hospitalservice that transfer to another hospital

EPSES: 88%EPSES: 88% (NEISS 75% CI:41-100%)

Percent of hospitals w/o PICU that transfer Percent of hospitals w/o PICU that transfer to another hospital to another hospital

EPSES: 89%EPSES: 89% (NEISS 91% CI:82-99%)

Pediatric ExpertisePediatric Expertise

Medical SpecialtyMedical Specialty Number Number of EDsof EDs

Percent Percent of EDsof EDs

NEISS findingsNEISS findings

Board Certified Board Certified Emergency Medicine Emergency Medicine Attending PhysicianAttending Physician

3,5503,550 72.972.9 66% (CI 56-76%)66% (CI 56-76%)

Board Certified Board Certified PediatricPediatric Emergency Emergency Medicine Attending Medicine Attending PhysicianPhysician

1,2701,270 26.126.1 23% (CI 14-32%)23% (CI 14-32%)

Board Certified Board Certified Pediatric Pediatric Attending Attending PhysicianPhysician

3,2493,249 66.766.7 64% (CI 52-76%)64% (CI 52-76%)

Attending Physician Specialty Attending Physician Specialty (available 24/7 in-house or on-call)(available 24/7 in-house or on-call)

Availability of PediatriciansAvailability of Pediatricians

Only 9% had a pediatrician on duty in the Only 9% had a pediatrician on duty in the ED 24 hours/7days per weekED 24 hours/7days per week

On-call: 26% of hospitals had written On-call: 26% of hospitals had written protocols stating under what conditions a protocols stating under what conditions a pediatrician would be called to the EDpediatrician would be called to the ED

Variation in availability of board certified Variation in availability of board certified attending physician specialty by inpatient attending physician specialty by inpatient

pediatric structurepediatric structure

0

10

20

30

40

50

60

70

80

90

100

BC Emergency Med BC Pediatric EM BC Pediatric Attending

Medical specialty

Per

cen

t o

f E

Ds

All EDs Don't Admit Peds Admit Peds Admit Peds w/Ward

Pediatric EquipmentPediatric Equipment

Totally SuppliedTotally Supplied

Only Only 10.8%10.8% of EDs answered YES to all 131 of EDs answered YES to all 131 pediatric emergency supplies on the list.pediatric emergency supplies on the list.

Range: airway management (15.8%)- Range: airway management (15.8%)- resuscitation medication chart, tape, or other resuscitation medication chart, tape, or other dose estimation system (94.7%) dose estimation system (94.7%)

More supplies may be located in: NICU, OB, More supplies may be located in: NICU, OB, newborn nursery, central supply, pharmacy, newborn nursery, central supply, pharmacy, nearby children’s or sister hospitals.nearby children’s or sister hospitals.

Distribution of the percent of pediatric Distribution of the percent of pediatric supplies available in the ED: US 2002supplies available in the ED: US 2002

0

5

10

15

20

25

30

35

40

0-10* 11-20* 21-30 31-40* 41-50* 51-60* 61-70* 71-80 81-90 91-100

Value of pediatric supply average

Fre

qu

ency

Variation of supply availability score by inpatientVariation of supply availability score by inpatient pediatric structure, US 2002 pediatric structure, US 2002

0

10

20

30

40

50

60

70

80

90

100

Monitoring VascularAccess

AirwayMgmt

Sp.Pediatric

Trays

Fx Mgmt Misc. Resus.Meds

AllSupplies

Per

cen

t av

aila

ble

No admit peds No separate peds ward Separate peds ward All EDs

What about hospitals that don’t What about hospitals that don’t admit and are undersupplied?admit and are undersupplied?

Of the 6% of hospitals in our sample that Of the 6% of hospitals in our sample that did not admit peds and were <85% did not admit peds and were <85% supplied, all had other hospitals within the supplied, all had other hospitals within the same county that either had peds beds or a same county that either had peds beds or a separate peds ward. separate peds ward. Additional write in responses explained that Additional write in responses explained that

some hospitals have EMS agreements to some hospitals have EMS agreements to bypass their facility for nearby “sister” or bypass their facility for nearby “sister” or children’s hospitals.children’s hospitals.

Next StepsNext Steps

Currently combining 2002-03 data to provide in-Currently combining 2002-03 data to provide in-depth analysis on ED pediatric care by depth analysis on ED pediatric care by combining EPSES variables (e.g. structure, combining EPSES variables (e.g. structure, expertise, equipment) with the NHAMCS visit file expertise, equipment) with the NHAMCS visit file to look for relationships between items such as: to look for relationships between items such as:

Medications prescribedMedications prescribed DiagnosisDiagnosis Type of injuryType of injury Source of paymentSource of payment