Welcome everybody to our seminar today, which is addressing the new pediatric readiness standards at your trauma center. I am Kim Wallenstein. I'm the Pediatric Trauma Medical Director at Upstate Medical Center in Syracuse, New York. And I'll be moderating today's panel. We have some great speakers today. And as you listen to them, feel free to type any questions that you have in the chat box and we will get to them at the end. The first speaker today is Dr. Aaron Jensen. He is an Associate Professor of Surgery at the University of California, San Francisco, where he maintains a busy clinical practice in pediatric surgery and serves as the Trauma Medical Director at UCSF Benioff Children's Hospital in Oakland. He also serves as the Trauma Domain Co-Lead at the Emergency Medical Services for Children Innovation and Improvement Center, as well as on the American College of Surgeons Committee on Trauma as the Vice Chair for Pediatrics for Northern California. His research focuses on quality improvements in pediatric trauma care, particularly as it relates to pediatric readiness at non-pediatric centers and within the overall context of the trauma system. So we'll welcome Dr. Jensen. Thanks, Kim. That was a lot. Thank you. Welcome everybody. I see our participant list continues to grow. We're up to 50 already, 54, great. Like Dr. Wallenstein said, I'm Aaron Jensen and I'm joined by Michelle and Lisa today. And we're gonna talk about pediatric readiness. See if I can get these to advance. This is the educational statement from the TCAA about accreditation. All of the opinions that we are presenting today are our own and not necessarily those of the TCAA. None of us have any financial disclosures. All of us do, however, get some salary support from the federal government to do this very work. So we put a lot of work, a lot of effort into getting the word out about pediatric readiness. And we're really happy and thankful for the opportunity to come here today and share some of these concepts and the importance of these concepts and hopefully help you improve the readiness at your centers. So I assume this is why everybody's here today because of the new standards, the 2022 standards that were actually announced back at the 2021 ACST QIP meeting. Centers are now being verified under what we all call the gray book, but the ACS is very clear that it's not the gray book. It's the 22 standards. And the one standard that we're gonna talk about today is this standard about pediatric readiness for all trauma centers. So you'll notice that this doesn't only apply to pediatric trauma centers. And honestly, it probably applies more to adult trauma centers, level ones, twos and threes, because most pediatric trauma centers have pretty high levels of pediatric readiness. And what this standard calls for is that all trauma centers will evaluate and have a plan to treat any deficiencies in pediatric readiness. So we're gonna sort of go over this today. We're gonna help you guys figure out how to evaluate pediatric readiness and also give you some practical approaches to have a plan to address deficiencies and also go over what the heck is pediatric readiness and what does that really mean to begin with. So here's our objectives. We're gonna give a little background for why this is important, why the American College of Surgeons decided to make this a quality standard. I'll provide a little overview of what pediatric readiness is and why it's important. And then I'll hand the baton off to Lisa Gray, who's gonna talk about how to assess pediatric readiness. And she'll talk about the Pediatric Readiness Toolkit and some of the resources that are free that you can use to address pediatric readiness in your center. And then Michelle's gonna wrap us up today to talk about what is a Pediatric Emergency Care Coordinator and how does a PEC relate to your trauma program? That might be the one thing that all centers can do to improve pediatric readiness quickly. So this is a problem in the United States and this is why it matters. This is an old study. We have reproduced this study and it's not been published yet, but I'll be honest, it hasn't changed much in the last decade. This is access to pediatric trauma centers either by air or by ground within 60 minutes. And you can see it's all centered around major metropolitan areas. And there's a lot of white space on that map where kids live and they don't have access to pediatric trauma centers. A little bit different way to look at it. This is done by the federal government, a little bit newer study in 2017, where they looked state by state, not necessarily with a geospatial analysis, but they found that 57% of kids nationally had access within 30 miles of a trauma center. And the only region of the country that's shaded in nice and dark green with 100% coverage is up where Dr. Wallenstein lives in the Northeast. But the rest of the country has major deficiencies in access to timely pediatric trauma center care. However, we have pretty good coverage, pretty good access to high level trauma center care. So these are level ones, twos and threes. And you can see that there's no white on this map and that most of the states have pretty high, greater than 75% access for kids to a level one, two or three trauma center. And even those that have less than stellar access are still between 50 and 75%. So this really presents an opportunity to optimize access for kids to high quality resuscitative care within the context of our trauma system. If we can optimize the readiness of these adult trauma centers to at least take care of these kids for the first hour. And that's why this matters. This is a study that we did a few years back that shows that when you look at kids compared to adults, kids that die from trauma, they're gonna die early. You can see this is survival over time. Most deaths are within the first 24 hours. And this over time, late deaths in kids are very rare. There's a different way to look at it. Were kids dead on arrival or in the ED? So about 52% of children die very early after injury. So this really suggests that the greatest impact for saving lives and lives that can be saved is with early initial resuscitative care for kids. We would argue, and the ACS is now arguing that any trauma center should have the ability to provide early resuscitative care for children. You may not be able to do a craniotomy. You may not be able to do a laparotomy, but you probably should be able to put in an endotracheal tube. You should be able to give blood in appropriate ratios. You should be able to establish vascular access. You should be able to put chest tubes in. You should be able to medically manage critical TBI in kids and maintain normal perfusion, ventilation, saturation, so forth and so on. And more importantly, you should be able to recognize what kids need to be transferred out and activate the triage system quickly and get them transferred out. This is pediatric readiness, right? So early resuscitative care, emergency room care for children that should be able to be provided at all of our trauma centers, even if you don't have the ability to provide definitive care, because this can improve access for kids. So I'd ask everybody, is your center ready? Kids are hard because all these sizes, right? One size may fit all, maybe two sizes fit all for adults, but kids, you need all these endotracheal tube sizes. You might need different chest tube sizes. We got to use these little measuring devices to get fluids, because if you give a little baby a liter of fluid, that's going to be a bad day. So it's complicated, right? So how do we make sure that centers are able to take care of kids that they're not used to taking care of? We have these weight-based or length-based weight estimation tapes. There are some commercially available drug dosing packs that you can use. Pre-existing protocols for massive transfusion or blood volumes for kids. So there are ways that we can protocolize this and we can help. And Lisa's going to go over some of these in her toolkit. But is your center ready to take care of a kid? Some of these different needs for different ages and different physiologic responses. And can you manage that kid for the first hour while the aircraft or ambulance is in route? Does it matter? I'll argue it does matter. So this is a study that was published two years ago, where they looked at 832 EDs and over 300,000 kids. And they looked at the pediatric readiness score of the initial receiving hospital for the kid. And they looked at risk-adjusted mortality. And they looked at quartiles of pediatric readiness. So this is a risk-adjusted analysis. The dotted line here is lowest quartile centers. So those are the ones that have the lowest level of pediatric readiness. And this is the highest quartile. And you can see that risk-adjusted mortality is much lower, much, much lower, 58% lower in centers with high levels of pediatric readiness. So severe TBI, right? You have a head IAS that's high. Any head IAS, severe ISS, all of these subgroups, same effect. High pediatric readiness, lower risk-adjusted mortality. And they did a sort of number needed to treat calculation. And they estimated that if all of the kids that were treated in lowest readiness quartiles, if all of those hospitals could be moved to high readiness quartiles, 126 lives nationally might be able to be saved based on this risk reduction attributed to pediatric readiness. So this is really the first paper that showed an impact on mortality of pediatric readiness at the initial receiving hospital. So this really does matter. And it really does present a real opportunity to optimize care for kids in our trauma system, which really has limited access to care. This is the pediatric readiness. The last time the national assessment was done was 2013. It was just redone last year and some new papers are coming out. Again, not much has changed in the last 10 years. So even though this data is eight years old, it's pretty reflective of what's going on. Children's hospitals, of course, have very high levels of pediatric readiness. So the weighted pediatric readiness score, the highest you can get is 100. And on average, children's hospitals are 99 and change, which you would expect. So EDAP, Emergency Department Approved for Pediatrics is a program in California that sort of comes out and does site surveys to look at your ability to provide emergency care for kids in your emergency room. And hospitals that are certified by that program also have high levels of pediatric readiness, by definition, right? You have to be certified. But if you look at trauma hospitals that have not undergone external facility recognition for pediatric readiness, you see that pediatric readiness in trauma centers, adult trauma centers, it's really no different than general community hospitals nationally. And I think this is really the biggest opportunity that we have. Because remember, our trauma system, only 57% of kids have access to a pediatric trauma center, but 88% of kids have access to an adult trauma center. So if we can take that one third of kids that have access to an adult center, but not a pediatric center, and we can improve the pediatric readiness in those hospitals, perhaps we can save lives. So these are the domains of pediatric readiness. And again, Lisa is gonna talk about how this gets measured and provide some resources to address these. I think the one that's the easiest to understand, I showed you a picture about equipment and supplies. You have to make sure you have the right size laryngoscopes and endotracheal tubes and IV lines and maybe central lines and so forth and so on. We all kind of understand that. Staffing and making sure that your nurses and physicians and other care providers have minimum competency in being able to resuscitate a kid in case they come in. Care coordination. So a lot of this gets towards, do you have a person in your emergency department who's making sure that you have equipment that's making sure your protocols are up to date to make sure that your staff competencies are up to date? And this is that pediatric emergency care coordinator that Michelle's gonna talk about. And having somebody to ensure that you have all of these things in place can really go a long ways. A pediatric specific quality improvement plan. So are you doing PI on the kids that come through your center? You may only see three or five kids a year. So you'd say, it doesn't really matter. We're low volume. We don't need to look at those cases. But in the newer data that's gonna be published this fall, all of the studies that are coming out are all highlighting that a pediatric specific quality improvement plan seems to be the number one predictor of outcomes related to pediatric readiness in centers. So having a PI program that looks at kids, particularly in low volume centers, and just opening up those cases and saying, what could we have done better? Is the one thing that I would recommend doing in order to focus on improving pediatric readiness. Policies and procedures. You know, do you have a pediatric massive transfusion protocol? Because if you give a 10 kilo kid a whole adult unit of blood, that's like giving an adult six units of blood. You've already massively transfused them just by giving them one unit of blood. So having policies for pediatric TBI, pediatric hemorrhagic shock, medication administration protocols, which starts to get into patient safety. So all of these different domains of pediatric readiness are measurable and you can address them with the tools that we're gonna give you. So this is the kind of how we break pediatric readiness down and we talk about it in its individual components. Pediatric readiness can be improved. This is a very busy slide. All you really need to look at is a pre and a post, pre and a post, pre. These weren't all that different, but you know, these two were, which is the administration QI domains and policies and procedures. So this was a simulation-based multi-center study done in the Northeast where they took 36 general EDs that worked with regional children's hospitals and they all improved their pediatric readiness scores by 16 points. Okay, so from 62 up to 79. And remember this is out of a hundred and most trauma centers are sitting in mid to high 60s. And the study that showed improved mortality, going from 60 to 79 takes you from quartile one all the way up to the top of quartile three. And if you can get into quartile four, that's where we start to see the mortality benefit. So with directed efforts, we know that pediatric readiness can be improved. So this is not a hopeless fight. This is something that you can do and something that you can improve upon. It just does take some effort, okay? So next time I'm gonna hand the baton over to Lisa Gray, who's the co-lead for the trauma domain at the MSC Innovation Improvement Center. And I think Kim has a few more things to say about Lisa. Thanks all, I'll be back for questions. Great, thank you. So next up we have Lisa Gray. Lisa is the co-lead for the Emergency Medical Services for Children Innovation and Improvement Center Hospital and Trauma Domains. She is co-chair of the National Pediatric Readiness Project Steering Committee. Prior to joining the EIIC, she was the director of trauma services at a level two adult and pediatric trauma center. She's a past president of the Pediatric Trauma Society. In addition, she has over 15 years of pediatric critical care nursing experience. Her current role is dedicated to ensuring that emergency departments are pediatric ready and have the resources to provide high quality emergency care for children. Welcome to Lisa. Thank you, Dr. Wallenstein. All right, really quick, because I am a full-time employee of the EMSC program within HRSA, I do have to include an additional disclaimer that none of the content or information that is shown in today's PowerPoint or shared with you all today are necessarily the views of the government. So I'll leave that up here for you to look at for just a second, but we're gonna move right on. All right, so Dr. Jensen gave some very important points to kind of set the stage for how you all can get this, how you can move the scale to improve pediatric readiness in your emergency department and your trauma centers. So the increased focus of pediatric readiness initiatives is commonly attributed to the 2006 report, Future of Emergency Care Series by the Institute of Medicine. And it was called Emergency Care for Children, Growing Pains. So 2006 sounds like a long time ago. That being said, as Dr. Jensen mentioned a little bit, we're moving the needle, but it's super slow. So this work continues to be a major priority. This report noted significant inadequacies in the nation's emergency care systems' capacity to care for managed injured or ill children. Both of the joint policy statements that you see on your screen, pediatric readiness in the emergency department, and then pediatric readiness in emergency medical, emergency medical services systems, or EMS, if you will, support the recommendations from the Institute of Medicine, now called the National Academy of Medicine, and describe the organizational principles to guide and define pediatric health care system and improve the health of all children. These policies statements are considered national P-DREADY standards. So when I think of these standards, they're akin or similar to trauma standards. However, these standards are for all pediatric readiness. They delineate the recommended resources necessary to prepare EDs to care for all pediatric patients. This report called for both hospitals and EDs This report called for both hospitals and EMS systems to identify qualified coordinators of pediatric emergency care. And really it's about moving the needle to improve care for children. These findings resulted in the National Pediatric Readiness Project, or NPRP, back in 2006. So a lot of work has been done since that time. And I'm gonna use a lot of acronyms, so bear with me. The NPRP is a multi-phase quality improvement initiative that ensures all U.S. emergency departments have the essential guidelines and resources in place to provide effective emergency care for all. So Dr. Jensen reviewed the standard. I'll show it on the screen again. I am confident that most of you have probably looked at this standard over and over again and said, so now what do I do? So we're gonna talk about that. We're gonna jump right in to what this new standard means for the trauma program, the trauma service. I'm gonna switch gears and share perspective, information, and resources that I think will help you in your role at your trauma center. As Dr. Wallenstein mentioned, prior to joining the EIIC, I was a trauma program manager for over 12 years. So I'm gonna, during that time, underwent four successful trauma site visits for the American College of Surgeons Committee on Trauma. So I'll try and share some ideas and resources that will help you start conversations with your colleagues in trauma and the emergency department as you work towards this goal of meeting this new standard in your hospital. So what, so I'm gonna break this down and I'm gonna try and divide it up for you. I talked a little bit about the joint policy statements and those are basically the standards. So again, I think of trauma standards and I think of Puget Ready standards. Then we're gonna talk now about the assessment. How do you assess if your emergency department is ready or not? So there is a mechanism in place to evaluate your Puget Ready and it's called the National Pediatric Readiness Assessment. This assessment provides a basic indicator of your ED's capacity to treat pediatric patients. This assessment, like I mentioned, is based on the policy statements and it gauges an ED's capability to provide high quality care based on their adherence to those guidelines that I've mentioned. Once completed, once you do this assessment or if your emergency department has already done the assessment, you'll receive a pediatric readiness score and Dr. Jensen reviewed some of those scores and the four tiles and what they mean. You'll also receive an average pediatric readiness score of like or similar ED's as well as benchmarking and a gap report to help you address gaps that you may have and actually target pediatric readiness initiatives. So I believe Dr. Jensen mentioned that this assessment was done in 2013 and we did it again in 2021. So you're looking on your screen, you can see participation. This was the first, this NPRP assessment was the first of its kind to really gauge compliance. I think it's, it speaks volumes that both response rates, 80, almost 83 and 71 really are quite impressive, even with the 2021 results being during, right after or during a COVID pandemic. So clearly there's an interest in improving pediatric readiness on a national scale and it is a good possibility that your emergency department has maybe even already taken the assessment. So we're going to talk about that. So maybe, so we're going to talk about the assessment, if you've already done it, if you have not already done it, and then what are you going to do for trauma standards to have a plan to address any of those deficiencies. So I'll move, talk very briefly about what the assessment provides. I told you a little bit, it will give you a score based on zero to 100, it gives you a score based on centers with like, or of like size, and it does also give you a report to benchmark from. I'm going to share now with you a gap report that you'll receive. So you've read the joint policy statements. You've now looked and seen if your ED has taken the assessment, and if they have, you're going to try and get a copy of that. But we're going to walk a little, take the next step and go into that gap report. So this gap report is a wonderful tool. This is what it will look like. It's a sample gap report. It includes the overall readiness score, and then also scores in particular areas of the assessment. Dr. Jensen mentioned the domains that it assesses, that competencies, equipment, supplies, and medication, et cetera, et cetera. Those are all addressed and you receive a score for each section, as well as a compiled score. So a couple examples of that, you can see this particular example, this particular emergency department didn't have any guidelines around QI or PI for pediatric patients, so they got a zero. However, they had quite a few guidelines and policies and procedures, so got a pretty high score out of that section. So the bottom line is, each section of the assessment, you get a score, then an overall score, but it helps you identify where you need to work, what you need to work on. And that's that assessment piece, if the college is asking, okay, I've done the assessment, I've looked at my report, maybe I'm going to come up with a plan now, how to address those gaps. So this is where the EIIC comes in to help you with free resources and tools to really work on those things. So what you'll see on your screen is a QR code that will take you to this checklist, some toolkits, and then I'm going to go a little bit further into a little bit more information. So what you see on the right-hand side is the icons for the toolkit that look exactly like they do on our website. But what you see in the middle of your screen is that checklist. So I would suggest starting with the checklist, going through it completely and saying, what do we have, what do we don't have, and where do I need to start? What this checklist does is it drives you to the toolkit, and in the toolkit, there are resources for each of these areas to help you meet those expectations or checkmark, if you will, to be prepared and have things in order in your emergency department to really work on that score, bolster that score, to really start improving care. I would be remiss if I didn't say all of these two resources, the checklist and the toolkit, line up completely with the joint policy statement. So if you're trying to educate yourself on where do I need to go, those three resources are great to have. Get that policy statement out, get your checklist out, and then access that toolkit online and really dive a little bit deeper into each of the sections because it will help you find resources and meet all of the requirements for pediatric readiness. The last thing I'll mention as far as free resources from the EIIC are these, what we call peaks. They're on our website. They are pediatric education and advocacy kits. They are based on topics. There's one on seizures in pediatrics. There's one on pain management. Coming down the pike is one on child abuse. We are working behind the scenes on a trauma peak. So lots of work being done on the pediatric readiness side to provide you all, as trauma centers, resources to get this PEDS-ready status accomplished. All right. So what's your plan going to be? So do you know if your ED has taken the assessment? This is the time when you reach out to your ED colleague, your ED nurse manager, or perhaps you already have a pediatric champion or a pediatric emergency care coordinator in your emergency department. Touch base with those folks and say, have we done the assessment, have we not? If you have not, I will direct you at the end of this presentation on where to go, that you can take it at any time, even outside of national assessment time. But the second thing you'll do is say, okay, what was our score? What do we have to work on? Let's look at that gap report and work together on addressing some of these gaps that we have in our emergency department. And then really find out if they're working, if your ED colleagues are working on any pediatric readiness initiatives. They might already be working on it and just unbeknownst to you. So I'm going to turn it over, and the big pondering question here is that can help you accomplish a lot of these things is, does your emergency department have a pediatric champion? And this is where I'm going to turn it over to Michelle. Great. All right. Thank you, Lisa. So next we have Michelle Medling. Michelle is the UH Rainbow Babies and Children's Hospital program coordinator for pediatric readiness across the university hospital system. Prior to this, she has 20 plus years experience as a staff nurse, educator, and disaster preparedness expert in a level one pediatric trauma center. She's a senior project manager on ASPR grants, Eastern Great Lakes, region five for kids for the past three years. She's a subject matter expert on the EMSC innovation and improvement center disaster domain and a co-nurse lead of the EIIC hospital domain. Michelle is also a subject matter expert on pediatric pandemic network. She has worked collaboratively to improve disaster and pediatric preparedness for the care of children and families, along with creating a facility recognition tool. She has experience in team science, driving organizational excellence and improving processes and outcomes. Welcome to Michelle. Thank you, Dr. Wallenstein. It's a lot, isn't it? I'm here today to talk to you about what is a PEC and how does this really relate to your trauma program or your emergency department? So what is a pediatric champion or a PEC? This is an individual or a group of individuals who really are responsible for ensuring the EDs follow national recommendations for pediatric emergency care. We want to familiarize colleagues with pediatric specific policies, protocols, promote pediatric quality improvement efforts, including that with trauma and managing pediatric equipment and supplies. We do know that the most valuable way to improve and achieve high pediatric readiness score is having at least one pediatric champion, whether that's a nurse or a physician, or you can have a group, you can have both a nurse and a physician, which actually will increase your scores even more. I'm not going to go into every detail of the roles of the PEC, but having a designated PEC can help ensure the highest quality of emergency care for children by enhancing staff's pediatric knowledge, skills, and competencies. The presence of a PEC is really strongly correlated with enhanced pediatric readiness, independent of all other factors, and correspondingly, a higher level of pediatric readiness in EDs has been shown to be associated with decreased morbidity and mortality, as Dr. Johnson talked about, in critically ill and injured children, regardless of trauma designation. We also know what the value of the PEC is in the emergency department. We know that 83% of children arrive to general emergency departments versus arriving to pediatric emergency departments. Increased pediatric readiness scores are really associated with decreased mortality, and most of these emergency departments actually see less than 10 to 15 kids a day. The Institute of Medicine identified that these children are often seen in EDs that are not well-prepared to care for them, both in terms of availability of equipment, supplies, as well as training and readiness of the ED staff. The National Pediatric Readiness Project assessment data has found that EDs with designated PECs were more ready than those EDs that did not have a PEC. So we know that the presence of this physician or nurse PEC strongly correlated to these improvements. When we look at this study in 2015, really looking at the impacts of the Pediatric Emergency Care Coordinator, the average national pediatric readiness score, if you didn't have a PEC, was 66.5. It got slightly better with just having that nurse PEC, and even having just a physician PEC, it increased even more. When you have both a nurse and a physician PEC, it really shows the evidence of how much it can improve care of children. Physician PECs are in only 48% of EDs, and nurse PECs in 59% of EDs. We do know with the last survey and with COVID, the presence of a PEC had really decreased. So it's really looking at how do we create that position and keep somebody in that. The PEC role in EDs, both physician and nurse PEC are recommended. This is recommended to be a full-time nurse position, but we know that that can't always happen. Even if it's a shared role, a PEC may serve in multiple systems or responsibilities. It really does need to be a role of somebody in the emergency department. The roles may be shared by multiple individuals. You can have a nurse and physician PEC. You can have a PEC team where you have three to four nurses sharing that. One of our system hospitals, they have a group of six PECs that work and share, and that way they can touch and collaborate with all staff and educate everybody, not just being one person having to do that. They should have a little bit of protected time, a specific job description, and recognition and support from their administration. The individuals don't need to be solely dedicated to the PEC role like we had mentioned. It could be a trauma core nurse in the ED that could be your PEC. Their role can be part of an existing duties. These individuals don't necessarily need pediatric specific expertise or background, but they need to be willing to learn more about pediatrics. Whether it's through classes like PALS or EMPC, or even connecting with your local children's hospital and seeing if they can come down and shadow or connect with an educator in the ED. This role really should, like I said, be based in the ED, not in the trauma department because it needs to be somebody who knows their staff, knows what policies the ED has already, and can help grow that team to become more pediatric ready. So why does this role matter? We know that a PEC presence, both nursing and physician, can really increase staff confidence, both nursing and providers, if you have one of each. Can offer additional training opportunities. If you have well-trained PECs, they can be providing short little snippets even during huddles of education of how we can improve things for our pediatric patients, how we can be ready for that pediatric trauma that could arrive. It also improves care and then giving that pediatric voice. You treat children a little bit different than you do adults is a lot of times getting the parents in there, letting the parents stay with them, even if they're a trauma patient. That will help keep the child calm and keeps the whole scene calm and more in control. So how do we collaborate between the trauma program manager and the PEC and the ED? It's really creating that shared vision of care for the children in the emergency department, utilizing their trauma program's infrastructure and their expertise, sorry, to include the PEC and pediatric readiness initiatives, including these in your PIPs process, your operational meetings, and including that PEC in those processes as well. When you're talking about pediatric patients, it's that collaboration. Just looking at some of the trauma program and PEC similarities, it's really important for them to connect with the other departments across the organization, connect with that PEDS champion in your ED or work with your ED manager to see if you guys can find somebody who wants to be that PEDS champion. Change maker, really providing feedback and input, providing feedback to staff what went well and where do they have opportunities. Also using data to help support this, look at how it does improve everything from patient satisfaction to outcomes of children that are coming in in full arrest or traumas. You really want to mimic the trauma infrastructure in collaboration. Like we mentioned before, looping the PEC in with quality improvement plans and closing cases out. Doing some audits to see how you guys are doing initially and seeing where you're improving. Operations and system meetings, working together with the ED committees and the EMS committees. So where do you start? Start by looking at your survey and surveying your ED staff and seeing what their educational needs are. You can get some of this data from the NPRP survey, but some of this is just asking staff what they need. If you had a recent trauma case, what did staff feel comfortable with? What did they feel they needed additional education or training on? Follow up on those difficult and complex cases. It's really good to know what you guys did well and letting them know that they did something really well. Team and individual review. How comfortable are they? How prepared are they to take care of children? Does staff know where their equipment is? When you look at the NPRP survey, most hospitals have most of the equipment, but staff may not know where that equipment is. Information available to tell the story of what happened to that patient. Other perceived knowledge gaps that staff may have or that the trauma team sees that are gaps that maybe the ED doesn't understand why they have that gap. Include all who may be involved and really focus on collaboration and communication because that's really key to being effective with this. So PEDS QI and PI projects. Things like you can look at is time to CT scan. C collars. Do you have the appropriate size C collars to put on an infant? We recently found one of our sites thought they had all the equipment they needed, but they had a nine-month-old that needed a collar, a C collar, and the pediatric hard collars didn't fit and they didn't have any Aspen collars. So just thinking about things like that. Do staff know what normal vital signs are for pediatric patients? Do they have badge backers or a resource for that? Looking at your equipment supplies and reorganizing it so it fits where the staff think it should be and how it should be set up. Looking at your supply rotation. If you don't use something a lot, especially your PEDS supplies, a lot of those will expire. So making sure you're keeping track of that and rotating that. Thinking about imaging, image gently, pediatric radiation dosing. Is your hospital set up to give less dosing for pediatric patients? Making sure that you're getting the appropriate image, not pan scanning every child that comes in, and don't delay transfers for imaging. Really having that connection with your, if you have to transfer a child to a level one trauma center, having that connection with that site and knowing, do they want you to call sooner or do they want you to scan and then call them? Within our system, if the kid is able to get out, they want to get the kid out. If they can get the CT before transport arrives, that's great. If not, let's get them out, especially those acute patients. So some key takeaways is pediatric readiness really does matter. Your emergency department may have already taken the NPRP assessment and received that gap report. If not, you'll have the ability to take it either on paper or in the system. There's a multitude of resources available as Lisa shared on EIC and on PEDS ready. The new standard is another opportunity for trauma programs to collaborate with emergency departments to improve care of all children. You can utilize this existing infrastructure of the trauma program to work closely with a pediatric champion or your PECs in the ED. And really having these champions can really make a difference in saving a life. The end of last year, we had a nine-year-old that arrived at one of our community hospitals, came in via car, had like three to four gunshot wounds. They ended up having a bullet in his arm, his leg, abdomen, and one in his atrium. They were able to stabilize him, give him TXA, give him blood, get a chest tube in him and get him out within an hour to the pediatric trauma center where he went straight to the OR. And he went to rehab and was walking and talking and did well. So having the structures and being able to train staff and practice knowing where stuff is really does make a difference. Additional NPRP resources can be found on pedsready.org and also this QR code here. And especially when you're thinking about these, if you have critical access hospitals or hospitals that are far out, they're rural hospitals that may be trauma, those patients get ATV accidents and everything else, especially the more land you have, the more likely they have injuries with kids. Thank you. Right, thank you to our three speakers. Those were fantastic talks. So I encourage everybody who is listening to take advantage of the accumulated knowledge and wisdom here and put some questions into the chat. I don't see any questions right now from the audience, but I'm sure those will come up soon. So we have a few ringer questions here. So I'll start out. So what about centers with limited resources? Because we know that throughout the country there's definitely different sets of resources for different areas. What aspect of pediatric readiness should be addressed first? I can start. I'm sure Michelle and Lisa will have comments on this. You know, I think it's hard to say what should be addressed first because they're all important. I think most people think the equipment is probably the most important because if you don't have a endotracheal tube to put in, you can't put one in. Then again, if you don't know how to put it in a tracheal tube, then you can't put one in. So most would really advocate that just identifying a PEC, right? Identifying a person to just start working on this stuff. Many small hospitals can't afford a full FTE of a PEC. Maybe it's, you know, a half day a week, right? It's just start somewhere. Identify a single individual to start working on this stuff. Reviewing cases. And as you review cases, you can sort of identify what equipment you need. You know, the resources that Lisa presented, they're free. So that pediatric readiness checklist is free. You can download it for free and it has an equipment list of what you should have. So if you have a PEC armed with that checklist and say, you know, start working on this, it might take some time, but I think that's a good start. And the 2013 data that's all been very heavily analyzed all suggests that the number one most important factor is having a PEC. And that's actually changed as we start to, like, analyze the most recent assessment that was done in 2021. And a lot of those papers are now starting to come out. And in the newer version, it seems that having a pediatric specific quality improvement plan seems to be a greater driver towards outcomes. A lot of us sort of say that you can't really have a quality improvement plan without a PEC. So they may be sort of not mutually exclusive, but you can sort of see how it all goes together. But I think identifying the resource and the single individual, whether it be a nurse PEC or a physician PEC or are part of both, to just have a single person that's tasked with tackling pediatric readiness. And if you have a passionate individual, they're just, you know, going to go to town and take care of it and a lot of this stuff doesn't cost a lot of money. It just takes a little bit of time to set up. I don't know, Michelle, Lisa, do you have any comments on- I would totally agree that having that PEC is probably the biggest thing to start with because then they can help you go from there and help with quality improvement, help with training staff, making staff more comfortable, knowing where their equipment is, their supplies, what protocols are they lacking? Yeah. The other thing we hear fairly frequent is I don't even know where to start. This list is huge. And we frequently suggest to start small. Pick one or two things that you want to work on. And we know it's sometimes hard to implement change in emergency departments, especially around PEDs if staff are uncomfortable taking care of them. So start with one or two small projects and then work your way. It's not going to be successful. It's not going to be success overnight, but baby steps. I would say also having a PEC can help build relationships with your regional pediatric center. Most of us will give our protocols. If you want my pediatric MTP, I guess ask April or Deb and they'll forward your message to me and I'll send it to you, right? So I believe there's no reason that all adult trauma centers should not have a written out pediatric weight-based massive transfusion protocol. It's free. It doesn't cost anything and you just give it to your blood banker and you say, look, if it's a bad day and we're having to massively transfuse a kid while waiting to transfer out, here's the recipe for how we're going to do that. So, you know, a lot of this stuff doesn't cost a lot of money. It just takes a little bit of investment of time. All right, a question from the audience about the Pediatric Readiness Assessment. Can you go a little bit into detail about how it is completed online and submitted and the process for that? And I guess related to that, how many times can an ED take that assessment? Sure, I can take a stab at this one. So at the end of, so what we know is that there is an official national assessment time and that was in 2013 and 2021. You, however, and that was the official assessment with an official GAP report and that's used for research data analysis, et cetera, et cetera. Pediatric Readiness Improvement is ongoing over time. So what you can do, that last QR code that you saw on your screen, it's pedready.org, you can scan that QR code and take that assessment at any time. You download it, you can print it, but you can also, but you will also at that time submit your answers and the GAP report won't look nearly as fancy as the original one that happens during national assessment time, but it gives you the exact same information. So for example, I am at a level two trauma center. I got my first report from my ED nurse manager and we had some areas to work on. Our first score was 67. I wanna see, we've done some work. I wanna see if we've made any improvement. So I would go to that assessment, take it again and see what I got. So it's open all the time now because of this trauma center standard actually, it's open all the time. So that last QR code that's on your screen, go there and that's where the assessment is. I think I would just like to amplify though that this is not trauma program pediatric, this is pediatric readiness in the emergency department. So we wanna discourage trauma program managers and trauma programs from going out and filling out the online assessment unless your emergency department flat out refuses to do it, right? So somebody in your ER, the response rate to the 2021 assessment was really high. I think over 80, 85% of hospitals actually responded. So most likely your hospital responded and already has a gap report in hand. It's just that your ER is the one who filled this out. So you need to figure out who is the person in your emergency department, who is the designee that filled out the pediatric readiness assessment and has the gap report. It took me a while in my own pediatric center to figure out who that person was, but I was able to figure it out by just going to our ED nursing director. So I would discourage trauma programs from sort of going rogue and just doing the assessment on your own because pediatric readiness applies to more than just trauma patients. It's all pediatric patients in the ED. And quite frankly, you're probably seeing more pediatric general medical patients than you are trauma patients. And you wanna partner and collaborate with your ER to address pediatric readiness globally for all pediatric emergency care in your emergency department. So really just reach out to your ED and see who filled this out and who has the gap report. Now, if they haven't done it, it would be nice if they would do it, not you, because they know their ED better than you do, particularly for the asthmatics and the bronchiolitics and the sepsis and the UTF, you know, all those kids. So really the ED should be filling this out. If they won't do it and they refuse to do it, you can fill it out through pedsready.org and you can get a gap report back. But all that work really should have already been done and you just need to take a look at that gap report. Let's start with your nurse, nurse manager or nurse director in the ED because they're gonna know where a lot of equipment may be hidden that you aren't gonna know about and same with policies and procedures. I wanted to make one more comment and Dr. Jensen, you can add on to this. I hear a lot of, I hear some folks talk about deficiencies in the pediatric readiness assessment, deficiencies and we don't have this and what will the college, you know, think about that. I think this is our first shot with the ACS COT to really start raising awareness and becoming more pediatric ready. I don't think it is the goal of the college to say, oh, you don't have a MTP. They're not going to give you deficiencies based on gaps on your pediatric readiness assessment. They wanna see that you have looked at it. You're working closely with your ED to say, how can we do better? How can we raise, how can we make that gap smaller, shorter? Not, oh, we're gonna do this. Yeah. They want a CPI, right? I mean, they want you to document that you're working on this problem. You're aware of the problem and you're working on it. Yeah. You're not gonna fix the world in a day. Yeah. And related to that, so we have, now everybody's asking questions there. Awesome. That's what we were hoping for. So what is the best way to present all of this to the ACS during these reviews? Through PI meetings, through dashboards, and for an adult center, what would you recommend aside from gap analysis? Well, it starts with a gap analysis, but I think really what this is, is, you know, you're, you know, maybe not your multidisciplinary trauma committee, maybe at your multidisciplinary trauma committee, but maybe at your weekly PI meetings, or, you know, your tier two PI meetings, you just make this a standing PI agenda item. And each week you address it. You know, you look at your gap report and you say, you know, we have some deficiencies here. We looked at the Pete's Readiness Toolkit. We pulled out these few resources and we've, you know, we've ordered some extra endotracheal tubes. We've brought in some, you know, trainers to improve our nurse competencies. We've identified a PAC. You know, just, we all have PI, right? You have a bad complication and you do a bunch of PI on that. We're really good at documenting that. Just make this a standing PI item that you're working on regularly and keep a PI file. It's hard to put in the registry because it's not really a patient. But you know what? Maybe there was a kid who came through your center and you went back and you looked at that case and you had some opportunities for improvement. You can just use that patient and you can use PI and you can put your Pete's Ready Gap Assessment and what you've done to address the deficiencies. And again, like Michelle said, you're not going to fix everything in a day, but we know how to do PI and trauma, right? And the needs assessment and the gap report and figuring out what it is you need to address is freely available. So that's where it starts, but that's not where it ends. Great. So what do centers do if they don't quite have scores that they like? So this question says, I just received a report back and we earned a 79. Where do I start from here with discussing with the ED team? Yeah. So congratulations on getting a 79 that puts you towards the top of quartile three, mid to top quartile three. That's good. That's good. You know, to get into quartile four, that number is about 90. So it doesn't take a whole lot to get another 11 points, but really look at the gap report. The gap report will tell you where your deficiencies are and look at what can be addressed. And, you know, I don't know, Michelle or Lisa, what other tips you have. Talk to the ED leadership to see where do they think they'll get the biggest bang for the buck? Where do they want to improve first and start? Because if you get their buy-in, it's going to make it a lot easier on you as a trauma program manager, for sure. And you don't have to fix everything, like we said. Next question. So how do you feel this differs for large hospitals that have a pediatric hospital next to their adult hospital versus adult hospitals not associated with the children's hospital? So basically it's hard to get engagement on the topic of pediatric readiness in these places that rarely see kids. Well, you have to think about also disaster preparedness. There's been a lot of school shootings across the US and they keep going more and more. One hospital, that children's hospital is not going to be able to manage if there's a bad event in your area. You're going to have to be able to help them manage those kids coming in. I mean, it's happening everywhere. I mean, I guess you have to ask, you have to ask yourself, like, how do you think you're going to be able to manage I mean, I guess you have to ask, you have to ask yourself, like, you may have a Peds hospital and an adult hospital and maybe you have two different EDs and maybe they're connected. If they're functioning under one license, it's really one Peds readiness score for the whole ED, right? So just ask yourself, if a patient shows up through the adult ambulance bay and it's a kid because the parents drove them in in a private car and they didn't know where to go, they just went to where it said emergency. If a kid shows up to the adult side of your ER in a full traumatic arrest, is it close enough for you to wheel the gurney to a Peds recess bay or are you going to have to play ball in an adult recess bay? And if you're going to have to play ball in an adult recess bay, you either need to have a go-kart from the Peds side that you could push over to that recess bay or you need to have supplies and a team that can come to that bay because parents don't know the difference between a pediatric trauma center and a trauma... They know their kid's been shot and they're going to show up. You know, I have a kid in my ICU right now. It's been there 14 days. He was shot and he was shot two blocks from the adult trauma center. It's 1.1 miles up the street from my freestanding pediatric trauma center. They do not do kids there. EMS does not bring them kids. But the mom brought the kid who was in a full traumatic arrest to this adult level one trauma center because the sign said trauma center and the mom's like, great, I'm here. So the kid might get dropped off and that adult trauma center saved this child's life and they stabilized him, gave him some blood, intubated him and transferred him to us. But the first 20 to 30 minutes in that adult trauma center was on them. So I think it's those centers that think they don't need Peds readiness that actually need it the most, right? Places that take care of kids more often probably have a little more experience and they have the equipment and they have the resources and they have wherewithal and provider competencies. So I think that it's centers that don't take care of kids often is really where this is most important. And to echo what Michelle brought up about disaster preparedness, if you can't take care of a kid on a random Tuesday morning, you're not gonna be able to take care of them when the power's out and the phones are out and it's a real disaster and everybody's at surge capacity. So I think preparing to take care of children on a routine basis, even if you don't like it, but being able to provide emergency resuscitative care for kids, even in the absence of a disaster prepares our whole trauma system to provide better care for kids in the event of a disaster. So I think there are multiple reasons that all trauma centers need to do this, even if there's a Peds center across the parking lot. Ours is actually attached and they share, but they're two different licenses. So they have to be able to speak to, yes, you can speak to, you can go get the equipment from the Peds side, but you have to still be able to speak to it. Right. And there's a policy and a protocol and a way to do that. Yeah. Next question. Are you able to speak to the definition of a pediatric emergency department in the standard for level two adult centers admitting pediatric patients and how it relates to pediatric readiness? I think if I'm interpreting that and the person who wrote it can correct me if I'm wrong, but in those adult centers that are level two centers, but they do admit some pediatric patients. How do you define your pediatric emergency department? I guess when it's within a full emergency department. I don't, I mean, I guess it's wherever the kids are seen. Yeah, I don't know that I fully understand the question, but I think it's a little bit more than I understand the question, but I don't know that there's a real definition for it. I mean, if you have a hospital and you have a sign on the wall that says PZD, then that's your PZD. But if you're an adult too, that admits some kids, but you only have one emergency department for everybody, then that's your PZD. It's gonna be pretty institution specific. I am not aware of any specific definitions, but I'd have to look through the book, but pediatric readiness applies to all years, whether you're a PZD or an adult ED or a rural ED or an urban ED. It's the same assessment for all EDs. So it doesn't really call out differences in center type. It's universally applicable. And this person is referencing standard 2.6. I have to admit, I don't know that off the top of my head though, so. Yeah, I'd have to get out my gray book and I'm not allowed to call it gray. No, I need my book. If you wanna email me offline, it's erin.jensen at ucsf.edu. I'm happy to dig into that further for you and see if I can find you some answers. So far the only other question I see right now and everybody is welcome to in the last minute to put one in is it's kind of a specific question. Somebody who completed the pediatric readiness assessment in 2021 and a deficiency identified was on the policy for immunization assessment and management of the under immunized child. Just wondering what other hospitals are doing to clear this deficiency. I think making sure you have at least your tetanus for both adults, pediatric patients and for infant size patients that come in because usually that's the biggest one you're gonna give in the emergency department for vaccinations. And maybe rabies. Yeah. Reach out to your pediatric center. They'll share theirs with you for free. All right. I think we've reached the end of our audience questions. Great questions, great presentations. So I wanna thank everybody for attending this webinar. You can expect an evaluation to be emailed out and thank everybody for attending and thank you to our presenters. Thanks for having us. Thank you.

pediatric readiness standards

trauma centers

early resuscitative care

equipment

supplies

staff competency

patient outcomes

National Pediatric Readiness Assessment

emergency department

Pediatric Emergency Care Coordinator