It has been two years since 12-year-old Rory Staunton died from overwhelming sepsis, a severe bloodstream infection and the number one killer in hospitals and 11th leading cause of death in the United States. His death triggered a major initiative nationwide to reduce the morbidity of this rapidly progressive and frequently fatal disease. In fact, Governor Andrew Cuomo announced last year that New York would lead the nation as the first state to require hospitals to adopt evidence-based protocols and checklists to facilitate quick diagnosis and timely life-saving treatment for children with sepsis. In children’s hospitals all over the state, the term “sepsis guidelines” has become household lingo, as hospital task forces struggle to meet the governor’s deadline to initiate these protocols. The energy behind this endeavor is infectious and one is led to believe that the initiation of these guidelines is the singular answer to saving children’s lives.
But is it?
The adage that children are not just small adults is especially true in the case of emergency medicine, where weight-based dosing and age-appropriate vital signs come as second nature to pediatricians and as a foreign language to non-pediatric trained MDs.
It is if you believe that protocols and checklists can practice medicine. But there are at least some who believe that reliance on guidelines can impart to young and inexperienced physicians—or to physicians not savvy in the care of sick kids—a sense of false security, which can lead to under-appreciation of critical warning signs that can hide from institutional guidelines.
In 2005, there were over 20 million emergency department (ED) visits in the United States by children under 18 years of age. It is a little known fact that only one in 10 of those visits were to pediatric EDs staffed by physicians with six years of post-medical school residency and sub-specialty training in pediatrics and pediatric emergency medicine. The remaining 90 percent of children were cared for in community hospital EDs by undoubtedly smart, talented, caring, and conscientious emergency physicians with four years of training in emergency medicine but, in most cases, only four monthsof training in pediatrics. Their education in pediatrics represents less than 10 percent of their training, while close to 30 percent of their patients fall into the pediatric age group. Throughout the U.S., and even where major medical centers abound and where groundbreaking advances in medicine are made daily, children are cared for by community hospital emergency physicians not sufficiently trained to treat them.
This disconnect was highlighted in a 2006 Institute of Medicine report, “Emergency Care for Children: Growing Pains,” published by the National Academy of Sciences, that found that many providers of general, not sub-specialty, emergency care feel stress and anxiety when caring for children that they do not feel when caring for adults. Often, these providers undertreat or fail to stabilize seriously ill children, and there is wide variation of treatment patterns. Simply put, general emergency care providers in community EDs, who are the consummate experts in the treatment and resuscitation of critically ill adults, are not as equipped to care for our kids as are specially trained pediatric emergency care providers.
This year, the work of a privately supported non-profit quality improvement program called ImPACTS (Improving Pediatric Acute Care Through Simulation) has led to the same conclusion. Through 200 simulated pediatric emergencies run in 25 EDs nationwide, including 17 general (community) EDs and eight pediatric EDs, the group found that 93.3 percent of pediatric EDs were compliant with guidelines in the treatment of pediatric septic shock compared with only 13.6 percent of general EDs. Community EDs showed deficiencies in delivering life-saving fluids and blood pressure medications, were less likely to correctly dose medications to kids, and were less likely to comply with American Heart Association guidelines in pediatric cardiac arrest.
The adage that children are not just small adults is especially true in the case of emergency medicine, where weight-based dosing and age-appropriate vital signs come as second nature to pediatricians and as a foreign language to non-pediatric trained MDs. But there’s more than that going on here. There’s a certain gestalt about what makes a child normal or not normal, sick or not sick, that comes with treating children all day, every day, over years of practice; it’s a look, a smell, a feel a pediatrician has when looking at a kid. This can’t be achieved through guidelines and protocols and checklists.
It is crystal clear that emergency medicine physicians who move on after residency to treat children in community hospital EDs are often unprepared to deliver the standard of care to our nation’s acutely ill or injured, and the provision of guidelines and protocols is a first step to fix that. But it’s a quick fix, and an insufficient one at that.
Throughout the U.S., and even where major medical centers abound and where groundbreaking advances are made daily, children are cared for by community hospital emergency physicians not sufficiently trained to treat them.
What is needed is greater exposure to pediatrics and pediatric emergency care successfully and innovatively incorporated into formal training. In addition, there should be a mandatory component of continuing medical education for emergency medicine residency graduates—targeted specifically toward community hospital emergency physicians—that includes continuing education in pediatrics. Finally, and probably most importantly, systems should be in place whereby formal partnerships are established between community hospital EDs and regional children’s hospitals. These collaborations will allow a continuous exchange of information, including just-in-time pediatric consultations, pediatric education forums, and ongoing simulation exercises with pediatric emergency medicine physicians. Not every community can support a designated children’s hospital with a dedicated pediatric ED. These collaborations could go a long way toward narrowing the information gap.
Naysayers may argue that four-year-long emergency medicine residency programs are already lengthy, and that there is not enough flexibility in the schedule to allow more pediatric training. These residency programs have multiple requirements already specified by the Accreditation Council for Graduate Medical Education, including training in obstetrics, adult critical care, emergency preparedness, and EMT. Some argue that physicians should be able to learn pediatrics from on-the-job training. But it is difficult to imagine that these physicians can become experts in a patient population that is not their primary focus; while community hospital emergency doctors see close to 90 percent of the nation’s sick kids, these children still represent at most, and often much less than, 25 percent of the emergency patients they see.
The future will bring many patients like Rory Staunton. Children will continue to sustain trauma, develop cancer, slip into coma, suffer from heart disease, have seizures, and, yes, they will contract sepsis too. Just like adults, they will continue to suffer the misfortune of serious and potentially fatal trauma and illness. Guidelines alone cannot possibly treat all of the pathology that these children will exhibit. The state-mandated sepsis guidelines that are generating so much enthusiasm among advocacy groups, hospitals, and politicians are just a single step in the right direction. Their strength is in their power to standardize management, and certainly can’t hurt; however, they will likely cure only a small part of the problem.