Pediatric emergency care: Determinants and systematic barriers

Abstract

Pediatric emergency care (PEC) encompasses the specialized medical care delivered to infants, children, and adolescents facing urgent medical situations, addressing critical conditions such as infections, allergic responses, seizures, respiratory distress, and trauma. PEC calls for prompt, focused interventions to address each child's developmental and physiological needs. The literature was searched using Google Scholar, PubMed, and the Cochrane Library to retrieve studies assessing quality indicators and outcomes in pediatric emergencies. The search was limited to papers published in peer-reviewed journals between 01 Jan 2000 and 15 Dec 2024. This review evaluates current PEC standards such as patient safety, diagnostic precision, timeliness, and patient and family satisfaction. Patient safety is vital because children are particularly vulnerable to medical errors, such as inappropriate doses of medication. The provision of high-quality PEC is hampered by systemic issues such as inadequate training, a lack of resources, and restricted access to treatment. Telemedicine, pediatric transport units, artificial intelligence applications for diagnostics, and simulation-based training are suggested approaches to overcome these challenges. Research networks and quality improvement initiatives are important steps to improve PEC care.

Key Words: Artificial intelligence; Diagnostic accuracy; Emergency department; Healthcare delivery; Pediatric emergency care; Quality improvement

Core Tip: Pediatric emergency care (PEC) addresses many critical conditions, such as infections, allergic responses, seizures, respiratory distress, and trauma. We searched Google Scholar, PubMed, and the Cochrane Library to retrieve the studies assessing quality indicators and outcomes in pediatric emergencies. This article showed the current PEC standards, systemic barriers to providing high-quality care, and quality improvement projects to improve outcomes. Telemedicine, pediatric transport units, and simulation-based training are suggested approaches to overcome these challenges.

INTRODUCTION

Pediatric emergency care (PEC) is one of the most urgent aspects of healthcare, providing prompt, precise, and tailored treatments[1]. High-stakes decisions are necessary in all emergency care situations; however, pediatric emergencies are particularly complex due to children's distinct physiology, anatomy, and developmental stages compared to adults. Furthermore, children require careful incubation measures during cardiac resuscitation due to their narrow airways, which make them more susceptible to respiratory distress. Because they have faster metabolic rates than adults, they may decline more quickly from dehydration, illness, or blood loss. Shock management in neonates can be more challenging, as the heart rate significantly impacts blood pressure regulation more than the vascular tone[2]. These incidents highlight the importance of using expert medical knowledge and skills to treat young children in crisis. Children's continuous growth and development also affect how they experience and communicate symptoms, discomfort, and fear during emergencies. A child's developmental stage also determines how they react to trauma or illness[3].

Effective assessment can be more difficult with younger children since they may not have the linguistic ability to explain their symptoms or understand the situation. In addition to communicating with the patient's guardians, healthcare providers must consider these variables while choosing the best interventions. Furthermore, due to these unique features, PEC necessitates a specific methodology that can handle a variety of clinical presentations and the variation in patient height, weight, and developmental stage.

Children who get subpar emergency care may suffer long-term effects. Additionally, inadequate therapy occurs when the criteria for managing pediatric crises do not advance timeliness, safety, accuracy, or patient-centeredness[4]. For instance, even little delays in emergency procedures can have significant long-term effects since children's bodies lack the physiological reserves to adjust for prolonged illness or premature injury. Additionally, when trauma occurs, improper treatment of brain damage or fractures may result in long-term cognitive and physical challenges. Still, improper treatment of psychological trauma may also have a long-lasting effect on a child's mental and emotional well-being. Children and their families may lose trust in the medical institution due to bad experiences or subpar care in an emergency room, which may decrease the likelihood that they will seek treatment.

Pediatric emergency medicine (PEM) was recognized as a distinct specialty in response to growing awareness of the need for specialized care for children in emergencies[5]. In the past, pediatric patients were treated in regular emergency departments (EDs) alongside adult patients, typically by staff members who lacked the training necessary to treat conditions unique to children. As representatives and healthcare professionals became increasingly conscious of the requirements of children in acute care settings in the 1980s, the specialty of PEM started to take shape. Specialized fellowship programs and board certification pathways for physicians were established in 1987 when the American Board of Pediatrics first recognized PEM as a subspecialty[6]. Pediatric emergency rooms were widely used and thrived in large hospitals in the following decades. Doctors with expertise in emergency medicine and general pediatrics frequently operated on them.

Since organizations like the PEC Applied Research Network (PECARN) are leading efforts to improve clinical practices and outcomes in pediatric emergencies[7], clinical research and education have also become increasingly advanced in tandem with these developments. PEM is still developing because of ongoing efforts to improve care delivery models, integrate new technologies like telemedicine, and close access gaps to pediatric emergency services in rural areas. Nevertheless, substantial work is necessary to ensure that all children receive timely, effective, and high-quality care in an emergency. This review examines the underlying principles of PEC, standards of care, and systemic barriers and discusses effective quality improvement (QI) techniques to improve PEC.

METHODOLOGY/ EVIDENCE ACQUISITION

A systematic search of the literature was conducted using databases such as Google Scholar, PubMed, and the Cochrane Library to identify studies assessing quality indicators, QI activities, and outcomes in pediatric emergencies. To gather the most current and relevant data on PEC quality, the search was limited to papers published in peer-reviewed journals between 01 Jan 2000 and 15 Dec 2024. The search strategy combined free-text keywords with medical topic headings (MeSH).

RESULTS AND DISCUSSION

The findings were categorized into quality indicators, systemic barriers, and QI strategies.

Quality in PEC

The term "quality" in healthcare refers to how well health services align with current professional knowledge and maximize the likelihood of desired health outcomes for individuals and populations. Several important factors are measured and monitored to evaluate the quality of PEC, including patient satisfaction, timeliness, safety, and diagnostic accuracy[4,8-11]. Each indicator is essential for assessing advancements in the provision of efficient PEC. Using these indicators helps measure and improve PEC quality by identifying the trouble spots and concentrating on improvement initiatives.

Timeliness of care

Timeliness is the speed at which young patients receive necessary medical attention. Timeliness of care is of utmost importance for pediatric patients due to their distinct physiological and developmental requirements. Although children recover from diseases and accidents more quickly than adults, waiting too long to seek medical attention may delay this recovery. Timeliness is one of the most important quality measures in EDs, as rapid deterioration or worsening may occur if attention is delayed, such as in respiratory distress, trauma, and infection[11,12]. Mullen et al[9] showed that a 25% reduction in diagnostic and treatment delays for childhood cancers decreased mortality rates by over 20%. Furthermore, rapid intervention during pediatric sepsis reduced mortality rates by 40%, as demonstrated in a systematic review by Choy et al[12].

Door-to-doctor time: This is the period between a patient's arrival at the ED and the first assessment by a medical expert. For pediatric patients, this time was significantly influenced by hospital size, staffing levels, and triage procedures. In diseases including sepsis and trauma, shorter wait times between patients and doctors have been linked to better outcomes[9,10].

Time to treatment: This refers to the time it takes from the patient’s evaluation to start the essential treatment. Studies have shown that prompt antibiotic care in suspected pediatric sepsis is associated with lower fatality rates, while delayed automated external defibrillator administration in pediatric cardiac arrest may result in prolonged hospital stays and complications[12].

Length of stay in the ED: This indicator shows how long patients stay in the ED before being admitted or discharged. Extended lengths of stay could indicate ineffective therapy, bed shortages, or delayed diagnosis[13]. The prolonged Length of stay (LOS) in ED is associated with overcrowding, higher hospital-acquired infections, and more stress and anxiety for patients and their parents. In a retrospective study by Hofer and Saurenmann[14], physician referral, gastrointestinal infections, and morning admissions were significantly associated with prolonged ED-LOS. Zdęba-Mozoła et al[15] conducted a lean management analysis in the ED and demonstrated a 20% shortened LOS by reducing unnecessary steps in ED workflows, improving patient outcomes and satisfaction.

Patient safety

Patient safety is another crucial PEC excellence requirement[16]. In pediatric EDs, adverse events and avoidable injuries are common, including medication errors, surgical complications, management issues, and diagnostic delays[16-18]. Multiple studies have identified neglecting to treat airway issues or delaying sepsis treatment as a significant challenge in pediatric EDs. Common causes of avoidable harm include inadequate personnel and poor adherence to pediatric care protocols. Plint et al[18] found that one in 33 children suffered ED-related adverse events, and most of them (76%) were preventable. The common adverse events included management (52.5%) and diagnostic issues (19.3%). Studies have shown that children's different body weights increase their risk of medication errors, so precise dose calculations are necessary. Errors in the ED are frequently linked to staff fatigue, inadequate pediatric training, and inadequate communication. The evaluation found that error rates were particularly high in high-stress scenarios that needed quick decisions, like pediatric trauma resuscitation[19]. A recent systematic review showed a 10%-15% prevalence of medication errors, and 39%-49% of these were dosing errors resulting mainly from inaccurate weight estimations and dose miscalculations[20].

Diagnostic accuracy

Accurate diagnosis is crucial in PEC since a delayed or inaccurate diagnosis might have harmful consequences. Children sometimes exhibit uncommon symptoms, which complicates their investigation. The evaluation highlights specific circumstances where diagnostic precision is crucial. These are as follows.

Trauma: Because children's anatomy and physiology differ from those of adults, pediatric trauma presents difficulties. It is commonly known that internal injuries, such as abdominal trauma, are frequently misdiagnosed and that failure to diagnose such fatal conditions can have disastrous consequences[10,11].

Sepsis: To lower mortality rates for pediatric patients, sepsis must be detected early. Research indicates that diagnostic delays are frequently caused by vague early symptoms, including fever or lethargy, which might mimic less serious illnesses. Although sepsis methods have often improved early detection, diagnostic errors are still a serious risk[12,21].

Respiratory disorders: Asthma and bronchitis are among the respiratory disorders that pediatric EDs commonly treat[22]. Inadequate care, lengthy hospital stays, and, in severe cases, respiratory collapse can arise from incorrect diagnosis or a failure to recognize the severity of respiratory distress.

Patient and family satisfaction

Patient and family satisfaction is vital to high-quality care in pediatric crises[23]. A comprehensive literature study, enclosed surveys, and interviews measure patient and family perceptions of treatment. Physical environments in pediatric EDs may impact patient satisfaction. Families have been found to prefer pediatric EDs with pediatric treatment-trained staff and child-friendly waiting rooms. Families and medical personnel must communicate effectively during pediatric emergencies[23]. According to the research, families that participate in decision-making and are informed report higher satisfaction. However, communication problems are common, especially in overcrowded EDs that lack adequate staffing. Bucknall et al[24] reported that involving families in care planning improved adherence to treatment by 45% and reduced readmission rates by 25%. This evidence underscores the need to prioritize effective communication strategies in PEC.

Systemic barriers to high-quality PEC

Many systemic obstacles have been identified affecting the provision of high-quality PEC. These challenges are universal in many circumstances; however, they differ based on the region, healthcare system, and hospital resources. Various quality indicators, systemic barriers to the quality PEC, and proposed solutions are summarized in Table 1.

Table 1 Summary of systemic barriers and proposed solutions for the quality of pediatric emergency care.

Category	Key components
Quality indicators
Timeliness of care	Door-to-doctor time: Influenced by hospital size, staffing, triage[9,10]
	Time to treatment: Quick intervention improves survival[12]
	ED length of stay (LOS): It is an indicator of efficiency, and prolonged LOS could indicate ineffective therapy, bed shortages, or delayed diagnosis[13-15]
Patient safety	Adverse events include medication errors, misdiagnosis, and procedural mistakes[16-18]
	Root causes: Staff fatigue, poor communication, protocol non-adherence[20]
Diagnostic accuracy	Trauma: High misdiagnosis risk (e.g., abdominal injuries)[11]
	Sepsis: Early vague symptoms lead to delay[21]
	Respiratory issues: Misjudged severity impacts outcome[22]
Patient & family satisfaction	Influenced by communication, environment, and provider interaction[23]
	Family involvement improves satisfaction and treatment adherence[24]
Systemic barriers
Resource constraints	Lack of infrastructure[25,26]
	Poor staffing
	Lack of pediatric emergency physicians and protocols
Training gaps	Lack of specific pediatric training among ED practitioners
Outdated infrastructure	Outdated or ineffective infrastructure puts patient safety at risk and delays care[28]
	Lack of integrated care systems leading to delays in inpatient admissions, specialist consultations, and diagnostic testing
Proposed solutions
Telemedicine	To provide real-time support to rural and remote areas[30]
Mobile units	Helpful to stabilize children before transfer to a specialized hospital or to offer on-site care
Training	Structured pediatric emergency care training to ED members[31]
	Simulation-based trainings improve competence and confidence by enabling them to practice uncommon but crucial procedures under controlled conditions[33]
Clinical protocols	Use of protocols is helpful to standardize clinical practices
	Use in trauma/sepsis care has improved the outcome[32]
Research networks	Help improve the global standards and diagnostic accuracy
	PECARN: Helped to enhance the evidence-based practices for asthma, trauma, and sepsis
Artificial intelligence	Assists with the identification of critical cases using data analytics
	Promising early results in efficiency and safety
Quality improvement efforts	Focus on clinical protocols, early warning systems, and symptom-based training
	Effective in improving accuracy and reducing delays
Leadership role	Pediatric leaders drive QI, staff training, and policy adherence
	Leads to sustained pediatric care improvements

ED: Emergency department, PECARN: Pediatric emergency care applied research network; QI: Quality improvement.

Resource constraints

In many rural or poor locations, pediatric EDs have severe resource shortages, leading to delays in care and poor results[25,26]. These include insufficient infrastructure and a labor deficit. Rural and underserved regions face significant challenges in delivering quality PEC. Newgard et al[10] demonstrated that trauma centers with higher pediatric readiness scores reduced mortality rates by 4.9% compared to those with lower readiness. This highlights the importance of addressing resource disparities in rural and underserved regions. Glass et al[11] have also found that pediatric survival rates improved by 15% when EDs were equipped with specialized pediatric resources and protocols.

Training deficits

The investigation identified a major challenge as the absence of specific pediatric training among ED practitioners. Many medical staff in general EDs are not sufficiently trained in pediatric-specific treatment, which leads to inadequate handling of pediatric crises. Yuknis et al[27] reported a 35% increase in successful outcomes for simulated pediatric emergencies following structured training programs. This underscores the role of simulation-based training in bridging skill gaps among healthcare providers.

Healthcare infrastructure

Hospital systems that are outdated or ineffective put patient safety at risk and delay care[28]. The lack of integrated care systems was the primary cause of the review's identification of several infrastructure problems. Delays in inpatient admissions, specialist consultations, and diagnostic testing might result from EDs' poor integration with larger healthcare networks. Extended stays in EDs elevate the risks of hospital-acquired infections and increase stress and anxiety among pediatric patients and their families. Zdęba-Mozoła et al[15] suggested implementing lean management tools to reduce inefficiencies and minimize ED stays.

Addressing systemic barriers

Telemedicine: Systemic problems such as limited access, poor training, and a lack of resources must be resolved to provide high-quality PEC. Telemedicine is a practical remedy for the lack of emergency care for children in remote or underdeveloped areas[29]. Through telemedicine, tertiary care centers can empower physicians in rural and remote areas to provide emergency care by helping them with real-time diagnosis and treatment decisions. Bhaskar et al[30] reported that implementing telemedicine in rural pediatric emergency settings improved diagnostic accuracy and reduced patient transfer, saving critical time for treatment.

Mobile units: Mobile units can be a useful tool to address the gaps in emergency care admission in areas with an insufficient healthcare infrastructure. In underprivileged areas, these supplies might be delivered to stabilize children before their transfer to a more specialized hospital or to offer on-site care.

Training in PEC: It is imperative to address the lack of training among ED personnel. Many EDs, especially those in general hospitals, operate as medical specialists without any official PEC training. Inappropriate treatment and a rise in medical blunders could arise from this. Making PEC training a must for all ED professionals is another possible remedy. This will guarantee that every member of the ED has the abilities and knowledge required to manage pediatric crises[31].

Clinical protocols

Standardized clinical practices have significantly improved the outcomes in pediatric EDs. For instance, protocols for treating trauma and sepsis in children have been extensively adopted and associated with lower rates of morbidity and mortality. These protocols give precise, research-based treatment parameters, ensuring that care is delivered consistently, even under high-stress conditions. Pereira et al[32] found that adherence to evidence-based guidelines for pediatric sepsis reduced treatment variability by 40% and decreased mortality by 15%.

Simulation-based training

It has been discovered that simulation-based training programs improve specialists' abilities to handle pediatric emergencies[33]. For instance, hospitals that employed pediatric revival simulation training saw higher success rates under actual circumstances. By enabling them to practice uncommon but crucial procedures under controlled conditions, these trainings help healthcare professionals become more skilled and self-assured in handling real-world emergencies. Yuknis et al[27] reported a 28% improvement in healthcare providers’ confidence and competence when managing pediatric emergencies after simulation-based training.

PECARN

A noteworthy research project called “PECARN" has evolved to enhance clinical judgment and results in PEC. Multi-center trials and evidence-based research have also impacted many clinical decision-making standards and treatment practices utilized by EDs worldwide. These also include guidelines for treating asthma, sepsis, and head trauma, all of which have been demonstrated to improve patient outcomes and lower diagnostic errors.

Use of artificial intelligence

Artificial intelligence (AI) is also a more sophisticated strategy for PEC that prioritizes dedication. It is being used to power analytic appliances that will assist hospitals in detecting dangerous diseases such as sepsis and traumatic brain injuries. Additionally, by analyzing vast volumes of medical data, AI can assist doctors in more accurately and swiftly identifying patients, particularly by evaluating enormous amounts of medical data, mainly in complex or vague cases.

QI initiatives: The review identified numerous effective QI initiatives that addressed the challenges with improved PEC after implementing them. Enhancing diagnostic accuracy through clinical procedures, early warning systems, and training in pediatric patients symptomatically is necessary because children need to obtain an accurate diagnosis and treatment as soon as feasible[34-36].

The role of leadership in QI

Effective leadership is essential to implement QI projects in pediatric EDs[31]. Prioritizing pediatric care leadership frequently improves outcomes and increases adherence to QI criteria in hospitals and EDs. Effective leadership guarantees that QI initiatives are implemented successfully and that continuous monitoring and improvement are made in response to real-time data and changing industry best practices. The employment of pediatric care leaders in Eds has also been demonstrated to improve results. These leaders, who are typically outstanding physician or nurse leaders, advocate for staff training, quality control, and the establishment and implementation of pediatric-specific policies. Effective leadership plays a pivotal role in QI initiatives.

CONCLUSION

To conclude, the development of PEC should be prioritized by healthcare systems worldwide. Since these metrics directly affect outcomes, targeted approaches can address critical quality indicators like timeliness, diagnostic accuracy, patient safety, and satisfaction. Many systemic barriers have been identified, including resource limitations, training shortages, and admission equity, that can be addressed by using telemedicine, simulation-based training, and the creation of mobile pediatric emergency units. A robust administrative culture centered on quality indicators is essential to the success of these initiatives.