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

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Results of the 2002 Emergency Pediatric Services
and Equipment Supplement (EPSES) to the National
Hospital Medical Care Survey (NHAMCS)
Division of Health Care Statistics Kimberly
Middleton BSN MPH
Centers for Disease Control and
Prevention National Center for Health Statistics
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Overview

• Background
• EPSES Methodology
• Results
• Next Steps

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Background
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American Academy of Pediatrics Recommendations

• A schedule of pediatricians on call to every ED
• All EDs to establish transfer agreements with
  facilities with higher levels of pediatric care
  to ensure timely access to pediatric emergency
  care for critically ill and injured children

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American Academy of Pediatrics Guidelines

• All equipment and supplies listed, including
  age-appropriate and size-appropriate equipment
  for children of all ages and sizes from premature
  infants through adolescents
• Each hospital must develop a method for storage
  and provide accessibility of medications and
  equipment for children

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1998 NEISS Findings

• Hospitals w/o pediatric dept, ward or trauma
  service usually transfer critically injured
  pediatric trauma patients
• Nearly 10 of hospitals w/o pediatric intensive
  care unit (PICU) admit critically injured
  pediatric trauma patients
• 7 of all hospitals admit pediatric patients
  requiring intensive care to adult intensive care
  unit (ICU) instead of transferring to hospital
  with PICU

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1998 NEISS Findings contd

• Few hospitals have protocols for obtaining peds
  consultation for peds emergencies
• Appropriate sized equipment for infants and
  children was more likely to be missing than
  adult-sizes
• A significant number of hospitals did not have
  adequate equipment to care for newborn
  emergencies.

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Emergency Pediatric Services and Equipment
Supplement (EPSES)

• Funded by HRSA to replicate study of pediatric
  services done by NEISS in 1998.
• Added as a supplement to the 2002-03 NHAMCS.

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EPSES comparison

• Findings When compared to the NEISS study, the
  2002 EPSES data did not show a difference in
  estimates.
• Implication There has been no increase in the
  availability of pediatric emergency services
  since 1998.

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2002 NHAMCS/EPSESMethodology
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Characteristics of NHAMCS
Survey Type of Data Years fielded Current sample size (approximate)
National Hospital Ambulatory Medical Care Survey (NHAMCS) Visits to hospital emergency department (ED) and outpatient departments (OPD) 1992-present 480 hospitals 35,000 ED visits 24,000 OPD visits
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NHAMCS Methodology

• National probability sample
• Not Federal, military, or Veterans
  Administration facilities
• Located in 50 states and D.C.
• 4 stage sample design
• 4 week reporting period
• Data collected by Bureau of Census

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EPSES Methodology

• Short set of questions related to hospital
  services followed by a listing of 131 pieces of
  AAP recommended pediatric equipment.
• Self-administered questionnaire

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EPSES Response

• Raw number of hospitals 480
• of hospitals with no ED 83 (17)
• of hospitals that refused 51 (13)
• Number of participating hospitals 346
• Response rate 87

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EPSES concepts measures

• Pediatric Structure
• does not admit pediatric patients
• admits pediatric patients, but has no separate
  pediatric ward
• admits pediatric patients and has a separate
  pediatric ward.

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EPSES concepts and measures

• ED Pediatric Caseload
• Annual volume of ED cases by children under 18
• Percent of visits to an ED by children under 18
  years of age
• Availability of Pediatric Equipment
• Totally supplied-100 of recommended equipment
• Percent available out of all recommended supplies
  
• Adequately supplied- above the median in terms of
  available pediatric equipment

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Results

• Structure
• ED caseload
• Services
• Expertise
• Equipment

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Average Emergency DepartmentAnywhere, USA

• Sees between 1500-7500 pediatric patients in a
  given year, which represents 20-30 of their ED
  caseload.
• Hospital is not likely to have a pediatric ward.
• Probably has a board certified emergency medicine
  attending, but unlikely to have a pediatric
  emergency medicine attending or pediatric
  attending.
• Has about 80 of the recommended pediatric
  supplies and 5 are fully supplied.

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Average Pediatric VisitAnywhere, USA

• Average pediatric visit is to a hospital ED that
  has a large pediatric volume (gt7500)
• Hospital is more likely to have a separate
  pediatric ward and PICU (25)
• These EDs are more likely to have a board
  certified pediatric EM attending and a board
  certified pediatric attending when compared to
  the average hospital
• Have 91 of recommended pediatric supplies and
  20 of these EDs are fully supplied.

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Pediatric Structure
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Among hospitals with 24hr EDs

• 10 do not admit pediatric patients
• 52 admit pediatric patients but do not have a
  separate pediatric ward or department, i.e., one
  intended for exclusively treating children
• 38 admit pediatric patients and have a separate
  pediatric ward or department

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Distribution of EDs by the relative size of the
pediatric ED patient mix and pediatric structure
of the hospital United States, 2002
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Pediatric Services
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Services for critically injured pediatric
patients

• 37 of all pediatric ED visits are for injury
• 3 of EDs have a separate pediatric emergency
  service area (ESA)
• 18 of hospitals with EDs, have a pediatric
  23-hour observation unit
• 16 of hospitals with EDs, have a coordinated
  pediatric trauma service
• 10 of hospitals with EDs, have a PICU

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Pyramid of pediatric ED cases
1.25
5
100
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Pediatric transfers

• 53 of hospitals had written transfer agreements
  to facilities with a pediatric trauma service.
• 57 of hospitals had written transfer agreements
  to facilities that have a pediatric intensive
  care unit.

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Among EDs w/o critical care services, percent
with written transfer agreements by inpatient
pediatric structure, US 2002
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Pediatric Transfers for Critically Injured Trauma
Patients

• Percent of hospitals w/o peds trauma service that
  transfer to another hospital
• EPSES 88 (NEISS 75 CI41-100)
• Percent of hospitals w/o PICU that transfer to
  another hospital
• EPSES 89 (NEISS 91 CI82-99)

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Pediatric Expertise
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Attending Physician Specialty (available 24/7
in-house or on-call)
Medical Specialty Number of EDs Percent of EDs NEISS findings
Board Certified Emergency Medicine Attending Physician 3,550 72.9 66 (CI 56-76)
Board Certified Pediatric Emergency Medicine Attending Physician 1,270 26.1 23 (CI 14-32)
Board Certified Pediatric Attending Physician 3,249 66.7 64 (CI 52-76)
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Availability of Pediatricians

• Only 9 had a pediatrician on duty in the ED 24
  hours/7days per week
• On-call 26 of hospitals had written protocols
  stating under what conditions a pediatrician
  would be called to the ED

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Variation in availability of board certified
attending physician specialty by inpatient
pediatric structure
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Pediatric Equipment
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Totally Supplied

• Only 10.8 of EDs answered YES to all 131
  pediatric emergency supplies on the list.
• Range airway management (15.8)- resuscitation
  medication chart, tape, or other dose estimation
  system (94.7)
• More supplies may be located in NICU, OB,
  newborn nursery, central supply, pharmacy, nearby
  childrens or sister hospitals.

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Distribution of the percent of pediatric supplies
available in the ED US 2002
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Variation of supply availability score by
inpatient pediatric structure, US 2002
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What about hospitals that dont admit and are
undersupplied?

• Of the 6 of hospitals in our sample that did not
  admit peds and were lt85 supplied, all had other
  hospitals within the same county that either had
  peds beds or a separate peds ward.
• Additional write in responses explained that some
  hospitals have EMS agreements to bypass their
  facility for nearby sister or childrens
  hospitals.

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Next Steps

• Currently combining 2002-03 data to provide
  in-depth analysis on ED pediatric care by
  combining EPSES variables (e.g. structure,
  expertise, equipment) with the NHAMCS visit file
  to look for relationships between items such as
• Medications prescribed
• Diagnosis
• Type of injury
• Source of payment