Emergency departments score poorly in child-saving drills

A mock-drill study conducted in a third of North Carolina's hospital emergency departments (EDs) revealed that nearly all failed to properly stabilize seriously injured children during trauma simulations, according to a team of researchers at the Johns Hopkins Children's Center and Duke University Medical Center.

Simulations were conducted in 35 of North Carolina's 106 EDs. Of the 35 EDs in the study, five were designated trauma centers (out of a total of 11 in the State of North Carolina), and 30 were located in community hospitals. A report on the work by the research team stating the results probably apply to hospitals nationwide is published in the March issue of Pediatrics.

Although researchers caution that observations during mock codes do not necessarily represent performance in an actual health emergency, the study's results do suggest that hospital EDs are not fully prepared to deal with pediatric emergencies, according to lead author Elizabeth A. Hunt, M. D., M. P. H., assistant professor of Anesthesiology and Critical Care Medicine at Johns Hopkins.

Hunt and colleagues staged "mock codes," using life-size child mannequins. They presented each ED team with a vignette describing the patient's symptoms, appearance and vital signs. Researchers then observed and rated the team's performance on 44 stabilization tasks, such as evaluating an airway, administering fluids and ordering appropriate tests.

None of the departments performed flawlessly, Hunt says, and while mistakes were ubiquitous, certain failures were more worrisome than others. For example, of the 35 EDs studied, 34 failed to administer dextrose properly to a child in hypoglycemic shock (a life-threatening sharp drop in blood sugar). Also, 34 of 35 failed to correctly warm a hypothermic child.

Thirty-one of the 35 also failed to order proper administration of IV fluids, and personnel in 24 out of 35 did not either attempt or succeed at accessing a child's bloodstream through a bone, a critical alternate avenue for rapidly delivering fluids and medicines to sick children whose veins may have constricted due to hypothermia or blood loss.

Researchers said they were surprised to find that emergency medicine staff failed to follow safe patient transport procedures. Only 12 of the 35 hospitals prepared appropriate medications, monitoring equipment and personnel needed to transport a child safely within the hospital. The observation adds new insight to why transportation within the hospital is a high-risk time for patients, Hunt states.

Despite the failures, Hunt says, departments successfully handled many of the 44 mock code tasks well, including:

• Calling appropriate members for assistance
• Initial airway assessment
• Initiating bag-mask ventilation
• Ordering appropriate imaging tests
• Initial vital signs assessment

"There is no definitive evidence to say whether performance during simulation reflects performance during actual events," Hunt says. "However, this study gives us very specific targets for attempting to improve stabilization procedures for children." For example, Hunt suggests hospitals conduct periodic drills to look for recurrent patterns that identify areas most vulnerable to error.

Trauma is the number-one cause of death among children, according to the Centers for Disease Control and Prevention (CDC). Of the 30 million children who seek treatment in emergency departments each year, 81 percent are treated in community hospitals, such as the majority of the hospitals in this study.

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