Toward Emergency Department Preparedness:One Step at a TimePraveen Kumar, MBBS, DCH, MD

In 1993, the Institute of Medicine published a report onthe state of emergency medical services across the nation

and found that systems for the care of children were oftenfragmented and unable to meet the needs of children andthus recommended that all emergency departments (EDs)be prepared to provide pediatric emergency care [1]. Theserecommendations led to a critical appraisal of existingresources and ways to improve the quality of pediatric carein EDs. A subsequent study reported that the equipmentnecessary to provide optimal care was frequently unavail-able in many EDs and that this problem was particularlymore frequent in smaller lower pediatric volume EDs [2].The results of a survey conducted around the same time bythe Society for Academic Emergency Medicine suggestedthat emergency medicine residents' exposure to newbornresuscitation and care was limited and therefore meritedfurther attention during pediatric emergency medicinetraining [3]. In response to these concerns, the AmericanCollege of Emergency Physicians and the AmericanAcademy of Pediatrics published a policy statement in2001 on the guidelines for preparedness of EDs that carefor children [4]. The Society for Academic EmergencyMedicine subsequently published a position statement in2003 stating that physicians certified in emergencymedicine possess the knowledge and skills required toprovide quality emergency medical care to children [5].However, in a more recent report released in 2006, theInstitute of Medicine again identified pediatric emergencyservices as an area requiring special attention, noting thatthe level of emergency pediatric care throughout the nationwas “uneven”, and recommended that every pediatric andemergency care–related health professional credentialing

Department of Pediatrics, Feinberg School of Medicine, NorthwesternUniversity, Chicago, IL.

Division of Neonatology, Northwestern Memorial Hospital, Children'sMemorial Hospital, Chicago, IL.

Reprint requests and correspondence: Praveen Kumar, NorthwesternMemorial Hospital, Prentice Pavilion, 333 East Superior St., Suite 404Chicago, IL 60611-2950. (E-mail: p-kumar@northwestern.edu)

1522-8401/$ – see front matter C 2008 Elsevier Inc. All rights reserve

doi:10.1016/j.cpem.2008.06.001

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and certification body should define pediatric emergencycare competencies and require practitioners to receive theappropriate level of initial and continuing educationnecessary to achieve and maintain those competencies [6].

The need to maintain an appropriate level of compe-tency is especially acute in the area of neonatal care.Significant physiological changes necessary for a smoothtransition from fetus to newborn occur at birth, andfrequently encountered neonatal diseases such as perina-tally acquired infections, ductal-dependent congenitalheart defects, metabolic disorders, bilirubin encephalo-pathy, and congenital abnormalities of organ systems canhave similar and/or nonspecific clinical presentations.These distinctive characteristics make it imperative foremergency physicians to be familiar with neonatalphysiology and the differences in presentation of neonatescompared to that of older children and adults. Thecommonly heard saying that “children are not just littleadults” is thus particularly relevant; however, it is equallyimportant to realize that “neonates are not just littlechildren” either.

Several studies have shown that early neonatal utiliza-tion of emergency services has risen significantly over thepast 2 decades [7,8]. This shift has been attributed toshorter postpartum hospital stays and a combination ofpsychosocial factors such as primiparity, single maritalstatus, young maternal age, and health insurance status[7-10]. Most neonatal visits to the EDs in these studieswere for nonacute conditions and were self-referred byparents. Although the most frequent diagnoses werenormal physiology, jaundice, feeding problems, orsuspected sepsis, nearly 15% of neonates had a seriousdiagnosis such as congenital heart disease, seizures, bowelobstruction, hypoglycemia, or pneumonia [7]. In addi-tion, nearly 10% to 30% of all neonates presenting to EDswere reported to require admission for further care [7,8],and in one study, nearly 6% required resuscitation [10].These findings reaffirm that all ED physicians must befamiliar with normal variations in newborn physiology

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and be able to identify presentations of importantneonatal conditions that may have the potential tocause serious sequelae, and even death, if not recognizedand managed properly.

This issue of Clinical Pediatric Emergency Medicine isdedicated to “The Neonate” and provides currentinformation on neonatal physiology and some commonneonatal conditions, both serious and benign, which maylead to an ED visit. The article on perinatal physiologyand principles of neonatal resuscitation, for example,describes the transition from fetal to newborn period andreviews current Neonatal Resuscitation Program guide-lines, controversies regarding the use of 100% oxygen inneonatal resuscitation, and alternative airway mainte-nance techniques in infants with difficult airways. Thearticle on the evaluation and management of a critically illneonate in the ED provides a review of the importantaspects of the neonatal history and examination, the roleof thermoregulation, and a brief overview of differentialdiagnoses in critically ill neonates. Furthermore, thearticle on complications after preterm birth provides abrief summary of common morbidities in critically illneonates such as bronchopulmonary dysplasia, intraven-tricular hemorrhage, periventricular leukomalacia, andnecrotizing enterocolitis. Other articles in this issue focuson important topics of particular interest and importanceto ED physicians such as neonatal sepsis, neonataljaundice, neurological emergencies in newborns, commonskin lesions in newborns, evaluation, and management ofthe cyanotic neonate and newborns with an acute lifethreatening episode.

I greatly appreciate and want to thank all the authors forthe time and effort they have taken to prepare these articles

and sincerely hope that this issue of Clinical PediatricEmergency Medicine will bring us a step closer to providingquality emergency medical care to all neonates.

References1. Durch JS, Lohr KN. From the Institute of Medicine. JAMA 1993;270:

929.2. McGillivray D, Nijssen-Jordan C, Kramer MS, et al. Critical pediatric

equipment availability in Canadian hospital emergency departments.Ann Emerg Med 2001;37:371-6.

3. Tamariz VP, Fuchs S, Baren JM, et al. Pediatric emergency medicineeducation in emergency medicine training programs. SAEM PediatricEducation Training Task Force. Society for Academic EmergencyMedicine. Acad Emerg Med 2000;7:774-8.

4. American Academy of Pediatrics Committee on Pediatric EmergencyMedicine, American College of Emergency Physicians PediatricsCommittee. Care of children in the emergency department: guidelinesfor preparedness. Ann Emerg Med 2001;37:423-7.

5. Lewis RJ. The Society for Academic Emergency Medicine position onpediatric care in the emergency department. Acad Emerg Med 2003;10:1299.

6. Handel DA, Sklar DP, Hollander JE, et al. Executive summary: theInstitute of Medicine report and the future of academic emergencymedicine: the Society for Academic Emergency Medicine andAssociation of Academic Chairs in Emergency Medicine Panel:Association of American Medical Colleges annual meeting, October28, 2006. Acad Emerg Med 2007;14:261-7.

7. Millar KR, Gloor JE, Wellington N, et al. Early neonatal presentationsto the pediatric emergency department. Pediatr Emerg Care 2000;16:145-50.

8. Sacchetti AD, Gerardi M, Sawchuk P, et al. Boomerang babies:emergency department utilization by early discharge neonates.Pediatr Emerg Care 1997;13:365-8.

9. Donovan EF, Perlstein PH, Atherton HD, et al. Prenatal care andinfant emergency department use. Pediatr Emerg Care 2000;16:156-9.

10. Ung S, Woolfenden S, Holdgate A, et al. Neonatal presentations to amixed emergency department. J Paediatr Child Health 2007;43:25-8.