Who Let All These People In?

Abstract

Children’s hospitals are wonderful places full of dedicated pediatricians, nurses, respiratory therapists, pharmacists, paramedics, and others focused on optimizing the outcomes for pediatric patients. Over the years, more “free-standing” children’s hospitals have been built that are isolated from adult medicine counterparts to support the specialized staff and programs required for cutting edge clinical care while providing a developmentally appropriate environment for children and families at their most vulnerable time.1 Free-standing children’s hospitals are designed to take care of kids, from the emergency department, to radiology, to the wards, outpatient clinics, and ICUs. The staff are trained experts in caring for kids enabling them to excel at their mission while also creating a unique vulnerability, which includes dealing with the occasional medical emergency of all the adult pediatric providers, support staff, and a majority of the parents, grandparents, and other family members who visit children’s hospitals. The dedicated, highly-trained code response team is usually the one called because of the Emergency Medical Treatment and Labor Act in the United States.2 The response necessary for adult emergencies will be very different than that necessary for a typical hospitalized child, in which thoughts of “could this be a STEMI?” or “what is their Cincinnati Stroke score?” are exceedingly rare.3In this month’s issue, Hoffman et al4 also rightly identify that beyond being a hospital, most children’s hospitals are actually large medical centers with a far larger outpatient population than inpatient. The authors note that their highly qualified emergency response team for managing acutely deteriorating hospitalized children is frequently called on to manage both outpatient children and visiting adults, neither of which match the typical population for which the team was likely designed. Simply calling 9-1-1 is not a good option, partly because of the aforementioned Emergency Medical Treatment and Labor Act rules, but also because many municipalities struggle to fully staff their emergency medical services, and pulling a response to the hospital may delay responses to locations that do not have trained medical personnel handily available (personal communication, local emergency medical services director). Fortunately, actual need for a full resuscitative effort including chest compressions and defibrillation for these nonhospitalized individuals is rare. The authors report only a single event requiring defibrillation; importantly, the shock was delivered before arrival of the code team thanks to the availability of a public access automated external defibrillator.There are two big take home points from this article: first is that there are more nonhospitalized individuals than patients in a children’s hospital; therefore, planning for adult and outpatient responses are important. The second is that because the events are both common and rarely severe, a different level of response may be optimal to decrease the drain on resources in the intensive care units or within the emergency departments. As always, the responding team should be prepared and comfortable with all potential emergencies, including adult emergencies. More notably, the most significant adult event described in the paper was managed by bystanders by using a public access automated external defibrillator before the team’s arrival. No matter the emergency response chosen by a children’s hospital, encouraging all employees to learn basic life support, including cardiopulmonary resuscitation and automated external defibrillator use, can be lifesaving. As we build more free-standing children’s hospital to continue to support pediatric patients and their families, we must continue to care for not just the hospitalized children but also the outpatients and the families and staff that exist within this environment. Hoffman et al4 help us to understand the type of team we might need and the best way to help others.