Facility Categorization Toolbox

Hospitals and emergency departments are not all alike: in addition to basic services, individual facilities may also specialize in the provision of certain types of care or specific clinical conditions.  The concept of categorizing healthcare facilities with regard to specialized capabilities and/or resources is not new: trauma, burn, perinatal, and stroke centers have existed for years or even decades.  Facility categorization has also become associated with Regionalization, the notion of identifying available health resources within a given area and coordinating healthcare services to meet the needs of specific patient populations.
The 2006 Institute of Medicine (IOM) report Emergency Care for Children: Growing Pains supports the categorization of emergency care for children.  Experts agree that a categorization system for hospitals capable of providing essential resources for children should have the following services in place:

• pediatric-specific equipment;
• caregivers (i.e. nurses and physicians) trained in pediatric emergency/resuscitation care;
• pediatric-specific policies and protocols;
• a system in place for monitoring pediatric care and performance improvement;
• organized transfer processes, such as interfacility agreements and guidelines facilitating movement of pediatric patients and resources as necessary; and
• processes to assure family integration

Note: The NRC has developed separate toolboxes on Pediatric Equipment, Family-centered Care, and Interfacility Transfer. Please review these toolboxes for additional resources that may also apply to the broader term “facility categorization.”

HEALTHCARE PROVIDER RESOURCES

EMSC National Resource Center (NRC)

• EMSC State Partnership Performance Measures. To measure the effectiveness of federal grant programs, the Health Resources and Services Administration (HRSA) requires grantees to report on specific performance measures related to their grant funded activities. The measures are part of the Government Performance Results Act (GPRA).  EMSC performance measures (PM) address operational capacity to provide pediatric emergency care, including the existence of a standardized statewide, territorial, or regional system that recognizes hospitals capable of stabilizing and /or managing pediatric medical emergencies and trauma (see PMs 74 and 75) . (Accessed February 2010).

• EMSC Webcasts. This section of the NRC website includes links to upcoming and archived webcasts, including the following:
  • State of Emergency Department Preparedness for Children: Release of Joint Statement – A Consensus on the Essentials.  This February 23, 2010 online presentation provides additional information relevant to the 2009 Guidelines for Care of Children in the Emergency Department endorsed by the American Academy of Pediatrics, the American College of Emergency Physicians, and the Emergency Nurses Association.  The webcast site also links to relevant downloadable documents, including a list of helpful links and resources. (Accessed February 2010)
    
  • ESI for Pediatric Triage. This March 25, 2010 webcast provides information on the Emergency Severity Index – a system of triaging patients based on the time-sensitivity and resource utilization requirements of their cases – as related to pediatric emergency care. (Accessed February 2010)

• Best Practices: A Guide for State Partnership Grantees on the Implementation of EMSC Performance Measures. This NRC downloadable document contains additional information regarding the EMSC State Partnership performance measures, and includes best practices from state activities related to facility categorization, as well as interfacility transfer agreements. (June 2009)

• Making Trauma Systems Work for Injured Children – EMSC Performance Measures Can Make a Difference, an Internet Archive Webcast.  Developed by the NRC, and presented online through MCHB, this webcast covers such topics as:
  • pediatric field triage and transfer of the injured child to appropriate resources; 
    
  • system processes that assure appropriate resources for critically ill and injured children; and
    
  • critical components of pediatric trauma care that contribute to improved outcomes. (September 2006)

• Joint Policy Statement for Guidelines for Care of Children in the Emergency Department. Endorsed by the American Academy of Pediatrics' (AAP) Committee on Pediatric Emergency Medicine, the American College of Emergency Physicians' (ACEP) Pediatric Committee, and the Emergency Nurses Association's (ENA) Pediatric Committee, these guidelines outline the essential resources (medications, equipment, policies, and education) and staff to ensure that hospital emergency departments are prepared to care for children of all ages, from neonates to adolescents.  The guidelines are consistent with the recommendations of the Institute of Medicine’s (IOM) 2006 report Future of Emergency Care in the United States Health System, and are also available online through the ACEP website. (Approved April 2009, published in Pediatrics September 2009)
  • AAP News: Policy Offers Blueprint for Care of Children in the ED. This AAP commentary piece provides background information and a concise summary of the key recommendations contained in the 2009 Guidelines for Care of Children in the ED endorsed by the AAP, ACEP, and the ENA. (November 2009)
    
  • Guidelines Checklist. In accordance with the AAP, ACEP, and ENA 2009 Guidelines for Care of Children in the ED, this checklist allows healthcare facilities to assess their own preparedness to manage pediatric emergencies. (Accessed February 2010)

• Preparing for Pediatric Emergencies: Drugs to Consider. Applicable to healthcare facilities providing pediatric emergency care, this AAP Clinical Report provides current recommendations regarding the selection and use of drugs in preparation for pediatric emergencies.  Where possible, dosage recommendations are also included. (July 2008)

• Preparation for Emergencies in the Offices of Pediatricians and Pediatric Primary Care Providers. Recognizing that pediatricians may be called upon to stabilize and/or arrange transport for pediatric patients experiencing health emergencies, this AAP policy statement speaks to the necessary equipment, medications, and provider skill sets for emergency preparedness in primary care settings. (July 2007)
  
• Clinical Report: Facilities and Equipment for the Care of Pediatric Patients in a Community Hospital. This Clinical Report provides guidance to community hospitals on essential furnishing, equipment, policies/procedures, referral networks, and transfer arrangements for the care of pediatric patients. (September 2007)

• Consensus Report for Regionalization of Services for Critically Ill or Injured Children. A joint publication of the AAP and the pediatric sections of the American College of Critical Care Medicine (ACCCM), this document establishes recommendations for regionalized, integrated emergency medical care for critically ill or injured children.  (January 2000)

• Pediatric Care Recommendations for Freestanding Urgent Care Facilities. Given that free standing urgent care centers may be used as an alternative to hospital emergency departments, this policy statement AAP’s Committee on Pediatric Emergency Medicine addresses recommendations and resources for assuring appropriate stabilization in pediatric emergency situations and timely transfer to a hospital for definitive care when necessary. (May 1999)

American College of Surgeons

• Regional Trauma Systems: Optional Elements, Integration, and Assessment. Given that trauma is the most extensively regionalized emergency care system in the United States, this resource from the American College of Surgeon’s Committee on Trauma demonstrates the far-reaching potential of facility categorization and specialty care designation for specific patient populations.  It contains historical perspective on trauma system implementation, as well as practical information for the development, maintenance, and evaluation of dedicated care centers. (2008)

Centers for Disease Control and Prevention, U.S. Department of Health and Human Services

• Availability of Pediatric Services and Equipment in Emergency Departments: United States, 2002-03. Containing the results of the Emergency Pediatric Services and Equipment Supplement to the Centers for Disease Control and Prevention’s 2002-3 National Hospital Ambulatory Medical Care Survey (NHAMCS), this report presents estimates on the availability of pediatric services, expertise, and supplies for treating pediatric emergencies in U.S. hospitals.  Results indicate that emergency departments in hospitals with specialized inpatient facilities for  children are more likely to meet the AAP/ACEP guidelines for pediatric emergency care capabilities. (February 2006)

Emergency Nurses Association

• Care of the Pediatric Patient in the Emergency Setting.  This Emergency Nurses Association (ENA) position statement, along with its corresponding white paper,  articulates ENA’s support for emergency departments seeking designation as: emergency pediatric centers (EPCs), emergency departments approved for pediatrics (EDAPs), and stand-by emergency departments for pediatrics (SEDPs), or similar designations as determined by individual states (April 1995)

Institute of Medicine

• Emergency Care for Children: Growing Pains. The IOM Committee on the Future of Emergency Care in the United States Health System was convened in 2003 to examine the state of emergency care in the U.S. and to create a vision for the future of emergency care. In 2006, the committee released “Growing Pains,” an analysis of: (1) the role of pediatric emergency services as an integrated component of the overall health system; (2) system-wide pediatric emergency care planning, preparedness, coordination, and funding; (3) pediatric training in professional education; and (4) research in pediatric emergency care. With its call for an over-arching system of emergency care that is coordinated, regionalized, and accountable, this publication contains numerous references to the need for pediatric emergency facility categorization. (2006)

Society of Critical Care Medicine

• Guidelines and Levels of Care for Pediatric Intensive Care Units. Written in part by the Society of Critical Care Medicine’s ACCCM, these guidelines discuss the scope of pediatric critical care services in terms of: (1) organizational and administrative structure, (2) hospital facilities and services, (3) personnel, (4) drugs and equipment, (5) quality monitoring, and (6) training and continuing education. (2004)

EXAMPLE PRACTICES

Illinois EMSC Facility Recognition Program

Since 1998, more than 100 Illinois hospitals (including two in Iowa) have received recognition by the Illinois Department of Public Health and the Emergency Medical Services for Children Program through the Illinois EMSC Facility Recognition initiative.  This voluntary program serves to identify the readiness and capabilities of healthcare facilities and staff for providing optimal pediatric emergency and critical care. 

Hospitals with enhanced pediatric emergency care resources and abilities can apply for one of three levels of voluntary recognition:

1. Facilities with pediatric intensive care units that can provide specialty inpatient pediatric services can seek designation as a Pediatric Critical Care Center (PCCC);
2. Hospitals that can provide comprehensive emergency services and meet pediatric emergency care requirements can be recognized as Emergency Departments Approved for Pediatrics (EDAP); and
3. Hospitals that can provide pediatric stabilization and have transfer agreements in place when more definitive care is indicated can be categorized as Standby Emergency Departments for Pediatric (SEDP).

According to the Illinois EMSC Program, hospitals seeking one of these voluntary designations receive a site visit by the EMSC program staff to verify that the emergency department and pediatric department are capable of meeting the following key pediatric care standards based on the level being applied for: 

• Professionals specially trained in pediatric emergency and critical care;
• Adequate staffing and provisions for pediatric consultation and backup;
• Availability of essential pediatric equipment, supplies and medication;
• Protocols for the treatment of critically ill and injured children, and protocols to assist in the transfer process;
• Conduction of pediatric quality improvement activities.

Finally, the Illinois EMSC Facility Recognition web page also includes links to a variety of resources relevant to facility categorization.  These include: a list of recognized hospitals, a list of requirements for each level of categorization, a slide presentation reviewing the Facility Recognition Program, and a link to the contents of an AAP/ACEP pediatric toolkit CD-ROM containing information on the resources, equipment, and staffing needed to ensure that hospitals are adequately prepared for pediatric emergencies. (Accessed February 2010)

For additional information about the Illinois Facility Recognition program, see “A Statewide Model Program to Improve Emergency Department Readiness for Pediatric Care,” published in the Annuals of Emergency Medicine, Vol 54, Issue 2, pp 198-204, August 2009.


Oklahoma EMSC Program

Oklahoma initiated EMSC State Partnership Performance Measures 74 and 75 – referring to the percent of hospitals recognized through a statewide, territorial, or regional standardized system that are able to stabilize and/or manage pediatric medical and traumatic emergencies – by utilizing the statewide Trauma Advisory Committee established by the Governor’s Task Force.  Research findings from a 1992 Oklahoma EMSC research project on pediatric equipment availability and gaps in emergency medical care helped provide the committee with evidence needed to encourage inclusion of pediatrics within the state’s existing trauma system.

To establish the guidelines for pediatric categorization/recognition, Oklahoma EMSC then utilized the Emergency Department Approved for Pediatrics (EDAP) standards and the American College of Surgeons (ACS) standards for Level 1, II, III, and IV trauma centers.  The state Department of Health added strength to the process by developing mandates requiring that that all facilities with emergency departments be categorized at one of the four ACS levels.  As a result of these collaborative efforts, pediatrics was ultimately included in the state’s rules and regulations on facility categorization.

For information about Oklahoma’s process toward establishing a facility categorization program, see the NRC publication Best Practices: A Guide for State Partnership Grantees on the Implementation of EMSC Performance Measures.

Tennessee Department of Health

Through its Board for Licensing Healthcare Facilities, Tennessee’s Department of Health has official Rules and Regulations establishing mandatory Standards for Pediatric Emergency Care Facilities.  These statewide criteria define the characteristics of hospitals licensed to provide pediatric emergency care, addressing minimum requirements for pediatric regional networking, interfacility transfer agreements, equipment, staffing and resources, education and training, quality monitoring and improvement, and standards of care protocols among other pertinent topics.  

Tennessee standards further classify pediatric emergency care facilities into four separate categories based on their ability to provide emergency medical services to children as described below:

1. Comprehensive regional pediatric healthcare facilities provide comprehensive specialized pediatric medical and surgical care to acutely ill or injured children and serve as regional referral centers.
2. General pediatric healthcare facilities have separate inpatient pediatric services and departments of pediatrics within their medical infrastructure.
3. Primary pediatric healthcare facilities provide basic services, have limited capabilities for the management of minor pediatric inpatient problems, and may accept appropriate regional pediatric transfers only when more specialized care center are  unavailable.
4. Basic pediatric healthcare facilities identify, stabilize, and transfer critically ill or injured children. (Accessed February 2010)

FAMILY AND CAREGIVER RESOURCES

EMSC National Resource Center

• Getting Started, Staying Involved: An EMSC Toolkit for Family Representatives. This NRC publication, developed for EMSC family representatives, includes sections addressing the importance of Hospital Recognition for pediatrics.  It also contains advice for families on how to work with state EMSC Advisory Committees to develop standardized systems for categorizing facilities based on their ability to stabilize and/or manage pediatric medical and traumatic emergencies. (2008)

American Academy of Pediatrics

• When Your Child Needs Emergency Medical Services. This tip sheet for families and caregivers provides information on how to react to pediatric healthcare emergencies, including what to bring to the emergency department, and how to communicate with emergency care providers. (Accessed February 2010)

American College of Emergency Physicians

• Emergency Care of Children. This fact sheet answers questions that parents may have about emergency care for children, such as:
  • Which local emergency department is best for your child?
  • What role do pediatric emergency specialists play in the care of your child?
  • What are emergency physicians doing to improve the care of children?
  • How do you make sure your child gets appropriate treatment in an emergency? (Accessed February 2010)