RESEARCH
PEDIATRIC READINESS IN INDIAN
HEALTH SERVICE AND TRIBAL EMERGENCY
DEPARTMENTS: RESULTS FROM THE NATIONAL
PEDIATRIC READINESS PROJECT
Authors: Juliana Sadovich, PhD, RN, Terry Adirim, MD, MPH, Russell Telford, MAS, Lenora M. Olson, PhD, MA,
Marianne Gausche-Hill, MD, and Elizabeth A. Edgerton, MD, MPH, Rockville, MD, Philadelphia, PA, Salt Lake City,
UT, and Torrance, CA
Earn Up to 6.0 CE Hours. See page 91.
Introduction: In 2014, 45 Indian Health Service (IHS)/Tribal
emergency departments serving American Indian and Alaskan
Native communities treated approximately 650,000 patients
of which, 185,000 (28%) were children and youth younger than
19 years. This study presents the results of the National Pediatric
Readiness Project (NPRP) assessment of the 45 IHS/Tribal
emergency departments.
Methods: Data were obtained from the 2013 NPRP national
assessment, which is a 55-question Web-based questionnaire
based on previously published 2009 national consensus
guidelines. The main measure of readiness is the weighted
pediatric readiness score (WPRS), with the highest score
being 100.
Results: The overall mean WPRS for all emergency
departments is 60.9. Of the IHS/Tribal emergency depart-
ments that had pediatric emergency care coordinators,
scores across all domains were higher than those of
emergency departments without pediatric emergency care
Juliana Sadovich is Nurse Consultant for EMSC, Indian Health Service, U.S.
Department of Health and Human Services, Rockville, MD.
Terry Adirim is Professor, Pediatrics and Emergency Medicine, Section of
Emergency Medicine, Department of Pediatrics, Drexel University College of
Medicine, Philadelphia, PA.
Russell Telford is Biostatistician II, National EMS for Children Data Analysis
Resource Center, University of Utah, Salt Lake City, UT.
Lenora M. Olson is Principle Investigator, National EMS for Children Data
Analysis Resource Center, University of Utah, Salt Lake City, UT.
Marianne Gausche-Hill is Director of Emergency Medical Services,
Department of Emergency Medicine and Pediatrics, Harbor-UCLA Medical
Center, Torrance, CA.
Elizabeth A. Edgerton is Director, Division of Child, Adolescent, and
Family Health, Maternal and Child Health Bureau, Health Resources and
Services Administration, U.S. Department of Health and Human Services,
Rockville, MD.
January 2017 VOLUME 43 ISSUE 1
coordinators. All 45 emergency departments have readily
available a pediatric medication dosing chart, length-based
tape, medical software, or other system to ensure proper
sizing of resuscitation equipment and proper dosing of
medication. Of the 45 IHS/Tribal 37% report having 100% of
the equipment items, and 78% report having at least 80% of
these items.
Discussion: This article reports the results of the NPRP
assessment in IHS/Tribal emergency departments that, despite
serving a historically vulnerable population, scored favorably
when compared with national data. The survey identied areas
for improvement, including implementation of QI processes,
stocking of pediatric specic equipment, implementation of
policies and procedures on interfacility transport, and
maintaining staff pediatric competencies.
Key words: Pediatric readiness; Pediatric emergency care;
Quality improvement; American Indian/Alaskan Native
The National Pediatric Readiness Project is supported by grant
U03MC00008 for Emergency Medical Service (EMS) for Children network
development and by grant U07MC09174 for EMS for Children National
Resource Center from the Health Resources and Services Administration
(HRSA) of the US Department of Health and Human Services (HHS).
This information or content and conclusions are those of the authors and should not
be construed as the ofcial position or policy of, nor should any endorsements be
inferred by, HRSA, the Indian Health Service, the HHS, or the US government.
For correspondence, write: Juliana Sadovich, PhD, RN, Department of
Health and Human Services, Indian Health Service, 801 Thompson Ave,
Rockville, MD 20154; E-mail: Julie.sadovich@gmail.com.
J Emerg Nurs 2017;43:49-56.
Available online 31 October 2015
0099-1767
Copyright 2017 Emergency Nurses Association. Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.jen.2015.09.004
WWW.JENONLINE.ORG 49
RESEARCH/Sadovich et al
F
orty-ve Indian Health Service (IHS)/Tribal emer-
gency departments serve American Indian and
Alaskan Native communities in 11 states throughout
the United States. Wide variation exists in the structure,
sites, and capabilities of the 45 emergency departments. For
example, 2 of the IHS/Tribal emergency departments are
stand-alone emergency departments in health centers with
no inpatient services, and 5 are within hospitals designated
critical access hospitals. Eight of the hospitals emergency
departments are designated trauma centers, with 6
designated as level IV, one designated as level III, and one
designated as level II. No dedicated pediatric emergency
departments exist within the IHS/Tribal health care system.
Furthermore, within the IHS/Tribal system, unintentional
injuries are the leading cause of morbidity and mortality in
the pediatric age group. The leading causes of hospitaliza-
1
tions include respiratory diseases, injuries, and poisonings.
Although investigators have reported on pediatric
readiness in emergency departments in general, little
information has been published regarding the emergency
care of American Indian and Alaska Native children in
Tribal areas. 2 However, information has been published
regarding pediatric readiness in emergency departments in
general. In 2006 the Institute of Medicine released a
3-volume report on emergency care in the US, including
Emergency Care for Children: Growing Pains. 3 This
report noted the many issues in providing emergency care to
children and elucidated challenges to readiness of general
emergency departments to care for children. 3 Gausche-Hill
et al 4 examined the readiness of emergency departments to
provide care for children and found that issues cited as
barriers to preparedness of care for children include the lack
of available pediatric-specic equipment, lack of imple-
mentation of published guidelines for care of children, and
lack of pediatric experience and training of nurses and
physicians. In 2009, Cichon et al 5 identied similar issues
relating to the implementation of a statewide program to
improve ED readiness for pediatric care. A 2009 study from
the United Kingdom echoed the previous reports on ED
care of children. This study by Prentiss and Vinci 6 stated
that The minimal requirements as outlined in these
documents of pre-hospital care services and in-hospital
needs, such as stafng, medication, equipment and supply
requisites, must be met by any system that cares at any time
for children in order to effectively evaluate, stabilize and,
when necessary, transfer acutely ill children.
In 2001, the American Academy of Pediatrics (AAP)
and the American College of Emergency Physicians (ACEP)
developed the rst joint guidelines on care for children in
the emergency department to address gaps in readiness to
care for children in general emergency departments. In
50 JOURNAL OF EMERGENCY NURSING
2009, ENA and the federal Emergency Medical Services for
Children program joined with AAP and ACEP to update
the guidelines and established the National Pediatric
Readiness Project (NPRP). Emergency nurses have had a
key role in the execution of this project as co-investigators
and as participants in the project, representing their
emergency departments. The purpose of the NPRP is
3-fold: (1) to establish a composite baseline of the nations
capacity to provide care to children in the emergency
department, (2) to create a foundation for emergency
departments to engage in an ongoing quality improvement
(QI) process that includes implementing the Guidelines for
the Care of Children in the Emergency Department (2009
national guidelines), and (3) to establish a benchmark that
measures an emergency departments improvement over
time. 7,8 The rst phase of this initiative was completed in
2013. In 2015, Gausche-Hill et al 7 published a report on
the results of the NPRP assessment, nding general
improvement in readiness for pediatric care in emergency
departments. To date, readiness of emergency departments
within the IHS/Tribal health care system has not been
specically evaluated. This study presents the results of the
NPRP assessment of the 45 IHS/Tribal emergency
departments that serve a vulnerable population in largely
rural geographic areas.
Methods
Data were obtained from the 2013 NPRP national
assessment, for which the detailed implementation methods
have been previously described. 7 Briey, the NPRP
assessment is a 55-question Web-based questionnaire
(pediatricreadiness.org) based on the 2009 national guide-
lines, a joint consensus-based policy statement by AAP,
ACEP, and ENA. 7 The assessment was completed online
via a Web page link that was sent by E-mail to each of the
ED nurse managers. The assessment addresses the coordi-
nation of pediatric patient care, including physician/nurse
stafng and training, QI activities, patient safety initiatives,
policies and procedures, and availability of pediatric
equipment. Data regarding hospital demographics, includ-
ing ED conguration and annual overall and pediatric
patient volume, were also collected, and rural and urban
location was designated using geocoding. 9 The main
measure of readiness is the weighted pediatric readiness
score (WPRS). The WPRS was based on the results of an
expert panel modied Delphi process that resulted in 24 of
the 55 questions being weighted to generate a score that was
normalized to a 100-point scale. 7
VOLUME 43 ISSUE 1 January 2017

TABLE 1
Indian Health Service hospital weighted pediatric readiness score and location by pediatric patient volume
Pediatric patient volume category
Low
(N = 11)
Average WPRS 58.2
Hospital geographic location
Urban/suburban (%) 3 (27.3)
Rural/remote (%) 8 (72.7)
WPRS, Weighted pediatric readiness score.
Summary statistics were calculated to detect differences
between IHS/Tribal health ED WPRS scores and overall
national ED WPRS scores. Responses to survey questions
were summarized using frequencies and percentages. WPRS
scores were compared using the Wilcoxon Rank Sum Test.
Statistical analyses were conducted using SAS software,
version 9.4 (Cary, NC).
Results
The IHS/Tribal health care system response rate for the NPRP
assessment was 100% (n = 45). Approximately 80% of the
emergency departments identied the upper age limit for
pediatrics as 17 or 18 years old. The majority of the emergency
departments are congured as general emergency departments
with adult and pediatric patients treated in the same area, and
more than half (62%) are located in rural or remote areas.
Pediatric patient volume varied: 24% (n = 11) are
considered low volume (annual pediatric volume b 1800);
49% (n = 22) are considered medium volume (annual
pediatric volume 1800-4999); and 27% (n = 12) are
considered medium/medium-high volume (annual pediatric
volume 5000-9999). Most of the emergency departments
(80%) admit children from the emergency department to
their adult inpatient services. The overall mean WPRS for all
emergency departments is 60.9, and the mean WPRS scores
according to patient volume are 58.2 for the low-volume
emergency departments, 60.9 for the medium-volume
emergency departments, and 63.4 for the medium-high and
high-volume emergency departments (see Table 1).
IHS/TRIBAL RESULTS BY ASSESSMENT DOMAIN
The NPRP assessment is organized by the 6 domains identied
in the AAP-ACEP national guidelines. The results for the IHS/
Tribal emergency departments by domain are as follows.
January 2017 VOLUME 43 ISSUE 1
Sadovich et al/RESEARCH
Medium Medium high/high Overall
(N = 22) (N = 12) (N = 45)
60.9 63.4 60.9
8 (36.4) 6 (50.0) 17 (37.8)
14 (63.6) 6 (50.0) 28 (62.2)
Pediatric Emergency Care Coordinator
The rst domain focuses on the nurse and physician pediatric
emergency care coordinator (PECC). The PECC is a nurse or
physician who is identied as having the responsibility of
facilitating and promoting activities to improve emergency
care of pediatric patients in the emergency department, across
the hospital, and within the community. 8 Almost half (42%;
n = 19) reported having a nurse coordinator, and less than a
quarter (22%; n = 10) reported having a physician
coordinator. Most hospitals responded that they had a
written job description for the PECC. Table 2 shows that
emergency departments with a nurse or physician PECC had
higher WPRS scores for each of the 6 domains compared with
emergency departments without a PECC.
Clinical Competency
Thirteen (29%) of the emergency departments require
specic competency evaluations of physicians, and 67%
require specic competency evaluations for nurses stafng
the emergency departments. These ndings are similar to
the national NPRP, which showed that emergency
departments require specic nurse competency evaluations
more often than they require physician competency
evaluations. With regard to pediatric-specic continuing
education, Pediatric Advanced Life Support certication is
required in 86%, 93%, and 78% of the emergency
departments for physicians, nurses, and mid-level practi-
tioners, respectively. Only 33% require ED nurses to
maintain Basic Pediatric Life Support certication, and
31% require nurses to complete the Emergency Nursing
Pediatric Course.
Quality Improvement/Performance Improvement
Fourteen (31%) of the emergency departments report
having a pediatric patient care review process, with 10
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RESEARCH/Sadovich et al
TABLE 2
Average points earned per domain by pediatric emergency care coordinator presence
Domain
No coordinator
(N = 24)
Administration and coordination (19 points) 0.0
Physicians, nurses, and other ED staff (10 points) 4.2
QI/PI in the emergency department (7 points) 1.8
Pediatric patient safety (14 points) 9.2
Policies, procedures, and protocols (17 points) 8.5
Equipment, supplies, and medications (33 points) 28.3
PECC, Pediatric emergency care coordinator; QI/PI, quality improvement/performance improvement.
of these emergency departments (71%) reporting that
they collect and analyze pediatric emergency care data
and 5 (36%) having quality indicators for children in
their QI/performance improvement (PI) plan. A comparison
of IHS/Tribal ED and national ED WPRS scores for
QI/PI found similarly low scores regardless of volume
or location.
Patient Safety
A majority of the emergency departments (64%; n = 29)
report obtaining pediatric patient weights in kilograms;
however, 9 of the 29 emergency departments do not
document the weights in kilograms in the medical record.
All of the 45 emergency departments (100%) report
having pulse oximetry monitoring available and all record
temperature, heart rate, and respiratory rate for children.
Twenty-six of the 45 emergency departments (58%)
report having written procedures for notifying the
physician of abnormal vital signs for pediatric patients.
With regard to other safety indicators, 30 emergency
departments (67%) report having a process for the use
of precalculated drug dosing, and 28 (62%) report having
24 hours a day/7 days a week interpreter services available
in the emergency department.
Policies, Procedures and Protocols
More than 50% of the IHS/Tribal emergency departments
report having the policy in place for 6 of the 9 policies
addressed in the NPRP assessment. The top 3 policies most
frequently reported as adopted by emergency departments
include child maltreatment, care for children with social and
52 JOURNAL OF EMERGENCY NURSING
PECC presence P value
At least one coordinator
(N = 21)
13.1
5.5 .225
2.1 .720
10.2 .202
9.8 .311
30.4 .024
mental health issues, and pediatric patient assessment and
reassessment. The 3 policies least likely to be reported as
adopted were the death of a child in the emergency
department, reduced dose radiation for imaging, and
hospital disaster plans specically addressing pediatrics.
Regarding interfacility transfers, 24 (53%) reported having
executed interfacility transfer agreements with other
hospitals, and 30 (67%) reported having interfacility
transfer guidelines. A majority of the 30 emergency
departments with written interfacility transfer agreements
also met each of the 8 requirements for interfacility transfer
agreements according to the AAP-ACEP national guide-
lines. The interfacility transfer guidelines element most
often lacking was providing directions to the family (see
the Figure).
Equipment, Supplies, and Medication
All 45 emergency departments have readily available a
pediatric medication dosing chart, length-based tape, medical
software, or another system to ensure proper sizing of
resuscitation equipment and proper dosing of medication. All
emergency departments require all of their staff to be trained
regarding the location of pediatric equipment and medica-
tions. Thirty-six (80%) reported that they have a daily
method to verify the proper location and function of pediatric
equipment and supplies. With regard to the 54 required
equipment items, 37% of the emergency departments report
having 100% of the equipment items, and 78% of the
emergency departments report having at least 80% of the
equipment items. Table 3 identies the 11 most frequently
missing equipment items reported by the IHS/Tribal and
national emergency departments.
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 Sadovich et al/RESEARCH

FIGURE
Interfacility transfer guidelines and agreements for Indian Health Service/Tribal emergency departments by location.

IHS/TRIBAL ED WPRS SCORES COMPARED WITH than do the rural/remote emergency departments in 4 of the
RURAL/REMOTE AREA ED WPRS SCORES 6 domains. The rural/remote emergency departments have
higher mean domain WPRS scores in the QI/PI and policies,
Within the 6 domains, we compared the 17 urban/suburban procedures, and protocols domains. Generally the urban/
emergency departments with the 28 rural/remote emergency suburban and rural/remote WPRS scores by volume follow
departments. The results show that the urban/suburban the same pattern. However, the rural/remote low-volume
emergency departments have higher mean WPRS scores IHS/Tribal emergency departments had a higher mean

TABLE 3
Comparison of equipment items most commonly identied as not available in the emergency department a
Equipment item National IHS/Tribal % not available
% not available
Central venous catheters (any 2 sizes in range, 4F-7F) 37 56
Laryngeal mask airways (size 1) 43 31
Laryngeal mask airways (size 1.5) 45 38
Laryngeal mask airways (size 2) 39 27
Laryngeal mask airways (size 2.5) 42 33
Laryngeal mask airways (size 3) 34 29
Supplies/kit for pediatric patients with difcult airways 24 42
Tracheostomy tubes (3.0 mm) 32 56
Tracheostomy tubes (3.5 mm) 32 53
Tracheostomy tubes (4.0 mm) 25 44
Umbilical vein catheters (3.5F or 5.0F) 38 44
a
Items reported as not available by more than 20% of emergency departments. One additional item (laryngoscope blades: straight, size 00) was reported as not available by more than 20% of national
emergency departments.

January 2017 VOLUME 43 ISSUE 1 WWW.JENONLINE.ORG 53

RESEARCH/Sadovich et al
WPRS score than did urban/suburban low-volume emer-
gency departments in the administration and coordination
category. This pattern is also seen in a comparison of
national low-volume emergency departments with national
urban/suburban and rural/remote emergency departments.
In a comparison of national and IHS/Tribal WPRS
scores by location, the IHS/Tribal rural/remote ED mean
domain WPRS scores exceed the national rural/remote
ED domain WPRS scores in 4 of the 6 categories. These
domains include physicians, nurses, and other ED staff;
QI/PI in the emergency department; policies, procedures,
and protocols; and equipment, supplies, and medication.
However, the urban/suburban IHS/Tribal ED domain
WPRS scores are lower than national urban/suburban ED
scores in each of the 6 domains.
Discussion
Our ndings within the IHS/Tribal emergency care system
are similar to the overall national ndings. For example, we
found that not all general emergency departments have all
the equipment, policies and process, and pediatric patient
care review processes that are important to provide quality
pediatric emergency care. These similarities suggest that the
ndings of these study are generalizable to other emergency
departments and may provide insight for emergency nurses
engaging with emergency departments of varying size and
pediatric volumes. Although this article reports the results of
the NPRP assessment in emergency departments that serve
a specic and historically vulnerable population, American
Indians and Alaska Natives, the results can be useful to
emergency nurses in similar rural and low pediatric volume
institutions. Even though the sample of emergency
departments is small compared with the total number of
emergency departments within the NPRP assessment, it
represents all of the IHS/Tribal emergency departments and
therefore captures an entire health system. Furthermore,
there is a paucity of information for emergency nurses
regarding indicators of quality for pediatric emergency care.
The NPRP assessment identied several issues that
merit further study. One of these issues includes the
equipment domain. The most common 11 equipment
items reported as missing were the same for IHS/Tribal
and national emergency departments. It is not clear why
many emergency departments do not carry these 11 pieces
of equipment. This result may suggest that from a clinical
perspective, there are other equipment options to treat
patient conditions that providers may use more often and
may be more comfortable in using. Alternatively, these
emergency departments may not treat enough children with
54 JOURNAL OF EMERGENCY NURSING
conditions where this equipment would be necessary.
Further, emergency departments may not stock this
equipment because of the expense. These results suggest
that the 2009 national guidelines should be re-evaluated to
determine why these 11 equipment items are not stocked
and further whether these items are really required for every
emergency department regardless of size or volume.
Moreover, the ndings may lead emergency nurses to
champion the development of alternatives in the guidelines,
such as recommending that if there are children and youth
with special health care needs in the catchment areas of an
emergency department, the hospital can and should develop
policies and procedures with regard to the stocking of
required equipment for treating these children and provide
better coordination with these childrens health care
providers to ensure that these children are cared for in
institutions that can meet their needs. 10,11
The emergency departments with a PECC score higher
in each of the domains compared with emergency
departments that do not have a PECC. This study supports
the nding of Gausche-Hills 2007 and 2015 studies
demonstrating that emergency departments with PECCs
were better prepared to care for pediatric patients and
supports the recommendations by the Institute of Medicine
in their 2006 report The Future of Emergency Care in the
United States Health System. 4,7,9 Interestingly, both the
low-volume rural/remote IHS/Tribal and national emer-
gency departments had higher WPRS scores than did the
urban/suburban low-volume emergency departments in the
administration and coordination domain. It is possible that
there may be a greater likelihood of identifying specic staff
to champion pediatric issues in rural hospitals. These
ndings suggest areas for future emergency nursing research
to examine system designs to promote quality pediatric
emergency care in low-volume hospitals, such as the role of
pediatric nursing care coordinators in improving pediatric
patient outcomes in the emergency department.
Another area for closer examination includes QI/PI. The
IHS/Tribal ED and national ED overall WPRS scores for QI/
PI, regardless of volume and location, were low. Only national
emergency departments with medium high/high volume and
in urban/suburban areas had a WPRS score above 50% of the
total points for QI/PI. The lack of pediatric care review
processes and pediatric-specic indicators for QI could be an
area for improvement for all emergency departments. Next
steps for the NPRP should be a focus on improving the
implementation of QI/PI processes to ensure high-quality
and safe pediatric emergency care. 1214
Emergency departments that cannot provide denitive
care for children should make provision for ensuring the
transfer of these children to institutions that can provide
VOLUME 43 ISSUE 1 January 2017

appropriate care. In fact, the literature suggests that
emergency departments could improve timeliness and
coordination of transfers by instituting interfacility transfer
agreements and guidelines. 15 It is interesting that the results
demonstrate that some emergency departments with
transfer guidelines reported that they did not have transfer
agreements, which may indicate that in some geographic
areas only one transfer location is available, medical centers
have been identied that always accept transfers, or
emergency departments exist within hospital systems. Also
of interest was the reporting of the lack of communication
with families, including the communication of the
directions to the receiving institution and other information
about the transfer. Emergency nursing has been a leader in
this era of family-centered care in the emergency depart-
ment. This study highlights the importance of emergency
nurses leading efforts to ensure implementation of inter-
facility transfer policies and procedures that are consistent
with family-centered care delivery to improve patient
outcomes and family satisfaction.
LIMITATIONS
The main limitation of this study includes the nature of the
assessment. The assessment is a self-reported tool with no
on-site verication of results. Also, the assessment is based on
guidelines that were derived by expert consensus and not by
determining the linkages between the recommendations and
outcomes. Further, the WPRS scoring system was also based
on expert consensus and has not been linked to outcomes.
IMPLICATIONS FOR EMERGENCY NURSES
The results of this study present emergency nurses with
specic issues in which to advocate to ensure that their
emergency departments can provide quality emergency care
to children. Moreover, this study underscores the need for
emergency nurses to ensure that their emergency depart-
ments have appropriate equipment and written policies and
that they lead patient safety and PI initiatives. Also,
emergency nurses have a role in advancing evidence-based
practice by engaging in research to determine which
elements of the NPRP, including the national guidelines,
improve outcomes of children treated in the emergency
care system.
Conclusion
Despite the limitations of the study, the NPRP assessment
provides a snapshot of ED readiness for pediatric emergency
care for IHS/Tribal emergency departments. Perhaps the
January 2017 VOLUME 43 ISSUE 1
Sadovich et al/RESEARCH
most important results of this study are the identication of
system issues that have the potential to result in less than
optimal pediatric patient outcomes, such as a lack of QI
programs. Even though the IHS/Tribal health care systems
emergency departments are typically small general emer-
gency departments in rural and austere areas, the data
demonstrate that the pediatric readiness of IHS/Tribal
emergency departments is at least on par with that of
national emergency departments. IHS/Tribal emergency
departments play an important role in access to care for
children and families of underserved and vulnerable
populations living in rural and remote locations. This
assessment is unique in that it captured an entire health care
system and highlights areas that warrant further research
while providing a starting point to begin QI initiatives.
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