TEXAS EMS FOR CHILDREN STATE PARTNERSHIP

Voluntary Pediatric Readiness Program for Emergency Departments

IMPLEMENTATION PLAN

Table of Contents

1 Introduction

1.1 Purpose1.2 Program Overview1.3 Program Description1.4 Justification for Texas

2. Program Implementation

2.1 Background on Implementation Activities2.2 Implementation Costs2.3 Annual Costs to Maintain the Program2.4 Creation of a Non-Profit Organization2.5 General Costs to Hospital2.6 Implementation Schedule

3.0 Implementation Schedule and Process

4.0 Performance Monitoring

5.0 Pilot Process and Facility Selection

6.0 Periodic Program Review

7.0 Appeals Process

APPENDIX A: Project Implementation Plan Approval

APPENDIX B: Application Forms

APPENDIX C: Pediatric Readiness Assessment Data from 2013

APPENDIX D: Minimum Data Set

DEFINITIONS

1 Introduction

1.1 Purpose

The purpose of this implementation plan is to provide an updated description of the Texas Voluntary Pediatric Readiness Program (VPRP) and to define the systematic steps and processes that are required to implement a VPRP for emergency departments/divisions (ED) in the State of Texas.

1.2 Program Overview

The VPRP will prepare EDs to provide higher quality care for infants, children, and adolescents for the evaluation, treatment, and/or stabilization of children with medical and traumatic emergencies. One of the primary goals of pediatric readiness programs for EDs is to bolster pediatric readiness within communities and critical access hospitals such that children and families can benefit from the availability of at least one ED in their own community that is equipped to stabilize and/or manage common emergencies for children.

1.3 Program Description

On a national level in 2005, the federally-funded EMS for Children (EMSC) program established performance measures to assure the existence of a standardized statewide, territorial, or regional system that acknowledges hospitals capable of stabilizing and/or managing pediatric medical emergencies and traumatic injuries. The goal previously set by EMSC was for each state/territory to have a system in place by 2017.

Similar to trauma center designation, a pediatric readiness program aids facilities in self-identifying areas in which they can optimize care. Unlike trauma center designation, however, the purpose of the VPRP is NOT to differentiate EDs based on the level of care they can provide for children. Rather, the purpose is to promote basic readiness for ALL EDs to be able to provide initial stabilization of children with emergency conditions given that nationally, 30% of ED patients are children. Additionally, greater than 90% of children are seen in general EDs when they have an emergency, not at a children’s hospital. The intent of the VPRP is to equip all EDs with the ability to safely treat and manage children in their own communities when appropriate, not to bypass these facilities.

At its core, pediatric readiness provides the foundation to ensure high quality pediatric emergency care. Successful pediatric readiness programs share many common traits:

Enhance awareness of pediatric emergency care gaps Recognize hospital and EMS infrastructures within the state Establish and maintain strong partnerships between hospitals and EMS

agencies

Define minimum criteria to promote pediatric readiness in the following areas:o Staff qualificationso Quality improvemento Policies/procedureso Continuing educationo Equipment/supplies

Adaptable to refine the process on an ongoing basis

1.4 Justification for Texas

In 2013, 305 of 504 hospitals in Texas participated in the National Pediatric Readiness Project (NPRP) assessment. These 305 hospitals cumulatively treat 1,572,835 children annually in their EDs. Of these children, 799,959 (51%) were treated in a pediatric ED in either a children’s hospital or general hospital ED, while the remainder were treated in general EDs without a separate area for pediatric patients. In addition, 75% of these hospitals have the capability to admit a child to an inpatient unit, while 38% have a Neonatal Intensive Care Unit (NICU), and 9% have a pediatric intensive care unit (PICU). While not every hospital may have a pediatric ED or the capability to admit a child, every ED must be equipped for the basic evaluation, management, and/or stabilization of a child with an emergency.

Based on NPRP data from Texas, it is clear that variability exists among EDs in their ability to provide basic care to children. This variability does not necessarily correlate with geography or annual pediatric ED volume. There are some EDs with low pediatric volumes that scored high on the NPRP assessment, while there are some EDs that see more children that scored lower. Also, there are some rural EDs that scored higher on the NPRP assessment than urban EDs.

Some feedback that has been provided to the EMSC State Partnership from some EDs that see a low volume of children is that it is not necessary to invest the resources required to have the components assessed by the NPRP, since these children can be transferred to other EDs that are more equipped, such as children’s hospitals. Though children’s hospitals play a vital role in providing a higher level of care to children when medically necessary, the unnecessary transfer of children to children’s hospitals, which are often located in urban areas, has negative consequences for patients, families, and local hospitals. If not covered by insurance, families must pay for the cost of the inter-facility transport. Also, being far from home can create social hardships for families by interfering with the ability for caregivers to go to work or safely return home after being discharged. Over time, such practices may also weaken the abilities of community EDs to be prepared to stabilize critically ill and/or injured children. Thus, critical access and/or community EDs may glean the greatest benefit from participating in a VPRP.

Texas Summary: In Texas, there are 504 emergency departments (EDs) that met the inclusion criteria for the pediatric readiness assessment (see Appendix C). Of the 504 EDs, 305 responded to the assessment, which is 60.5% of all EDs in the state. On a national level, Texas represents 7% of the national data. Overall, Texas performed similar to other states. Data shown in Appendix C are also summarized below.

Overall Readiness Scores: As the pediatric volume of an ED increases, its average pediatric readiness score is also higher.

Texas Emergency Department Demographics: Only 7% of the hospitals in Texas have a pediatric ED. In Texas, most EDs are general EDs. Only 4% of EDs are based in children’s hospitals whereas another 3% of EDs have a separate pediatric section in a general hospital ED.

Every ED should be equipped to care for children at a basic level. When children require a higher level of care, it is helpful for EMS agencies and other hospitals to know the capabilities of other facilities, so that transfers to the appropriate facility can occur. In the event of a disaster or mass casualty incident, it is also important for hospitals and EMS agencies to know the EDs in their area that have the resources available to meet the needs of children.

Texas Emergency Department Age Cut-Off: Most hospitals in Texas use an age cut-off of 17-18 years to distinguish between a child and adult, both for medical and traumatic conditions. This varies from region to region and between hospitals within a region. For the purposes of the VPRP, the intent is to focus on ages 0-17 years, since this is the age range used by most hospitals to define a “pediatric” patient. The American College of Surgeons Committee on Trauma defines a child as under 15 years old.

Texas Pediatric Inpatient Capabilities: Of the hospitals in Texas, 36% have an inpatient unit, and 28% have a Neonatal Intensive Care Unit (NICU); only 9% of hospitals in Texas have a Pediatric Intensive Care Unit (PICU). Though inpatient pediatric services are not available in all hospitals in Texas, every ED must be equipped to stabilize children and be able to identify the hospitals that can provide a higher level of care, if required.

Presence of a Physician or Nurse Coordinator in the Emergency Department: Another factor that was assessed from each ED was the presence of a nurse or physician coordinator to focus on pediatric emergency care. Having at least one pediatric emergency care coordinator (PECC) ensures that someone is tasked with identifying and meeting the needs of children in the ED. The PECC may be a full or part-time position and it may be part of the job description of an existing ED role, such as a trauma coordinator, ED director, or a quality improvement coordinator, to name a few examples. The PECC can focus on some or all of the following: ongoing education and skills competencies in pediatric ED care, ensuring that policies and procedures are in place for children, creating a quality improvement plan for pediatric patients, ensuring that appropriate medications and supplies are stocked, and that pediatric care is included in staff orientation. National data from the NPRP shows that having a PECC is associated with having a higher pediatric readiness score

Physician Staffing: Physician staffing was also assessed. Emergency medicine (EM) and pediatric emergency medicine (PEM) training equips physicians to care for children in emergencies. General pediatrics and family medicine training may do this

as well, if the skills are maintained. Specific training in handling pediatric emergencies is often lacking for other specialties.

Physician Board Certification: In Texas, 36% of hospital emergency departments have all of their physicians board-certified in either emergency medicine or pediatric emergency medicine. Of the EDs in Texas, 16% require neither board certification in EM or PEM for the entire medical staff.

Pediatric Patient Care Review Process: In Texas, 47% of EDs have a pediatric patient care review process in place. Having a patient care review process is also essential to identify system issues that may impact safety and quality of care.

Weighing and Recording in Kilograms: In Texas EDs, only 51% of pediatric patients have their weight both measured and recorded in kilograms. Weighing a pediatric patient in kilograms is important to ensure pediatric patient safety with respect to medication dosing. Since pediatric medication doses are calculated based on weight in kilograms, this is one of the most important areas for improvement in pediatric care.

Hospital Pediatric Disaster Plan: Only 41% of the hospitals in Texas include pediatrics in their disaster planning process. On a regional level, there is a variation in the presence of a disaster plan that addresses the needs of children. Planning for pediatric needs in disasters requires coordination between EMS and hospitals and it requires coordination between hospitals. This can often be overlooked.

Equipment Availability: Greater than 90% of the emergency departments in Texas have the recommended pediatric equipment available. For a list of items that are present less than 90% of the time, please refer to Appendix C (C12 – Equipment Availability).

2. Program Implementation

2.1 Background on Implementation Activities

After preliminary research on pediatric facility readiness by EMSC program staff, the concept was initially presented to the Governor’s EMS and Trauma Advisory Council (GETAC) for endorsement. After receiving endorsement from the GETAC, the EMSC program embarked on a multi-phased program implementation process that included a series of steps and milestones. Stakeholder meetings and webinars were conducted where attendees from a diverse set of backgrounds and organizations throughout the state, engaged in meaningful and deliberate discussions on facility readiness. The first stakeholder meeting was held on September 26, 2016 in Austin where participants brainstormed on several issues and considerations that go into implementing a facility readiness program in the context of three domains:

Critical Factors for Success Potential Obstacles

Potential Solutions

These three domains were then horizontally evaluated across several categories that were felt to be critical and essential in implementing a successful program. The categories were:

Host Organization Communications Conflicts Networking Buy-In Funding Criteria/Tiers Surveyors Nonparticipation Implications Data Implementation

The results of the first stakeholders’ meeting along with the detailed information gleaned from the discussions were distributed to all attendees as well as other individuals who were part of the EMSC listserv who requested to receive periodic information/updates from the EMSC program.

The results of the first meeting provided a baseline understanding of the structure and framework of a successful facility readiness program. The meeting also helped stakeholders prepare for the second meeting that was scheduled for November 18, 2016 in Dallas. The main objective of the November meeting was to discuss and identify various stakeholders throughout the state that would serve the program well in terms of the implementation of, and the sustainability of a successful VPRP. Specifically, a “world café” format for discussion was utilized to illicit comments and input from attendees on potential stakeholders at different levels (e.g. Federal, National and local levels) and to discuss how these individual organizations and agencies would appropriately fit within one of four quadrants of the “Stakeholder’s Grid”. The stakeholder’s grid is a common tool used by many groups to identify stakeholders and determine their impact and importance to an intended goal or mission. The four specific categories that were used in the meeting were:

During the world café rounds, the participants were first divided into five groups and each group was instructed to provide input and identify potential stakeholders under each category. There were five stations with the following categories:

Regulatory Agencies State Level Organizations Advocacy Groups/Organizations Provider / Professional Organizations Two Hospital Systems/Administrations

Specific entities/organizations were identified and through brief discussions, the entities were assigned to one of four grid quadrants. The focus of the exercise was not only to gain a broad understanding of the stakeholder landscape vis-à-vis our readiness program but to also focus on those entities that were placed in the “High Power, Low Interest” category. The importance of knowing which entities are in the “High Power, Low Interest” category is to focus attention and efforts on garnering support from them in the hopes that their influence and leverage would strengthen the successful implementation of the program. Another important topic discussed was what structure of VPRP would be appropriate and effective for the State of Texas. The group discussed whether creating a single-tiered system or one that involved multiple tiers would best fit

the needs of our state. After much discussion, including conversations about what other states have done, the group unanimously decided on a multi-tiered system to ensure that smaller, very rural facilities are afforded the opportunity to meet the Pediatric Ready level of readiness and not be excluded from the program because of barriers and challenges germane to rural facilities (e.g. financial, logistics, resources, etc.). The meeting yielded valuable insight and recommendations that were subsequently shared with the participants after the meeting as well as those on the EMSC list serv.

In the subsequent weeks, an introductory webinar was conducted to present a comprehensive overview of the VPRP as well as updates from the previous stakeholder’s meetings. The webinar touched on relevant background information and key data and benchmarks such as the National Pediatric and Readiness Project (NPRP) and specific data from Texas that justified the need for a pediatric facility readiness program in our state. The webinar also intended to keep stakeholders informed and engaged in the program and attendees were provided with updates on recent developments that arose subsequent to the face-to-face stakeholders meeting. The participants also discussed next steps in terms of future meetings and/or webinars and milestones to achieve.

The third stakeholders meeting was held on May 8, 2017 in Austin where participants were asked to deliberate and provide specific suggestions on the multi-tiered VPRP. Specifically, the attendees where asked which items on the Guidelines for Care of Children in the Emergency Department should be included in the readiness program for Texas. Adopting work done by the EIIC Facility Recognition Program Multi-State Collaborative, a three-tiered system was adopted based on the following structure:

While the Texas VPRP adopted the EIIC framework for a multi-tiered program, the decision was made to rename each level from Minimal, Attainable with Support and Stretch Goals to “Pediatric Ready”, “Pediatric Champion” and “Pediatric Innovator” respectively.

Prior to the May 2017 meeting, the EMSC program office staff analyzed the results of the NPRP data for Texas and crosschecked scored items that were 86% and above with matching items on the Guidelines Checklist. For items that

scored 86% or better on the NPRP survey and had a corresponding match on the Guidelines Checklist, the decision was made to identify these items as meeting the “Pediatric Ready” level of readiness. The list was then provided to participants in advance of the stakeholder meeting for review and was approved by consensus during the actual meeting with minimal deliberation. The remaining items on the checklist were then presented to the participants to decide on which level each item should be placed (e.g. Champion or Innovator). Utilizing the SMS polling tool “Poll Everywhere”, the group was asked to vote on each item and the voting results were expressed in percentages of votes. Items that received 75% of votes for a particular level were then permanently assigned to that level. Every item that was voted on, exceeded the required 75% threshold and was assigned to a category. The final list was then formatted into a check list and through discussions with the EMSC program director, the agreed upon acceptable documentation(s) and/or meetings to demonstrate that the facility has met the requirements for readiness, were detailed and are included in the check list found in Appendix B.

2.2 Implementation Costs

Much of the program’s development and implementation costs have been covered by the Texas EMSC State Partnership Program and to date, those costs have been limited to EMSC staffs’ time coordinating stakeholder meetings and typical administrative and clerical work. Future program evaluation and administrative requirements, e.g. record keeping, reporting, etc. will continue to be administered through the Texas EMSC State Partnership Program In addition to the implementation costs. The following are the anticipated costs to maintain and administer the program:

a) Infrastructure:

Physical and/or virtual meeting(s) of the EMSC Advisory Committee along with EMSC leadership to oversee the management and coordination of the program as well as potential meetings with our state, national and federal government partners.

Develop databases for tracking hospital participation and application/survey/post-survey information collection (can be done internally or can be contracted out)

b) Criteria development

It is anticipated that during the implementation phase, changes may have to be made to the process/program as a result of facility feedback on the application process as well as issues with regards to requirements at each level of readiness. These modifications/changes will be received and evaluated by the EMSC Program staff in conjunction with the EMSC Advisory Committee.

c) Pilot phase:

The implementation phase will be separated into three staggered start dates with the “Pediatric Ready” readiness level process starting in 2018. The “Pediatric Champion” Level surveys will be implemented in 2019 followed by the “Pediatric Innovator” Level surveys in 2020. To mitigate the cost of surveying, the Pediatric “Ready” and “Champion” Level surveys will be conducted via teleconferencing using a mobile tablet device such as an iPad so that interviews can be conducted live and equipment can be visualized to confirm their presence. The rational for taking this innovative approach is to mitigate the high cost of sending a team of professionals to each facility throughout Texas. Interviews with staff can be easily conducted and visualization of required equipment can be done through the use of an iPad. The equipment (iPad) will be shipped to a receiving hospital along with accessories and instructions on how to connect with the survey team well in advance of the survey. Requisite software/applications will be pre-loaded to the iPad for easy and convenient use by facility staff. Once the survey is completed, the iPad will come with a prepaid stamped package so the equipment can be returned to the EMSC office. This method of surveying will only be available for the first two levels: Ready and Champion. The equipment and shipping container can then be reused for the next scheduled survey. The facilities will be asked to acknowledge that by accepting the equipment, that they will be responsible for any loss and/or damage in accordance with Baylor College of Medicine policy. The initial costs (approximate) of this method of surveying are detailed below:

This gradual implementation of the survey process will also allow time for the EMSC program to find ways to help hospitals defray the cost of on-site surveys for those facilities seeking Pediatric Innovator readiness level.

During the Pediatric Ready level surveys, facilities will also be provided with the criteria/check list of the Pediatric Champion and Innovator Level requirements so they are aware of them and can consider preparations to move on to the next level of readiness. The aim is for a majority of hospitals to achieve the highest appropriate level of readiness for their facility.

Lastly, we will solicit the help of Public Health students, medical students and residents to assist in the review of records submitted by facilities to help adjudicate applications.

d) Surveyors

To conduct the virtual and/or on-site surveys, a panel of surveyors will be put together and we plan on soliciting organizations like the Texas College of Emergency Physicians (TCEP) and the Emergency Nurses Association (ENA) for volunteers or suggestions. The general composition of each survey team shall consist of a) Pediatric Emergency Medicine (PEM) Physician or Fellow or Emergency Medicine trained provider. b) Registered Nurse (RN) with pediatric experience or RN with Certified Pediatric Emergency Nurse (CPEN) credentials and c) individual with hospital administration experience. We will actively solicit the assistance of the Children’s Hospital Association of Texas (CHAT) to recommend individuals with hospital administration experience as well. The EMSC Program Manager will actively participate in every survey, whenever possible and will act as the overall coordinator and resource person. The EMSC program will also ensure that surveyors will not survey a facility or system affiliated facility if he/she works or lives within a 150-mile radius of the facility being surveyed to prevent any possibility of bias or conflict of interest. For on-site surveys, the approximate costs of each visit involving a minimum of two individuals are described below:

Cost Description Cost Units TotalAirfare (RT) 450.00$ 2 900.00$ Lodging (two nights) 250.00$ 2 500.00$ Ground Transportation (Taxi, Ride share) 75.00$ 2 150.00$ Meals (standard $55.00/day) 110.00$ 2 220.00$ Honorarium 500.00$ 2 1,000.00$

2,770.00$ Grand Total:

e) Community Outreach and Education:

Build buy-in from hospitals, e.g., conduct "town hall" meetings to build awareness, clarify misconceptions and answer questions (EMS for Children staff/dedicated committee time/effort; travel expenses)

Conduct regional/hospital educational sessions to encourage participation (EMS for Children staff time/effort; travel expenses; printing expenses)

Cost Description Cost Units TotalTransportation (Airfare/Mileage) 250.00$ 3 750.00$ Lodging (one night) 250.00$ 3 750.00$ Meals (standard $55.00/day) 110.00$ 3 330.00$ Printing Expense 150.00$ 3 450.00$

2,280.00$ Grand Total:

2.3 Annual Cost to Maintain the Program

1. Staff salaries (including benefits)/ time/effort to develop resources to help participating hospitals meet facility readiness requirements and ensure

consistency (e.g., educational modules, continuing education tracking software, etc.).

2. Travel reimbursement (EMSC staff to attend meetings around the state). 3. Committee meetings related to facility readiness issues (EMSC and

committee member’s time/effort; meeting preparation, meeting coordination/correspondence, post-meeting tasks, printing expenses).

4. Staff continuing education reimbursement (variable).5. EMSC Staff/Site surveyor’s time/effort to schedule, coordinate and conduct

facility readiness site surveys (re-surveyed on a routine cycle e.g., every 3 years; including honorarium and travel expenses).

6. Equipment/supplies (printing, computers, software, purchasing other publically available resources for distribution).

8) Database maintenance (EMSC staff time/effort; cloud based data warehousing, Application Service Provider (ASP subscription), etc.)

2.4 Creation of a Non-Profit Foundation

We have initiated the discussion of possibly creating a Non-Profit Foundation for the primary goal of raising funds that can be used towards defraying the cost of on-site surveys for qualifying rural facilities. The foundation can also support other related activity of the VPRP program like training, etc. We have also discussed the possibility of searching for an existing non-profit organization in Texas that would be interested in bringing the EMSC VPRP program under their organization to accomplish the same goals.

2.5 General Costs to Hospital

Depending on the readiness level, there will essentially be two survey options for hospitals to choose from in order to participate in the VPRP program: a) virtual/paper survey and b) on-site and as described in Section 2.2(c and d). Some additional considerations are:

a) Time/labor costs of possibly more than one ED and administration staff member to coordinate the survey with the EMSC program.

b) QI Multidisciplinary committee - each hospital will probably require a committee/process to discuss ED pediatric QI issues which require staff time and commitment. Some hospitals meet monthly, some meet quarterly however, there is no mandated number of meetings per year.

c) Equipment/supply costs (cost varies by hospital based on their level of readiness prior to being a pediatric ready facility).

d) Required certifications – depending upon the readiness level, this ranges from all staff being required to have specialized certifications/competencies, to only one staff member on duty.

e) Pediatric-specific continuing education (some hospitals cover this cost, others do not reimburse for CE).

3.0 Implementation Schedule and Process

General steps of the survey and acknowledgement process:

In-Person Survey and verification of ALL items on check list (Ready, Champion and

Innovator)

Division or Department of Emergency Medicine

Participate

Do Not Want to Participate

Pediatric Ready and Champion

Pre-Survey Submission of required documents and

scheduled survey via video conference

Pediatric Innovator

Certificate of Pediatric Readiness

Certificate of Pediatric Readiness

Below is the proposed implementation schedule for “Pediatric Ready” Level of readiness:

DATE ACTIVITY28-Feb-18 Applications are due.30-Apr-18 Complete Review of all applications23-May-18 Announce Pediatric Ready Facilities on EMSC Day

The proposed schedule of implementation for the Pediatric Champion and Innovator Level of readiness will be provided in a separate document.

To encourage hospitals throughout Texas to participate in the VPRP program, several recruitment strategies were proposed during the Aug 2017 meeting EMSC Advisory Committee meeting. Some of the suggestions are presented below:

Offer free PALS training/ ENPC courses for facilities that are interested in program.

Online QI modules and QI teaching for institutions to start CQI programs. Tell hospitals where they rank in terms of QI/ competencies, etc. Data will

need to be de-identified. Possibility of sharing policies and clinical practice guidelines between

facilities. Helping obtain missing equipment through bulk purchasing/cooperative

agreements. Certificate or Plaque. Opportunities for facilities to request assistance in closing their gaps. Business case to demonstrate return on investment. Media kit to promote readiness to the community (bragging rights). Listing facility on Texas EMSC site. Search engine optimizer for ready facilities during public internet

searches. Camera ready logo on a data file. Dissemination on social media (e.g. Twitter, Facebook). Governor’s proclamation annually listing the newest facilities that have

been acknowledged or reached to a higher level, Acknowledge facilities on the same day so that no one is first.

The estimated costs associated with these suggestions will also be presented in a different document as well.

Every effort will also be made to disseminate information about the pilot program and will be shared with the following stakeholders and partners:

Texas Hospital Association Listserv

Hospital Preparedness Program

RACS TPS TCEP Hospital administration

listserv

ENA CHAT TORCH

The general milestones for the Pilot VPRP Implementation phase will be as follows:

4.0 Performance Monitoring

In an effort to evaluate the effectiveness of the VPRP, data will be requested from each facility and for the data to be reported directly to the EMSC program office on a periodic basis. The method of gathering the data will be determined at a later date and the frequency of reporting will also be determined through consultation with participating facilities. We intend to ensure that data is seamlessly shared between EMSC and each participating facility. At a minimum, the metrics described and listed in Appendix D are being suggested as starting points in terms of the type of data that will need to be captured and reported.

5.0 Pilot Process and Facility Selection

The initial pilot phase will be conducted through the following proposed process:

Review of Plan by EMSC

Advisory Committee

Present Plan to GETAC Pediatric

Committee for review

Submit to GETAC for

prelimi-nary

review

Present to GETAC for

formal endorsement

Pilot Program

for "Ready"

2018

Pilot Program for "Champion"

2019

Pilot Program

for "Innovator"

2020

One Year program review

Selection of Pilot

Facilities for "Ready"

Level

Recieve completed applications from facilitiesReview for completeness

Schedule Vitual Surveys

Conduct and determine results of vitual survey and then adjudicate application based on results

Notification of

Application results

Review and make any required modifications to overall program application /approval process

Proceed to next level of readiness

Report results of first round of surveys to GETAC and proceed to next level

During the pilot phase, a select number of hospitals will be invited to participate in the program.To ensure that a variety of hospitals are invited to participate in the pilot program, we will select from four different types of hospitals based on the volume of pediatric patients they see and treat each year. The ranges for each category are described here:

Type I = Less than 1800 patients per yearType II = Between 1800 to 4999 per yearType III = Between 5000 to 9999 per yearType IV = Greater than 10000 per year

Moreover, for each level of readiness, we will limit the number of hospitals that will be invited to participate in the pilot program to only three hospitals for each type for a total of 12 hospitals maximum at each readiness level.

6.0 Periodic Program Review

As the program continues to grow, periodic program evaluation and review will be conducted by the EMSC Program Office, EMSC Advisory Committee and stakeholders. This process will allow the program to evaluate the efficacy and benefits of the VPRP to the community and whether there were any improvements in the care and treatment of infants and children during medical and traumatic emergencies. For example, the evaluation and review process will allow the program to determine if certain items that were initially placed in the Pediatric Champion and Pediatric Innovator levels of preparedness should be moved and listed under the Pediatric Ready level of preparedness. Similarly, for the purposes of quality improvement, new items/equipment may be added to one or more levels as facilities become more prepared for pediatric emergencies based on input from the EMSC Advisory Committee (EAC), stakeholders and facilities themselves.

7.0 Appeals Process

Every effort will be made by the survey team to assist a facility/hospital meet the requirement of the readiness program both prior to the actual survey and after. Every survey will be different and therefore each issue can be addressed on a case by case basis. If a facility/hospital has any question or concerns regarding an unfavorable result of their survey, hospitals are welcomed to submit a written explanation of why they disagree with the decision and to request for a new panel of surveyors to conduct a second survey. The overall aim of the VPRP is to help every emergency department in the state be better prepared to treat and manage pediatric trauma/medical emergencies within their communities and so every effort will be made by the program to help each facility reach that goal.

APPENDIX A: Implementation Plan Template Approval

The undersigned acknowledge that they have reviewed the Voluntary Pediatric Readiness ProgramImplementation Plan Template for EDs and agree with the information presented within this document. Changes to this Implementation Plan Template will be coordinated with, and approved by, the undersigned, or their designated representatives.

Prepared By:

Signature: Date:Print Name: Joseph Santos, MPH, NREMTTitle: Program Manager

Approved By:

Signature: Date:Print Name: Saranya Srinivasan, MDTitle: Program Director

APPENDIX B: Application Forms

TEXAS EMSC STATE PARTNERSHIP6621 Fannin Street, Suite A2210

Houston, TX 77030Phone: 832-824-3672

Fax: 832-825-1182Email: emsctexas@bcm.edu

www.bcm.edu/pediatrics/emsc

August 2017

Dear Hospital Administrator:

Congratulations on your decision to participate in the Texas EMS for Children Voluntary Pediatric Readiness Program!

Enclosed is information on our program as well as documents that will need to be submitted to our office for review and consideration. The readiness program is an excellent opportunity for your Division or Department of Emergency Medicine to prepare and be ready to manage pediatric emergencies within your community. By preparing your facility to become pediatric ready, you will receive acknowledgement from your community and local media outlets that you are voluntarily choosing to go “above and beyond in your care of children.”

It is important to note that your decision to participate in this readiness program will in no way impact your licensure by the Texas Department of State Health Services Office of EMS and Trauma Systems.

Please review this packet and complete and return the attached application along with the supporting documents for review by our office. Organizations who successfully meet the requirements will receive a Certificate of Readiness to acknowledge their accomplishment and commitment to the infants and children of Texas.

Please do not hesitate to contact me or our Texas EMSC Program Manager Mr. Joseph Santos with any questions at 832-824-EMSC (3672) or joseph.santos@bcm.edu

Sincerely,

Saranya Srinivasan, MD, FAAPProgram Director, Texas State PartnershipEmergency Medical Services for Childrensxsriniv@texaschildrens.org

APPLICATION FORM

Thank for your interest in participating in the Texas EMS for Children Voluntary Pediatric Readiness Program. In order to process your application, please complete the following form and forward this application to the Texas EMS for Children State Partnership office via one of the following methods:

Mail: 6621 Fannin Street, Suite A2210Houston, TX 77030

Fax: 832-824-1182Email: joseph.santos@bcm.edu

Name of Facility/Organization:

Address:

Texas License Number:

Primary Contact Offi cial:

Email address for Offi cial:

Telephone/Fax:

PEDIATRIC READY

PEDIATRIC CHAMPION

PEDIATRIC INNOVATOR

Level of Readiness Applying For:

PROGRAM LEVELS

PEDIATRIC READYTo meet the “Pediatric Ready” level of readiness, the facility MUST meet all the requirements under the “Pediatric Ready” list of items detailed in the checklist under the following headings:

1. Participation in the National Pediatric Readiness Project2. Physicians, Nurses and Other Healthcare Providers Who Staff the ED3. Guidelines for Improving Pediatric Patient Safety4. Guidelines for Equipment, Supplies, and Medications for the Care of Pediatric Patients in

the ED

PEDIATRIC CHAMPIONTo meet the “Pediatric Champion” level of readiness, the facility MUST meet all the requirements under the “Pediatric Ready” check list AND the items under the following headings for “Pediatric Champion”:

1. Guidelines for Equipment, Supplies, and Medications for the Care of Pediatric Patients in the ED

PEDIATRIC INNOVATORTo meet the “Pediatric Innovator” level of readiness, the facility MUST meet all the requirements under the “Pediatric Ready” and “Pediatric Champion” checklists plus the items under the following headings for Pediatric Innovator:

1. Physicians, Nurses and Other Healthcare Providers Who Staff the ED2. Guidelines for Equipment, Supplies, and Medications for the Care of Pediatric Patients in the ED3. Guidelines for QI/PI in the ED4. Quality Improvement Initiatives

TEXAS FACILITY READINESS PROGRAM CHECK LISTPEDIATRIC READY

Official Completing Form (please print): ___________________________________ Date: _____________ Initials: ________________

Instructions: The requirements and acceptable documentation are detailed for each item on the list by type of survey. For each item, please initial in the box provided for each line item/equipment to indicate that the acceptable forms of documentation/material were submitted and interviews/meetings were properly

conducted via video conferencing or the type of survey requested (e.g. VCT or on site). Please attach any documentation/material as an addendum to this application.

DESCRIPTION Type of SurveyParticipation in the National Pediatrics Preparedness Project PAPER/VTC ON SITE INIT

ALL APPLICANTS ARE REQUIRED TO PARTICIPATE IN THE NATIONAL PEDIATRIC PREPARDNESS PROGRAM. https://www.pedsready.org/ Physician, Nurses and Other Healthcare Providers Who Staff the ED PAPER/VTC ON SITE INIT

Physicians who staff the ED have the necessary skill, knowledge, and training in the emergency evaluation and treatment of children of all ages who may be brought to the ED, consistent with the services provided by the hospital. This means that there is 24/7 provider coverage of the ED by a physician board certified in Emergency Medicine, Pediatrics, Family Medicine, Peds Emergency Medicine OR if they are not board certified in one of the aforementioned subspecialties they are current providers in PALS OR APLS.

A de-identified list of current medical staff and their board certification, if not board certified in EM, Peds, FM, or PEM, then then expiration date of

their APLS/PALS certification.

Nurses and other ED health care providers have the necessary skills, knowledge, and training in providing

emergency care to children of all ages who may be brought to the ED, consistent with the services offered by the hospital and have providers that are current in APLS, PALS or ENPC. Provider coverage must be 24/7.

A de-identified list of current nursing and ED health care providers and the

expiration date of their APLS, PALS or ENPC provider verification.

Guidelines for Improving Pediatric Patient Safety PAPER/VTC ON SITE INIT

ALL infants and children presenting to the ED have the following vital signs recorded in the medical record: temperature, heart rate, respiratory rate.

Copy of Written policy and

review of xx number of de-

identified records for specified common

Sample Audit of charts

pediatric chief complaints via

video-conferencing

(VC).

Blood pressure and pulse oximetry monitoring are available using the appropriate size equipment for children of all ages on the basis of illness and injury severity.

Official equipment list for unit with

hospital logo on the document from central

supply/biomed department OR a

picture of the equipment.

Visual Inspection of equipment by visiting surveyor

A process in in place that allows for 24/7 access to interpreter services in the ED.

A demonstration of the process used to access the interpreter

with VC

Demonstrate to visiting surveyor how to access the interpreter

Guidelines for Equipment, Supplies, and Medications for the Care of Pediatric Patients in the ED PAPER/VTC ON SITE INITNeonatal, infant AND child (BP cuff)

Official equipment list for unit with

hospital logo on the document from central

supply/biomed department and

random visualization of equipment via

VTC.

Visual Inspection of equipment by visiting surveyor

Electrocardiography monitor/defibrillator with pediatric and adult capabilities including pads/paddles 20, 22 AND 24 gauges (intravenous catheters over needles) Pediatric IO device (with appropriately - sized needles) for infants and children. IV administration sets with calibrated chambers and extension tubing and/or infusion devices with ability to regulate rate and volume of infusate. Un/cuffed 2.5-6.0 mm endotracheal tubes 0, 1, AND 2 Straight and 2 curved laryngoscope blades Oral airways sizes 0-3 Pediatric stylet Infant and child suction catheters Infant (450 mL) self-inflating bag mask with a safety pop-off valve Neonatal, infant, AND child mask fit bag-mask device adaptors Standard infant and child clear O2 masks Infant AND child nasal cannulas Pediatric physician coordinator who is a specialist in pediatrics, emergency medicine, or family medicine, appointed by the ED medical director, who through training, clinical experience, or focused continuing medical education demonstrates competence in the care of children in emergency settings including resuscitation.

Name of person and copy of

official position description and brief interview

30-minute interview by site

surveyor with this person to

discuss their role

via VC.

Pediatric nurse coordinator who is a registered nurse (RN), appointed by the ED nursing director, who possesses special interest, knowledge, and skill in the emergency nursing care of children.

Name of person and copy of

official position description and brief interview

via VC.

30-minute interview by site

surveyor with this person to

discuss their role

Baseline and periodic competency evaluations must be completed for all ED clinical staff, including nurses, that are age specific and include evaluation of skills related to neonates, infants, children, adolescents, and children with special health care needs.

Written policy regarding scope and frequency of evaluations for staff and view a personnel file via

VC with documentation of competency

evaluations.

Review de-identified

evaluations of 10 staff

The hospital has a pediatric patient care-review process using outcome-based measures for internal review. (e.g. number of pediatric patients seen in the ED, admission rate, incoming and outgoing transfer %, mortality, and return visit rate).

Submission of specified data in

this line item

Interview with person

responsible for doing this to describe the

process used and to get feedback

All children seen in the ED are weighed in kilograms (kgs) AND that weight is recorded in the ED medical record in kg only

Copy of Written policy and verify with records and

looking at the scale via VC.

Chart audit of 10 charts

A process for identifying age-specific abnormal vital signs and notifying the physician or APP of these abnormal vital signs are present.

1. Copy of Written Policy

AND 2. discussion with

person who takes vitals (PCA

or RN) to describe what

they do if something is

abnormal via VC AND 3. Either

verbal confirmation of

notification process OR a

chart audit of 10 charts with abnormal

Both a discussion with person who takes vitals (PCA

or RN) to describe what

they do if something is abnormal and

chart audit of 10 charts with abnormal

pediatric vitals to check for

documentation of reporting

pediatric vitals to check for

documentation of reporting.

There are processes in place for safe medication storage, prescribing, and delivery that includes pre-calculated dosing guidelines for children of all ages.

A description of the process and demonstrate via

VC.

Discussion with RN, MD/DO,

Pharmacist about a case example

(with a controlled substance) to describe the

process used in the ED to store, prescribe, and

deliver a medication

The ED has a process that promotes family-centered care (e.g. family presence at the bedside, family involvement in clinical decision making, caregiver education, etc.).

A written description of the facility's

process

Interview staff (RN, MD/DO, child life if

applicable) to describe

management of a case scenario (a

child in respiratory

distress who needs to be intubated)

The ED uses a validated triage tool AND has a triage policy that specifically addresses ill and injured children.

Name of the tool and a copy of

the policy, which also specifies how staff are

trained to use it

Chart audit of 10 cases that

demonstrates triage

documentation and triage level

assigned

The ED has a policy addressing how frequently children should be reassessed. Copy of Written policy

Chart audit of 10 cases that

demonstrates that the policy is

adhered to

The ED has a process for assessing immunization/ vaccination status and risk stratifying the under/ un-immunized patient.

A description of the process

Discussion with RN, MD/DO,

Pharmacist about a case example

(12 y/o with dirty wound and needs

a tetanus booster) to

describe the process used in the ED to store, prescribe, and

deliver a medication

The hospital has a written guideline for the initial management and transfer of children with behavioral and mental health issues out of the facility to an appropriate facility.

A description of the process

Discussion with RN, MD/DO about a case example

(13 y/o with suicidal ideation) to describe the process used to

transfer the patient

The ED has a policy for the initial identification/evaluation and management of suspected child neglect and/or abuse.

Copy of Written policy

Discussion with RN, MD/DO about a case example (4 y/o brought in due to alleged sexual abuse that occurred that day) to describe the

process used to evaluate and coordinate

transfer or follow up for the patient

The ED adheres to a policy on how to handle the death of a child in the ED. Copy of Written policy

Discussion with RN, MD/DO about a case example

(3 month old found apneic in crib, brought by

EMS)

The ED adheres to a policy of medical imaging that addresses pediatric age- or weight-based appropriate dosing for studies that impart radiation consistent with the ALARA (as low as reasonably achievable) principle, if a computed tomography (CT) scanner is available at the facility.

Copy of Written policy

Discussion with radiologist and radiology tech about how the

policy is applied. (Case example: 5 y/o with altered mental status after a head

injury and needs a head CT)

The ED or hospital has an all-hazard disaster-preparedness plan that addresses issues specific to the care of A copy of the Discussion with

children. plan

RN, MD/DO about a case example (Bus accident

with 10 injured children coming to their ED) to describe the

process used to evaluate and coordinate

transfer for the patient, if needed

The ED has an inter-facility transfer policy defining the roles and responsibilities of the referring facility and referral center.

Copy of Written policy

Discussion with MD/DO about where they

would send the following

patients, if services could

not be provided at their own

facility: • A 3 y/o with >30% burns• A 2 y/o in MVC

with a head bleed

• A 6 y/o with a Type 3

supracondylar fracture

• A 6 month-old with bronchiolitis,

intubated for respiratory

failure• A 15 y/o with

ectopic pregnancy

• A 13 y/o with suicidal ideation

Medication chart, length-based tape, medical software, or other systems are readily available to ensure proper sizing of resuscitation equipment and proper dosing of medications.

A description of the tool(s) used

Discussion with RN, MD/DO,

pharmacist about a case example

(3 y/o with status epilepticus who

needs medication for

seizure and then needs to be intubated) to identify the

proper doses of medications

The following medications are available in the ED if a national shortage is not currently in effect: Atropine, Adenosine, Amiodarone, Anti-Emetic agents, Calcium chloride OR gluconate, Dextrose (D10W, D50W), Epinephrine (1:1000; 1:10 000 solutions), Lidocaine, Magnesium sulfate, Naloxone hydrochloride, Sodium bicarbonate (4.2%, 8.4%), Activated charcoal, Topical, oral, and parenteral Analgesics, Antimicrobial agents (parenteral and oral), Anticonvulsant medications, Antidotes (common antidotes should be accessible to the ED), Antipyretic drugs, Bronchodilators, Corticosteroids, Inotropic agents, Neuromuscular blockers, Sedatives, Vaccines, Vasopressor Agents, Insulin

A list of the medications in

the ED. If a national

shortage is in effect, submit

documentation that the facility attempted to acquire the medication.

Discussion with RN, pharmacist

about where each medication

is kept (crash cart vs.

pharmacy vs. Omnicell/Pyxis machine vs.

medication room) Prostaglandin E1 (PGE1) The ED has a patient warming device for all ages including infants.

Full listing of the name of the

equipment/device and how many are kept in the ED / Random

visualization of equipment via

VC

Visual inspection of the

equipment/device by the visiting

surveyor

Weight scale in kilograms (not pounds) Doppler device Rectal thermometer A continuous end-tidal CO2 monitoring device Dextrose 5% in normal saline Dextrose 10% in water C-Collars or a method by which to stabilize the cervical spine or restrict cervical motion for patients of all ages Extremity splints in pediatric sizes Pediatric Magill forceps Infant AND Child Nasopharyngeal Airways Nonrebreather mask for infant AND child (clear O2 mask) Infant AND Child, 8 AND 10F (NG tube) Extraglottic/ supraglottic airways in sizes 1-3 (e.g. LMA, King, IGel) Supplies/kit for patients with difficult airways (e.g. needle cricothyrotomy supplies, surgical cricothyrotomy kit) Pigtail or open chest tube thoracostomy supplies with appropriately sized chest tubes: Infant (10-12F) AND Child (16-24F) Newborn delivery kit, including equipment for resuscitation of an infant (umbilical clamp, scissors, bulb syringe, and towel)

PEEP valve

PEDIATRIC CHAMPIONGuidelines for Equipment, Supplies, and Medications for the Care of Pediatric Patients in the ED PAPER/VTC ON SITE INIT

UVCs 3.5 or 5 French

Visual Inspection by the visiting surveyor

Central Lines in 2 of the following sizes: 4.0, 5.0, 6.0 or 7.0 F Lumbar-puncture tray including infant 22 gauge, pediatric–22 gauge, and adult 18-21 gauge lumbar puncture needles Urinary catheterization kits and urinary (indwelling) catheters (6F–22F)

Appropriateness of management and transfer for infants (<90 days old) with feverIn depth discussion with pediatric

care coordinator or other QI personnel to describe how this is

being accomplished. Quality Improvement Initiative PAPER/VTC ON SITE INIT

The hospital agrees to participate in a QI initiative with EMSC, and they will submit de-identified information through an online portal. The facility should provide a description of what the facility is doing to address the gaps identified from this data (one example would be implementation of a clinical practice guideline or doing research on the issue), in a format that could potentially be used as a QI publication. This may include one or more of the following: Written description of initiative to

include data set and process for capturing data.

CT use for traumatic head injuryAppropriateness of imaging and transfer for suspected appendicitisAppropriateness of transfer for orthopedic injuryAppropriateness of management and transfer for asthma and pneumoniaAppropriateness of management and transfer for (febrile) seizures

There is an individual in the hospital with a current certification in NRP 24/ 7 that is available to respond to the ED if there is not a provider in the hospital at the same time who is board certified in Pediatrics, Emergency Medicine, Pediatric Emergency Medicine, or Family Medicine

Provide surveyor with de-identified list of current medical staff and the

expiration date of their NRP certification

tubes in sizes 2.5-5.5 mm Tracheostomy

Visual inspection of device/equipment by visiting

surveyor. Equipment list can be submitted in advance for prior

review

PEDIATRIC INNOVATORPhysician, Nurses and Other Healthcare Providers Who Staff the ED ON SITE INIT

Baseline and periodic competency evaluations must be completed for all ED clinical staff, including physicians and APPs, that are age-specific and include evaluation of skills related to neonates, infants, children, adolescents, and children with special health care needs. Competencies are determined by each institution’s hospital policies and medical staff privileges as a part of the local credentialing process for all licensed ED staff.

Provide surveyor with de-identified evaluations of 10 staff. Written

policy may be submitted in advance describing frequency and scope of

evaluations.

Guidelines for QI/PI in the ED ON SITE INIT

Components of the QI process interface with out-of-hospital, ED, inpatient pediatric, pediatric critical care, and hospital-wide QI/PI activities

In depth discussion with pediatric care coordinator or other QI

personnel to describe how this is being accomplished. Submission of a written description of the process should be provided in advance of

site survey.

APPENDIX C: Pediatric Readiness Assessment Data from 2013

Appendix C.1 – Texas Summary

Number of Hospitals Sent Assessment: 504Number of Hospitals that Responded: 305Response Rate: 60.5%

69n=4,146

NATIONAL MEDIAN SCORE of

PARTICIPATING HOSPITALS

71STATE MEDIAN and

AVERAGE SCORE OUT of 100

Appendix C.2 – Benchmarking

National Results

Appendix C.3 – Texas Emergency Department Demographics

Appendix C.4 – Texas Emergency Department Age Cut-Off

Number of hospitals with a Pediatric ED in either a

children’s hospital or a general hospital

Appendix C.5 – Texas Pediatric Inpatient Capabilities

Appendix C.6 – Presence of MD and RN Coordinator in the Emergency Dept

IMPORTANCE Guide EMS in regional destination plans Avoid unnecessary transfers Anticipate surge capabilities in disasters

Appendix C.7 – Physician Staffing

Appendix C.8 – Physician Board Certification

• EM physicians staff most of the EDs in Texas• Collaboration with EM physicians to improve

pediatric readiness in EDs is essential

84%

64%

15% 14% 13%5% 4%

16% require neither in Texas

Are all of your physicians in the ED who care for children board certified in Pediatric Emergency Medicine or ABEM

or ABOEM?

Appendix C.9 – Pediatric Patient Care Review Process

47% in Texas

Appendix C.10 – Weighing and Recording in Kilograms

Appendix C.11 – Hospital Pediatric Disaster Plan

41% in Texas

Appendix C.12 – Equipment Availability

Does your hospital disaster plan

address issues specific to the care of children?

Appendix D – Minimum Data Set

Available in 70-79 % of TX EDs

• Tracheostomy tubes (4.0; 71%)

• Laryngoscope (straight 00: 76%)

• Supplies/kit for pediatric difficult airway (76%)

Available in <70% s

• Umbilical vein catheters (49%)

• Central venous catheters (4-7F: 62%)

• Tracheostomy tubes (3.0, 3.5: 63-65%)

• Laryngeal mask airways (1, 1.5, 2, 2.5; 61-69%)

• All other equipment, supplies, and medications in TX EDs were available in >90% of EDs

Available in 80-90% of TX EDs

• Continuous end-tidal CO2 monitoring (80%)

• Pediatric Magill forceps (82%)

• Nasopharyngeal airways (infant/child: 82-88%)

• Non-rebreather masks (infant: 84%)

• Nasal cannula (infant: 86%)

NPI#Tx DOH #RACNameAddress (Full)Facility Phone NumberER Phone NumberCEOCEO email addressCNOCNO email addressAdminstration Phone NumberER Total Bed CapacityER Pediatric Bed CapacityPediatric Bed CapacityIMU (if separate) Bed CapapacityPICU Bed Capacity

Subspecialty Capabilities Y/N Value List Pediatrics, PEM, Gastro, Ortho, Gen Sur, Trauma Surg, Neuro, NS, Cards, CTS, ICU

Total Patients (Adult & Pediatric) Seen in ER Pediatric is < 17Total Pediatric Seen in ER Calculated from DataTotal Pediatric Transfers Out Calculated from DataTotal Pediatric Transfers In Calculated from DataTotal Pediatric Deaths Calculated from Data

Chart Review Data TypePediatric Record ID Text YYYY-ID#, Serial IncrementMode of Transport Text POV, EMS-Ground, EMS-AirFacility Point of Entry Value List ER, Floor, IMU, ICUAdmission Type Value List ER, Direct Admission, TransferAdmission Status Value List Inpatient, ObservationDate & Time of Arrival Date/TimeDate & Time of Discharge Date/TimeICD10 Diagnosis Codes TextICD10 Procedure Codes TextTransferred From Value ListTransferred To Value ListChief Complaint / Admitting Diagnosis TextInitial Height (cm) Number 1 decimal Initial Weight (kg) number 3 decimalPCP Y/NDischarge / Final Diagnosis TextDischarge Type Value List Home, Transfer HLOC, Transfer LTAC, DeathHighest Level of Care

Suspected AppendecitisCT Type w/o Cont, w/w/o Cont, w/ContCT ResultUS Result

Asthmatic Y/NSteroids w/in 1h arrival to administration Y/NContinuous AlbuterolMagnesium Sulfate AdminPASS Initial ScorePASS Final Score

TBICTMRIHighest GCSLowest GCS

BehavioralCPS Report Filed Y/NSusptected Abuse/Neglect Screening Result Y/NSuicide Risk Assessment Completed Y/N

Facility Information

Program Submission

DEFINITIONS

VPRP Voluntary Pediatric Readiness Program

ED Emergency Department

EMSC Emergency Medical Service for Children

EMS Emergency Medical Service

NPRP National Pediatric Readiness Project

NICU Neonatal Intensive Care Unit

PICU Pediatric Intensive Care Unit

PEM Pediatric Emergency Medicine

GETAC Governor’s EMS and Trauma Advisory Council

TCEP Texas College of Emergency Physicians

ENA Emergency Nurses Association

RN Registered Nurse

CPEN Certified Pediatric Emergency Nurse

CHAT Children Hospital Association of Texas

PALS Pediatric Advance Life Support

ENPC Emergency Nurse Practitioner - Certified

QI Quality Improvement

CQI Continuous Quality Improvement

RAC Regional Advisory Councils

TPS Texas Pediatric Society

TORCH Texas Organization of Rural and Community Hospital