EIIC: Emergency Medical Services for Children | Innovation and Improvement Center

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, i.e. stroke, trauma. The concept of categorizing healthcare facilities with regard to specialized capabilities and/or resources is not new, Early systems of pediatric care built upon categorization of facilities, as determined by resources and capabilities include, trauma and perinatal; both address high risk patient groups in which time critical diagnosis and treatment are essential and for which the needed specialty physicians, care, and resources are not readily available in all hospitals.

Categorization of Trauma, burn, perinatal, and stroke centers has existed for years. Categorization provides a mechanism whereby appropriate resources are determined to be readily available to provide optimal support and thereby optimal outcomes for high acuity, often low volume, time-sensitive diagnoses for patient groups requiring specialty care. Children are low volume specialty patients seen in all emergency departments but for which specialty services are not readily available.

Systems of care for children, built upon the categorization of facilities, were identified as important and first advocated for in the 1993 Institute of Medicine (IOM) report Emergency Medical Services for Children. Facility categorization is associated with developing a system of care or the notion of identifying available health resources within a given area and coordinating healthcare services to meet the needs of specific patient populations. The efficient use of resources through the categorization, integration, and coordination of emergency services, pre-hospital and hospital resources into one system assures that the larger emergency system is more efficient and can more effectively meet the needs of all children.

The 2006 Institute of Medicine (IOM) report Emergency Care for Children: Growing Pains also 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 EMSC NRC 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 Program Materials

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 address operational capacity to provide pediatric emergency care, including the existence of a standardized statewide, territorial, or regional systems that recognize hospitals capable of stabilizing and /or managing pediatric medical emergencies and trauma (see PMs 74 and 75). (Accessed December, 2014).
Best Practices: A Guide for State Partnership Grantees on the Implementation of EMSC Performance Measures
This EMSC NRC booklet 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).
EMSC Webinars
This section of the website includes links to upcoming and archived webcasts, including the following:
Pediatric Readiness Data: An Opportunity to Improve Quality of Care in Your Emergency Department
This program defined quality improvement, highlighted key components of the quality improvement process, and discussed how to apply essential quality improvement methodologies to improve pediatric emergency care using the National Pediatric Readiness data. (Dec. 17, 2014)
This is a recording of a webinar originally presented in Adobe Connect. The recording limits the functionality available to the user. Scrolling through Q&A as well as other functionality specific to Adobe Connect in the presentation will not be available.
EMSC Opportunities for Enhancing Pediatric Emergency Care: Planning and Processes to Improve Pediatric Access to Specialty Care
This program highlighted practices and lessons learned from California and New Mexico in implementing components of regionalized systems of pediatric emergency care. (Nov. 17, 2014)
Enhancing Pediatric Emergency Care Through Trauma Performance Improvement
This live internet program highlighted three EMSC Targeted Issues projects focused on pediatric trauma performance improvement from the prehospital to the hospital setting, and the critical importance of integrating patient and family centered care into these settings. (Sept 27, 2013) Slides | Transcript
Partnerships and Relationships – Keys to Facility Recognition Success
This live internet program highlighted two EMSC Targeted Issues projects that have focused on pediatric facility recognition. A preview of a soon to be released tool kit to assist states in development/implementation of a pediatric facility recognition program was also shared. (Sept. 23, 2013)
Transfer Processes – An Opportunity for Improving Pediatric Emergency Care
This panel presentation highlighted the importance of organized inter facility transfer processes, their role in assuring access to pediatric specialty care, as well as sections of the newly released Inter facility Transfer Tool Kit. (Sept. 12, 2013) Transcript
Working Beyond Borders and In Partnership to Create a Pediatric Recognition System
This April 8, 2011, webcast examines Georgia EMSC’s effort to develop a pediatric recognition system. To assure they understood what this undertaking would involve and to tap into the experience of others, the Georgia EMSC program staff sought the support and guidance of the California EMSC team. The webcast provides an overview of how Georgia EMSC established the partnership, what they learned and how they intend to proceed thus far. Transcript | Slides (April 2011)
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 (AAP), the American College of Emergency Physicians (ACEP), and the Emergency Nurses Association (ENA). Transcript | Slides
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. Transcript | Slides (March 2010).
Joint Policy Statement for Guidelines for Care of Children in the Emergency Department
Endorsed by the AAP’s Committee on Pediatric Emergency Medicine, ACEP’s Pediatric Committee, and ENA’s 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 IOM 2006 report Future of Emergency Care in the United States Health System, and are also available online through the ACEP website (Published in Pediatrics September 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. (2010).
Pediatric Regional Critical Care Hospitals: White Paper on Evidence and Improvement Opportunities in New York
This White Paper reports on an evaluation of pediatric critical care services undertaken by the New York State EMSC Advisory Committee. The White Paper summarizes published research regarding outcomes at high volume pediatric regional critical care hospitals versus other facilities. Potential barriers interfering with access to pediatric critical care facilities in New York are described. The paper also offers approaches that should be considered for improvement of critical care services for children in New York. One of the recommendations from this White Paper includes establishing an “authority and a process necessary to designate facilities appropriate for pediatric critical care.” (February 2008).

American Academy of Pediatrics

Management of Pediatric Trauma
This article states that improving outcomes for the injured child requires an approach that recognizes childhood injury as a significant public health problem. Efforts should be made to improve injury-prevention programs, emergency medical care, and trauma systems for pediatric patients. The pediatric trauma system functions best as part of the inclusive EMS, trauma, and disaster response system for the region or state. It has been shown that younger and more seriously injured children have better outcomes at a trauma center within a children’s hospital or at a trauma center that integrates pediatric and adult trauma services. (April 2008).
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).

Clinical Pediatric Emergency Medicine

Pediatric Patients in the Adult Trauma Bay–Comfort Level and Challenges
“Most pediatric trauma patients are cared for in non-children’s hospitals by providers without pediatric specialty training and in facilities that may not be used to caring for children. Children have different physiologic and psychologic responses to injury than adults. Several studies have shown that pediatric trauma patients have improved outcomes with lower mortality, fewer operations, and improved function when cared for in pediatric facilities or adult trauma centers with pediatric expertise. Limitations in the availability of pediatric specialists require that all hospitals be prepared to effectively and successfully treat pediatric trauma patients.” (Clinical Pediatric Emergency Medicine, Vol 11, Issue 1, pp 48-56, March 2010).

Emergency Nurses Association

Care of the Pediatric Patient in the Emergency Setting
This position statement articulates ENA’s support for emergency departments seeking designation as: emergency pediatric centers, emergency departments approved for pediatrics, and stand-by emergency departments for pediatrics, or similar designations as determined by individual states. (May 2007).

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. (2007).

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, 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

Snapshot of States having Facility Recognition Programs

This table, a product resulting from a Targeted Issues Grant, was developed by the Illinois EMSC Grantee. The chart provides aggregate information on existing state facility recognition programs. Information included in the table includes:

  • Historical background, including discussion of regulatory authority granted to individual states when developing facility recognition programs.
  • Identifies if hospital participation in the categorization process is mandatory or volunteer.
  • Naming convention/terminology used by states in categorizing tiers of facilities and their capabilities.
  • Survey process employed by states when validating capabilities and resources of individual facilities when being categorized.
  • Fee Structure utilized in categorization process.

EMSC State and Territory Program Mandates

The following are examples of state and territorial laws related to EMSC performance measures 74 (The percent of hospitals recognized through a statewide, territorial, or regional standardized system that are able to stabilize and/or manage pediatric medical emergencies) and 75 (The percent of hospitals recognized through a statewide, territorial, or regional standardized system that are able to stabilize and/or manage pediatric trauma emergencies).

Many of these laws were enacted prior to the establishment of the performance measures and may not be an exact match to each performance measure. For example, a law may only apply to the state’s trauma system as opposed to the entire EMS system. Therefore, these examples are meant to be a starting point and not a one-size-fits-all model. Some laws cited below may not be sufficient to achieve the EMSC priorities, but instead may be helpful as examples of how other states regulate EMSC activities.

Florida Department of Health: Trauma Center Standards

The Florida Department of Health has developed a pamphlet that outlines the standards for trauma center across the state. The contents of this pamphlet are “based in part on the standards published in the 1998 version of this pamphlet, in part on the guidelines published in the American College of Surgeons’ Resources for Optimal Care of the Injured Patient: (2006), and in part on the experience gained during site surveys conducted at Florida trauma center applicant hospitals since 1990.”

The pamphlet is broken into chapters that define standard trauma system terms, the standards for Level I & Level II trauma centers, and standards for pediatric trauma centers. (January 2010).

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 EMSC 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, and a slide presentation reviewing the Facility Recognition Program.(Accessed October 2014).

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.

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 July 2015).

Family And Caregiver Resources

EMSC Program Materials

Getting Started, Staying Involved: An EMSC Toolkit for Family Representatives
This EMSC NRC publication, developed for parents and caregivers interested in EMSC, 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 May 2015).
What is a Pediatric/Neonatal Critical Care Transport Team?
Developed by the AAP’s Section on Transportation Medicine, this document provides explanation on the need for and composition of pediatric-specific transport teams. (2004).

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 November 2011).