critical pediatric equipment availability in canadian hospital emergency departments

P E D I A T R I C S / S U R V E Y A R T I C L E

David McGillivray, MD*

Cheri Nijssen-Jordan, MD§

Michael S. Kramer, MD*‡

Hong Yang, MSc‡

Robert Platt, PhD*‡

From the Departments of Pediatrics,Division of Emergency Medicine,* andEpidemiology and Biostatistics, Re-search Institute,‡ Montreal Children’sHospital, McGill University, Montreal,Quebec, Canada; and the Departmentof Pediatrics, Division of EmergencyMedicine, Alberta Children’s Hospital,University of Calgary, Calgary,Alberta, Canada.§

Received for publication July 9, 1999.Revisions received February 9, 2000,August 18, 2000, andSeptember 18, 2000. Accepted forpublication October 4, 2000.

Oral presentation at the AmbulatoryPediatric Association/EmergencyMedicine meetings, New Orleans, LA,May 1998, and poster presentation atthe Canadian Pediatric Association/Emergency Medicine annual meeting,Hamilton, Ontario, Canada,June 1998.

Supported by a Canadian Associationof Emergency Medicine, Hoffmann-LaRoche grant.

Address for reprints: DavidMcGillivray, MD, Montreal Children’sHospital, 2300 Tupper Street, RoomA-103, Montreal, Quebec, H3H 1P3;E-mail [email protected].

Copyright © 2001 by the AmericanCollege of Emergency Physicians.

0196-0644/2001/$35.00 + 047/1/112253doi:10.1067/mem.2001.112253

See editorial, p. 388.

Study objective: Of all child visits to emergency departments,1% to 5% involve critically ill children who require cardiopul-monary resuscitation. Numerous versions of pediatric equip-ment lists for EDs have been published. Despite these efforts,many EDs remain unprepared for pediatric emergencies. Theobjectives of this study were to assess the availability of pedi-atric resuscitation equipment items in Canadian hospital EDsand to identify risk factors for the unavailability of these items.

Methods: Using the updated database of the CanadianAssociation of Emergency Physicians (CAEP), a questionnairesurvey was sent to 737 Canadian hospital EDs with a maximumof 3 mailings to nonresponders. On-site visits to a selected sub-set of hospital EDs were completed to validate the results ob-tained by the mailed questionnaire.

Results: The response rate was 88.3% (650/737). Resultsshowed the following overall equipment unavailability: intra-osseous needle, 15.9%; pediatric drug dose guidelines, 6.6%;infant blood pressure cuff, 14.8%; pediatric defibrillator pad-dles, 10.5%; infant warming device, 59.4%; infant bag-valve-mask device, 3.5%; infant laryngoscope blade, 3.5%; 3-mmendotracheal tube, 2.5%; and pediatric pulse oximeter, 18.0%.Low percentage of pediatric visits, lack of an on-call pediatri-cian for the ED, and lack of a pediatric advanced life support–trained physician on staff were independently associated withequipment unavailability.

Conclusion: This study demonstrated that essential pediatricresuscitation equipment is unavailable in a disturbingly highnumber of EDs across Canada and has identified several deter-minants of this unavailability.

[McGillivray D, Nijssen-Jordan C, Kramer MS, Yang H, Platt R.Critical pediatric equipment availability in Canadian hospitalemergency departments. Ann Emerg Med. April 2001;37:371-376.]

Critical Pediatric Equipment Availability in

Canadian Hospital Emergency Departments

A P R I L 2 0 0 1 3 7 : 4 A N N A L S O F E M E R G E N C Y M E D I C I N E 3 7 1

C R I T I C A L P E D I A T R I C E Q U I P M E N T A V A I L A B I L I T YMcGillivray et al

I N T R O D U C T I O N

Approximately 30% of visits to general hospital emergencydepartments are by children, and 10% of all paramediccalls are for children. However, only 1% to 5% of all childvisits to EDs involve critically ill children who requirecardiopulmonary resuscitation. Because ambulances andother emergency transport vehicles often go to the nearestavailable ED for assistance, every ED is at risk for receiv-ing critically ill children. Preparation for the arrival ofcritically ill children is essential.1

Numerous versions of pediatric equipment lists forEDs have been published.2-9 Despite these efforts, previ-ous studies have documented regional problems withpediatric equipment unavailability, and the 1995 Insti-tute of Medicine Report on emergency medical servicesfor children found that many EDs were unprepared forpediatric emergencies.10,11 In Canada, recommendedguidelines for EDs are of a general nature and do not listsignificant specific pediatric resuscitation equipmentitems that should be available.12

Our study had 2 objectives: first, to assess the avail-ability of essential pediatric resuscitation equipment inCanadian hospital EDs, and second, to identify the deter-minants of equipment unavailability. To our knowledge,ours is the first large national study to examine theseissues.

M A T E R I A L S A N D M E T H O D S

The updated database of the Canadian Association ofEmergency Physicians (CAEP) was used to identify allhospital EDs in the 12 provinces and territories of Canada.We developed a multiple-choice questionnaire to assessthe availability of essential resuscitation equipment. Thequestionnaire defined available equipment as equipmentthat was present and readily available in the ED for use ofa physician or nurse. If an equipment item was only avail-able elsewhere in the hospital, it was considered unavail-able for immediate resuscitation. Items were selected onthe basis of previously published equipment lists,2-4 withpriority given to those affecting the possibility of a suc-cessful resuscitation outcome: intraosseous needles,infant-sized endotracheal tubes, pediatric-sized defibril-lator paddles, pediatric drug dosing guidelines, pediatricpulse oximeter device, infant bag-valve-mask system, andinfant warming device. The absence of these equipmentitems is most likely to seriously impair the ability of thephysician to perform a successful resuscitation. TheCommittee on Pediatric Equipment and Supplies for

3 7 2 A N N A L S O F E M E R G E N C Y M E D I C I N E 3 7 : 4 A P R I L 2 0 0 1

Emergency Departments of the National EmergencyMedical Services for Children Resource Alliance has listedall the equipment in this study as part of guidelines forminimum equipment and supplies for the care of pediatricpatients in EDs.7

To achieve the second objective of the study, we inquiredabout potential determinants of equipment unavailabil-ity. The potential determinants included annual EDpatient census, percentage of pediatric visits, presence orabsence of consultant pediatricians and/or physicianstrained in pediatric advanced life support (PALS), dis-tance from a university center, number of pediatric resus-citations (defined as cardiac arrest, status epilepticus, orrespiratory failure) per year, and level of care given in theED (as defined by the American Medical AssociationCommission on Emergency Medical Services and en-dorsed by the American Academy of Pediatrics).13 A levelI center has comprehensive pediatric resources (people,equipment, facilities) available for definitive pediatriccare. Level II centers have extensive pediatric resourcesavailable but lack comprehensive subspecialty expertise,whereas level III centers are first-line care hospitals withminimal pediatric resources but have the ability to stabi-lize seriously ill and injured children before transport.The levels of care were defined on the questionnaire. Thesepotential determinants were chosen a priori based on ourhypothesis that insufficient patient load, complexity ofpatients seen, or training were most likely to adverselyaffect equipment unavailability. A maximum of 2 addi-tional mailings were sent after 1 to 2 months to nonre-sponders. If the director of the ED did not respond to thequestionnaire, one of the mailings was sent to the headnurse of the ED. All EDs were assured of the confidential-ity of their individual responses.

To assess the validity of the responses received, asample of 38 hospitals were selected for an on-site visitto verify the equipment availability reported on themailed questionnaire. The validation study occurredwithin 1 year of the completion of mailings. Sevenemergency physicians from university centers in 5 of the12 provinces in Canada participated in the validationstudy. The hospitals were selected according to the feasi-bility of the participating physician or his or her nurserepresentative or research assistant knowledgeable inemergency medicine to perform an on-site visit. All 3 cat-egories of individuals were used in the site validationstudy. The site visitors used the same equipment list as themailed questionnaire. They were asked to assess at least 5hospitals within their geographic area. The selected sitevisit hospitals were contacted before the visit to obtain


justed) bootstrap confidence intervals (200 bootstrap rep-etitions) were computed for the logistic models for 3 ofthe equipment items (intraosseous needle, pulse oxime-ter, and pediatric defibrillation paddles).15,16 For theother 3 items (drug dosing guidelines, endotracheal tube,and infant bag-valve-mask system), unavailability wastoo rare to compute a bootstrap confidence interval. There-fore, confidence intervals for these items were calculatedby Wald’s method.17 The goodness of fit of these 6 modelswas examined by the Hosmer-Lemeshow test.18

Because this study did not involve human subjects, itwas given an exemption by the institutional review board.

R E S U L T S

After excluding the hospitals or EDs that had closed sincethe development of the CAEP registry (N=65), 650 (88.3%)of 737 remaining hospital EDs returned the questionnaire.The lowest response rate from any of the 12 provinces orterritories was 71.4% and the highest was 100%. The 2lowest responding provinces (one 71.4% and the other73.7%) have 7 and 95 EDs per province, respectively. Theremaining 10 provinces all had response rates greaterthan 82.5%. Descriptive data on the responding hospitalsas a group are shown in Table 1.

The results of the validation study are shown in Table2. Percentage agreement was generally high. Equipmentunavailability at the time of the site visit was higher for allequipment items except for pediatric defibrillation pad-dles.

Crude rates of equipment unavailability are shown inTable 3 for the overall study sample and according to thepotential determinants of equipment unavailability. The

permission for the visit and arrange an appropriate time,but the specific reason for the visit was not disclosed tothe hospital’s ED personnel.

An SAS personal computer statistical software programwas used for all statistical analyses.14 Hospital demo-graphic information is presented in a descriptive fashion,as are crude rates of unavailability (calculated as a per-centage of responding hospitals). Polychotomous deter-minants were dichotomized by combining categorieswith homogeneous effects on equipment unavailability,while ensuring adequate numbers in each category.

Multiple logistic regression was used to assess theindependent effects of the potential determinants. Allpotential determinants were included in the regressionmodel to minimize confounding. Bias-corrected (ad-


Table 1.Description of independent variables for responding hospitals.

Potential Determinants No.* %

Hospital level 579Level I 6.4Level II 19.0Level III 74.6Community population 616<20,000 54.2≥20,000–<50,000 17.9≥50,000–<100,000 9.6≥100,000 18.3Annual ED census 589<10,000 43.5≥10,000–30,000 28.5≥30,000–50,000 21.6≥50,000 6.5Percentage of pediatric patients 541<10 35.3≥10–<20 31.1≥20–<30 22.0≥30 11.6Pediatrician on call for ED 605Yes 70.4No 29.6PALS-trained physician in ED 563Yes 29.7No 70.3Distance from university center 619<200 km 59.5≥200 km 40.5Pediatric resuscitations/y 615<3 65.53–5 13.86–10 9.3>10 11.4*No.=total number of respondents to this question.

Table 2.Results of validation study.

Mailed SiteSurvey % Visit % Agreement

Variable Unavailability Unavailability (%)

Intraosseous needle 24.3 37.8 86Drug dosing guidelines 7.9 13.2 89Infant blood pressure cuff 10.8 16.2 73Pediatric defibrillation paddles 18.9 5.4 81Warming device 64.9 81.1 68Infant bag-valve-mask system 2.7 5.4 92Infant laryngoscope blade 5.4 8.1 863-mm endotracheal tube 5.3 13.2 82Pediatric pulse oximeter 24.2 24.2 82


intraosseous needle was the equipment item most fre-quently unavailable. However, deficiencies were notedfor all types of equipment, even for drug dosing guidelines.

Results of the logistic models and bootstrap 95% confi-dence intervals for selected essential equipment unavail-ability and potential determinants are shown in Table 4.The Hosmer-Lemeshow goodness-of-fit test of the 6 mod-els showed that none was significant (P>.1), indicating anexcellent fit for all models.

D I S C U S S I O N

An ED’s ability to handle a pediatric emergency requires 3levels of preparation: equipment availability, knowledgeof when and how to use that equipment, and finally, thepsychomotor skills necessary to resuscitate a critically illchild. This study addresses only the first level of prepara-tion.

Our data indicate that a substantial number of EDsacross Canada have major deficiencies in the availability


of essential pediatric resuscitation equipment. Unavaila-bility of equipment could significantly affect the outcomeof resuscitation efforts. The conclusion of a recent inquestin Ontario noted that the staff members in charge wereunaware of the availability of intraosseous needles, eventhough they were on the resuscitation cart, that the defi-brillator used to reverse the cardiac arrest of the child hada minimum energy capacity that was 6 times the recom-mended dose for the child, that inappropriate adult-sizeddefibrillator paddles were used in the resuscitation, andthat an inappropriate dose of lidocaine was administered.19

Our study indicates that deficiencies in knowledge,equipment availability, and pediatric drug dose chartsremain despite the availability of numerous publicationsoutlining the required pediatric resuscitation equipmentfor EDs.2-9

Despite the excellent response rate to our questionnaire,concern remains that nonresponding hospitals may haveinfluenced the results. To assess the potential impact ofthe nonresponding group, we examined their effect on

Table 3.Crude rates (percentages) of pediatric emergency equipment unavailability.

Equipment Unavailability

Drug Infant Blood Pediatric Infant Infant 3-mm PediatricIntraosseous Dosing Pressure Defibrillator Warming Bag-Valve- Laryngoscope Endotracheal Pulse

Needle Guidelines Cuff Paddles Device Mask Blade Tube OximeterPotential Determinants (No.)* (627) (637) (636) (637) (628) (636) (635) (642) (628)

Overall group 15.9 6.6 14.8 10.5 59.4 3.5 3.5 2.5 18.0Hospital levelLevel III 18.8 7.5 17.4 12.3 60.3 4.0 4.0 2.6 19.5Level I/II 10.1 4.7 9.5 7.0 57.5 2.4 2.4 2.3 15.1Annual ED census<10,000 visits 30.5 12.5 22.9 17.9 54.9 6.1 6.9 3.6 25.4≥10,000 visits 6.8 2.8 9.6 5.7 62.3 1.8 1.3 1.8 13.3Percentage of pediatric visits<10% of total visits 32.4 12.2 16.9 18.5 63.0 7.1 6.0 1.8 27.0≥10% of total visits 9.4 4.4 13.9 7.3 57.9 2.0 2.4 4.3 14.4Pediatrician on call for EDNo 21.3 7.7 17.5 12.8 58.9 4.8 4.8 3.1 19.2Yes 2.9 2.3 6.9 3.5 59.2 0.6 0 0.6 11.6PALS-trained physician on staffNo 32.3 14.8 24.1 19.9 57.4 6.1 6.8 5.4 27.2Yes 10.5 3.8 11.6 7.2 60.0 2.6 2.3 1.5 14.8Distance from university center>200 km 21.8 8.6 21.1 12.2 64.2 3.7 4.9 3.2 21.4≤200 km 12.4 5.0 10.5 9.4 56.0 3.6 2.5 1.9 15.5Pediatric resuscitations/y<3 30.0 12.8 25.5 17.5 63.6 6.4 6.9 3.9 29.0≥3 8.8 2.5 8.2 6.7 56.6 1.8 1.2 1.2 11.8*No.=the number of hospitals responding to this part of questionnaire.


the equipment can be purchased for less than $1,000(Canadian funds).20

Our results suggest that on-call pediatricians, with orwithout at least one PALS-trained physician on staff in theED, have beneficial impacts on equipment availability. Inaddition to the effect on the availability of equipment,PALS training should also have an impact on knowledgeand psychomotor skills necessary for use of the equipment.

The specialty of emergency medicine in Canada con-sists of either a 5-year Royal College Emergency Medicineprogram or a 3-year combined program of family medi-cine (2 years) and emergency medicine (1 year). Thesespecialty programs are relatively new in Canada. Ourquestionnaire inquired about the type of postgraduatetraining in emergency medicine by the ED staff. The num-bers were too small to draw any conclusions about theeffect of these programs on equipment availability be-cause of the concentration of these physicians in the largeruniversity centers. Most emergency medicine is practicedby physicians who obtained their experience while inpractice or during their family medicine training. Althoughit may be preferable to have emergency medicine physi-cians who have undergone extensive subspecialty train-ing in emergency medicine to ensure that all standards aremet, this is not a realistic short-term objective. The num-ber of training positions is currently insufficient to guar-antee the presence of emergency medicine–trained physi-cians in all EDs across Canada. At present, the PALScourse, like the adult advanced cardiac life supportcourse, is the most realistic way to influence equipmentunavailability in the near future.

the availability of an intraosseous needle and drug doseguidelines. If all nonresponders had had both of theseitems available, the unavailability of the intraosseous nee-dle and the drug dose guidelines would have decreasedonly slightly: from 15.9% to 14.0% and 6.6% to 6.0%,respectively. If none of the nonresponders had had eitherof these items available, the unavailability would haveincreased substantially, from 15.9% to 26.2% for theintraosseous needle and 6.6% to 17.8% for drug doseguidelines. It is likely that equipment availability amongnonresponders would be similar to or worse than thatamong responders. This conclusion is supported by theresults of our validation study. Discordance between theresults of the mailed questionnaire and the site visit areconsistent with potential problems of finding the equip-ment needed at the time of an acute resuscitation. Suchdisagreement may indicate that certain individuals do notknow where or what equipment is available, or thatequipment is not being checked or replaced on a consis-tent basis. Thus, true unavailability is likely to be moreprevalent than suggested by our results.

Given the poor response to publicized lists of neces-sary resuscitation equipment, other solutions to the prob-lem should be sought to ensure that pediatric equipmentis available. The most efficacious solution would be a re-quirement by hospital-accrediting organizations thatpediatric resuscitation equipment be available in all hos-pital EDs. Given that most hospitals already have a defi-brillator and pulse oximeter but merely require the pedi-atric adapters, the estimated cost of equipping an ED formost of the items listed in this study is very low. Most of


Table 4.Adjusted odds ratios (and 95% CIs) for selected pediatric resuscitation equipment unavailability.

Equipment Items

Pediatric 3-mm InfantIntraosseous Drug Dosing Pulse Defibrillation Endotracheal Bag-Valve-Mask

Potential Determinants Needle* Guide Oximeter* Paddles* Tube† System

Hospital level III 1.38 (0.57, 6.40) 3.27 (0.38, 28.22) 0.90 (0.46, 1.81) 1.72 (0.49, 11.50) NA† 1.50 (0.16, 13.71)Annual census <10,000 2.00 (0.84, 4.47) 1.90 (0.57, 6.30) 1.22 (0.62, 2.64) 1.87 (0.54, 5.70) 0.34 (0.06, 1.93) 2.62 (0.58, 11.74)<10% of pediatric visits 2.47 (1.36, 5.35) 1.08 (0.43, 2.70) 1.61 (0.95, 3.04) 1.75 (0.79, 4.25) 3.98 (0.62, 25.56) 1.44 (0.45, 4.57)No pediatrician on call for ED 3.12 (1.12, 11.34) 1.20 (0.31, 4.63) 1.05 (0.49, 1.97) 1.62 (0.57, 6.31) 2.58 (0.28, 23.80) 3.47 (0.40, 30.14)No PALS-trained physician on staff 2.18 (1.33, 3.50) 3.76 (1.45, 9.78) 1.85 (1.03, 3.27) 1.84 (0.88, 3.91) 4.66 (1.03, 21.00) 2.41 (0.75, 7.77)Distance >200 km from university center 1.66 (1.05, 3.24) 1.37 (0.62, 3.03) 1.26 (0.75, 1.91) 0.85 (0.46, 1.74) 1.53 (0.43, 5.46) 0.75 (0.28, 1.20)<3 pediatric resuscitations/y 1.61 (0.87, 3.08) 2.44 (0.98, 6.10) 1.85 (1.07, 3.27) 1.42 (0.69, 3.15) 1.44 (0.34, 6.16) 1.41 (0.48, 4.15)

NA, Not available.*CIs calculated by the bootstrap method; other CIs calculated by Wald’s method.†The logistic regression model for the 3-mm endotracheal tube excludes hospital level, as the model including this potential determinant did not converge.


In summary, this study has demonstrated that essentialpediatric resuscitation equipment is unavailable in a dis-turbingly high number of EDs across Canada. Anecdotalreports are available to suggest that these deficiencieshave played a role in difficult pediatric resuscitations.19 Asystematic review of past coroners’ inquests across Canadawould help to confirm the adverse consequences of un-available emergency equipment. In the meantime, physi-cians and hospital administrators should ensure that basicpediatric resuscitation equipment is available in all EDs.

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19. Wilson T. Inquest into the death of Jad El-Khatib deceased March 19, 1995. File number14850. Province of Ontario: Office of the Coroner; April 1996.

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critical pediatric equipment availability in canadian hospital emergency departments

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