AIRWAY/RESPIRATORY MANAGEMENT Essential (E) Desired (D) Minimum Quantity Necessary Available 1. Bag-valve-mask resuscitator, self-inflating □ Infant (240 cc) E 2 □ Yes □ No □ Child (500 cc) E 2 □ Yes □ No □ Adult (1000 cc) E 2 □ Yes □ No 2. Masks to fit bag-mask device adaptor □ Neonatal E 2 □ Yes □ No □ Infant E 2 □ Yes □ No □ Child E 2 □ Yes □ No □ Adult E 2 □ Yes □ No
3. Continuous Positive Airway Pressure Device (CPAP) D 1 □ Yes □ No 4. Chest tubes □ Infant (8.5 – 12 F) [at one size in this range] E 2 □ Yes □ No □ Child (16 – 24 F) [at least one size in this range] E 2 □ Yes □ No □ (28 – 40 F) [at least one size in this range] E 2 □ Yes □ No 5. Endotracheal (Cuffed Preferred) Cuffed or Uncuffed □ 2.5 mm E 2 □ Yes □ No □ 3.0 mm E 2 □ Yes □ No
□ 3.5 mm E 2 □ Yes □ No □ 4.0 mm E 2 □ Yes □ No □ 4.5 mm E 2 □ Yes □ No □ 5.0 mm E 2 □ Yes □ No □ 5.5 mm E 2 □ Yes □ No Cuffed □ 6.0 mm E 2 □ Yes □ No □ 6.5 mm E 2 □ Yes □ No □ 7.0 mm E 2 □ Yes □ No
□ 7.5 mm E 2 □ Yes □ No □ 8.0 mm E 2 □ Yes □ No 6. Laryngoscope blades Curved □ 2 E 1 □ Yes □ No □ 3 E 1 □ Yes □ No Straight □ 0 E 1 □ Yes □ No □ 1 E 1 □ Yes □ No □ 2 E 1 □ Yes □ No □ 3 E 1 □ Yes □ No
7. Laryngoscope Handle E 1 □ Yes □ No 8. Nasal cannula □ Infant E 2 □ Yes □ No □ E 2 □ Yes □ No □ Adult E 2 □ Yes □ No 9. Feeding Tubes □ 5 F E 1 □ Yes □ No □ 8 F E 1 □ Yes □ No 10. Nasopharyngeal Airways to include: □ Infant D 2 □ Yes □ No
□ Child D 2 □ Yes □ No □ Adult D 2 □ Yes □ No 11. Nebulizer E 2 □ Yes □ No 12. Oral airways E 1 □ Yes □ No □ 00 E 1 □ Yes □ No □ 0 E 1 □ Yes □ No □ 1 E 1 □ Yes □ No □ 2 E 1 □ Yes □ No □ 3 E 1 □ Yes □ No □ 4 E 1 □ Yes □ No □ 5 E 1 □ Yes □ No
13. Clear oxygen masks (standard and nonrebreathing) Standard □ Infant E 2 □ Yes □ No □ Child E 2 □ Yes □ No □ Adult E 2 □ Yes □ No Nonrebreathing □ Infant E 2 □ Yes □ No □ Child E 2 □ Yes □ No □ E 2 □ Yes □ No 14. Magill Forceps to include
16. Stylets (for endotracheal tubes) □ Pediatric E 2 □ Yes □ No □ Adult E 2 □ Yes □ No 17. Suction catheters (flexible) Infant □ 6 F E 4 □ Yes □ No □ 8 F D 4 □ Yes □ No Child □ 10 F E 4 □ Yes □ No □ 12 F D 4 □ Yes □ No Adult □ 18 F E 4 □ Yes □ No
18. Tracheostomy tubes (Available within the hospital) □ 2.5 mm E 2 □ Yes □ No □ 3.0 mm E 2 □ Yes □ No □ 3.5 mm E 2 □ Yes □ No □ 4.0 mm E 2 □ Yes □ No □ 4.5 mm E 2 □ Yes □ No □ 5.0 mm E 2 □ Yes □ No □ 5.5 mm E 2 □ Yes □ No 19. Yankauer suction tip E 2 □ Yes □ No 20. Laryngeal Mask Airway (LMA) E 1 □ Yes □ No
□ Size 1 E 1 □ Yes □ No □ Size 1.5 E 1 □ Yes □ No □ Size 2 E 1 □ Yes □ No □ Size 2.5 E 1 □ Yes □ No □ Size 3 E 1 □ Yes □ No □ Size 4 E 1 □ Yes □ No □ Size 5 E 1 □ Yes □ No 21. Needle Cricothyrotomy Supplies E 1 □ Yes □ No 22. Surgical Cricothyrotomy Kit E 1 □ Yes □ No
CONTINUING Education (At least ONE RN per shift must meet these qualifications.) Essential (E) Desired (D) Available 1. Death of a child in Emergency Department/SIDS □ PALS; or □ ENPC E □ Yes □ No 2. Cardiac care to include: Bradycardia, Ventricular Fibrillation/Pulseless Ventricular Tachycardia, Asystole/Pulseless Electrical Activity, and Narrow Complex Tachycardia □ ACLS; or □ ENPC; or □ PALS; or □ PEPP E □ Yes □ No 3. Community, staff, and physician education programs in pediatric emergency care □ APLS; or □ ENPC; or □ PALS, or □ PEPP □ Hospital education for staff in pediatric patients and age specific/cultural diversity education may be hospital specific, trauma community or injury prevention. E □ Yes □ No 4. Infectious Diseases D □ Yes □ No
9. Pediatric Basic Life Support □ CPR E □ Yes □ No 10. Pediatric Interfacility transport, evaluation, and management □ ENPC, or □ PALS, or □ TNCC; or □ Yearly Hospital protocols, policies, and transfer agreements (hospital specific) E □ Yes □ No 11. Poisoning □ ENPC; or □ PALS D □ Yes □ No 12. Respiratory to include: Asthma/bronchiolitis □ ENPC; or □ PALS, or □ PEPP E □ Yes □ No
Croup □ ENPC; or □ PALS; or □ PEPP E □ Yes □ No Epiglottitis □ ENPC; or □ PALS; or □ PEPP E □ Yes □ No Pneumonia □ ENPC; or □ PALS E □ Yes □ No Respiratory failure □ PALS, or □ PEARS; or □ PEPP; or □ TNCC; or E □ Yes □ No
□ PEARS; or □ ENPC Cardiogenic shock □ ENPC; or □ PALS; or □ PEARS; or □ PEPP E □ Yes □ No 14. Trauma to include: Abdominal trauma/multi-trauma □ ENPC; or □ PALS; or □ PEPP; or □ TNCC E □ Yes □ No Amputations/avulsions □ ENPC; or □ PALS; or E □ Yes □ No
□ TNCC Burns – cyanide poisoning □ ENPC; or □ PALS; or □ TNCC E □ Yes □ No Burns – smoke inhalation □ ENPC; or □ PALS; or □ TNCC E □ Yes □ No Chest Trauma □ ENPC; or □ PEPP; or □ TNCC E □ Yes □ No Child abuse □ ENPC; or □ PEPP; or □ TNCC; or E □ Yes □ No
EMERGENCY DEPARTMENT SERVICES Essential (E) Desired (D) Available 1. 24-hour operating room D □ Yes □ No 2. Helipad (on-site/on-campus) D □ Yes □ No 3. Transfer guidelines and agreements (are capable of evaluating, managing, and transferring) E □ Yes □ No 4. Pre-hospital education program offerings D □ Yes □ No 5. Telemedicine: Capability with pediatric regional referral center. Recommended □ Yes □ No
IMMOBILIZATION Essential (E) Desired (D) Minimum Quantity Necessary Available 1. Extremity splints Femur splints □ Child E 1 □ Yes □ No □ Adult E 1 □ Yes □ No 2. Pediatric restraining devices (i.e. Papoose Board or other appropriate restraint device) E 1 □ Yes □ No 3. Spinal stabilization devices appropriate for children of all ages 4. Rigid Cervical Collars □ Infant E 2 □ Yes □ No □ Pediatric E 2 □ Yes □ No □ Adult E 2 □ Yes □ No
Long Spine Board E 2 □ Yes □ No LABORATORY SERVICES Essential (E) Desired (D) Minimum Quantity Necessary Available 1. 24-hour basic clinical Lab (including techniques for small sample sizes) E □ Yes □ No □ Microsampling Capability E □ Yes □ No
MISCELLANEOUS Essential (E) Desired (D) Minimum Quantity Necessary Available 1. Weight scale locked in kilograms (not pounds) E N/A □ Yes □ No 2. External heat source must include each of the following: □ Blanket warmer E 1 □ Yes □ No □ Infrared lamps E 1 □ Yes □ No □ Overhead warmer (Available within the hospital) E 1 □ Yes □ No □ Bair Hugger D 1 □ Yes □ No 3. Medication tape, or other system to ensure ready access to information on proper per kilogram doses for resuscitation drugs and equipment sizes # E 1 □ Yes □ No Type your facility uses: □ Broselow® Pediatric Emergency Tape® (Current Edition) □ Pedi-Wheel®
4. Doppler ultrasonography devices D 1 □ Yes □ No 5. Electrocardiography monitor/defibrillator with pediatric and adult capabilities including pediatric pads. E 1 □ Yes □ No 6. End-tidal CO2 Detection Device E 1 □ Yes □ No 7. Wave Form Capnography D 1 □ Yes □ No 8. Monitor Electrodes □ Pediatric E N/A □ Yes □ No □ E N/A □ Yes □ No 9. Pulse oximeter with sensors □ Neonatal E 1 □ Yes □ No □ Infant E 1 □ Yes □ No □ Child E 1 □ Yes □ No
11. Sodium bicarbonate □ 4.2% E □ Yes □ No □ 8.4% E □ Yes □ No 12. Activated charcoal (mixed with water) E □ Yes □ No 13. Analgesics □ Topical E □ Yes □ No □ Oral E □ Yes □ No □ Parenteral E □ Yes □ No 14. Antimicrobial agents (including cefotaxime or gentamicin) □ Parenteral E □ Yes □ No
15. Anticonvulsants medications □ Levetiracetam (Keppra) D □ Yes □ No □ Lorazepam E □ Yes □ No □ Fosphenytoin or Phenytoin E □ Yes □ No □ Phenobarbital E □ Yes □ No □ Diazepam E □ Yes □ No 16. Antidotes (common antidotes should be accessible to the Emergency Department.) N-acetylcysteine
□ Oral D □ Yes □ No □ IV E □ Yes □ No Fomepizol E □ Yes □ No 17. Antipyretic drugs Acetaminophen □ Suspension E □ Yes □ No □ Tablets E □ Yes □ No □ Suppository E □ Yes □ No Ibuprofen □ Suspension E □ Yes □ No □ Tablets E □ Yes □ No 18. Bronchodilators □ Albuterol □ Yes □ No
E □ Racemic Epinephrine E □ Yes □ No 19. Corticosteroids E □ Yes □ No 20. Inotropic/Vasopressor agents □ Epinephrine E □ Yes □ No □ Dopamine E □ Yes □ No □ Milrinone D □ Yes □ No 21. Intravenous solutions to include: □ normal saline E □ Yes □ No □ dextrose 5% in normal saline E □ Yes □ No □ dextrose 10% in water E □ Yes □ No □ 3% sodium chloride D □ Yes □ No
One Nurse per shift with PALS or ENA Pediatric Emergency Nursing Course (ENPC)Completed/Current E □ Yes □ No 6. Other Clinical Social Worker on-call □ Yes □ No Pastoral care provider on-call □ Yes □ No POLICIES, PROCEDURES, AND/OR PROTOCOLS Essential (E) Desired (D) Available 1. ED Pediatric Triage addressing ill and injured children E □ Yes □ No 2. ED Pediatric Patient Assessment and Reassessment E □ Yes □ No 3. Immunization Assessment and Management of the Child E □ Yes □ No
Written guidelines for the transfer of children with social and mental health issues to an appropriate facility policy 11. Emergency Department trained on the location of all pediatric equipment and medication E □ Yes □ No 12. Daily method for the proper location and function of pediatric supplies and equipment and method for restocking after use E □ Yes □ No 13. Emergency Department restocking and evaluating medication expiration dates. E □ Yes □ No 14. Procedure and codes for child abduction alert in your facility E □ Yes □ No 15. Guidelines for referring children or their laboratory specimens to an appropriate facility when the capability of the hospital is exceeded. E □ Yes □ No 16. Policy for obtaining and transfusing blood products in pediatric patients (Less than 20 kg) E □ Yes □ No
QUALITY ASSURANCE/PERFORMANCE IMPROVEMENT Essential (E) Desired (D) Available 1. Structured Quality Assurance/Performance Improvement program/process for the pediatric population (Written Policy and Procedures) E □ Yes □ No 2. Review of all pediatric deaths E □ Yes □ No 3. Review of all pediatric incident reports E □ Yes □ No 4. Multidisciplinary trauma and resuscitation conferences D □ Yes □ No 5. Participate in Trauma registry D □ Yes □ No 6. Review of all Emergency Department readmits 48 hour □ Yes □ No Other (Describe) □ Yes □ No D □ Yes □ No 7. Review of pediatric transports and pre-hospital care D □ Yes □ No
RADIOLOGY Essential (E) Desired (D) Available MEDICAL IMAGING CAPABILITY 1. A documented process for referring pediatrics to appropriate facilities for necessary radiologic procedures when medical capabilities are unavailable (Policy can be covered through interagency agreements/guidelines). E □ Yes □ No 2. Computed Tomography (CT Scan) D □ Yes □ No 3. Magnetic Resonance Imaging (MRI) Recommended □ Yes □ No 4. Radiography (X-ray) □ Bone E □ Yes □ No □ Chest E □ Yes □ No 5. Ultrasound Capabilities D □ Yes □ No 6. Ability to transmit/transfer radiographic images to referring center □ Electronic (i.e. Image Grid) D □ Yes □ No □ Hard copy disk D □ Yes □ No
SPECIALIZED PEDIATRIC KIT/TRAY Essential (E) Desired (D) Minimum Quantity Necessary Available 1. Lumbar puncture – Spinal Needle (may be inside the lumbar puncture tray) □ 20G –1 ½ length D 1 □ Yes □ No □ 20G – 2 ½ Length D 1 □ Yes □ No □ 22G – 1 ½ Length E 1 □ Yes □ No □ 22G – 2 ½ or 3 ½ Length E 1 □ Yes □ No 2. Newborn Delivery kit including equipment for resuscitation of an infant □ Bulb syringe E 1 □ Yes □ No □ Meconium aspirator E 1 □ Yes □ No □ Scissors E 1 □ Yes □ No □ Towels E 1 □ Yes □ No □ Umbilical E 1 □ Yes □ No □ Umbilical vessel cannulation supplies E 1 □ Yes □ No
3. Obstetric pack (to include all of the following items) □ Baby Blanket (for drying) E 2 □ Yes □ No □ Bulb Syringe E 1 □ Yes □ No □ Cord Clamps E 2 □ Yes □ No □ Sterile Scalpel E 1 □ Yes □ No 4. Tube thoracotomy tray E 1 □ Yes □ No 5. Water seal drainage capability E 1 □ Yes □ No 6. Urinary catheterization with pediatric catheters □ 6F or □ 8F E 1 □ Yes □ No □ 10F or □ 12F E 1 □ Yes □ No □ 14F or □ 16F E 1 □ Yes □ No
7. Venous cutdown D 1 □ Yes □ No VASCULAR ACCESS Essential (E) Desired (D) Minimum Quantity Necessary Available 1. Arm boards (Pediatric) E 2 □ Yes □ No 2. Butterfly needles □ 19 g or □ 21 g D N/A □ Yes □ No □ 23 g D N/A □ Yes □ No □ 25 g D N/A □ Yes □ No 3. Catheter-over-needle devices □ 14 g E N/A □ Yes □ No □ 16 g E N/A □ Yes □ No
□ 18 g E N/A □ Yes □ No □ 20 g E N/A □ Yes □ No □ 22 g E N/A □ Yes □ No □ 24 g E N/A □ Yes □ No 4. Central venous access kit (with pediatric catheters) D N/A □ Yes □ No 5. Infusion Device/Pump E 2 □ Yes □ No 6. Intraosseous Access Equipment: Infant E 2 □ Yes □ No □ Manual Intraosseous Needle □ EZ-IO® Intraosseous Infusion System □ (please indicate) E 2 □ Yes □ No
□ Manual Intraosseous Needle □ EZ-IO® Intraosseous Infusion System □ Other (please indicate) 7. Intravenous fluid/blood warmers E 1 □ Yes □ No 8. Syringes □ 1cc E 5 □ Yes □ No □ 3 cc E 5 □ Yes □ No □ 10 cc E 5 □ Yes □ No