Adult Level I Trauma Center Pediatric Readiness Needs Assessment

Pediatric patients present unique clinical challenges that require specific resources and protocols. Many adult Level I trauma centers lack ample pediatric-specific policies and training to treat the traumatically injured child. Implementing strategies to strengthen the adult trauma center promotes pediatric readiness. This Doctor of Nursing scholarly project aimed to conduct a needs assessment to identify barriers and best practices for achieving pediatric readiness in an American College of Surgeons (ACS) verified adult Level I trauma center without pediatric verification. Key issues include the lack of a Pediatric Emergency Care Coordinator (PECC), gaps in pediatric-specific policies, limited staff training and education, inadequate pediatric equipment and supply management, institutional reluctance and potential financial constraints, under utilization of organizational resources, and staff fear of litigation. Addressing these issues is essential for the trauma center to meet the ACS Committee on Trauma's pediatric readiness standard and provide high-quality pediatric trauma care. The project was guided by the Johns Hopkins Evidence-Based Practice model, collecting data through a review of existing pediatric standards, staff training programs, cause and effect analysis, and a benchmark survey of sixteen adult Level I trauma centers. Interventions included a literature review identifying best practices. Key stakeholders were engaged in planning and designing a benchmark survey to adult Level I trauma centers without pediatric verification. Organizational clinical practice and policy were reviewed. Strength, Weaknesses, Opportunities, and Threats (SWOT) analyses were conducted examining a pediatric case review, staff dialogs, and stakeholder discussions. Significant gaps were found in pediatric-specific policies, particularly in patient transport. The absence of a PECC was a critical weakness. Staff reported discomfort with pediatric cases due to low exposure and limited training. Organizational resources were unknown or underutilized. Benchmark survey insights highlighted the importance of collaboration with pediatric trauma centers and the need for regular training and simulation scenarios. The pediatric case review emphasized the need for improved pediatric supply and equipment management. This needs assessment identified critical areas for improvement in pediatric readiness at an adult Level I trauma center without pediatric verification. Implementing the recommended strategies will enhance the trauma center's ability to provide high-quality care to traumatically injured pediatric patients, aligning with ACS standards to improve patient outcomes.

1 Adult Level I Trauma Center Pediatric Readiness Needs Assessment Cherisse Marie Davis, Luanna Schmelter College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III 28 April 2025 2 Abstract Background Pediatric patients present unique clinical challenges that require specific resources and protocols. Many adult Level I trauma centers lack ample pediatric-specific policies and training to treat the traumatically injured child. Implementing strategies to strengthen the adult trauma center promotes pediatric readiness. This Doctor of Nursing scholarly project aimed to conduct a needs assessment to identify barriers and best practices for achieving pediatric readiness in an American College of Surgeons (ACS) verified adult Level I trauma center without pediatric verification. Local Problem Key issues include the lack of a Pediatric Emergency Care Coordinator (PECC), gaps in pediatric-specific policies, limited staff training and education, inadequate pediatric equipment and supply management, institutional reluctance and potential financial constraints, underutilization of organizational resources, and staff fear of litigation. Addressing these issues is essential for the trauma center to meet the ACS Committee on Trauma’s pediatric readiness standard and provide high-quality pediatric trauma care. Methods The project was guided by the Johns Hopkins Evidence-Based Practice model, collecting data through a review of existing pediatric standards, staff training programs, cause and effect analysis, and a benchmark survey of sixteen adult Level I trauma centers. Interventions Interventions included a literature review identifying best practices. Key stakeholders were engaged in planning and designing a benchmark survey to adult Level I trauma centers without 3 pediatric verification. Organizational clinical practice and policy were reviewed. Strength, Weaknesses, Opportunities, and Threats (SWOT) analyses were conducted examining a pediatric case review, staff dialogs, and stakeholder discussions. Results Significant gaps were found in pediatric-specific policies, particularly in patient transport. The absence of a PECC was a critical weakness. Staff reported discomfort with pediatric cases due to low exposure and limited training. Organizational resources were unknown or underutilized. Benchmark survey insights highlighted the importance of collaboration with pediatric trauma centers and the need for regular training and simulation scenarios. The pediatric case review emphasized the need for improved pediatric supply and equipment management. Conclusion This needs assessment identified critical areas for improvement in pediatric readiness at an adult Level I trauma center without pediatric verification. Implementing the recommended strategies will enhance the trauma center’s ability to provide high-quality care to traumatically injured pediatric patients, aligning with ACS standards to improve patient outcomes. Keywords: needs assessment, pediatrics, adult Level I trauma center 4 Adult Level I Trauma Center Pediatric Readiness Needs Assessment Problem Description Traumatic injury remains a leading cause of death among children (Melhado et al., 2024; Ross et al., 2023; Stone, 2022). The First National Pediatric Readiness Assessment, which included 4,100 hospitals, revealed that general emergency centers, rather than definitive care centers, treat over 80% of children (Gausche-Hill et al., 2015). Inconsistent levels of oversight have been challenging for decades; this complicated the establishment of a standardized approach for emergency departments (EDs) to treat pediatric patients (American Academy of Pediatrics et al., 2009; Melhado et al., 2023a). Medical community representatives have encouraged regulatory bodies to incorporate pediatric readiness for emergency rooms to prevent harm that can occur without proper preparation; data suggests that inadequate pediatric readiness can lead to increased morbidity and mortality among injured children (Melhado et al., 2023a; Newgard et al., 2023b; 2024; Remick & Cramer, 2020). In 2022, the American College of Surgeons Committee on Trauma (ACS COT) introduced standard 5.10, mandating pediatric readiness for all trauma centers they verify (Ross et al., 2023). Two elements measure compliance to this standard: (a) annually completing the national pediatric readiness assessment and (b) addressing the identified gaps (ACS, 2022). An ACS-verified adult Level I trauma center completed this national readiness assessment in October 2023, scoring approximately 63 out of 100; the center has not addressed the identified gaps. This score ranks at the lower mid-range for an adult Level I trauma center, indicating that while the ED meets some pediatric care standards, critical elements are still lacking, presenting significant opportunities for improvement (Melhado et al., 2024). The lack of crucial pediatric readiness elements is unacceptable to the trauma program leadership, who are 5 committed to continuous improvement and strive to provide optimal care for all trauma patients. This needs assessment addressed the gaps in the adult Level I trauma center. Available Knowledge Despite similar clinical practices to manage severely injured patients, children provide unique clinical challenges requiring specific resources and protocols (Russell & Biswas, 2023). Anatomical and physiological differences, such as large heads, weak necks, pliable bones, and small, crowded torsos, differ from adults. Children also mask the typical signs of traumatic injury, such as quickly developing hypoxia and losing significant blood volume without exhibiting hypovolemic shock (Russell & Biswas, 2023). These differences are significant enough that the ACS created a pediatric center verification. However, not all health centers have found the need to obtain this verification— clinical outcomes between pediatric trauma centers and adult centers have not proven significant enough to mandate it (Russell & Biswas, 2023). While pediatric verification is not required, a standard of pediatric readiness was felt to be needed to address disparities in the trauma system and improve access to quality pediatric trauma care, garnering national and statewide attention (Stephens & Fallat, 2024; Stone, 2022). In 2006, the National Pediatric Readiness Project (NPRP) was launched, recognizing the disparities in accessing quality resuscitative pediatric care (Melhado et al., 2023b). Four years later, there was a call for standardized statewide, territorial, and regional systems to manage pediatric medical emergencies and trauma (Melhado et al., 2023b). In 2015, a weighted pediatric readiness assessment tool was created for national benchmarking and comparison, utilizing a weighted Pediatric Readiness Score (wPRS). Centers that scored a high wPRS produced impactful, significant outcomes, such as, a 60-76% reduction in mortality (Gausche-Hill et al., 6 2015; Melhado et al., 2023a; Newgard et al., 2021; 2023b; Stone, 2022). The best practice threshold of maintaining a Pediatric Readiness Score (PRS) of 90 or higher demonstrated the biggest impact on reducing childhood mortality and indicated that centers have improved resource allocation, organizational standards, and staff training (Newgard et al., 2024). A call to integrate pediatric readiness into regulatory body standards prompted the American College of Surgeons to take action (ACS, 2022). Adult Level I trauma centers are not exempt from this standard (ACS, 2022). Both low-volume (<1800 patients per year) and medium-volume (1,800 to 4,999 patients per year) general EDs demonstrated success in reaching pediatric readiness levels obtained by high-volume centers (>10,000 patients per year) as they implement best practice interventions and work collaboratively with pediatric medical centers (Abulebda et al., 2022; Barata et al., 2020). Pediatric readiness has been proven highly cost-effective, providing good value to a healthcare system ($9,300 compared to a typical $50,000+) for monies spent to improve one year of healthy life (Remick et al., 2024; Weyant et al., 2024). Its improvement expenditures vary, ranging from $23,775 to $145,521 (around $4 to $48 per pediatric patient), with equipment costs expense only 0.9-5.0% of the total—seemingly not cost-prohibitive (Remick et al., 2024). Engaging both a physician and nurse pediatric emergency care coordinators (PECCs) is the most endorsed best practice to improve an ED’s pediatric readiness (Auerbach et al., 2023; Barata et al., 2020; Boggs et al., 2021; Desai & Remick, 2024; Foster et al., 2023; Gausche-Hill et al., 2015; Ray et al., 2021; Samuels‐Kalow et al., 2024). The PECC role is associated with facility improvements in the coordination of care, maintenance of staff’s skill competency and continued education, better clinical care practice outcomes, quality program implementation, and improved 7 equipment and resource management (Abulebda et al., 2021; Barata et al., 2020; Samuels-Kalow et al., 2022; Tucker et al., 2024). Establishing the best practice of recording weight in kilograms is a simple and essential way to improve pediatric readiness (Newgard et al., 2023a; Remick et al., 2019). Whereas the lack of or non-adherence to specific organizational policies, e.g., transportation, assessment, triage, mental health, and disaster planning, produce gaps toward sound pediatric care (Freire et al., 2023; Newgard et al., 2023a; Remick et al., 2019). Rationale The Johns Hopkins Evidence-Based Practice Model (JHEBPM) guided this project (Figure 1) (Dang et al., 2022). JHEBPM's three phases are: (a) identifying the problem, (b) gathering evidence, and (c) translating the evidence. The initial inquiry focused on how an adult Level I trauma center meets the ACS COT standard using a preliminary literature search to identify best practices and clinical gaps. This review guided the analysis of Strengths, Weaknesses, Opportunities, and Threats (SWOT) (Helms & Nixon, 2010). The model emphasized understanding current practices, leading to a benchmark survey for evaluation and learning. Evidence was translated into actionable steps for the emergency department’s pediatric readiness plan and clinical practices, prompting further inquiry for continuous quality improvement. Utilizing JHEBPM highlighted the importance of a standardized approach for planning, developing, and executing the needs assessment. Specific Aims This Doctor of Nursing (DNP) scholarly project aimed to conduct a needs assessment to identify barriers and best practices for adult Level I trauma centers to achieve pediatric readiness status. A secondary purpose was to provide stakeholders with guidance and recommendations for 8 the ACS-verified adult Level I trauma center’s ED to effectively meet the ACS COT’s pediatric readiness standard. The project also evaluated stakeholder feasibility, usability and satisfaction to ensure practical implementation and acceptance of the recommendations. Methods Context This ED needs assessment was conducted at a 600+ bed academic medical center in the urban Salt Lake region. This facility was Utah’s first ACS-verified adult Level I trauma center. The ED treats over 3,000 pediatric patients from all socioecological backgrounds and ethnicities annually. Pediatric patients under 18 years old accounted for about 6% of the total trauma volume, with 2.6% under 15. The trauma catchment area includes Utah and the surrounding seven states (Montana, Idaho, Wyoming, Colorado, Arizona, Nevada, and New Mexico) and their urban, suburban, and rural regions. Participants include an interdisciplinary leadership team—specifically the trauma program leadership, trauma physician providers, the ED trauma physician liaison, and ED nursing leadership. Intervention(s) The SWOT analysis initiated in phase one, followed by an evidence-based practice (EBP) review, focused on high-quality studies from the past five years, including observational cohort studies and systematic reviews. These studies, such as those examining the PRS and its link to improved pediatric trauma survival rates, provided valuable insights into best practices and identified barriers to improving trauma centers’ pediatric readiness. The department’s current system-level readiness was assessed by reviewing their national pediatric readiness assessment score and engaging in discussions with the ED Assistant Nurse Manager and Trauma Program Manager. These meetings fostered open-ended dialogue regarding current care practices and the 9 project's overall usability, feasibility, and satisfaction. National benchmarking with the Trauma Center Association of America (TCAA) emerged as a critical need to determine specific steps for success. TCAA has identified other adult-only trauma centers and upcoming findings that will be distributed to trauma centers in the forthcoming months. Organizational trauma educational offerings, training, policies, and procedures were evaluated and summarized to identify potential gaps or missed opportunities. In phase two, the continued SWOT analysis identified and assessed barriers to implementing a pediatric readiness plan. A targeted benchmark survey (Appendix A) was created and disseminated to other adult Level I trauma centers without their pediatric verification. Survey results were collected and analyzed, revealing common themes, and subjected to descriptive statistical analysis. Phase three focused on compiling the action plan to address gaps in order to meet the pediatric readiness standard. This plan included the summation of EBP, benchmarking, and organizational-specific findings. All findings, conclusions, and recommendations were presented to trauma program leadership and ED leadership stakeholders. Their elicited feedback was incorporated into the readiness plan. The feasibility, usability, and satisfaction of the final readiness plan were evaluated through open dialogue, leading to an executive summary and a recommendation plan for the ED to implement going forward. Study of the Intervention(s) This needs assessment evaluated pediatric readiness in an adult Level I trauma center without pediatric verification. It identified critical gaps by reviewing literature best practices, benchmarking, examining current clinical practices, and interviewing staff. A benchmark survey (Appendix A) with other ACS-verified adult Level I trauma centers identified best practices and 10 barriers. The survey focused on defining pediatric readiness, best practice strategies, barriers, PECC employment resuscitation skills and staff certification and training. Comparing the trauma center’s current state to survey findings gauged usable and feasible improvements, allowing peer comparison of staff training, pediatric-specific protocols, and resources. Data were organized into SWOT analyses, revealing internal strengths and weaknesses, opportunities, and threats. Preliminary findings confirmed the trauma center’s lack of pediatric readiness. The needs assessment benchmarking, SWOT analyses, stakeholder input to determine feasibility, usability and satisfaction to form a readiness plan and executive summary aimed to ensure future compliance with ACS Standard 5.10. Measures The benchmarking survey and SWOT analyses evaluated the processes and outcomes of pediatric trauma care. The trauma program manager and TCAA’s Director of Education and Projects provided contacts for other ACS-verified adult Level I trauma centers assumed not pediatric-verified. TCAA included the survey in their October newsletter. Surveys were sent to 26 locations; one contact was outdated, and three opted out due to different verification statuses. Benchmark survey data were collected using REDCap (Research Electronic Data Capture) tools hosted at the University of Utah (Harris et al., 2009; 2019). The survey included validated qualitative and quantitative questions adapted from previous pediatric readiness assessments (Remick et al., 2023; Samuels-Kalow et al., 2022). The survey’s pilot test confirmed clarity and consistency. REDCap is a secure, web-based software platform designed to support data capture for research studies, providing (a) an intuitive interface for validated data capture; (b) audit trails for tracking data manipulation and export procedures; (c) automated export procedures for seamless data downloads to common statistical packages; and (d) procedures for 11 data integration and interoperability with external sources. Feasibility and usability insights were found in the qualitative questions identifying barriers and best practices, while quantitative questions described the trauma center’s characteristics, staffing, and training. The qualitative data sources included benchmarking survey results, post-trauma event case reviews, and staff and stakeholder discussions. Face-to-face interviews with open-ended questions allowed participants to express their thoughts and experiences, with additional probing questions for clarification. Interviews and group discussions were transcribed verbatim, and observation notes were taken. Qualitative analysis categorized data into strengths, weaknesses, opportunities, or threats. A presentation of needs assessment findings to stakeholders gathered feedback on feasibility, usability, and satisfaction, culminating in an executive summary and readiness plan with recommendations for the next steps. Analysis Descriptive statistics characterized benchmark survey content, including facility characteristics, proximity to pediatric trauma centers, and staff certifications. Qualitative content analysis identified key themes and categorized responses to open-ended questions. Further qualitative analysis was iterative, starting after the first staff interview and continuing until all staff were represented and data showed repetition. A similar process was used for stakeholder discussions, demonstrating data saturation. Ethical Considerations The University of Utah deemed this pediatric readiness needs assessment a quality improvement project, exempting it from institutional review board oversight. All benchmark survey participant data were de-identified and stored securely on the REDCap platform. The pediatric case review was also de-identified, protecting confidentiality, and participants were 12 limited to direct medical care providers. The results anonymized stakeholder discussion feedback. All participants in the benchmark survey and stakeholder discussions received information about the purpose of the needs assessment and voluntarily provided their input. There were no conflicts of interest. Results Standards Review A review of the existing organizational pediatric standards revealed nineteen policies and guidelines, excluding the inpatient burn center's pediatric standards (Table 1). Most were related to the adult center's air ambulance team. Three addressed patient transport, but the adult center's policy lacked specific guidance for pediatric patients from the adult trauma center's ED to the children's hospital. Other policies addressed clinical care needs, e.g., managing airway, mental health, pain, diagnostic imaging, and medications. The disaster plan emphasized treating any injured person during a disaster, regardless of age. The emergency medicine director affirmed that bi-annual disaster drills include one to two pediatric patients. None of these policies referred to the Utah Pediatric Trauma Network (UPTN) standards. UPTN, a state-supported program, aims to improve pediatric trauma outcomes and implement injury-prevention initiatives across Utah. It identified seventeen clinical guidelines for adult-only trauma centers (Table 1) based on the Pediatric Emergency Care Applied Research Network (PECARN) and the American Pediatric Surgical Association (APSA) standards. UPTN plans to expand these guidelines and encourage their use (Appendix B). A UPTN report demonstrated sport as the primary mechanism of injury for the adult Level I trauma center's pediatric patients, differing from the rest of the state (Appendix C). Staff Training and Education 13 The ED’s pediatric resources were assessed (Table 2). Content included pediatric crash cart staff education, a reference list with medical supply and equipment photos, and a checklist for maintaining items. A general staff training module reviewed high-level pediatric care and unit-specific practices. All ED RN staff completed the Trauma Nursing Core Course (TNCC) and Pediatric Advanced Life Support (PALS) training; ED charge nurses also completed the Advanced Trauma Care for Nurses (ATCN) course, which includes a pediatric component. Trauma Advanced Practice Clinicians (APCs) do not receive PALS training and lack this certification. In 2022, the trauma program purchased sixteen trauma-specific education modules from the Society of Trauma Nurses (STN), but only seven were made available. A pediatric trauma module was one of the missing nine. In 2024, 18% of ED staff completed the available modules (Figure 2). The BTICU is the only unit endorsing inpatient trauma pediatric care. Since 2019, BTICU has developed and conducted regular in-person pediatric training—basic and critical (Table 2), covering trauma skills like primary and secondary assessment, fluid resuscitation, triaging injury, and respiratory management. Internal System SWOT A discussion with BTICU leadership and staff (n=5) revealed themes completing an internal facility SWOT analysis. This SWOT revealed five main themes for the strengths, weaknesses, and threats, and four for the opportunities (Table 3). Strengths identified were existing collaboration possible with the pediatric hospital, current burn trauma pediatric initiatives, pediatric guidelines and protocols, simulation-based training, and the skin bud role (Table 4). Weaknesses identified were the absence of a PECC, knowledge gaps, high staff 14 turnover, fragmented current policies and protocols, resource and financial limitations, and pediatric equipment and supply management (Table 5). Opportunities included leveraging the pediatric hospital’s relationship, shared training programs, enhanced use of UPTN guidelines, and improved collaboration across departments (Table 6). Threats included fear of litigation, institutional reluctance, limited pediatric resource availability, uncertain financial support, and limited pediatric pharmacy support (Table 7). Benchmark Survey and SWOT Sixteen adult Level I trauma centers without pediatric verification took the benchmark survey. All centers completed the demographics portion (Table 8). Most survey respondents were trauma program managers (n=9, 56.3%). Demographics revealed that the adult Level I trauma centers held ACS verification for an average of 18.5 years. Most (n=10, 66.7%) were located within five miles of a pediatric trauma center, and the majority were not associated with that center (n=8, 53.3%). The benchmarked centers staffed on average 149 RN full-time equivalent (FTE), were located in an urban region (n=14, 87.5%), held the not-for-profit tax status (n=13, 81.3%), and were an academic center (n=11, 73.3%). Most centers comprised the general and comprehensive ED types (n=6, 37.5%). Six centers completed the best practice portion of the benchmark survey, which included quantitative and qualitative responses (Table 9). The majority of centers do not employ an MD PECC (60%) but do use a non-MD PECC (60%)—a full-time RN without additional compensation, e.g., shift differential or increased salary. Most centers (80%) felt confident meeting the ACS pediatric readiness standard. These centers expressed equal confidence levels for airway management, vascular access, and resuscitating (comfortable 40%, somewhat comfortable 40%), with less comfort expressed when stabilizing after a traumatic brain injury 15 (TBI) and chest trauma (a little 40%, comfortable 40%). The adult centers further indicated clinical task comfort at a minimum age of 8 years for airway management, resuscitating, and stabilizing after TBI and chest trauma and comfort with a minimum age of 4.5 years for vascular access. Benchmarked centers reported that the staff mostly completed the ATLS, PALS, TNCC, and ATCN training over other trainings. The qualitative benchmark survey best practice portion revealed further insight for a SWOT analysis—six main strengths and weaknesses, five opportunities themes, and four for the threats category (Table 10). Strengths identified were collaboration with pediatric facilities, education initiatives, dedicated personnel, established transfer processes, high pediatric readiness scores, and strong pediatric equipment management (Table 11). Weaknesses identified were low pediatric volumes, lack of MD PECC, barriers to transfer timing, staff hesitancy for pediatric champion roles, maintaining supplies and expirations, and lack of pediatric-specific physicians (Table 12). Opportunities included expanded pediatric training programs, enhanced PECC roles, interdisciplinary teams, dedicated pediatric QI processes, and simulation collaboration with pediatric hospitals (Table 13). Threats included skill attrition due to low pediatric cases, the misconception of the value of pediatric readiness at an adult center, inconsistent resource ownership, and difficulty retaining pediatric champions (Table 14). Pediatric Case Review and SWOT A serendipitous pediatric trauma case during the needs assessment allowed for a recent pediatric event review and further qualitative analysis. Six clinical team participants (trauma attending, physician assistants, a pharmacist, an ED provider, and an ED RN) received interview questions for a pediatric case review SWOT analysis; five completed the questionnaire (Appendix D). This SWOT analysis revealed six categories' main themes (Table 15). Strengths 16 included collaborative efforts, pharmacy competence, experienced staff, rapid recognition and triage, smooth transfer, and quick response (Table 16). Weaknesses included lack of familiarity with pediatric equipment, limited training, inconsistent protocols, dependence on ED staff, equipment gaps, and hesitation and lack of confidence (Table 17). Opportunities included enhanced simulation training, formal protocols, certification and training programs, collaboration with pediatric experts, improved pediatric supply and equipment management, and reference guides (Table 18). Threats included infrequent cases, inadequate anesthesia support, delayed responses, reliance on key personnel, uncertainty in protocols, and facility confusion (Table 19). Discussions with children's hospital trauma medical directors revealed provider and system-level improvement opportunities (Appendix E). A cause and effect diagram analyzed systems, processes, and individual factors, revealing six primary causes (Figure 3). Secondary causes included lack of pediatric expertise, limited experience with pediatric care and dosing, no formal trauma timeout, inefficient coordination, slow decision-making, missing, mislabeled or unfamiliarity with equipment and supplies, logistical issues, lack of protocols, inadequate communication, insufficient training, and delays due to comforting the child. Needs assessment findings and recommendations were presented to stakeholders (Appendix F). Stakeholders, including trauma program and emergency room leadership, expressed feasibility, usability, and satisfaction with the assessment, recognizing its potential to significantly enhance pediatric readiness in the adult Level I trauma center. They understood it was necessary to maintain ACS verification for the organization. However, they noted institutional reluctance to support pediatric readiness proactively, fearing it might only be endorsed following patient harm events. An executive summary was crafted for leadership (Appendix G). 17 Discussion Summary An ACS-verified adult Level I trauma center's ED conducted a national pediatric readiness assessment in response to the ACS Standard 5.10, guided by the JHEBP model. The national assessment score of almost 63 out of 100 indicated a lower mid-range ranking, demonstrating some pediatric care standards met but lacking critical elements. The needs assessment scholarly project revealed significant opportunities for improvement compared to the benchmarked centers. Findings aligned with the literature and identified new insights through direct observations, analysis, and stakeholder input. Some findings challenged assumptions and contradicted expectations, highlighting fundamental gaps and illuminating previously unrecognized barriers. Recognizing these findings enabled strategic realignment, improved standardization, practical solutions to meet ACS standards, and effective data-driven decisions. Strengths included participants’ willingness to share knowledge and the adult trauma center staffs’ strong desire to strengthen the trauma system, demonstrating project feasibility. Organizational stakeholders supported and planned to adopt the DNP project’s recommendations because it aligned with regulatory standards and with the adult center's mission to provide excellent trauma care—providing further feasibility, usability, and satisfaction. Interpretation Unsurprisingly, the lack of the PECC role was identified as a significant weakness. Literature supports the importance of this role to oversee pediatric standards, training, and protocol implementation (Abulebda et al., 2021; Auerbach et al., 2023; Barata et al., 2020; Boggs et al., 2021; Desai & Remick, 2024; Foster et al., 2023; Gausche-Hill et al., 2015; Ray et al., 2021; Samuels‐Kalow et al., 2024). Benchmarked centers typically used the non-physician 18 PECC, usually a nurse, and lacked a physician PECC—an absence identified as a weakness. Surprisingly, benchmarked centers reported confidence in their pediatric readiness, possibly overestimating their capabilities. PECCs and trauma educators were instrumental in organizing and maintaining pediatric readiness. However, benchmarked centers cautioned that staff might hesitate to champion or remain in the PECC role. Internal findings at the adult Level I trauma center showed a strong desire to assign a dedicated PECC, ideally a full-time RN, to act as a staff resource, connect with the national trauma system, the local children's hospital, UPTN, and liaise with the facility’s trauma program. Appointing an ED physician as an additional PECC would oversee protocols, maintain relationships with the pediatric hospital's trauma team, and provide oversight for continuous quality improvement. Staff reported discomfort with pediatric cases due to low exposure and limited training, despite over 3,000 pediatric ED visits annually. This may indicate a disconnect between fundamental readiness and trauma care team competency, suggesting the need for regular training. Literature shows that similar facilities achieved pediatric readiness equivalent to highvolume centers by implementing best practices, training staff, and collaborating with pediatric trauma centers (Abulebda et al., 2022; Barata et al., 2020). Benchmarked groups emphasized regular skills fairs, mock simulations, and required PALS, TNCC, and ATCN training to maintain skills and confidence. PALS is not required for the adult center's trauma APCs, and although the trauma program offered to cover costs, staff have not participated. Given the infrequency of high-acuity pediatric trauma cases, the adult trauma center should carefully focus on the pediatric clinical skills curriculum (Thornton et al., 2023). Benchmarked centers claimed 40% higher and 40% somewhat higher comfort levels for airway 19 management, vascular access, and resuscitation for children aged 8, 5, and 8, respectively. Comfort levels for stabilizing after traumatic brain injuries and chest trauma were 40% little and 40% high for children aged 8. The needs assessment suggested focusing on specific clinical skills and ages to improve staff comfort levels. While Newgard et al. (2023a) and Remick et al. (2019; 2024) strongly support pediatricspecific training for ED readiness, the needs assessment revealed a gap between available and utilized training. The adult center's BTICU conducts regular in-person two-part pediatric care series educating staff on basic and critical trauma components. Resource nursing and respiratory therapy attend these sessions, and the ED staff could join for all trauma-relevant content. The adult center purchased the Society of Trauma Nurses' trauma education modules, including a pediatric module, but nine modules are missing from the staff education platform. Only 18% of ED staff in 2024 completed the available modules, suggesting low engagement, lack of accountability or incentives, training fatigue, or other potential staff workload barriers in the high turnover department. Benchmarked peer groups reported success through collaboration with pediatric centers for training, simulations, and establishing efficient transfer protocols. Literature supports this, and the needs assessment showed underutilized collaboration with the children's hospital (Abulebda et al., 2022; Barata et al., 2020; Melhado et al., 2023b). The case review highlighted collaboration opportunities suggesting developing and integrating pediatric trauma scenarios into the adult center's regular trauma simulation training. The children’s trauma team could teach the adult center staff on how to balance compassion with trauma intervention priorities, since they are not used to the emotional response of treating injured children. Lastly, enhanced 20 communication between the adult and children hospitals' trauma teams would strengthen both programs. Despite a smooth patient transfer with the pediatric case, gaps remain in the patient transfer process. Staff were confused about policies preventing anesthesia providers from entering the adjoining pediatric trauma center. Literature supports standardizing pediatric trauma protocols, especially safe transfers (Freire et al., 2023; Newgard et al., 2023a; 2023b; Remick et al., 2019; Stephens & Fallat, 2024). The current protocol surprisingly lacked pediatric-specific guidelines for a critical transfer from the adult Level I trauma center’s ED to the children's hospital. Pediatric trauma leadership suggested developing a direct-to-operating room (OR) transfer protocol for critically injured children, specifically severe neurological injuries. The needs assessment disclosed the staff's perception of institutional reluctance and potential financial constraints to support essential pediatric readiness. This finding was not unique to the adult trauma center. Benchmarked peer facilities voiced similar concerns, claiming pediatric readiness may be undervalued by organizational leadership at adult Level I trauma centers. The literature suggests increased institutional buy-in for pediatric readiness when adult center leadership understands this practice is an ACS standard necessary for the Level I trauma verification and has proven significant mortality reductions and cost-effectiveness ($4-$48 per patient) (Newgard et al., 2023b; Remick et al., 2024; Weyant et al., 2024). The adult center’s staff uniquely expressed a stronger fear of litigation when participating in pediatric cases than found in the literature. Previous studies have noted this concern among adult center staff (Boggs et al., 2021; Russell & Biswas, 2023; Samuels‐Kalow et al., 2024). This fear aligns with the need to address staff confidence in pediatric skills and suggests that legal education or reassurance about liability protection could potentially mitigate this finding. 21 The needs assessment demonstrated that improved management of pediatric equipment and supplies at the adult trauma center is necessary. Staff struggled to locate and use pediatric supplies with carts understocked, mislabeled, or missing essential items despite existing visual guides and tip sheets. Critical equipment remained broken without an alternative. Previous studies emphasize the importance of equipment and supply availability and training, noting its direct impact on patient outcomes (Gausche-Hill et al., 2015; Newgard et al., 2023a; Remick et al., 2019). However, the literature does not highlight issues of disorganized, missing, or mislabeled stock. Staff reported that this mismanagement led to delays during pediatric trauma treatment. Benchmarked facilities echoed the difficulty of maintaining correct supply par levels and added that avoiding expiration remains a persistent challenge. Yet, they attributed strong pediatric equipment management part of their readiness success. The internal analysis indicated difficulty in obtaining appropriate pediatric equipment and supplies, suggesting a lack of administrative buy-in or hesitancy to prioritize pediatric readiness for the institution. Staff also questioned financial support, claiming budget constraints too restrictive to support needs adequately. The needs assessment confirmed the importance of developing a pediatric trauma readiness continuous quality improvement (CQI) program. Literature strongly supports robust CQI programs, central to an ideal safety culture, where data are collected, analyzed, and shared to improve outcomes (American Academy of Pediatrics et al., 2009; Desai & Remick, 2024; Gausche-Hill et al., 2015; Melhado et al., 2024; Remick et al., 2016). Benchmarked facilities reported success with formalized reviews, feedback on pediatric trauma cases, and interdisciplinary CQI teams. The adult trauma center’s trauma program already has a wellestablished CQI process for reviewing and monitoring trauma outcomes. 22 Recommendations This pediatric readiness needs assessment confirmed the adult center’s national pediatric readiness findings, demonstrating opportunities for system improvements. It revealed previously unknown gaps in the current pediatric readiness status, served as a forum for staff to express their concerns and opinions, benchmarked best practices with similar centers, and acted as an improvement roadmap offering recommendations for system-level enhancements. The assessment disclosed multiple areas of opportunity to strengthen the trauma program and enhance pediatric readiness in the adult Level I trauma center's ED. Establish PECC Role ED nurse leadership should designate a PECC. Ideally, a registered nurse would fill this role alongside a physician PECC. Together, they would focus on promoting appropriate clinical protocols, advocating for and securing necessary resources, and driving an ongoing quality improvement program. The PECC role provides the foundation for a strong, sustained readiness platform, acting as the glue connecting staff with the many resources available to support clinical practice. Enhance Pediatric Specific Training and Education The adult center has established several training and educational opportunities but can expand offerings further. Trauma APCs should complete and maintain PALS training to improve comfort levels with clinical skills. The fear of litigation, which seems connected to the staff's skill level and confidence, should be addressed directly. Consider adding provider and practitioner staff education regarding legal protections to ease hesitancy in caring for pediatric cases. Additionally, provider-focused protocol tip sheets for quick-reference guides should be developed for use in the trauma bay during events. 23 A pediatric scenario should be added to the trauma team in-situ simulation training curriculum, allowing medical and nursing staff to practice clinical skills. Simulation content should be derived from the most frequent mechanism of injury and formulated in collaboration with the pediatric hospital's trauma team. Consider integrating ED staff into BTICU's pediatric basic and critical clinical skills education. Ensure clinical staff complete the nine missing Society of Trauma Nurses (STN) trauma modules in the organization's education platform. At a minimum, the nursing PECC role should be required to complete the STN pediatric module and attend the UPTN education offerings to stay current with evidence-based practices and disseminate this information to staff. The adult center should consider adding a more substantial pediatric component for future organizational disaster drills to test the logistics of the trauma system's capacity management and system response effectiveness between the adult center's ED and the pediatric hospital. To date, the adult center has only tested scenarios with minimal pediatric involvement. Drills should consider including a larger volume of pediatric patients arriving at the adult center's ED to test mass casualty incidents or various system impacts, e.g., power outages, exposing resource management vulnerabilities. Improve Pediatric Supply and Equipment Management Assign specific ED staff to conduct regular pediatric supply and equipment audits, ensuring the correct items are readily available. This includes rotating supplies to remove expired products, stocking to correct par levels, and ensuring that storage shelves and drawers are properly labeled and legible. All missing and broken equipment should be found, repaired, or replaced. Backup equipment, shared between departments, should be routinely assessed for availability and functionality. 24 Develop or Clarify Pediatric Protocols and Optimize Transfer and Transport Logistics Connect the PECC to the recommended UPTN adult trauma center pediatric protocols. Evaluate the content for relevance and appropriateness for use within the adult center's system and ensure access to this content. Develop additional rapid care protocols, e.g., direct-to-OR, for situations where transfer time is critical for life-threatening conditions. Revise the adult center's critical transport policy to include pediatric patient transfers from the ED to the pediatric trauma hospital. Remove inter-facility access barriers between the adult center and the children's hospital. Strengthen Collaboration with the Pediatric Trauma Hospital Collaborate with the children's hospital for pediatric simulation training and consider annual joint grand rounds for further staff training. Improve the communication pathways to assist with real-time events. Practice intra-facility transfers for disaster drill scenarios. Maintain a Pediatric Continuous Quality Improvement Program Implement a structured review of all pediatric trauma cases to identify areas for ongoing improvement. Report patient outcomes, system vulnerabilities, and successes to the adult center's trauma program. Monitor pediatric readiness metrics, including completing the national pediatric readiness needs assessment at least annually and addressing improvement opportunities. Track staff training completions and hold staff accountable to meet established parameters. Engage Institutional Leadership for Pediatric Readiness Buy-In Pediatric readiness in an adult trauma center cannot succeed without institutional support. Advocating for leadership support, emphasizing cost-effectiveness, providing staff training time, funding repairs and replacements for broken or missing equipment and supplies, and establishing sustainable processes demonstrates commitment for pediatric readiness. Institutions that 25 prioritize a patient safety culture proactively implement and promote preventative quality initiatives. Pediatric readiness should be considered a fundamental standard within such systems, such as, a verified trauma center. Limitations While the needs assessment considered strategies all adult trauma centers should focus on to meet ACS standard 5.10, it centered around a specific healthcare system within the Intermountain West, potentially limiting the findings' generalizability to other adult Level I trauma centers. However, it can be assumed that benchmarking with similar adult Level I trauma centers that were not pediatric verified produces analogous findings relatable to all adult trauma centers. The benchmark survey relied on volunteer participation through direct contact with the adult center or potential participants noticing the opportunity to participate in TCAA's October newsletter. This selection bias may have limited the overall survey enrollment. Additionally, the benchmark survey comprised two separate parts: a demographic section and a best practice section. Fewer centers completed the best practice portion than the demographic section. The survey design may have attributed to this lower participation. While explicit instruction urged participants to continue, they could quit when completing the demographic portion. Despite this flawed design, data saturation was achieved for a productive benchmark analysis. Conclusions Investing in pediatric readiness for an adult Level I trauma center is critical not only for meeting regulatory standards but also for providing care to traumatically injured pediatric patients who may enter the emergency doors. By strengthening the entire trauma network, 26 pediatric readiness elevates emergency community response and prepares adult centers for future organizational growth, anticipating greater demand for these services. Adult trauma centers face a particular challenge as pediatric readiness is often underestimated—it is not their primary focus. Leadership at adult trauma centers must recognize the value pediatric readiness adds to their institution and actively provide commitment and support. Feasibility, usability, and satisfaction were obtained from the stakeholders, confirming the practicality and effectiveness of this needs assessment. Moving forward, it is important for the ED and trauma program to secure leadership buy-in, implement the recommendations, and share best practices with other adult-only trauma centers to strengthen the pediatric readiness within the trauma system. 27 Acknowledgments I want to express my sincere gratitude to my chair, Dr. Luanna Schmelter, for her insightful guidance and solid support in shaping this project—Lu, you straightened me out when I went astray. My program manager, Dr. Teresa Garrett, is purely inspirational—a true nurse leader and friend, thank you. The Dick and Timmy Burton Scholarship funded monies to thank participants and print a poster—that invaluable backing is greatly appreciated. My cohort, friends, and family were a tremendous support. It has been quite a journey, and I am a better person because of all of you. Janet, your support, love of, and vision for outstanding trauma systems is truly inspirational—making the world a better place one-step at a time. Brava! A special thanks to my cousin and friend, Tiffany, for her steadfast encouragement, expert editing, and invaluable assistance—I hope the process was not too egregious on your part! Most importantly, my deepest and heartfelt thanks go to my parents, Delmar and Marie, whose constant belief, love, and unwavering support in me have made all the difference—this one’s for you. Deepest gratitude; hou je tij! 28 References Abulebda, K., Lutfi, R., Petras, E. A., Berrens, Z. J., Mustafa, M., Pearson, K. J., Kirby, M. L., Abu-Sultaneh, S., & Montgomery, E. E. (2021). Evaluation of a Nurse Pediatric Emergency Care Coordinator–Facilitated Program on Pediatric Readiness and Process of Care in Community Emergency Departments After Collaboration With a Pediatric Academic Medical Center. Journal of Emergency Nursing, 47(1), 167–180. Scopus. https://doi.org/10.1016/j.jen.2020.06.006 Abulebda, K., Whitfill, T., Mustafa, M., Montgomery, E. E., Lutfi, R., Abu-Sultaneh, S., Nitu, M. E., Auerbach, M. 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Health Affairs, 43(10), 1370–1378. https://doi.org/10.1377/hlthaff.2023.01489 36 Table 1 Adult Level I Trauma Center’s Pediatric Policies and UPTN Pediatric Clinical Standards Adult trauma center pediatric clinical guidelines UPTN guidelines recommended for the PED-ED center AirMed Adult/Pediatric: Blunt Abdominal Injury Combative, Agitated and/or Uncooperative Patients Blunt Chest Injury Emergent Obstetric Care Blunt TBI General Trauma Care Burn Treatment AirMed Pediatric: Cervical Spine Injury Airway Management Cervical Spine Screening Anaphylaxis Child Physical Abuse Cardiac Emergencies Expedited Transport DKA Facial Trauma General Medical Transport Hypothermic Arrest General Transport Guideline Open Fracture Seizure Orbital Trauma Sepsis Pediatric Massive Transfusion Pediatric Trauma Patient Psychiatric Consult Activation Pelvic Fracture Pediatric Patients MRI Prehospital TBI RT Adult/Pediatric High Flow Nasal Cannula Supracondylar Fracture RT Pediatric Mechanical Ventilation Thoracolumbar Spine Injury Pain Assessment, Reassessment and Management Patient Abuse, Neglect and/or Exploitation Patient Transport Transfer a Disaster Plan/Mass Casualty Incident b Note. The table exhibits current standards found at the adult trauma center and those recommended by UPTN; UPTN = Utah Pediatric Trauma Network; PED-ED = adult only trauma center that stabilizes and transfers a pediatric patient; ED = Emergency Department; DKA = Diabetic ketoacidosis; TBI = Traumatic Brain Injury; RT = Respiratory Therapy. a This policy lacks transport guidance for a pediatric patient from the adult trauma center’s ED to the children’s hospital, but contains several examples of steps taken to transfer a child from the children’s hospital to the adult center for clinical procedure purposes. b This standard merely emphasizes the facility plans to treat any injured person who arrives during a disaster or mass casualty incident and denotes that bi-annual disaster drills include one to two pediatric injured patients to test system management. 37 Table 2 Pediatric Resources at the Adult Level I Trauma Center ED’s current pediatric references and training Pediatric Crash Cart Supplies Checklist Pediatric Crash Cart and Equipment Pediatric Crash Cart Reference Sheet Pediatric Education Details Excel file identifying an itemized list of supplies for each drawer PowerPoint dated October 2022 Word document with photos showing drawer content PowerPoint dated September 2022 and PowerPoint on the pediatric tile on Education’s PULSE site Triage Process Checklist Word document Training TNCC, PALS, and ATCN required for ED staff TNCC and PALS for all ED RN staff; ATCN for all charge nurses Trauma program The trauma program manager purchased the STN trauma training modules and uploaded them into the LMS (an organizational staff education software). STN modules with Pediatric Component • The Trauma Team From Prehospital Through the ED • Emergency Preparedness • Traumatic Brain Injury • Mechanism of Injury • Maxillofacial and Ocular Injuries • Abdominal Trauma • Hemorrhagic Shock Pediatric Basic and Critical Trauma Training Improvement suggestion Add supply par levels and reorder number Add that weights should be in kilograms only Add trauma information Integrate department education with STN module State weights should be in kilograms Maximize STN module usage. . Upload all STN modules into LMS. Nine are missing—the pediatric module is one of those missing. Require at a minimum the PECC to complete the pediatric module. Establish accountability for module completion. BTICU In-person two-day pediatric skills training. Basic created in 2019, revised 2022; critical with simulation created 2023. Allow ED staff to join sessions. Note. This table denotes all known quick references, staff education, and training currently available at the adult Level I trauma center; ED = Emergency Department; TNCC = Trauma Nursing Core Course; PALS = Pediatric Advanced Life Support; ATCN = Advanced Trauma Care for Nurses; RN = Registered Nurse; PULSE = organization’s Sharepoint site that contains all intra facility communication; STN = Society of Trauma Nurses; LMS = Learning Management System 38 Table 3 Internal System SWOT STRENGTHS • • • • • Existing collaboration possible with the pediatric hospitals Burn trauma pediatric initiatives Pediatric guidelines and protocols Simulation-based training Skin Bud role OPPORTUNITIES • • • • Leveraging the children hospital’s relationship Shared training programs Enhanced use of UPTN guidelines Improved collaboration across departments WEAKNESSES • • • • • Absence of PECC Knowledge gaps and high staff turnover Fragmented current policies and protocols Resource and financial limitations Pediatric equipment and supply management THREATS • • • • • Fear of litigation Institutional reluctance for pediatric care Limited pediatric resource availability Uncertain financial support Limited pediatric pharmacy support 39 Table 4 Internal System SWOT Strengths Analysis Major themes • Existing collaboration possible with pediatric hospitals • Subcategories • Strong partnerships with the pediatric hospital and statewide networks that facilitate shared protocols and resources. Access to statewide pediatric resources, such as the Pediatric Pandemic Network and Western Region Alliance can help strengthen readiness. Burn trauma pediatric initiatives • Burn trauma has robust pediatric-specific education efforts including critical care classes and mock code scenarios. • Guidelines and protocols • Usage of Utah Pediatric Trauma Network (UPTN) evidencebased pediatric-specific guidelines. Collaborative protocols with the ED ensures unified approaches. • Simulation-based training • Regular simulations tailored to pediatric scenarios in BTICU joined by resource nursing and respiratory therapy. • Skin Bud role • Informal role providing mentorship and skill reinforcement for new staff in pediatric care—specializes in continual staff education on equipment, clinical skills, and protocol updates. 40 Table 5 Internal System SWOT Weakness Analysis Major themes Subcategories • Absence of PECC • No dedicated PECC for nursing or physicians roles. • Knowledge gaps and high staff turnover • Staff turnover and limited pediatric training have eroded institutional knowledge. • Fragmented current policies and protocols • Pediatric policies are not standardized or easily accessible across departments in the organization—hard to find. • Resource and financial limitations • Budget constraints and limited institutional support for pediatric readiness and care. • Pediatric equipment and supply management • Difficulty in obtaining appropriate pediatric equipment and supplies. 41 Table 6 Internal System SWOT Opportunities Analysis Major themes Subcategories • Leveraging the children hospital’s relationship • Adopting existing protocols and training from the children’s hospital could save time, improve relationships, and strengthen readiness. • Shared training programs • Burn unit already has pediatric training that ED staff could join for similar and relevant content. • Enhanced use of UPTN guidelines • Integrate UPTN’s guidelines into current trauma pediatric care. • Improved collaboration across departments • Strengthen partnerships between ED, trauma, and burn units for unified pediatric care strategies, such as resource management. Model the Skin Bud model used by Burn Trauma for a pediatric role in the ED. 42 Table 7 Internal System SWOT Threats Analysis Major themes Subcategories • Fear of litigation • Staff reluctance of participating in pediatric cases due to malpractice concerns can hinder care delivery. • Institutional reluctance for pediatric care • Lack of administrative buy-in and hesitancy amount staff to prioritize pediatric readiness. • Limited pediatric resource availability • Challenges in maintaining specialized equipment and trained personnel for pediatric care. • Uncertain financial support • Budget constraints and institutional priorities threaten sustained pediatric readiness efforts. • Limited pediatric pharmacy support • Lack of pharmacists formally trained in pediatrics; inability for providers to order some medications. 43 Table 8 Benchmark Survey Demographics N=16 (%) Survey respondent’s role TPM 9 (56.3) PI Coordinator 2 (12.5) TMD Other 1 (6.3) 4 (25.0) Mean ± SD Median (Min, Max) 18.5 (12.37) 18 (1, 40) <5 Miles 5-10 Miles 11-20 Miles 21-50 Miles >50 Miles 10 (66.7) 1 (6.7) 0 (0.0) 1 (6.7) 3 (20.0) Yes No 7 (46.7) 8 (53.3) Mean ± SD Median (Min, Max) 148.91 (116.84) 100 (50, 372) Urban Suburban Rural 14 (87.5) 1 (6.3) 1 (6.3) For-profit Not-for-profit Government 0 (0.0) 13 (81.3) 3 (18.8) University Community Non-teaching 11 (73.3) 3 (20.0) 1 (6.7) Standby Basic General Comprehensive 0 (0.0) 4 (25.0) 6 (37.5) 6 (37.5) Years as verified adult Level I Nearest pediatric trauma center Associated with pediatric center Emergency department RN FTEs Facility geographical location Facility tax status Facility type Facility ED type 44 Table 9 Benchmark Survey Best Practice Analysis Uses MD PECC (n=5) Y (2, 40%) N (3, 60%) Uses non-MD PECC (n=5) Y (3, 60%) N (2, 40%) PECC compensated (n=3) Y (0, 0.0%) N (3,100%) Non-MD PECC FTE (n=2) 1.0 (100%) Non-MD PECC role (n=3) RN 3 (100%) EMT/Paramedic, Advanced practice provider, other 0 (0.0%) Confident pediatric readiness standard met (n=5) Agree Neutral 4 (80.0%) 1 (20.0%) Clinical Care a Airway management Vascular access Not 0 (0.0%) A Little 1 (20.0%) Somewhat 2 (40.0%) Comfortable 2 (40.0%) 0 (0.0%) 1 (20.0%) 2 (40.0%) 2 (40.0%) Resuscitating 0 (0.0%) 1 (20.0%) 2 (40.0%) 2 (40.0%) Stabilizing after TBI/chest trauma 0 (0.0%) 2 (40.0%) 1 (20.0%) 2 (40.0%) % Training c ATLS Min 0 Max 100 Mean 33.33 StDev 57.74 PALS 2 100 67.33 56.58 TNCC 20 100 67.40 34.91 ATCN 0 100 29.20 41.24 ENPC 1 10 5.50 6.36 CEN 10 30 20 10 TCRN 10 10 10 0 Disagree 0 (0.0%) Minimum Age b Mean ± SD 7.75 (6.95) Median (Min, Max) 8 (0, 15) Mean ± SD 6 (6.38) Median (Min, Max) 4.5 (0,15) Mean ± SD 7.75 (6.95) Median (Min, Max) 8 (0, 15) Mean ± SD 7.75 (6.95) Median (Min, Max) 8 (0, 15) Note. This table demonstrates the dichotomous questions and Likert scale used in the best practice portion of the benchmark survey (Appendix A). a Indicates the number of facilities comfortable performing the specified clinical care. b Indicates the youngest age the benchmarked facility was comfortable with in performing the specified clinical task; minimum age 0; maximum age 18. c Indicates the percentage of ED staff that have completed the specified clinical training. 45 Table 10 Benchmark Best Practice SWOT STRENGTHS • • • • • • Collaboration with pediatric facilities Education initiatives Dedicated personnel Established transfer processes High pediatric readiness scores Strong pediatric equipment management OPPORTUNITIES • • • • • Expanded pediatric training programs Enhanced PECC roles Interdisciplinary teams Dedicated pediatric QI processes Simulation collaboration with pediatric hospitals WEAKNESSES • • • • • • Low pediatric volumes Lack of MD PECC Barriers to transfer timing Staff hesitancy for pediatric champion roles Maintaining supplies and expirations Lack pediatric-specific MD THREATS • • • • Skill attrition due to low pediatric cases Misconception of value Inconsistent resource ownership Difficulty retaining pediatric champions 46 Table 11 Benchmark Best Practice SWOT Strengths Analysis Major themes Subcategories • Collaboration with pediatric facilities • Adult Level I trauma centers benefits from proximity and partnerships with pediatric hospitals for aiding in training, simulations, and transfers. • Education initiatives • Regular skills fairs and mock simulations to maintain staff competency. Require PALS, TNCC, and ATCN. • Dedicated personnel • Pediatric Emergency Care Coordinators (PECCs) and trauma educators were mentioned as instrumental in organizing and maintaining pediatric readiness. • Established transfer processes • Emphasized rapid stabilization and transfer processes and strong pre-hospital triaging. • High pediatric readiness scores • Centers conducted readiness gap analyses with notable improvements in their scores after identifying weaknesses. • Strong pediatric equipment management • Centers emphasized organized and stocked pediatric supplies, including dedicated pediatric carts and trauma bays. 47 Table 12 Benchmark Best Practice SWOT Weakness Analysis Major themes Subcategories • Low pediatric volumes • Adult Level I trauma centers report low pediatric patient volumes that lead to skill attrition and reduced staff confidence. • Lack of MD PECC • The absence of an MD PECC reduces leadership and oversight for pediatric trauma readiness. • Barriers to transfer timing • Delays occur in transferring pediatric patients, particularly from rural facilities. • Staff hesitancy for pediatric champion roles • Challenges exist in identifying individuals willing to champion pediatric readiness initiatives. • Maintaining supplies and expirations • Ensuring par levels of supplies and avoiding expiration issues remains a persistent challenge. • Lack of pediatric-specific MD • Some centers lack pediatric-focused providers. 48 Table 13 Benchmark Best Practice SWOT Opportunities Analysis Major themes Subcategories • Expanded pediatric training programs • Increase training through PALS, ATCN, and mock trauma simulations to maintain competence and confidence. • Enhanced PECC roles • Introducing or formalizing a MD PECC to provide stronger leadership and coordination. • Interdisciplinary teams • Creating pediatric readiness interdisciplinary teams that involve Trauma, Pre-Hospital, Pharmacy, and QI for continuous improvement. • Dedicated pediatric QI processes • Formalized reviews and feedback on pediatric trauma cases. • Simulation collaboration with pediatric hospitals • Continued partnership with pediatric hospitals to refine care through joint simulations. 49 Table 14 Benchmark Best Practice SWOT Threats Analysis Major themes Subcategories • Skill attrition due to low pediatric cases • Minimal exposure to pediatric patients can erode staff readiness and confidence. • Misconception of value • Organizational leadership may undervalue pediatric readiness. • Inconsistent resource ownership • Pediatric readiness may falter if not “owned” by a committed department. • Difficulty retaining pediatric champions • Staff reluctance to take on PECC responsibilities . 50 Table 15 Pediatric Case Direct Care Provider SWOT STRENGTHS • • • • • • Collaborative efforts Pharmacy competence and accuracy Presence of experienced staff Rapid recognition and triage Smooth transfer processes Quick response time WEAKNESSES • • • • • • OPPORTUNITIES • • • • • • Enhanced simulation training Formal pediatric protocols Certification and training programs Collaboration with pediatric experts Improved pediatric supply and equipment management Reference guides for clinical practice Lack of familiarity with pediatric equipment Limited pediatric training Inconsistent or lack of understanding protocols Dependence on ED staff for pediatric expertise Equipment gaps Hesitation and lack of confidence THREATS • • • • • • Infrequent pediatric cases Inadequate anesthesia support Delayed responses Reliance on key ED personnel Uncertainty in pediatric protocols Facility confusion 51 Table 16 Pediatric Case Direct Care Provider SWOT Strengths Analysis Major themes Subcategories • Collaborative efforts • Trauma team effectively collaborated with ED providers, a pediatric RN specialist, and other key departments to improve patient outcomes (e.g., pharmacy and anesthesia). • Pharmacy competence and accuracy • • Presence of experienced staff • Reliable pharmacy support ensured proper dosing. Accurate and timely medication dosing calculations based off kilograms and supported with use of Broselow tape. Case benefited from ED physician and ED RN with stronger pediatric experience. • Rapid recognition and triage • Strong initial response to the critically ill pediatric patient. • Smooth transfer processes • Transfers to the pediatric facility was handled effectively. • Quick response time • Trauma team was already in the ED when the patient arrived. 52 Table 17 Pediatric Case Direct Care Provider SWOT Weaknesses Analysis Major themes Subcategories • Lack of familiarity with pediatric equipment • Difficulty locating and using pediatric-specific equipment and supplies. Some was missing or not stocked properly. • Limited pediatric training • • Inconsistent or lack of understanding protocols • Gaps in training for trauma, respiratory therapy (RT), and ED staff, such as ATLS, PALS or simulation-based pediatric scenarios. Absence or lack of standardized pediatric protocols. Policy barriers preventing anesthesia providers from entering the pediatric facility. • Dependence on ED staff for pediatric expertise • Trauma teams relied on ED expertise due to insufficient pediatric-specific knowledge. • Equipment gaps • Pediatric carts were understocked, poorly labeled and lacked essential items. Reliance on adult ventilator by RT. • Hesitation and lack of confidence • Providers and staff expressed discomfort and fear due to minimal pediatric exposure. 53 Table 18 Pediatric Case Direct Care Provider SWOT Opportunities Analysis Major themes Subcategories • Enhanced simulation training • Tailoring simulations to pediatric trauma scenarios to build familiarity with pediatric scenarios and increase competency. • Formal pediatric protocols • Developing and adopting standardized protocols to guide clinical care, including inter-facility transfers. Get help from pediatric facility to create protocols as needed. • Certification and training programs • Requiring certifications like PALS for APCs or suggesting ENPC training to improve the competence of some staff. Increase exposure to pediatric trauma in residency and APC training. • Collaboration with pediatric experts • Engaging with pediatric facility trauma leaders to conduct grand rounds or assist in protocol development and simulation training. • Improved pediatric supply and equipment management • Introducing checklists and better stocking practices for maintaining the pediatric carts. • Reference guides for clinical practice • Developing bedside quick reference sheets or tip sheets for pediatric clinical care. 54 Table 19 Pediatric Case Direct Care Provider Threats Analysis Major themes • Subcategories • Low pediatric trauma volume leading to skill attrition among staff and skill degradation. • Infrequent pediatric cases Inadequate anesthesia support • Limited availability of anesthesia for pediatric airway management in emergencies. • Delayed responses • Slow responses due to unfamiliarity with equipment, protocols, and pediatric scenarios. • Reliance on key personnel • Case expertise depends on the availability of individuals with pediatric experience. • Uncertainty in pediatric Protocols • Staff were unfamiliar with key pediatric interventions. • Facility confusion • Families confusing the adult Level I center as the pediatric medical center. 55 Figure 1 Johns Hopkins Evidence-Based Practice Model (2020) Note. (Dang et al., 2022). 56 Figure 2 Available Society of Trauma Nurses Staff Education Modules Usage A 2024 Number of Staff Who Completed STN Trauma Modules Available STN Modules Abdominal Trauma 31 Maxillofacial/Ocular Injuries 27 TBI 27 Hemorrhagic Shock 46 MOI 33 Emergency Preparedness 33 Trauma Team Prehosp Thru ED 37 0 10 20 Number of Staff 30 40 50 B STN Modules Percentage Completed by Unit IP #1 1% IP #2 1% Nursing Units Adult ED 18% IP #3 48% IP #4 6% IP #5 3% IP #6 0% Flight 2% Other ED 8% Other 12% 0% 10% 20% 30% 40% Percentage Completion 50% 60% Note. The figure denotes the STN modules currently available for staff education; STN = Society of Trauma Nurses. 57 Figure 3 Trauma Pediatric Case Review Cause and Effect Diagram with Actionable Items Determine Actionable Items • • • • • • Training: Develop and integrate pediatric trauma scenarios into regular simulation training in collaboration with the pediatric trauma center’s trauma team. Coordination: Emphasize rapid role assignment and use of an abbreviated timeout process. Equipment: Ensure essential pediatric equipment is accessible and properly labeled. Emotional Response: Educate staff on balancing compassion with trauma priorities. Transport Protocols: Reassess and improve transport protocols. Communication: Enhance communication between adult and children’s trauma teams. 58 Appendix A Benchmark Survey 59 Appendix A (continued) 60 Appendix A (continued) 61 Appendix B Utah Pediatric Trauma Network (UPTN) Vision and 2025 Goals As a state-supported program, UPTN's vision is to network with all regions and hospitals in Utah to improve pediatric traumatic injury outcomes and collectively implement injurypreventative initiatives. The 2025 goals: 1) Formalize Education Program. Components include grand rounds with national guest speakers focusing on evidence-based best practices, case reviews for evaluation and learning from actual patient care scenarios, and a journal club. Held 2nd Thursday of each month at 0700. 2) Implement New Guidelines. UPTN’s website hosts multiple guidelines as a reference for all Utah hospitals. They intend to add head imaging, cervical spine imaging, chest imaging, abdominal imaging, and brain injury guidelines in 2025. UPTN guidelines originate from the Pediatric Emergency Care Applied Research Network (PECARN) national standards of PECRN and the American Pediatric Surgical Association (APSA). The local children’s hospital modifies content as needed and approves it through UPTN's executive group, which maintains evidence-based medical best practice standards and approves any content alterations. These guidelines are forwarded to Utah’s Trauma System Advisory Council (TSAC) for final approval through Utah’s trauma system. UPTN posts these guidelines for all hospitals on their website and encourages their use as a reference. Utah’s hospitals are self-categorized into one of four pediatric hospital types: • • PED-ED: These hospitals' emergency departments are the only units in their system to manage traumatically injured pediatric patients, stabilize them, and transfer them to a children's trauma center. PED: These hospitals can manage an injured pediatric patient for 24 hours postinjury. 62 Appendix B (continued) • • PED+: These hospitals can manage an injured pediatric patient for 48 hours postinjury. PED1: These hospitals offer the highest level of medical care for pediatric traumatic injured patients and do not transfer patients. Currently, UPTN provides guidelines for all hospitals in the network. For example, the University of Utah Health Care, an adult Level I trauma center, is categorized as PED-ED and associated with 17 UPTN guidelines. The number of guidelines offered increases above the PED-ED level. 3) Standardize UPTN Data. UPTN will sunset its legacy REDCap database and transition to ImageTrend to align with the state of Utah’s trauma data repository. 4) Annual Conference. UPTN aims to establish a second annual pediatric conference closer to rural centers. 5) Partner with EMS-C. UPTN aims to strengthen pre-hospital pediatric trauma care. 6) Hospital Reports. UPTN intends to develop quarterly benchmark reports for all Utah hospitals participating in the trauma network. 63 Appendix C 2024 Utah Pediatric Trauma Network (UPTN) vs. Adult Trauma Level I 64 Appendix C (continued) 65 Appendix C (continued) 66 Appendix C (continued) Note. Adapted with permission from Utah Pediatric Trauma Network. Copyright 2025 by Tricia Boulton. 67 Appendix D Pediatric Case Direct Care Provider SWOT Questionnaire Strengths: 1. How confident were you in assessing and treating the child based on your current training and experience? 2. Did the existing pediatric protocols and guidelines (if available) assist you in delivering care for this child? If so, how? 3. Do we need to create any new protocols? 4. Was the necessary pediatric equipment (e.g., sized airway management tools, monitoring devices) readily available and easy to access during treatment? Weaknesses: 1. Did you encounter any challenges in treating this pediatric patient due to gaps in training or lack of specific pediatric experience? 2. Were there any issues related to the availability of pediatric-specific resources (e.g., equipment, medications, or specialists) during care? 3. Did you feel there was a lack of clarity or challenges in the pediatric protocols, such as triage or pain assessment guidelines? Opportunities: 1. How would you suggest improving pediatric training or protocols to better support your care for children in this age group? 2. Were there any moments during the treatment where collaboration with a pediatric specialist would have been beneficial? 3. What additional tools, equipment, or protocols would have made your care of the child easier or more efficient? Threats: 1. Were there any moments during the treatment where you felt the lack of pediatricspecific training or resources could negatively impact the outcome? 2. Do you feel that the frequency of pediatric cases in the ED is sufficient to maintain your skills and familiarity with pediatric emergency care? 68 Appendix E Trauma Pediatric Case Review Summary and Analysis The adult Level I trauma center invited the children's hospital trauma medical directors to attend a video case review where the adult trauma team reviewed the events of a minor admitted to an adult trauma center for a Level I trauma activation. This event presented a collaborative learning experience where the pediatric trauma leadership joined the adult trauma leadership to review and analyze the adult trauma team’s clinical actions. Several themes emerged, and the group discussed actionable items to mitigate future recurrence. Summary of Events: • A six-year-old girl with altered consciousness was brought to the emergency department (ED) following an unwitnessed fall. • The ER team had no formal trauma timeout. The trauma team arrived in the trauma bay simultaneously with the patient. • The patient exhibited traumatic brain injury symptoms, including vomiting and loss of consciousness. The trauma evaluation lacked the typical efficient coordination. • The team deliberated on airway management, sedation, and intubation. The ED provider eventually intubated the child, but the process took over 20 minutes. The trauma team stabilized this patient, sent them to the CT scanner at the adult center, and then transferred them to the children’s hospital. Lessons Learned / Action Items: 1. Pediatric Trauma Familiarity: o Lack of comfort and familiarity with pediatric trauma care contributed to delays in intubation and primary survey. Many participants admitted limited experience with pediatric care and dosing protocols. o Action: Develop and integrate pediatric trauma scenarios into regular simulation training. Unite the adult trauma center and the children’s trauma center for in-situ simulation training. Scenarios focusing on the infants and young children (those under 15 years of age) suggested: 1. General Pediatric 69 Appendix E (continued) 2. Head Injury 3. Facility Power Outage and Trauma Scenario for either the adult and/or children’s center 4. Epidural and Trauma 2. Role Assignment and Coordination: o Coordination issues led to slow decision-making. The timeout process facilitates team coordination, and the trauma team lead can repeat it. For example, repeating the initial timeout to reset the team's actions and clearly assign roles emerged as an appropriate strategy and critical factor to improve efficiency and team alignment. o Action: The Trauma Team Lead will emphasize a rapid role assignment and use an abbreviated timeout process to re-engage staff and align the clinical actions required. Ensure that all clinical participants understand their specific responsibilities. 3. Equipment Readiness and Resource Utilization: o The Broselow tape (used for pediatric dosing and equipment sizing) was immediately available, but other equipment was missing or cart/mislabeled, causing delays. o Action: Ensure essential pediatric equipment (Broselow tape, pediatric intubation tools) is readily accessible and part of the trauma bay setup. Ensure staff are familiar with locating the pediatric equipment and supplies. 4. Pediatric Airway Management: o The debate over intubating versus sedation highlighted inconsistencies in managing pediatric airways. o Action: Incorporate decision-making on pediatric airway management into training, including using ketamine and intranasal sedation as alternatives. 5. Emotional Response Management: o The desire to comfort the child delayed the trauma team's critical interventions. o Action: Educate staff on balancing compassion with trauma priorities. Assign one team member to provide comfort while others perform essential trauma tasks. 6. Transfer and Transport Protocols: 70 Appendix E (continued) o Despite transferring the patient rapidly, transporting the patient to the children’s hospital presented some logistical issues, e.g., the anesthesiologist did not accompany the patient the entire way, and the staff was unfamiliar with the facility’s transfer policy. The group questioned adequate access, including bridge access on off hours and potential delays. o Action: Reassess transport protocols for critical pediatric patients from the ED to the children’s hospital (bridge vs ambulance). Ensure door access is available for the clinical team at all hours. Explore options for direct OR access (the children’s hospital has a direct-to-OR policy, especially with epidural and bypasses ED— perhaps a similar protocol is required for the adult center) or expedited transfers across facilities. 7. Improved Communication Between the Adult Center and the Children’s Trauma Attendings o Discussion occurred over how the adult and children’s trauma groups can more easily communicate with each other. o Action: Have the adult center share the call list with the children’s center so they have residents' on-call info, and ensure the children’s center has the adult center operator's number. There is a possible electronic health record solution. Conclusion: The case review emphasized the need for improved pediatric trauma readiness through simulation, equipment accessibility, and better-defined protocols. While the child’s outcome was positive, areas for improvement included decreasing delays, particularly in rapid assessment, airway management, and intra-team communication. The trauma team plans to develop and integrate pediatric trauma scenarios into simulation training to better prepare for future cases. 71 Appendix F Stakeholder Presentation 72 Appendix F (continued) 73 Appendix F (continued) 74 Appendix F (continued) 75 Appendix F (continued) 76 Appendix G Executive Summary Executive Summary: Adult Level I Trauma Center Pediatric Readiness Needs Assessment Situation In 2022, the American College of Surgeons Committee on Trauma (ACS-COT) added standard 5.10, requiring pediatric readiness for verified trauma centers. The standard requires completing a pediatric readiness assessment and a plan to address the identified gaps. A national pediatric readiness assessment completed in October 2023 scored the trauma center at 62.94 out of 100, indicating that while the emergency department meets some pediatric care standards, key elements are still lacking, presenting system vulnerabilities and opportunities for improvement. Background Traumatic injury ranks in the top 10 leading causes of death for children. The National Pediatric Readiness Project (NPRP) recognized disparities in timely access to quality resuscitative care for children and called for integrating pediatric readiness guidelines into regulatory bodies. Many adult Level I trauma centers lack sufficient pediatric-specific policies and training to treat traumatically injured children. This Doctor of Nursing (DNP) scholarly project aimed to identify barriers and best practices for achieving pediatric readiness in an ACS-verified adult Level I trauma center without pediatric verification, which sees approximately 3200 pediatric patients annually (6% total trauma volume). Assessment The needs assessment collected data through a review of evidence-based literature, existing pediatric standards, staff training programs, a pediatric trauma case, SWOT analyses, and a benchmark survey of sixteen adult Level I trauma centers. Studies show pediatric readiness is highly cost-effective, providing good value for healthcare systems (expenditures range from $4 to $48 per pediatric patient annually), with equipment costs only 0.9-5.0% of the total. The needs assessment identified significant gaps in pediatric-specific policies—namely in patient transport. Further key issues include the absence of a Pediatric Emergency Care Coordinator (PECC), limited staff training and education, inadequate supply and equipment management, underutilization of organizational resources, and staff fear of litigation. Institutional reluctance to support and devaluation of pediatric readiness was identified as a significant finding, assuming that leadership would only support this initiative as corrective action after patient harm events instead of supporting preventative measures. Recommendation Addressing these issues is essential for the adult trauma center to meet the ACS-COT’s pediatric readiness standard 5.10 and provide high-quality trauma care. Recommended strategies are as follows: • appointing a PECC • developing or clarifying institutional standards • increasing staff training and education • improving pediatric supply and equipment management • leveraging organizational resources effectively • engaging institutional leadership