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In 1999 a set of standards was published by an intercollegiate working party, under the auspices of the Royal College of Paediatrics and Child Health (RCPCH). Accident and emergency services for children,1 often known as “the red book”, contained recommendations which were practical and feasible, so that the guidance was used widely among emergency physicians, emergency nurses and many inspection bodies, including the Healthcare Commission.
So where are we 8 years on? In May 2007 the Intercollegiate Committee published a second edition, renamed Services for children in emergency departments.2 Much change has occurred in UK emergency departments (EDs) since 1999, so that while the principles of the original document still hold true, much of the operational detail needed to be re‐written. The changes of the government 4 h emergency target, Modernising Medical Careers, and the coming of age of Paediatric Emergency Medicine (PEM) as a sub‐speciality have changed the landscape in a relatively short space of change. Are children getting a better service? I think so.
Shortly after publication of the original document, capital assistance from the UK government was granted to EDs to set aside areas for children, to protect them from the sights and sounds of disturbed or unwell adults. Many EDs topped this up with charitable funds, so that some sort of facility is now commonplace. Sadly in some cases these are pleasant but empty “white elephants” due to lack of staff. Others range from a small area with a couple of toys near the main waiting room, to separate waiting and treatment facilities. Some have created specific areas for toddlers, school‐aged children and adolescents. Few EDs operate these facilities 24 h a day—these services are restricted to the children's hospitals, and the few general hospital EDs which have sufficient paediatric attendances to run an overnight service.
A mainstay of the document is to emphasise that all staff who may have to treat children should have the basic competencies to deal with children to the same standard as when dealing with adult patients. This is more about equality than children being special or precious.
Since 1999 consultants from the College of Emergency Medicine and RCPCH worked collaboratively to develop competencies for PEM training for registrars in EM and in paediatrics. These are available on both College websites. Sub‐specialisation in PEM can now be recognised as a qualification on the Certificate of Completion of Training for trainees from either background. Around 14 sites are able to offer the training programme (see the Association of Paediatric Emergency Medicine website for useful information: www.apem.me.uk). These developments took time, so demand for such consultants still outstrips supply, and has lagged behind the targets set in the 1999 document. The current recommendations are that EDs seeing more than 16000 children per year should employ a consultant with PEM training. If an ED of this size has on‐site in‐patient children's services, there should also be a paediatric consultant with PEM training. For smaller EDs an emergency medicine consultant and a paediatric consultant (even if off‐site) should have designated liaison responsibilities.
The situation for nursing staffing is less rosy. Many hospitals have been unable to support training for ED nurses to reach the level of RN[Child]. Children's nurses working in EDs need to learn emergency skills. The Faculty of Emergency Nursing has produced some excellent competencies at various levels, which combine the skillsets of emergency medicine and paediatrics, to encourage the type of nurse we would all like in our EDs. Unfortunately cross‐speciality and financial support can be a practical obstacle. Readers are best advised to study the competencies in conjunction with senior ED nurses, and work out a local solution.
Probably the biggest current threat to improved services for children is the reconfiguration of emergency and urgent care services. The committee therefore chose to expand the remit of the document to make recommendations for walk‐in centres, primary care centres, minor injury units, etc, and also for commissioners considering closure of EDs or paediatric units, to recommend that adequate services for the child population are considered within a regional network of care.
Ambulance services are mentioned. There are specific sections in the document relating to sudden unexpected death in infancy, major incident planning, information technology, training, research and child protection.
Copies are available from http://www.bmj.com/cgi/content/full/330/7482/73 and from http://www.rcpch.ac.uk/Health‐Services/Emergency‐Care. We hope the document will be useful to all practitioners and organisations trying to improve emergency care for children.
Competing interests: None declared.