COPPER

Requirements for COPPER Recognition
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PP = Pediatric Prepared  (baseline pediatric preparedness)       
PA = Pediatric Advanced (highest level of pediatric preparedness)
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Required
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Not Required
Pediatric Emergency Care Coordinators
PP
PA
Physician coordinator for pediatric emergency care
Nurse coordinator for pediatric emergency care
 
Competencies of ED Health Care Providers
PP
PA
All ED physicians should have current Pediatric Advanced Life Support (PALS), Advanced Pediatric Life Support (APLS), or Pediatric Emergency Assessment, Recognition and Stabilization (PEARS) certifications
All ED physicians are board certified and/or eligible specialists in emergency medicine or pediatric emergency medicine
There is at least one physician with pediatric training and/or education who is available (on call or via telehealth) as a resource to the ED
For PP sites, there is at least one nurse on staff in the ED at all times who is trained in the emergency evaluation and treatment of children of all ages (e.g., PALS, APLS, ENPC certified) and for PA sites, there is a comprehensive pediatric training program ensuring all ED nurses participate in regularly scheduled pediatric training such as PALS, ENPC, APLS, etc.
Baseline and ongoing competency evaluations for ALL ED clinical staff are population specific and include a review of clinical skills unique to children of all ages
All staff are regularly oriented on the location of pediatric equipment
 
Quality and/or Performance Improvement
PP
PA
QI/PI plan includes the following pediatric specific indicators: weighing in kilograms, recording weight in kilograms, and weight-based medication doses
QI/PI plan also includes at least one of the following pediatric specific indicators: 1) avoiding antibiotics for viral illnesses and 2) readmission rates (within 3 days)
Pediatric specific indicators are reviewed at a minimum quarterly and action item follow-up is integrated into the ED QI/PI plan
There is a quarterly pediatric case review process for: 1) all pediatric deaths, 2) all critical care transfers out, and 3) 10 patients/month or 25% of overall pediatric admissions, or 100% of pediatric census, if less than 10/month
 
Pediatric Patient and Medication Safety
PP
PA
Children are weighed in kilograms
Weights are recorded in a prominent place on medical record
For children not weighed, a standard method for estimating weight in kilograms is used (e.g., a length-based system)
A full set of vital signs is recorded and reassessed for all children, including temperature, heart rate, respiratory rate, pulse oximetry, blood pressure, pain, and mental status (as indicated) (if unable to obtain BP in triage, attempt in the secondary assessment of patient)
Processes are in place for safe, weight-based medication administration, such as pre-calculated drug dosing and formulation guides; consider identifying a pediatric pharmacist resource and ensure that a pediatric dosing reference is available at all times
Pediatric emergency services are culturally and linguistically appropriate; this includes 24/7 access to interpreter services in the ED
Timely tracking and reporting of patient safety events; consider celebrating near misses/good catch events to encourage submission of possible safety events
 
Policies, Procedures, and Protocols
PP
PA
Intake and triage assessment of the pediatric patient
Pediatric patient assessment and reassessment
Documentation of a full set of vital signs including blood pressure on all pediatric patients
Identification of abnormal pediatric vital signs and notification to the responsible provider
Immunization status documentation and management of the underimmunized patient
Sedation and analgesia of the pediatric patient
Consent, including when parent or legal guardian is not immediately available
Social and behavioral health issues
Use of physical or chemical restraint of patients
Procedures for recognizing, assessing, and reporting suspected child maltreatment (hospital policy should specify where patients will be transferred if full assessment is not completed in house; if maltreatment is suspected, even if patients are transferred out, reporting is mandated and should be specified in hospital policy)
Management of family presence and family centered care during the death of the child in the ED
Do not resuscitate (DNR) orders
Referral policy for patients who lack a medical home
Children with special health care needs
Family-centered care
Communication with the patient's medical home or primary care provider as needed
All-hazard disaster preparedness / emergency operations plan that addresses pediatric issues
Written pediatric interfacility transfer procedures and/or agreements that include pediatric components
Monitoring of the pediatric patient, e.g., O2 saturations should be monitored during an infant lumbar puncture (LP), patients with DKA/new onset diabetes should be placed on an ECG monitor, CO2 should be monitored on children during sedation or intubation, etc.
 
ED Support Services
PP
PA
Medical imaging capabilities and protocols address age- or weight-appropriate dose reductions for children
Transfer of all care documentation or complete encounter record, including images, when a patient is transferred from one facility to another
Collaboration with radiology, laboratory and other ED support services to ensure the needs of children in the community are met
 
Equipment and Supplies
PP
PA
Pediatric appropriate resuscitation equipment and supplies shall be kept in the ED; other pediatric appropriate items may be housed elsewhere, ensuring accessibility by the ED team when needed
ED staff must be able to verbalize the location of all pediatric equipment and supplies listed in the sections below
There is a method in place to verify the proper location and function of pediatric equipment and supplies
General Equipment
PP
PA
Weight scale, in kilograms only, for infants and children or a process in place to ensure weight is recorded in kilograms (it is highly recommended that scales are locked in kilograms mode)
Weight- and length-based tool or chart for resuscitation medication dosing and airway management
Rigid boards for use in CPR
Monitoring Equipment
PP
PA
Blood pressure cuffs (neonatal, infant, child)
ECG monitor and/or defibrillator with pediatric and adult capabilities, including pediatric-sized pads and/or paddles
Pulse oximeter with pediatric and adult probes
Continuous end-tidal CO2 monitoring
Respiratory Equipment
PP
PA
Endotracheal tubes (uncuffed: 2.5mm, 3.0mm; cuffed or uncuffed: 3.5mm, 4.0mm, 4.5mm)
Laryngoscope blades (curved: 2; straight: 00, 0, 1, 2)
Pediatric Magill forceps
Pediatric and infant sized stylets for endotracheal tubes
Suction catheters (infant and child: 6F, 8F, 10F)
Self-inflating bag-valve-mask (manual resuscitator) (infant)
Simple oxygen masks (standard infant, standard child)
Oxygen masks (non-rebreather) appropriate for use with infant patients
Masks to fit bag-mask device adaptor (neonatal, infant, child)
Nasal cannula and securement device (infant)
Nasogastric (Salem Sump) tubes: infant (8F catheter) and child (10F catheter)
Nasal aspirator (recommend using something like the aspirators with the olive/mushroom tip)
Supraglottic device (e.g., LMA) (infant, child)
Vascular Access Equipment
PP
PA
Angiocatheter (14 - 24 gauge)
Intraosseous needles or device (pediatric sizes)
IV administration sets with calibrated chambers and/or infusion devices with the ability to regulate the rate and volume of infusion (including low volumes)
Manual rapid infusion device, rated for pediatrics, for easy push-pull fluid administration
Syringe pumps that can administer inotropic agents (e.g., epinephrine, norepinephrine, dopamine, and milrinone) at an appropriate pediatric drip rate
Atomizer for intranasal administration of medication
Equipment Required for High-Volume EDs*
PP
PA
A defined procedure for administering Alprostadil (prostaglandin E1)
Central venous catheters (4.0 - 7.0F)
Highly Recommended Equipment
These items are not required for COPPER Recognition. However, COPPER’s panel of expert advisors finds this pediatric specific equipment highly valuable.
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* EDs with > 10,000 pediatric patient visits per year

Medications*
PP
PA
Alprostadil (prostaglandin E1) (and a defined procedure for administering and monitoring)
Analgesics (oral, intranasal, and parenteral) and topical anesthetics (e.g., eutectic mixture of local anesthetics [EMLA]; lidocaine 2.5% and prilocaine 2.5%; lidocaine, epinephrine, and tetracaine [LET]; and LMX 4 [4% lidocaine]); ensure availability of atomizer for intranasal administration
Anticonvulsants: levetiracetam (PP and PA), valproate (PA), fosphenytoin (PP and PA), and phenobarbital (PA)
Antidotes including lipids, naloxone hydrochloride (common antidotes should be accessible to the ED)
Anticholinergics for Inhalation (Ipratropium Bromide)
Antiemetics (e.g., ondansetron and prochlorperazine)
Antihypertensives: hydralazine (PP and PA), labetalol (PA), nicardipine (PA), and sodium nitroprusside (PA)
Antimicrobials (parenteral and oral)
Antipsychotics (e.g., olanzapine and haloperidol)
Antipyretics (e.g., acetaminophen and ibuprofen); ensure liquid formulations are available
Benzodiazepines (e.g., midazolam and lorazepam)
Bronchodilators (albuterol, ipratroprium)
Corticosteroids: dexamethasone (PP and PA), methylprednisolone (PP and PA), and hydrocortisone (PA)
Dextrose (D10W)
Diphenhydramine
Furosemide
Glucagon
Insulin (regular insulin to prepare continuous infusion for DKA, hyperkalemia)
Lidocaine
Magnesium sulfate
Neuromuscular blockers (at a minimum rocuronium)
Oral glucose
Sucrose solutions for pain control in infants
Sedation medications (e.g., etomidate and ketamine for induction and fentanyl and midazolam to maintain sedation / longer duration of action)
Vaccines: Tetanus vaccine (e.g., DT, DTaP, Td) (PP and PA) and tetanus and rabies immunoglobulin (PA)
3% hypertonic saline (Mannitol may be substituted)
Resuscitation Medications
PP
PA
Adenosine
Amiodarone
Atropine
Calcium Chloride: calcium chloride (PP and PA) and calcium gluconate (PA)
Epinephrine (1 mg/mL [IM] and 0.1 mg/mL [IV] solutions)
Lidocaine, Procainamide, Sodium bicarbonate (4.2%)
Vasopressor agents (e.g., dopamine, epinephrine, and norepinephrine)

* Use liquid formulations when available and appropriate