Children and adolescents, who account for nearly a third of hospital emergency-room visits, have unique physical characteristics that require special care and equipment. But according to the Centers for Disease Control and Prevention, fewer than 6 percent of ERs have on hand all the pediatric equipment recommended by the American Academy of Pediatrics (AAP) such as needles, catheters, breathing tubes and oxygen masks in different infant, child and adolescent sizes. Only a quarter have access to a doctor who is board-certified in pediatric emergency medicine.

Errors in prescribing medicine occur more frequently in kids than adults, including mistakes in calculating medication doses, which have to be adjusted for children's weight. In one study of over 1,500 charts for kids treated in the ER, there were prescribing errors in 10 percent of charts, and more errors in the charts of the most seriously ill children.

A recent report on pediatric emergency care by the Institute of Medicine found that many providers don't know how to properly stabilize seriously injured or ill children or fail to recognize cases of child abuse. While kids who live near large medical centers and specialty children's hospitals are generally well cared-for, "where a child lives has an important impact on whether a child can survive a serious illness or injury," the IOM report said.

With funding from the federal Maternal and Child Health Bureau, the AAP is taking a number of steps to correct the imbalance, including surveying 5,200 hospitals on quality of care in five critical areas -- asthma, long-bone fracture, head trauma, seizures, and diarrhea/dehydration. The AAP and the American College of Emergency Physicians are conducting a trial at 20 hospitals to see if a "preparedness kit" they have created -- with guidelines for what pediatric care and equipment are necessary -- can improve pediatric outcomes in the ER.

"We need to make sure that every hospital has at minimum the right equipment, staff and training to care for sick kids," says Marianne Gausche-Hill, a pediatric emergency-medicine specialist at UCLA-Harbor Medical Center in Torrance, Calif., who is leading the project.

Baptist Hospital of Miami is building a new $122 million emergency room with 100 exam rooms, including a separate children's emergency center with 20 exam rooms that can accommodate family members and two pediatric trauma rooms. Baptist Children's Director Denise Harris says the hospital staffers take quarterly tests in such skills as the "ABC" pediatric assessment method -- for Airways, Breathing and Circulation -- used to quickly evaluate a child's condition. The hospital recently began videotaping mock drills where staffers practice resuscitation on dolls.

Hospitals are also providing additional training for regular emergency personnel. This year, for example, Kadlec Medical Center in Richland, Wash., is sending its 50 emergency-room nurses through a special two-day pediatric emergency-care course sponsored by the Emergency Nurses Association, which costs $300 per person.

But many hospitals can't afford or don't give staffers time off or funding to attend even brief training courses. "Pediatric emergency care is in trouble, not because people don't care, but because it's just not a priority" for some hospitals, says Susan Hohenhaus, a nurse who is project manager of a Duke University Health System project to improve emergency medical services for children.

Proper training can make a difference, however. Mock pediatric exercises conducted in North Carolina emergency departments in 2001 showed staffers commonly misused a standard tool called the Broselow-Luten tape, which measures children's height and includes corresponding guidelines for dosages of medications and equipment sizes. After a study showed that training in proper use of the tape dramatically reduced errors at three hospitals, Duke recently began offering a free Web-based training course (dukehealth1.org/deps) for use of the tape.

Often, of course, parents don't have a choice of emergency rooms, especially in rural areas. But parents can do some homework on which hospitals in a city or community are best equipped to handle pediatric patients, such as identifying the nearest "Level 1" pediatric trauma center, a designation for hospitals that can perform surgery on critically ill patients immediately. Hospital Web sites often provide detailed information about their pediatric emergency facilities, and the federally funded Emergency Medical Services for Children Program (ems-c.org) has information on states that have passed legislation mandating programs to improve pediatric emergency care.

Alfred Sacchetti, chief of emergency medicine at Our Lady of Lourdes Medical Center in Camden, N.J., says parents may want to avoid hospitals with pediatric emergency-care areas that are actually part of regular ERs, because these typically operate only at peak periods such as the after-school hours or early evening. His studies show that critically ill children show up at all hours of the day, and medical staffs at hospitals with part-time pediatric emergency services tend not to have enough encounters with sick children to keep their pediatric skills up. "At a hospital with that kind of policy, you risk less-than-optimal care outside of those hours," Dr. Sacchetti says.

There are a number of steps hospitals are taking to be more family-friendly in emergency rooms, with liberal policies for allowing families to watch resuscitation and invasive procedures. Stanford's Lucile Packard is one of a growing number of facilities that have hired "child life" specialists who not only comfort children in hospitals, but can act as liaisons between family and staff when there are questions. Hospitals are also doing a better job of measuring and treating pediatric pain, such as using sedation techniques designed for children and topical creams to blunt the pain of needle sticks and IV tubing.

"Children used to be borderline tortured in emergency rooms," says Bernard Dannenberg, director of pediatric emergency medicine at Lucile Packard Children's Hospital at Stanford. The goal, he says, is to create an "ouchless" pediatric ER that makes a child's visit "as painless as possible."