After email outreach to 32 potential participating hospitals, 21 hospitals indicated interest in the pilot (66% response rate) with 11 non-responders. Sixteen out of 21 hospitals completed the assessment tool (76% completion rate). Barriers to completion of the assessment tool included inability to obtain hospital-specific approval (N = 3), technological issues (N = 1), and ED renovations (N = 1) that necessitated postponement of the pilot.

Across the 16 participating sites, 36 individuals in multi-disciplinary teams provided responses to the assessment tool. The professional titles of participants included doctor (72%, 26/36), nurse (11.1%, 4/36), pharmacist (8%, 3/36), physician assistant (2.8%, 1/36), administrator (2.8%, 1/36), and physical therapist (2.8%, 1/36). Participant group sizes ranged from 1 to 10 individuals (one person N = 10, two people N = 2, three people or more N = 4).

The duration of time from starting the assessment to submission ranged from 0.6 to 411.5 h (including time without active data entry), with a median of 25.9 h (interquartile range: 2.6–174.7 h). The median time for tool completion for individuals was 25.9 h (range 0.6 to 411.5 h) and 82.2 h for groups (range 1.2–219.5 h).

Of blank responses, 23% (32/140) were not branching logic questions. The number of blank responses were distributed across domains: demographics N = 15, hospital characteristics N = 2, protocols and policies N = 1, staffing and training N = 26, equipment and consumables N = 7, and medicines N = 19.

Of the participating hospitals, 56.3% were national or academic hospitals and 31.3% were district hospitals. 75% of hospitals were public or government-run. The greatest regional representation was Western (56.3%) and Southern Africa (25%) (Table 1). The upper age limit for pediatric patients seen at the participating hospitals ranged from 12 to 18 years old (median 14 years old).

Of the participating hospitals, 87.5% (14/16) had inpatient pediatric wards, 62.5% (10/16) had nurseries, 68.8% (11/16) had neonatal intensive care units, and 31.3% (5/16) had pediatric intensive care units. One participating hospital had no inpatient pediatric services.

Three EDs (18.8%, 3/16) had access to current online medical references. Medical records in 87.5% (14/16) of the EDs were paper charts. Pharmacy services for pediatric ED patients included medications dispensed from a shared pharmacy for the ED and hospital (43.8%, 7/16). Ten hospitals (62.5%) had pharmacy services available 24 h a day for pediatric ED patients.

Twenty-four-hour laboratory services were available at 87.5% (14/16) of hospitals. Blood transfusion was available in all EDs, though the ability to perform transfusions within 2 h more than 75% of the time was available at 62.5% (10/16) of EDs. The most available radiology services for pediatric patients were X-ray (81.3%) and ultrasonography (75%) (Table 1).

Of the 68.8% of EDs with a formal pediatric triage protocol, the South African Triage Score (54.5%, 6/11) and WHO ETAT guidelines (36.4%, 4/11) were most used. When no formal pediatric triage process was in place, 80% (4/5) of those EDs had a list of emergency signs for pediatric patients who require immediate treatment. Ten EDs (62.5%) used a formal pediatric resuscitation protocol, 40% used Pediatric Advanced Life Support (PALS), 20% used Advanced Pediatric Life Support (APLS), 10% used the WHO ETAT.

Protocols that were least commonly available included pain assessment (31.3%, 5/16), protocols for acute mental health complaints (18.8%, 3/16), and suicide screening (6.3%, 1/16) (Table 2).

Ten of the sixteen hospitals (62.5%) had a dedicated doctor staffing the ED 24 h a day. Training background for ED doctors were primarily pediatrics (68.8%, 11/16) and general/family practitioners (68.8%, 11/16) (multiple responses were available for selection). Subspecialists had varying availability for consultation (Table 3). Mental health providers were available at 50% (8/16) of EDs.

For resuscitation training, greater than 56.3% of doctors and nurses completed training in pediatric basic life support (9/16). In 50% (8/16) of EDs, a doctor or nurse with advanced pediatric life support skills (e.g. PALS, APLS) was available in the ED more than 50% of the time. Advanced life support training was available to staff at 62.5% (10/16) of EDs. Doctors or nurses were available more than 50% of the time to perform the following airway skillsets in EDs with the following frequencies: bag-valve mask ventilation 100% (16/16), surgical airway (e.g. needle cricothyrotomy) 91.7% (11/16), basic airway maneuvers (jaw thrust, chin tilt) 75% (12/16), oral airway insertion 75% (12/16), nasal airway insertion 68.8% (11/16), endotracheal intubation 56.3% (9/16).

Continuing medical education opportunities for staff were weekly in 43.8% (7/16) of EDs for doctors, 30% (5/15) for nurses, and 30% (5/15) for support staff (respiratory therapists, pharmacists).

50% of EDs (8/16) had a doctor “pediatric champion,” and 7 of those 8 EDs also had a nurse “pediatric champion” (87.5%, 7/8) who served as leaders that raise awareness of the special emergency needs of children [22].

Basic respiratory and airway support equipment such as oxygen, pediatric bag-valve masks, and nasal cannulas were widely available (100% of EDs). Advanced respiratory support including high-flow nasal cannula and continuous positive airway pressure (CPAP) were available at 37.5% (6/16) of EDs. Resuscitation equipment availability varied, with 68.8% (11/16) of EDs with pediatric resuscitation trollies/carts, 50% (8/16) with defibrillators (25%, 4/8, with pediatric defibrillator paddles), 25% (4/16) with intraosseous drills (Fig. 2). There was no clear association between equipment availability and annual pediatric ED volumes.

Availability of equipment and consumables by category

Most medicines from the WHO Essential Medicines were available at the participating EDs except for certain paralytic agents, anti-epileptics, and antibiotics (Fig. 3).

Medicine availability by category