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lGILNCY
, Lit
for
J
RIEN
Committee on Pediatric Emergency Medical Services
lane S. Durch and Kathleen N. Lohr, Editors
Division of Health Care Services
INSTITUTE OF MEDICINE
NATIONAL ACADEMY PRESS
Washington, D.C. 1993
1C
S
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NATIONAL ACADEMY PRESS · 2101 Constitution Avenue, N.W. · Washington, D.C. 20418
NOTICE: The project that is the subject of this report was approved by the Governing Board
of the National Research Council, whose members are drawn from the councils of the National
Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.
The members of the committee responsible for the report were chosen for their special competences
and with regard for appropriate balance.
This report has been reviewed by a group other than the authors according to procedures
approved by a Report Review Committee consisting of members of the National Academy of
Sciences, the National Academy of Engineering, and the Institute of Medicine.
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist
distinguished members of the appropriate professions in the examination of policy matters
pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863
congressional charter responsibility to be an adviser to the federal government and its own
initiative in identifying issues of medical care, research, and education.
Support for this project was provided by the Maternal and Child Health Bureau of the Health
Resources and Services Administration, U.S. Department of Health and Human Services, un-
der Grant No. MCJ-117025-02. The views presented are those of the Institute of Medicine
Committee on Pediatric Emergency Medical Services and are not necessarily those of the
funding organization.
Library of Congress Cataloging-in-Publication Data
Emergency medical services for children / Jane S. Durch and Kathleen
N. Lohr, editors
p. cm.
"Committee on Pediatric Emergency Medical Services, Division of
Health Care Services Institute of Medicine."
Includes bibliographical references and index.
ISBN 0-309-04888-5
1. Pediatric emergency services-United States-Planning.
I. Durch, Jane S. II. Lohr, Kathleen N., 1941- . III. Institute of
Medicine (U.S.). Committee on Pediatric Emergency Medical Services.
[DNLM: 1. Emergencies-in infancy & childhood. 2. Emergency
Medical Services. WS 200 E5273 1993]
RJ370.E433 1993
362.1'8'083-dc20
DNLM/DLC
for Library of Congress
93-8084
CIP
Additional copies of this book are available from the National Academy Press, 2101 Consti-
tution Avenue, N.W., Box 285, Washington, D.C. 20055. Call 800-624-6242 or 202-334-
3313 (in the Washington Metropolitan Area).
Copyright 1993 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost all
cultures and religions since the beginning of recorded history. The image adopted as a logo-
type by the Institute of Medicine is based on a relief carving from ancient Greece, now held by
the Staatlichemuseen in Berlin.
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COMMITTEE ON PEDIATRIC EMERGENCY
MEDICAL SERVICES
DONALD N. MEDEARIS, JR.,* Chair, Charles Wilder Professor of
Pediatrics, Harvard Medical School, and Chief, Children's Service,
Massachusetts General Hospital, Boston' Massachusetts
RICHARD B. DONKER, Vice President, Clinical Services, Memorial
Hospitals Association, Modesto, California
MARTIN R. EICHELBERGER, Professor of Surgery and Pediatrics,
George Washington University School of Medicine, and Director of
Emergency Trauma Services, Children's National Medical Center,
Washington, D.C.
J. ALEX HAILER, JR., Professor of Pediatric Surgery, Pediatrics, and
Emergency Medicine, Children's Medical and Surgical Center, The
Johns Hopkins Hospital, Baltimore, Maryland
ROBERT L. HARMAN, Administrator, Grant Memorial Hospital,
Petersburg, West Virginia
EDGAR B. JACKSON, JR.,* Clinical Professor of Medicine, Case
Western Reserve University School of Medicine, and Associate Chief
of Staff, University Hospitals of Cleveland, Cleveland, Ohio
MARILYN A. KRUEGER, Commissioner, Second District, Saint Louis
County, Duluth, Minnesota
JENNIFER LEANING, Medical Director, Health Centers Division,
Harvard Community Health Plan, Inc., Brookline, Massachusetts
SUSAN D. McHENRY, Director, Emergency Medical Services, Office of
Emergency Medical Services, Virginia Department of Health,
Richmond, Virginia
PATRICIA A. MURRIN, Prehospital Coordinator, Division of Emergency
Medical Services, Department of Health Services, County of San
Diego, California
JAMES L. PATURAS, Director, Emergency Medical Services, Bridgeport
Hospital, Bridgeport, Connecticut
BARRY G. RABE, Associate Professor of Health Politics, Department of
Public Health Policy and Administration, School of Public Health,
University of Michigan, Ann Arbor, Michigan
DONALD F. SCHWARZ, Assistant Professor of Pediatrics, Section on
Adolescent Medicine, Department of Pediatrics, University of
Pennsylvania, Philadelphia, Pennsylvania
JAMES S. SEIDEL, Professor of Pediatrics, UCLA School of Medicine,
and Chief, General and Emergency Pediatrics, Harbor-UCLA Medical
Center, Torrance, California
*Institute of Medicine member
. . .
[z!
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CALVIN C.J. SIA, Clinical Professor of Pediatrics, Department of
Pediatrics, School of Medicine, University of Hawaii, Honolulu,
. .
Hawaii
RUTH E.K. STEIN, Professor and Vice Chairman, Department of
Pediatrics, Albert Einstein College of Medicine, and Pediatrician-in-
Chief. Bronx Municipal Hospital Center' Bronx, New York
GARY R. STRANGE, Associate Professor of Emerge-nc-:r Medicine,
University of Illinois, College of Medicine, Chicago, Illinois
J.J. TEPAS III, Professor of Surgery, Division of Pediatric Surgery,
University of Florida College of Medicine, Department of Surgery,
Jacksonville, Florida
JOSEPH A. WEINBERG, Associate Professor, Division of Critical Care,
Department of Pediatrics, University of Tennessee, Memphis, and
Director, Emergency Services, Le Bonheur Children's Medical Center,
Memphis, Tennessee
Study Staffs
JANE S. DURCH, Associate Study Director
KATHLEEN N. LOHR, Deputy Director, Division of Health Care Services
and Study Director, beginning April 1992
MICHAEL L. MILLMAN, Study Director, through March 1992
DONNA D. THOMPSON, Administrative Assistant
KARL D. YORDY, Director, Division of Health Care Services
IV
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Preface
The problem of childhood injuries and illnesses and the emergency care
they require is immense and its consequences tragic. If the recent past is an
indication of the immediate future, then more than 20,000 children under 19
years of age will die this year in the United States as a result of injury. An
additional 30,000 will have a permanent disability as a result of brain in-
jury. As disturbing as these data are, they are but the top of a huge pyra-
mid; for each death of a child due to injury in this country, as many as 42
children are hospitalized and 1,120 children visit an emergency room. Moreover,
emergency room visits by children as a result of injury are only one-third of
the total number of visits by children to emergency rooms. The other two-
thirds of those visits are due to illnesses, many of which are serious; these
include debilitating asthma and life-threatening meningitis.
One cannot be aware of these data and not want to reduce their number
and their impact. That goal can be achieved. The rates of death and
disability in the United States exceed the comparable rates in Canada, France,
the former Federal Republic of Germany, and Great Britain. If this country
would energetically pursue preventive health measures, including the estab-
lishment of continuous, family-oriented, community-based primary care for
all children, there is no reasonable doubt but that the number of injuries and
episodes of illness and their consequences-could be significantly reduced.
Moreover, if that were accomplished, the savings would be enormous in
economic as well as humanitarian terms.
The charge to this Institute of Medicine committee, however, was not to
design the ideal medical home (primary care) for children, nor was it to
develop strategies for the development and implementation of effective in-
jury prevention measures. It was to review the nature and extent of pediat-
ric emergencies and the emergency care available to children and to define
v
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Vl
PREFACE
the characteristics of an emergency medical services system for children
(EMS-C system), the elements of a data system needed for planning and
evaluation, and the role of government in that system. In developing its
response to this charge, the committee utilized fully the remarkable diver-
sity in expertise and background of its multidisciplinary membership and
prepared a report that is scholarly and detailed. It idex~tified the essential
components of an EMS-C system. It considered how best to ensure access
to that EMS-C system. It recognized the very special needs of children in
terms of anatomy, physiology, and psychology, and underscored how these
must be met by EMS-C programs and personnel. Thus, there must be
different and special equipment, different-sized instruments, different doses
of different drugs, and different approaches to the psychological support
and remedial care to be given to the ill or injured child. Guidelines by
which personnel essential for the provision of emergency care for infants
and children are to be trained, educated, and restrained and re-educated
must take into account these factors. Thus, the committee called attention
to the importance of fully developing and organizing in a system all those
special emergency services that children must have.
The committee believed that it was of critical importance to develop an
initial uniform data set about these services in order to begin to obtain
information that would be used to assess the system and its effectiveness.
Mindful of the tragic toll of injury and illness emergencies, the committee
further recognized the great importance of obtaining data needed for devel-
oping prevention strategies as well as for improving the EMS-C system as a
whole.
The recommendations that reflect these matters are directed at all levels
of government, many different health care professionals, and a wide range
of voluntary groups. Some recommendations are directed to the whole of
emergency medical services (EMS), for example, the need to develop an
expanded 9-1-1 system nationally to provide access to EMS. Some are
aimed at subtle modifications or minor (but significant) improvements in
the existing system. Others require putting what now exists in some places
into those places where no EMS now exists. All do, as they must, take into
account the local and regional diversity of this country.
In recommending these special services for children, the committee
concluded that the EMS-C must not be separate from, but instead should be
an integrated part of, the entire emergency medical system. At the same
time, the committee recognized how very important it will be to make sure
that the needs of children will not be lost again in the continuing develop-
ment of that larger emergency medical system. To ensure that, the commit-
tee has recommended the creation of specific agencies and defined specific
roles for them in both state and federal governments. These public agencies
must be effectively linked with the private sector.
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PREFACE
. .
V11
The committee recognized the extremely important role that effective
rehabilitation services can and must play in this matter. Nonetheless, just as
it was not the committee's charge to design the ideal medical home for
children, it was not the committee's charge to design rehabilitation services.
Instead this was addressed by stressing the need for extremely effective
linkages between EMS-C and rehabilitation.
Thus, throughout its deliberations, the co~mm~ttee recognized the very
great importance of establishing effective communication systems and of
developing an information system that could obtain data to be used to as-
sess the effectiveness of the system (and improve it continually) and to
provide information useful in developing the means to prevent emergencies.
If there were but one thing that this author would stress, it would be that.
In this time of rational economic duress, the committee was cognizant
that the matter of costs and benefits would be raised. Obtaining accurate
and comprehensive data on the cost or the benefits of emergency medical
systems is extremely difficult. The direct and immediate health care costs
of nonfatal injuries in children are estimated to be in excess of $5 billion a
year, and the indirect costs, including the loss of productive life, greatly
exceed those direct costs of caring for injured children. Available estimates
indicate that the implementation of comprehensive and effectively linked
services for emergency medical care does ensure better outcomes and that
the economic benefits of an emergency medical system for children would
be very large. Therefore, the committee believes that the cost of developing
an effective EMS-C would be well worth it.
The committee is aware that great thought, effort, and time will be
required to develop the EMS-C that our children need and deserve. These
efforts can build on the accomplishments of many groups during the past
quarter-century since the landmark NRC report Accidental Death and Dis-
ability: The Neglected Disease of Modern Society. The committee believes
that this is an opportune time to develop EMS-C since the country seems to
be on the threshold of significant health care reform. Therefore, we hope
this report will stimulate increased attention to and development of these
urgently needed emergency medical services in the context of an effective
system of primary care for children.
In closing, I wish to express my great appreciation and admiration to
the committee and to the IOM staff for their commitment, energy, and ex-
pertise, all of which were provided ceaselessly and patiently and, most
important, very productively. I have not listed them here because they are
listed elsewhere, but that must not detract from the debt I owe or the admi-
ration I have for them.
Donald N. Medearis, Jr., M.D.
Chair
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Acknowledgments
The Committee on Pediatric Emergency Medical Services would like to
acknowledge the assistance that they and the study staff received from sev-
eral individuals and groups during this study.
The study conducted by this committee was funded by the Maternal and
Child Health Bureau (MCHB) of the Health Resources and Services Admin-
istration (HRSA) through the Emergency Medical Services for Children
(EMS-C) Demonstration Grant Program. MCHB staff members David
Heppel, M.D., Director of the Division of Maternal, Infant, Child, and Ado-
lescent Health; Peter Conway, the study's project officer; and Jean Athey,
Ph.D., Director of the EMS-C and Injury Prevention Programs-helped keep
the committee and staff informed of relevant activities and provided access
to useful background material on the demonstration grant awards. Also
generous with their assistance were members of the staff of the Emergency
Medical Services Division of the National Highway Traffic Safety Adminis-
tration at the Department of Transportation: Susan Ryan, M.S., chief of the
division, and Highway Safety Specialists Gary Criddle, R.N., Thomas Dolan,
and Charles Glass.
The committee benefited from presentations by guests invited to two
meetings. In December 1991, the committee was joined by Paul Anderson,
Chief of the Idaho Emergency Medical Services Bureau, Wade Spruill, Jr.,
Director of Emergency Medical Services for Mississippi, and Javier Gonzalez
del Rey, M.D., from the staff of the Shenandoah Community Clinic in Martins-
burg, West Virginia, to discuss emergency medical care in nonmetropolitan
and rural areas. In March 1992, George Foltin, M.D., Director of Pediatric
Emergency Medical Services, Bellevue Hospital Center, New York City,
spoke with the committee on behalf of the National Association of Emer-
gency Medical Services Physicians regarding medical control of prehospital
IX
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x
ACKNOWLEDGMENTS
care. Laurie Flaherty, R.N., chair of the pediatric committee of the Califor-
nia chapter of the Emergency Nurses Association, addressed nursing issues
for the committee.
Members of the committee and staff were able to attend conferences in
June 1991 and February 1992 that were held as part of the EMS-C demon-
strat~n grant program. The conferences gave the committee members an
opportunity to meet grantees from some 30 EMS-C projects, to learn about
their activities and experiences, and to gain insight into the issues in this
field. The two EMS-C resource centers have been especially helpful to the
study staff; in particular, the committee thanks Jane Ball, R.N., Dr.P.H., and
Bryna Heifer of the EMS-C National Resource Center in Washington, D.C.,
and Deborah Henderson, R.N., M.A., of the National EMS-C Resource Alli-
ance in Torrance, California.
The committee appreciates the willingness of individuals from a variety
of organizations to speak with members of the study staff and to provide
background materials: Albert N. Brasile, Centers for Disease Control and
Prevention; Donald C. Bross, J.D., Ph.D., C. Henry Kempe National Center
for the Prevention and Treatment of Child Abuse and Neglect; Douglas E.
Brown, EMS Data Systems, Inc.; Ceil M. Hendrickson, R.N., Children's
National Medical Center; Ronald Kropp, M.H.S., Maryland Institute for
Emergency Medical Services Systems; David Lloyd, National Center on
Child Abuse and Neglect; Susan Mackenzie, Ph.D., Health and Welfare
Canada, Laboratory Center for Disease Control; Stephen Mawn, American
Society for Testing and Materials; Meri McCoy-Thompson, M.A.L.D., Na-
tional Center for Education in Maternal and Child Health; Greg McDonald,
Arrowhead (Minnesota) EMS System; Mary McDonald, R.N, M.S.P.H.,
National Heart, Lung, and Blood Institute; Deborah Nadzam, Ph.D., R.N.,
Joint Commission on Accreditation of Healthcare Organizations; Mary Overpeck,
National Institute of Child Health and Human Development; I. Barry Pless,
M.D., Montreal Children's Hospital; and William E. Stanton, National Emergency
Number Association.
The committee also received helpful contributions from Joanne Lukomnik,
M.D., a consultant to the committee. Jennifer McGrady, a student intern at
the Institute of Medicine (IOM), helped prepare for the first committee
meeting and began the task of assembling background materials. Greg
Pearson, a free-lance writer, produced the earliest draft of some of the
material for the report. The report has benefited from the useful (anony-
mous) critiques received as a result of the formal review that must be con-
ducted before the release of any IOM report.
Finally, the committee expresses its considerable appreciation to mem-
bers of the IOM staff whose efforts have ensured the successful completion
of the study and this report. Donna Thompson, Administrative Assistant,
provided essential secretarial support. Other members of the IOM staff
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ACKNOWLEDGMENTS
Xl
contributing to this project include Holly Dawkins, Research Assistant; Jo
Harris-Wehling, Program Officer; and Nina Spruill, Financial Associate.
The study began under the direction of Michael Millman, who did much to
assist the committee in organizing its approach to the study and in formulat-
ing the recommendations reflected in the report. Finally, throughout the
study, Karl Yordy, Director of the Division of Health Care Services, pro-
vided invaluable guidance and support.
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Contents
SUMMARY
1 INTRODUCTION
The Issue: Ensuring Emergency Medical Care for
Children Who Need It, 27
The Institute of Medicine Study, 28
A Vision of the Ideal System: Establishing Critical Linkages, 30
Guiding Principles, 33
Organization of the Report, 34
Audience for This Report, 36
The Committee's Goal, 36
Note, 37
2 RISKING OUR CHILDREN'S HEALTH: A NEED FOR
EMERGENCY CARE
Definitions, 39
Why Children Need Special Attention, 41
Epidemiology of Childhood Emergencies, 45
Costs of Injury and Illness, 61
Summary, 63
Notes, 64
EMERGENCY MEDICAL SERVICES SYSTEMS:
ORIGINS AND OPERATIONS
Development of EMS and EMS Systems, 67
Providing Emergency Medical Services, 83
Structure of EMS Systems, 85
. . .
X111
26
38
66
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XlV
Summary, 97
Notes, 98
Appendix 3A, 100
Appendix 3B, 103
4 LEARNING HOW TO PROVIDE GOOD CARE:
EDUCATION AND TRAINING
Education and Training for the Public, 108
Education and Training for Health Care Professionals, 118
Other Concerns, 138
Summary, 145
Notes, 147
5 BEING READY TO DELIVER GOOD CARE: PUTTING
ESSENTIAL TOOLS IN PLACE
Definitions, 149
Equipment, 150
Protocols, 156
Medical Control, 167
Categorization and Regionalization, 170
Summary, 183
Notes, 185
6 CONNECTING THE PIECES: COMMUNICATION
Public Access to the Emergency Care System, 188
Prehospital Communication, 200
Communication in Hospital Care, 205
Follow-up: Enhancing Continuity of Care, 211
Feedback, 216
Other Important Forms of Communication, 217
Summary, 221
Notes, 222
KNOWING WHAT IS HAPPENING AND WHAT
IS NEEDED: PLANNING, EVALUATION,
AND RESEARCH
Understanding the Information Gap, 225
Planning, Evaluation, and Research, 227
Understanding Current and Emerging Sources of Data
and Data Systems, 230
Improving Information Resources, 246
Implementing a Research Agenda, 252
Summary, 259
CONTENTS
~8
149
187
224
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CONTENTS
Notes, 261
Appendix 7A, 265
Appendix 7B, 274
8 LEADERSHIP FOR DEVELOPING EMERGENCY MEDICAL
SERVICES FOR CHILDREN
The Disjointed "System" of Today, 281
A Focus for Emergency Medical Services for Children, 283
A Federal Center for Emergency Medical Services
for Children, 284
State Agencies and Advisory Councils on Emergency Medical
Services for Children, 298
The Case for New Entities to Address Emergency Medical Services
for Children, 310
Financing Centers, Agencies, and Related Activities, 313
Summary, 316
Notes, 317
9 IMPROVING EMERGENCY MEDICAL SERVICES FOR
CHILDREN: LOOKING TO THE FUTURE
Benefits and Costs, 321
A Changing Health Care Environment, 325
Final Thoughts, 334
Notes, 334
REFERENCES
APPENDIXES
A Acronyms, 369
B Biographies of Committee Members, 373
INDEX
280
321
336
367
379
TABLES
Deaths from Injury Among Children and Adolescents
Ages 0 to 19, by Cause, Age, and Sex, 1988
Deaths from Specified Categories of Illness Among
Children and Adolescents Ages 0 to 19, by Cause,
Age, and Sex, 1988
Hospitalizations for Injury and Specified Categories
of Illness Among Children and Adolescents Less than
15 Years Old, by Cause, 1990
48
52
54
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XVI
i
3-1 Essential Components of Emergency Medical Services
Systems, as Specified by the Emergency Medical
Services Systems Act of 1973 (P.L. 93-154)
3B-1 Projects Funded by the EMS-C Demonstration Grant
Program, 1986-1992
Percentage Qua Population Covered by a 9-1-1 System
by State
7-1 Priority Data Elements for a National Uniform Data Set
for Emergency Medical Services for Children: Prehospital
Services and Emergency Departments
7-2 Summary of High-Priority Topics for a Research Agenda
in Emergency Medical Services for Children
7B-1 Data Elements Considered for a National Uniform Data
Set for Emergency Medical Services for Children:
Prehospital Services and Emergency Departments
CONTENTS
72
104
190
249
255
276
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RG
y
ED
for
RVICES
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