Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 101
Emergency Care for Children: Growing Pains 3 Building a 21st-Century Emergency and Trauma Care System The committee’s vision for the emergency and trauma care system is rather simple. The committee envisions a system in which patients of all ages and in all communities receive well-planned and -coordinated emergency care services. Consideration of pediatric concerns during the planning stages will ensure that the system meets the needs of children. Dispatch, emergency medical services (EMS), emergency department (ED) providers, trauma care, public safety, and public health will be fully interconnected and united in an effort to ensure that each patient receives the most appropriate care, at the optimal location, with the minimum delay. From the standpoint of pediatric patients and their parents or guardians, delivery of emergency care services will be seamless. All service delivery will be evidence-based, and innovations will be rapidly adopted and adapted to each community’s needs. The performance of the system will be completely transparent, so that emergency medical technicians (EMTs) and parents will know which hospitals are best able to deliver care to critically ill or injured children (see Box 3-1). The committee recognizes that improved care for children cannot be accomplished without addressing some of the failings in the larger emergency care system. The committee’s vision centers on three goals: coordination, regionalization, and accountability. While this vision may appear innovative, many of its elements have been advocated for decades. However, early progress toward achieving these elements was derailed as a result of deeply entrenched political interests and cultural attitudes, as well as funding cutbacks and practical impediments to change. These obstacles remain today, and represent the chief challenges to realizing the committee’s vision. Con-
OCR for page 102
Emergency Care for Children: Growing Pains BOX 3-1 A Vision of Pediatric Emergency Care in 2010 In a rural area, a car slides off the road and crashes 30 minutes from the nearest town. An automated crash notification system provides an emergency response center with detailed information about the location and characteristics of the crash. Passenger weights indicate that an adult and child, both properly restrained, are in the car. A dashboard displays information about the crash to air and ground response teams, emergency departments, and trauma facilities throughout the region. Because of the large impact of the crash, the automated triage system launches two advanced life support (ALS) response teams. An air medical response team is placed on standby. Once the EMS teams are on the scene, patients’ complete medical histories and alerts, obtained through a regional information system, are instantly available. Using an evidence-based triage protocol, one of the EMS teams determines that the child, an 8-year-old boy, is suffering from serious injuries. In accordance with regional transport protocols, the first responders call for air transport to bring the boy to the nearest trauma center. The paramedics stabilize the boy using age- and size-scaled equipment and drugs, and begin transmission of telemetry and on-board diagnostic scans to the trauma center. The other EMS team assesses the child’s father and determines that although he requires a lower level of care, he should be transported to the trauma center to accompany his son. An air transport team arrives at the scene and transports the child and father to a level I trauma center with the resources and medical experts needed to handle high-level pediatric and adult trauma cases. Care continues to be certed, cooperative efforts at multiple levels of government and the private sector are necessary to finally break through and achieve these goals. This chapter is dedicated to describing the three goals of the committee’s vision for the emergency care system of the future, with a special focus on pediatric emergency care. In some areas of the country, states and regions are already developing coordinated, regionalized systems that incorporate elements of accountability; some of these efforts are described as well. GOAL 1: COORDINATION The current emergency care system faces a number of problems, but among the most long-standing of these is that emergency services are fragmented, resulting in poor communication and delayed services. EMS,
OCR for page 103
Emergency Care for Children: Growing Pains delivered en route in accordance with evidence-based treatment guidelines. The pediatric trauma specialist—alerted to the emergency when the air medical team was dispatched—performs emergency surgery when the child arrives at the hospital, and a pediatric intensivist is available for consult. The child receives the highest level of care based on the available clinical evidence. His medications, all approved for use in children, are delivered according to dosage guidelines for his age and size. The child’s pediatrician and father’s primary care provider are notified of the event. The child’s mother, who was not in the vehicle, is contacted immediately and apprised of the status of her husband and son. While understandably upset at the news, she takes some comfort in knowing that her husband and son are at a trauma center that has earned high marks for quality care delivery. When the mother arrives at the hospital, she is met by a social worker and nurse and given a clear explanation of the surgery being performed on her son. Hospital staff remain available to answer all of her questions. After surgery, the child is admitted to the hospital, where he spends a couple of days in recovery. When the child is eventually released from the hospital, the parents are given clear instructions for his continued care. A record of the event is automatically collected by the region’s emergency care information system, capturing information from the ground and flight paramedics as well as the hospital. A copy of that information is sent to both the state trauma registry and the National Trauma Data Bank. Additionally, the automatic crash notification system identifies that the crash occurred in an area where crashes are common and sends a notification to the public health department. hospitals, trauma centers, and public health have traditionally worked in silos, a situation that largely persists today (NHTSA, 1996). For example, public safety and EMS agencies often lack common communications frequencies and protocols for communicating with each other during disasters. Similarly, emergency care providers do not have access to patient medical histories that could be useful in decision making. Even within those silos, coordination may be limited. For example, only about half of hospitals with EDs have pediatric interfacililty transfer agreements (MCHB, 2004), which are necessary in case a hospital receives a critically ill or injured child but lacks the resources to properly manage his or her care. Jurisdictional borders also contribute to fragmentation under the current system. For example, one county in Michigan has 18 different EMS systems with different service models and protocols. Medicaid and other payer policies contribute
OCR for page 104
Emergency Care for Children: Growing Pains to geographic fragmentation when reimbursement does not follow patients seamlessly across state lines. The problem is exacerbated in some regions by turf wars between firefighters and EMS personnel that were documented in a series of articles for USA Today (Davis, 2003). Even within EDs, there may be friction between emergency staff trying to admit patients and personnel on understaffed inpatient units who have no incentive for speeding up the admissions process. Lack of coordination between EMS and hospitals can result in delays that compromise care, and EDs may clash with on-call specialists over delays in response. Also contributing to fragmentation is that pediatric concerns often are not included in the initial planning stages of the emergency care system. Either pediatric concerns are overlooked entirely, or planning for adult and pediatric care occurs independently. This is particularly true of disaster and trauma planning. A 2003 National Association of State EMS Directors (NASEMSD) survey found that only 14 states involved pediatric experts in state, regional, and local disaster planning. It is not surprising, then, that the majority of state disaster plans fail to address pediatric equipment and medications at hospitals (NASEMSD, 2004). Only about half of states report having designated pediatric trauma centers and trauma registries, indicating another important gap in planning (MCHB, 2004). Importance of Linkages with Public Health The ED has a special relationship with the community and state and local public health departments because it serves as a community barometer of both illness and injury trends (Malone, 1995). In her analysis of heavy users of ED services, Malone argued that “emergency departments remain today a ‘window’ on wider social issues critical to health care reforms” (p. 469). A commonly cited example is the use of seat belts. We now know that increased utilization of seat belts reduces the number of seriously injured car crash victims in the ED—the ED served as a proving ground for documenting the results of seat belt enforcement initiatives. Although prevention activities have been limited in the emergency care setting, that setting represents an important teaching opportunity. To take advantage of this opportunity, emergency care providers would benefit from the resources and experiences of public health agencies and experts in the implementation of injury prevention measures. Perhaps now more than ever, with the threat of bioterrorism and outbreaks of such diseases as avian influenza and severe acute respiratory syndrome (SARS), it is essential that EMS, EDs, trauma centers, and state and local public health agencies partner to conduct surveillance for disease
OCR for page 105
Emergency Care for Children: Growing Pains prevalence and outbreaks and other health risks. Hospital EDs can recognize the diagnostic clues that may indicate an unusual infectious disease outbreak so that public health authorities can respond quickly (GAO, 2003). However, a solid partnership must first be in place—one that allows for easy communication of information between emergency providers and public health officials. Importance of Linkages with Other Medical Care Providers According to the American College of Emergency Physicians (ACEP), EDs “define their mission in terms of unlimited access regardless of citizenship, insurance status, ability to pay, day of week, or time of day…it is the only source of care available for certain populations” (O’Brien, 1999, p.19). Indeed, EDs fill many existing gaps within the health care network, serving as key safety net providers in many communities (Lewin and Altman, 2000). Studies have shown that a significant number of patients use the ED for nonurgent purposes because of financial barriers, lack of access to clinics after hours, transportation barriers, convenience, and lack of a usual source of care (Grumbach et al., 1993; Young et al., 1996; Peterson et al., 1998; Koziol-McLain et al., 2000; Cunningham and May, 2003). There is also evidence that clinics and physicians are increasingly using EDs as an adjunct to their practice, referring patients to the ED for a variety of reasons, such as their own convenience after regular hours, reluctance to take on a complicated case, the need for diagnostic tests they cannot perform in the office, and liability concerns (Berenson et al., 2003; Studdert et al., 2005). Unfortunately, in many communities there is little interaction between emergency care services and community safety net providers—this even though they share a common base of patients, and their actions may affect one another substantially. The absence of coordination represents missed opportunities for enhanced access; improved diagnosis, patient follow-up, and compliance; and enhanced quality of care and patient satisfaction. Previous Calls for Improved Coordination The value of integrating and coordinating emergency care has long been recognized. The 1966 National Academy of Sciences/National Research Council (NAS/NRC) report Accidental Death and Disability: The Neglected Disease of Modern Society called for better coordination of emergency care through Community Councils on Emergency Medical Services, which would bring together physicians, medical facilities, EMS, public health, and others “to procure equipment, construct facilities and ensure optimal emergency care on a day to day basis as well as in disaster or national
OCR for page 106
Emergency Care for Children: Growing Pains emergency” (NAS and NRC, 1966, p.7). In 1972, the NAS/NRC report Roles and Responsibilities of Federal Agencies in Support of Comprehensive Emergency Medical Services promoted an integrated, systems approach to planning at the state, regional, and local levels and called for the Department of Health, Education, and Welfare (DHEW) to take an administrative and leadership role in federal EMS activities. The Emergency Medical Services Systems Act of 1973 (P.L. 93-154) created a new grant program in the Division of EMS within DHEW to foster the development of regional EMS systems. The Robert Wood Johnson Foundation added support by funding the development of 44 regional EMS systems. Although the drive toward system development waned after the demise of the DHEW program and the block granting of EMS funds in 1981, the goal of system planning and coordination has remained paramount within the emergency care community. In 1996, the National Highway Traffic Safety Administration’s (NHTSA) Emergency Medical Services Agenda for the Future also emphasized the goal of system coordination: EMS of the future will be community-based health management that is fully integrated with the overall health care system. It will have the ability to identify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to treatment of chronic conditions and community health monitoring…. [P]atients are assured that their care is considered part of a complete health care program, connected to sources for continuous and/or follow-up care, and linked to potentially beneficial health resources…. EMS maintains liaisons, including systems for communication with other community resources, such as other public safety agencies, departments of public health, social service agencies, departments of public health, social service agencies and organizations, health care provider networks, community health educators, and others…. EMS is a community resource, able to initiate important follow-up care for patients, whether or not they are transported to a health care facility. (NHTSA, 1996, pp. 7, 10) Successes Achieved While progress toward a highly integrated emergency care system has been slow, there have been some important successes in the coordination of emergency care services, which point the way toward solutions to the fragmentation that dominates the system today. For example, the trauma system in Maryland, described in more detail later in this chapter, provides a comprehensive and coordinated approach to the care of injured children. Children’s hospitals have also been successful at accomplishing regional coordination to ensure the transport and appropriate care of children needing specialized services. The pediatric intensive care system is a leading example
OCR for page 107
Emergency Care for Children: Growing Pains of regional coordination among hospitals, community physicians, and EMTs (Gausche-Hill and Wiebe, 2001). These are but a few examples demonstrating the possibilities for enhancing coordination of the system as a whole. One promising public health surveillance effort is Insight, a computer-based clinical information system at the Washington Hospital Center (WHC) in Washington, D.C., designed to record and track patient data, including geographic and demographic information. The software proved useful during the 2001 anthrax attacks, when it enabled WHC to transmit complete, real-time data to the Centers for Disease Control and Prevention (CDC) while other hospitals were sending limited information with a lag time of one or more days. The success of Insight attracted considerable grant funding for the system’s expansion; WHC earmarked $7 million for Insight to link it to federal and regional agencies and to integrate it with other hospital systems (Kanter and Heskett, 2002). Many communities have established primary care networks that integrate hospital EDs into their planning and coordination efforts. A rapidly growing number of communities, such as San Francisco and Boston, have developed regional health information organizations that coordinate the development of information systems to facilitate patient referrals and track the sharing of medical information between providers to optimize a patient’s care across settings. The San Francisco Community Clinic Consortium brings together primary and specialty care providers and EDs in a planning and communications network that closely coordinates the care of safety net patients throughout the city. The Importance of Communications Communications are a critical factor in establishing systemwide coordination. An effective communications system is the glue that can hold together effective, integrated emergency care services. It provides the key link between 9-1-1/dispatch and EMS responders and is necessary to ensure that on-line medical direction is available when needed. It enables ambulance dispatchers to tell callers what to do until help arrives and to track a patient’s progress following the arrival of EMS responders. An effective communications system also enables ambulance dispatchers to assist EMS personnel in directing patients to the most appropriate facility based on the nature of their illness or injury and the capacity of receiving facilities. It links the emergency medical system with other public safety providers—such as police and fire departments, emergency management services, and public health agencies—and facilitates coordination between the medical response system and incident command in both routine and disaster situations. It helps hospitals communicate with each other to organize interfacility trans-
OCR for page 108
Emergency Care for Children: Growing Pains fers and arrange for mutual aid. And it facilitates medical and operational oversight and quality control within the system. GOAL 2: REGIONALIZATION The goal of regionalization is to improve patient outcomes by directing patients to facilities with the optimal capabilities and best outcomes for any given type of illness or injury. A regionalized system ensures access to care at a level appropriate to patient needs while maintaining efficient use of available resources (Wright and Klein, 2001). Because not all hospitals within a community have the personnel and resources to support high-level pediatric emergency care delivery, critically ill and injured children should not be directed simply to the closest facility, but to the nearest facility with the pediatric expertise and resources needed to deliver high-level care. Regionalization of emergency care is not a new concept. The Institute of Medicine (IOM) report Emergency Medical Services for Children noted that “categorization and regionalization are essential for full and effective operation of [pediatric emergency care] systems” (IOM, 1993, p. 171). Steps to regionalize certain pediatric services were supported by the American College of Critical Care Medicine and the Society of Critical Care Medicine in their 2000 Consensus Report for Regionalization of Services for Critically Ill or Injured Children (Committee on Pediatric Emergency Medicine Pediatric Section and Task Force on Regionalization of Pediatric Critical Care, 2000). Because of higher volume, regional providers gain experience in treating severely injured children, which in turn results in higher-quality care. Two recent studies found that child trauma patients have better outcomes at specialized pediatric centers (Stylianos, 2005; Densmore et al., 2006). Mortality among pediatric patients with respiratory failure or head injury is lower in hospitals that provide tertiary-level pediatric intensive care than in those that do not (Pollack et al., 1991; Tilford et al., 2005). There is substantial evidence that regionalization of services to designated hospitals with greater experience improves outcomes and reduces costs across a range of high-risk conditions and procedures for adult patients, including cardiac arrest and stroke (Grumbach et al., 1995; Imperato et al., 1996; Nallamothu et al., 2001; Chang and Klitzner, 2002; Bardach et al., 2004). The literature also shows improved outcomes and lower costs associated with the regionalization of care for severely injured patients (Mullins and Mann, 1999; Jurkovich and Mock, 1999; Mann et al., 1999; Nathens et al., 2001; Chiara and Cimbanassi, 2003; Bravata et al., 2004), although the evidence in this regard is not uniformly positive (Glance et al., 2004). Regionalization benefits triage, medical care, outbreak investigations, security management, and emergency management. It may also be a cost-effective
OCR for page 109
Emergency Care for Children: Growing Pains strategy for developing and training teams of response personnel (Bravata et al., 2004). An example of a pediatric regionalization effort is the regionalization of neonatal care. The use of neonatal intensive care services in the 1960s and 1970s proved to decrease neonatal mortality (Williams and Chen, 1982), but not all hospitals could purchase and support the sophisticated equipment and specialized staff needed to care for the small number of infants requiring such care (Holloway, 2001). In the interest of using resources efficiently and ensuring access to neonatal care, in 1976 a Committee on Perinatal Health organized by the March of Dimes recommended the development of a regionalized system of neonatal intensive care (Cifuentes et al., 2002). Under the system, premature or very ill newborns were to be transferred to the nearest designated center to receive the level of care they required (Jones, 2004). While it is difficult to draw a definitive conclusion, studies suggest that regionalization has contributed to lower neonatal mortality rates (Bode et al., 2001; Holloway, 2001; Cifuentes et al., 2002). Another example is organized trauma systems, which have been shown to improve outcomes of trauma care and to reduce mortality from traumatic injury through regionalization (Mullins et al., 1994; Jurkovich and Mock, 1999; MacKenzie, 1999; Mullins and Mann, 1999; Nathens et al., 2000; MacKenzie et al., 2006). While the literature has long reported benefits of such systems for adult patients, there is less evidence for children (Wright and Klein, 2001); however, the limited available research indicates benefits from regionalized pediatric trauma care. The initiation of a regionalized trauma system in Oregon resulted in a reduction in the risk of death from serious pediatric injuries (Hulka et al., 1997; Hulka, 1999). In New York, the triage of moderately to severely injured children to centers within regionalized systems reduced the risk of death compared with nonregionalized systems operating in other parts of the state (Cooper et al., 1993; Hulka, 1999). Many states and/or communities have taken steps toward regionalizing pediatric emergency care by designating hospitals that meet certain requirements as “stand-by emergency departments approved for pediatrics” (SEDPs), “emergency departments approved for or accepting pediatrics” (EDAPs), and/or “emergency pediatric centers” (EPCs) (Gausche-Hill and Wiebe, 2001). In some areas, only EDAP or EPC hospitals are allowed to accept pediatric patients who have been transported by advanced life support (ALS) EMS providers. However, a state-by-state analysis shows that many states have still not formally regionalized pediatric intensive care or trauma (Adomako and Melese-d’Hospital, 2004). Most pediatric trauma patients are not brought to pediatric trauma centers, and they receive less-than-optimal care as a result (Densmore et al., 2006).
OCR for page 110
Emergency Care for Children: Growing Pains Simply designating hospitals as SEDPs, EDAPs, or EPCs and formalizing pediatric EMS transport protocols to reflect those designations is not sufficient, however. As noted in Chapter 2, the vast majority of children do not access EMS before arriving at an ED (McCaig and Burt, 2005), and in part for this reason, most children are seen in general EDs (Gausche-Hill et al., 2004). In all likelihood, many of these EDs are not designated as SEDPs, EDAPs, or EPCs; this is certainly so if the state lacks a designation process. It is natural for many parents simply to bring their children to the closest ED. Therefore, all hospitals, especially those not recognized as having the ability to care for critically ill or injured pediatric patients, must be linked to a broader regional system. There must be clear protocols for transferring such patients from an ED without specialized pediatric capabilities to a better-equipped facility. Regionalization of emergency care helps ensure that pediatric patients receive definitive care as soon as possible, even in rural or remote areas. Concerns About Regionalization One concern about the regionalization of pediatric emergency and trauma care is that moving too many children to regional centers would further dilute the pediatric experience of community hospitals. But all hospitals must have some baseline of pediatric readiness. As noted above, they must have the capability to stabilize pediatric patients and must have formal transfer agreements in place with regional pediatric centers. Another concern is that regionalizing services could adversely impact the overall availability of other services in a community. For example, loss of certain type of patients could result in the closure of a hospital unit or an entire hospital, particularly a small, rural hospital. The survival of small, rural facilities may require identification and treatment of those illnesses and injuries that do not require the capacities and capabilities of larger facilities, as well as repatriation to the local facility after stabilization at the tertiary center for long-term care and follow-up. A systems approach to regionalization considers the full effects of regionalizing services on a community. Determining the appropriate metrics for this type of analysis and defining the process for applying them within each region are significant research and practical issues. Nonetheless, in the absence of rigorous evidence to guide the process, planning authorities should take these factors into account in developing regionalized systems of emergency care. Configuration of Services The design of the emergency care system envisioned by the committee bears similarities to the inclusive trauma system concept that was espoused
OCR for page 111
Emergency Care for Children: Growing Pains by the American College of Surgeons (ACS) and has been widely adopted throughout the United States. Under the ACS approach, every hospital in the community can play a role in the trauma system by undergoing verification and designation as a level I to level IV/V trauma center, based on its capabilities. Trauma care is optimized in the region through protocols and transfer agreements that are designed to direct trauma patients to the most appropriate level of care available given the type of injury and the relative travel times to each center. As discussed earlier, the advantages of such a system are evident from studies demonstrating improved outcomes when patients receive care at designated facilities with specialized resources. These benefits accrue to pediatric patients as well as adults (Stylianos, 2005; Densmore et al., 2006). The committee’s vision expands this concept beyond trauma to encompass all illnesses and injuries, and beyond hospitals to encompass the entire continuum of emergency care—including 9-1-1 and dispatch and prehospital EMS, as well as clinics and urgent care providers that may play a role in emergency care. In this model, every provider organization can play a role in providing emergency care in the community according to its capabilities. All hospitals are categorized in a manner similar to the way some states and communities have designated SEDPs, EDAPs, and EPCs. Initially, this categorization may simply be based on the existence of a dedicated pediatric ED; recommended pediatric equipment; and specialized pediatric services, such as pediatric neurosurgery. Over time, the categorization process may evolve to include detailed information, such as the times specific emergency procedures are available; arrangements for on-call pediatric specialty care; service-specific outcomes; or general emergency service indicators, such as time to treatment, frequency of diversion, and ED boarding. Prehospital EMS services may be similarly categorized according to pediatric capabilities. The result is a complete inventory of emergency care assets and capabilities within a community. A standard national approach to the categorization of emergency care providers that reflects both adult and pediatric capabilities is needed. Categories should reflect meaningful differences in the types of emergency care available, yet be simple enough to be understood easily by the provider community and the public. The use of national definitions will ensure that the categories are understood by providers and by the public across states or regions of the country, and will also promote benchmarking of performance. The committee concludes that a standard national approach to the categorization of emergency care is essential for the optimal allocation of resources and provision of critical information to an informed public. Therefore, the committee recommends that the Department of Health and Human Services and the National Highway Traffic Safety Administration, in part-
OCR for page 140
Emergency Care for Children: Growing Pains Objectives of the lead agency The lead agency’s mission would be to enhance the performance of the emergency and trauma care system as a whole, as well as to improve the performance of the various components of the system, such as prehospital EMS, hospital-based emergency care, trauma systems, pediatric emergency and trauma care, prevention, rural emergency and trauma care, and disaster preparedness. The lead agency would set the overall direction for emergency and trauma care planning and funding; would be the primary collector and repository of data in the field; and would be the key source of information about emergency and trauma care for the public, the federal government, and practitioners themselves. It would be responsible for allocating federal resources across all of emergency and trauma care to achieve systemwide goals, and should be held accountable for the performance of the system and its components. Location of the lead agency The lead agency would be housed within DHHS. The committee considered many factors in selecting DHHS over DOT and DHS. The factor that drove this decision above all others was the need to unify emergency and trauma care within a medical care/public health framework. Emergency and trauma care is by its very nature involved in multiple arenas—medical care, public safety, public health, and emergency management. The multiple identities that result from this multifaceted involvement reinforce the fragmentation that is endemic to the emergency and trauma care system. For too long, the gulf between EMS and hospital care has hindered efforts at communication, continuity of care, patient safety and quality of care, data collection and sharing, collaborative research, performance measurement, and accountability. It will be difficult for emergency and trauma care to achieve seamless and high-quality performance across the system until the entire system is organized within a medical care/public health framework while also retaining its operational linkages with public safety and emergency management. Only DHHS, as the department responsible for medical care and public health in the United States, can encompass all of these functions effectively. Although DOT has played an important role in both EMS and acute trauma care and has collaborated effectively with other agencies, its EMS and highway safety focus is too narrow to represent all of emergency and trauma care. DHS houses the Fire Service, which is closely allied with EMS, particularly at the field operations level. But the focus of DHS on disaster preparedness and bioterrorism is also too narrow to encompass the broad scope of emergency and trauma care. Because emergency and trauma care functions would be consolidated in a department oriented toward medical care and public health, there is a risk that public safety and emergency management components could re-
OCR for page 141
Emergency Care for Children: Growing Pains ceive less attention, stature, or funding. Therefore, it is imperative that the mission of the new agency be understood and clearly established by statute so that the public safety and emergency management aspects of emergency and trauma care will not be neglected. Programs included in the lead agency The committee envisions that the lead agency would have primary programmatic responsibility for the full continuum of EMS; emergency and trauma care for adults and children, including medical 9-1-1 and emergency medical dispatch; prehospital EMS (both ground and air); hospital-based emergency and trauma care; and medical-related disaster preparedness. The agency’s focus would be on program development and strategic funding to improve the delivery of emergency and trauma care nationwide. It would not be primarily a research funding agency, with the exception of a few of the existing grant programs mentioned above. Funding for basic, clinical, and health services research in emergency and trauma care would remain the primary responsibility of existing research agencies, including the National Institutes of Health (NIH), AHRQ, and CDC. Because of the limited research focus of the lead agency, it would be imperative for existing research agencies, NIH in particular, to work closely with the new agency and strengthen their commitment to emergency and trauma care research. On the other hand, it may be appropriate to keep certain clinical and health services research initiatives with the programs in which they are housed, and therefore bring them into the new agency. For example, responsibility for funding the infrastructure for the Pediatric Emergency Care Applied Research Network (PECARN) would be moved into the new agency along with the rest of the EMS-C program. In addition to existing functions, the lead agency would become the home for future programs related to emergency and trauma care, including new programs that would be dedicated to the development of inclusive systems of emergency and trauma care. Working group While the committee envisions consolidation of most of the emergency care–related functions currently residing in other agencies and departments, it recognizes that many complex issues are involved in determining which programs should be combined and which left in their current agency homes. A deliberate process should be established to determine the exact composition of the new agency and to coordinate an effective transition. For these reasons, the committee is recommending the establishment of an independent working group to make recommendations regarding the structure, funding, and responsibilities of the new agency, and to coordinate and monitor the transition process. The working group should include representatives from federal and state agencies and profes-
OCR for page 142
Emergency Care for Children: Growing Pains sional disciplines involved in emergency care. The committee considered whether FICEMS would be an appropriate entity to assume this advisory and oversight role and concluded that, as currently constituted, it lacks the scope and independence to carry out this role effectively. Role of FICEMS FICEMS is a highly promising entity that is complementary to the proposed new lead agency. FICEMS would play a vital role during the proposed interim 2-year period by continuing to enhance coordination and collaboration among agencies and providing a forum for public input. In addition, it could play an important advisory role to the independent working group. Once the lead agency had been established, FICEMS would continue to coordinate work between the lead agency and other agencies, such as NIH, CMS, and DoD, that would remain closely involved in various emergency and trauma care issues. Structure of the lead agency While the principle of integration across the multiple components of emergency and trauma care should drive the structure, operation, and funding of the new lead agency, the committee envisions distinct program offices to provide focused attention and programmatic funding for key areas, such as the following: Prehospital EMS, including 9-1-1, dispatch, and both ground and air medical services Hospital-based emergency and trauma care Trauma systems Pediatric emergency and trauma care Rural emergency and trauma care Disaster preparedness To ensure that current programs would not lose visibility and stature within the new agency, it would be critical for each program office to have equal status and reporting relationships within the agency’s organizational structure. The committee lacks the expertise to specify the organizational structure in further detail. Rather, it envisions a national dialogue over the coming year—coordinated by the proposed independent working group, aided by input from FICEMS, and with the involvement of the Office of Management and Budget and congressional committees with jurisdiction—to implement the committee’s recommendation. Funding for the lead agency Existing programs transferring to the new agency would bring with them their full current and projected funding. Congress should also establish additional funding to cover the costs associ-
OCR for page 143
Emergency Care for Children: Growing Pains ated with the transition to and the new administrative overhead associated with the lead agency. In addition, Congress should add new funding for the offices of hospital-based emergency and trauma care, rural emergency and trauma care, and trauma systems. In light of the pressing challenges confronting emergency care providers and the American public, this would be money well spent. While the committee is not qualified to estimate the costs associated with establishing a unified lead agency, it recognizes that these costs would be substantial. At the same time, however, the committee believes that substantial cost savings would result from reduced duplication and lower overhead. New funding that flowed into the agency would result in new programming, rather than an increase in existing overhead. Mitigation of concerns regarding the establishment of a lead federal agency The committee recognizes that transitioning to a single lead agency would be a difficult challenge under any circumstances, but would be especially difficult for an emergency and trauma care system that is already under duress from funding cutbacks, elimination of programs, growing public demand on the system, and pressure to enhance disaster preparedness. During this critical period, it is imperative that support for emergency and trauma care programs already in place in the various federal agencies be sustained. In particular, the Office of EMS within NHTSA has ongoing programs that are critical to the EMS system. Similarly, existing emergency care–related federal programs, such as those in HRSA’s EMS-C program and Office of Rural Health Policy and at CDC, should be supported during the transition period. If the committee’s proposal is to be successful, the constituencies associated with established programs must not perceive that they are being politically weakened during the transition. The committee believes the proposed consolidation of agencies would enhance support for emergency and trauma care across the board, benefiting all current programs. But it also believes avoiding disruptions that could adversely affect established programs is critically important. Therefore, the committee considers it imperative for legislation creating the new agency to protect current levels of funding and visibility for existing programs. The new agency should balance its funding priorities by adding to current funding levels, not by diverting funds away from existing programs. The committee acknowledges the concern that removing medical-related emergency and trauma functions from DHS and DOT would create additional fragmentation. The committee believes the public safety aspects of emergency and trauma care must continue to be addressed as a core element of the emergency and trauma care system. But the primary focus of the system must be medical care and public health if the recognition, stature, and outcomes that are critical to the system’s success are to be achieved.
OCR for page 144
Emergency Care for Children: Growing Pains THE EMERGENCY MEDICAL SERVICES FOR CHILDREN PROGRAM It is the committee’s hope and expectation that in the future, existing deficiencies in pediatric emergency care will be eliminated, and providers will be equally prepared for the care of both children and adults. However, the work of the EMS-C program today remains relevant and vital. In the chapters that follow, the committee outlines a number of recommendations for improving pediatric emergency care. Implementing these recommendations will require the leadership of a well-recognized, well-respected entity not just within pediatrics, but within the broader emergency care system. The EMS-C program, with its long history of working with federal partners, state policy makers, researchers, providers, and professional organizations across the spectrum of emergency care, is in the best position to assume this leadership role. The committee recommends that Congress appropriate $37.5 million per year for the next 5 years to the Emergency Medical Services for Children program (3.7). The committee is not suggesting that the EMS-C program should assume full responsibility for funding the implementation of the recommendations presented in this report; rather, the program should serve as a facilitator to initiate the implementation process. For example, the EMS-C program could convene national conferences involving individuals with multidisciplinary expertise to address how the committee’s various recommendations should be implemented. However, additional funding will be needed to ensure that the program has the capacity to initiate these efforts. An additional $500,000 should be allocated to the program’s budget to sponsor four to five national conferences per year. The program’s budget should also be expanded to accommodate an increase in the award size for the State Partnership Grants. In fiscal year 2005, EMS agencies (or a designated alternative) in 54 U.S. states and territories received grant support from the program to institutionalize pediatric EMS improvements. In many states, however, the award from the EMS-C program ($100,000 to $115,000) represents the state’s largest or only investment in pediatric emergency care. After covering salary and overhead for a staff person, the current size of the grant leaves little to be spent on programmatic initiatives. An additional $8 million per year is needed to increase the annual award amount to $250,000 per state/territory. This additional funding would better enable a state representative to initiate improvements, which could include organizing pediatric disaster drills, increasing the level of available pediatric emergency care training, participating in and organizing statewide pediatric emergency care planning, and meeting with provider organizations to encourage and facilitate improvements in pediatric preparedness.
OCR for page 145
Emergency Care for Children: Growing Pains The EMS-C program also provides financial support for the infrastructure of PECARN through its network demonstration cooperative agreements. The importance of PECARN cannot be overstated. While it remains small in size, it is perhaps the best resource for conducting multicenter randomized trials in pediatric emergency care. As the network is currently organized, however, its linkages to prehospital providers are limited, thereby constraining the ability of researchers to conduct analyses across the continuum of care. Additional funding is needed to build a sustainable link between the four research nodes of PECARN and the prehospital providers in those nodes. EMS-C program funding should be increased to provide each research node $1 million per year to establish data linkages with local prehospital providers, for a total cost of $4 million per year. Looking to the future of PECARN, its administrators should also explore the possibility of integrating more general hospitals into the network and expanding research nodes in the south and southeast to improve the network’s geographic reach. Finally, the program is in need of additional funding that could be directed toward special initiatives or one-time projects addressing important needs. For example, the program is currently funding two projects for the development of clinical practice guidelines ($250,000 per year for 3 years for each project). Justification for expanding this initiative is provided in Chapter 4, where the committee calls for the development, evaluation, and updating of pediatric clinical practice guidelines. An additional $5 million per year would allow the EMS-C program to support approximately 18 similar large projects. Examples of other types of special projects that could be supported with this funding are the development of pediatric dosing guidelines for certain medications and the development of labeling techniques to reduce medication errors. The 5-year timeframe is suggested so that the program will have the capacity to address the deficiencies in the pediatric emergency care system quickly. The program should focus on creating sustainable activities and strive to integrate pediatrics into emergency care planning at the federal, state, and local levels. The proposed 5-year period is not intended as a limit on federal funding dedicated to improving pediatric emergency care; indeed, there will always be a need to monitor and study emergency care for children. However, the committee’s expectation is that the various elements of emergency care leadership at the federal level will be better integrated and consolidated in the future (as discussed above). Support for pediatric emergency care will always remain a vital aspect of that federal leadership, but it may not be in the form of a separate program. After 5 years, it will be necessary to reexamine how best to identify and fund pediatric emergency care objectives at the federal level, as well as to reevaluate future funding levels for the EMS-C program.
OCR for page 146
Emergency Care for Children: Growing Pains SUMMARY OF RECOMMENDATIONS 3.1 The Department of Health and Human Services and the National Highway Traffic Safety Administration, in partnership with professional organizations, should convene a panel of individuals with multidisciplinary expertise to develop evidence-based categorization systems for emergency medical services, emergency departments, and trauma centers based on adult and pediatric service capabilities. 3.2 The National Highway Traffic Safety Administration, in partnership with professional organizations, should convene a panel of individuals with multidisciplinary expertise to develop evidence-based model prehospital care protocols for the treatment, triage, and transport of patients, including children. 3.3 The Department of Health and Human Services should convene a panel of individuals with emergency and trauma care expertise to develop evidence-based indicators of emergency and trauma care system performance, including the performance of pediatric emergency care. 3.4 Congress should establish a demonstration program, administered by the Health Resources and Services Administration, to promote coordinated, regionalized, and accountable emergency care systems throughout the country, and appropriate $88 million over 5 years to this program. 3.5 The Department of Health and Human Services should adopt rule changes to the Emergency Medical Treatment and Active Labor Act and the Health Insurance Portability and Accountability Act so that the original goals of the laws are preserved, but integrated systems may further develop. 3.6 Congress should establish a lead agency for emergency and trauma care within 2 years of the release of this report. The lead agency should be housed in the Department of Health and Human Services, and should have primary programmatic responsibility for the full continuum of emergency medical services and emergency and trauma care for adults and children, including medical 9-1-1 and emergency medical dispatch, prehospital emergency medical services (both ground and air), hospital-based emergency and trauma care, and medical-related disaster preparedness. Congress should establish a working group to make recommendations re-
OCR for page 147
Emergency Care for Children: Growing Pains garding the structure, funding, and responsibilities of the new agency, and develop and monitor the transition. The working group should have representation from federal and state agencies and professional disciplines involved in emergency and trauma care. 3.7 Congress should appropriate $37.5 million per year for the next 5 years to the Emergency Medical Services for Children program. REFERENCES Adomako SA, Melese-d’Hospital I. 2004. State-by-State Profiles: The Integration of Pediatric Care Components into the EMS System. Rockville, MD: MCHB, NHTSA, HRSA. Bardach NS, Olson SJ, Elkins JS, Smith WS, Lawton MT, Johnston SC. 2004. Regionalization of treatment for subarachnoid hemorrhage: A cost-utility analysis. Circulation 109(18):2207–2212. Berenson RA, Kuo S, May JH. 2003. Medical malpractice liability crisis meets markets: Stress in unexpected places. Issue Brief (Center for Studying Health System Change) 68:1–7. Bode MM, O’Shea TM, Metzguer KR, Stiles AD. 2001. Perinatal regionalization and neonatal mortality in North Carolina, 1968–1994. American Journal of Obstetrics and Gynecology 184(6):1302–1307. Bravata D, McKonald K, Owens D, Wilhelm ER, Brandeau ML, Zaric GS, Holty JC, Sundaram V. 2004. Regionalization of Bioterrorism Preparedness and Response. Rockville, MD: AHRQ. Chang RK, Klitzner TS. 2002. Can regionalization decrease the number of deaths for children who undergo cardiac surgery? A theoretical analysis. Pediatrics 109(2):173–181. Chiara O, Cimbanassi S. 2003. Organized trauma care: Does volume matter and do trauma centers save lives? Current Opinion in Critical Care 9(6):510–514. Cifuentes J, Bronstein J, Phibbs CS, Phibbs RH, Schmitt SK, Carlo WA. 2002. Mortality in low birth weight infants according to level of neonatal care at hospital of birth. Pediatrics 109(5):745–751. CMS (Centers for Medicare and Medicaid Services). 2003. Emergency Medical Treatment and Active Labor Act (EMTALA) Interim Guidance. Letter to State Survey Agency Directors. Ref: S&C-04-10. CMS. 2005a. Report Number One to the Secretary, U.S. Department of Health and Human Services, from the Inaugural Meeting of the Emergency Medical Treatment and Labor Act Technical Advisory Group. Washington, DC: CMS. CMS. 2005b. Report Number Two to the Secretary, U.S. Department of Health and Human Services, from the Emergency Medical Treatment and Labor Act Technical Advisory Group. Washington, DC: CMS. CMS. 2005c. Report Number Three to the Secretary, U.S. Department of Health and Human Services, from the Emergency Medical Treatment and Labor Act Technical Advisory Group. Washington, DC: CMS. CMS. 2005d. Hospital Compare. [Online]. Available: http://www.hospitalcompare.hhs.gov/hospital/home2.asp [accessed November 23, 2005]. CMS. 2005e. Medicare Spotlights. [Online]. Available: http://www.medicare.gov [accessed November 22, 2005]. Committee on Pediatric Emergency Medicine Pediatric Section and Task Force on Regionalization of Pediatric Critical Care. 2000. Consensus report for regionalization of services for critically ill or injured children. Pediatrics 105(1):152–155.
OCR for page 148
Emergency Care for Children: Growing Pains Cooper A, Barlow B, DiScala C, String D, Ray K, Mottley L. 1993. Efficacy of pediatric trauma care: Results of a population-based study. Journal of Pediatric Surgery 28(3):299–303; discussion 304–305. Cunningham P, May J. 2003. Insured Americans drive surge in emergency department visits. Issue Brief (Center for Studying Health System Change) 70:1–6. Davis R. 2003, July. The method: Measure how many victims leave the hospital alive. USA Today. P. A1. Densmore JC, Lim HJ, Oldham KT, Guice KS. 2006. Outcomes and delivery of care in pediatric injury. Journal of Pediatric Surgery 41(1):92–98; discussion 92–98. EMS Performance Measures Project. 2005. Performance Measures in EMS. [Online]. Available: http://www.measureems.org/performancemeasures2.htm [accessed January 5, 2006]. GAO (General Accounting Office). 2001. Emergency Care. EMTALA Implementation and Enforcement Issues. Washington, DC: GAO. GAO. 2003. Infectious Diseases: Gaps Remain in Surveillance Capabilities of State and Local Agencies. Washington, DC: GAO. Gausche-Hill M, Wiebe R. 2001. Guidelines for preparedness of emergency departments that care for children: A call to action. Pediatrics 107(4):773–774. Gausche-Hill M, Lewis R, Schmitz C. 2004. Survey of US Emergency Departments for Pediatric Preparedness: Implementation and Evaluation of Care of Children in the Emergency Department: Guidelines for Preparedness. Unpublished results. Glance LG, Osler TM, Dick A, Mukamel D. 2004. The relation between trauma center outcome and volume in the national trauma databank. Journal of Trauma-Injury Infection & Critical Care 56(3):682–690. Grumbach K, Keane D, Bindman A. 1993. Primary care and public emergency department overcrowding. American Journal of Public Health 83(3):372–378. Grumbach K, Anderson GM, Luft HS, Roos LL, Brook R. 1995. Regionalization of cardiac surgery in the United States and Canada. Geographic access, choice, and outcomes. Journal of the American Medical Association 274(16):1282–1288. Harris Interactive. 2004. Trauma Care: Public’s Knowledge and Perception of Importance. Rochester, NY: The Coalition for American Trauma Care. Health Level 7. 2005. Emergency Care Special Interest Group. [Online]. Available: http://www.hl7.org/Special/committees/emergencycare/index.cfm [accessed November 30, 2005]. Holloway MY. 2001. The Regionalized Perinatal Care Program. Princeton, NJ: The Robert Wood Johnson Foundation. Hulka F. 1999. Pediatric trauma systems: Critical distinctions. The Journal of Trauma 47(Suppl. 3):S85–S89. Hulka F, Mullins RJ, Mann NC, Hedges JR, Rowland D, Worrall WH, Sandoval RD, Zechnich A, Trunkey DD. 1997. Influence of a statewide trauma system on pediatric hospitalization and outcome. The Journal of Trauma 42(3):514–519. Imperato PJ, Nenner RP, Starr HA, Will TO, Rosenberg CR, Dearie MB. 1996. The effects of regionalization on clinical outcomes for a high risk surgical procedure: A study of the whipple procedure in New York state. American Journal of Medical Quality 11(4):193–197. IOM (Institute of Medicine). 1993. Emergency Medical Services for Children. Washington, DC: National Academy Press. IOM. 2002. Fostering Rapid Advances in Health Care: Learning from System Demonstrations. Washington, DC: National Academy Press. Jones J. 2004. Neonatal nursing: The first six weeks. Critical Care Nursing (Suppl.):6–8. Jurkovich GJ, Mock C. 1999. Systematic review of trauma system effectiveness based on registry comparisons. Journal of Trauma-Injury Infection & Critical Care 47(Suppl. 3): S46–S55.
OCR for page 149
Emergency Care for Children: Growing Pains Kanter RM, Heskett M. 2002. Washington Hospital Center (B): The Power of Insight. Watertown, MA: Harvard Business School Publishing. Koziol-McLain J, Price DW, Weiss B, Quinn AA, Honigman B. 2000. Seeking care for nonurgent medical conditions in the emergency department: Through the eyes of the patient. Journal of Emergency Nursing 26(6):554–563. Lewin ME, Altman S. 2000. America’s Health Care Safety Net. Washington DC: National Academy Press. Lindsay P, Schull M, Bronskill S, Anderson G. 2002. The development of indicators to measure the quality of clinical care in emergency departments following a modified-delphi approach. Academic Emergency Medicine 9(11):1131–1139. MacKenzie EJ. 1999. Review of evidence regarding trauma system effectiveness resulting from panel studies. Journal of Trauma-Injury Infection & Critical Care 47(Suppl. 3): S34–S41. MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, Salkever DS, Scharfstein DO. 2006. A national evaluation of the effect of trauma-center care on mortality. New England Journal of Medicine 354(4):366–378. Malone RE. 1995. Heavy users of emergency services: Social construction of a policy problem. Social Science Medicine 40(4):469–477. Mann NC, Mullins RJ, MacKenzie EJ, Jurkovich GJ, Mock CN. 1999. Systematic review of published evidence regarding trauma system effectiveness. Journal of Trauma-Injury Infection & Critical Care 47(Suppl. 3):S25–S33. McCaig LF, Burt CW. 2005. National Hospital Ambulatory Medical Care Survey: 2003 Emergency Department Summary. Hyattsville, MD: National Center for Health Statistics. McConnell KJ, Newgard CD, Mullins RJ, Arthur M, Hedges JR. 2005. Mortality benefit of transfer to level I versus level II trauma centers for head-injured patients. Health Services Research 40(2):435–457. MCHB (Maternal and Child Health Bureau). 2004. Emergency Medical Services for Children. Five Year Plan 2001–2005: Midcourse Review. Washington, DC: EMS-C National Resource Center. Mullins RJ, Mann NC. 1999. Population-based research assessing the effectiveness of trauma systems. Journal of Trauma-Injury Infection & Critical Care 47(Suppl. 3):S59–S66. Mullins RJ, Veum-Stone J, Helfand M, Zimmer-Gembeck M, Hedges JR, Southard PA, Trunkey DD. 1994. Outcome of hospitalized injured patients after institution of a trauma system in an urban area. Journal of the American Medical Association 271(24):1919–1924. Nallamothu BK, Saint S, Kolias TJ, Eagle KA. 2001. Clinical problem-solving of nicks and time. New England Journal of Medicine 345(5):359–363. NAS, NRC (National Academy of Sciences, National Research Council). 1966. Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, DC: National Academy of Sciences. NASEMSD (National Association of State EMS Directors). 2004. Pediatric Disaster and Terrorism Preparedness. Falls Church, VA: NASEMSD. Nathens AB, Jurkovich GJ, Rivara FP, Maier RV. 2000. Effectiveness of state trauma systems in reducing injury-related mortality: A national evaluation. The Journal of Trauma 48(1):25–30; discussion 30–31. Nathens AB, Jurkovich GJ, Maier RV, Grossman DC, MacKenzie EJ, Moore M, Rivara FP. 2001. Relationship between trauma center volume and outcomes. Journal of the American Medical Association 285(9):1164–1171. National Center for Injury Prevention and Control. 2004. DEEDS—Data Elements for Emergency Department Systems. [Online]. Available: http://www.cdc.gov/ncipc/pub–res/deedspage.htm [accessed November 25, 2005]. NHTSA (National Highway Traffic Safety Administration). 1996. Emergency Medical Services Agenda for the Future. Washington, DC: U.S. DOT.
OCR for page 150
Emergency Care for Children: Growing Pains NQF (National Quality Forum). 2002. National Voluntary Consensus Standards for Adult Diabetes Care. [Online]. Available: http://www.qualityforum.org/txdiabetes–public.pdf [accessed November 23, 2005]. NQF. 2003. National Voluntary Consensus Standards for Hospital Care: An Initial Performance Measure Set. [Online]. Available: http://www.qualityforum.org/txhospmeasBEACHpublicnew.pdf [accessed November 23, 2005]. NQF. 2004a. National Voluntary Consensus Standards for Nursing Home Care. [Online]. Available: http://www.qualityforum.org/txNursingHomesReportFINALPUBLIC.pdf [accessed November 23, 2005]. NQF. 2004b. National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set. [Online]. Available: http://www.qualityforum.org/txNCFINALpublic.pdf [accessed November 23, 2005]. NQF. 2005. National Voluntary Consensus Standards for Home Health Care. [Online]. Available: http://www.qualityforum.org/webHHpublic09-23-05.pdf_ [accessed November 23, 2005]. O’Brien PM. 1999. The emergency department as a public safety net. In: Fields W, ed. Defending America’s Safety Net. Dallas, TX: American College of Emergency Physicians. Orr RA, Han YY, Roth K. 2006. Pediatric transport: Shifting the paradigm to improve patient outcome. In: Fuhrman B, Zimmerman J, eds. Pediatric Critical Care (3rd edition). Mosby, Elsevier Science Health. Pp. 141–150. Peterson LA, Burstin HR, O’Neil AC. 1998. Non-urgent emergency department visits: The effect of having a regular doctor. Medical Care 36:1249–1255. Pollack MM, Alexander SR, Clarke N, Ruttimann UE, Tesselaar HM, Bachulis AC. 1991. Improved outcomes from tertiary center pediatric intensive care: A statewide comparison of tertiary and nontertiary care facilities. Critical Care Medicine 19(2):150–159. Pollock DA, Adams DL, Bernardo LM, Bradley V, Brandt MD, Davis TE, Garrison HG, Iseke RM, Johnson S, Kaufmann CR, Kidd P, Leon-Chisen N, MacLean S, Manton A, McClain PW, Michelson EA, Pickett D, Rosen RA, Schwartz RJ, Smith M, Snyder JA, Wright JL. 1998. Data elements for emergency department systems, release 1.0 (deeds): A summary report. Deeds Writing Committee. Journal of Emergency Nursing 24(1):35–44. Rosenbaum S, Kamoie B. 2003. Finding a way through the hospital door: The role of EMTALA in public health emergencies. Journal of Law, Medicine & Ethics 31(4):590–601. State of California Office of the Patient Advocate. 2005. 2005 HMO Report Card. [Online]. Available: http://www.opa.ca.gov/report_card/ [accessed January 12, 2006]. Studdert DM, Mello MM, Sage WM, DesRoches CM, Peugh J, Zapert K, Brennan TA. 2005. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. Journal of the American Medical Association 293(21):2609–2617. Stylianos S. 2005. Outcomes from pediatric solid organ injury: Role of standardized care guidelines. Current Opinion in Pediatrics 17(3):402–406. Tilford JM, Aitken ME, Anand KJS, Green JW, Goodman AC, Parker JG, Killingsworth JB, Fiser DH, Adelson PD. 2005. Hospitalizations for critically ill children with traumatic brain injuries: A longitudinal analysis. Critical Care Medicine 33(9):2140–2141. Williams RL, Chen PM. 1982. Identifying the sources of the recent decline in perinatal mortality rates in California. New England Journal of Medicine 306(4):207–214. Wright JL, Klein BL. 2001. Regionalized pediatric trauma systems. Clinical Pediatric Emergency Medicine 2:3–12. Young GP, Wagner MB, Kellermann AL, Ellis J, Bouley D. 1996. Ambulatory visits to hospital emergency departments. Patterns and reasons for use. 24 hours in the ED Study Group. Journal of the American Medical Association 276(6):460–465.
Representative terms from entire chapter: