1
Introduction

In 2002, children under age 19 made more than 29 million visits to emergency departments (EDs) in the United States (2002 National Hospital Ambulatory Medical Care Survey [NHAMCS] data, calculations by Institute of Medicine [IOM] staff). Approximately 20 percent of children make one or more visits to an ED each year; 7 percent make two or more visits (National Center for Health Statistics, 2005). Despite this heavy reliance on the emergency care system, the public typically gives little thought to the adequacy of the system for children. Yet they have lofty expectations. Parents and caregivers expect emergency and trauma care providers to deliver high-quality care to their children when it is needed. They expect the system to be agile, able to respond quickly at any hour of the day or night and handle any type of pediatric emergency appropriately (Harris Interactive, 2004). In reality, however, the public knows little about how well local emergency care and trauma systems perform, both absolutely and in comparison with other systems. In particular, there is little understanding of the major shortcomings of the emergency care system in the United States today.

Emergency care systems are largely local in nature, and they vary accordingly. State and local prevention laws, the training of prehospital emergency medical technicians (EMTs), and the availability of hospitals and pediatric emergency medicine physicians are but a few examples of such variations—key elements that have an important impact on the functioning of the emergency care system. Some areas of the country, particularly urban settings, have children’s hospitals and hospitals with pediatric EDs staffed by pediatric emergency specialists and equipped with the latest technologies for the care and treatment of children. In other areas, however, pediatric-



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Emergency Care for Children: Growing Pains 1 Introduction In 2002, children under age 19 made more than 29 million visits to emergency departments (EDs) in the United States (2002 National Hospital Ambulatory Medical Care Survey [NHAMCS] data, calculations by Institute of Medicine [IOM] staff). Approximately 20 percent of children make one or more visits to an ED each year; 7 percent make two or more visits (National Center for Health Statistics, 2005). Despite this heavy reliance on the emergency care system, the public typically gives little thought to the adequacy of the system for children. Yet they have lofty expectations. Parents and caregivers expect emergency and trauma care providers to deliver high-quality care to their children when it is needed. They expect the system to be agile, able to respond quickly at any hour of the day or night and handle any type of pediatric emergency appropriately (Harris Interactive, 2004). In reality, however, the public knows little about how well local emergency care and trauma systems perform, both absolutely and in comparison with other systems. In particular, there is little understanding of the major shortcomings of the emergency care system in the United States today. Emergency care systems are largely local in nature, and they vary accordingly. State and local prevention laws, the training of prehospital emergency medical technicians (EMTs), and the availability of hospitals and pediatric emergency medicine physicians are but a few examples of such variations—key elements that have an important impact on the functioning of the emergency care system. Some areas of the country, particularly urban settings, have children’s hospitals and hospitals with pediatric EDs staffed by pediatric emergency specialists and equipped with the latest technologies for the care and treatment of children. In other areas, however, pediatric-

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Emergency Care for Children: Growing Pains specific resources are highly limited. Dedicated, well-intentioned prehospital emergency medical services (EMS) and ED providers make do without the resources that most would expect to be available for the care of children. For example: Only about 6 percent of hospitals have available all the pediatric supplies deemed essential by the American Academy of Pediatrics and American College of Emergency Physicians for managing pediatric emergencies, although about half of hospitals have at least 85 percent of those supplies (Middleton and Burt, 2006). Of hospitals that do not have a separate pediatric inpatient ward, only about half have written transfer agreements with other hospitals (Middleton and Burt, 2006), which are necessary in case a critically ill or injured child arrives at a hospital that lacks pediatric expertise. Although research shows that pediatric skills deteriorate after a short time without practice (Su et al., 2000; Wolfram et al., 2003), pediatric continuing education is not required or is extremely limited for many prehospital providers (Glaeser et al., 2000). Many medications prescribed and administered to children in the ED are “off label,” meaning they have not been adequately tested in pediatric populations and therefore are not approved for use in children by the U.S. Food and Drug Administration (FDA). Disaster preparedness plans largely overlook the needs of children, even though children’s needs in the event of a disaster often differ from those of adults (Dick et al., 2004; NASEMSD, 2004). The lack of preparedness carries a cost: many children with an emergency medical condition do not receive appropriate care under the current system. This conclusion is clear from a recent mock drill conducted in 35 of North Carolina’s EDs, including 5 trauma centers. Nearly all of the EDs in the study failed to stabilize seriously injured children properly during trauma simulations. Almost all failed to administer dextrose properly to a child in hypoglycemic shock (a life-threatening drop in blood sugar), correctly warm a hypothermic child, or order proper administration of intravenous (IV) fluids (Hunt et al., 2006). Ongoing research suggests that these problems are not unique to North Carolina EDs. While data on pediatric emergency care outcomes are largely unavailable, data on practice patterns indicate shortcomings in the treatment and care of pediatric patients. Examples include high rates of pediatric medication errors (Selbst et al., 1999; Hubble and Paschal, 2000; Kozer et al., 2002; Fairbanks, 2004; Marcin et al., 2005), low rates of pain management for pediatric patients (Brown et al., 2003), and many missed cases of child abuse (Petrack and Christopher, 1997;

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Emergency Care for Children: Growing Pains Saade et al., 2002; Kunen et al., 2003; Trokel et al., 2006). Studies also indicate wide variation in practice patterns in the care of children (Glaser et al., 1997; Isaacman et al., 2001; Hampers and Faries, 2002; Davis et al., 2005), as well as an undertreatment of children in comparison with adults (Su et al., 1997; Gausche et al., 1998; Orr et al., 2006). Providing quality pediatric emergency and trauma care is not just about having the right training and equipment. Indeed, the delivery of care should be built on a strong foundation in which emergency care is well planned and coordinated, care is based on scientific evidence, data are collected so providers can learn from past experience, and system performance is monitored to ensure quality. Moreover, since preventing an injury or illness is almost always better and more cost-effective than even the best emergency care, the emergency care system should promote prevention through surveillance, research, and patient education. Unfortunately, today’s emergency care system generally does not function in this way. STUDY CONTEXT The Current Emergency Care System While not new, the problems facing the nation’s emergency care system that are reviewed in this report have been growing and have become more visible to the public. Critical stories have increasingly been appearing in the media regarding slow EMS response, ambulance diversions, trauma center closures, the medical malpractice crisis, ground and air ambulance crashes, and the alarming decline in on-call specialist coverage. The events of September 11, 2001, and more recent disasters, such as the train bombings in Madrid, the bus and train bombings in London, and Hurricane Katrina, have heightened the visibility of the issue. Although emergency care is a vital component of the nation’s health system, to date there has been no comprehensive study of emergency care in the United States. A study of the emergency care system is a logical extension of previous work conducted by the National Academy of Sciences and the IOM. In 1966, the National Academy of Sciences (NAS) and the National Research Council (NRC) produced the landmark report Accidental Death and Disability: The Neglected Disease of Modern Society (NAS and NRC, 1966), which helped focus attention on the lack of adequate trauma care in the United States and is widely recognized as the impetus for the development of the prehospital EMS system in place today. Other reports, such as Emergency Medical Services at Midpassage and The Emergency Department: A Regional Medical Resource (NAS and NRC, 1978), have also had a major impact in shaping the development of the emergency care system. More

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Emergency Care for Children: Growing Pains recently, several IOM studies on injury and disability have emphasized the need for skilled emergency care to limit the adverse consequences of illness and injury. Additionally, in 1993 the IOM produced the report Emergency Medical Services for Children (IOM, 1993), which focused a great deal of attention on the subject. The emergency care system has reached a critical point in its development. The specialty of emergency medicine has achieved a substantial level of maturity; the capabilities of EMS have expanded dramatically; trauma systems in a few states are beginning to attain full development; technology offers the potential to revolutionize emergency care services; and the events of September 11, 2001, and subsequent disasters have lent new public visibility and urgency to emergency care planning. In contrast to these advances, the organization and delivery, regulation, and financing of emergency care remain in an outdated, politically entrenched mode that is resistant to change. As emergency care providers become increasingly stressed, timely access to quality emergency care is jeopardized for everyone. Overview of Pediatric Emergency Care Nearly 30 percent of all ED visits are made by children (see Figure 1-1). While the majority of pediatric ED visits involve children over age 5, there are 96.2 ED visits per 100 infants, more than twice the rate for all children under age 15 of 40.8 ED visits per 100 (see Figure 2-2 in Chapter 2) (McCaig and Burt, 2005). The most frequent diagnoses for young children (under age 10) in the ED are upper respiratory infection and otitis media (ear infection). Among older children (ages 10–17), the most common diagnoses are superficial injury/contusion and sprains and strains (2002 State Emergency Department Database [SEDD] data supplied by Agency for Healthcare Re- FIGURE 1-1 Emergency department visits by age, 2002. SOURCE: 2002 NHAMCS data, calculations by IOM staff.

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Emergency Care for Children: Growing Pains search and Quality [AHRQ] staff). Only 4 percent of all pediatric ED visits result in a hospital admission (2002 NHAMCS data, calculations by IOM staff; 2002 SEDD data supplied by AHRQ staff). Just 1 percent of children who visit the ED are transferred to another hospital (2002 NHAMCS data, calculations by IOM staff), presumably a higher-level facility. Children’s hospitals are an important source of pediatric emergency care. They are the most specialized centers of care for children in the United States, and because they are focused solely on the care of children, they are the hospitals that tend to be best prepared for emergency pediatric visits in terms of expertise and pediatric resources (Gausche-Hill et al., 2004). However, children’s hospitals represent only about 5 percent of all U.S. hospitals (NACHRI, 2005). According to one estimate, only 7 percent of ED visits made by children are to a children’s hospital (Gausche-Hill et al., 2004). Some non-children’s hospitals have a separate pediatric ED. Like children’s hospitals, they tend to be better prepared for pediatric emergency visits in terms of pediatric expertise, equipment, and policies and procedures (Gausche-Hill et al., 2004). Taken together, it is estimated that only 18 percent of all pediatric visits are to pediatric EDs at either a children’s or a general hospital (2002 NHAMCS data, calculations by IOM staff). Thus, the vast majority of pediatric ED visits are made to general hospitals that treat adults and children in the same department. The quality of emergency care provided to children at these EDs is of concern because, as noted, they tend be less well prepared for pediatric emergencies than dedicated pediatric EDs. While data on outcomes by facility type are largely unavailable, studies indicate that pediatric trauma patients treated at children’s hospitals have lower mortality rates, lengths of stay, and charges than those treated at adult hospitals (Densmore et al., 2006). EDs that treat both children and adults are unlikely to have a pediatric emergency medicine physician on staff, and many lack basic pediatric equipment and supplies (Gausche-Hill et al., 2004; Middleton and Burt, 2006). Even more concerning, between 19 and 26 percent of all pediatric ED visits are to hospitals in rural and remote areas (Gausche-Hill et al., 2004; 2002 NHAMCS data, calculations by IOM staff). Many of those hospitals lack around-the-clock physician coverage, have relatively few pediatric visits, and lack a separate pediatric inpatient ward. Having a low volume of pediatric patients, lacking a separate pediatric ward, and being located in a rural area are hospital characteristics independently associated with lower levels of preparedness for pediatric ED patients (Gausche-Hill et al., 2004; Middleton and Burt, 2006). While children make nearly 30 percent of all ED visits, their use of prehospital services is relatively limited (see Figure 1-2); in fact, children represent only 5–10 percent of all EMS calls (Seidel et al., 1984; Federiuk et al., 1993). The low proportion of pediatric EMS volume represents a

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Emergency Care for Children: Growing Pains FIGURE 1-2 Percentage of patients that arrive at the emergency department by ambulance. SOURCE: McCaig, 2005. challenge because it is difficult for EMTs to maintain pediatric skills when they encounter critically ill or injured pediatric patients so infrequently. In contrast to the situation with adults, about half of prehospital calls for children are for injuries, the other half for medical problems (Seidel et al., 1991). Similar to ED visits, medical complaints are more common in children under 5, while older children are more likely to be transported for injuries (Sapien et al., 1999). While the majority of pediatric EMS transports are appropriate (Foltin et al., 1998), many are medically unnecessary (Camasso-Richardson et al., 1997; Kost and Arruda, 1999; Hamilton et al., 2003). NEED FOR A SEPARATE REPORT ON PEDIATRIC EMERGENCY CARE The statement “children are not little adults” is often used to convey the fact that children have unique medical needs relative to adults. In fact, the anatomical, physiological, developmental, and emotional attributes of children impact not only their susceptibility to illness and injury, but also the ways in which providers need to assess and treat them (see Table 1-1). Caring for sick and injured children requires that providers have specialized training and skills, as well as access to specialized equipment and supplies. However, the initial development of the nation’s emergency system largely

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Emergency Care for Children: Growing Pains TABLE 1-1 Examples of Differences Between Children and Adults and Implications for Care   Pediatric Characteristic Implications for Illness and Injury Implications for Care Anatomical Differences Greater surface area relative to body volume. Greater risk of excessive loss of heat and fluids; children are affected more quickly and easily by toxins that are absorbed through the skin. Increased body surface area makes children more susceptible to greater heat loss when they are exposed during resuscitation; the higher percentage of body surface area devoted to the head relative to the lower extremities must be taken into account when determining the percentage of body surface area involved in burn injuries.   Smaller airways; tongue is large relative to the oropharynx; larynx is higher and more anterior in the neck; vocal cords are at a more anterocaudal angle; epiglottis is soft and shaped differently from that in adults. A right main stem intubation can lead to iatrogenic complications; more susceptible to respiratory distress due to airway swelling from infection or inflammation. Special equipment and training are needed for intubation; appropriately sized endotracheal intubation tubes, stylettes, and laryngoscope blades are necessary. A child’s airway is more difficult to maintain and intubate. Children are at higher risk for a right mainstem bronchus intubation.   Less protective muscle around internal organs. Internal organs are more susceptible to traumatic forces. Recognition of internal injury requires a high degree of suspicion, and such injury should not be ruled out based on the absence of external signs of trauma.   Small size. More vulnerable to exposure and toxicity from agents that are heavier than air, such as sarin gas and chlorine, and that accumulate closer to the ground.  

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Emergency Care for Children: Growing Pains   Pediatric Characteristic Implications for Illness and Injury Implications for Care   Less fat, less elastic connective tissue, and closer proximity of chest and abdominal organs. Higher frequency of multiple organ injury.     Head is proportionally larger and heavier in children. Head injury is common in young children. Head size also makes children more susceptible to greater heat loss when they are exposed during resuscitation.   More pliable skeleton; thoracic cage of a child does not provide as much protection of organs as that of adults. More susceptible to fracture and other injuries from blunt trauma. Orthopedic injuries with subtle symptoms are easily missed; hepatic or splenic injuries can go unrecognized and produce significant blood loss, leading to shock. Physiological Differences Respiratory and heart rates vary with age. More susceptible to air pollutants. Knowledge of normal and abnormal rates based on age is required; normal vital signs differ for children and adults. An increased heart rate is often the first sign of shock in a pediatric patient, versus blood pressure in an adult. Children maintain heart rate during the early phases of hypovolemic shock, creating a false impression of normalcy.   Higher metabolic rates. More susceptible to contaminants in food or water; greater risk for increased loss of water when ill or stressed. Medication doses must be carefully calculated based on the child’s weight and body size.

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Emergency Care for Children: Growing Pains   Pediatric Characteristic Implications for Illness and Injury Implications for Care   Lower blood pressure levels than adults; levels vary with age.   Indicators of serious illness may not appear until the child is near collapse. Vital signs are less reliable indicators of serious illness than in adults. Respiratory arrest is more common than cardiac arrest; cardiopulmonary arrest is signaled by respiratory arrest or shock, rather than by cardiac arrhythmias.   Immature immunological systems. Greater risk of infection; less herd immunity from infections such as smallpox.   Developmental Differences Communication barriers may exist in all pediatric age groups, but the nature of the barrier varies by age (infants and young children cannot articulate symptoms).   Assessment tools need to be tailored to reflect age-appropriate responses. Emotional Differences Greater, varying emotional needs based on developmental level.   Need for family-centered policies and a family-friendly environment in EDs. Depending on age, children require or prefer the presence of a parent during treatment.   Higher sensitivity to environmental factors during treatment. Age and developmental level of child, characteristics of event, and parental reactions play significant roles in determining the child’s reactions and recovery. Providers must manage the mental health needs of pediatric patients and parents’ reactions.

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Emergency Care for Children: Growing Pains overlooked the unique needs of children. The system was originally directed by physicians trained in adult medical specialties, many of whom had little experience with pediatric patients and the unique features of pediatric care. As a result, pediatric emergency care did not advance as quickly as adult emergency care, and performance and outcomes for children trailed those for adults (Seidel et al., 1984; Mishark et al., 1992; Boswell et al., 1995; Doran et al., 1995). The committee’s vision for the future, outlined in Chapter 3 of this report, is that of a fully integrated emergency care system that appropriately meets the needs of both adult and pediatric patients. Under this system, pediatric concerns are included in all aspects of emergency care planning, research, and evaluation. The committee’s hope is that a separate report outlining basic shortcomings in the emergency care system’s ability to meet the needs of pediatric patients will not be necessary in the future. Today, however, the key shortcomings reviewed below stand as impediments to the future system envisioned by the committee, and must be acknowledged and addressed if that vision is to be realized. System Planning No organization or individual is responsible for overseeing the operation or ensuring the quality of the nation’s emergency care system. At the federal and state levels, the current system is largely fragmented and uncoordinated. This fragmentation is a particularly critical problem for pediatric emergency care because EMS agencies and hospitals tend to vary in capability, commitment, and training standards for pediatric emergency care. In many states, hospitals are not categorized according to their ability to care for critically ill and injured children. In the absence of such categorization, it is difficult for EMTs, much less parents, to identify which hospitals are most appropriate for a critically ill or injured child. Another example of the lack of planning is the absence of transfer agreements between hospitals (Middleton and Burt, 2006). Provider Training Table 1-1 shows some examples of the specialized pediatric knowledge required of emergency care providers when they encounter a sick or injured child. Emergency care providers who lack pediatric training, experience, and treatment protocols may find it difficult to distinguish a critically ill or injured child from other children with less serious conditions. They may also have difficulty determining the proper course of treatment or deciding whether a higher level of care is needed. It is not surprising that emergency

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Emergency Care for Children: Growing Pains providers generally feel more stress and anxiety caring for pediatric patients than for adults (Federiuk et al., 1993; Glaeser et al., 2000; Frush and Hohenhaus, 2004). Despite its importance, many emergency physicians have little formal training in pediatric emergency medicine (Moorhead et al., 2002). Additionally, studies have shown that knowledge and skills gained through education and training deteriorate fairly quickly if not practiced and reinforced regularly. Yet continuing education requirements in pediatrics for EMTs vary from community to community and do not exist in many areas (Glaeser et al., 2000). Disaster Preparedness Children suffer disproportionately in the event of a disaster. For example, they are more vulnerable to a biological or chemical attack because they take more breaths per minute, and their breathing zone is closer to the ground. They also have thinner skin, which provides less protection and allows greater absorption of chemicals (AAP, 2002). Moreover, some antidotes available for the treatment of adults in the event of such an attack are not currently available for children (Markenson, 2005). Children are often more vulnerable to biological agents, as well as naturally occurring diseases, that produce vomiting and/or diarrhea because they have less fluid reserve than adults and can become dehydrated more rapidly (Illinois EMS-C, 2005). If children sustain burns, they have a greater likelihood of life-threatening fluid loss and susceptibility to infection (Shannon, 2004). If they sustain injuries that cause massive blood loss, they develop irreversible shock more quickly (AAP, 2002). Additionally, children are dependent on adults for everyday care; in the event that they are separated from their caregiver(s) in a disaster, they lose their support system. As noted above, initial efforts at disaster planning did not incorporate the needs of children. Even today, many states do not address pediatric issues in their disaster plans (NASEMSD, 2004), and disaster drills frequently lack a realistic pediatric component (Mace and Bern, 2004; Dick et al., 2004; Maniece-Harrison, 2005). As a result, most communities are not as prepared as they should be for pediatric care in the event of a disaster. Moreover, local disaster plans often fail to address specific pediatric needs in the event of mass decontamination, sheltering, or evacuation. Research Base Pediatric emergency care is a relatively young field, so its research base is limited. Some significant advances have occurred in the research infrastructure in the field, including the development of a Pediatric Emergency

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Emergency Care for Children: Growing Pains Care Applied Research Network (PECARN) and two national databases (National Hospital Ambulatory Medical Care Survey and Healthcare Cost and Utilization Project) that allow for analyses of pediatric emergency care in the ED. Nonetheless, many of the triage methods, treatment patterns, and prevention initiatives used for pediatric populations in the EMS and ED environments are not supported by scientific evidence. Additionally, little is known about patient outcomes and system performance. In the case of prehospital care, the knowledge gap is even greater. Some of the most basic questions, including how many children are served by the EMS system and what services are provided to pediatric patients, remain unanswered. Quality of Care Haste, uncertainty, and interruptions abound in the EMS and ED environments, increasing the risk of errors and adverse events for patients of all ages. Delivering care to children presents added challenges to quality care delivery: some children are preverbal and cannot self-report their symptoms; many children have multiple caregivers, which increases the likelihood that emergency care providers will be given an incomplete, inaccurate, or conflicting medical and medication history; and children are likely to be accompanied by parents suffering from great anxiety, which requires staff to attend to the parents while also staying focused on the needs of the child (Chamberlain et al., 2004). Providing high-quality emergency care services to children requires an infrastructure designed to support care to pediatric patients. However, many of the advances made in emergency care have not been appropriate or well designed for pediatric emergency care. For example, studies to determine the safety and efficacy of emergency care medications for children are rarely conducted; thus, as noted above, medication is often prescribed for children off label (Rapkin, 1999). New medical technologies often are not designed with children in mind, but nevertheless are used on pediatric patients, sometimes with unintended consequences. One example is the infusion pump, which delivers medications and fluids intravenously; the original design of the pumps contributed to pediatric dosing errors (Reves, 2003). Information systems and provider decision-support systems that lack pediatric dosing information or those that prohibit providers from entering data on a scale small enough for children are of little benefit to pediatric patients. Additionally, despite the clear evidence on the effectiveness of family-centered care, an approach to health care delivery that promotes the inclusion of family members in the child’s care, many EMS agencies and EDs lack policies that support and implement such approaches to care in emergency settings (Loyacono, 2001; MacLean et al., 2003).

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Emergency Care for Children: Growing Pains STUDY OBJECTIVES AND FRAMEWORK The IOM’s study of the future of emergency care in the U.S. health system was initiated in September 2003. Support for the study was provided by the Josiah Macy, Jr. Foundation, the National Highway Traffic Safety Administration (NHTSA), AHRQ within the U.S. Department of Health and Human Services (DHHS), the Centers for Disease Control and Prevention (CDC), and the Health Resources and Services Administration (HRSA). The study was designed to build on previous work in the field by bringing together all of the key components of emergency care—prehospital EMS, hospital-based emergency care, trauma care, and injury prevention and control. The committee was charged with assessing the current emergency care system, identifying its strengths and weaknesses, creating a vision for the future system, and making policy recommendations for achieving that vision. The committee was structured to balance the desire for a highly integrated systems approach to the study with an interest in focusing attention on pediatric, EMS, and hospital-based emergency care issues. The result was a main committee and three subcommittees representing those three focus areas (see Figure 1-3). The main committee guided the overall study process. The three subcommittees examined the unique challenges associated with the provision of emergency services to children, issues related to prehospital EMS, and issues related to hospital-based emergency and trauma care. The charge to the pediatric subcommittee is shown in Box 1-1. The membership of the main committee and subcommittees overlapped—the 11-member pediatric subcommittee, for example, included 5 members from the main committee. Subcommittees met both separately, reporting their discussions and findings to the main committee, and in combined session with the main committee. Altogether, 40 individuals served on one or more of the four committees.1 See Appendixes A and B, respectively, for a listing of all committee and subcommittee members and for biographical information on members of the main committee and the subcommittee on pediatric emergency care. Three reports covering each of the three subject areas were developed. The present report presents the committee’s findings with regard to pediatric emergency care. The recommendations from all three reports appear in Appendix E. A total of 17 main committee and subcommittee meetings were held between February 2004 and October 2005. The committee commissioned 11 technical papers (see Appendix D) and heard testimony from a wide 1 One committee member, Henri R. Manasse, Jr., resigned from the original 41-member body during the course of the study.

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Emergency Care for Children: Growing Pains FIGURE 1-3 Committee and subcommittee structure. range of experts (see Appendix C). Staff and committee members met with a variety of stakeholders and interested individuals, conducted site visits, and participated in public meetings sponsored by stakeholder groups and the study sponsors. BOX 1-1 Subcommittee on Pediatric Emergency Care Services: Statement of Task The objectives of this study are to: (1) examine the emergency care system in the United States; (2) explore its strengths, limitations, and future challenges; (3) describe a desired vision of the emergency care system; and (4) recommend strategies required to achieve that vision. In this context, the Subcommittee on Pediatric Emergency Care Services will examine the unique challenges associated with the provision of emergency services to children and families, and evaluate progress since the publication of Emergency Medical Services for Children (IOM, 1993). The subcommittee will consider: the role of pediatric emergency services as an integrated component of the overall health system; system-wide pediatric emergency care planning, preparedness, coordination, and funding; embedded pediatric training in professional education; and health services and clinical research.

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Emergency Care for Children: Growing Pains KEY TERMS AND DEFINITIONS To ensure clarity and consistency, the following terminology is used throughout this study’s three reports. Emergency medical services, or EMS, denotes prehospital emergency medical services, such as 9-1-1 and dispatch, emergency medical response, field triage and stabilization, and transport by ambulance or helicopter to a hospital or between facilities. EMS system refers to the organized delivery system for EMS within a specified geographic area—local, regional, state, or national—as indicated by the context. Emergency care is broader than EMS, and encompasses the services involved in emergency medical care, including EMS, hospital-based ED and trauma care, and on-call specialty care. Emergency care system refers to the organized delivery system for emergency care within a specified geographic area. It is important to note that the committee’s definitions of emergency care and the emergency care system may be narrower than other definitions, such as those used by the federal Emergency Medical Services for Children (EMS-C) program, which also encompass injury prevention and rehabilitation services. Trauma care is the care received by a victim of trauma in any setting, while a trauma center is a hospital specifically designated to provide trauma care; some trauma care is provided in settings other than a trauma center. Trauma system refers to the organized delivery system for trauma care at the local, regional, state, or national level. Because trauma care is an essential component of emergency care, it is always assumed to be encompassed by the terms hospital-based or inpatient emergency care, emergency care system, and regional emergency care system. The term pediatric emergency medical services denotes prehospital care for children, while pediatric emergency care refers to the full continuum of services involved in emergency medical care for children. Note that the terms emergency medical services for children are used only in reference to the EMS-C program. From a development perspective, there is no precise age at which childhood ends and adulthood begins. EMS agencies and hospitals use different age ranges to define pediatric patients. For the purposes of this report, however, a child is someone aged 18 or younger, while an infant is a child who is under age 1. ORGANIZATION OF THE REPORT This report presents the committee’s findings and recommendations regarding pediatric emergency care. Chapter 2 provides a brief history of the development of pediatric emergency care, as well as a look at the state of emergency care for children in 2006. The chapter examines some of the threats to children’s health, as well

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Emergency Care for Children: Growing Pains as children’s use of emergency care services. It also looks at the quality of those services and some of the funding challenges associated with delivering pediatric emergency care. Chapter 3 sets forth the committee’s vision for the emergency care system of the future, which encompasses three goals: improving the coordination of emergency care, expanding regionalization of emergency care services, and introducing accountability into the system. The chapter also offers a number of recommendations for achieving this vision. Chapter 4 examines workforce issues. It describes the training that emergency care workers receive in pediatric emergency care and notes deficiencies. The importance of skill maintenance is emphasized since, as noted above, many emergency providers encounter critically ill or injured children infrequently. Chapter 5 reviews the threats to pediatric patient safety in the prehospital and ED environments and the resources needed to address some of those threats. The chapter also describes new initiatives in pediatric emergency care, such as the promotion of family-centered approaches and the development of information technologies and medical devices designed with the needs of children in mind. Chapter 6 addresses a particularly timely topic—the special needs of children in the event of a disaster. The discussion includes a look at children’s medical and nonmedical needs after a major disaster, such as Hurricane Katrina, and suggests areas in which federal agencies and regional authorities could direct their attention to meet those needs. Finally, Chapter 7 focuses on research needs in pediatric emergency care. It reviews the progress the field has made to increase its research base and suggests the steps that should be taken to expand that base. REFERENCES AAP (American Academy of Pediatrics). 2002. The Youngest Victims: Disaster Preparedness to Meet the Needs of Children. Washington, DC: AAP. Boswell W, McElveen N, Sharp M, Boyd CR, Frantz EI. 1995. Analysis of prehospital pediatric and adult intubation. Air Medical Journal 14:125–127. Brown J, Klein E, Lewis C, Johnston B, Cummings P. 2003. Emergency department analgesia for fracture pain. Annals of Emergency Medicine 42(2):197–205. Camasso-Richardson K, Wilde J, Petrack E. 1997. Medically unnecessary pediatric ambulance transports: A medical taxi service? Academic Emergency Medicine 4(12):1137–1141. Chamberlain J, Slonim A, Joseph J. 2004. Reducing errors and promoting safety in pediatric emergency care. Ambulatory Pediatrics 4(1):55–63. Davis DH, Localio AR, Stafford PW, Helfaer MA, Durbin DR. 2005. Trends in operative management of pediatric splenic injury in a regional trauma system. Pediatrics 115(1):89–94. 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.

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