2
History and Current State of Pediatric Emergency Care

Before setting forth a vision for emergency care in the future, it is important to understand the system that exists today and how it evolved. This chapter describes the development and current state of the emergency care system with respect to children.

The first part of the chapter provides a historical overview of pediatric emergency care. The field is surprisingly young and has trailed the development of the broader emergency care system by a decade or two. In this review, attention is focused on two important topics: (1) the creation, activities, and achievements of the Emergency Medical Services for Children (EMS-C) program, a federal program that aims to ensure essential emergency medical care for ill or injured children and adolescents, and (2) the 1993 Institute of Medicine (IOM) report Emergency Medical Services for Children, which represented the first comprehensive look at the need for and effectiveness of pediatric emergency care services in the United States. An understanding of the development of pediatric emergency care provides a sense of progress, as well as greater insight into the system’s resources, challenges, successes, and failures. In fact, many of the challenges facing the system today are the same ones that existed more than a decade ago.

The second part of the chapter focuses in detail on pediatric emergency care in 2006. It begins with an overview of illness and injury in children based on the most recent national data available. This is followed by a discussion of trends in emergency care use by children.

The chapter continues with an assessment of how well the emergency care system works today. The committee concludes that while considerable progress has been made over the past two decades, the system falls short of



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Emergency Care for Children: Growing Pains 2 History and Current State of Pediatric Emergency Care Before setting forth a vision for emergency care in the future, it is important to understand the system that exists today and how it evolved. This chapter describes the development and current state of the emergency care system with respect to children. The first part of the chapter provides a historical overview of pediatric emergency care. The field is surprisingly young and has trailed the development of the broader emergency care system by a decade or two. In this review, attention is focused on two important topics: (1) the creation, activities, and achievements of the Emergency Medical Services for Children (EMS-C) program, a federal program that aims to ensure essential emergency medical care for ill or injured children and adolescents, and (2) the 1993 Institute of Medicine (IOM) report Emergency Medical Services for Children, which represented the first comprehensive look at the need for and effectiveness of pediatric emergency care services in the United States. An understanding of the development of pediatric emergency care provides a sense of progress, as well as greater insight into the system’s resources, challenges, successes, and failures. In fact, many of the challenges facing the system today are the same ones that existed more than a decade ago. The second part of the chapter focuses in detail on pediatric emergency care in 2006. It begins with an overview of illness and injury in children based on the most recent national data available. This is followed by a discussion of trends in emergency care use by children. The chapter continues with an assessment of how well the emergency care system works today. The committee concludes that while considerable progress has been made over the past two decades, the system falls short of

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Emergency Care for Children: Growing Pains consistently providing quality emergency care to children, and that continued efforts are needed to address its deficiencies. The chapter concludes with a look at the financing of pediatric emergency care services. This review highlights a number of issues surrounding reimbursement for pediatric services and/or reimbursement at children’s hospitals that have become a growing problem for some providers. DEVELOPMENT OF EMERGENCY CARE FOR CHILDREN 1940s–1960s: The Beginning of the Modern Emergency Care System The modern emergency room developed at a time when the specialization of medical practice swept the nation after World War II. As the number of house calls from general physicians declined, patients increasingly turned to the local hospital for treatment. This trend was reinforced by the development of private insurance plans, which geared payments toward hospitals and away from home visits (Rosen, 1995). The development of the emergency room also reflects the passage of the Hill-Burton Act of 1946, which gave states federal grants to build hospitals provided that the states met a variety of conditions, including a community service obligation. Among other things, the community service obligation required hospitals that received the federal funding to maintain an emergency room. This requirement applies to the vast majority of nonprofit U.S. hospitals in operation today (Rosenblatt et al., 2001). Emergency care as a field advanced as the result of several forces that drew attention to emergency care in the 1950s and 1960s. One was new knowledge about the value of prompt prehospital treatment and transport derived from military experience in Korea. During that conflict, technical innovations such as the creation of battalion aid stations and rapid transport by helicopter to mobile field hospitals were introduced and resulted in dramatically improved survival rates for battle-wounded soldiers. Experience in Vietnam led to advances in trauma care. Surgeons returning to the United States from Korea and Vietnam recognized that the systems developed by the Army for triage, transport, and field surgery could surpass anything available to civilians at home (Rosen, 1995), and they believed that similar innovations could and should be applied to civilian care. Around the same time, advances in cardiac care, such as the creation of “mobile coronary care units,” improved the survival rate of patients prior to reaching the hospital (Pantridge and Geddes, 1967). Another major turning point was the publication of the landmark National Academy of Sciences (NAS)/National Research Council (NRC) report Accidental Death and Disability: The Neglected Disease of Modern Society

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Emergency Care for Children: Growing Pains in 1966 (NAS and NRC, 1966). The report described the epidemic of injuries and deaths from automobile crashes and other causes in the United States and lamented the deplorable system for treating those injuries nationwide. In 1966, prehospital and hospital services were largely inadequate or nonexistent. Although a few communities were providing ambulance services through their fire or police departments, it is estimated that morticians provided about half of such services. No specific training was required for ambulance attendants. Most emergency rooms could offer only advanced first aid, and only a few hospitals appeared to have the infrastructure necessary to provide complete care for the critically ill and injured. The 1970s: Rapid Development of EMS Systems The 1966 NAS/NRC report stimulated a flood of public and private initiatives designed to enhance highway safety and improve the medical response to accidental injuries. These initiatives included the development of the national trauma system, the creation of the specialty of emergency medicine, and the establishment of federal programs to enhance the nation’s emergency care infrastructure and research base. Perhaps most significant was passage of the Emergency Medical Services Systems (EMSS) Act of 1973 (P.L. 93-154), which created a categorical grant program that led to the nationwide development of about 300 regional EMS systems (IOM, 1993). Despite these achievements, the need to treat pediatric emergencies in a unique way was not fully appreciated at the time. The EMSS Act led to the development of systems that were focused primarily on adult trauma and adult cardiac care. Specialized pediatric needs received little attention; indeed, only limited expertise in pediatric emergency medicine existed (Foltin and Fuchs, 1991). Nonetheless, some initial efforts were made in the 1970s in certain geographic areas to incorporate the needs of children into emergency medicine and EMS systems. Dedicated pediatric emergency departments (EDs) began to develop, staffed by pediatricians who were willing to devote their full attention to emergency care. Also, some hospitals established pediatric intensive care units (PICUs) and began conducting research on pediatric emergency care. In 1975, Maryland established a regional pediatric trauma center, one of the first in the country. Physicians in Los Angeles, along with local professional societies and the county EMS agency, developed a pediatric-focused training curriculum for paramedics and management guidelines for pediatric emergency care (IOM, 1993). The level of sophistication of emergency rooms generally improved during this time, and the term shifted from “emergency room” to “emergency department” as emergency services began to constitute a full department within hospitals.

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Emergency Care for Children: Growing Pains The 1980s: Pediatric Emergency Care in Its Infancy The burgeoning EMS system suffered a setback in 1981 when Congress passed legislation that indirectly resulted in a sharp loss of funding for state EMS activities. Categorical federal funding that had been dedicated to EMS was replaced by the Preventive Health and Health Services Block Grant, which essentially shifted responsibility for EMS from the federal to the state level. Because the states were given greater discretion regarding the use of funds and EMS was a relative newcomer without a significant political constituency, most states chose to spend the money in other areas of need. The immediate impact of the shift to block grants was a considerable reduction in total funding allocated to EMS (Office of Technology Assessment, 1989). Conversely, attention to pediatric emergency care grew dramatically throughout the 1980s as initial data on this domain of care became available. For example, studies indicated that children represented about 10 percent of all ambulance runs (Seidel et al., 1984); that young children were likely to suffer from respiratory distress, whereas older children were likely to need trauma care (Fifield et al., 1984); and that up to half of pediatric deaths due to trauma might be preventable (Ramenofsky et al., 1984). Studies also indicated that children’s outcomes, given the same severity of injury, tended to be worse than those of adults (Seidel et al., 1984; Seidel, 1986a). For example, a study of 88 general acute care hospitals in Los Angeles County found nearly twice as many deaths among children with serious traumatic injuries as among adults with similar injuries (Seidel et al., 1984). Most of the deaths occurred in areas lacking pediatric tertiary care centers. The studies also revealed that prehospital personnel generally had little training in pediatric care. Also, most lacked the equipment needed to treat children (Seidel, 1986b). Findings of these early studies led to recognition of the need to address pediatric emergency care and of the existence of a distinct body of knowledge that should be applied in so doing. This recognition stimulated action on several fronts. First, there were advances in resources for care. In the 1980s, several cities designated pediatric trauma centers. Advocates for pediatric emergency care in Los Angeles developed a new two-tiered approach for organizing such care. Under this system, seriously ill or injured children were to be treated only at hospitals that had been certified as meeting a certain set of requirements and capabilities for pediatric care. Perhaps the most significant development for pediatric emergency care was the establishment in 1984 of the federal EMS-C program, a grant program that assists states in addressing pediatric deficiencies within their emergency care systems. The first federal funding for EMS-C was made available in 1985, and later appropriation acts continued to increase funding for the program. The EMS-C program is discussed in detail later in the chapter.

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Emergency Care for Children: Growing Pains Second, there were advances in resources for information. In the early 1980s, the U.S. Department of Education, through the National Institute of Disability and Rehabilitation Research, funded the development of the National Pediatric Trauma Registry. The registry enabled researchers to identify the demographics of pediatric trauma. Data from the registry revealed that automobile crashes were the primary source of pediatric trauma, that injuries were most often blunt, and that an injured child stood a 3 percent chance of dying from trauma. Data from the registry were also used to develop the Pediatric Trauma Score, a system used to help EMTs determine the facility to which an injured child should be transported (Harris, 1987). Third, professional societies began to give greater attention to pediatric emergency care. In the late 1970s, pediatricians who worked in EDs began to discuss issues in pediatric emergency care; the result was the formation of a section on pediatric emergency medicine within the American Academy of Pediatrics (AAP) in 1981 (Pena and Snyder, 1995; AAP, 2000). In 1983, the American College of Emergency Physicians (ACEP) held an interspecialty conference on childhood emergencies that led to the establishment of a joint AAP/ACEP Task Force on Pediatric Emergency Medicine the following year (AAP, 2000). ACEP also formed a member section on pediatric emergency medicine in 1998 (Pena and Snyder, 1995). In 1985, a Provisional Committee on Pediatric Emergency Medicine was created within AAP; it became a full committee in 1998 (AAP, 2000). Both the Emergency Nurses Association (ENA) and the National Association of EMS Physicians (NAEMSP) had established pediatric sections by the end of the 1980s (IOM, 1993). Fourth, there were important advances in pediatric emergency medicine. By the early 1980s, many physicians had recognized that emergency care for children was not as well advanced as that for adults and that specialized resources for the training of providers in pediatric emergency care was needed. The longest-running pediatric emergency medicine fellowship was established in 1980 (Pena and Snyder, 1995; Macias, 2005). Early experts in the field began to synthesize knowledge in the area and make it more widely available. The first pediatric emergency care textbook was published in 1983, and the first journal devoted to pediatric emergency care was launched in 1985. A number of training courses were developed as well. In 1988, the American Heart Association and the AAP initiated the Pediatric Advanced Life Support (PALS) course. The AAP and ACEP joint task force developed and sponsored the Advanced Pediatric Life Support (APLS) manual, published in 1989. Some courses were also developed locally. An example is the Pediatric Emergency Medical Services Training Program (PEMSTP) at Children’s National Medical Center in Washington, D.C., which prepared EMT instructors to teach pediatric aspects of emergency care. Progress continued in the early 1990s when the ENA developed standardized training for

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Emergency Care for Children: Growing Pains emergency nurses with its Emergency Nursing Pediatric Course (ENPC). All of these efforts helped develop an emergency care workforce with enhanced pediatric skills. Finally, injury prevention efforts, which had gained momentum in the 1970s, expanded greatly in the 1980s. The Poison Prevention Packaging Act of 1970 required manufacturers of toxic, corrosive, or irritative substances to use child-resistant closures (Harborview Injury Prevention and Research Center, 2006). The first state law requiring the use of child safety seats was enacted by Tennessee in 1978; by 1985, however, all states had passed such legislation (Traffic Safety Center, 2002). Additionally, state and local laws were passed to establish requirements for the installation of smoke detectors, window guards, and pool fencing. Concern about the prevention of injury and illness was reflected in national health promotion and disease prevention goals first published in 1980 and updated in 1990 and 2000 (DHHS, 1980, 1990, 2000). The 1985 IOM report Injury in America highlighted the heavy toll of injuries and called for more research in prevention and improved care. Much as the NAS/NRC report Accidental Death and Disability led to the passage of the EMSS Act of 1973, Injury in America: A Continuing Health Problem led to the creation of an injury prevention program at the Centers for Disease Control and Prevention (CDC), which later became CDC’s National Center for Injury Prevention and Control (IOM, 1993). Today, the incidence of sudden infant death syndrome (SIDS) and pediatric cardiac arrest has declined as parents have learned the proper sleep position for infants (AAP, 1992; Willinger, 1995). Injury prevention efforts, such as the poison prevention packaging law, bicycle helmet requirements, child passenger restraint requirements, smoke detector promotion programs, and drowning prevention programs, are beginning to decrease morbidity and mortality due to injury in children (Clarke and Walton, 1979; Rivara et al., 1997; Stenklyft, 1999; Haddix et al., 2001; Macpherson and MacArthur, 2002; Mittelstaedt and Simon, 2004). Many of these prevention efforts were spearheaded by programs such as the National Safe Kids Campaign, founded in 1987. In addition to injury, prevention efforts targeted reducing pediatric illness. In 1980, for example, Starko and colleagues (1980) produced a study indicating that the use of aspirin may be associated with the onset of Reye’s syndrome, a deadly disease most common in children that affects all organs of the body and occurs after a viral infection, such as the flu or chickenpox (National Institute of Neurological Disorders and Stroke, 2006). As parents learned of the link between aspirin and Reye’s syndrome, there was a decline in both the use of children’s aspirin and the number of Reye’s syndrome cases reported to CDC (Arrowsmith et al., 1987; Belay et al., 1999). Prevention efforts have successfully changed the scope of pediatric illness seen in the ED. For example, the Hemophilus influenzae (Hib) vac-

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Emergency Care for Children: Growing Pains cine, introduced in 1990, has nearly eliminated epiglottitis in children and markedly decreased the incidence of meningitis, sepsis, and septic shock (Subedar and Rathore, 1995; Stenklyft, 1999). And the introduction of the PCV7 vaccine has reduced the number of invasive pneumococcal infections among children (Kaplan et al., 2004). The 1990s: Birth of a New Subspecialty The number of pediatric emergency medicine fellowships had begun to increase, although most of these had been developed at children’s hospitals under the leadership of pediatricians. In the late 1980s, representatives from the American Board of Emergency Medicine (ABEM) and the American Board of Pediatrics collaborated to ensure that such fellowships would be accessible to both pediatricians and emergency medicine physicians. Together, the two organizations submitted a proposal to the American Board of Medical Specialties that pediatric emergency care be a recognized subspecialty (Pena and Snyder, 1995). The proposal was approved, and in 1992, the first subspecialty certifying exam in pediatric emergency medicine was administered (Stenklyft, 1999). In 1998, pediatric emergency medicine fellowships became accredited. Most fellowship programs are now 3 years in duration and include a research component (Stenklyft, 1999). By 1999, the nation had approximately 1,000 board-certified subspecialists in pediatric emergency medicine. In 1993, the IOM released findings from its comprehensive study on the need for and effectiveness of pediatric emergency care (IOM, 1993). Despite the advances in pediatric emergency care that had occurred through the 1980s and early 1990s, the study identified gaps in several major areas, including education and training; appropriate equipment and supplies; communications; funding; and planning, evaluation, and research. In response to these findings, the Maternal and Child Health Bureau (MCHB) within the Health Resources and Services Administration (HRSA) and the National Highway Traffic Safety Administration (NHTSA) published a 5-year plan for pediatric emergency care in 1995. That plan was revised and updated in 2000 (DHHS et al., 2000), and a new plan was published in 2001 (DHHS et al., 2001). Additionally, ACEP and the AAP published recommended equipment guidelines for prehospital units and emergency departments (Guidelines for Pediatric Equipment, 1996; AAP, 2001). Pediatric Emergency Care in 2006 If there is one word to describe pediatric emergency care in 2006, it is uneven. As mentioned in Chapter 1, the specialized resources available to treat seriously ill or injured children vary greatly based on location. Some

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Emergency Care for Children: Growing Pains children have access to children’s hospitals and hospitals with separate pediatric inpatient capabilities, which tend to be well prepared for pediatric emergencies; others must rely on hospitals with limited pediatric medical expertise and equipment (Middleton and Burt, 2006). Requirements for pediatric continuing medical education for EMTs vary greatly across states. Some states and communities have organized trauma systems and designated pediatric facilities, while others do not. As a result, not all children have access to the same quality of care. While data on system performance are not routinely collected, it appears that where a child lives has an important impact on whether the child can survive a serious illness or injury. The day-to-day presentation of pediatric patients is challenging enough for emergency care systems in some areas; addressing new and emerging threats to children’s health may be beyond the capabilities of the current system. Experience has shown that the outbreak and management of contagious diseases, such as new strains of influenza and severe acute respiratory syndrome (SARS), can cause a major disruption in the emergency care system (Augustine et al., 2004). The effect of these new health threats on children is not yet well understood. Several case studies of SARS have been published, but most of the clinical, laboratory, and radiological information available is based on adult patients (Bitnun et al., 2003). Some case studies suggest that while children are susceptible to SARS, symptoms of the disease may be milder in young children as compared with adolescents and adults (Fong et al., 2004; Leung et al., 2004). However, these studies are based on a very small sample. The efficacy of pediatric treatment for SARS requires additional evaluation; indeed, no pediatric treatment regime for SARS currently exists (Leung et al., 2004). Avian influenza is another emerging threat that could put children at particular risk. Children may be more susceptible to the disease because of their increased proximity to one another at schools and day care centers. They may also be more likely to come into contact with poultry or bird fecal matter while playing. It is unknown whether immunity differences in children have any significance in their susceptibility to avian influenza, since it is presumed that the vast majority of humans have no immunity against the H5N1 virus, the strain of greatest concern (U.S. Department of State, 2006). Development of Pediatric Trauma Care Trauma represents a particular kind of medical emergency. It is typically defined as having a physical wound caused by force or impact, such as a fall or automobile accident; burns and other severe wounds are also deemed a form of trauma. Other life-threatening medical conditions caused by preexisting conditions are generally not considered trauma. Trauma

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Emergency Care for Children: Growing Pains care is distinguished from care received in a general ED by the specialized diagnostic and treatment procedures necessary to care for the traumatically injured patient. Trauma centers are designed to meet the complex surgical demands of critically ill patients immediately. To qualify as a trauma center, a hospital must have a number of capabilities, including a resource-intensive ED, a high-quality intensive care ward, and an operating room that is functional at all times. Ideally, traumatically injured children are cared for in a pediatric trauma center, a facility with the personnel, equipment, space, and other resources required to provide the necessary care 24 hours a day, 7 days a week (Ramenofsky, 2006). The American College of Surgeons’ (ACS) Committee on Trauma has defined the term “pediatric trauma center” in its categorization of trauma centers into levels based on their capabilities. A level I pediatric trauma center, the highest level, is a children’s hospital or an adult center with pediatric expertise (Ramenofsky, 2006). Given that the development of pediatric emergency care has lagged behind that of adult emergency care, it is surprising that the first pediatric trauma center was established in 1962—5 years before the first adult trauma center was established (Ramenofsky, 2006). In 1970, the American Pediatric Surgical Association (APSA) was founded; 2 years later, one of the members requested greater emphasis on trauma, and the association established a Committee on Trauma, which continues today. Also in 1972, the APSA joined the American Medical Association, the ACS, the American Academy of Orthopedic Surgeons, and the American Association for the Surgery of Trauma in sponsoring the American Trauma Society (ATS) (Personal communication, M. Stanton, March 12, 2006). The ATS, established in the late 1960s, was an advocate for the EMSS Act of 1973. Today it works to promote trauma care and prevention, serving as an advocate for trauma victims and their families and for optimal care for all trauma victims (ATS, 2006). However, advanced resources for the care of pediatric trauma patients were largely unavailable until the 1980s. In 1982, the Journal of Trauma published the first description of resources necessary to treat the injured child. Others followed. In 1984, the ACS Committee on Trauma included an appendix on pediatric trauma care in its standards manual, which was the first document to define the standards of care necessary to treat trauma patients. A chapter on pediatric trauma appeared in the ACS resource manual in 1987 (Ramenofsky, 2006). Today, most regions have dedicated trauma facilities, board-certified surgeons have training and experience in trauma care and pediatric surgery, and most states have organized trauma systems. Injuries are no longer viewed as “accidents” but as predictable events that can be prevented through the application of harm reduction strategies (Cooper, 2006). As detailed later in the chapter, however, unintentional injury continues to be the leading cause of death in children over age 1 and an important source of

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Emergency Care for Children: Growing Pains ED visits. While this report is focused on the emergency care system and the pediatric component of that system, the committee emphasizes that greater effort is needed to build a comprehensive injury control strategy or system to reduce injuries among both children and adults. The Emergency Medical Services for Children Program The creation of the federal EMS-C program in 1984 grew at least in part out of policy makers’ personal experiences with the pediatric emergency care system. Several congressional staff members had had disturbing experiences with the emergency care system’s ability to care for their children. Their experiences highlighted serious shortcomings of a typical ED’s capacity to care for children in crisis. Around the same time, emergency physicians began approaching federal lawmakers to tell them that children were arriving at the ED in worse condition than adults. As a result, Senators Daniel Inouye (D-HI), Orrin Hatch (R-UT), and Lowell Weicker (R-CT) sponsored the creation of the EMS-C demonstration grant program under the Health Services, Preventive Health Services, and Home Community Based Services Act of 1984 (IOM, 1993; CPEM, 2001). The goal of the EMS-C program is to reduce child and youth morbidity and mortality resulting from severe illness or trauma by supporting injury prevention programs and improvements in the quality of medical care received by children. The program aims to ensure (1) that state-of-the-art emergency medical care is available for ill or injured children and adolescents; (2) that pediatric services are well integrated into an EMS system backed by optimal resources; and (3) that the entire spectrum of emergency services—including illness and injury prevention, acute care, and rehabilitation—is provided to children and adolescents as well as adults (Perez, 1998). While this report is focused on pediatric EMS and hospital-based pediatric emergency care, the EMS-C program covers a broader continuum of care, from illness and injury prevention to bystander care, dispatch, prehospital EMS, definitive hospital care, rehabilitation, and return to the community (see Figure 2-1). The EMS-C program is the only federal program that specifically supports essential emergency medical care for ill or injured children and adolescents. The program is administered by HRSA with support from NHTSA. The program initially focused on providing grants to states and accredited schools of medicine for needs assessments and demonstration projects (Advocates for EMS, 2004; Krug and Kuppermann, 2005). Its original authorization provided $2 million in funding for fiscal year 1985 (IOM, 1993). That funding supported four state partnership demonstration projects that created some of the first strategies for addressing important pediatric emergency care issues, such as disseminating education programs for pre-

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Emergency Care for Children: Growing Pains FIGURE 2-1 Continuum of care of the Emergency Medical Services for Children program. hospital and hospital-based providers, establishing data collection processes to identify significant pediatric issues in the EMS system, and developing tools for assessing critically ill or injured children (CPEM, 2001). Growth of the EMS-C Program Funding for the EMS-C program has grown since its inception, as have the number and types of initiatives funded. Reauthorization of the program in 1988 lifted the initial limit of four grants per year and provided funding of $3 million for fiscal year 1989, $4 million for fiscal year 1990, and $5 million for fiscal year 1991 (IOM, 1993). The program underwent several changes in 1991. First, the focus of the state grants shifted from demonstration to implementation projects (IOM, 1993). The objective of implementation projects is to put into place what is known to work (HRSA, 1994). Second, the program introduced new Targeted Issues Grants. These grants target specific issues related to the de-

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