This information, in turn, could be used to develop protocols that would guide EMTs in the transport of patients. However, more research and discussion are needed to determine under what circumstances patients should be brought to the closest hospital for stabilization and transfer instead of being transported directly to the facility with the highest level of care if that facility is farther away. Debate also continues over what procedures are effective for the care of children in the field. Therefore, the committee also recommends that the National Highway Traffic Safety Administration, in partnership with professional organizations, 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 (3.2).


Without accountability, participants in the emergency care system need not accept responsibility for failures and can avoid making changes to improve the delivery of care. Accountability has failed to take hold in emergency care to date because responsibility is dispersed across many different components of the system, so it is difficult even for policy makers to determine where system breakdowns occur and how they can subsequently be addressed. When hospitals lack pediatric transfer agreements, when providers receive no continuing pediatric education, and when pediatric specialists and on-call specialists are not available, no one party is to blame—it is a system failure.

To build accountability into the system, the committee recommends that the Department of Health and Human Services 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 (3.3). Because of the need for an independent, national process with the broad participation of every component of emergency care, the federal government should play a lead role in promoting and funding the development of these performance indicators. The indicators developed should include structure and process measures, but evolve toward outcome measures over time. These performance measures should be nationally standardized so that statewide and national comparisons can be made. Measures should evaluate the performance of individual providers within the system, as well as that of the system as a whole. Measures should also be sensitive to the interdependence among the components of the system; for example, EMS response times may be related to EDs going on diversion.

Using the measures developed through such a national, evidence-based, multidisciplinary effort, performance data should be collected at regular

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