given long wait times to be seen and uncomfortable environments. In some EDs, adults and children wait together and are treated in the same patient care areas, which can frighten children.

Timely

People expect that patients with life-threatening problems will have prompt access to emergency care in the prehospital setting as well as in the ED. But timeliness of care is compromised in overcrowded EDs. The practices of ambulance diversion and patient boarding and their effects in delaying care were discussed above. Likewise, long ED wait times can result in protracted pain and suffering and delays in diagnosis and treatment (Derlet et al., 2001; Derlet, 2002; James et al., 2005). Unfortunately, existing studies on timeliness of care do not include analysis specific to pediatric patients.

Of particular concern are children who leave the ED without being seen. Several studies have investigated which patients leave without being seen and why. Most have concluded that patients do so because the wait was too long (Stock et al., 1994; Quinn et al., 2003), although one Canadian study found that children most often leave because they begin to feel better (Rowe et al., 2003). The majority of patients who leave without being seen have conditions of low acuity (Fernandes et al., 1994), but in some cases such patients are in need of immediate medical attention (Baker et al., 1991; Fernandes et al., 1997). In one study, two-thirds of patients who left without being seen could identify no alternative site of care that would be available to them other than the ED (Baker et al., 1991). Patients who leave without being seen are more likely than those who receive care to report pain or worsening of the seriousness of their problem (Bindman et al., 1991). Many end up returning to the ED at another time, and a small percentage subsequently require hospitalization (Sainsbury, 1990; Bindman et al., 1991).

Specific data on prehospital response times for pediatric patients based on acuity are not currently available. However, seriously ill or injured children pose a real challenge to the system’s ability to provide timely care, particularly when pediatric specialists are needed. Ambulances may have to drive to a distant hospital to access providers with pediatric expertise. But more troubling, some EMS agencies authorize ambulances to transport patients only to the nearest hospital, even if that hospital is not appropriate for the patient. In addition, geographic boundaries of an EMS catchment area may limit where ambulances may transport patients.

Timeliness also encompasses the treatment of pain, and there is some evidence indicating that children do not receive pain management in a timely manner. In one study of hospitals in Illinois, only half of children (aged 15 and younger) in severe or moderate pain were offered an analgesic. Older



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