age. Thirty percent of these children are covered by Medicaid or the State Children’s Health Insurance Program (SCHIP) (compared with 19 percent of urban/adjacent rural children), and 1 in 5 are uninsured (Kaiser Family Foundation, 2003).

Rural residence has been demonstrated to be predictive of ED use by low-income children (Polivka et al., 2000). Sharma and colleagues (2000) determined that for infants, the highest rate of ED use, 1.8 per person-year, was among rural white infants on Medicaid. The lowest rate, 0.4 visits per person-year, was among urban white infants with commercial insurance (Sharma et al., 2000).

Rural emergency care for pediatric patients is characterized by many of the same issues that affect emergency care in other areas. However, many studies have shown differences in the use of pediatric emergency care between rural and urban areas. In an examination of pediatric coroners’ cases in both rural and urban California counties, rural children were found to be less likely to use EMS provider services than their urban counterparts (66 versus 84 percent), and a significantly greater number of rural children died on the street or highway (Gausche et al., 1989). Seidel and colleagues (1991) found that trauma was a more frequent complaint in rural areas of California, responsible for 64 percent of all rural prehospital calls. A study by Svenson and colleagues (1996) found trauma in rural settings of Kentucky to be responsible for nearly 50 percent of EMS calls. Rural trauma centers have also been demonstrated to receive proportionately more victims of motor vehicle crashes (28.5 percent of patients) and “other” categories of injury (28.2 percent), to which bicycle injuries are assigned (Nakayama et al., 1992). Similar injury patterns were noted by Serleth and colleagues (1999) between 1990 and 1993, with more than half of all pediatric trauma admissions being the result of injuries related to falls, recreational activities, and motor vehicle crashes.

Despite the variations in time and setting in the above studies, each found trauma to be a leading cause of EMS activation by rural children. Yet there are deficiencies in the provision of ALS in rural areas. The use of BLS/ALS has been found to be dependent on the patient’s age and the level of provider care, with provision of ALS to younger children being less frequent than that to older patients. Failure to provide ALS occurred even though time on scene would not have been prolonged (Svenson et al., 1996). Gausche and colleagues (1989) found that only 66 percent of rural child victims of trauma received ALS interventions, 31 percent fewer than urban children in the same study (Gausche et al., 1989). Thus rural children are more likely to require EMS for traumatic injuries but less likely to obtain EMS services and appropriate life support modalities. Additionally, results of a recent study of admissions in rural EDs indicate higher nonessential admission rates at rural hospitals and by nonpediatric EM physicians, which



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