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lGILNCY , Lit for J RIEN Committee on Pediatric Emergency Medical Services lane S. Durch and Kathleen N. Lohr, Editors Division of Health Care Services INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1993 1C S

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NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Support for this project was provided by the Maternal and Child Health Bureau of the Health Resources and Services Administration, U.S. Department of Health and Human Services, un- der Grant No. MCJ-117025-02. The views presented are those of the Institute of Medicine Committee on Pediatric Emergency Medical Services and are not necessarily those of the funding organization. Library of Congress Cataloging-in-Publication Data Emergency medical services for children / Jane S. Durch and Kathleen N. Lohr, editors p. cm. "Committee on Pediatric Emergency Medical Services, Division of Health Care Services Institute of Medicine." Includes bibliographical references and index. ISBN 0-309-04888-5 1. Pediatric emergency services-United States-Planning. I. Durch, Jane S. II. Lohr, Kathleen N., 1941- . III. Institute of Medicine (U.S.). Committee on Pediatric Emergency Medical Services. [DNLM: 1. Emergencies-in infancy & childhood. 2. Emergency Medical Services. WS 200 E5273 1993] RJ370.E433 1993 362.1'8'083-dc20 DNLM/DLC for Library of Congress 93-8084 CIP Additional copies of this book are available from the National Academy Press, 2101 Consti- tution Avenue, N.W., Box 285, Washington, D.C. 20055. Call 800-624-6242 or 202-334- 3313 (in the Washington Metropolitan Area). Copyright 1993 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logo- type by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

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COMMITTEE ON PEDIATRIC EMERGENCY MEDICAL SERVICES DONALD N. MEDEARIS, JR.,* Chair, Charles Wilder Professor of Pediatrics, Harvard Medical School, and Chief, Children's Service, Massachusetts General Hospital, Boston' Massachusetts RICHARD B. DONKER, Vice President, Clinical Services, Memorial Hospitals Association, Modesto, California MARTIN R. EICHELBERGER, Professor of Surgery and Pediatrics, George Washington University School of Medicine, and Director of Emergency Trauma Services, Children's National Medical Center, Washington, D.C. J. ALEX HAILER, JR., Professor of Pediatric Surgery, Pediatrics, and Emergency Medicine, Children's Medical and Surgical Center, The Johns Hopkins Hospital, Baltimore, Maryland ROBERT L. HARMAN, Administrator, Grant Memorial Hospital, Petersburg, West Virginia EDGAR B. JACKSON, JR.,* Clinical Professor of Medicine, Case Western Reserve University School of Medicine, and Associate Chief of Staff, University Hospitals of Cleveland, Cleveland, Ohio MARILYN A. KRUEGER, Commissioner, Second District, Saint Louis County, Duluth, Minnesota JENNIFER LEANING, Medical Director, Health Centers Division, Harvard Community Health Plan, Inc., Brookline, Massachusetts SUSAN D. McHENRY, Director, Emergency Medical Services, Office of Emergency Medical Services, Virginia Department of Health, Richmond, Virginia PATRICIA A. MURRIN, Prehospital Coordinator, Division of Emergency Medical Services, Department of Health Services, County of San Diego, California JAMES L. PATURAS, Director, Emergency Medical Services, Bridgeport Hospital, Bridgeport, Connecticut BARRY G. RABE, Associate Professor of Health Politics, Department of Public Health Policy and Administration, School of Public Health, University of Michigan, Ann Arbor, Michigan DONALD F. SCHWARZ, Assistant Professor of Pediatrics, Section on Adolescent Medicine, Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania JAMES S. SEIDEL, Professor of Pediatrics, UCLA School of Medicine, and Chief, General and Emergency Pediatrics, Harbor-UCLA Medical Center, Torrance, California *Institute of Medicine member . . . [z!

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CALVIN C.J. SIA, Clinical Professor of Pediatrics, Department of Pediatrics, School of Medicine, University of Hawaii, Honolulu, . . Hawaii RUTH E.K. STEIN, Professor and Vice Chairman, Department of Pediatrics, Albert Einstein College of Medicine, and Pediatrician-in- Chief. Bronx Municipal Hospital Center' Bronx, New York GARY R. STRANGE, Associate Professor of Emerge-nc-:r Medicine, University of Illinois, College of Medicine, Chicago, Illinois J.J. TEPAS III, Professor of Surgery, Division of Pediatric Surgery, University of Florida College of Medicine, Department of Surgery, Jacksonville, Florida JOSEPH A. WEINBERG, Associate Professor, Division of Critical Care, Department of Pediatrics, University of Tennessee, Memphis, and Director, Emergency Services, Le Bonheur Children's Medical Center, Memphis, Tennessee Study Staffs JANE S. DURCH, Associate Study Director KATHLEEN N. LOHR, Deputy Director, Division of Health Care Services and Study Director, beginning April 1992 MICHAEL L. MILLMAN, Study Director, through March 1992 DONNA D. THOMPSON, Administrative Assistant KARL D. YORDY, Director, Division of Health Care Services IV

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Preface The problem of childhood injuries and illnesses and the emergency care they require is immense and its consequences tragic. If the recent past is an indication of the immediate future, then more than 20,000 children under 19 years of age will die this year in the United States as a result of injury. An additional 30,000 will have a permanent disability as a result of brain in- jury. As disturbing as these data are, they are but the top of a huge pyra- mid; for each death of a child due to injury in this country, as many as 42 children are hospitalized and 1,120 children visit an emergency room. Moreover, emergency room visits by children as a result of injury are only one-third of the total number of visits by children to emergency rooms. The other two- thirds of those visits are due to illnesses, many of which are serious; these include debilitating asthma and life-threatening meningitis. One cannot be aware of these data and not want to reduce their number and their impact. That goal can be achieved. The rates of death and disability in the United States exceed the comparable rates in Canada, France, the former Federal Republic of Germany, and Great Britain. If this country would energetically pursue preventive health measures, including the estab- lishment of continuous, family-oriented, community-based primary care for all children, there is no reasonable doubt but that the number of injuries and episodes of illness and their consequences-could be significantly reduced. Moreover, if that were accomplished, the savings would be enormous in economic as well as humanitarian terms. The charge to this Institute of Medicine committee, however, was not to design the ideal medical home (primary care) for children, nor was it to develop strategies for the development and implementation of effective in- jury prevention measures. It was to review the nature and extent of pediat- ric emergencies and the emergency care available to children and to define v

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Vl PREFACE the characteristics of an emergency medical services system for children (EMS-C system), the elements of a data system needed for planning and evaluation, and the role of government in that system. In developing its response to this charge, the committee utilized fully the remarkable diver- sity in expertise and background of its multidisciplinary membership and prepared a report that is scholarly and detailed. It idex~tified the essential components of an EMS-C system. It considered how best to ensure access to that EMS-C system. It recognized the very special needs of children in terms of anatomy, physiology, and psychology, and underscored how these must be met by EMS-C programs and personnel. Thus, there must be different and special equipment, different-sized instruments, different doses of different drugs, and different approaches to the psychological support and remedial care to be given to the ill or injured child. Guidelines by which personnel essential for the provision of emergency care for infants and children are to be trained, educated, and restrained and re-educated must take into account these factors. Thus, the committee called attention to the importance of fully developing and organizing in a system all those special emergency services that children must have. The committee believed that it was of critical importance to develop an initial uniform data set about these services in order to begin to obtain information that would be used to assess the system and its effectiveness. Mindful of the tragic toll of injury and illness emergencies, the committee further recognized the great importance of obtaining data needed for devel- oping prevention strategies as well as for improving the EMS-C system as a whole. The recommendations that reflect these matters are directed at all levels of government, many different health care professionals, and a wide range of voluntary groups. Some recommendations are directed to the whole of emergency medical services (EMS), for example, the need to develop an expanded 9-1-1 system nationally to provide access to EMS. Some are aimed at subtle modifications or minor (but significant) improvements in the existing system. Others require putting what now exists in some places into those places where no EMS now exists. All do, as they must, take into account the local and regional diversity of this country. In recommending these special services for children, the committee concluded that the EMS-C must not be separate from, but instead should be an integrated part of, the entire emergency medical system. At the same time, the committee recognized how very important it will be to make sure that the needs of children will not be lost again in the continuing develop- ment of that larger emergency medical system. To ensure that, the commit- tee has recommended the creation of specific agencies and defined specific roles for them in both state and federal governments. These public agencies must be effectively linked with the private sector.

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PREFACE . . V11 The committee recognized the extremely important role that effective rehabilitation services can and must play in this matter. Nonetheless, just as it was not the committee's charge to design the ideal medical home for children, it was not the committee's charge to design rehabilitation services. Instead this was addressed by stressing the need for extremely effective linkages between EMS-C and rehabilitation. Thus, throughout its deliberations, the co~mm~ttee recognized the very great importance of establishing effective communication systems and of developing an information system that could obtain data to be used to as- sess the effectiveness of the system (and improve it continually) and to provide information useful in developing the means to prevent emergencies. If there were but one thing that this author would stress, it would be that. In this time of rational economic duress, the committee was cognizant that the matter of costs and benefits would be raised. Obtaining accurate and comprehensive data on the cost or the benefits of emergency medical systems is extremely difficult. The direct and immediate health care costs of nonfatal injuries in children are estimated to be in excess of $5 billion a year, and the indirect costs, including the loss of productive life, greatly exceed those direct costs of caring for injured children. Available estimates indicate that the implementation of comprehensive and effectively linked services for emergency medical care does ensure better outcomes and that the economic benefits of an emergency medical system for children would be very large. Therefore, the committee believes that the cost of developing an effective EMS-C would be well worth it. The committee is aware that great thought, effort, and time will be required to develop the EMS-C that our children need and deserve. These efforts can build on the accomplishments of many groups during the past quarter-century since the landmark NRC report Accidental Death and Dis- ability: The Neglected Disease of Modern Society. The committee believes that this is an opportune time to develop EMS-C since the country seems to be on the threshold of significant health care reform. Therefore, we hope this report will stimulate increased attention to and development of these urgently needed emergency medical services in the context of an effective system of primary care for children. In closing, I wish to express my great appreciation and admiration to the committee and to the IOM staff for their commitment, energy, and ex- pertise, all of which were provided ceaselessly and patiently and, most important, very productively. I have not listed them here because they are listed elsewhere, but that must not detract from the debt I owe or the admi- ration I have for them. Donald N. Medearis, Jr., M.D. Chair

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Acknowledgments The Committee on Pediatric Emergency Medical Services would like to acknowledge the assistance that they and the study staff received from sev- eral individuals and groups during this study. The study conducted by this committee was funded by the Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Admin- istration (HRSA) through the Emergency Medical Services for Children (EMS-C) Demonstration Grant Program. MCHB staff members David Heppel, M.D., Director of the Division of Maternal, Infant, Child, and Ado- lescent Health; Peter Conway, the study's project officer; and Jean Athey, Ph.D., Director of the EMS-C and Injury Prevention Programs-helped keep the committee and staff informed of relevant activities and provided access to useful background material on the demonstration grant awards. Also generous with their assistance were members of the staff of the Emergency Medical Services Division of the National Highway Traffic Safety Adminis- tration at the Department of Transportation: Susan Ryan, M.S., chief of the division, and Highway Safety Specialists Gary Criddle, R.N., Thomas Dolan, and Charles Glass. The committee benefited from presentations by guests invited to two meetings. In December 1991, the committee was joined by Paul Anderson, Chief of the Idaho Emergency Medical Services Bureau, Wade Spruill, Jr., Director of Emergency Medical Services for Mississippi, and Javier Gonzalez del Rey, M.D., from the staff of the Shenandoah Community Clinic in Martins- burg, West Virginia, to discuss emergency medical care in nonmetropolitan and rural areas. In March 1992, George Foltin, M.D., Director of Pediatric Emergency Medical Services, Bellevue Hospital Center, New York City, spoke with the committee on behalf of the National Association of Emer- gency Medical Services Physicians regarding medical control of prehospital IX

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x ACKNOWLEDGMENTS care. Laurie Flaherty, R.N., chair of the pediatric committee of the Califor- nia chapter of the Emergency Nurses Association, addressed nursing issues for the committee. Members of the committee and staff were able to attend conferences in June 1991 and February 1992 that were held as part of the EMS-C demon- strat~n grant program. The conferences gave the committee members an opportunity to meet grantees from some 30 EMS-C projects, to learn about their activities and experiences, and to gain insight into the issues in this field. The two EMS-C resource centers have been especially helpful to the study staff; in particular, the committee thanks Jane Ball, R.N., Dr.P.H., and Bryna Heifer of the EMS-C National Resource Center in Washington, D.C., and Deborah Henderson, R.N., M.A., of the National EMS-C Resource Alli- ance in Torrance, California. The committee appreciates the willingness of individuals from a variety of organizations to speak with members of the study staff and to provide background materials: Albert N. Brasile, Centers for Disease Control and Prevention; Donald C. Bross, J.D., Ph.D., C. Henry Kempe National Center for the Prevention and Treatment of Child Abuse and Neglect; Douglas E. Brown, EMS Data Systems, Inc.; Ceil M. Hendrickson, R.N., Children's National Medical Center; Ronald Kropp, M.H.S., Maryland Institute for Emergency Medical Services Systems; David Lloyd, National Center on Child Abuse and Neglect; Susan Mackenzie, Ph.D., Health and Welfare Canada, Laboratory Center for Disease Control; Stephen Mawn, American Society for Testing and Materials; Meri McCoy-Thompson, M.A.L.D., Na- tional Center for Education in Maternal and Child Health; Greg McDonald, Arrowhead (Minnesota) EMS System; Mary McDonald, R.N, M.S.P.H., National Heart, Lung, and Blood Institute; Deborah Nadzam, Ph.D., R.N., Joint Commission on Accreditation of Healthcare Organizations; Mary Overpeck, National Institute of Child Health and Human Development; I. Barry Pless, M.D., Montreal Children's Hospital; and William E. Stanton, National Emergency Number Association. The committee also received helpful contributions from Joanne Lukomnik, M.D., a consultant to the committee. Jennifer McGrady, a student intern at the Institute of Medicine (IOM), helped prepare for the first committee meeting and began the task of assembling background materials. Greg Pearson, a free-lance writer, produced the earliest draft of some of the material for the report. The report has benefited from the useful (anony- mous) critiques received as a result of the formal review that must be con- ducted before the release of any IOM report. Finally, the committee expresses its considerable appreciation to mem- bers of the IOM staff whose efforts have ensured the successful completion of the study and this report. Donna Thompson, Administrative Assistant, provided essential secretarial support. Other members of the IOM staff

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ACKNOWLEDGMENTS Xl contributing to this project include Holly Dawkins, Research Assistant; Jo Harris-Wehling, Program Officer; and Nina Spruill, Financial Associate. The study began under the direction of Michael Millman, who did much to assist the committee in organizing its approach to the study and in formulat- ing the recommendations reflected in the report. Finally, throughout the study, Karl Yordy, Director of the Division of Health Care Services, pro- vided invaluable guidance and support.

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Contents SUMMARY 1 INTRODUCTION The Issue: Ensuring Emergency Medical Care for Children Who Need It, 27 The Institute of Medicine Study, 28 A Vision of the Ideal System: Establishing Critical Linkages, 30 Guiding Principles, 33 Organization of the Report, 34 Audience for This Report, 36 The Committee's Goal, 36 Note, 37 2 RISKING OUR CHILDREN'S HEALTH: A NEED FOR EMERGENCY CARE Definitions, 39 Why Children Need Special Attention, 41 Epidemiology of Childhood Emergencies, 45 Costs of Injury and Illness, 61 Summary, 63 Notes, 64 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS Development of EMS and EMS Systems, 67 Providing Emergency Medical Services, 83 Structure of EMS Systems, 85 . . . X111 26 38 66

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XlV Summary, 97 Notes, 98 Appendix 3A, 100 Appendix 3B, 103 4 LEARNING HOW TO PROVIDE GOOD CARE: EDUCATION AND TRAINING Education and Training for the Public, 108 Education and Training for Health Care Professionals, 118 Other Concerns, 138 Summary, 145 Notes, 147 5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE Definitions, 149 Equipment, 150 Protocols, 156 Medical Control, 167 Categorization and Regionalization, 170 Summary, 183 Notes, 185 6 CONNECTING THE PIECES: COMMUNICATION Public Access to the Emergency Care System, 188 Prehospital Communication, 200 Communication in Hospital Care, 205 Follow-up: Enhancing Continuity of Care, 211 Feedback, 216 Other Important Forms of Communication, 217 Summary, 221 Notes, 222 KNOWING WHAT IS HAPPENING AND WHAT IS NEEDED: PLANNING, EVALUATION, AND RESEARCH Understanding the Information Gap, 225 Planning, Evaluation, and Research, 227 Understanding Current and Emerging Sources of Data and Data Systems, 230 Improving Information Resources, 246 Implementing a Research Agenda, 252 Summary, 259 CONTENTS ~8 149 187 224

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CONTENTS Notes, 261 Appendix 7A, 265 Appendix 7B, 274 8 LEADERSHIP FOR DEVELOPING EMERGENCY MEDICAL SERVICES FOR CHILDREN The Disjointed "System" of Today, 281 A Focus for Emergency Medical Services for Children, 283 A Federal Center for Emergency Medical Services for Children, 284 State Agencies and Advisory Councils on Emergency Medical Services for Children, 298 The Case for New Entities to Address Emergency Medical Services for Children, 310 Financing Centers, Agencies, and Related Activities, 313 Summary, 316 Notes, 317 9 IMPROVING EMERGENCY MEDICAL SERVICES FOR CHILDREN: LOOKING TO THE FUTURE Benefits and Costs, 321 A Changing Health Care Environment, 325 Final Thoughts, 334 Notes, 334 REFERENCES APPENDIXES A Acronyms, 369 B Biographies of Committee Members, 373 INDEX 280 321 336 367 379 TABLES Deaths from Injury Among Children and Adolescents Ages 0 to 19, by Cause, Age, and Sex, 1988 Deaths from Specified Categories of Illness Among Children and Adolescents Ages 0 to 19, by Cause, Age, and Sex, 1988 Hospitalizations for Injury and Specified Categories of Illness Among Children and Adolescents Less than 15 Years Old, by Cause, 1990 48 52 54

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XVI i 3-1 Essential Components of Emergency Medical Services Systems, as Specified by the Emergency Medical Services Systems Act of 1973 (P.L. 93-154) 3B-1 Projects Funded by the EMS-C Demonstration Grant Program, 1986-1992 Percentage Qua Population Covered by a 9-1-1 System by State 7-1 Priority Data Elements for a National Uniform Data Set for Emergency Medical Services for Children: Prehospital Services and Emergency Departments 7-2 Summary of High-Priority Topics for a Research Agenda in Emergency Medical Services for Children 7B-1 Data Elements Considered for a National Uniform Data Set for Emergency Medical Services for Children: Prehospital Services and Emergency Departments CONTENTS 72 104 190 249 255 276

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RG y ED for RVICES

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