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4 Learning How to Provide Good Care: Education and Training Previous chapters have emphasized that many aspects of emergency medical care are different for children than for adults. With the recognition of these differences comes the need to ensure that individuals responsible for the emergency care of children have the knowledge, understanding, and skills necessary to provide appropriate care. Evidence exists, however, that errors in various phases of emergency care for injured children have led to unnecessary loss of life (Ramenofsky et al., 1984~. Education to prevent such errors in caring for injured or ill children must be a high priority for the public and for health care providers. This chapter reviews the need for education and training for the public and for health care providers, proposes the desirable elements of such edu- cational efforts, and discusses ways that such coursework is now presented and how it might be enhanced and augmented. It also presents seven of the committee's formal recommendations, which promote its view that better education and training are essential for achieving larger goals for EMS-C and that improvements can be made in a relatively short period of time. EDUCATION AND TRAINING FOR THE PUBLIC Parents, as well as others with routine responsibility for the well-being of children, play a vital role in preventing illness and injury, in recognizing (when prevention has failed) that urgent medical care is needed, and in gaining access to such care. Evidence suggests a variety of shortcomings in successfully fulfilling these roles, however. Parents are not always aware 108

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LEARNING HOW TO PROVIDE GOOD CARE 109 of the greatest risks to their children, and they can, therefore, be poorly prepared to prevent them. In one study, parents showed little understanding of children's risk of death from burns and drowning (two of the leading causes of injury deaths after motor vehicle crashes), and reported taking few measures to prevent such injuries (Eichelberger et al., 1990~. The public also must understand when and how to use the EMS system. In ~ study of injury deaths in children, deIay in seekir~g emergency care was the most frequent error (Ramenofsky et al., 1984~. In some cases, neces- sary emergency care may be delayed by efforts to contact a primary care provider first. In other cases, unnecessary use of EMS resources can impair the system's ability to provide care for true emergencies. Thus, educational efforts directed at parents and other responsible adults, and the public at large, must be especially clear about appropriate and inappropriate use of prehospital and hospital services. Who Should Be Included Parents and Other Responsible Adults Public information and education programs on emergency medical care for children should ultimately reach the entire population, including chil- dren themselves. In planning such efforts, reaching adults who are involved most directly in the care, education, and oversight of children should be the highest priority. Parents are obvious and important targets for educational efforts. Educational efforts must also aim to reach other "responsible adults" with whom children spend extended periods of time; the committee includes in this group individuals such as teachers, day-care providers, coaches, life- guards and other camp and recreation personnel, and scouting and other youth group leaders. Unlike parents, whose responsibility usually focuses on only two or three children, adults in these other roles are often respon- sible for large groups of children. Other Adults, Adolescents, and Children Ideally, all adults should acquire a minimum level of understanding of the EMS system to be able to obtain help for children, but reaching the general population is likely to remain a long-term goal. In the near term, adolescents and even elementary school children are a promising audience. The American Academy of Pediatrics (AAP, 1993) has, in fact, recommended that high school students receive training in basic life support (BLS) and pediatric BLS as part of the health education curriculum. Programs di- rected at these young people, perhaps as early as kindergarten, have the potential to increase their personal awareness of prevention and their ability

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110 EMERGENCY MEDICALSERVICES FOR CHILDREN to take appropriate steps when adult supervision is not available. Targeting young people directly has the additional positive effect, over time, of in- creasing the level of knowledge in the general population. What Needs to Be Taught The committee concluded that public education efforts should focus on three areas: prevention and safety; basic first aid and cardiopulmonary resuscitation (CPR), and when and how to use the EMS system. The spe- cific needs of communities and individuals should shape these efforts. Prevention and Safety The public must come to recognize that some illnesses and many inju- ries in children can be avoided by active attention to prominent risks. Im- munization, for example, is a strong defense against many serious diseases including measles, pertussis (whooping cough), poliomyelitis, and hepatitis B. In fact, the success of past immunization efforts has made these diseases so rare that parents and the public in general may not appreciate how seri- ous they can be or that unimmunized children are at risk. Parents in par- ticular need to understand the importance of immunization and of complet- ing the immunization process. School-entry requirements help to ensure that children are immunized by 5 or 6 years of age, but delays until that age leave infants and toddlers at risk of serious illness. Factors such as limited access to health care in general and specifically to immunization clinics, lack of insurance coverage for immunizations, and missed opportunities to provide immunization services or to educate parents about them are serious obstacles to complete immunization for some children (Interagency Com- mittee to Improve Access to Immunization Services, 1992~. Injury prevention efforts should address the sources of risk for injury, explain the degree of risk of injury and death, and identify specific steps that can lessen the risks. Nationally, the greatest risks of injury-related death for children under the age of 15 come from motor vehicle crashes (involving occupants, pedestrians, and bicyclists), drowning, and residential fires (Waller et al., 1989~. Specific steps such as using child safety seats in cars, having children wear bicycle helmets, improving fencing around pools, and installing smoke detectors in homes illustrate actions that parents and communities can take to help prevent injuries and deaths. Other concerns should include emphasizing the value of comprehensive primary care and a "medical home" in helping to avoid serious illness and injury (see Chapter 1~. Parents and the public in general need to be aware of the important contribution that careful management of factors such as medication, diet, and exercise can make in averting crises that require emer- gency care for common chronic disorders such as asthma, diabetes, and

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LEARNING HOW TO PROVIDE GOOD CARE 111 epilepsy. Parents should be cautioned about their own behaviors as well. Smoking, for example, poses a risk of fire in the home and exposes children to the harmful effects of passive smoking. Child abuse also must be ad- dressed; parents should be made aware of counseling and other resources available to prevent or end abusive behavior in the home. Prevention and safety efforts need to false into account developmental differences among children and the implications those differences have for the nature and degree of injury risk and for the kinds of interventions that will be appropriate. For instance, guidance regarding toddlers and young children should address protecting children against household hazards such as poisons (including medications), scalds, falls on stairs, and firearms. Outside the home, pedestrian injuries shift from nontraffic events (e.g., in driveways) for 1- and 2-year-olds to traffic events for 3- and 4-year olds, who do not yet have the cognitive skills for pedestrian safety (Wine et al., 1991~. For older children, bicycle safety becomes an important concern. Basic First Aid and CPR With sound training in first aid and CPR, parents and other responsible adults can treat minor conditions and, for more serious conditions, can provide essential interim care until more skilled assistance is available. The most recent guidelines on CPR and emergency cardiac care issued by the American Heart Association (AMA, 1992a,c) emphasize preparing the pub- lic to make contact with the EMS system and to initiate CPR or other appropriate care. A newly developed National Standard Curriculum for Bystander Care from the National Highway Traffic Safety Administration (NHTSA) is intended to teach the public a few essential skills to apply at the scene of a motor vehicle crash (Ryan, 1992~. When parents were asked in a survey about what safety information they wanted, they were most interested in receiving material on first aid and CPR (Eichelberger et al., 1990~. Organizations such as the AHA and the American Red Cross, as well as community hospitals and EMS agencies, can provide this kind of training. Important topics include rescue breathing, CPR, airway management, control of bleeding, wound care, and burn treat- ment. Parents and others who care for children with chronic conditions that carry a special risk for cardiopulmonary arrest, such as those with chronic airway disease or congenital heart disease, have a special need for training in pediatric BLS care (AMA, 1992a). When and How to Use EMS Understanding when emergency care is needed can help avoid danger- ous delays in treatment and unnecessary use of emergency services for relatively minor problems when other sources of primary care are available.

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2 EMERGENCY MEDICAL SERVICES FOR CHILDREN When emergency care is needed, knowing how to obtain assistance is criti- cal. In many areas, 9-1-1 telephone access systems are available; where 9-1-1 is not available, parents should know the local emergency phone number. Indeed, many experts argue that even young children need to know when and how to call 9-1-1 (or other emergency numbers). Safety pro- grams for children often include teaching them about proper use of 9-1-1 (see, e.g., Nordberg, 1985; Franckowiak, 1992; Stringer, 1992~. (Further discussion of 9-1-1 systems appears in Chapter 6.) An additional part of the public education agenda should be informing parents and the rest of the public about the kinds of emergency care that can be provided within the community so that public expectations are appropri- ate. For example, the severity of a child's illness or injury may call for transport to a regional center rather than the nearest hospital. On the other hand, some parents may insist, inappropriately, that a child be taken to a specialty hospital when appropriate care could be provided more promptly at a nearby community hospital. NHTSA's public education activities place special emphasis on the com- ponents and capabilities of an EMS system, on how the public gains access to the system, and on the public's role in promoting successful operation of the system (NHTSA, 1990b). Together with the U.S. Fire Administration, NHTSA provides materials for a public education program called "Make the Right Call," which addresses awareness of the role of EMS and of when and how to use the EMS system (U.S. Fire Administration and NHTSA, no date). Opportunities for Education and Training Public education efforts can operate through a variety of channels. En- counters with health care providers are important opportunities to reach parents. Community, school, recreation, and worksite programs are able to reach the broader range of responsible adults who should have such train- ing. Many opportunities also are available to provide children with valu- able training in safety and emergency care. To be able to reach as large an audience as possible, public education programs need to be a continuing activity rather than a special project. Furthermore, programs must be re- viewed periodically to ensure that their content is consistent with current medical practice guidelines. Health Care Visits Primary care providers, who traditionally have had an ongoing relation- ship with children and their parents, should teach parents about prevention and safety measures, basic first aid, where to learn CPR, and when to seek emergency assistance; they can also direct families to a variety of books

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LEARNING HOW TO PROVIDE GOOD CARE 113 and other useful materials (Ludwig and Selbst, 1990; AAP, 1992e). An AAP program The Injury Prevention Program (TIPP) outlines guidance on injury prevention for children of various ages and can provide written materials to distribute to parents. Studies suggest that parents are espe- cially receptive to such counseling (Eichelberger et al., 1990; Bass et al., 1991~. Ideally, much of this information is provided in the course of rou- tine v-~s and can be rued when children are seen for minor injuries and illnesses. Primary care providers also must be prepared to give more immediate and specific guidance when seriously ill or injured children are brought to the office and when parents seek advice over the telephone. The expanding role of nurse practitioners in primary care is increasing the op- portunity for patient education and counseling. Pediatric nurse practitioners often take the opportunity during children's routine examinations to educate parents and caregivers. Courses organized around childbirth preparation and infant care pro- vide an opportunity for some of the training that parents should have. They are also models for new courses that could be created specifically to address prevention, safety, first aid, and emergency care for children. Ludwig and Selbst (1990) argue that parents should be devoting at least as much time to learning pediatric BLS as they do to childbirth preparation. ED visits offer an opportunity to address prevention and safety. Post- ers, written materials, and individual counseling are among the approaches being used in ED-based injury prevention programs (e.g., Ellerby and Ward, 1989; Barlow, 1992; Zylke, 19921. ED staff in some hospitals are teaching parents about the immunization and other primary care needs of their chil- dren and may also be able to help parents arrange for those services in settings that are more appropriate for ongoing care than the ED is. The ED also provides a vantage point from which to identify specific injury and illness risks in a community; Harlem Hospital, for example, has worked with city government and community groups to address local problems of window falls, pedestrian and bicycle risks, dangerous playground equip- ment, and violence (Barlow, 1992~. Not all such interventions may be immediately effective. An effort to promote helmet use among children seen for bicycle injuries at one hospital's ED produced no greater adoption of helmets among the test group than among the control group (Cushman et al., 1991a). The investigators specu- late that achieving adoption of a relatively unfamiliar practice, such as wearing a bicycle helmet, may require broader community acceptance of the practice in addition to physician recommendations. Schools, Day Care, Recreation, and Community Programs As noted above, specific groups of responsible adults who supervise

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4 EMERGENCY MEDICAL SERVICES FOR CHILDREN organized activities for children should be trained in prevention, safety, first aid, and access to emergency care. The locales in which those activities take place schools (and their ancillary facilities such as gymnasiums, are- nas, libraries, and multipurpose rooms), community centers, and local li- braries are sites that should be considered for this type of training. Instruction of various kinds can be provided by professional educators and also by trained staff Mom hospitals, EMS agencies, local fire and police departments, and the state police, many of which have outreach programs that involve the community and local schools. School nurses are a resource already situated in the school system. A few of the many specific examples of such activities are cited here. Community programs in CPR, which are often built around materials developed by the American Red Cross or the AHA and taught by EMS and hospital personnel, offer an opportunity for a broad range of people to participate. Some communities and their EMS systems have made CPR training for the public a high priority. For example, during the 1970s, about 265,000 residents in Seattle and surrounding King County were trained in CPR (Cobb and Hallstrom, 1982~. The proportion of resuscitations initiated by bystanders rose from 5 percent in 1970 to 40 percent in 1980. A variety of other programs are offered in communities across the country. For example, the Phoenix Fire Department has addressed prevention of child drowning in materials that describe fencing requirements for pools, pool safety practices, and the appropriate response if a child is found in distress in a pool (Phoenix Fire Department, 1990; Worley and Simmons, 1990~. An annual fair for children on safety and health, which is organized by the Southern Region EMS Council in Anchorage, Alaska, includes par- ticipants from the police and fire departments, the state police, hospital programs on health and safety, and the Alaska School Nurses Association (Stringer, 1992~. In the Boston area, a medical center's nurses, emergency medical technicians (EMTs), and paramedics have organized a program for schools and community groups on reducing alcohol-related emergencies (Nordberg, 1988~. National EMS Week, an event recognized by presiden- tial proclamation since 1990, has provided a valuable opportunity to en- courage media attention to national, state, and local EMS issues and to organize participatory activities for the community that can increase aware- ness and understanding of the EMS system (ACEP, no date). Private organizations also play an important role by developing educa- tional materials and by sponsoring programs in the community. National Safety Council publications and activities, for example, highlight injuries in specific settings (home, school, workplace). The National SAFE KIDS Campaign and the American Red Cross each produce a variety of materials and sponsor activities for adults or older adolescents responsible for child care as well as for children. The National SAFE KIDS Campaign materials,

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LEARNING HOW TO PROVIDE GOOD CARE 115 such as How to Protect Your Child from Injury, generally emphasize five high-risk areas: traffic injuries (to motor vehicle occupants, bicyclists, and pedestrians), drowning, burns and scalds, choking and poisoning, and falls (Feely and Bhatia, 1993~. A new program from the American Red Cross (1992), First Aid for Children Today (FACT), is aimed at children in kinder- garten through third grade. It uses stories, games' posters. and workbooks to help children learn about -injury prevention arid first aid. A similar program, Basic Aid Training (or BAT), is for 8- to 10-year-olds. These activities only begin to illustrate resources in safety and injury prevention. The media including newspapers, magazines, radio, and television also contribute to public education through public service announcements, news reports that highlight prevention measures (e.g., use of seatbelts), and feature stories. Safety messages have also been incorporated into entertainment programs. Professional groups such as the AAP, the American Academy of Orthopaedic Surgeons (AAOS), and the American College of Emergency Physicians (ACEP), which usually work through their physician members, sometimes target the public directly. For example, the AAP's TIPP, which generally provides resources for pediatricians to use in advising parents during office visits, has also developed a public education program to encourage use of bicycle helmets. In 1991, the AAOS began a public education program that, in its initial phases, is focusing on playground safety (AAOS, 1991~. The ACEP has developed various materials including a public service announcement for television on drowning prevention and an extensive home health packet (HOME: Home Organizer for Medical Emergencies), which is intended to help families organize important medical information, prevent injury and illness, and recognize and respond appropriately to emergencies that do occur (ACEP, 1992b). ~`1 r ~ In assessments of state EMS systems, NHTSA (1992) found that most states needed to give greater attention to public information and education activities on prevention and EMS system use. Only 8 of 26 states studied had funding dedicated to these activities, and in all 26 states, public educa- tion was among the first areas to be affected by EMS budget cuts. At the national level, the extensive injury control activities at NHTSA and at the National Center for Injury Prevention and Control (NCIPC) and the Maternal and Child Health Bureau (MCHB) in the Department of Health and Human Services (DHHS)~ contribute to programs at the state and local levels. NHTSA's focus on highway safety has led it to develop programs to prevent impaired driving (due to alcohol consumption); to promote occu- pant safety measures, including a child safety component; and to improve motorcycle safety (NHTSA, 1990b). The NCIPC addresses a broad range of injury risks including falls, drowning, poisoning, burns, and injuries due to violence (CDC, 1992b), and MCHB supports projects to prevent violence and various unintentional injuries.

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116 Legislative Actions EMERGENCY MEDICAL SERVICES FOR CHILDREN Successful implementation of prevention measures generally requires continuing educational efforts and may require legislative mandates as well (e.g., Walton, 1982; Margolis et al., 1988, National Committee for Injury Prevention and Controls 1989; Runyan and Runyan. 1991; Cote et alit 1992) The federal Po~or~ P-revent~or~ Packaging Act, passed Art 1970, succeeded -in reducing the number of ingestions of toxic substances and associated deaths; by 1978, the death rate from poisoning was less than half what it had been at the time the law was passed (Walton, 1982~. Child restraint laws, which have been enacted separately by each state, have been found to reduce fatalities in motor vehicle collisions (Agran et al., 1990~2 and to reduce the number of head injuries requiring hospitalization (Margolis et al., 1988~. Efforts to ensure that responsible adults can provide immediate assis- tance in the event of an emergency have resulted, in some places, in legisla- tive or administrative requirements for specific- training. California, for example, now requires that all teachers have CPR training (California Edu- cation Code, EDC44261, c. 307, ~ 2, 1991), and Virginia requires that two staff members in each school be trained in first aid and CPR (Common- wealth of Virginia, 1989J. Individual states and localities will need to evaluate the appropriateness and cost-effectiveness of such steps for their specific circumstances. Even with a legislative mandate, however, lack of funding to implement training programs or lack of enforcement can keep such laws from having much impact. Legislated requirements for the use of bicycle helmets have been par- ticularly successful in increasing the proportion of children who use them (Cushman et al., l991a,b; Cote et al., 1992; Pendergrast et al., 1992~. Over a one-year period in two adjacent Maryland counties, an education program raised helmet use from 8 percent to 19 percent in one county, but legislation requiring helmets brought use from 4 percent to 47 percent in the other county (Cote et al., 1992~.3 Five states (California, Massachusetts, New Jersey, New York, and Pennsylvania) have now passed legislation on helmet use (Feely, 1992~. Even legislative action may be limited in scope, how- ever: California's helmet law applies only to children less than 5 years old or less than 40 pounds who are bicycle passengers, not to older bicycle riders who are, nevertheless, at risk for serious head injury (Kamela and Demes, 1991~. Meeting Local Needs To be most effective, public education programs should address both a core of universally appropriate material and issues of specifically local con- cern. Guidance in using the EMS system, for example, must always take

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LEARNING HOW TO PROVIDE GOOD CARE 117 into account specific local mechanisms for requesting assistance, the capa- bilities within the system components, and the particular risks for illness and injury that children in that community face. As noted in Chapter 2, injury to motor vehicle occupants is, overall, the leading cause of injury-related death among children, but in some states and communities, drowning or house fires are greater threats (Waller et al., 19891. IT} various urban areas, falls from buildings, pedestrian injuries, house fires, and, far too often, firearm injuries and homicide require atten- tion (Barlow, 1992; Ropp et al., 1992; Weesner et al., 1992~. Where swim- ming pools are common, drowning should be a special concern (Wintemute, 1990~. Rural areas face the problem of injuries from farm equipment (Brennan et al., 1990; Rhodes et al., 1990~. Specific settings also must be considered. For example, the AAP (199Oa) has published guidelines for schools for developing plans to meet urgent care needs in the absence of school medical personnel; these guidelines stress having designated staff members trained in first aid, CPR, and ana- phylaxis treatment.4 One or more emergency care manuals and medical kits should be in specified locations, written first-aid orders should be available, and procedures for requesting EMS or other assistance should be in place. Materials specifically on the management of asthma have been prepared for schools by the National Asthma Education Program of the National Insti- tutes of Health in DHHS (National Asthma Education Program, 1991~. Lo- cal efforts may target schools as well. San Diego, for example, developed materials for school staff on the importance of rapid contact with the EMS system through 9-1-1 when there is any possibility that a child (or school staff member) may need emergency care (San Diego County Division of Emergency Medical Services, 1991~. States and communities also must consider how to reach populations that may have unusual needs or that may not be part of the mainstream culture. Children who are chronically ill are likely to require emergency medical aid more frequently than other children, and they may need special types of care as well. Their parents and the teachers and other adults involved with such children need to be familiar with the particular risk factors for injury and illness and with the first aid or other care that they should render when emergency assistance is requested. Approaches geared specifically to the cultural, ethnic, linguistic, and economic characteristics of communities are likely to be more effective in reaching those populations (National Committee for Injury Prevention and Control, 1989; Narita, 1991; Belkin, 1992; Buchwald et al., 1992~. The families of homeless children may be especially difficult to reach. Many projects in the Health Resources and Services Administration (HRSA) EMS-C demonstration grant program produced public education materials, often aimed at specific community concerns (Shaperman and Backer,

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118 EMERGENCY MEDICAL SERVICES FOR CHILDREN 1991~. Among these products are public service announcements for televi- sion (Arkansas, Wisconsin), water safety programs (Alaska, Hawaii), play- ground safety programs (Maine, Vermont), first aid courses for parents and for child care providers (New York, Vermont), and a graphic brochure on child health, safety, and emergency care adaptable to various non-English- speaking audiences (Washington). A Need for Public Education Programs Reviewing these factors led the committee to a consensus on recom- mendations for education and training for the public in matters relating to the delivery of high quality emergency care to children. Specifically, the committee recommends that states and localities develop and sustain programs to provide to the general public of all ages adequate and age- appropriate levels of education and training in safety and prevention, in first aid and cardiopulmonary resuscitation, and in when and how to use the emergency medical services system appropriately for children. It recommends further that: . community; the content of such programs resect the particular needs of each the content of such programs reflect the special medical, devel- opmental, and social needs of children; parents and other adults who are responsible for the care and education of children (e.g., day-care workers, teachers, coaches) receive highest priority in such programs; and adolescents also be a high priority in this endeavor. Finally, the committee recommends that states and localities develop and maintain specific guidelines or criteria to ensure basic consistency and quality of educational programs across communities and popula- tions reached, including specific content elements that those education programs should cover. EDUCATION AND TRAINING FOR HEALTH CARE PROFESSIONALS Until very recently, there has been little overlap between training for emergency medical care and for pediatrics. Training for pediatricians, fam- ily physicians, nurse practitioners, physician assistants, and other pediatric primary care providers has not given sufficient attention to recognition and management of emergencies or to the appropriate use of EMS systems. At the same time, programs in emergency medicine have not adequately ad

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38 EMERGENCY MEDICAL SERVICES FOR CHILDREN and appropriate than it will for "national" programs. The experience of the Maine EMS-C Project (1991) illustrates this situation: it chose to support the nationally recognized PALS course to train providers after determining that no organization in the state was able to make a commitment to continue the unique course that had been developed by the project. The response to increased availability Qua training in pediatric emer- gency care has generally been er~husiast~c, but providers face demands for additional training in other areas as well. For example, providers ire emer- gency medicine and prehospital care must deal with the rapidly changing features of adult cardiac care, whereas pediatricians must contend with re- newed concerns over infectious disease. More broadly, many physician specialties are confronting challenges raised by the growing (and aging) elderly population, acquired immune deficiency syndrome (AIDS), and the unceasing introduction of new health care technologies. Although emer- gency care providers must be prepared to give essential care to all of their patients, the importance of EMS-C training must be emphasized to those who may not recognize that they are not adequately prepared to care for children. Trying to obtain all of the "appropriate" training can place a heavy burden in time and expense on individual providers and on the EMS agen- cies and hospitals that employ them. When courses are not available lo- cally, the costs of travel are added to costs of the courses themselves. In smaller hospitals and communities ensuring adequate staffing can be diffi- cult if some staff members are away for training. The many EMTs and paramedics, especially outside of major metropolitan areas, who provide their services as volunteers find it especially difficult to devote the added time to additional training. They often must bear the cost of training as well. Even in urban areas, staffing and funding constraints in hospitals and EMS agencies may make them reluctant, or unable, to support staff training. OTHER CONCERNS Making Education and Training Available As should be clear from the discussion above, education and training can and is being made available to the EMS community in many ways, both formal and informal. The traditional classroom format, supplemented by "hands-on" skill stations, continues to play a large role. Professional soci- eties may link course offerings with major membership meetings. For ex- ample, the Committee on Trauma of the American Pediatric Surgical Asso- ciation presents courses at the association's annual meeting under the rubric of "What's New in Pediatric Trauma Care?" Some courses require special- ized equipment and are most easily offered in a fixed location. For some

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LEARNING HOW TO PROVIDE GOOD CARE 139 students, however, attending courses away from their community (or even place of work) is a serious impediment to additional training. Emergency care providers in rural areas, who see few seriously ill or injured children and thus have little opportunity to apply their knowledge and skills in this area, have expressed a particular need for periodic access to such training (Henderson and Avery 1992~. They can face considerable difficulty ~n obtair~ing it, however. Local training resources are I~kely to be limited, and staffing shortages and financial constraints can make it difficult to travel to courses that are available but only in relatively distant locations. Courses that can be brought to providers often reduce burdens in time and costs. Idaho has devoted substantial resources to bring training to health care providers widely scattered in rural areas across a large, moun- tainous state. In the early 1980s, the statewide communications system was equipped to provide an interactive teleconference capability, which is used to conduct educational programs for providers throughout the state (Ander- son et al., 19903. Another project led to the development of mobile training units, which travel across the state bringing a computer-based training module and mate- rials necessary to provide hands-on training in specific skills (Anderson et al., 1986~. The initial focus was on adult trauma for EMTs, but a pediatric training station was added soon after the program began (in the mid-1980s). In addition, the units have been used to train nurses in rural hospitals. Assisted by its EMS-C grant, Idaho has now added interactive videodisc (IVD) training stations to its mobile training fleet (Anderson et al., 1990~. The first IVD course addresses pediatric respiratory management. Other "electronic" options include videotapes, often accompanied by course manuals and other written documents. A"low-tech" approach to providing local training is reflected in the previously noted pediatric emer- gency nursing course being developed jointly by EMS-C grantees and the ENA (Henderson and Brownstein, forthcoming). The course will use case studies in a self-instruction approach, which will maximize its accessibility to nurses in rural areas and to others who have difficulty attending continu- ing education courses. In principle, many different clinical settings should be used as the sites for education and training. These most obviously include hospitals and hospital EDs not only as training locales for the hospital staff but also as sites for hospital rotations for paramedics and EMTs. Other, less common sites of pediatric emergencies and EMS-C activities (offices and clinics, for example, or airplane or helicopter transport) would be far more difficult to use for educational purposes, owing to the low volume of cases overall and the unpredictability of pediatric cases. Use of "case study" material from these settings as input into quality assurance or educational programs might be practical, however.

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140 EMERGENCY MEDICAL SERVICES FOR CHILDREN A more in foal but important source of education is the exchange of information among providers across various stages of care. This feedback is especially valuable in emergency care because of the segmented nature of that care, which often makes it difficult to learn about the outcome of a case. Prehospital providers pass their patients along to EDs, which may then need to transfer a patient to an ICU or other inpatient setting ~n the same hospital or at ~ referral center, some p~tTOTIts WTi} eventually move on to rehabilitation services. A child's primary care physician may or may not play a direct role in emergency care but is, nevertheless, an important mem- ber of this continuum of care. Without feedback between these stages of care, it is difficult for providers to learn whether their care has had a posi- tive or negative impact on patients. When they have such information they are better able to correct mistakes and learn about alternative approaches to patient care. Providing the Right Course to the Right Audience Even with the growing number of special courses on pediatric emer- gency care, health care providers in various settings may still face difficul- ties in obtaining the most appropriate training. In fact, the continuing development of new courses often reflects the fact that available options do not meet the needs of specific students or the need for specific kinds of training. Two conflicting concerns surround the development of customized courses, however. The desire to have training resources targeted to the specific needs and circumstances of a particular locality or provider group must be weighed against the resource demands (in staff, time, and money) that are imposed by developing and maintaining a high quality educational product for each specific audience. Use of the PALS course, for example, illustrates some of the concerns that arise. Because it is available nationally, PALS has become widely recognized as a source of training in pediatric resuscitation skills. It is often adapted to meet the needs of specific provider groups such as para- medics, nurses, or physicians. When adapted for one of these groups, how- ever, the course is then not as appropriate for, and often not even open to, other kinds of providers. Where demand is high, it may be difficult to offer enough versions of the course to meet the needs of all providers (Thomas, 1991a). Taking PALS will still leave providers without training in other impor- tant aspects of pediatric emergency care. Emergency nurses have found that PALS is able to provide much needed training in caring for children with life-threatening emergencies, but it does not address the nursing needs of the many moderately ill and injured children who are cared for in EDs (Laurie Flaherty, California ENA, personal communication, March 1992~.

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LEARNING HOW TO PROVIDE GOOD CARE 141 The content of the APLS course is broader than that of PALS, but APLS is less widely available. Luten (1990) has commented that, as valuable as PALS is for paramedics, a course specifically designed for paramedic train- ing would be ever better. For the many EMTs and other prehospital provid- ers with only BLS skills, the value of PALS and other courses that empha- size more advanced levels of care may be seriously limited. As EMS-C training programs and materials proliferate, it becomes in- creasingly difficult to know what is available and to assess the quality of those materials. In the committee's view, a recognized locus of information and expertise in EMS-C is needed. Such an operation would have at least three major responsibilities: (1) to identify training resources, curricular materials, guides, and the like; (2) to review and assess those program materials, course guides, and similar documents; and (3) to serve as a source to which interested groups can turn for references and directions to those in the field who can then provide direct assistance, copies of materials, and other guidance. NERA, currently funded by HRSA's EMS-C grant pro- gram, performs similar functions. The committee judges that an activity of this sort is of such importance that it needs to be provided for on a long- term basis. The committee recommends in Chapter 8 of this report that a federal center with responsibility for EMS-C ensure that developing infor- mation resources is a high priority. Evaluating Education and Training Efforts Even though the development of education and training materials in EMS and EMS-C has been substantial, not enough attention has yet been given to evaluating either the effectiveness of those materials or the teach- ing methods being used. NERA's ongoing assessment of the prehospital training programs developed by EMS-C grantees makes a contribution on this front. In addition, studies are needed to assess the impact that educa- tion and training have on how emergency care providers manage patient care-what knowledge and skills do they decide to use as opposed to how well are they able to perform specific procedures. Evaluation of training programs appears to be needed for EMS in general as well as for EMS-C. In its assessments of state EMS systems, NHTSA (1992) noted that only 7 of 26 states studied evaluate EMS training programs; 11 of these states train EMS instructors and monitor their performance. A recent review of studies of continuing medical education (CME) sug- gests greater effectiveness in changing provider practice with CME methods that actively engage the participants (e.g., case reviews or practicing spe- cific procedures) or that make use of feedback or reminders in conjunction with informational approaches (e.g., lectures, printed materials) (Davis et al., 1992~. At the most fundamental level, work needs to be done to deter

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42 EMERGENCY MEDICALSERVICES FOR CHILDREN mine more clearly what education and training providers actually need in order to provide effective care for their patients. With only limited re- sources available for education and training, it is important to learn where they are most needed and how to use them in the most appropriate ways. Retaining Knowledge and Skills A particular concern regarding EMS-C education and training is that the public and most health care professionals who work outside pediatric specialty facilities will encounter relatively few seriously ill or injured chil- dren. This circumstance gives them little opportunity to apply the knowl- edge and skills that they may acquire; without use, expertise and compe- tence in practical tasks may wither away. A substantial literature exists regarding the rapid decay of CPR skills in the general public and among health care professionals (e.g., Gas s and Curry, 1983; Wilson et al., 1983; Kaye and Mancini, 1986; Kellermann et al., 1989; Yakel, 1989; Cavanagh, 1990; Seraj and Naguib, 1990~. In the worst case, the EMS system is still left unable to provide adequate care for children and has consumed valuable resources in time and money to train providers. One key step, therefore, is to determine, across the types of providers, settings, and curricula already discussed, the best means of ensuring long- term retention of knowledge and skills. Attention to both the content of the training and the process of training is needed. Current approaches to teach- ing these materials need to be studied in order to learn what techniques are most effective. A variety of tactics may be needed to accommodate differ- ences in learning styles and differences in the kinds of students being trained. Assessments of CPR training in particular and of training more gener- ally in a variety of fields suggest certain factors that tend to enhance long- term retention of skills (NRC, l991b; Moser and Coleman, 19921. A higher level of mastery of skills during initial training improves retention and can itself be encouraged by sufficiently high criteria for successful performance, by continued practice of skills after performance standards have been met, by distributing a given amount of practice over a longer period of time, by improving the trainee's understanding of a task (rather than simply the sequence of steps to be performed), and by active participation of trainees. Some have suggested that inadequately trained instructors, insufficient practice time, and inaccurate assessment of trainee performance may be contributing to poor retention of CPR skills (Kaye et al., 1991~. Studies specifically related to training emergency care providers are exploring the effectiveness of new technologies that can be used for teach- ing. One study found, for example, that computer-assisted instruction pro- duced better knowledge retention (over a two-month period) among para- medics than lecture- or video-based instruction (Porter, 19911. IVD instruction

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LEARNING HOW TO PROVIDE GOOD CARE 143 in advanced airway management has also been found to be more effective in improving psychomotor skills than a lecture-demonstration-practical approach (Stoy et al., 1992~. Another study found that paramedics trained in endotra- cheal intubation using only mannequins were as successful in field incubations of adults as were those whose training included experience with human subjects (Stratton et al., 1991~. For providers In all settings, oppo-rtun-~es are needed to practice skills such as CPR. Simple reviews of motor skills can make some contribution. Even more valuable are periodic exercises that simulate pediatric emergen- cies of various types; such exercises can test the ability of teams of provid- ers to perform specific procedures and to respond appropriately to all as- pects of a case. With infant and child mannequins, trainers can even include a certain level of "hands-on" practice for various procedures. Computer- based training systems are another resource for reviewing infrequently en- countered pediatric scenarios. The declining cost of personal computers makes it increasingly feasible for EMS agencies and hospitals to provide permanent access to training that was previously available only through instructor-led courses. Optimal intervals for periodic retraining should be investigated. Providing Incentives for Education and Training Many health care providers have eagerly sought additional training in pediatric emergency care as it has become available. The committee con- cludes, however, that relying on voluntary responses to ensure that adequate levels of training in pediatric emergency care are achieved across the coun- try will not be prudent. Various incentives and regulations can and should be applied to help ensure that individual providers obtain needed training. Such steps will also be needed to influence the "behavior" of hospitals, EMS agencies, ambulance services, and various other public and private organizations (e.g., community centers or health maintenance organizations) to ensure that they facilitate the development of EMS-C capabilities of the organization and staff. Financial incentives are often very effective in promoting a preferred course of action. For example, reducing malpractice premiums upon completion of EMS-C training is likely to appeal to individuals as well as institutions. Another approach might be for the federal government to establish EMS-C training requirements as a condition for receiving initial or continuation funds from demonstration or block grant programs. Linking reimbursement levels from Medicaid or other sources to specific training requirements might also be possible. A "regulatory" approach might be used as well. Specifications for EMS-C training might be incorporated in state and local requirements for

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44 EMERGENCY MEDICAL SERVICES FOR CHILDREN initial provider (or health care facility) licensing or certification and for recertification. Similarly, professional certifying bodies for EMT and para- medic training and for medical or nursing specialties could set requirements regarding training in pediatric emergency care. Although requirements such as these may promote additional training, they also may place serious bur- dens on providers and on training resources If these burdens are too greats they may discourage some providers from seeking to qualify, thus defeating the effort to improve their ability to care for children. Financing Education and Training Meeting the nation's need for better and more extensive education and training in pediatric emergency care cannot be accomplished without ad- equate financial resources. Funds are needed to support the staff and activi- ties for both start-up and maintenance of the improvements sought by the committee and others. Start-up costs are associated with developing public education programs, revising curricula for health care providers, conducting initial training for the current provider population, and acquiring necessary equipment to support training efforts. Maintenance costs arise from con- tinuing programs of public education, monitoring and revising provider cur- ricula in accordance with changing practice guidelines, providing continu- ing education courses needed to maintain provider skills, and maintaining training equipment. Some of these costs are recovered in fees charged for course participants, but those fees must be such that providers (and the public) can afford to obtain the training that is available. Many EMS systems are based on publicly funded prehospital services, so states and localities facing increasingly severe budget constraints may find it difficult to establish new training programs or fund participation in training elsewhere. Hospitals also may be unable or unwilling to support training for their staff members. Providers themselves can and have ab- sorbed some training costs, but there is a limit, especially for volunteer EMTs and paramedics, to how much expense they are willing to incur. For rural communities, which rely heavily on volunteers for prehospital ser- vices, the financial barriers to training can be particularly high. Special community fundraising projects can be used to provide some resources for training but are probably not a reliable long-term funding mechanism. The committee believes that a commitment is needed at the federal level to ensure a minimum level of funding for training and all other aspects of EMS-C development. Federal funding would not only provide direct financial support but also indicate to states and communities the priority that the government has assigned to this field. Part of the federal funding recommended in Chapter 8 might be targeted to these educational uses.

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LEARNING HOW TO PROVIDE GOOD CARE 145 SUMMARY This chapter reviews the need for education and training for the public and for health care providers to ensure that children receive high quality emergency medical care. The committee proposes desirable elements of such educational efforts, discusses ways that such coursework is now pre- sented and how it might be enhanced and augmented? and offers several formal recommendations for steps that it believes will improve emergency medical care for children (see Box 4-1~. With respect to education and training for the public, reaching parents and other adults responsible for the care of children must be a first priority; attention to other adults, adolescents, and children should be the second priority. Training should address prevention and safety, basic first aid and CPR, and when and how to use the EMS system. Opportunities for training include health care visits, schools, day care, recreation, and community programs. A child's primary care provider should play an important role in ongoing education of parents. Public education programs should be de- signed to meet local needs and take account of local factors. With respect to education and training for health care professionals, general education and training needs include recognizing characteristic signs of serious illness and injury in children of all ages, rendering essential care for all pediatric patients, and addressing psychosocial aspects of pediatric emergency care. Further training is needed by specific types of providers (including dispatchers, EMTs, paramedics, physicians, and nurses) in spe- cific settings (prehospital, ED, inpatient, and primary care). The committee takes the view that adequately preparing health care professionals to provide emergency medical care to children will require curriculum changes in several areas. Attention should be given to the initial qualifying training for prehospital providers, to the beginning years of edu- cation for other health professionals, to curricula for graduate and residency training programs for physicians and nurses, and to specialized continuing education courses. The current reliance on special courses to enhance the skills of existing practitioners is not sufficient by itself as a long-term ap- proach to providing needed training. Continuing education is, however, an essential component of an overall program of EMS-C training. Because most providers will have limited opportunities to apply the knowledge and skills that are needed in emergency care of children, they need training resources that will enable them to refresh their skills and to learn about current practice guidelines. Finally, this chapter discusses several other concerns that all parties involved with EMS-C should address. These include evaluating education and training efforts with special attention to the problem of poor retention of CPR and other skills (by members of the public and by health care

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LEARNING HOW TO PROVIDE GOOD CARE 147 providers), providing the right course to the right audience, establishing an information resource for EMS-C training materials, and financing education . . and training. NOTES 1. The National Center for Injury l~event~on and Control in the (:enters for Disease Con- trol and Prevention (CDC) was established June 25, 1992; before the creation of the center, injury prevention activities at the CDC were the responsibility of the Division of Injury Con- trol of the Center for Environmental Health and Injury Control. The MCHB effort is funded through Special Projects of Regional and National Significance that include grants on school playground injuries, violence among adolescents, health professional training, and technical assistance to injury prevention coalitions. 2. Unfortunately, some of the reduction in mortality achieved in the early 1980s with the implementation of child safety seat laws has been lost in more recent years. Agran and colleagues (1990) suggest that factors such as misuse of safety seats, higher speeds, and greater numbers of miles traveled (and therefore greater exposure to the risk of injury) may be contributing to the increases in mortality. 3. The committee hopes that legislative efforts to increase the numbers of children using bicycle helmets will meet with less resistance than those aimed at motorcyclists. State laws requiring helmets for motorcyclists remain controversial even with evidence of fewer head- injury-related deaths from motorcycle crashes in those states that require helmet use (Sosin and Sacks, 1992). 4. With respect to anaphylaxis, Yunginger (1992) has noted that in many states nonmedical personnel are not permitted to administer the immediate dose of epinephrine needed to initiate treatment. EMS planners and regulators need to consider carefully how to achieve the best balance between protecting the public from unskilled medical care and providing for immedi- ate access to potentially life-saving treatment administered by informed bystanders. 5. In taking vital signs in pediatric cases, prehospital providers are least likely to take blood pressure measurements, especially among younger patients. Gausche and her colleagues (1990) found that nearly 60 percent of paramedics felt that uncooperative children were fre- quently an obstacle to taking blood pressure and other vital signs. Only about 25 percent attributed the problem to inadequate equipment or noise levels at the scene of the emergency. Even though only 5 percent believed that inadequate skills frequently prevented them from taking vital signs for a pediatric patient, about 50 percent expressed a lack of confidence in their ability to obtain those measurements for children less than seven months old. 6. The committee noted that dentists also may encounter children requiring emergency care, which makes EMS-C issues relevant for dental education. The dental community has already demonstrated an interest in resuscitation training. Further discussion of EMS-C in dental education was beyond the expertise of this committee; such a topic might more appropriately fall to a new IOM committee that has recently been formed specifically to examine the future of dental education. 7. The literature of the past several decades is replete with studies of undergraduate and graduate training of health professionals. A recent report of the Pew Health Professions Commission, for example, addressed implications of changes in the health care system and in health care needs for schools training health care professionals (Shugars et al., 1991). In 1993, the Institute of Medicine had under way various studies in this area, including ones on dental education, on career paths in clinical research, and on increasing minority participation in the health professions. 8. Training needed to prepare pediatric surgeons and pediatricians for EMS-C was dis

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148 EMERGENCY MEDICAL SERVICES FOR CHILDREN cussed at a recent conference on pediatric emergency medical services. Training for surgeons (O'Neill, 1989) was envisioned as covering issues such as the epidemiology of injury in childhood; differences in physiology among adults and children of various ages from infant (O to 6 months old) to older children (12 to 16 years of age); resuscitation; specific injuries (chest, abdomen, central nervous system, head and neck, extremities, and burns); and a broad set of specific techniques (e.g., intubation, tracheostomy, venous and intraosseous access, peritoneal ravage, and use of cardiovascular drugs). Training outlined for pediatricians (Peterson, 1989) ~-~s ~ ion g I~t ~ elements that ought to ~ part of the~r educational I; ~n particular, specific instruction should be given on the concept and organization of EMS-C, the available EMS communication and transport systems, differences between pediatric and adult illness, technical procedures relevant to care of injured or acutely ill children in various set- tings, and data systems in operation. 9. The Accreditation Council for Graduate Medical Educators (ACGME) is the organiza- tion through which standards for residency programs and procedures for accreditation of those programs are established. The ACGME promulgates General Requirements applicable to all residency training programs. For each specialty field, a Residency Review Committee is charged by the ACGME to establish standards for residency training programs and to evaluate, usually by site survey, the compliance of programs with the requirements. The specific stan- dards for each specialty are published as the Special Requirements for that field. In 1991, there were some 86 accredited emergency medicine programs with 1,876 resi- dents; 217 programs and 6,233 residents in pediatrics; 393 programs and 6,610 residents in family practice; 281 programs and 7,712 residents in general surgery; and 22 programs and 38 residents in pediatric surgery (AMA, 1992). Eleven combined programs in emergency medi- cine and internal medicine had 25 residents; 3 combined pediatrics and emergency medicine programs had 5 residents; and 81 combined internal medicine and pediatrics programs had 622 residents (AMA, 1992). 10. Joint residency training in pediatrics and emergency medicine combines in a five-year program the major components of each specialty's three years of residency. Pediatrics in- cludes attention to ambulatory care, inpatient services, subspecialty experience, weekly conti- nuity clinic, adolescent medicine, and clinic and ED experience in acute illness. Requirements in emergency medicine include ED experience that presents the opportunity to manage patients of all ages and sexes with a minimum of 2 percent of the patient population having critical illnesses or injuries; rotations are to include adult critical care. 11. "Skill stations" connotes an element of emergency care training that involves instructor demonstration and ample student practice of key steps in specific procedures, for instance, bag-valve-mask ventilation and peripheral and central venous cannulation.