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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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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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46
EMERGENCY MEDICAL SERVICES FOR CHILDREN
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LEARNING HOW TO PROVIDE GOOD CARE
147
providers), providing the right course to the right audience, establishing an
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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.
Representative terms from entire chapter:
pediatric emergency
