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6
Connecting the Pieces:
Communication
Communication is a critical element in the successful operation of sys-
tems of emergency medical care. The many separate parts of these sys-
tems individual health care providers, emergency medical services (EMS)
agencies, emergency departments (EDs), critical care units, and various oth-
ers must each perform their roles well, and they must also be able to work
together. Communication, through formal and informal channels and through
high-technology equipment and simple face-to-face conversations, is the
thread that ties the separate pieces into a system.
This chapter views communication from several perspectives. First, the
context in which communication takes place creates special (perhaps even
unique) communication needs. Delivery of services to specific patients
raises different issues than do planning and information exchange that are
independent of patient care. Second, the mechanisms by which communi-
cation is achieved raise special questions. Some forms of communication-
enhanced 9-1-1 emergency access systems and statewide microwave radio
networks are cases in point- depend on the application of particular tech-
nologies or equipment. Often, however, ordinary telephone calls can meet
important communication needs. The third important factor is the partici-
pants in the communication process. Patients and their families (or other
bystanders), providers, and administrators need to interact in various com-
binations and for various purposes. Fourth, better communication among
all the providers who care for a patient is a special concern. "Follow-up"
on patient outcomes and further care and "feedback" from other providers
characterize two important forms of that communication. Through follow
187
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188
EMERGENCY MEDICAL SERVICES FOR CHILDREN
up efforts, providers actively seek information on the condition of patients
whom they have treated and on whether recommended care has been re-
ceived. Feedback gives providers valuable information on the consequences
of their care.
This chapter reviews the communication links that the committee views
as most important {c': emergency medical services for children (EMS~C)
and discusses ways in which those links should be strengthened. Several
issues addressed in the previous two chapters (e.g., education In how to use
the EMS system; the special training and guidance that dispatchers should
have; on-line medical control; the interhospital links needed for regionalization
of services) receive further attention here. Although the issues raised in this
chapter are framed in terms of emergency care for children, they are not
unique to children. The committee's observations point to ways to help
make good emergency care available for all patients.
PUBLIC ACCESS TO THE EMERGENCY CARE SYSTEM
To benefit from the services of an EMS system, children who are ill or
injured must first of all gain access to it. Many children initially receive
such care at a hospital emergency room, where their parents have taken
them without any prior contact with the EMS system. For children who
need urgent care but not any of the services available in the prehospital
setting, this can, in fact, be an appropriate way to reach emergency services.
For many other children-those with major trauma or serious respira-
tory distress, for example prehospital care from trained providers may be
essential for a good outcome. The telephone (or equivalent media such as
Citizen's Band radio) is the usual means of contacting the EMS system to
obtain such assistance. Adoption of a universal emergency access num-
ber namely, 9-1-1-is widely supported, to make it as easy as possible to
request EMS assistance. ~
Sometimes it may not be clear whether emergency care is needed; in
these situations, advice provided by telephone may help clarify what steps
to take. Poison control centers are well-recognized sources of specialized
information regarding situations that may range from harmless to life-threat-
ening. Parents also seek advice from staff at EDs or from primary care
providers on the care their children need. Although many in the medical
community find this telephone advice valuable, sometimes in averting un-
necessary ED visits, others are concerned that this indirect assessment of a
child's condition may miss serious disorders.
The discussion that follows reviews basic and augmented features of
9-1-1 telephone systems and the added features of enhanced 9-1-1 and pre-
sents the committee's recommendation supporting universal adoption of the
system. Following the examination of points relating to 9-1-1, this section
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189
presents a brief overview of the operation of poison control centers and
discusses some issues related to other forms of telephone advice.
Universal Access Through 9-1-1
For a quartex-century' nationwide adoption of a universal emergency
access number such as 9-~-l has been recommended or endorsed by many
groups (e.g., NASINRC, 1970a, 1972, 1978a,b; Brinegar, 1973; Whitehead,
1973; ACEP, 1976; AHA-ACEP-AMA, 1988; National Committee for In-
jury Prevention and Control, 1989; NHTSA, 1990b; Seidel and Henderson,
1991~. Throughout much of the country today, a telephone call to 9-1-1
provides access to police, fire, and EMS services. Table 6-1 presents recent
estimates of the proportion of each state's population covered by 9-1-1.
Communities began working with their local telephone companies as
long ago as 1968 to implement 9-1-1 service (Whitehead, 1973~.2 Accord-
ing to the Advisory Commission on State Emergency Communications (un-
published tables, August 1989), about 20 years later more than 40 states had
legislation either authorizing or mandating adoption of 9-1-1. Various ap-
proaches are used to fund these systems, including state or local telephone
subscriber fees (especially the latter) and state or local taxes. Implementa-
tion generally must be managed by individual counties or other local gov-
ernmental units that can coordinate the interests and resources of the public,
the public safety agencies, and the telephone company for financing and
operating the system.
Substantial progress has thus been made toward the goal of universal
access enough that a National Emergency Number Association (NENA)
was founded in 1982 to further the mission of "One Nation, One Number."
As of mid-1992, NENA had nearly 2,000 members across all regions of the
country; the association issues a quarterly magazine (NENA News, now in
its tenth year of publication), offers an 800 number for updates and infor-
mation on legislation and issues affecting the 9-1-1 field, and holds an
annual conference. The Associated Public-Safety Communications Officers
(APCO) organization also gives considerable attention to 9-1-1 issues (partly
in collaboration with NENA); for instance, its journal (APCO Bulletin) pub-
lishes an annual issue on 9-1-1 topics.
Typically, more than 80 percent of the calls handled by 9-1-1 systems
are for police services and about 10 percent are for EMS. For instance,
NENA cites information from Orange County, Florida (population over 430,000),
suggesting that of nearly 294,000 sheriff, fire, and rescue calls, 87 percent
were to the sheriff and 11 percent were "medical patches"; for the city of
Kissimmee (population 30,300), 66 percent of about 16,700 calls were for
police, 17 percent were for the EMS system (NENA News, 1992~. Never-
theless, it is the EMS community that is working through the American
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EMERGENCY MEDICAL SERVICES FOR CHILDREN
TABLE 6-1 Percentage of Population Covered by a 9-1-1 System,
by State
StatePercent _ State Percent
Alabama60 Montana
Alaska90 Nebraska 65
Arizona Nevada 95
Arkansas25-50 New Hampsh~re lob
California100 New Jersey 35b
Colorado85 New Mexico 75
Connecticut100 New York 80
Delaware100 North Carolina 76
District of Columbia100 North Dakota 33
Florida99 Ohio 60
Georgia76 Oklahoma 80
Hawaii95 Oregon 95
Idaho68 Pennsylvania 60
Illinois64 Rhode Island 100C
Indiana49 South Carolina 72
Iowa South Dakota 70
Kansas80 Tennessee 83
Kentucky56 Texas 97
Louisianaa Utah 85
Maine25 Vermont 25
Maryland100 Virginia 75
Massachusetts38b Washington 40
Michigan60 West Virginia 43
Minnesota100 Wisconsin 78
Mississippi60 Wyoming 97
Missouri62
NOTE: , not reported.
aExtent of coverage is unknown.
bStatewide implementation of enhanced 9-1-1 is under wa
C9-1-1 or similar access number.
SOURCE: Emergency Medical Services ( 1992).
Society for Testing and Materials (ASTM, 1991) to develop national con-
sensus guidelines for planning and developing enhanced 9-1-1 systems. The
National Highway Traffic Safety Administration (NHTSA, 1990a) also par-
ticipates in the ASTM guidelines effort.
Benefits of 9-1-1
Standard Capabilities The 9-1-1 systems provide a simple, easy-to-
remember telephone number that callers, including young children, can use
to make quick contact with emergency services of all kinds. A common
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191
number across the country eliminates the need to learn separate numbers for
specific emergency services or in various communities. With such a sys-
tem, callers do not waste valuable time trying to determine what number to
use or waiting for a telephone operator reached through "O" to provide
appropriate information about the correct agency (and relevant local tele-
phone number) to contact. (To illustrate the profusion of numbers that has
existed, in the early 1970s, a 21-~unty area in Nebraska had 184 separate
ambulance service phone numbers tNAS/NRC, 1978b].) In short, the local
benefits of a single, easy-to-dial telephone number for access to emergency
services are multiplied in our highly mobile society, because people can
rely on being able to use that same number no matter where they are and be
confident that it will be answered by an "emergency-oriented" individual.
The benefits of 9-1-1 and enhanced 9-1-1 do not accrue solely to the
health field. Reduced response times are very important, for instance, in
law enforcement and firefighting. A functioning 9-1-1 system can also be
important in disaster situations, such as tornados. More generally, the fi-
nancial, psychological, and public relations benefits (in terms of public
regard for a "public good" agency) of simply having a more efficient, more
cost-effective system of emergency services should not be underestimated.
New Capabilities Certain new features have been developed to aug-
ment standard 9-1-1 capabilities (other than enhanced 9-1-1 described be-
low). A TDD keyboard (i.e., Telecommunications Device for the Deaf) has
been developed that will meet the requirement of the Americans with Dis-
abilities Act (ADA) that telephone emergency services provide direct access
for persons with speech or hearing impairments (Lopez and Dion, 1991;
Suchat, 1992~; with related advanced computer technologies, TDD calls can
be displayed on a computer screen, enabling the call-taker to communicate
with the individual calling in.
Another advance for 9-1-1 lies in helping those who do not speak En-
glish to use the 9-1-1 system successfully. EMS agencies can, by subscrib-
ing to a telephone interpreter service available through AT&T ("Language
Line Services"), obtain real-time access (all day, every day) to interpreters
who can assist operators to communicate with callers in as many as 140
different languages (Moedinger, 19921. This kind of service makes it pos-
sible to handle some calls strictly by telephone and to send response units
(fire, police, or EMS) appropriate to the situation instead of every type of
unit because of lack of understanding of the actual emergency.
Enhanced 9-1-1
The original 9-1-1 service provides the benefit of simplified access to
emergency services. Newer, enhanced 9-1-1 systems (E9-1-1) offer the
ability to draw on computerized databases to identify automatically the
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EMERGENCY MEDICAL SERVICES FOR CHILDREN
telephone number and location of the caller respectively, Automatic Num-
ber Identification (ANI) and Automatic Location Identification (ALI). The
automatic availability of that information means that the EMS system can
route calls to appropriate jurisdictions, when that is important in the par-
ticular area. More significantly, it enables the EMS system to send assis-
tance even if callers cannot speak English or communicate effcet~vely be-
cause of their c-ond~on or for other reasons. AlI these factors mean that
response times can be reduced, with presumably improved levels of inter-
vention and, ultimately, of patient outcomes. The TDD and translation
services noted above for standard 9-1-1 are also available for enhanced
systems.
New radio devices now make it possible for children or adults with
chronic illnesses or other high-risk conditions to transmit a call to 9-1-1 by
pressing the radio transmitter (Keller, 1992~. Some "Lifeline" systems based
on radio transmitter systems are more complex. They are often monitored
by hospitals, alarm companies, and other third parties, which keep data on
subscribers' medical history and conditions and persons to reach in an emergency;
when the subscriber triggers the transmitter, monitors call the residence or
nearby family or friends before a call is initiated to 9-1-1 or the relevant
EMS agency. Although such systems have obvious advantages, they also
have some drawbacks. For example, if there is no answer, all resources and
equipment may be sent to the home, for what often turns out to be a false
alarm. Moreover, use of an intermediary may in fact delay entry into the
EMS system.
important Considerations for 9-1-1 Systems
Despite progress in 9-1-1 technologies and as valuable as 9-1-1 systems
are believed to be, some obstacles to complete adoption and implementation
of these systems remain. Not all of these relate to EMS per se, and cer-
tainly not to EMS-C, but they must be understood if the EMS and EMS-C
fields are to be persuasive in arguing for comprehensive adoption of 9-1-1
and successful in helping to devise ways to bring that about.
Installation and Operation Implementing an ALI component of an
E9-1-1 system can require additional work in local areas, especially rural
areas, that do not have "city-style" addresses. Converting to such addresses
in various municipalities requires close collaboration with the U.S. Postal
Service. The Postal Service has jurisdiction over the city, state, and ZIP
code parts of a mailing address; a municipality has responsibility for street
names and house numbers. The Postal Service believes that its guidelines
on good addresses can be helpful to localities that are moving toward E9-1-1
but currently lack appropriate addresses to use in such a system (Pensabene,
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193
1991~. The increasing use of mobile cellular phones poses its own techno-
logical challenge to the locator aspect of enhanced 9-1-1 since no fixed
address is associated with them.
The cost of installing and operating a 9-1-1 system, especially E9-1-1,
may be an obstacle, especially given the current financial constraints that
many states and 1Q081ilieS face- Old telephone switching -equipmer~t may
need to be replaced to accommodate 9-~-1; additional andior different per-
sonnel may be needed; and stand-alone databases may be required for E9-1-1
capabilities. Further, the costs of an E9-1-1 system will depend heavily on
the amount of mapping and numbering that must be done for locations
without street addresses. Developing and maintaining the database for tele-
phone numbers and addresses will also contribute to installation and opera-
tion costs. Patsey et al. (1992) report installation charges in North Carolina
ranging from $18,000 to $160,000 for basic and enhanced 9-1-1, respec-
tively, and monthly operating charges of $4,000 (basic) and $8,000 (en-
hanced). One county in Iowa estimated that implementing an E9-1-1 sys-
tem (for about 16,000 persons) would cost about $280,000 initially and
require about $30,000 annually to operate (Petricca, 1992~. There are clear
justifications for enhanced 9-1-1 in rural areas more rapid call-taking,
better response times, better assistance for children who need emergency
assistance but cannot describe where they live but the cost and logistical
requirements lead some experts to question whether the benefits are suffi-
cient to warrant outlays such as those quoted above.
Some communities for a variety of reasons continue to rely on seven-
digit phone numbers; further, they may have separate numbers for police,
fire, and EMS. These arrangements continue, in some cases, because juris-
dictional disputes have made it impossible to implement 9-1-1 a political
factor that this committee finds unpalatable when public and patient safety
is at stake. Communities may be unwilling to work together if doing so
requires giving up local control of their public safety agencies. New call-
routing technologies, however, now generally make it possible for a 9-1-1
system to direct calls to specific communities based on where the call origi-
nates. Communities or public safety agencies themselves may resist giving
up the separate phone numbers that provide direct access to each agency;
one compromise position is to require such agencies to participate directly
in the 9-1-1 system and also operate a separate phone number if they choose
to do so, but experts worry that two separate phone numbers might be more
confusing than helpful.
Call Answering and Dispatch Services Once calls to 9-1-1 are placed,
the EMS system needs to be prepared to answer them. Various approaches
are used, depending on the particular needs of each system. All 9-1-1 calls
are received at a public safety answering point (PSAP). In some systems,
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EMERGENCY MEDICAL SERVICES FOR CHILDREN
individual communities within a 9-1-1 area will maintain independent PSAPs,
with calls routed to the appropriate point based on the caller's location or
telephone exchange. The PSAP determines the kind of service needed (e.g.,
police, fire, medical) and either directs the call to the appropriate agency's
dispatch center or performs the dispatch function itself.
Because most 9-1-1 calls ~e pol~ce-relamd~ dispatch functions for all
emergency services are frequently handled by employees of the police de-
partment who may have little or no EMS training. All dispatchers who
handle EMS calls should have minimum levels of training and access to
medical guidance. (The committee's views on the training and protocols
needed by dispatchers are presented in Chapters 4 and 5.) Some commer-
cial programs are available, such as "Medical Priority Dispatch," that use
set protocols to give police department employees appropriate questions to
ask and appropriate responses to caller inquiries or statements. Finding that
80 percent of the paramedic runs dispatched in one year were for "false
alarms" (essentially all calls, including bogus ones, in which paramedics
did not evaluate or treat a patient at the scene) led Ramenofsky and col-
leagues (1983) to conclude that better dispatch criteria were clearly needed.
Brodsky's (1992) study on road accident reports points up some of the
difficulties in making dispatch decisions. If callers do not provide specific
information about the need for an ambulance, police dispatchers must de-
cide whether to alert EMS, and those decisions may be delayed or incorrect.
For example, although most highway collisions do not require ambulance
service, in nearly 20 percent of fatal crashes in Missouri, the delays in
notifying EMS were 5 minutes or longer. Brodsky also notes that specific
policies on notifying EMS varied across the state; some local EMS systems
believe that they, not the police, should detains whether to send an ambu-
lance. He concludes that greater efforts should be made to link information
on police dispatch with that on collisions to learn more about the impact of
specific dispatch policies on morbidity and mortality.
The impact of 9-1-1 systems on morbidity and mortality has not been
adequately assessed. An analysis of trauma death rates in North Carolina
counties before and after implementation of 9-1-1 showed that counties
with 9-1-1 had a lower average trauma death rate than counties without 9-1-1,
but the presence of 9-1-1 could not account for the difference after control-
ling for other factors (Patsey et al., 19921. More significant than the ab-
sence of 9-1-1 was the fact that those counties were more rural, less likely
to have a trauma center, and less likely to have advanced life support (ALS)
services available. These results suggest that a 9-1-1 system cannot by
itself ensure better outcomes for trauma; other pieces of the EMS system
must be available as well. This study does not, however, provide any
insight into benefits that 9-1-1 might bring in other kinds of emergencies,
perhaps by facilitating speedier response to cardiac emergencies or by pro-
viding access to prearrival instructions for first aid.
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Public Access and Use One very practical concern, in both rural and
urban areas, can be availability of telephone service. Some people in rural
or remote areas may rely on radio communications, but others may have no
local telecommunications resources at all. Factors that account for the lack
of telephone services sparse population, terrain, poverty are likely to be
of a long-standir~g nature and axe unlikely to succumb to remedial efforts
based solely on arguments about 9-~-! service. Even ~n -urban areas, some
households have no telephone service. One study found that families of 9
percent of the patients in a public assistance managed care plan who were
seen in the pediatric ED of a major city hospital did not have a telephone
(Glotzer et al., 1991~. Such families are likely to rely on neighbors' tele-
phones or on nearby public telephones. Either way, some of the benefit of
rapid access to EMS that 9-1-1 is intended to provide is compromised by
delay in reaching a telephone, and the locator benefits of enhanced 9-1-1
are reduced because the caller is not at the scene of the emergency.
Installing even the most sophisticated 9-1-1 system will not guarantee
that the public will use the EMS system appropriately or that the EMS
system will provide an appropriate response. Public education efforts are
needed to prepare parents and others responsible for the care of children to
recognize emergency conditions and to know how to respond, including
how to contact the EMS system. (See Chapter 4 for a more extensive
discussion of public education needs in this area.) As is the case with all
emergency services, attention also must be given to when 9-1-1 should not
be used. Inappropriate calls make it more difficult for those who really
need emergency care to reach the EMS system; unnecessary dispatch of
equipment risks squandering scarce staff and ambulance resources. Some
inappropriate calls may, however, signal a need for other kinds of informa-
tion and transportation services to assist people in getting to doctors' of-
fices, clinics, and pharmacies for nonurgent medical care. In these situa-
tions, having a "municipal services" or other nonemergency number may be
useful.
Managed Care Guidelines for Using 9-1-1 Efforts to promote use of
9-1-1 have received limited support from many managed care programs or
health maintenance organizations (HMOs). Members of such programs may
be requested, or required, to telephone the HMO offices first before call-
ing 9-1-1 except in obviously life-threatening emergencies. Such policies
are intended as an administrative mechanism to reduce unnecessary ED
visits, which are a serious burden for some EDs and are costly for insurers.
Given the difficulty with which parents or other responsible adults (or ado-
lescents, siblings, or younger children) might have in discerning what is a
life-threatening emergency in a child and what is not, requirements to con-
tact the HMO first can pose problems if the definition of "emergency" is
too narrow or too rigidly enforced.
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EMERGENCY MEDICAL SERVICES FOR CHILDREN
A study in the Chicago metropolitan area found that 15 of 16 large
HMOs (accounting for 95 percent of HMO enrollees in the area) advised
their members to contact the HMO (or gatekeeper physician) first in the
event of an emergency; one advised going to the nearest hospital (some
advised this as a secondary response in the most serious emergencies); none
advised calling 9-1-1 as the first response (~ossfel`1 Ed Ryan, 1989~3
Similar policies were found among ~ representative sample of federally
qualified HMOs (Kerr, 1989~. The vast majority allowed enrollees to pro-
ceed to a hospital ED without permission when the problem was life-threat-
ening and required permission when it was not; the mechanisms for acquir-
ing permission from a gatekeeper by telephone varied across the HMOs. In
some cases, patients would be allowed or directed to go only to a hospital in
the HMO network (and not necessarily to the nearest one). If a true emer-
gency exists, such policies run counter to EMS guidelines.
Kerr (1989, p. 2763 notes that some "medical directors believed that
telephone triage systems introduce undue delay in ED access and for that
reason were not used by their HMOs," and he goes on to comment on the
dearth of information about the safety of telephone gatekeeping systems of
this sort in the EMS context. Others, however, have reported on advantages
of a well-developed HMO telephone triage system (Daley et al., 1988; Leaning
et al., 1991~. HMO staff have access to patient records during a call, can
advise callers unaware of the seriousness of a condition how and where to
seek appropriate emergency care (especially if no 9-1-1 system is avail-
able), and can summon emergency transport for patients who might other-
wise avoid seeking such assistance. The experience of the Harvard Com-
munity Health Plan suggests that the participation of emergency physicians
in HMO plans can provide greater appreciation within the organization of
the need for efficient access to the EMS system (Daley et al., 1988~.
Knopp (1986) argued for HMOs to take four steps to improve access to
emergency services: (1) base reimbursement decisions on review of the
initial presentation of the patient to an appropriate emergency facility or
physician, not on the final diagnosis; (2) develop a cooperative relationship
with the local EMS system, including providing enrollees with information
on how to use it; (3) instruct HMO physicians and nurses to "err on the side
of patient care, not cost containment" in making telephone triage decisions;
and (4) develop better triage methods so that potential life-threatening situ-
ations can be appropriately identified and the EMS system called into play
in a timely fashion.
Legal and Ethical Issues Privacy and confidentiality issues may be-
come a concern precisely because of the caller identification capabilities
that are at the heart of the E9-1-1 system. In principle, it does not seem
reasonable to expect callers into an EMS system to object to this feature, as
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it arguably is always in their best interests. In practice, however, fears
about invasion of privacy and breaches of confidentiality relating to sensi-
tive medical information have reached quite high levels (as briefly explored
in Chapter 7~. Such concerns may trouble even those who do not make
direct use of the system because of the need to maintain a comprehensive
database of telephone numbers and addresses for an entire service area.
Another question that arises with E9-l-l is whether there is an obIiga-
tion to dispatch response personnel or equipment (police, fire, or EMS) in
response to very brief calls in which the location of the call is known but
the caller has seemingly deliberately hung up before completing the call. In
these situations, when the call-takers may suspect but not be certain that the
call is a hoax, a decision must still be made as to whether to respond and, if
so, with what kind of service. Frequently, 9-1-1 centers will call the num-
ber back and send police to ensure that no emergency exists.
Recommendation for 9-1-1
This study committee strongly believes that universal adoption of 9-1-1
must be a national goal. It recognizes that 9-1-1 systems in themselves
cannot ensure that efficient and effective emergency services will be avail-
able in response to a call; 9-1-1 systems are, instead, one part of the EMS
system that needs to be in place to make such care available, and the capa-
bilities of E9-1-1 make it especially valuable. Successful adoption of 9-1-1
is not necessarily simple; it will require communities to address a variety of
interlocking challenges. In the committee's view, however, 9-1-1 is an
essential EMS system element, for all the reasons and benefits offered above.
Therefore, the committee recommends that all states ensure that 9-1-1
systems are implemented. The 9-1-1 system must be universally acces-
sible and effectively linked to the emergency medical services system.
Communities with 9-1-1 systems in place should move toward enhanced
9-1-1 capabilities. Communities with no 9-1-1 system should move di-
rectly to an enhanced 9-1-1 system.
More specifically, the committee advises that the federal center and
state agencies described in Chapter 8 make the 9-1-1 issue one of their key
priorities. For example, smaller communities that have not yet implemented
9-1-1 at all may need encouragement and assistance from federal or state
bodies to overcome financial and administrative obstacles to adopting 9-1-1,
and this help should be forthcoming at the earliest possible moment. Lo-
calities that wish to move from standard to E9- 1-1 capabilities should
also receive high priority attention or assistance. In all cases, attention
should be directed at understanding and overcoming the various impedi-
ments to 9-1-1 and enhanced 9-1-1 outlined above. The committee also
believes that attention to these issues should proceed on a broad front relat
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a child to be treated in the ED. Managed care plans generally require that
patients pick a primary care physician who then serves as a gatekeeper to
other forms of care, including ED care. Care received without prior autho-
rization from this gatekeeper-physician or other designated representative
may not be reimbursed. Under most plans, however, "unauthorized" ED
care will be covered in the event of a serious emergency (as defined by the
plan). (See al~so the discussion varier In this chapter on HMO policies on
use of 9-1-1.)
Managed care plans serve families with typical employer-based insur-
ance and are covering increasing numbers of families participating in Med-
icaid or other publicly funded health care programs. Implementation of
these public programs is intended to provide low-income families with bet-
ter access to more comprehensive services, particularly primary care. The
focus on primary care may, however, be unfamiliar to many of these fami-
lies. The ED has traditionally been their most accessible source of unsched-
uled care, and some may continue to seek care there rather than from more
appropriate primary care providers. When emergency care is needed, con-
tact with the primary care provider may give the ED better access to infor-
mation about the patient and facilitate arrangements for appropriate follow
up care.
Communication with a primary care provider or other plan representa-
tive is a major feature of managed care plans. For some participants, par-
ticularly in public assistance plans, this element may create problems in
using services in intended ways. They may, for example, have difficulty
contacting their primary care physician or using after-hours advice services
if they lack reliable access to telephone service or cannot speak English
well. One study found that the ED could reach by telephone only 21 per-
cent of the families of a group of children whose publicly funded managed
care plan had denied approval for ED care (Straw et al., 1990~. Also worri-
some was evidence that only 60 percent of parents kept appointments that
had been scheduled for their children when ED care was denied.
Because families such as these can be difficult to contact and may not
obtain the care recommended for their children, a decision to deny approval
for ED care must be based on reliable communication between the ED and
the primary care provider. On both sides, the responsibility for these com-
munications should rest with personnel qualified to assess the clinical sig-
nificance of information about the child's condition. Some observers have
expressed concern that denying approval for ED care during hours when
clinics and other primary care sites are not open may increase the possibil-
ity that serious problems will be missed (Glotzer et al., 1991~. Both EDs
and managed care plans should ensure that their mutual communication
responsibilities receive serious and sufficient attention and that they are
alert to lapses that may occur.
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EMERGENCY MEDICAL SERVICES FOR CHILDREN
Improving Follow-up Care
Most children treated in EDs do not require admission to the hospital,
but many do need further care at home or from a primary care provider.
Too often, however, ED recommendations for such care are not followed
(Jones et al., 1988; Nelson et al., 19911. Several factors appear to contrib-
ute to th~s [allure -to comply -huh instructions. Jones and her colleagues
(1988) found that patients who had no regular health care provider or who
had difficulty arranging for temporary care of their children were signifi-
cantly less likely to obtain recommended follow-up evaluations. For low-
income families, the recommended treatment may prove too costly. Investi-
gators in Boston found, for example, that the quantity of a commercial oral
electrolyte solution needed to treat a seriously ill child would cost nearly 5
percent of a family's monthly grant from the city's Aid to Families with
Dependent Children program (Meyers et al., 1991~.
Patients and their families may also fail to remember or to understand
the instructions given to them in the ED. A recent study found that, on
leaving the ED, parents in the control group could recount accurately as
little as 5 percent of the guidance they had received on "worrisome signs"
that should prompt them to contact the ED again (Isaacman et al., 1992a).
Language and cultural differences between patients and providers may make
it notably difficult for ED physicians to communicate successfully with
their patients. Interviews with Hispanic patients in one emergency room
revealed that misunderstood instructions resulted not only in failure to seek
recommended care but also in occasional adverse effects from mistaken
care (Narita, 1991~.
EDs and other parts of the EMS-C system need to explore ways to
achieve better compliance with the care that they recommend. Compliance
would be a chapter, if not a book, in itself, and communication skills of the
health care provider are probably the most important factor. Nonetheless,
the various parts of the EMS system can take positive steps.
For example, mechanisms for routine follow-up contact with patients
can be instituted or expanded. Telephone calls within a week of an ED visit
have helped to increase the proportion of patients who seek recommended
care (Jones et al., 1988; Nelson et al., 19913. Standardized delivery of
simplified instructions has been shown to improve parents' ability to recall
correctly the information they were given on medications and on positive
and negative signs in their child's recovery (Isaacman et al., 1992a). For-
mal programs have been developed by some pediatric EDs for instance,
Bronx Municipal Hospital Center in New York and Children's Hospital of
Philadelphia-to follow up on children about whom they are worried, such
as those with abnormal laboratory results or those who failed to return for
follow-up examinations. Such programs, successfully staffed by nurse prac
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215
titioners and physician assistants, can help foster compliance with treatment
recommendations as well as identify possible deterioration in a child's con-
dition before a crisis develops.
EDs and other emergency care providers that serve a culturally diverse
population may need to offer services such as trained interpreters. Staff
may need better tra~x~ng in cultural differences related to expectations and
understandings regarding health care. One model effort is the cultural di-
versity training manual that the EMS-C demonstration program in Washing-
ton State developed for use in a course for ED staff (Washington EMS-C
Project, 1991~. It has received support from the state's hospital community
and has generated interest in similar training for prehospital and primary
care providers.
Rehabilitation Services
As improvements in EMS-C, including trauma centers and critical care
facilities, lead to increased survival of more seriously injured children, the
need for rehabilitation services increases. Children with spinal cord inju-
ries and traumatic brain injuries account for a large portion of the patients
needing rehabilitation; necrologic damage secondary to other injuries and
illness adds to this population (IOM, 1991b). Burns may require substantial
long-term rehabilitation and plastic surgery. Twenty percent of hospital
admissions for burns involve children, most of whom are 2 to 4 years or 17
to 25 years of age (CDC, 1992b). Rehabilitation may benefit other injured
children as well; fractures and other nonneurologic injuries can leave func-
tional limitations for as long as six months after discharge from the hospital
(Wesson et al., 1989~.
The value of early and well-integrated rehabilitative care is supported
by the success of the regional pediatric trauma program at Johns Hopkins
University Hospital in Baltimore, Maryland; among the children more than
2 years of age, 88 percent have recovered without major motor or intellec-
tual deficits (Hailer and Beaver, 1989~. Operational configurations for pe-
diatric rehabilitation programs can differ; for instance, they can be based in
a freestanding facility, a hospital-based freestanding program, or an inte-
grated inpatient program. These differences can, in turn, lead to differences
in the timing of rehabilitative interventions and in the mix of providers
(acute care, primary care, outpatient specialists) who participate in manag-
ing a child's care (Quint, 1992~.
Regardless of the specifics of a particular program, a child's acute care
providers must take into account the need for longer-term rehabilitative
care. Early planning for such care and coordination between acute care
services and rehabilitation providers will help ensure that a child gets ap-
propriate care. The District of Columbia EMS-C Project (1991) focused on
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EMERGENCY MEDICAL SERVICES FOR CHILDREN
the residual effects of traumatic brain injury and developed tools to assess
the rehabilitation needs of these children. This project also developed a
guide that nurses and other case managers can use in arranging transfers of
children to rehabilitation programs (Wright, 1990~.
Physical rehabilitation may be the most obvious need. Nevertheless,
children. need access to other services to address the psychological and
behavioral consequences of injury. Social services that can assist families
in managing the additional demands placed on them are an important ad-
junct to care of the child (Quint, 19924.
In sum, the range of services that contribute to rehabilitation is quite
broad. Unfortunately, these services are often poorly coordinated, making
it difficult to determine what resources are available and to realize the most
effective use of them. Again, this may be an arena in which a federal center
and, especially, state agencies (see Chapter 8) can play a helpful role.
FEEDBACK
Very early in its discussions, the committee agreed that more and better
feedback throughout EMS and EMS-C systems would promote optimal pa-
tient care and effective linkages between system components. Feedback
takes many forms. Information on performance and patient outcomes should
flow within the various components of these systems as well as between
them. Communication needs to occur as an individual patient progresses
through the system components; it also needs to take place in a more sys-
tematic and comprehensive manner to address the overall aspects of system
performance in the care of all patients. Feedback should reach individual
providers and the organizational entities in which they work, and the child's
private physician should not be overlooked in the feedback loop. It should
be informative and constructive; successes should be acknowledged as well
as problems.
EMS-C systems should seek to develop a systemwide expectation for
feedback. Within parts of the system, activities that can meet this need,
such as hospital quality assurance or quality improvement programs, may
already exist. Systems may, however, have to work at developing channels
through which information can flow routinely from one part of the system
to another between EDs and EMS agencies or between referral centers and
community hospitals, for example. It is important that these information
flows be seen as an integral part of the operation of an EMS-C system, not
simply as a professional courtesy or an opportunity to assign blame.
Feedback and systematic data collection are synergistic. For example,
learning the frequency with which patients seek care for various conditions
can help planners identify training or equipment needs; it can also help
health care professionals target prevention activities more efficiently. In
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turn, being able to collect good data may depend on feedback: when data
produce information that is useful to the people who collect it, they have a
greater incentive to ensure that those data are accurate and complete. Issues
such as these are discussed more extensively in Chapter 7.
OTHER IMPORTANT FORMS OF COMMUNICATION
Important communication about EMS-C takes place separately from the
process of delivering care to children. Planning for and managing EMS-C
systems need to bring together providers, administrators, and government
officials to ensure that important issues are recognized and competing needs
balanced. The participants in EMS-C should also have a good working
relationship with the community in which they provide services. Good
communication within the EMS-C professional community deserves atten-
tion as well.
System Planning and Coordination
Providers with expertise in EMS-C should play an active role in the orga-
nization and operation of EMS systems. They also need to develop working
relationships with other influential individuals and organizations whose pri-
mary focus is not EMS, such as hospital boards, regional planning groups, and
local and state legislators. Only if EMS-C providers do so can they influ-
ence system policies and priorities, make people aware of EMS-C concerns,
and thus ensure that adequate attention is given to the needs of children.
Vocal support for and involvement in the activities of the national and
state EMS-C agencies proposed in Chapter 8 may help foster improved
system planning and operations. Participation in advisory groups is another
avenue at, say, the local or regional level; involvement in EMS councils
will influence development of pediatric medical control guidelines, encour-
age pediatric equipment purchases, and generally raise the level of under-
standing about EMS-C issues. Closer to home, participation on hospital
committees enables EMS-C advocates to assemble a "code team" that com-
prises the best specialists from key departments in the institution and can
respond quickly to an intrafacility crisis. Providing pediatric EMS training
programs is often a useful "foot in the door" insofar as it influences the
development of pediatric protocols and enhances awareness of special needs
of pediatric patients.
Communication with the Community
Public education efforts are one of the more important forms of com-
munication between the EMS-C system and the community it serves. Such
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EMERGENCY MEDICAL SERVICES FOR CHILDREN
programs should try to reach a broad audience so that they can educate the
public about the need for an EMS system, use of the system, and implemen-
tation of the system, as well as develop support for EMS-C activities per se.
These efforts vary widely: for example, pediatricians teach parents about
steps to prevent injury; EMS agencies promote the appropriate use of 9-1-1;
and local EMTs, paramedics' nurses, and physicians teach CPR courses.
Specific topics that public education should address are discussed at length
in Chapter 4. Here, the committee's point is that public education is a
significant form of communication that should be an integral part of the
activities of EMS and EMS-C systems.
An annual event such as National Emergency Medical Services Week,
which has been held for several years and recognized by presidential proc-
lamation since 1990, provides a valuable opportunity to focus broad com-
munity attention on EMS and EMS-C issues. With federal agencies and
professional organizations as sponsors, this program has received recogni-
tion from state and local governments and has encouraged individual EMS
agencies, fire departments, ambulance services, and hospitals to organize
community activities. In addition to providing information about child safety
to adults, many activities are designed for direct participation by children
themselves (ACEP, no date).
Injury prevention work with the community should receive an espe-
cially high priority. The EMS-C system sees a broad range of injuries; it
can identify those that occur most frequently and those that are especially
serious. Providers can contribute their expertise and perspective to commu-
nity efforts to reduce a variety of injury risks such as those related to
automobiles, bicycles, residential hazards, and sports (Stevens, 1992~. As
was cited in Chapter 4, for example, Harlem Hospital in New York City
studied data on its admissions of injured children to develop an injury
prevention program that targeted the specific risks that children in that
community face (Barlow, 19921. Their emphasis has been on improving
pedestrian and bicycle safety, upgrading playground equipment, and reduc-
ing violence. An earlier program in New York City Children Can't Fly-
substantially reduced falls from windows by promoting the use of window
guards and supporting the passage of legislation requiring their installation
(Speigel and Lindaman, 19771.
One approach to linking prehospital providers with injury prevention is
participation in programs such as the National SAFE KIDS Campaign, which
has local, state, and national activities. A directory of violence and uninten-
tional injury prevention projects funded by the Maternal and Child Health
Bureau of the Health Resources and Services Administration, Department of
Health and Human Services (DHHS), offers other models (NCEMCH, 1991~.
For example, a New York State Department of Health project aims to reduce
morbidity and mortality from childhood home injuries (falls, scalds, burns,
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and poisonings) by training EMTs in primary prevention and encouraging
their participation in community efforts. Contact with the National Center
for Injury Prevention and Control at the Centers for Disease Control and
Prevention in DHHS will also be helpful.8
Professional Communication
Opportunities for valuable communication among providers exist through
various professional activities. Practitioners who are already active in EMS-
C can make use of conferences and publications for the EMS-C community
to share information in areas such as clinical observations in caring for
children, EMS system planning and operation, and results of research. Con-
ferences and publications with a broader focus offer the opportunity to
bring EMS-C issues to the attention of colleagues who are not familiar with
them.
As the historical discussion in Chapter 3 emphasized, professional or-
ganizations such as the American Academy of Pediatrics, American College
of Emergency Physicians, American College of Surgeons, Emergency Nurses
Association, and National Association of Emergency Medical Technicians
have been important channels for informing providers about EMS-C. Other
organizations whose efforts in this area must not be overlooked include the
Ambulatory Pediatric Association, American Association of Critical Care
Nurses, American Academy of Orthopaedic Surgeons, American Trauma
Society, Association of Air Medical Services, National Association of EMS
Physicians, and Society of Pediatric Nurses. Local and regional chapters of
national organizations or other groups formed around a common interest
give providers a more immediate chance to become acquainted with each
other, perhaps facilitating cooperation when future cases require access to
outside resources. Public safety and related organizations (such as NENA
or APCO, and groups such as the International Association of Fire Chiefs)-
even though their concerns extend beyond emergency medical services
should also be seen as useful partners in communication about EMS and
EMS-C to other groups, health care professionals, and the community at
large.
One collaborative effort that has developed is the Children's EMS Alli-
ance, which began in 1990 as the Year of the Child in EMS. It brings
together professional organizations and hospitals to inform the professional
community and the public about EMS-C issues (Luten, 19911. The program
seeks to educate the membership of participating organizations and to en-
hance the operation of EMS systems by fostering cooperation among medi-
cal and administrative organizations.
The EMS-C demonstration grant program has placed particular empha-
sis on information exchange among grantees and with other audiences as
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EMERGENCY MEDICAL SERVICES FOR CHILDREN
well. National conferences have brought grantees together periodically to
share the results of their work. For a major conference in 1991, the grant-
ees prepared a report, Emergency Medical Services for Children: A Report
to the Nation, which presents their conclusions and recommendations re-
garding areas where further work is needed (Seidel and Henderson, 1991~.
One project (the National EMS-C Resource Alliance, or HERA) publishes
EMSC News on a quarterly basis to bring information about EMS-C projects
and innovations in pediatric emergency care to a broad audience. Another
EMS-C effort (the EMS-C National Resource Center) provides information
to grantees on legislative activities and possible funding sources.
Many EMS-C projects have distributed samples of training materials
and other grant products to other grantees, and catalogs of the materials
produced by the grantees have been published (Shaperman and Backer,
1991; NERA, 1993~. For many of the projects, however, once EMS-C grant
funding ends no other source of funds may be available to continue produc-
ing copies of these materials; some materials may remain available if they
have been adopted by state or local government or another sponsor such as
a medical school. Even when materials continue to be available, organiza-
tions may not be able to support the "marketing" necessary to make the
EMS community aware of them or to undertake the appropriate updating as
information increases and technologies change.
am. . ~ . _ ~
~-~ .r - - ~ ~ ~_ OF ,
the committee believes that post-M-(-grant difficulties such as these-
for instance, in producing materials and informing people of their availabil-
ity- argue for ongoing federal support for an organization that can provide
clearinghouse services; these might include collecting and evaluating prod-
ucts developed by the demonstration grants and by other groups. This work
might be based within a federal agency such as the EMS-C center that the
committee proposes in Chapter 8, or it might be performed by other organi-
zations (public or private) under a federal contract or grant. (A variant on
this idea is the creation of one or more "national resource centers"; for sim-
plicity the term " clearinghouse" is retained here.) A clearinghouse might also
help develop new materials that facilitate provider communication. For ex-
ample, a prehospital resource guide produced by the AAP (1990b) and a re-
cently published directory of injury prevention professionals (Children's Safety
Network, 1992) might serve as models for other EMS-C publications.
As proposed in Chapter 8, a federal center as well as state agencies
might support other types of consultation. For instance, the federal office
directly or indirectly could make materials or advice available to various
community organizations and professional associations that wish to estab-
lish EMS-C coalitions. Guidelines and consultation for public policy activ-
ity at the state level are also needed, so that the public can be mobilized to
support needed changes in EMS-C through legislation and regulatory change.
Finally, a clearinghouse or resource center activity might be helpful in gen
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221
crating advice about long-term funding options, so that coordination of EMS-
C activities does not falter upon the termination of the EMS-C demonstra-
tion projects.
SUMMARY
This chapter explores the critical role that communication plays in
the successful operation of systems of emergency medical care. It devotes
considerable attention to issues of public access to the EMS system, espe-
cially through promotion of 9-1-1 and E9-1-1 emergency response systems.
The committee's firm belief in the advisability of universal adoption of 9-1-1
or E9-1-1 led to a formal recommendation that each state ensure implemen-
tation of such systems (see Box 6-1~. Telephone access to poison control
centers, especially those certified by the AAPCC, fills a need among the
public and emergency care providers for specialized guidance for managing
the care of children exposed to potentially toxic materials. Parents also
seek telephone advice from hospital EDs; this service can provide benefits,
but it also poses risks because no direct assessment of a child's condition
can be made. The committee strongly advocates appropriate training, clear
protocols, careful documentation, and routine monitoring in ED programs
offering telephone advice.
Prehospital services employ a range of communications technologies
(e.g., standard telephone links, radio systems, microwave networks, and
satellite links). On-line medical control requires direct communication be-
tween designated medical personnel and prehospital providers. It is used
for authorizing ALS procedures and advising on other aspects of prehospital
patient management. EMS systems vary in the extent to which they use on-
line medical control.
In the hospital setting, good communication is critical. Emergency care
may require ED consultation with specialists in the hospital or in the com
,"' ~ i"" ~ i'"', "I ' 'I'm "I ~ ~ ' " "' "~''~''~"'~''~-'~' ~"'~ "'' " "'' ~'~"~"'~'-~"' ~ I've '" ~'"""'~''~ "'"'''''" ~ ~ ~"'''~.' "
'"'~''-"'"'~"'' ~
2~'~'~'" " ''' ''I
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Aft"' "' "'"'""~'~"""'""'~'"'"''""'''""'"'"'"""'~;~""~''" """""'"'am'' "" ~ """',""'"'",,,,,,,,, " '',,"'',,
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222
EMERGENCY MEDICAL SERVICES FOR CHILDREN
munity as well as a child's primary care provider. Consultation with re-
gional or national experts at pediatric referral centers or poison control
centers may be needed and is facilitated by mechanisms such as telephone
hot lines and facsimile communication. When children must be transferred
to referral centers, clear communication between hospitals and health care
providers involved is essential to ensure that v~1 cling and administra-
t~e ~nforn,~tion is exchanged. Here the committee believes that written
transfer agreements between hospitals make an important contribution to
speeding the transfer process by settling many procedural and administra-
tive matters in advance. Development of centralized communication ser-
vices also may ease transfer arrangements and help make efficient use of
regional resources.
Communication plays an important role in ensuring that an ill or in-
jured child obtains the full range of services, from prevention to acute care
and on to rehabilitation, that comprise EMS-C. The committee thus argues
that EMS-C systems must give special attention to follow-up in three areas:
primary care, post-ED care, and rehabilitation.
More and better feedback is needed throughout EMS and EMS-C sys-
tems to promote optimal patient care and effective linkages between system
components. Information regarding care for individual patients and regard-
ing the overall pattern of care is needed. EMS systems may have to work at
developing channels through which information on system performance and
patient outcomes can flow routinely. Feedback needs to reach individual
providers as well as managers and administrators and may require system-
atic data collection.
Important communication about EMS-C should occur independently of
the delivery of care to children. Providers with pediatric expertise need to
be active in the organization and operation of EMS systems, and public
education should be an integral part of the activities of EMS and EMS-C
systems. Public safety organizations, even though their concerns extend
beyond EMS per se, should be viewed as useful partners in communication
about EMS and EMS-C to other public agencies, health care professionals,
and the community at large. The EMS-C demonstration grant program and
the efforts of individual grantees have encouraged communication across
the country. In the committee's view, the need to maintain and build on
these activities argues for creation of a national EMS-C clearinghouse that
can collect and evaluate EMS-C materials and serve as a focal point for
information exchange.
NOTES
1. Some experts in the public safety community argue that 9-1-1 should be thought of as a
"response" number rather than an "emergency" number, for at least two reasons. First, many
people have difficulty distinguishing an emergency from a nonemergency (i.e., they make
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erroneous distinctions about "real" emergencies); second, 9-1-1 is intended to provide access
to potential dispatch of any type of public safety response unit (not just medical services). In
certain situations, however, this can be problematic, as when the public uses 9-1-1 to access
any city service and thereby clogs the telephone system with nonemergency calls. A single,
communitywide seven-digit phone number, perhaps available 24 hours a day, should be estab-
lished to handle the calls for nonemergency services.
2. One advantage of 9-1-1 apart from being easy to remember, is that it meets require-
ments ~r num~g plans and switching conti=~rations of ~e telephone industry; 9-~! ~s
unique, for instance, in that it has never been authorized as an area code or a service code
(NENA, no date).
3. The potential dangers when HMOs do not properly advise members about 9-1-1 are
illustrated by Kerr (1986). He reports on three adult HMO enrollees with severe cardiac
symptoms who followed HMO procedures to call the triage physician and were directed to
distant EDs; all patients endured considerable delay in reaching appropriate emergency and
definitive care and suffered more serious sequelae than might otherwise have been the case. A
later article (Kerr, 1989) gave the following examples of life-threatening events in the HMO
context: heart attack, stroke, loss of consciousness, poisoning, uncontrolled bleeding, acute
allergic reaction, shock, convulsions, and the like; non-life-threatening cases included rash,
minor chest pain, high fever, vomiting, asthma, allergic reaction, and gas pains. Exactly where
the main problems accounting for emergency situations for children would fit is not clear.
4. EMS communication systems are currently confronting limitations in the availability of
radio frequency spectra. At present, eight med-channel pairings are allocated for regional
EMS systems. Operating at frequencies in the 460 megahertz (MHz) range of the ultra-high
frequency (UHF) spectrum, these channels are subject to significant "channel crowding" and
"bleed over," especially in urban areas. Along the border with Mexico, some EMS radio
systems encounter interference because allocation of frequencies is not covered by enforceable
treaties with Mexico. Additional frequency spectra, dedicated to EMS use, must be authorized
by the Federal Communications Commission (FCC); the FCC has recently released new 800
MHz and some 900 MHz spectra.
5. The EMS-C projects cited in this chapter are those of the federal demonstration grant
program supported by the Maternal and Child Health Bureau, Health Resources and Services
Administration, U.S. Department of Health and Human Services.
6. In addition to the medical considerations in patient transfers, hospitals must be aware of
legal obligations. Federal legislation the Consolidated Omnibus Budget Reconciliation Act
of 1985 (P.L. 99-272) and the Omnibus Budget Reconciliation Act of 1989 (P.L. 101-239)-
established regulations designed to ensure that patients receive appropriate assessment and
stabilization before any transfer is made, to ensure that transfers are made in appropriate
vehicles and to facilities that are able to provide necessary care, and to deter "dumping" of
patients from one hospital to another on the basis of the patient's ability to pay.
7. Care for children with severe burns and the use of burn centers illustrate the critical need
in EMS-C for attention to optimal sites for care and to long-term follow-up. Burn centers
might, for example, have direct linkages with emergency departments and community hospi-
tals, so that children in this situation would be triaged directly to them rather than to the
hospital's intensive care unit. EMS-C systems should promote early planning for the extended
follow-up care that many of these children will need for procedures such as plastic surgery.
Ideally, this planning should look to a medical home or other source of primary care to assure
continuing attention to the special health care needs of children with severe burns. (We thank
one of our anonymous reviewers for elucidating this particular example.)
8. The National Center for Injury Control and Prevention was established at the Centers for
Disease Control and Prevention in June 1992. Previously, injury prevention activities were the
responsibility of the Division of Injury Control of the National Center for Environmental
Health and Injury Control.
Representative terms from entire chapter:
medical services
