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8
Leadership for Developing Emergency
Medical Services for Children
The committee has, by now, clearly set forth its support for two goals:
ensuring the development of high quality emergency medical services for
children (EMS-C) as integral components of existing emergency medical
services (EMS) systems and ensuring strong links to the broader realm of
child health care. Although the committee's charge refers only to emer-
gency medical care, its positions rest on the belief that society has a special
obligation to attend to the health care needs of children. They depend on
others for their care and have no independent political voice through which
they can make their needs known.
At present, EMS-C has significant shortcomings. Many can be attrib-
uted to insufficient integration of EMS-C with other areas of health care. In
particular, we note inadequate attention to the needs of children on the part
of an emergency care system developed to meet the needs of adults from
emergency dispatch centers to emergency transport systems, emergency de-
partments (EDs) and intensive care, and rehabilitation and support services
in the community. We record also inadequate attention to children's emer-
gency care needs on the part of the pediatric community, which has tradi-
tionally focused heavily on primary care. Overcoming these problems will
require efforts on many fronts and by many people. Currently, however,
EMS-C has neither a readily identifiable source of authoritative and visible
leadership nor any forum for cooperative efforts that can coordinate the
activities that the committee proposes.
The committee is heartened to see that clear weaknesses in EMS-C
have begun to receive much needed attention. It concludes, however, that
280
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LEADERSHIP FOR DEVELOPING EMS-C
281
further work is required in several areas to bring both the quantity and the
quality of EMS-C to appropriate levels across the country. As presented in
preceding chapters, these areas include:
.
education and training for the public, for health professionals gener-
ally, and for emergency care providers specifically;
~ organization and delivery of care' especially regarding equipment'
protocols and guidelines, medical control, categorization of facilities, and
regionalization of care;
· communication, including universal adoption of 9-1-1 for telephone
access to the emergency system and movement toward enhanced 9-1-1; and
· planning and evaluation, including efforts to institutionalize a na-
tional uniform data set appropriate for EMS-C and to require reporting of
ICD-9-CM E-codes for injury diagnoses, and augmented research activi-
ties.
As a way to focus attention and resources on efforts to improve EMS-
C, the committee sets forth in this chapter recommendations for establishing
EMS-C agencies at the federal and state levels and discusses the rationale
for its position. It reviews the broad range of parties whose representation
is essential, chiefly through national or state advisory councils to these
agencies; it also discusses the issues that should be high on the agenda of
such bodies. Finally, the committee considers the value of such an ap-
proach for accommodating the very diverse needs, resources, and organiza-
tional characteristics that individual states and localities bring to efforts to
improve emergency medical care for children.
THE DISJOINTED "SYSTEM" OF TODAY
Response to the committee's diverse concerns regarding EMS-C calls
for leadership in many circles because of the complicated nature of the
"system" in which EMS-C operates. Changes in training programs for
physicians, for instance, need to be implemented by bodies very different
from those that ensure that ambulances carry appropriate equipment or those
that institute 9-1-1 telephone systems. Interested parties include various
agencies in the federal government, elements of state and local govern-
ments, hospitals and their component departments, EMS agencies, individual
health care and emergency services providers, professional organizations,
community groups, and the public. Each group has its particular priorities
and opportunities for action, but there are common concerns that each of
those groups should know about and take into account within their separate
spheres.
Across the country, communities have developed EMS systems that
reflect local conditions and expectations. Ideally, these systems coordinate
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EMERGENCY MEDICAL SERVICES FOR CHILDREN
the activities of the separate pieces, helping them work together in a smooth,
consistent, and effective fashion. The pieces remain, nevertheless, under
the jurisdiction of largely independent entities, whose priorities and con-
cerns may not always be consistent with those of the system or its other
component parts. This fragmentation of responsibility and authority for
emergency care services can hinder optimal day-to-day operations and make
long-term system planning difficult. It also creates many independent chan-
nels through which changes such as those sought by the committee must be
pursued.
Many states and localities attempt to overcome some of this fragmenta-
tion through EMS advisory councils, which can bring together representa-
tives from many areas of interest and expertise. These standing bodies,
often legislatively mandated at the state level, have varying responsibilities,
authority, and structure. They represent an existing mechanism through
which some EMS-C issues might be addressed, but their scope is at once
too broad and too narrow to be able to address the full range of EMS-C
concerns raised by the committee. For instance, these advisory bodies must
concern themselves with services to patients of all ages, but generally only
for prehospital care. Part of the vision advanced in this report is that EMS-
C must concern itself with a broader range of services running from preven-
tion through primary care, inpatient care, and rehabilitation in addition to
the traditional prehospital and ED concerns.
Federal efforts have played an important part over the past 25 years in
promoting the development of EMS systems across the country. The lim-
ited federal role in the delivery of emergency medical care has rested largely
with the health care systems of the Indian Health Service in the Department
of Health and Human Services (DHHS) and the Department of Defense
(DOD).2 Much more important have been program guidance and funding
from DHHS and the Department of Transportation (DOT), but DHHS con-
tributions to EMS were significantly curtailed in the early 1980s, when
dedicated funding was abandoned in favor of block grants. DOT's National
Highway Traffic Safety Administration (NHTSA) has been the one federal
office with a continuing program in EMS since the late 1960s.
Since 1984, the federally funded EMS-C demonstration grant program,
administered by the Maternal and Child Health Bureau (MCHB) of the
Health Resources and Services Administration (HRSA) in DHHS, has given
valuable assistance to states and localities to begin to address EMS-C, but it
does not provide for ongoing activities at the federal or the state level.
Further, it has not served (nor was it designed) to establish and maintain
links among the many federal activities related either to emergency care or
to child health (although it has promoted informal networking among state
EMS-C programs). Neither was creation of an EMS-C advisory body with
a role for experts and interested parties outside the federal government
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LEADERSHIP FOR DEVELOPING EMS-C
283
within its mandate. With the adoption of the Trauma Care Systems Plan-
ning and Development Act of 1990 (Public Law [P.L.] 101-590), HRSA's
role in EMS-related activities has expanded; an advisory council, grant awards,
and other program activities will be directed toward assisting states to im-
prove their trauma systems.
Professional organizations, such as the American Academy of Pediat-
rics (AAP), the Ambulatory Pediatric Association, the American College of
Emergency Physicians, the American College of Surgeons, and the Emer-
gency Nurses Association, have served as focal points for bringing attention
to EMS-C concerns. Given their national memberships, such organizations
can help spread interest in EMS-C across the country. For example, the
AAP reaches a broad spectrum of pediatric primary care and hospital-based
practitioners. At the same time, it does not encompass in its membership
other providers, such as nurses and emergency medical technicians (EMTs),
who are important participants in emergency care services, and it also has
no formal link with the public agencies that are responsible for many as-
pects of EMS. Thus, the responsibility for promoting more cohesive and
comprehensive EMS-C efforts cannot rest entirely on the shoulders of pro-
fessional groups.
A FOCUS FOR EMERGENCY MEDICAL
SERVICES FOR CHILDREN
In sum, progress in improving the quality of emergency care given to
children and the readiness of EMS systems to provide that care depends on
ensuring that essential EMS-C components become an integral part of both
EMS in general and the broader realm of child health care. To promote that
integration, EMS-C needs to be given recognition and priority in both areas.
As a means of bringing this level of attention to EMS-C issues, the com-
mittee recommends that Congress direct the Secretary of the Depart-
ment of Health and Human Services to establish a federal center or
office to conduct, oversee, and coordinate activities related to planning
and evaluation, research, and technical assistance in emergency medical
services for children. The committee also recommends that Congress
direct the Secretary to establish a national advisory council for this
center; members should include representatives of relevant federal agencies,
representatives of state and local governments, the health care commu-
nity, and the public at large.
Although some might argue that establishing a formal EMS-C center or
office is not necessary, the committee concluded, after considering alterna-
tives, that lesser steps would not be adequate.3 The Secretary could assign
this EMS-C responsibility to an existing agency or give it to a newly cre-
ated entity. Either way, the committee emphasizes two concerns. First,
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EMERGENCY MEDICAL SERVICES FOR CHILDREN
EMS and EMS-C are important matters of health and health care in which
DHHS must assume a leading role. Second, past experience suggests that
children's needs will not be adequately represented without an identifiable
. . . .
institutional voice.
Furthermore, the proposed federal center can provide a national frame-
work within which to encourage the continued efforts of the many indiYidu
als and organizations across the country that have been responsible over the
past decade for bringing EMS-C issues to the attention of health care pro-
viders and EMS systems. The EMS-C center will be in a position to con-
tribute to the long-term success of efforts to formulate widely recognized
and consistent goals for EMS-C.
Because the organization and delivery of emergency care services rest
not with the federal government but with state and local governments and
health care providers in the private sector, action at the federal level alone
is not sufficient. Therefore, the committee further recommends that states
establish a lead agency to identify specific needs in emergency medical
services for children and to address the mechanisms appropriate to
meeting those needs. The committee also recommends that state advi-
sory councils be established for these agencies; members should include
representatives of relevant state and local agencies, the health care com-
munity, and the public at large. In making this recommendation, the
committee emphasizes that its call for an EMS-C agency is not intended to
isolate EMS-C from other EMS activities or to promote development of
separate EMS-C systems; rather it is intended to ensure that EMS-C issues
are visible and have adequate representation.
These two pairs of major recommendations for agencies at both the
federal and state levels take as their starting point the myriad issues con-
fronting EMS-C that were detailed in earlier chapters. The next section of
this chapter explains the functions of the proposed federal center more fully,
and the subsequent section addresses functions of the proposed state agen-
cies.4 The final sections address questions of funding and examine further
some of the obstacles to successful implementation of entities of this sort
and how those challenges might be met.
A FEDERAL CENTER FOR EMERGENCY MEDICAL
SERVICES FOR CHILDREN
Charge and Agenda
National leadership is essential to improving the quality of EMS-C
across the country. In the committee's judgment, a federal EMS-C center or
office can be a significant vehicle for exercising that leadership, demon-
strating through its activities a commitment to EMS-C at the highest levels
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LEADERSHIP FOR DEVELOPING EMS-C
285
of government. This center should be charged and authorized to propose
federal policies and carry out programs in two main areas.
The first part of the charge to a federal EMS-C center presupposes a
national perspective and targets the following eight areas:5
1. developing a national strategy;
2. coordinating efforts throughout the federal government;
3. disseminating information and providing for a clearinghouse function;
4. improving access to care;
underscoring medical illness as a special concern in EMS-C;
6. assisting education and training efforts;
7. collecting and analyzing data; and
8. supporting enhanced research efforts.
The second part of the charge to a federal EMS-C center aims to foster
state and local efforts, with three main thrusts:
1. creating incentives for state action;
2. providing technical assistance; and
3. encouraging regional coordination.
Developing a National Strategy
Perhaps the highest priority for the federal EMS-C center is to develop
a clear national strategy for ensuring that the emergency care needs of
children are met. As a nationally recognized entity that can represent or
respond to many interests, the EMS-C center together with its national
advisory council would be able to speak to such a broad need in an authori-
tative voice not always available to other groups. It should lay out a strat-
egy that is in keeping with the health promotion and disease prevention
objectives of Healthy People 2000 (DHHS, 1991~. An evaluation of the
effectiveness of projects supported under the demonstration grant program
could provide valuable guidance as a strategy evolves.
Secondarily, the EMS-C center needs to consider various practical, po-
litical, and logistics issues that emerge directly from that strategy. Opportu-
nities must exist for review and revision, with the implicit expectation of
public accountability. Annual reports for example, to the Secretary of
DHHS, to Congress, or to "the public" can help the center meet that re-
sponsibility. Such yearly (or otherwise regular and periodic) reports, from
either the center or its national advisory council, might analyze the results
of EMS-C efforts across the nation for instance, in data collection and
analysis and progress on a uniform EMS data set. Such reports might
examine where revised policies and procedures are needed and develop
specific research questions and hypotheses warranting future investigation.
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286
Coordinating Federal Efforts
EMERGENCY MEDICAL SERVICES FOR CHILDREN
As noted in earlier chapters, a variety of ongoing activities in federal
agencies relate to EMS-C issues. In the past, no mechanism has existed for
identifying or coordinating those activities. The EMS-C center should carry
out that function. Given the aim of ensuring that EMS-C is integrated into
broader emergency and child health cares the EMS-C center should be charged
with increasing the awareness among such agencies of the place of children's
emergency medical care needs in their programs. The center also might
undertake a review of the statutory charges to these agencies in areas re-
lated to EMS-C to identify existing opportunities for action. Of particular
importance is work on EMS systems, trauma and trauma systems, injury
prevention, rehabilitation, and pediatric critical care.
Prominent work in these areas includes the activities in HRSA of the
MCHB and the Trauma and Emergency Medical Systems Division. Major
programs at NHTSA in DOT include curriculum development for training
prehospital personnel, technical assistance in assessment of state EMS sys-
tems and development of trauma systems, highway safety, and public edu-
cation.
Numerous agencies in DHHS have programs in relevant areas. At the
Centers for Disease Control and Prevention (CDC), the newly created Na-
tional Center for Injury Prevention and Control is intended to provide lead-
ership in a broad national program related to nonoccupational injury pre-
vention and control, with the aim of preventing premature death and disability
from intentional injuries resulting from violent and abusive behavior and
from unintentional injuries. Activities at the National Institutes of Health
include research and education programs in asthma and emergency cardiac
care at the National Heart, Lung, and Blood Institute; work on injury and
injury surveillance at the National Institute of Arthritis and Musculoskeletal
and Skin Diseases; work on child health, injuries, and medical rehabilitation at
the National Institute of Child Health and Human Development; and shock
and trauma research at the National Institute for Neurological Disorders and
Stroke. Also in DHHS is the Indian Health Service (IHS), which delivers
health care services to American Indian and Native Alaskan communities.
The EMS-C center should also help bring to the attention of the EMS-C
community those programs with less obvious but still relevant connections.
A case in point is the set of programs in outcomes and effectiveness re-
search, clinical practice guidelines, database development, and cost, quality,
and access administered by the Agency for Health Care Policy and Research
(AHCPR) in DHHS. Other relevant activities in DHHS include those of the
National Center on Child Abuse and Neglect (NCCAN) and the Office of
Disease Prevention and Health Promotion (ODPlIP), which are discussed
below as possible models for the proposed EMS-C agency.
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LEADERSHIP FOR DEVELOPING EMS-C
287
The activities of the Health Care Financing Administration (HCFA)
concerned with both Medicaid and Medicare should also be of interest.
Medicaid relates directly to the health care coverage of children in low-
income families. Medicare regulations, which apply principally to elderly
patients,6 can also be important because they exert such a strong influence
on hospital operations' phvs~c~an reimbursement' and the health care deliv-
ery system generally.
Among the other federal agencies with activities of interest for EMS-C
include the DOD, farm safety activities of the Department of Agriculture,
the Consumer Product Safety Commission of the Department of Commerce,
the National Institute on Disability and Rehabilitation Research of the De-
partment of Education, the Federal Communications Commission, and the
Federal Emergency Management Agency.
Disseminating Information
One part of this broad scope to coordination is information dissemina-
tion and exchange. To that end, the federal EMS-C center should provide
for a clearinghouse for the products of various EMS-C grants and contracts
that it awards over the years. These may well relate to education and
training programs, planning and evaluation tools, results of data collection
and analysis, communication techniques, and many other subjects identified
in Chapters 4 through 7 of this report. The committee takes no stance on
whether the clearinghouse function ought to be based "in-house" or be
contracted to an outside group. It does argue, however, that the materials
and documents catalogued, disseminated, and exchanged should have a di-
rect bearing on the national strategy that the center formulates.
Improving Access to Care
Numerous factors can limit the availability of appropriate emergency
medical care for children and can otherwise distort patterns of seeking and
receiving nonemergency care, which in turn impinges on the EMS system.
The EMS-C center should identify ways in which actions at the federal
level can overcome some of those limitations or help states and municipali-
ties to do so. One step is to consider what the appropriate federal role is in
ensuring adequate staffing in hospitals and EMS agencies, particularly be-
cause shortages are encountered in both urban and rural areas. It might, for
example, review the issue of staffing "standards," as has been called for in
other areas such as nursing homes.
Consideration of staffing issues will also require that the EMS-C center
take broader questions of availability of facilities (or units within facilities)
into account. The continuing closures of rural hospitals can leave commu
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EMERGENCY MEDICAL SERVICES FOR CHILDREN
nities dependent on facilities in distant towns and affect the availability of
prehospital emergency services as well. In suburban and urban areas, some
hospitals are closing their EDs, thus reducing the availability of services
and increasing the burden on remaining facilities. Access to emergency
services may also be affected by policies of health maintenance organiza-
tions.
Lack of health insurance and Iow provider reimbursement rates in the
Medicaid program constrain access to primary care, which increases the
demand for ED services in two somewhat conflicting ways. First, children
are often sicker when they finally seek care, and second, they are often
brought to EDs for routine care. The latter problem may actually be the
more difficult to solve (and questions about the troubling prospects for EDs
of the future are revisited in Chapter 9~. The EMS-C center, in concert with
other appropriate federal agencies, should consider whether federal actions
through Medicaid, MCH block grants, or other programs can help lower
barriers to primary care and thus reduce the inappropriate use of EMS
(particularly ED) services for nonurgent problems. These issues must be a
serious concern because, as hospitals face increasing burdens from under-
and uncompensated care, access to emergency care is threatened as well.
Drawing Attention to Illness-Related Emergencies
Emergencies from serious illness have, overall, received less attention
than injury, yet illness is a major reason for young children, especially the
very young, to require emergency care and hospitalization. As discussed in
Chapter 7, for example, much less progress has been made for illness than
injury in developing measures of severity. The EMS-C center should ensure
that illness-related emergencies are not overlooked in the system develop-
ment and research priorities of either federal programs or the provider com-
munity. One step might be to ensure that groups engaged in trauma and
trauma system research (from funders to researchers) are better connected
to groups concerned with those illnesses likely to create emergencies in
children (e.g., asthma, seizures, or certain infections). Finally, the EMS-C
center should also work to guarantee that due attention is paid to outcomes
of care, broadly defined to include functional, emotional, and other out-
comes that matter to patients and their families.
Enhancing Education and Training
The value and effectiveness of the current potpourri of education and
training programs and curricula in EMS and EMS-C remain in question.
This committee has emphasized the role of the states in educational matters,
but in its judgment the federal government has a role to play as well. In
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.
LEADERSHIP FOR DEVELOPING EMS-C
289
particular, federal leadership could be pivotal in promoting appropriate con-
tent of curricula, with an emphasis on components crucial to training in
pediatric emergency care (such as assessment, cardiopulmonary and new-
born resuscitation, trauma care, and management of severe illness). It should
also ensure integration of EMS-C content into EMS educational programs.
Finally' the federal c-enter could also develop ways to act as or support ~
clearinghouse through which proven, or innovative, curricular programs and
other teaching materials might be shared.
Collecting and Analyzing Data
The committee believes that assembling a core of nationally comparable
data on pediatric emergency care is essential. The current scarcity of data and
the lack of comparability in the data that are available pose serious impedi-
ments to assessment of emergency care needs, efforts to prevent injury and
illness, evaluation of the care that is given, research on the clinical effective-
ness of care, and research on the effective organization and delivery of care.
Therefore, the federal EMS-C center should provide a locus for stable
funding for the development of a national uniform core EMS data set to be
used in nationwide surveillance of EMS-C systems and functions. This
work should give particular attention to coding schemes that will categorize
patients by disease process, acuity, and interventions and that will support
periodic analyses and comparisons of local, state, and regional information.
(The committee's preliminary proposal for some of the elements of such a
data set appears in Chapter 7.) Consistent with promoting the adoption of a
uniform data set, the committee believes that the EMS-C center should
assume responsibility for developing a national EMS-C database and pro-
viding, at a minimum, annual descriptive reports based on those data.
In this work the center should consult with the National Center for Health
Statistics in CDC to ensure that effective use is made of existing data and that
new data sets are, to the extent possible, consistent with other relevant data
programs. In short, a significant part of the work of the EMS-C center will
be to define the federal role in EMS-C data collection and analysis.
Similarly, the center should devise ways to support continued progress
in methods to collect data reliably and in (near) real time. Advances in
computer-based patient records, patient questionnaires, and trauma registry
information systems illustrate the kinds of technologies and methods the
center might investigate. It also should promote sharing of technologies
and instruments for data collection that may be developed or adopted in
various places around the country. In addition, the center should investigate
the advantages and disadvantages of central registries of patients served by
EMS systems that might enhance longitudinal surveillance. Controlling the
costs of data collection must be a concern as well.
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EMERGENCY MEDICAL SERVICES FOR CHILDREN
Finally, the federal agency assigned responsibility for EMS-C data should
promote the use of those data for planning and evaluation at the national,
state, and local levels. Thus, the EMS-C center must also work to make
clear to funders and administrators the need for adequate resources (in the
form of funding, personnel, and equipment) to support data collection ac-
tivit~es' and it should promote reasoned allocation of those resources at the
federal, state, and local levels.
A special word is needed about measuring funding for and costs of
EMS-C and EMS systems. As noted in several places throughout this re-
port, assembling complete, reliable, and valid dollar figures on the costs, or
benefits, of EMS systems (let alone EMS-C programs and services) is ex-
tremely difficult. For example, programs appear in different parts of state,
county, or city budgets (depending on where programmatic authority and
responsibility lie); they are funded in different ways; and accounting sys-
tems differ across states and municipalities. Costs borne by hospitals and
other providers for uncompensated care can be hard to estimate as is the
value of services provided by volunteers.
Putting a dollar value on benefits is quite difficult, for a considerable
number of methodologic reasons. Even more problematic are the difficul-
ties, in ethical terms, of placing "value" on human life in general (and for
the pediatric age range in particular) and on life-years saved, especially
taking the quality of the lives saved into account. In fact, trying to move
toward cost-benefit calculations may prove sufficiently demanding that
policymakers and researchers may choose to focus on cost-effectiveness,
where the equations would balance costs of services against effectiveness
and outcomes not measured in dollar terms.
Notwithstanding these challenges, credible numbers for the costs of
EMS-C must be found, if the programs are to be held accountable, evalu-
ated, and justified to an increasingly beleaguered public. For this reason,
the committee advises that the federal center give early and strong priority
to developing methods for generating good cost and cost-effectiveness data
and to making the case to the states that they, in turn, will need to find ways
to obtain these data. Both the federal and state advisory councils can be
used to carry this message to the broad set of interested parties in both the
public and private sectors. All such groups must come to understand (1)
that progress will be impeded to the extent that believable cost and financ-
ing numbers cannot be generated and (2) that all have a role in generating
the relevant information.
Supporting Research
Finally, the committee sees the federal EMS-C center as one that can
provide contract and grant support for targeted and investigator-initiated
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EMERGENCY MEDICAL SERVICES FOR CHILDREN
areas of health care, environmental protection, criminal justice, and eco-
nomic development. These constraints, coupled with considerable uncer-
tainty about economic prospects and concerns about continued federal man-
dates in programs such as Medicaid (Weissert, 1992), make states notably
less likely than before to be amenable to assuming any new funding respon-
sibilities, no matter how worthy. This may be an especially significant
barrier in states requiring balanced budgets, such as (California and Michi-
gan, where statutes would not permit them to finance EMS-C efforts with-
out "paying" for them directly.
The present lack of credible data on the costs and benefits of EMS-C,
or on the marginal costs and benefits if such programs were expanded,
makes arguing for such efforts more complicated. In the short run, propo-
nents must to some extent fall back on clinical, ethical, and political reason-
ing; but in the longer run, should the committee recommendations be force-
fully acted upon, better cost, outcome, and effectiveness data should be
available, ameliorating this problem to some extent.
THE CASE FOR NEW ENTITIES TO ADDRESS
EMERGENCY MEDICAL SERVICES FOR CHILDREN
While fully aware that its recommendations for new federal and state
entities may face some obstacles, the committee nonetheless firmly believes
that ensuring adequate emergency medical care for children is of such sig-
nificance that those obstacles must be understood, met, and overcome. In
seeking to bring major attention to children's needs, the committee is not
proposing to establish a new entitlement for children's medical care. In-
stead, it is trying to ensure that children are not deprived of the level of care
that is the expected norm for adult patients. EMS systems and EDs are
widely assumed to be equally capable of caring for children and adults. In
fact, this is not true. Children's needs have been (and continue to be)
overlooked in emergency medical care, and the committee wants to see that
oversight corrected.~4
In recommending the formation of federal and state centers and advi-
sory councils for EMS-C, the committee believes that they can and will
have the following special merits:
.
Advancing an ethical imperative. One might first consider the ethi-
cal argument: Surely no compelling rationale exists for ignoring or downplaying
the needs of children vis-a-vis those of nonelderly adults or the elderly.~5
Both the national and the state agencies and councils can make this point
directly and forcefully to many different audiences.
· Counterbalancing the weakness of children as a political force. Be-
cause children must depend on others for their care, the committee believes
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LEADERSHIP FOR DEVELOPING EMS-C
311
that society has a special responsibility to ensure that they receive appropri-
ate care. Unlike adults, children have no political voice to raise on their
own behalf in pursuing such care. Therefore, a voice must be raised for
them. This committee's report is one such voice, but to sustain it, espe-
cially at the state and local level, the committee believes that entities such
as those described above will be necessary.
Furthermore, advisory councils, in particular, are well suited to br~ng-
ing to the table groups in the private sector that may, for whatever reasons,
rarely if ever engage in productive discussions or negotiations about EMS
or EMS-C. That is, councils can be, in effect, a neutral arena in which the
various parts of the professional and health care delivery communities, the
business sector, labor, the voluntary associations, and others can usefully
exchange views and work toward mutually beneficial programs and ser-
vices. Solid achievements along the lines of the recommendations in this
report might have beneficial spillover effects for other knotty health policy
issues in those states and localities.
· Providing visibility for an important health need. The committee is
seeking to establish highly visible and prestigious focal points for address-
ing EMS-C issues quickly and aggressively. It believes that the entities
recommended in this chapter should be appointed by the Secretary of DHHS
and the state governors in order to invest them with sufficient stature and
influence to be able to bring to EMS-C issues the level of attention that they
require. In the majority of states, a gubernatorial body has ample precedent
to be a vehicle for serious policy deliberation and innovation; the same is
true of secretarial-level groups. They ought to be able, therefore, to bring
together the diverse groups that have important roles to play in EMS-C but
which would otherwise lack an established means of working together. They
would provide a channel for information and ideas to flow among a broad
range of groups.
· Strengthening partnerships across federal, state, and local levels of
government. These proposals at both the federal and state levels reflect the
committee's position that neither level alone can adequately address the full
range of issues that must receive attention. Some matters, such as develop-
ing nationally comparable data or broad guidelines for education and train-
ing, will benefit from the national perspective. Other matters, such as
provider certification requirements or medical control procedures, which
relate more directly to the delivery of care, are appropriately addressed at
the state (or perhaps local) level. Substantial areas of overlap exist between
national and state concerns for example, using federal funding to create
incentives for state action, collecting and analyzing data, or disseminating
the results of research and this factor should lead to coordination of ef-
forts between federal and state agencies or advisory councils or both.
The proposed structures might in many respects be a model for the sort
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EMERGENCY MEDICAL SERVICES FOR CHILDREN
of federal-state partnership that may prove increasingly desirable in health
policy in the future. Given the serious fiscal constraints of the federal
government and a majority of the states, future intergovernmental initiatives
in health policy are unlikely to be successful if they require substantial
amounts of new funding. Various recent federal mandates, including many
in health care and public health regulation, have generated requirements for
additional Bale spending with little or no federal funding support, leaving
states increasingly cynical toward new initiatives from Washington (Conlan,
1991; Zimmerman, 19911. As a result, any EMS-C policy strategies that
call for major new state expenditures or impose significant new federal
oversight are virtually certain to meet state and local government resis-
tance and face considerable implementation problems.
By contrast, the proposed federal center, plus state lead agencies, are
intended to stimulate rather than impose requirements for state actions.
This approach recognizes the extraordinary diversity in state capacity to
fund effective EMS-C programs as well as the tremendous interstate varia-
tion in the challenges that EMS-C providers face. Rather than attempt to
compress these different states and situations into a uniform national model
for EMS-C, the idea is to give new prominence and visibility to the issue at
both the national and state levels while permitting each state to explore its
own unique circumstances and opportunities for improvement.
In fact, a growing body of literature on intergovernmental relations
emphasizes the limitations of federal policy interventions that involve rigor-
ous federal "command and control" over state actions (Conlan, 1988; Anton,
1989~. More coercive interventions may be warranted in those situations
where a need for a uniform federal standard exists and its implementation is
feasible. Construction of interstate highways is a case in point, as are
eligibility standards for Social Security and Supplemental Security Income,
Medicare reimbursement practices, and standards for federal MCH block
grants. All of these programs, however, run a risk of fostering intergovern-
mental conflict and developing a preoccupation with procedural compliance
rather than creative problem-solving; more innovative partnerships may be
more desirable and more effective (Wilson, 1989; Osborne and Gaebler,
1992~.~6
In some ways, the committee proposals may be in the tradition of past
federal health policy efforts under the Hospital Survey and Construction Act
of 1946 (the Hill-Burton Act), which is seen as a unique model of intergov-
ernmental problem-solving and relative ease of implementation (Peterson et
al., 1986~. The primary purpose of the Hill-Burton Act was to fund hospital
construction and expansion, but it also provided each state with a small
amount of funding to develop planning groups that could examine state
hospital needs and develop statewide priorities for allocating subsequent
Hill-Burton dollars. This approach recognized the enormous interstate variation
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LEADERSHIP FOR DEVELOPING EMS-C
313
in hospital capacity and need, and it enabled each state to tailor plans with
minimal federal direction.
· Improving organizational efficiency. Yet another political argument
is one of efficiency in government. All states, whether in fiscal turmoil or
not, can benefit from streamlined, nonduplicative bureaucracies and agen-
c~e~s, less interagency conflict over tud, clearer policy directives and author-
ity, and better communication with and accountability to the public. The
committee's view is that appropriately constituted and supported agencies,
especially at the state level, can address jurisdictional problems and foster
more efficient planning, oversight, and operations of EMS and EMS-C pro-
grams, at least those parts of such programs that relate to the public sector
or are affected by governmental policies and funds.
· Improving economic efficiency and countering economic losses. An
economic argument can be made to the effect that promoting the delivery of
high quality emergency care to children can reduce both the direct and the
indirect costs associated with adverse outcomes from inadequate care. For
example, if an injured child receives no care or inadequate care, the years of
life and labor lost are much greater than what would be calculated for an
adult. Arguably, the psychic costs for the child and his or her family are
greater as well. Furthermore, additional direct economic costs may be in-
curred in rectifying the problems that timely and appropriate care could
have forestalled. Thus, these agencies and advisory councils can help en-
sure that services relating to prevention of injury and illness, disability
prevention, and rehabilitation for children are included in the state EMS
plan and are linked to more general planning for child health needs. More
broadly, they can work to guarantee that these and related emergency ser-
vices are universally available to all children residing in the state.
FINANCING CENTERS, AGENCIES,
AND RELATED ACTIVITIES
Proposing new programs and new organizational entities, no matter
how worthy, is irresponsible if not accompanied by some examination of
the cost implications. This is especially true when the programs and agen-
cies are in the public sector and when fiscal constraints on the public trea-
sury are as severe as they are in this nation today. It is: even more critical
when the mandates come from the federal level and the funding must be
found at the state, county, or municipal level.
This committee did not attempt to develop a thorough cost-benefit or
cost-effectiveness analysis of its recommendations doing so would have
been beyond its charge and, as discussed above, would not have been as full
as possible owing to the significant lack of appropriate, reliable, valid, or
generalizable cost data. The committee did, however, develop some rough
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EMERGENCY MEDICAL SERVICES FOR CHILDREN
estimates of levels offederal expenditures that would be needed to start and
sustain these efforts in the short run. It offers one specific funding recom-
mendation in this chapter, and returns to costs and benefits issues in the
final chapter.
The committee advocates congressional appropriations of new federal
monies for each of the ensuing five years for federal and federally sup:
ported activities related to emergency care for children. Part of this funding
would directly support federal center efforts; most of the funds would be
made available to support state agency programs (and perhaps, through the
states, some local activities).
Specifically, the committee recommends that Congress appropriate
$30 million each year for five years a total of $150 million over the
period- to support activities of the federal center and the state agencies
related to emergency medical services for children. The five-year time
frame is essentially arbitrary, and the committee has not made allowances
for inflation.
The total of $30 million per year might be allocated as follows, al-
though these figures are purely illustratively $1.5 million for direct opera-
tion of the federal center in DHHS (including staff costs, travel for advisory
council members and staff, and similar expenditures); $1 million for data
collection, analysis, and minimum data set activities, and $1.5 million for
technical assistance and clearinghouse tasks. An additional $2.5 million
might be allocated for research, which the committee explicitly assumes
will be awarded for extramural research; the committee takes no stance,
however, on whether the national advisory council should have review and
approval authority over such contracts or grants.
The remaining $23.5 million (that is, about three-quarters of the total
annual appropriation) might be allocated to the 54 "states" on the basis of a
two-part formula one part representing fixed costs and the other represent-
ing variable amounts based on population. The latter, for instance, might be
a function of the absolute number of children in the state (e.g., persons age
O to 17 years) or a function of children as a proportion of the entire state
population. Thus, for each entity, an annual grant of $250,000 for fixed
operational costs might be supplemented with population-based grants from
$50,000 to $500,000 per year. States and localities (e.g., counties, metro-
politan areas), as well as organizations in the private sector, would be eli-
gible to apply for federal funds for research, technical assistance, clearing-
house activities, and similar functions financed directly through the national
center. State agencies could establish policies for making some portion of
their own federal dollars available to local communities or in-state private
sector entities (in addition to whatever state funds such agencies might have
at their command for these purposes).
This committee cautions that the recommended level of support is the
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LEADERSHIP FOR DEVELOPING EMS-C
315
absolute minimum for development of an effective program. A token, underfunded
EMS-C program cannot discharge its responsibilities satisfactorily. Such an
effort may thus waste the resources that are provided, lead to a false sense
of security about the state of EMS for children today and tomorrow, and be
unable to demonstrate any meaningful effect on the planning and delivery
of emergency care for children.
Barr- to this two-part, five-~ar strategy might be considered.
For example, the EMS-C demonstration program in HRSA might be ex-
panded. The committee welcomes the FY 1993-97 reauthorization as an
interim, maintenance-of-effort step, but the panel also regards it, for long-
term progress, as too awkward and indirect an approach. First, a federal
grant program cannot easily accomplish many of the goals the committee
wishes to see accomplished now at the federal government level. Second,
continued reliance on simply a demonstration program (and one that is
sparsely funded at that) risks undercutting the visibility the committee wishes
to bring to the need to improve EMS-C throughout this country and delay-
ing needed progress at all governmental levels.
This committee clearly envisions a major expansion of EMS-C activi-
ties in both the private and public sectors as a consequence of its full set of
recommendations for education, communication, data, research, and the like.
A significant number of such programs would involve start-up efforts, and
many of these will be in states and locales facing drastic budget problems
of their own. The committee does not view a sixfold increase in existing
funding, under these circumstances, as inappropriate for giving the entire
program the visibility and influence it needs from the outset.
In its financing recommendations, the committee has specified a target
amount for the sake of concreteness and face validity. It recognizes, how-
ever, that detailed point estimates can be convenient targets for critics and
budget-cutters. Moreover, implementation can be a rocky road, and some
details and desirable (or not so desirable) aspects of this effort will emerge
only as the program progresses. Thus, it concedes that the recommended
dollar figures above might well be revised, either upward or downward,
over the proposed five-year funding period. Part of the reason for advising
that the federal center develop annual, public reports is to enforce account-
ability for monies expended, to provide ammunition to counter critics, and
to make the case, where it can be made, for increased levels of funding in
the future.
The committee also acknowledges that its recommendations may seem
costly in the face of stringent budget constraints at the federal and state
levels and the need for "pay-as-you-go" legislation at the federal level (pur-
suant to the Deficit Reduction Act of 1990 [Omnibus Budget Reconciliation
Act of 1990, P.L. 101-50831. It rejects, however, the notion that in absolute
terms this level of spending is excessive to address the myriad needs of a
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Representative terms from entire chapter:
emergency care
316
EMERGENCY MEDICAL SERVICES FOR CHILDREN
broad-based-program to expand and integrate EMS-C into a more compre-
hensive EMS program for the country and to promote stronger~links' with
broader child health concerns.
~,su~M~y
To focus attention on efforts to ~mprove-EMS--C, the committee set
forth in this chapter t.wo-pairs of recommendations regarding the establ'ish-
ment of EMS-C entities at the federal and state levels (see Box 8-1~. Spe-
cifically, the committee recommends: (1) that the U.S. Congress direct the
Secretary of DHHS establish. a federal center or office, together with a
national advisory council, to identify national concerns in EMS-C and.to
coordinate federal efforts in this area, and (2) that the. states establish lead
agencies, as well as related advisory councils,^.
LEADERSHIP FOR DEVELOPING EMS-C
317
councils), efforts to ensure that children's emergency care needs are met
will, at last, receive adequate attention.
NOTES
1. As discussed in Chapter 7, ICD-9-CM E-codes refer to the set of "external cause-of-
injury" codes that supplements the standard diagnostic codes of the International Classification
of Diseases, ninth edition, clinical modification.
2. The Department of Defense (DOD) has been responsible for much research into acute
emergency care and historically has trained many medics, corpsmen, and similar personnel.
This training' is not identical to civilian EMS training, but it may well meet paramedic certifi-
cation and licensing requirements in various states. Although DOD provides medical care,
including emergency care, to children of service personnel, its principal focus in research and
training is on care of active-duty personnel, particularly for combat casualties. The health care
system of the ' Department of Veterans Affairs also delivers some EMS care but obviously does
little if anything in' the pediatric 'EMS arena.
3. The committee considered at appreciable length various alternatives to the creation of a
federal center or office for EMS-C. These included continuation of the demonstration grant
program-essentially a status quo stance not favored by the committee or likely to be an
acceptable option to key interested parties, such as those in Congress. Also debated at great
length was creation of a federal or secretarial '`Task Force," which would fall quite short of a
new center or office. This was rejected as insufficient to the tasks and responsibilities outlined
318
EMERGENCY MEDICAL SERVICES FOR CHILDREN
in this chapter for the proposed center, as likely to have many administrative and political
drawbacks, and as likely to delay more effective federal action.
4. For purposes of the discussion Clout a federal center and state agencies, the committee
assumes a total of 54 "state" entities namely, the 50 existing states, t7~;~ District of Columbia,
Puerto Rico, the Virgin Islands, and a combined area of American Samoa, Guam, and the
Commonwealth of the Marianas. It uses the term "state" for simplicity of presentation.
5. A -report toy the congressional Office of Technology Assessment (OTA, 1989) on needs
in rural EMS identified five areas where federal leadership was needed: promoting training of
providers; facilitating the development of national guidelines; providing technical assistance to
states; supporting research; and providing incentives for state planning. The committee re-
gards these areas as equally appropriate for EMS-C; many relate directly to the policy and
program needs examined in Chapters 4 through 7. The committee's proposals also address
other concerns: supporting national data collection and analysis, with attention to a uniform
data set, conducting research, and disseminating research findings are cases in point.
6. In addition to elderly adults, Medicare regulations apply to children with end-stage renal
disease (IOM, 1991c).
7. With respect to funding EMS-C efforts, the committee takes no stance concerning formal
block or formula grant specifications enacted into law. It notes several problems with that
approach, however. First, if the legislation is not crystal clear, the process of developing
implementing regulations (which would require approval by the Office of Management and
Budget) or even formal guidance could be difficult and drawn out. Second, it is not a given
that such statutory language, regulations, or guidance could be made sufficiently flexible that
the EMS-C office could respond adequately to the quite varied circumstances of pediatric
emergency care across the states. That factor could thus inhibit the agency's ability to foster
the variety of different programs and activities that might be desirable in these locales.
8. Weissert (1992) examines the potential (and now real) effects of federal (chiefly con-
gressional) mandates to states in the absence of federal resources adequate to meet those
mandates. This committee is sensitive to the fiscal problems now facing many states, particu-
larly those in financial distress and those needing to upgrade their Medicaid programs substan-
tially. It therefore calls for federally mandated requirements on the states in the area of EMS
and EMS-C to be issued only when they can be accompanied by appropriate levels of federal
support.
9. Various models of a federal EMS-C center could be considered. The most direct is one
that operates as a government agency and is located, bureaucratically, within an existing
agency; the committee recommends this option, chiefly for its appeal in coordinating disparate
federal efforts and the clear accountability that can be maintained for the disbursement and use
of federal monies. A variant is to site the agency somewhere outside the government itself, as
in a university setting. Another option might parallel the "national laboratory" model, where
the government establishes and owns the facilities but contracts with an entity in the private
sector to run it; in this instance, the government can exercise a fair amount of control depend-
ing upon how stringently the contracts are written and enforced. A third possibility is the grant
model, in which an existing agency might simply award a long-term grant to a private sector
group such as a university; here the authority of the government to direct activities will be
weaker than through a contract mechanism.
10. The authority for making grants and contracts to the states (for "development of more
effective education, training, research, prevention, diversion, treatment, and rehabilitation pro-
grams in the area of juvenile delinquency and programs to improve the juvenile justice sys-
tem") is spelled out in considerable detail in amendments to the original legislation for the
OJJDP (U.S. House of Representatives, 1990, p. 10). Of interest, for example, is that funds are
allocated annually among states on the basis of population under 18 years of age, minimum
amounts for every state, and requirements for three-year state plans and annual performance
reports.
LEADERSHIP FOR DEVELOPING EMS-C
319
11. The committee is cognizant of the fact that federal advisory groups might be constructed
under several different rubrics and in several different ways. For instance, it might be called a
task force, a secretarial work group, a federal coordinating committee, or a national advisory
council (as this committee has done), or any number of other designations. In federal adminis-
trative terms, these have different connotations and, in theory at least, different memberships
and levels of authority. Some may have private sector voting members and federal govern-
ment nonvoting members, again as this committee has proposed. Others may be only inters
agency task forces with advisors and consultants from the private sector; yet others may be
constructed so as to involve both the public and private sectors in equivalently responsible
roles. Furthermore, some arrangements may be only advisory, with no implementation author-
ity or public accountability; others may have more far-reaching powers, such as the responsi-
bility to approve research grants above a certain dollar level.
12. For the discussion of lead EMS-C agencies at the state level, "state agency" refers
specifically to the recommended "lead agency" in each state's executive branch; to avoid
confusion, other elements of state government are designated as departments, offices, units, or
by some other rubric.
13. Significant impediments to progress toward computer-based patient records are often
encountered at the state level, through archaic requirements for maintaining paper records,
having physician signatures in ink, and similar conditions (IOM, 1991a). Obviously, expecting
a state EMS-C agency to take the lead in overcoming such obstacles is not realistic, but such
an agency can support appropriate change in state statutes and regulations that would permit
inpatient and outpatient settings and offices to move more expeditiously toward computerized
systems. it might be able to take an even more daring position concerning computer-based
record keeping for prehospital providers. Assistance might be available from the Computer-
based Patient Record Institute, established at the recommendation of an IOM committee (IOM,
1991a), which as of 1993 was temporarily housed in the Chicago offices of the American
Health Information Management Association.
14. Although attention to children has increased in some communities, EMS systems, and
training programs, pediatric concerns remain a low priority for others. East Tennessee Children's
Hospital, for example, resorted to suing the state of Tennessee to get children included in the
state trauma plan. More recently, early drafts of the National Trauma Plan mandated by the
Trauma Care Systems Planning and Development Act of 1990 (P.L. 101-590) omitted refer-
ence to existing pediatric standards and the specific needs of children despite explicit legisla-
tive language requiring their consideration; following public and professional review and com-
ment, later drafts corrected the oversight.
15. In other health policy spheres, the argument that the pendulum must swing back toward
children is already having some impact. Recently, general expansion of Medicaid programs
through the Omnibus Budget Reconciliation Acts of 1989 and 1990 (P.L. 101-239 and P.L.
101-508, respectively) has been targeted at women and children. For example, these statutes
have mandated complete state coverage of pregnant women and children up to 6 years of age
who are in families with incomes below 133 percent of the federal poverty level, with subse-
quent coverage phased in, one year at a time, for all children through 18 years of age with
family incomes less than 100 percent of poverty (Lee, 1992; Weissert, 1992). Some health
care reform proposals appear to be predicated on the need to address access problems that
affect disadvantaged populations, which clearly include intolerably high numbers of children
(NRC/TOM, 1992a).
16. Several IOM reports touch on these questions of federal-state-local relationships. The
landmark report, The Future of Public Health (IOM, 1988), delineated coordinated levels of
responsibility for public health activities at the federal, state, and local levels namely, "as-
sessment, policy development, and assurance" (pp. 7-8); it went on to specify functions and
responsibilities unique to communities, states, and the federal government in some detail. The
mission of public health introduced in that report- "fulfilling society's interest in assuring
320
EMERGEN'C'Y 'MEDICAL SERVICES FOR CHILDREN
conditions in which people can be healthy" (p. 7) is' vie with which the present committee's
'focus on EMS-C is quite congruent. This consistency with the earlier, broader report lends
additional credibility to the committee's recommendations that there be leadership from the
federal government but considerable operational action by states and localities:
A more recent monograph on prevention of disability (IOM, l991b) makes the point that
meeting~the challenges of disability and prevention calls for federal, state, and local responsi-
bility: "GQ~ernmen~t involvement at all three levels is a necessary condition for progress" (p.
2613. Tt calls on the federal level "to provide leadership, financial support and technical
resources totstates~ and localities" (p. 262) and for states and communities to act "on their own"
as well.' This'report goes on to argue that "input and contributions from the private sector" (p.
263), such as businesses and other private organizations and associations, also will be neces-
sary, further''underscoring the need for effective links to be forged between the public and
private sectors in addition to those developed across all levels of government.
Even a program 'such as Medicare can gain from approaches that extend beyond simple
federal administration. In a detailed examination of approaches for ensuring the quality of
health care delivered to the elderly (IOM, 1990b), yet another IOM 'committee laid out a
strategy that involved considerable collaboration between a federal agency (HCFA), state-
based (but private) Peer Review Organizations, and''iocal'provider organizations (hospitals',
physician offices, health maintenance organizations, and the like).
17. For comparison purposes, the following figures for the main (non-Medicaid) federal
program for children might be considered. For the RICH block grant program to the states,
which is administered by MCHB/HRSA, approximately $547 million was available in FY 1992
for direct block grants, approximately $96 million for SPRAINS grants (Special Playacts of
Regional and National Significance), and about $11 million for program operations at the
federal and regional office level, for a total of about $654 million. Operations thus constitute
about 1'.7 percent of the total. The proposed level of funding for EMS-C (i.e., $30 million
annually), much of which would 'tee a pass-throu'~h to states or would support special projects
and activities, represents the equivalent of about 4.6 percent of the MCH block grant effort.
Figures from the HRSA EMS-C demonstration grant program also provide a useful context.
For example, start-up funds for the initial four projects were approximately $500,000 each ($2
million annually in the early years of the program); more recently, annual aIl'ocations for two
resource centers totaled approximately $650,000. Appropriations in FY 1'99;1 were $5 million
for about 22 different projects. In Octobe'r 1992, the EMS-C~program was reauthorized until
1997 (P.L. 102-410) "for such sums as may be necessary' for each of the fiscal years 1993
through 1997"; funding had been $5 million ' for each of FY 1991 and 1992. This bridging
authorization is basically a means of ensuring some continuity in the EMS-C effort until action
can be taken on the IOM committee's recommendations.
