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OCR for page 66
Emergency Medical Services Systems
Origins and Operations
, ~
Efforts to ensure that children will receive good emergency care are a
recent development of the relatively young field of emergency medical ser-
vices (EMS). In the 1960s, emergency care in most communities and hospi-
tals was little more than first aid. Since then, efforts have been made to
achieve better outcomes by organizing services so that increasingly com-
plex care can be made available to patients as promptly as possible. A1-
though much work remains to be done in many areas to determine optimal
forms of emergency care, studies have demonstrated benefits from enhance-
ment of EMS systems. Trauma systems, for example, have been able to
improve survival (e.g., West et al., 1979; Shackford et al., 1986~. Until
recently, attention has focused primarily on adult patients. Promising re-
sults in recent studies of children argue for ensuring that EMS systems
attend to the needs of their pediatric patients as well (e.g., Pollack et al.,
l991;Cooperetal.,19931.
This chapter reviews the history of EMS systems and traces the emer-
gence of efforts on behalf of children. It also describes the diversity of
administrative and operational structures under which EMS systems func-
tion and through which the changes needed to incorporate services for chil-
dren (i.e., EMS-C) will be made. Some of the factors that have made it
difficult to address children's needs are discussed, as are some of the suc-
cesses to date.
66
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EMS SYSTEMS: ORIGINS AND OPERATIONS
DEVELOPMENT OF EMS AND EMS SYSTEMS
The 1960s and Earlier
67
Until the 1960s, emergency medical care had received little attention in
most communities or from health care providers. Care at the scene of an
emergency was based largely -on first aids and emergency departments (EDs)
at many hospitals could themselves do little for the severely ill or injured.)
Recognizing a Need
In the United States, EMS first became the focus of widespread and
continuing attention following publication in 1966 of the landmark report of
the National Academy of Sciences (NAS) and National Research Council
(NRC), Accidental Death and Disability: The Neglected Disease of Modern
Society (NAS/NRC, 1970a). Pointing to trauma, especially motor vehicle
crashes on highways, as the leading cause of prolonged disability and as the
fourth major cause of death in the United States, the report raised consider-
able concern among policymakers, health professionals, and the public be-
cause of the limitations and deficiencies it documented in the EMS systems
of the day.
At the time the NAS/NRC report was issued, neither prehospital nor
hospital services were adequate for emergency medical care. Although a
few communities provided ambulance services through their fire or police
departments, the report estimated that morticians provided about 50 percent
of such services. This rather pessimistic approach to prehospital care arose,
in large measure, because hearses were the only available vehicles that
could accommodate stretchers. No specific training was required for ambu-
lance attendants and many had very little. Most EDs appeared able to offer
only advanced first aid (NAS/NRC, 1970a). Only a few hospitals had the
staffing, equipment, and facilities needed to provide complete care for the
seriously injured or ill. Although the 1966 report focused on the needs of
trauma victims, many of the concerns and recommendations applied to emer-
gency care for illness as well.
Work in two areas set the stage for a strong response to the NAS/NRC
report. First, surgeons with military experience in Korea and Vietnam rec-
ognized that trauma care available to wounded soldiers was substantially
better than the care available to civilians (Boyd, 1983~. The need for rapid
response to serious injury had long been recognized on the battlefield, and
the medical services of the U.S. military had developed increasingly sophis-
ticated systems of triage, transport, and field hospital care for casualties
(NAS/NRC, 1970a). Important aspects of that experience were directly
applicable to the civilian setting. In particular, the growing interstate high
OCR for page 68
68
EMERGENCY MEDICAL SERVICES FOR CHILDREN
way system was contributing to increased risk of serious injury in high-
speed motor vehicle crashes in locations that might be distant from major
medical facilities. Active concern over safety deficiencies in motor vehicle
design was developing as well (National Committee for Injury Prevention
and Control, 1989~.
The second development was the- demonstration by physicians ire Iran
land that rapid treatment of cardiac emergencies could improve survival
(Partridge and Geddes, 1967~. Mobile intensive care units were developed
to bring care to patients more rapidly than they could reach the hospital
(Nagel et al., 1970; Lewis et al., 1972~. In Europe these units were staffed
by physicians, but in the United States this care was delegated to public
safety personnel already available in community fire departments. This
choice led to the development of specially trained personnel paramedics-
to provide this prehospital care.
This period generally was one of broad and growing interest in health
planning on a national level. Health planning, which included the notion of
regionalizing services, was seen as a way to distribute resources more equi-
tably and to expand access to the country's health care system (IOM, 1980a).2
EMS also was being influenced by increasing use of hospital EDs for nonurgent
care more than two-thirds of 40 million ED visits in 1966 (NAS/NRC,
1970a). With fewer primary care providers making house calls or keeping
extended hours, changes in the character of medical practice were contribut-
ing to the growing reliance on hospital EDs.
Initial Responses
The NAS/NRC report (1970a) put forward a broad range of recommen-
dations for actions by federal, state, and local governments and by the
medical community to improve emergency medical care. (The full text of
the recommendations from that report appears in Appendix 3A at the con-
clusion of this chapter.) Major points included the following:
· increase attention to accident prevention;
· expand public education in first aid;
· adopt standards and regulations for ambulance services and for rou-
tine use of radio and other means of communication between ambulances
and EDs;
consider a single national emergency access number;
assess the numbers and kinds of EDs needed for optimal care;
· implement routine evaluation of ED capabilities;
· develop trauma registries; and
· initiate clinical and health services studies on trauma and other
peels of emergency medical care.
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EMS SYSTEMS: ORIGINS AND OPERATIONS
69
The attention focused on highway fatalities led to federal action first
through highway safety legislation the Highway Safety Act of 1966 (Pub-
lic Law tP.L.] 89-564) which created the National Highway Traffic Safety
Administration (NHTSA) in the U.S. Department of Transportation (DOT).
Initial work on guidelines and curricula for training ambulance personnel
and guidelines [~r ambulance equipment was followed by broader activities
in EMS planning, training and personnel, communications, and transporta-
tion (NHTSA, 1990a). The agency's research and grant programs helped
states develop the EMS component of federally mandated highway safety
programs. The activities of the U.S. Department of Health, Education, and
Welfare (DHEW), through the Division of Emergency Health Services, were
limited at this time.
Subsequent NAS/NRC (1968, 1970b,c) reports on ambulance services
addressed training standards for ambulance personnel, identified specific
roles and responsibilities in providing care for patients, and specified medi-
cal requirements for ambulance design and for the equipment to be used by
ambulance personnel. Requirements for pediatric care received some atten-
tion in these early reports. For example, training and equipment require-
ments for airway management, ventilation, and oxygenation specifically men-
tioned the need to have masks and airway devices in sizes appropriate for
infants and children as well as adults (NAS/NRC 1968, 1970c). Although
proposals for hospital-based clinical training called for experience in ob-
stetrics, the nursery, and pediatrics, the detailed specifications included only
delivery, postdelivery care, and care of newborns (NAS/NRC, 1970b).
Drawing on the new developments and recommendations, individual
communities across the country began to enhance their capabilities for emergency
care through greater attention to resources, training, and coordination of
services, particularly for treating cardiac cases. The medical community
undertook activities of its own in response to the nation's concern over
emergency medical care. Training programs for emergency medical techni-
cians (EMTs) and paramedics were begun. An NAS/NRC conference pro-
duced recommendations that medical professionals and allied health staff be
trained in cardiopulmonary resuscitation (CPR) (Ad Hoc Committee on Car-
diopulmonary Resuscitation, 1966~.
Increasingly sophisticated hospital services became available. Special-
ized trauma units were established in hospitals in Chicago and Baltimore.
Advancing critical care skills and technology were reflected in the first
dedicated neonatal and pediatric intensive care units (NICUs and PICUs)
(Downes, 1992~. Regionally organized programs of neonatal intensive care,
which made use of specially equipped ambulances and hospital transport
teams, improved access to specialty services and succeeded in reducing
neonatal mortality. Similar programs for older children have been slow to
develop.
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70
EMERGENCY MEDICAL SERVICES FOR CHILDREN
New professional organizations created during the 1960s demonstrated
a growing sense of provider awareness of and identification with emergency
medical care (NAS/NRC, 1972~. Among them were the American College
of Emergency Physicians (ACEP), the Commission on Emergency Medical
Services of the American Medical Association, the American Trauma Soci-
ety. the Emergency Nurses Association (ENA), and the Matinal Association
of Emergency Medical Technicians (N'AE'MT). C)ther groups that 'had al-
ready existed, such as the Committee on Trauma of the American College of
Surgeons (ACS) and the American Academy of Orthopaedic Surgeons (AAOS),
became more active.
Other Activities
important work in injury prevention had begun well before attention
was drawn to EMS. Traffic safety became a concern as early as the 1920s.
Risks to children received attention in the early 1950s with the "anticipa-
tory guidance" that the American Academy of Pediatrics (AAP) urged phy-
sicians to give to parents about specific hazards (National Committee for
Injury Prevention and Control, 1989~. The first poison control centers also
were established in the 1950s. Federally funded demonstration projects in
the 1960s encouraged state and local public health programs to address a
variety of injury hazards in the home (National Committee for Injury Pre-
vention and Control, 19891. As EMS systems began to develop, they saw
prevention as an important aspect of their activities. NHTSA's prominent
role in early EMS development encouraged particular attention to injuries
related to motor vehicles.
The 1970s
EMS in General
Public support for EMS activities grew as people became more aware
of the potential benefits. The television program Emergency, which began
in 1971, contributed in a noticeable way to this growing awareness of EMS.
As interest and activities in EMS grew, strong recommendations were being
made for the highest levels of the executive branch of the federal govern-
ment to lead nationwide efforts to improve the delivery of emergency ser-
vices. The ACS and the AAOS addressed this issue in the proceedings of a
joint conference, Emergency Medical Services. Recommendations for an
Approach to an Urgent National Problem (ACS/AAOS, 19691. The NAS/
NRC (1972) made a similar recommendation in its report, Roles and Re-
sources of Federal Agencies in Support of Comprehensive Emergency Medi-
cal Services. The report went on to recommend assigning to DHEW the
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EMS SYSTEMS: ORIGINS AND OPERATIONS
71
administrative leadership role in federal-level EMS activities. (More than
20 agencies located across six cabinet-level departments had activities re-
lated to EMS.)
The NAS/NRC report also recognized the need for effective planning at
state, regional, and local levels to ensure the coordination of prehospital
and hospital phases of emergency medical care. This "systems approach"
was ~ [ur~damental aspect of a new federal program authorized by the Emer-
gency Medical Services Systems (EMSS) Act of 1973 (P.L. 93-1544.
The EMS S Act created a new categorical grant program in the Division
of Emergency Medical Services of DHEW.
. . .
This program became a deci-
s~ve rector In the nationwide development of regional EMS systems. Under
the new law, states established a total of about 300 EMS regions, most
covering several counties, which were eligible for up to five years of fund-
ing to develop EMS systems. About $30 million was available each year
Rural areas were targeted for specific
attention (OTA, 1989) as were certain patient populations (major trauma,
for regional grants (Boyd, 1983~.
. it. ~ ~ ~ ~
. . . . . .
burn injuries, spinal cord injuries, heart attacks and other acute coronary
events, poisonings, high-risk infants and mothers, and behavioral and psy-
chiatric emergencies) (Boyd, 1983~.
The expectation was that systems de
veloped to care for these patients would serve as models for care of other
categories of patients such as children.
The EMSS Act was intended specifically to promote the development
of regional systems built around 15 key components (see Table 3-1~: health
personnel, training, communications, transportation, medical facilities, spe-
cialized critical care units, other public safety personnel and equipment,
public participation in policymaking, access to service regardless of ability
to pay, transfer agreements, standardized record keeping, public education,
evaluation, disaster planning, and links to adjacent EMS systems (Boyd,
1983~. Although the grant program ended in 1981, these components con-
tinued to guide development and evaluation of EMS systems.
The emphasis in the EMSS Act on regional planning was consistent
with other federal programs. The 1974 National Health Planning and De-
velopment Act (P.L. 93-641) created and supported through federal monies
a two-tiered network of health planning agencies: 200 area-level agencies,
or Health Systems Agencies, and 57 State Health Planning and Develoo-
ment Agencies (IOM, 1980a).
This legislation called for each agency to
complete a health systems plan outlining long-range goals for the commu-
nity, mandated technical assistance centers, and emphasized creation of a
comprehensive database for health planning. Guidelines for national health
planning policy that were developed under this program included (among
11 different types of services) provisions related to neonatal special care
units and pediatric inpatient services (IOM, 1980a, Appendix B); emer-
gency services were not among those covered.
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72
EMERGENCY MEDICAL SERVICES FOR CHILDREN
TABLE 3-1 Essential Components of Emergency Medical Services
Systems, as Specified by the Emergency Medical Services Systems Act of
1973 (P.L. 93-154)
Personnel: adequate numbers of health professionals, allied health professionals, and other
personnel with appropriate training and experience
Training. adequate training and. continuing education opportunities for personnel. in. all
aspects of the EMS system
Communications: a centralized system to receive requests for assistance (ultimately through
9-1-1) and provide direct communication links among personnel and facilities throughout
the system and with other EMS systems
Transportation: adequate numbers of vehicles (ground, air, or water) appropriate for the
region, which meet standards for design, performance, and equipment and whose operators
have necessary training and experience
Medical facilities: adequate numbers of accessible emergency care facilities collectively
providing continuous services, with appropriate categorization of capabilities and
coordination with other system facilities
Critical care units: access (including transportation) to facilities with critical care services
within a local EMS system or to such facilities in neighboring areas
Public safety agencies: coordination and cooperation with public safety agencies (e.g.,
police, fire, lifeguards, park services) in use of personnel, facilities, and equipment
Consumer participation: opportunities for participation by the lay public in system policy-
making
Accessibility to care: access to services of the EMS system without regard to ability to pay
for those services
Transfer of patients: triage and transfer arrangements to ensure patient access to an
appropriate level of care
Coordinated patient record keeping: patient record systems that are consistent across
phases of care in key data elements and that allow a patient's care to be tracked across
those phases of care
Public information and education: programs to inform the public about how to use the
EMS system, about first aid and other interim care, and about the availability of training
programs
Review and evaluation: periodic, comprehensive reviews of the extent and quality of
services provided by an EMS system, with the results reported to DHEW
Disaster linkage: system plans for responding, with other local, regional, or state agencies
as necessary, to natural disasters, national emergencies, or other mass casualty events
Mutual aid: reciprocal agreements with neighboring EMS systems or other related agencies
to respond to an emergency in the neighboring system when that system cannot respond as
effectively
SOURCE: Boyd (1983).
Other federal efforts also were contributing to EMS development. NHTSA
worked through highway safety programs to help states improve the prehospital
components of their EMS systems and was overseeing the development of
standard curricula for varying levels of EMT training. Recommendations
from many sources for a national emergency telephone number led, in 1973,
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EMS SYSTEMS: ORIGINS AND OPERATIONS
73
to a policy statement by the White House Office of Telecommunications
Policy encouraging local authorities to establish 9-1-1 systems (Whitehead,
1973~. The statement emphasized the need for such systems to operate at
the local level so that they could respond to meet local needs and circum
stances.
In this same period? the Robert Wood Johnson (RWJ) Four~-dation. in
consultation with the NAS, committed $15 million to 44 regional EMS
projects (NAS/NRC, 1978b). The program improved availability of and
access to emergency services, improved links between system components,
upgraded communications and training, and developed community institu-
tions and resources for continuing support of EMS. It demonstrated that the
various players in emergency care-including health professionals, local
and regional governments, and concerned private organizations-could co-
operate effectively (NAS/NRC, 1978b). Efforts to further the adoption of
9-1-1 access systems were successful in nearly half of the projects. More
successful were efforts to reduce the variety of different emergency access
telephone numbers in use in a system and to identify a primary number for
EMS calls.
Through both the federal and foundation programs, as well as local
efforts, the level, type, and organization of emergency services were all
substantially improved. A steady proliferation of EMS systems was accom-
panied by establishment of state EMS offices and local EMS councils, widespread
state-level legislation setting standards for emergency vehicles and person-
nel, a large (more than 115,000) and growing number of EMTs, and im-
proved training and staffing for emergency departments (NAS/NRC, 1978a).
Also during this period, air transport services (via helicopter or airplane)
specifically for medical purposes began to develop (Freilich and Spiegel,
1990~.
Progress was not universal or uniform, however, and important issues
required further attention. In particular, efforts to develop regional systems
were hampered by several difficulties: deciding what constitutes an EMS
region, resolving who should determine its size and configuration, and de-
termining how to assess the success of regionalization. A narrow focus on
individual system components specified in the 1973 EMSS Act obscured the
need for broader planning based on the functional requirements of EMS
systems; it also limited the attention given to avoiding or resolving conflicts
arising from competing interests among system components (e.g., emer-
gency department resistance to categorization). System evaluation relied on
compliance with structural and process standards without addressing out-
come or cost-effectiveness. (Even today, outcome and cost assessments are
limited, especially for services other than adult cardiac and trauma care.)
Inadequate attention to long-term plans for operational funding left some
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74
EMERGENCY MEDICAL SERVICES FOR CHILDREN
systems with financing difficulties once their federal or RWJ grants had
expired.
EMS system development was also affected by the problems facing
hospital EDs. Although EDs are a critical component of successful EMS
operations, they had benefited less than prehospital services from the EMS
systems funding made available to communities (~ASJ~RC, l9SO). EDs
suffered then (and do today) the dual burdens of relative neglect and soar-
ing patient loads (both urgent and nonurgent cases). The ability of EDs to
treat acutely ill or injured patients was hampered by insufficient staffing,
limited availability of adequately trained staff, inadequate equipment, and a
lack of influence in hospital management (NAS/NRC, 1980~. Expanding
EMS systems with increasingly visible prehospital services contributed to
the pressures on EDs by raising public awareness of emergency care and
expectations for prompt treatment by highly skilled providers.
Despite slowness on the part of hospitals to devote adequate attention
and resources to their EDs, the field of emergency medicine was continuing
to develop. As early as 1974, the ACEP issued a policy statement on EMS
system needs, "Emergency Medical Services: Problems, Programs and Policies"
(ACEP, 19763. In 1976, the ACS adopted guidelines on hospital trauma
care requirements (ACS, 1990~. Cardiac resuscitation skills were spreading
through courses such as the American Heart Association's (AMA) Advanced
Cardiac Life Support (ACLS) course, which became available in 1975. The
first residency program in emergency medicine was started at the University
of Cincinnati in 1970; by 1980, programs were available across the country
(Seidel and Henderson, 1991~. Most, however, devoted relatively little time
to pediatric emergency care compared to the volume of pediatric patients
seen in the emergency room.
Children and EMS
Although the EMSS Act was encouraging the development of EMS
systems, children were not a target population, and only limited expertise in
pediatric emergency medicine existed in 1973 (Foltin and Fuchs, 1991~.
Members of the pediatric community began to recognize, however, that the
progress in trauma and cardiac care to meet the needs of the adult popula-
tion was not preparing EMS systems to care for children.
Children's emergencies are more likely than adults' to arise from respi-
ratory distress or seizures; their physiologic baselines and responses to ill-
ness and injury do not match adult patterns; important anatomic features are
different; and characteristic psychological and developmental responses not
only differ from adults' responses but differ among children of different
ages. (Chapter 2 discusses these differences more fully.)
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EMS SYSTEMS: ORIGINS AND OPERATIONS
75
Failure to differentiate between the needs of adult and pediatric emer-
gency patients was linked to poorer medical outcomes for pediatric patients
(Seidel et al., 1984; Seidel, 1986a,b). One study of 88 general acute care
hospitals in Los Angeles County, for example, found nearly twice as many
deaths among children with serious traumatic injuries (caused chiefly by
motor vehicles and guns) than among adults with similar injuries: 12 per-
cent versus 7 percent (Strudel et al., 1984~. Most of these deaths occurred in
areas lacking pediatric tertiary care centers.
By the mid-1970s, efforts were beginning on a variety of fronts to
incorporate pediatric needs into emergency medicine and EMS systems.3
Dedicated pediatric EDs with full-time coverage by pediatricians were be-
coming more widespread. Most major pediatric centers established PICUs.
The original programs, plus ones in Washington, D.C., Dallas, Baltimore,
and Boston, made especially significant contributions to the growth of this
field through their training of physicians and their research activities (Downes,
19924. In 1979, the AHA adopted standards for pediatric basic life support
and guidelines for neonatal resuscitation (National Conference on Cardio-
pulmonary Resuscitation and Emergency Cardiac Care, 1980~. In contrast
to the emphasis on trauma in adult emergency care, the developing services
for children gave considerable attention from the beginning to both illness
. .
ant injury.
Los Angeles was among the first areas to address guidelines for prehospital
care of pediatric patients. Concerned pediatricians working with local pro-
fessional societies and the county EMS agency developed a pediatric-fo-
cused training curriculum for paramedics and management guidelines for
pediatric prehospital care (Seidel, 1986b). Over the ensuing years, their
work led to the implementation of a two-tiered approach for organizing
EMS-C (Henderson, 1988; Seidel, 19899. At one level were Emergency
Departments Approved for Pediatrics (EDAPs), which had to meet a mini-
mum set of standards for the care of critically ill and injured children and
could provide basic emergency services. More specialized care would be
provided in Pediatric Critical Care Centers (PCCCs), which could offer
such services as PICUs and access to a broad set of medical and surgical
specialists with expertise in pediatric care.
Pediatric surgeons took the lead in focusing attention on specialized
trauma care for children. In 1975, Maryland established a statewide re-
gional pediatric trauma center, one of the first in the country (Hailer et al.,
1983~. This service operated through the Maryland Institute for Emergency
Medical Services Systems, a well-known model for a fully integrated EMS
and trauma system (Foltin and Fuchs, 1991~. Still, in the vast majority of
regions developing EMS systems, the special emergency care needs of chil-
dren remained unrecognized through the 1970s.
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76
The Federal Role in EMS
EMERGENCY MEDICAL SERVICES FOR CHILDREN
The 1980s to the Present
A Change in Focus In 1981, Congress passed legislation that funda-
mentally changed the philosophy of federal support for state EMS activities
and the manner in which states received federal funds. The focus of the
EMS S Act on regional planning and systems development reflected the
character of an era in which health planning agencies were expected to be
the agents of an efficient and effective allocation of health resources. The
federal government was to help direct and fund those efforts as part of its
responsibility to further broad social goals, in this particular case the im-
provement of EMS systems and emergency medical care.
Under the Omnibus Budget Reconciliation Act (OBRA) of 1981 (P.L.
97-35), the "categorical" funds that had been awarded specifically for re-
gional EMS activities were replaced by a new funding mechanism the
Preventive Health and Health Services Block Grant that folded the EMS
funds and money for six other preventive health programs into one lump
sum. All funding went to state governments, which became free to allocate
the grant monies among the seven preventive health service areas in the
manner that best suited their needs.4
The block grant program had the effect of shifting responsibility from
the federal government to the states for many preventive health activities.
Supporters saw this as a way to give states greater control over and flexibil-
ity in paying for these services. Critics of this "new federalism" charged
that the federal government was abdicating its responsibilities and warned
that the states would be unable or unwilling to support EMS at the pre-
block-grant level. In fact, block grant funding allocated to EMS-about
$13 million in FY 1990 is now less than half the $30 million available
annually under the EMSS Act (with no adjustment for inflation) (OTA,
1 989; Public Health Foundation, 199 1~.
In addition, the block grant program eliminated most EMS and emer-
gency medicine activities within DHEW (renamed the Department of Health
and Human Services [DHHS]~. NHTSA (in DOT) emerged as the most
prominent and most long-standing federal presence in EMS. The State and
Community Highway Safety Program ("Section 402") had included funds
for support of EMS systems since it was established in 1966, and EMS was
designated as a priority program after the passage of the 1981 OBRA legis-
lation (NHTSA, 1990a). Nevertheless, at the same time that the DHHS
block grant program was initiated, NHTSA's Section 402 funds were re-
duced.
Funding The immediate impact of these federal funding changes was a
reduction in total funds allocated by states to EMS. In 1983, states used
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EMS SYSTEMS: ORIGINS AND OPERATIONS
SUMMARY
97
EMS first received systematic attention from federal, state, and local
governments and from the medical community in the mid-1960s. A focus
on trauma (especially motor vehicle crashes) and on acute cardiac condi-
tions led to the development of an adult-oriented system. In the 1970s,
funding from federal agencies (particularly' DOT and DHHS tthen DHEWi)
and an RWJ Foundation grant program did much to stimulate the growth of
EMS systems. In 1981, folding DHHS funding for EMS into a block grant
program covering seven preventive health and health services programs led
to less federal funding for EMS. Over time, however, some states and
communities increased their own funding for EMS.
By the late 1970s, pediatricians and pediatric surgeons had begun to
recognize that children's emergency care needs had not received adequate
attention. Efforts in their own communities and through professional orga-
nizations began to gain wider attention with such developments as the des-
ignation of a regional pediatric trauma center in Maryland, the creation of
the EDAP program in Los Angeles, and the introduction of courses such as
PEMSTP, PALS, and APLS. In 1984, a federal demonstration grant pro-
gram specifically targeting EMS-C was approved. This ongoing program,
administered by HRSA, aims to expand access to and improve the quality of
EMS-C services available through existing EMS systems. It also is generat-
ing a body of knowledge and experience that other states and localities can
draw on in their efforts to enhance EMS-C capabilities. Since the first
grants were awarded in 1986, projects in a total of 31 states have produced
a variety of resource materials and taken many useful steps to improve
EMS-C.
Progressive development of EMS systems has made clear that certain
core functions need to be performed in every system. Fifteen system ele-
ments specified by the 1973 EMS S Act (e.g., training, communications,
transportation, critical care facilities, and standard record keeping) have
been important in shaping EMS systems. The committee sees seven essen-
tial responsibilities for EMS-C systems: (1) identification of emergencies
and the need for emergency care; (2) access to the services of the system
(e.g., a 9-1-1 emergency number) with the dispatch of personnel and equip-
ment; (3) appropriate prehospital care; (4) transportation to appropriate points
of care; (5) definitive treatment, including access to needed tertiary and
rehabilitative care; (6) reliable communication among emergency care pro-
viders; and (7) use of information systems and feedback to assess and im-
prove care and system performance and to point to areas for prevention.
Meeting these responsibilities involves medical and administrative con-
siderations and requires the participation and cooperation of a variety of
individuals and institutions. No one agency or institution has authority over
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98
EMERGENCY MEDICAL SERVICES FOR CHILDREN
all of the elements involved. State governments have broad authority over
EMS activities, principally through regulation and oversight of services and
providers. At the local level, EMS agencies (which provide prehospital
care) are generally regulated, and often operated, by local governments.
EDs and hospital inpatient services are also subject to governmental regula-
tion but are more likely than EMS agencies to be privately owned and
operated. (community hospitals provide emergency care for many children
while major referral centers, with highly skilled pediatric specialists and
pediatric intensive care facilities, are prepared to care for more seriously ill
or injured children. Other contributors to emergency care in the community
include health care providers. Primary care clinicians and parents (and
their surrogates) have special responsibilities for preventing injury and ill-
ness and initiating contact with the emergency care system.
In sum, EMS systems originally developed to care for adult victims of
trauma and acute cardiac disease have tended to overlook children and the
differences in care that they require. Efforts to address the emergency care
needs of children must consider all the elements that constitute EMS sys-
tems and understand the specific channels through which change can be
implemented in each. Progress can be seen in bringing these needs to
public and professional notice, and the EMS-C grant program has provided
valuable resources for these efforts. Still, the need for special attention to
the care of children must be more widely recognized in federal, state, and
local governments, in the health care community, and among the public. It
must be made a genuine and continuing priority with decisionmakers in a
position to influence the future direction of emergency medical care and to
ensure that adequate financial resources are available. Through this report,
the committee aims to identify areas of special concern regarding EMS-C
and to put forward suggestions and recommendations for specific actions on
the part of a variety of individuals and organizations.
NOTES
1. Throughout this report, "emergency department" and ED are used as generic terms that
encompass all varieties of organized hospital-based outpatient services available to provide
unscheduled care for patients whose conditions may require immediate treatment. In some
settings, such facilities may be known as emergency rooms; elsewhere emergency care is the
responsibility of a full-fledged hospital department.
2. An early step, the Hill-Burton hospital construction program under the 1946 Hospital
Survey and Construction Act, was followed in the early 1960s by the Regional Medical Pro-
gram (RMP) to apply better knowledge and technical development to medical care (especially
for heart disease, cancer, and stroke). The Comprehensive Health Planning program expanded
areawide planning (through the 1966 Community Health Planning Amendment to the Public
Health Service Act) at the same time that it de-emphasized hospital construction through Hill-
Burton and the disease-category approaches of RMPs.
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EMS SYSTEMS: ORIGINS AND OPERATIONS
99
3. For more detailed accounts of the history of EMS-C, see Haller (1989b), Foltin and Fuchs
(1991), and Seidel and Henderson (1991).
4. States could elect to use preventive health block grant monies to finance programs in the
following areas: EMS, comprehensive public health services, rodent control, fluoridation,
hypertension control, health education and risk reduction programs, and establishment of home
health agencies (OTA, 1989).
5. The amount spent on EMS by state health agencies does not include funds spent on EMS-
related activities by other state agencies or funds spent independently> by Iocal EMS systems
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100
EMERGENCY MEDICAL SERVICES FOR CHILDREN
Appendix 3A
Recommendations from Accidental Death and Disability:
The Neglected Disease of Modern Society
ACCIDENT PREVENTION
· Formation of a National Council on Accident Prevention at the Ex-
ecutive level for coordination of information and advice on implementation
of measures and regulations now vested in scattered private, industrial, and
federal agencies, and for research, public education, and development of
improved standards in accident prevention.
EMERGENCY FIRST AID AND MEDICAL CARE
First Aid
· Extension of basic and advanced first aid training to greater numbers
of the lay population.
· Preparation of nationally acceptable texts, training aids, and courses
of instruction for rescue squad personnel, policemen, firemen, and ambu-
lance attendants.
Ambulance Services
· Implementation of recent traffic safety legislation to ensure com-
pletely adequate standards for ambulance design and construction, for am-
bulance equipment and supplies, and for the qualifications and supervision
of ambulance personnel.
.
Adoption at the state level of general policies and regulations per
taining to ambulance services.
.
Adoption at district, county, and municipal levels of ways and means
of providing ambulance services applicable to the conditions of the locality,
control and surveillance of ambulance services, and coordination of ambu-
lance services with health departments, hospitals, traffic authorities, and
communication services.
· Pilot programs to determine the efficacy of providing physician-staffed
ambulances for care at the site of injury and during transportation.
· Initiation of pilot programs to evaluate automotive and helicopter
ambulance services in sparsely populated areas and in regions where many
communities lack hospital facilities adequate to care for seriously injured
persons.
SOURCE: NAS/NRC ( 1 970a, pp. 35-37)
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EMS SYSTEMS: ORIGINS AND OPERATIONS
Communication
101
· Delineation of radiofrequency channels and of equipment suitable to
provide voice communication between ambulances, emergency departments,
and other health-related agencies at community, regional, and national lev-
els.
Pilot studies across the nation for evaluation of models of radio and
telephone installations to ensure effectiveness of communication facilities.
· Day-to-day use of voice communication facilities by the agencies
serving emergency medical needs.
· Active exploration of the feasibility of designating a single nation-
wide telephone number to summon an ambulance.
Emergency Departments
· Initiation of surveys and pilot programs to establish patterns of and
the numbers and types of emergency departments necessary for optimal care
of emergency surgical and medical casualties in a selected number of cities,
groups of small communities, and sparsely populated areas.
· Development of a mechanism for inspection, categorization, and ac-
creditation of emergency rooms on a continuing basis.
· Federal fund support to design, construct, and in part, operate model
emergency facilities of each type.
Interrelationships between the Emergency Department
and the Intensive Care Unit
· Expansion of intensive care programs to ensure uninterrupted care
beyond the immediate measures rendered in emergency departments.
THE DEVELOPMENT OF TRAUMA REGISTRIES
· Establishment of trauma registries in selected hospitals as a mecha-
nism for the continuing description of the natural history of the various
forms of injuries.
· Subsequent consideration of establishment of a national computer-
ized central registry.
· Studies on the feasibility of designating selected injuries to be incor-
porated with reportable diseases under Public Health Service control.
HOSPITAL TRAUMA COMMITTEES
· Formation of hospital trauma committees, on a pilot basis, in se-
lected hospitals.
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102
EMERGENCY MEDICAL SERVICES FOR CHILDREN
CONVALESCENCE, DISABILITY AND REHABILITATION
· Development of additional studies on the quantitation of degrees of
disability and the stages of convalescence at which return to productive
work is indicated.
· Development of studies on rehabilitation with emphasis on measures
to loe initiated in the earliest phases of treatment*
MEDICOLEGAL PROBLEMS
· Judicial application of the principle of seeking impartial medical
advice in the determination of disability.
· Replacement, on a national scale, of lay coroners by medical exam-
iners who are not only physicians but also qualified pathologists experi-
enced in medicolegal problems.
AUTOPSY OF THE VICTIM
victims.
· Routine performance and analysis of complete autopsies of accident
CARE OF CASUALTIES UNDER CONDITIONS
OF NATURAL DISASTER
· Development of a center to document and analyze types and num-
bers of casualties in disasters, to identify by on-site medical observation
problems encountered in caring for disaster victims, and to serve as a na-
tional educational and advisory body to the public and the medical profes-
sion in the orderly expansion of day-to-day emergency services to meet the
needs imposed by disaster or national emergency.
RESEARCH IN TRAUMA
.
Increased federal and voluntary financial support of basic and ap-
plied research in trauma.
· Long-term financial support of specialized centers for clinical re-
search in shock and trauma.
· Expansion of clinical research in war wounds.
· Expansion within the U.S. Public Health Service of research in shock,
trauma, and emergency medical conditions, with the goal of establishing a
National Institute of Trauma.
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EMS SYSTEMS: ORIGINS AND OPERATIONS
Appendix 3B
Emergency Medical Services for
Children Demonstration Grant Program
103
The l~merge`ncy Medical Services for Children (EMS-C) demonstration
grant program, administered by the Health Resources and Services Admin-
istration of the Department of Health and Human Services, is aimed at
reducing the mortality and morbidity experienced by children as a conse-
quence of emergencies due to injury.and illness. The program is designed
to develop knowledge that can be applied to improving the pediatric care
capabilities of existing emergency medical services (EMS) systems around
the country. Specific priorities include learning about the types, frequen-
cies, and characteristics of pediatric emergencies and how EMS systems
address them; developing curriculum content appropriate for training EMS
personnel in the emergency care of children; designing effective EMS-C
systems, formulating strategies for developing and maintaining state and
local support for EMS-C; and reducing the impact of emergencies on chil-
dren and their families.
The initial federal legislation authorizing the EMS-C program was passed
in 1984 (P.L. 98-5551. It provided for $2 million annually to fund four new
grants in each year of a three-year program. The first grants were awarded in
early 1986. Reauthorization of the program in 1988 (P.L. 100-607) lifted the
initial limit of four grants per year and provided for funding of $3 million for
FY 1989, $4 million for FY 1990, and $5 million for FY 1991 and FY 1992.
With a further reauthorization in 1992 (P.L. 102-410), the program was ex-
tended through 1997; no limit was set on annual funding for this period or
the number of grants that can be made. From 1986 through 1992, a total of
36 projects in 31 states and two EMS-C resource centers were funded.
In 1991, the focus of the program shifted from "demonstration" projects
to "implementation" projects. The new orientation calls for use of existing
knowledge and the experience gained from the earlier projects to introduce or
improve state resources for the emergency care of children. Also introduced
in 1991 are "targeted issues" grants to address specific concerns such as re-
ducing the psychosocial impact of emergencies, developing information sys-
tems, or applying new technologies to education and training. The two re-
source centers offer information and assistance to grantees and others interested
in EMS-C. Some of the specific activities include publishing newsletters,
collecting and disseminating EMS-C grant products, providing technical assis-
tance on system development concerns and longer-term funding for EMS-C
activities, providing information about data collection systems, and provid-
ing guidance on developing community coalitions to further EMS-C efforts.
Individual EMS-C projects are listed in the table that follows.
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104
EMERGENCY MEDICAL SERVICES FOR CHILDREN
TABLE 3B-1 Projects Funded by the EMS-C Demonstration Grant
Program, 1986-1992
State Project Titlea
Grantee Organization Project Period
Demonstration and Implementation Grants
Alabama Demonstration Project for Division o[Pediatric February 1986 to
Pediatric EMS Systems Critical Care, University June 1989
Components of South Alabama
Alaska Alaska EMS for Children EMS Section, Division of October 1989 to
Public Health, Alaska September 1992
Department of Health and
Social Services
Arizona Emergency Medical Services University of Arizona October 1992b
for Children (I) College of Medicine
Arkansas Arkansas Demonstration Arkansas Children's October 1987 to
Project: EMS for Children Hospital, University of December 1990
Arkansas for Medical
Sciences
California Comprehensive Approach to Department of Emergency February 1986 to
Emergency Medical Services Medicine and Pediatrics, May 1989
for Children in Rural and Harbor-UCLA Medical
Urban Settings Center
Colorado Colorado EMS for Children EMS Division, Colorado October 1992b
Grant (I) Department of Health
District of Emergency Medical Services Children's National October 1987 to
Columbia for Children-Focus on the Medical Center, George September 1991
Neurologically Impaired Washington University
Child
Florida Emergency Medical Services University Medical Center, October 1987 to
Grant for Children University of Florida June 1991
Health Science Center,
Jacksonville
Hawaii Emergency Medical Services Emergency Medical October 1987 to
for Children Services Systems Branch, September 1991
Hawaii Department of
Health
Idaho Idaho Statewide EMSC EMS Bureau, Health October 1989 to
Project Division, Idaho September 1992
Department of Health
and Welfare
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EMS SYSTEMS: ORIGINS AND OPERATIONS
TABLE 3B-1 Continued
105
State Project Titlea Grantee Organization Project Period
Louisiana Emergency Services for Tulane University School October 1989 to
Children for Louisiana of Medicine September 1991
Maine Emergency Medical Services Maine Emergency Medical October 1987 to
for Children Services and Medical Care September 1991
Development, Inc.
Maryland Organization for
Comprehensive Emergency
Medical Services for
Children in Maryland
Massa
chusetts
Michigan
Missouri
Nevada
Emergency Medical Services
for Children (I)
Michigan Model for
Improving Pediatric EMS:
A Strategic Planning and
Systems Approach (I)
EMS C Project: Missouri (I)
EMSC Implementation
Demonstration Grant (I)
New Improving the Quality
Hampshire and Delivery of Emergency
Medical Care for Children
(I)
Maryland Institute for
EMS Systems, University
of Maryland at Baltimore
October 1987 to
September 1991
Massachusetts Department October 1992b
of Health
Michigan Department of October l991b
Health
Missouri Department of October l991b
Health
Nevada Division of October l991b
Health
Trustees of Dartmouth October l 991 b
College
New Jersey Pediatric EMS System New Jersey Department October l991b
Development for New of Health
Jersey (I)
New Emergency Medical Services Division of Emergency October 1990b
Mexico for Children Medicine, University of
New Mexico School of
Medicine
New York New York State EMS for New York State Health February 1986 to
Children and Health Research, Inc. June 1989
North Emergency Medical Services North Carolina Children's October 1990b
Carolina for Children Hospital, University of
North Carolina at Chapel
Hill
continued
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106
TABLE 3B-1 Continued
EMERGENCY MEDICAL SERVICES FOR CHILDREN
State Project Titlea Grantee Organization Project Period
Ohio Emergency Medical Services Division of Maternal October 1990b
for Children Demonstration and Child Health,
Grant Ohio Department of Health
Oklahoma Developing and Improving
the Capacity of Existing
Pediatric EMS in
Oklahoma (I)
University of Oklahoma October 1991b
Health Sciences Center
Oregon Emergency Medical Services Oregon State Health February 1986 to
for Children in Oregon Division May 1989
Texas Training, Public Education Texas Department of October l991b
and EMS/Trauma System Health
Planning, Pediatric Data
Management (I)
Utah
Utah Emergency Medical
Services for Children
Bureau of Emergency October 1990b
Medical Services, Utah
Department of Health
Vermont EMS for Children: EMS Division, Vermont October 1989 to
Improvement of the Department of Health September 1992
Pediatric Component of a
Rural EMS System
West Tri-State Appalachian
Virginia Alliance for EMSC (I)
Department of Pediatrics, October 1992b
West Virginia University
Washington Emergency Medical Services Washington EMSC, October 1987 to
for Children Children's Hospital September 1991
and Medical Center and
Washington Department
of Health
Wisconsin Improving Emergency
Services for Children in
Wisconsin
California Development of EMS for
Children Subsystems in
California
Emergency Medical October 1987 to
Services Section, Division September 1991
of Health, Wisconsin
Department of Health
and Social Services
Targeted Issues Grants
EMS Authority, State of October l991b
California
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EMS SYSTEMS: ORIGINS AND OPERATIONS
TABLE 3B-1 Continued
107
State Project Titlea Grantee Organization Project Period
Idaho "Pediatric Medical Idaho Department of October l991b
Emergencies" Interactive Program Health and
Videodisc Welfare
Maine Maine Pediatric Quality Maine Board of EiMS (October l991b
Assurance Project
New York
New York New York City EMSC
City Project
School of Medicine, October l991b
New York University
Rochester Development of a Regional School of Medicine and October l991b
Pediatric Data Surveillance Dentistry, University
System of Rochester
EMSC Resource Centers
State Center
Grantee Organization Project Period
California National EMSC Resource Research and Education October l991b
Alliance Institute, Inc., Harbor
UCLA Medical Center
District of EMSC National Resource Children's National October l991b
Columbia Center Medical Center, George
Washington University
a(I) designates Implementation Grants.
bOngoing project, no completion date set.
SOURCE: NCEMCH (1992); Peter Conway, Maternal and Child Health Bureau, personal
communication, November 1992.
Representative terms from entire chapter:
medical services
