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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

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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.