this classification was to provide optimal care in remote areas with limited resources and, when necessary, to ensure linkage to higher levels of care.

Special Populations

Children and the elderly are among the special populations that merit emphasis by trauma care systems. Injury is the foremost cause of death among children above 1 year of age and the fifth leading cause of death for the elderly age 65 or over (Chapter 2). Congress authorized the Emergency Medical Services for Children (EMS-C) Program in 1984 to ensure state-of-the-art emergency medical care for injured children and adolescents and to ensure that pediatric services are integrated into trauma systems. The program funds demonstration, implementation, and targeted-issues grants to states and medical schools for the provision of emergency medical services geared to children (IOM, 1993; NIH, 1995). The program grew out of the awareness that children have unique physiological responses to illness and injury and that their treatment requires specific training, equipment, and approaches not ordinarily available in systems designed for adults. The program focuses on the entire continuum of pediatric emergency services, from injury prevention through prehospital, acute care, and rehabilitation services. The committee commends the collaborative efforts of the Maternal and Child Health Bureau (MCHB) and the National Highway Traffic Safety Administration (NHTSA) on the EMS-C Program and urges similar collaborative efforts between MCHB and the National Institute of Child Health and Human Development for investigator-initiated research in the areas of childhood injury epidemiology and prevention.

Research has demonstrated that specialized pediatric trauma care is associated with lower rates of pediatric morbidity and mortality compared with rates at adult trauma care centers (or national norms), although adult trauma centers with a pediatric component may be able to achieve outcomes comparable to those of pediatric trauma centers (Pollack et al., 1991; Fortune et al., 1992; Knudson et al., 1992; Nakayama et al., 1992; Cooper et al., 1993; Hall et al., 1993, 1996; Rhodes et al., 1993; Bensard et al., 1994; Hulka et al., 1997). As important, targeted pediatric injury prevention programs have been shown in population-based studies to result in substantial decreases in the incidence of serious childhood injuries (Davidson et al., 1994; Durkin et al., 1996). The National Pediatric Trauma Registry (NPTR), was established in 1985 to study the causes, circumstances, and consequences of injuries to children. Sponsored by the National Institute on Disability and Rehabilitation Research and by the American Pediatric Surgical Association, the NPTR has detailed information on over 50,000 cases of injuries to children. As of October 1996, there were 78 participating centers (pediatric trauma centers or children's hospitals with pediatric trauma units) located in 28 states, Puerto Rico, and Ontario, Canada (NPTR, 1998).



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