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Emergency Medical Services for Children (1993)

Chapter: 3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS

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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Page 79
Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Page 83
Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Page 103
Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Page 105
Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Page 106
Suggested Citation:"3 EMERGENCY MEDICAL SERVICES SYSTEMS: ORIGINS AND OPERATIONS." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Page 107

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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

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

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.

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.

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

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.

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,

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

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.)

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.

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

EMS SYSTEMS: ORIGINS AND OPERATIONS 77 $17.6 million in block grant funds for EMS (OTA, 19891. In 1982, NHTSA had available $5.4 million for EMS from Section 402 funds, down from $12.7 million in 1981 (OTA, 1989~. An assessment by the U.S. General Accounting Office (GAO) of the impact in six states of changes in federal funding found that EMS funding fell by 34 percent between 1981 and 1983 (GAO, 1986) Over the next few years, some states Mope- with increases TO state furry for EMS (GAO, 1986~. Total federal and state spending on EMS in the six states in the GAO study was almost $18 million in 1981, with about 27 percent of this amount contributed by the states; in 1985, EMS expenditures were almost $16 million, with 50 percent funded by the states (the dollar amounts are apparently not adjusted for inflation). By 1988, estimates suggested that, on a national basis, state and local funds accounted for 82 percent of the support for state EMS programs (OTA, 1989~. Some states introduced special funding mechanisms, such as surcharges on fees for driver's li- censes and vehicle registrations, to raise money for EMS (NASEMSD, 1991~. Consequences The end of the categorical EMSS funding program pro- duced mixed results. Some states increased their involvement in EMS sys- tem development. For example, five of the six states examined by the GAO had expanded their authority in EMS, either by passing legislation or by developing new regulations (GAO, 1986~. In other states, however, the state EMS office retained only limited authority. The block grant program carried no requirement for states to adhere to the 15-component EMS system model that was central to the EMSS Act, but it allowed states to continue funding for EMS regions that were not eligible for additional categorical grants. There were, however, restrictions that prevented use of block grant funds for purchases of needed communications equipment. The GAO (1986) also found interest among states in a national clearinghouse through which they could learn about EMS activities in other states. Other Developments into the 1980s The 1970s and 1980s saw growing attention to prevention and a will- ingness to use legislation and regulation to implement prevention measures. In 1970, the Poison Prevention Packaging Act, for example, mandated the use of safety caps on a variety of products. The Consumer Product Safety Commission became responsible for enforcing use of flame-retardant fabric for children's sleepwear and product labeling on hazards to children. By 1985, every state had passed legislation requiring the use of child safety seats. State and local laws have been used to establish requirements regard- ing the installation of smoke detectors, window guards to prevent windo

78 EMERGENCY MEDICAL SERVICES FOR CHILDREN falls in multistory buildings, and pool fencing to reduce the risk of drown- ing. Broad DHHS concern regarding prevention of injury and illness was reflected in the publication of specific national health promotion and dis- ease prevention goals; the first set of goals, for 1990, was issued in 1980 and was followed with the 1990 release of goals for the year 2000 (DHHS, 198D, 19911. Injury-preven-~on was highlighted by a 1985 report, injury in America: A Continuing Public Health Problem (NRC/TOM, 19851. This report renewed attention to the heavy toll taken by injuries and called for research in prevention and improved care following injuries. Its recommen- dations led to creation of an injury prevention program at the Centers for Disease Control and Prevention (CDC) in DHHS. In June 1992, the pro- gram gained greater prominence with its designation at CDC as the National Center for Injury Prevention and Control. Concerns Emerging in the 1980s A 1988 conference on issues in emergency medical care highlighted the need to ensure the consistent delivery of high-quality care (AHA-ACEP- AMA, 1988~. Recommendations from the conference targeted the need for classification of system capabilities, medical control, system evaluation, research, national training standards, and adequate levels of financial sup- port. For EDs, uncompensated care and inadequate reimbursement for emer- gency care of Medicaid patients created problems. Some urban trauma centers found it difficult to remain within the trauma system because of the financial burden of caring for large numbers of seriously injured but unin- sured patients. In addition, federal legislation, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA 1985, P.L. 99-272) and OBRA 1989 (P.L. 101-239), established a universal requirement for EDs to evalu- ate, or stabilize for transfer to a more appropriate facility, any patient re- questing care. In rural areas, hospital closings further reduced the already limited emergency care resources in those areas. Hospitals also faced a serious shortage of nursing staff. The emergence of acquired immune defi- ciency syndrome (AIDS) during the 1980s created a new risk for health care providers. Efforts by the surgical community, led by the ACS, to develop emer- gency care systems specifically focused on trauma care had produced wide- spread acceptance of the value of such an approach. Implementation of trauma systems increased during the 1980s but faced continuing difficulties (Mendeloff and Cayten, 1991~. Only Maryland and Virginia had essentially statewide systems at the end of the decade (Mendeloff and Cayten, 1991~. Many other states have not sought authority or have not used available

EMS SYSTEMS: ORIGINS AND OPERATIONS 79 authority to direct the designation of trauma centers. Some hospitals have resisted creation of trauma systems out of concern over potential loss of paying patients or an increase in uninsured patients; for some hospitals, those apprehensions have proved quite real, resulting in serious financial consequences (GAO, l991b). Widespread coordination of highly diverse prehospital services has also been difficult. In addition, tensions continue w~-~n the medico} community. Surgical {leadership of trauma centers c-oTt- trasts with the primary role played by emergency physicians in other areas of EMS. Nominal federal support for further development of trauma systems was reflected in the passage in 1990 of the Trauma Care Systems Planning and Development Act (P.L. 101-590~. The act provides for an advisory council for the Secretary of DHHS, a clearinghouse, special attention to rural areas, and matching-fund grants for states to develop trauma system plans. Greater awareness of pediatric concerns is reflected in two require- ments in the law: that the advisory council include "an individual experi- enced or specially trained in the care of injured children" and that the model trauma care plan to be developed by DHHS take AAP standards into ac- count. For FY 1992, only $5 million of an authorized $60 million was appropriated (EMS-C National Resource Center, 1992~. In 1992, additional funds were authorized for grants to trauma centers to offset costs of uncom- pensated care to victims of drug-related violence (P.L. 102-321~. Children and EMS The l980s saw a substantial increase in attention to EMS-C issues. In some ways, this period of rapidly expanding developments in EMS-C paral- leled the experiences of the late 1960s and early 1970s for the original adult-focused development of EMS. Recognition of the need for EMS-C began to spread, professional organizations were created, new training pro- grams were developed, guidelines specifically addressing pediatric require- ments were introduced, and the federal government assumed a role in sup- porting development of systems of care. Greater Attention to EMS-C Local efforts in various places across the country were attracting greater attention to the need for EMS-C and produc- ing some visible changes. For example, the Los Angeles EDAP-PCCC program described above became firmly established; a network of PICUs in northern and central California coordinated services for the region; and pediatric trauma centers were established in several cities (Seidel and Henderson, 1991~. An increasing number of studies began appearing that provided badly needed information on the demographic characteristics of children who were

80 EMERGENCY MEDICAL SERVICES FOR CHILDREN using emergency services, the kinds of injuries and illnesses that they expe- rienced, and the readiness of providers to care for them. Evidence sug- gested that about 10 percent of ambulance runs were for children; young children were likely to be suffering from respiratory distress or seizures whereas older children and adolescents were likely to need care for trauma; up to- half of trauma deaths might be preventable' prehospital personnel g-~-~ally had 1~e ~g ~n pee Al often Iacked a;ppropr~e equipment berg., Halter et al., 1983; Ramenofsky et al., 1983, 1984; Fifield et al., 1984; Gallagher et al., 1984; Seidel et al., 1984; Seidel, 1986a,b; Tsai and Kallsen, 1987; Kissoon and Walia, 1989~. Developments in the Professional Communities Professional societies and similar organizations provided a national base for addressing EMS-C concerns. In 1981, AAP established its Section on Pediatric Emergency Medicine. A separate AAP task force evolved over time into the Committee on Pediatric Emergency Medicine, which has been the focal point for the Academy's substantial contributions to EMS-C. ACEP established a com- mittee on pediatric emergency medicine in 1984 and a section on pediatric emergency medicine in 1988. Together AAP and ACEP formed a Joint Task Force on Pediatric Emergency Medicine in 1984 to facilitate communica- tion and coordination between the two groups in their activities to improve emergency care for children. The Society of Critical Care Medicine established a pediatric section in 1982; in 1984, in a nice piece of symmetry, AAP created a section on critical care medicine (Downes, 1992~. AAP also formed a section on transport medicine in 1989. AHA established its Subcommittee on Pediatric Resuscitation in 1983. By the end of the decade, both ENA and the Na- tional Association of EMS Physicians (NAEMSP) had established pediatric sections. In the Ambulatory Pediatric Association a Special Interest Group on Emergency Medicine was established in 1985 and has become the fastest growing of all of the organization's special interest groups. A new organi- zation, the Society of Pediatric Emergency Medicine, had also been formed. Even more recent was the creation in 1991 of the Society of Pediatric Nurses (Fredrickson, 1992~. The National Association of Children's Hospi- tals and Related Institutions (NACHRI) has brought EMS-C concerns to the attention of its member organizations and has supported continuation of federal support for EMS-C activities (Pilotte, 1992~. Training and Educational Courses Valuable new training resources began to appear in the 1980s, although little material specifically on pediat- ric emergency care was being incorporated into basic qualifying curricula. Specialty training for physicians became available with fellowships in pedi- atric emergency medicine and pediatric critical care. Subspecialty certifica- tion in pediatric emergency medicine is now available through the Ameri

EMS SYSTEMS: ORIGINS AND OPERATIONS 81 can Board of Pediatrics and the American Board of Emergency Medicine and in pediatric critical care through the American Board of Pediatrics. Continuing education courses developed by national and by local groups offered needed pediatric training to providers already in practice, including physicians, nurses, paramedics, and EMTs. AHA addressed pediatric resus- c~:tation needs at its 1983 conference and, in 1985. issued revised standards for pediatric basic life support (13LSj and guidelines for training in pediatric advanced life support (ALS) and neonatal resuscitation (Chameides, 1990~. This work led to the development of the AMA's Pediatric Advanced Life Support (PALS) course (Seidel and Burkett, 1988; Chameides, 1990), which became widely available in 1988. Newly revised guidelines were issued in 1992 (AMA, 1992a,b). Over the decade, other courses also became available to a national audience. Recognition by AAP members that better training in the care of acutely ill and injured children was needed led to the development of the Advanced Pediatric Life Support (APLS) course (Bushore et al., 1989), which is offered under joint sponsorship of AAP and ACEP. ACS incorpo- rated in its 1984 revision of the Advanced Trauma Life Support (ATLS) course a module specifically addressing pediatric trauma stabilization (ACS, 1989~. In addition, the Pre-Hospital Trauma Life Support (PHTLS) course developed by NAEMT in cooperation with the ACS Committee on Trauma incorporated material on prehospital pediatric assessment and stabilization (NAEMT, 1990~. In 1993, ENA was scheduled to begin offering courses based on a Pediatric Emergency Nursing Curriculum (Etcetera, 1992~. ENA also collaborated with grantees in the federal EMS-C demonstration pro- gram to develop a self-instruction curriculum intended particularly for nurses in rural areas where opportunities for classroom training are limited (Henderson and Brownstein, forthcoming). Locally developed courses were also making an important contribution, particularly in training prehospital providers; AAP's Pediatric Resources for Prehospital Care identifies 16 such programs (Brownstein, 1990~. Children's National Medical Center in Washington, D.C., developed its Pediatric Emergency Medical Services Training Program (PEMSTP) specifically to prepare EMT instructors to teach pediatric aspects of emergency care (Eichelberger, 1989~. Training programs were also developed to meet the needs of nurses (e.g., Bonalumi, 1989; Moloney-Harman, 1989; Taylor and Soud, 1991; CNMC, 199 1, 1992~. A Federal Program for EMS-C Some members of the pediatric com- munity felt that the need to develop EMS-C capabilities and resources was sufficiently great and the task sufficiently difficult that a federally funded program was needed to spur progress. In the late 1970s, Calvin Sia began working with Senator Daniel Inouye (D-HI) and Patrick DeLeon of the

82 EMERGENCY MEDICAL SERVICES FOR CHILDREN Senator's staff to develop such a program. As a result of these efforts, the Emergency Medical Services for Children (EMS-C) Program was estab- lished by Congress through the Health Services, Preventive Health Ser- vices, and Home and Community Based Services Act of 1984 (P.L. 98-5553. The original authorization provided $2 million per year for up to four one- year demonstration grants peer year with the Q9tioD for grantees to seek approval for an additional yearts funding. Later reauthorizations of the program (P.L. 100-607 and P.L. 102-410) increased the available funds (to $5 million for FY 1992), allowed a third year of funding, and lifted the four-grant-per-year restriction. The program is currently authorized to con- tinue through 1997. From 1986 through 1992, the EMS-C program has funded projects in 31 states. The first 20 awards (1986 through 1990) were designated "dem- onstration" grants; 11 subsequent "implementation" grants have been made (1991 and 1992~. In addition, five "targeted issues" grants have been awarded to previous grantees to allow them to do further work on specific issues identified in their original projects. Beginning in October 1991, EMS-C funds have also supported the operation of two resource centers (described more fully in Chapter 8~. (Appendix 3B lists all EMS-C projects to date.) The 1990 guidance to grant applicants stated the following goals for these projects (Funke, 1992, p. 42, citing HRSA, 1990~: (1) expand and improve State and local capability for reducing pediat- ric emergencies and their consequences in the State and (ultimately, collec- tively, throughout the Nation), paying special attention to handicapped and minority populations, including Native Americans; (2) generate financial support from local and private sources for the continuation of the programs after Federal support terminates; and (3) foster in other States, the capability to reduce pediatric emergen- cies and their consequences. The intent has been for the projects funded by these grants to "demonstrate" both the outcomes of their activities and the processes that they used. In addressing these goals, individual projects have used a variety of approaches reflecting the specific needs and resources of the state or com- munity. Project activities have included collecting data on pediatric emer- gencies (to assess the need for specialized EMS-C programs); assisting in categorization of hospitals receiving pediatric emergencies and promoting regionalization of services; developing EMS-C standards, protocols, and algorithms for prehospital and ED care; and designing EMS-C training pro- grams for health care providers in prehospital and hospital settings (Shape~man and Backer, 1 99 1; Funke, 1 9921.

EMS SYSTEMS: ORIGINS AND OPERATIONS Committee Observations 83 Since the mid-1960s, the combined efforts of individuals, organiza- tions, and public agencies have enabled EMS in this country to achieve major progress. It has advanced from being the province of concerned but largely untrained volunteers and the most junior medical staff to a highly sophisticated field of medical and paramedical care for which even the many volunteers still involved must have special training. Even with the substantial accomplishments recounted above, however, EMS systems con- tinue to face very real problems in ensuring the consistent delivery of opti mum care. Children are at particular risk because of the long-standing failure to recognize the distinct nature of the care that they require. Over the past 10 years, clinical and organizational requirements in emergency care for chil- dren have gained much needed attention, and changes are beginning in the way providers are trained and EMS systems are run. For example, in Au- gust 1992, the Maryland EMS system named an associate medical director specifically for children's programs (MIEMSS, 1992), and in September 1992, the governor of New Jersey signed legislation establishing an EMS-C program in the state EMS office (New Jersey P.L. 1992, c.96~. In Texas, legislation to establish EMS-C has been drafted for consideration during the 1993 session of the state legislature (EMS-C National Resource Center, 1992~. Steps such as these must continue and the need for them must be widely recognized if children are to benefit from the full capabilities of modern emergency services. PROVIDING EMERGENCY MEDICAL SERVICES EMS systems must to be able to perform certain basic functions in order to deliver timely and appropriate care, but they must have both a narrow and a broad view of their responsibilities. In the narrow and most immediate situation, EMS systems have to address how to provide rapid access to effective care for each individual patient they see. From a broader perspective, they have to look at how the pieces of the system can be organized to bring that care to the largest number of cases. Achieving these goals involves both medical and administrative considerations. The 1973 EMSS Act was one of the first efforts to delineate EMS system functions. The 15 components that it specified shaped the develop- ment of EMS systems throughout the United States by defining the proper scope of such systems and the competencies needed to provide good care (see Table 3-1~. Although they are reflected in many systems, these compo- nents sometimes have become independent activities without the kind of interconnections that a true system of care requires (NAS/NRC, 1978a; Foltin

84 EMERGENCY MEDICAL SERVICES FOR CHILDREN and Fuchs, 1991~. Furthermore, these system components need to be revis- ited to ensure that adequate provision is made for optimum care for pediat- ric patients. Essential Services for Emergency Care of Children EMS-C should be able to provide a continuum of care frown initial problem identification through a broad spectrum of services that include prehospital care; hospital-based emergency, inpatient, and critical care; and rehabilitative services appropriate for children. An EMS-C system should ensure links with children's primary care providers and should apply its experience with illness and injury to prevention priorities. Parents and primary care providers, who are important system participants, should be working to prevent emergencies where they can and ready to respond ap- propriately when emergencies do arise. They also should be responsible for establishing the foundation of comprehensive and continuing primary care that should constitute a child's "medical home" (Sia and Stewart, 1989; AAP, 1992e); the medical home should provide a base from which to ad- dress all aspects of care that a child may require as a result of an emer- gency. The committee sees seven basic responsibilities for EMS-C systems: 1. identifying emergencies and the need for emergency care; 2. ensuring access to the services of the system (e.g., through 9-1-1 telephone service) with dispatch of personnel and equipment; 3. providing appropriate prehospital care; 4. transporting children to appropriate points of care; 5. providing definitive treatment, including access to tertiary and reha- bilitative care as needed; 6. ensuring communication among emergency care providers and with other interested parties including parents and primary care providers; and 7. using information systems and feedback to assess and improve pa- tient care and system performance and to point to areas for prevention efforts. Parents, primary care providers, and other adults responsible for the care of children (e.g., teachers, day-care providers, coaches) must be able to recognize conditions that require urgent medical attention and know how to obtain help from the EMS system. A simple and reliable means of contact- ing the EMS system should be available; the widely-used three-digit 9-1-1 telephone number often serves this purpose. EMTs and paramedics who are dispatched to provide prehospital care must be able to make accurate as- sessments of children's conditions and, at a minimum, to stabilize them for transport to an ED where more definitive care can begin. Many other

EMS SYSTEMS: ORIGINS AND OPERATIONS 85 children who need emergency care arrive at EDs without using EMS trans- port. Often, EDs can provide the definitive care necessary to treat serious conditions. Because they also treat many children who are not seriously ill or injured, they must have a sound triage system in place to identify the children who have the most immediate need for care. ED services alone cannot meet the needs of children in all emergencies. Therefore, EDs finest be able to recognize these children and direct them to appropriate inpatient or other follow-up care. In rural and community hos- pitals with limited resources in pediatric expertise and inpatient services, children may require skilled and timely transport to another hospital for more extensive care. Once an appropriate destination is reached, definitive care should ad- dress all aspects of a child's illness or injury in order to achieve the most complete recovery possible. Access to medical specialists or to specialized inpatient care (in a PICU, for example) may be needed. Early attention to possible rehabilitation needs must be a part of truly definitive care. EMS systems should not provide care in an information vacuum (a point explored more fully in Chapters 6 and 71. Individual providers ben- efit from learning about the outcomes of cases they have treated and whether the care they provided was appropriate. System planning benefits from descriptive data on numbers of cases, characteristics of patients, and kinds of treatments. Evaluators need to be able to assess more generally how well the various elements of an EMS system are performing. Furthermore, be- cause preventing emergencies is always preferable to coping with them after the fact, clinicians, administrators, planners, and the public should receive information that will highlight areas (diseases, environmental con- ditions, behaviors) in which prevention activities will have a large payoff. STRUCTURE OF EMS SYSTEMS EMS systems perform their functions through a variety of administra- tive and operational arrangements and with the participation of many people in various roles. Only rarely is a single mechanism in place with the authority to manage an entire EMS "system." Instead, the pieces of the system are the responsibility of separate agencies or institutions, and the EMS system arises out of cooperation among the separately managed pieces. The discussion that follows examines state and local aspects of EMS along with the role of professional and voluntary organizations. Across the coun- try, systems differ in significant ways because of factors such as geography, history, economics, and governmental arrangements. In general, the EMS agencies providing prehospital care are the part of the system most closely controlled by state and local governments, being

86 EMERGENCY MEDICAL SERVICES FOR CHILDREN either directly operated or heavily regulated. Some agencies have well- defined responsibilities centering on providing emergency medical care and emergency transport; in other configurations, EMS may be one of several functions for which an organization such as a fire department is responsible. Hospitals, on the other hand, provide ED care as only one of many services. They' too' are subject to governmental regulation but. are more likely to be privately owned and operated than are EMS agencies providing prehospital care. The medical community itself plays a large role in hospital oversight and regulation and in defining the practice of emergency medicine. Participants in the delivery of emergency medical care include physi- cians, nurses, allied health personnel such as respiratory therapists, para- medics with ALS skills, EMTs with varying levels of training, "first re- sponders" such as police and firefighters with essential CPR and first-aid skills, emergency service dispatchers, plus members of the public who may provide important interim or bystander care. Most hospital-based personnel are paid employees, but many of the people providing prehospital services are volunteers, especially in smaller communities and rural areas. Ensuring that EMS systems are prepared to care for children will re- quire reaching this diverse mix of organizations and individuals with appro- priate and compelling messages and useful guidance on needed improve- ments. The committee emphasizes that its goal is to enhance the ability of existing EMS systems to care for children, not to create a separate EMS system for children. State-Level Activities For the most part, state governments hold the broadest authority for addressing delivery of emergency medical care. The character of state involvement varies widely but generally relates more to regulation and oversight of services and service providers than to direct delivery of services. EMS Offices and Advisory Councils Every state has established an EMS Office, usually within the state health department, with responsibility for state activities related to prehospital emergency medical care. The authority and influence of these offices vary widely. A 1990 survey by the National Association of State EMS Directors on functions performed by state EMS offices determined that none of the functions was performed by every EMS office and that in some states the EMS office played a secondary rather than a primary role in performing particular functions (NASEMSD, 19914. The tasks for which the greatest number of EMS offices (about 35) have primary responsibility relate to oversight of EMTs with basic skill

EMS SYSTEMS: ORIGINS AND OPERATIONS 87 levels: adopting written qualifying tests, adopting practical tests, licensing (or certifying) personnel, and regulating their scope of practice (NASEMSD, 19911. Other common responsibilities include adopting curricula for basic and advanced training, testing and licensing providers with advanced train- ing, and licensing and regulating ambulance services. Some state EMS offices have a major role in establishing protocols for treatment. triage, and transfer and ~n categorizing or designating trauma centers. Fewer than five are responsible for such functions as providing training or operating a train- ing academy, approving training centers, or regulating ambulance rates. In addition, EMS offices may have a role in public information and education programs and in data collection and analysis. Most states also have EMS advisory councils. Many are established by statute, and appointments are made by the governor in some states. A1- though some councils are strictly advisory in nature, others have the author- ity to make independent proposals and funding recommendations and to review and approve state EMS plans, training programs, and regulations. Public Health and Health Care State health agencies other than the EMS office typically have responsi- bility for or authority over important pieces of EMS systems. State regula- tions governing licensing for hospitals and for physicians and nurses can influence the availability of services, and the standards applied can affect capabilities for providing emergency care. Responsibility for the develop- ment and oversight of trauma systems, including the operation of a trauma registry, frequently rests with state health agencies. Maternal and child health agencies may have strong influence in matters specifically related to care of children. Prevention programs, for both illness and injury, may fall under such agencies. Public Safety Public safety agencies also may have an interest in EMS systems, par- ticularly through highway safety matters. Some NHTSA programs, for example, operate through the Governor's Highway Safety Office. In Cali- fornia, the state highway patrol is responsible for ensuring compliance with ambulance equipment requirements (California Highway Patrol, 1990~; in Maryland, emergency helicopter transport and care are provided by the state police (Ramzy, 1990~. Emergency communications is also an area of con- siderable importance to EMS systems that may fall under the jurisdiction of other agencies. Regulation of or support for implementation of 9-1-1 tele- phone systems involves the interests of public safety agencies (police and fire departments as well as EMS) and public utility issues in connection

88 EMERGENCY MEDICAL SERVICES FOR CHILDREN with telephone companies. Some states have mandated statewide 9-1-1, whereas others have authorized its implementation by localities without directly participating in the implementation process. Two Examples of Unusual State-Level Efforts Maryland Maryland has established a unique private, nonprofit organi- zation with responsibility for coordinating EMS across the state-the Mary- land Institute for Emergency Medical Services Systems (MIEMSS) (Ramzy, 1990~. A statewide EMS system was first instituted by the governor in 1973. The MIEMSS was created in 1977 by the state legislature with the merger of the state Division of EMS and the Maryland Institute for Emer- gency Medicine at the University of Maryland, which had grown out of the pioneering work by R. Adams Cowley on treatment of shock and trauma. Until August 1992, the head of the MIEMSS served as the state's EMS director; a separate EMS director is now appointed by the head of MIEMSS (MIEMSS, 1992~. Emergency air and ground transportation are provided as a public service, and special EMS communication systems, including 9-1-1, are available throughout the state. The early emphasis on trauma led to a sophisticated trauma system that designates trauma centers on the basis of compliance with standards and demonstrated need for those services. A need for specialized pediatric trauma services, recognized in the mid-1970s, led to official designation of a regional pediatric trauma center as part of the state's trauma system (Hailer et al., 1983~. Idaho The EMS system in Idaho also has benefited from early attention at the highest levels of state government. In contrast to Maryland, Idaho is a large, mountainous state with widely scattered communities. In addition to the resident population, visitors make extensive use of wilderness areas. To be able to provide effective services under these conditions, Idaho has emphasized developing four aspects of its EMS system: a centrally coordi- nated statewide communication network that facilitates medical oversight of care and coordination of EMS system resources, rescue services specifically designed to respond to rural and wilderness emergencies, air and ground transportation services, and mobile training programs to reach rural provid- ers who have little opportunity for offsite continuing education (Anderson, 1981b; Paul Anderson, Idaho EMS Director, personal communication, De- cember 1991~. Enhancing EMS-C Efforts to enhance EMS-C must take into account the specific organiza- tional, political, and financial characteristics of state EMS activities. Those

EMS SYSTEMS: ORIGINS AND OPERATIONS 89 agencies beyond the EMS office that have an interest in and influence over critical aspects of EMS systems must be brought into a coordinated EMS-C effort. Agencies with responsibilities for child health must also be in- cluded. The diversity of state approaches to EMS and children's health issues ensures that no single means of implementing EMS-C will be appro- priate in every state. Local and Regional Activities It is at the local level that services reach individual patients. The organization of those services is likely to reflect traditional relationships in local government and with local hospitals and health care providers. Com- munity interest in EMS also influences the character of the system. In some states, counties or broader regions established under the 1973 EMSS Act play a significant role. In California, for example, counties have been given responsibility for administering local EMS programs, which requires coor- dinating the hospital and EMS resources for communities within the county (McArdle et al., 1990~. Prehospital Services Communities have taken many different approaches to organizing pre- hospital services. In 50 percent of the 200 most populous cities in the nation, EMS services are provided by the fire department, alone or in con- junction with a private provider (Cady, 1992~. In some fire department services, EMS providers have only EMS responsibilities, whereas in others firefighters perform both fire and EMS functions. In another 15 percent of these cities (accounting for 25 percent of the population of the surveyed cities), the EMS agency operates as a "third service" separate from the police or fire departments. In another 25 percent of the cities, private firms are the EMS providers. All but 4 of the 200 surveyed cities reported providing ALS services (Cady, 1992~. Most of these cities use a "one-tier" system with a direct ALS response for each call. Other cities use "two-tier" systems, which respond with varying combinations of ALS and BLS providers and emer- gency vehicles (some of which are not intended to transport patients) (Braun et al., 1990~. Among 25 moderately sized cities (population 400,000-900,000), 20 had 9-1-1 telephone service, and 17 used EMTs or paramedics as dis- patchers (Braun et al., 1990~. Although urban residents generally have access to ALS services, pa- tients in rural areas often do not. Medical oversight for ALS or BLS ser- vices in rural areas is often limited and may be reduced further, or lost, when rural hospitals close. Where those hospitals operated prehospital ser

go EMERGENCY MEDICAL SERVICES FOR CHILDREN vices, closure is likely to have an even greater impact on the availability of emergency care. The long distances and difficult terrain in rural areas make transportation to hospitals an important concern. Some states have attempted to protect against the delays that such conditions can create for ground transport by establishing an air transport network serving most of the state; access to air transport may however? be difficult to ensure because the low demand for service can make -it costly to provide (OTA, 19891. In most urban areas, EMTs and paramedics are paid employees of the public or private organizations that provide prehospital emergency services. In some urban areas and many rural areas, volunteers make up most of the prehospital provider staff. Many areas that rely on volunteers are finding it difficult to recruit and retain enough people to provide round-the-clock services (OTA, 1989~. Volunteers generally must meet the same training and certification requirements as paid providers, but personal costs in time and money can make it difficult for volunteers to acquire and maintain skills, especially at the advanced level. Volunteer agencies also may face significant costs in acquiring and maintaining ambulances. Hospitals: Emergency Services and Inpatient Care The American Hospital Association reported for 1990 that 5,024 acute- care hospitals had EDs and that 664 facilities were certified by states as trauma centers (American Hospital Association, 1991~. NACHRI (1992) reports that 45 freestanding, acute-care children's hospitals operate across the country. Of these, 37 have an ED and 22 are state-certified trauma centers; 5 of the other acute-care children's hospitals provide emergency care through arrangements with other hospitals. Another 105 children's hospitals provide specialty care such as orthopedics, rehabilitation, or psy- chiatric services. Some 2,400 general hospitals have specific pediatric units (American Hospital Association, 19911. Many EDs are faced with the need to accommodate substantial demand for less urgent care (an average of 43 percent of visits) without compromis- ing their ability to care for true emergencies (GAO, 1993~. Some busy EDs have found it possible to direct children (and adults) to clinics and physi- cians' offices when an assessment of their condition shows that they do not require emergency care (Rivara et al., 1986; Derlet and Nishio, 19901. It is essential, however, that EDs be backed up, within the same hospital or at a referral center, by adequate inpatient resources, particularly critical care services. Community hospitals are an important part of the EMS system, serving as the most readily accessible source of medical care for many patients. Because they lack the range of specialty services available at referral cen- ters, community hospitals need to be able to recognize children who require

EMS SYSTEMS: ORIGINS AND OPERATIONS 91 more advanced care and to have in place plans for transferring seriously ill and injured children to referral centers. This ability is especially critical because these facilities face several challenges: only a small fraction of the children they see will be true emergency cases; staff is likely to have little specific training in pediatric emergencies (and may, as well, have little formal training art emergency medicine or emergency nllrs~llg); and under these circumstances such institutions will find it harder to maintain skills and resources for treating emergencies in children. Rural areas face additional challenges. Many hospitals are unable to provide 24-hour physician staffing in their EDs, particularly by physicians with specialty training in emergency medicine. Limited numbers of pedia- tricians are available as well. Moreover, many of the nurses who provide the principal staffing for these EDs have additional responsibilities in other areas of the hospital; they also report a need for better pediatric training (OTA, 1989; Henderson and Avery, 1992~. Major referral centers with specialized pediatric and surgical services are able to provide more extensive care, including highly skilled pediatric intensive care, for the most seriously ill and injured children. These centers are usually large hospitals in major cities and are often affiliated with medi- cal schools; individual hospitals may have areas of special expertise. Typi- cally, they provide services to a larger region than the city in which they are located, which allows limited numbers of specialists to serve a greater num- ber of patients. This kind of "regionalization" of resources is especially necessary for those few hospitals providing highly specialized services such as burn centers, neuroaxis centers for treatment of spinal injuries, replantation centers for repair of severed limbs, or rehabilitation centers (Seidel and Henderson, 1991~. Some states have no hospitals able to offer this level of care; their EMS systems must rely on the services of hospitals in other states to provide definitive care for the most serious cases. Regionalization can help ensure that children (and adults) have access to the care they need and can help ensure that hospitals providing that care have sufficient num- bers of patients to sustain their specialty services. Trauma centers are equipped to provide specialized care for the most seriously injured patients. As noted earlier in the chapter, pediatric trauma centers have been established in several cities. In a few states (Maryland, Pennsylvania, and Virginia) and regions (e.g., New York City, San Diego County), trauma centers are designated in conjunction with a trauma system that attempts to coordinate the distribution of trauma care resources and establish the criteria for access to specific levels of care. Over the past 20 years, freestanding urgent care clinics have emerged in some areas of the country as an alternative source of care (Seidel et al., 1991a). They generally provide care on a walk-in basis for a variety of complaints. Some operate independently; others are affiliated with nearby

92 EMERGENCY MEDICAL SERVICES FOR CHILDREN hospitals. A survey found that, on average, centers saw 50 patients per day; 10 of those patients were children under 15 years old and another 8 patients were between 15 and 18 years old (Seidel et al., 1991a). About half of the centers reported treating potentially serious complaints such as anaphylaxis, seizures, and chest pain; about a third accepted patients brought by EMS or private ambulance. Primary Care Providers Primary care providers, including pediatricians, family practitioners, internists, and nurse practitioners, play at least three important roles in EMS systems (AAP, 1988b, 1992e; Sia and Stewart, 1989; Seidel and Henderson, 1991~. First, they need to be prepared to recognize and treat emergency conditions that they encounter in their offices. Some patients (and parents of patients) seek office care when a condition is actually serious enough to require ED services. Recent studies (Fuchs et al., 1989; Altieri et al., 1990; Schweich et al., 1991) suggest that pediatricians do not have necessary equipment or medications to treat important pediatric emergencies. Similar results have been reported regarding the preparedness of general medical offices to treat emergencies (Kobernick, 1986~. In another study, about half of pediatricians surveyed did not use EMS transport for taking seriously ill children from their offices to referral center hospitals (Baker and Ludwig, 1991). Second, primary care providers have a significant responsibility in edu- cating parents and children about prevention of injury and illness and about proper use of the EMS system. School nurses also are well-placed to help educate parents and children. A third important role, one that is especially pertinent for pediatricians to consider, is participating in the planning and operation of EMS systems. In rural areas and small communities, office- based physicians are an important source of medical direction for prehospital services. They can contribute pediatric expertise that may otherwise be lacking. The AAP's (1992e) recently published manual, Emergency Medi- cal Services for Children: The Role of the Primary Care Provider, provides valuable guidance for all of these roles. The Community Members of the community contribute to the operation of EMS systems in a variety of ways. Volunteers who provide prehospital services in many communities have, perhaps, the most visible role, but other activities are important as well. Public education programs on safety and on use of the EMS system organized by individuals, organizations, and schools help reach diverse groups and can emphasize specific messages (e.g., bicycle and sports

EMS SYSTEMS: ORIGINS AND OPERATIONS 93 safety for parents and children or appropriate responses to chest pain for older adults). Local fund-raising efforts for equipment and training can enable EMS systems to respond to special community needs, including EMS- C. Parents can bring EMS-C concerns to the attention of a variety of groups in the community and can-as role models-encourage children to adopt safe and healthful behaviors. Par0cipal;~on ~n advisory groups pro- -~r~des an opportunity lo shape policies. Members of the community can also become advocates for their concerns at the state level. Other EMS Systems Two other atypical EMS "systems" might be mentioned here, both with a need to provide care for pediatric patients. The Indian Health Service and the Department of Defense provide medical care to sometimes isolated populations scattered across the country. Their concerns combine the oversight typical at the state level in other EMS systems and the actual delivery of services at the local level. Planning in these medical systems needs to address guide- lines for pediatric emergency care that are appropriate for the settings in which their service providers operate. In addition, it should address coordi- nation with surrounding communities in order to facilitate access to appro- priate levels of care. Enhancing EMS-C at the Local Level At the local level, providing EMS involves many interested parties and includes political and jurisdictional concerns as well as those related to care of patients. For EMS-C, this means that there are many channels through which to work and which must be taken into account. As noted in Chapter 1, progress can be achieved through a "top down" approach in which local areas respond to new requirements implemented through the efforts of state and national agencies and organizations, but it can also be realized from the "bottom up" by making use of individual and community interest to pro- mote changes or provide resources that can lead to better care. Professional and Voluntary Organizations Many organizations that do not participate directly in the operation of EMS system elements or in the delivery of care are, nevertheless, important in influencing the development of EMS in general and EMS-C in particular. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), for example, establishes standards for hospital services, including the ED, and conducts periodic reviews at individual hospitals to monitor compliance with those standards (JCAHO, 1990~. The current ED requirements call for

94 EMERGENCY MEDICAL SERVICES FOR CHILDREN written policies and procedures on the management of pediatric emergen- cies and child abuse but make no other explicit reference to pediatric care. Because the JCAHO has such a substantial influence on hospital practices, it may prove to be an important vehicle for advancing EMS-C. Similarly, EMS-C advocates will need to work with organizations that oversee professional standards and that represent the interests of their m:em- bers. A long list of organizations could begin with groups such as the AAP, ACEP, ENA, and NAEMT, whose members deliver emergency care to chil- dren, the American Hospital Association, the American Medical Associa- tion, and the American Nurses Association, which have broad interests in health care services; and the Accreditation Council on Graduate Medical Education, the National League for Nursing, and the Committee on Allied Health Education and Accreditation, which have a role in the accreditation of training programs. As noted above, professional organizations representing the providers of emergency medical care have played an especially large role in establish- ing an identifiable field of expertise. Their guidelines for facilities, equip- ment, and care provide authoritative reference points for evaluating ele- ments of EMS systems, and their training programs help bring important new information and skills to providers already in practice. They provide their members with a forum for exchanging ideas and with a nationally recognized voice for speaking to broader audiences about issues of concern. For EMS-C, such organizations have pursued efforts to bring attention to deficiencies in pediatric emergency care, to implement new standards for care, to develop training materials, to secure federal and state funds for EMS-C programs, and to represent pediatric interests in legislative and pro- grammatic arenas. An organization not previously mentioned, which has been involved in developing standards for prehospital services, is the American Society for Testing and Materials (ASTM). This voluntary organization (whose activi- ties span a broad range of fields' provides a framework for interested par- ticipants to develop consensus standards. Working with NHTSA, an ASTM committee is addressing a variety of nonclinical aspects of EMS systems, including equipment, training, management, and communications. Public service and advocacy organizations also play a role in EMS and EMS-C issues, particularly in public education and awareness. The Ameri- can Red Cross, for example, has a long tradition of teaching first aid and water safety skills to children and adults. They and the AHA have each developed courses for the public in CPR. The National Safety Council, through a variety of publications and activities, promotes discussion of safety and health concerns. The National SAFE KIDS Campaign organizes na- tional and local activities to educate parents and children about injury pre- vention and seeks corporate and public-sector action to promote safety and

EMS SYSTEMS: ORIGINS AND OPERATIONS 95 injury prevention. Some private groups contribute considerable financial support for the operation of specific kinds of facilities; for example, the Kiwanis International Organization has underwritten creation of pediatric trauma centers, and the Shriners have given special support to burn centers. Many other organizations concerned with child health and welfare are potential advocates [or 1SMS-C on the national, state' and local levels. Some of these might include the Children~s Defense Fund, the Ch~dren~s Salty Network, church groups, Mothers Against Drunk Driving (MADD) and Stu- dents Against Drunk Driving (SADD), Parent-Teacher Associations, scout- ing organizations, YMCAs and YWCAs, and sponsors of organized sports for children. These organizations only begin to illustrate the many groups that are currently active (or that might become active) in efforts to prevent injury and illness in children and to ensure high-quality emergency care for children who need it. Funding for EMS Systems Funding mechanisms and levels for EMS systems are difficult to sum- marize. They vary across the components of systems, across systems within a state, and across states. At the local level, public funding (from local revenues or state allocations) may support or subsidize prehospital care as a public service similar to police or fire departments; some systems use sub- scription or fee-for-service approaches instead of or in addition to public funding. Some communities may depend on privately owned ambulance services to provide prehospital emergency care. For the many prehospital systems, especially in rural areas, that are built around volunteer providers, public funding may be available to offset some operating costs, but local fundraising efforts are often critical, especially for purchases of ambulances or other costly equipment. In general, hospital ED and inpatient care is provided on a fee-for- service basis (or under the prepayment or copayment arrangements of health maintenance organizations). Private insurance and Medicaid provide at least partial payment for many prehospital and acute care services. Insurance coverage of outpatient or rehabilitation follow-up care is generally limited, however. EMS agencies and hospitals, particularly trauma centers, that care for uninsured patients can incur substantial unreimbursed costs (GAO, l991b; Mendeloff and Cayten, 19911. In many states, EMS activities at the state and local levels are funded, at least in part, by state appropriations of general funds. The amount of such appropriations varies quite widely from none in Virginia to about $28 million in Hawaii (NASEMSD, 1991; Emergency Medical Services, 1992~. EMS can also receive state funds through specially designated ap- propriations. At least 18 states rely on fees or surcharges (e.g., on vehicle

96 EMERGENCY MEDICAL SERVICES FOR CHILDREN or driver registrations or on fines for moving violations) designed specifi- cally to raise funds for EMS activities (NASEMSD, 19911. Virginia, for example, added a $1.00 fee to motor vehicle registrations in 1983 (Mayer et al., 1990~; in 1990, the fee was raised to $2.00 (Code of Virginia, § 46.2- 694), generating about $10 million in 1991. In 1991, Minnesota adopted a $25.00 fine (increased from $10.00) [~r seatbelt violations, 90 percent c>f the fines collected are d~str~uted to the status eight regional EMS systems (Emergency Medical Services, 19921. Using a similar approach, various states and local areas have adopted surcharges on business and residential telephone service to fund 9-1-1 telephone systems. As has been described, federal funding is also available to support state and local EMS activities, particularly through the Preventive Health Ser- vices Block Grant and Section 402 highway safety funds. Overall, states allocated about $13 million to EMS out of $86 million in prevention block grant funds for FY 1990 (Public Health Foundation, 1991~. This represents about 10 percent of the total of $127 million that state health agencies are estimated to have spent on EMS (Public Health Foundation, l991~.5 A few states also have used small amounts from the Maternal and Child Health Block Grant for EMS. Beginning in 1986, the EMS-C demonstration grant program has contributed an additional $2 million to $5 million dollars. Unlike block grant funding, which is available to every state, only a limited number of EMS-C grants are made each year to support specific projects intended to advance EMS-C capabilities. Comparing EMS funding across states or communities is difficult. Ap- parent differences in levels of state support reflect not only differences in fundamental commitment to EMS but also in the regulatory and operational functions for which the state or locality is responsible (Smith, 1990~. An assessment of total funding for EMS activities in a state requires taking into account regional, county, and community contributions as well as state funding. Comparisons must also consider the value of EMS services provided by volunteers or by private ambulance services that, in other states, are paid for with public funds. The serious fiscal constraints facing many state and local governments mean that all publicly funded programs must be carefully scrutinized; the variety of approaches used across the country to organize EMS systems provide many models that might be considered. As federal legislation ex- tends Medicaid eligibility to more children, the impact of emergency sys- tem care may become a concern. The added children may, however, repre- sent only a small component of Medicaid costs. Even with a 25 percent increase over the past decade in the number of children served by Medicaid, they continue to represent about 44 percent of Medicaid recipients and only 14 percent of Medicaid expenditures (Cartland et al., 19933.

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

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.

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

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)

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.

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.

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.

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

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

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

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.

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How can we meet the special needs of children for emergency medical services (EMS) when today's EMS systems are often unprepared for the challenge? This comprehensive overview of EMS for children (EMS-C) provides an answer by presenting a vision for tomorrow's EMS-C system and practical recommendations for attaining it.

Drawing on many studies and examples, the volume explores why emergency care for children--from infants through adolescents--must differ from that for adults and describes what seriously ill or injured children generally experience in today's EMS systems.

The book points the way to integrating EMS-C into current emergency programs and into broader aspects of health care for children. It gives recommendations for ensuring access to emergency care through the 9-1-1 system; training health professionals, from paramedics to physicians; educating the public; providing proper equipment, protocols, and referral systems; improving communications among EMS-C providers; enhancing data resources and expanding research efforts; and stimulating and supporting leadership in EMS-C at the federal and state levels.

For those already deeply involved in EMS efforts, this volume is a convenient, up-to-date, and comprehensive source of information and ideas. More importantly, for anyone interested in improving the emergency services available to children--emergency care professionals from emergency medical technicians to nurses to physicians, hospital and EMS administrators, public officials, health educators, children's advocacy groups, concerned parents and other responsible adults--this timely volume provides a realistic plan for action to link EMS-C system components into a workable structure that will better serve all of the nation's children.

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