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Emergency Medical Services for Children (1993)

Chapter: 5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE

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Suggested Citation:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." 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:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Page 174
Suggested Citation:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Page 175
Suggested Citation:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Page 176
Suggested Citation:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Page 177
Suggested Citation:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Page 178
Suggested Citation:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Page 179
Suggested Citation:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Page 180
Suggested Citation:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Page 181
Suggested Citation:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Page 182
Suggested Citation:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
×
Page 183
Suggested Citation:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Page 184
Suggested Citation:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Page 185
Suggested Citation:"5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE." Institute of Medicine. 1993. Emergency Medical Services for Children. Washington, DC: The National Academies Press. doi: 10.17226/2137.
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Page 186

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

s Being Ready to Deliver Good Care: Putt.i.ng Essential Wo.is in Place Training members of the public and providers of health care how to respond to emergencies in children and how to use the emergency medical services (EMS) system is not enough in itself. Those providers need to have system resources available that enable them to use their training and skills successfully. The committee identified specific areas in which EMS systems warrant redoubled efforts to meet the needs of pediatric patients: equipment, protocols, medical control, categorization of facilities, and region- alization of care. This chapter cites advances that have been made to date, identifies persistent problems, and presents the committee's conclusions about appropriate steps to overcome those problems and to strengthen emergency medical services for children (EMS-C). DEFINITIONS Equipment refers to both reusable and disposable items that are used in providing emergency care. It includes supplies such as intravenous (IV) catheters, blood pressure cuffs, endotracheal tubes, medication charts, and field-to-hospital communications devices, as well as medications. Protocols are standardized sets of procedures or decision algorithms that are developed to guide patient care. They exist, and are generally needed, for all phases of emergency care. In some cases, protocols direct the process of care in the EMS system (e.g., logistics and procedures, such as determining the hospital to which a patient is taken). In other cases, they direct the content of care (e.g., specific interventions and medications). The 149

150 EMERGENCY MEDICAL SERVICES FOR CHILDREN concept of protocols overlaps considerably with that of "clinical practice guidelines," which the Institute of Medicine defines as "systematically de- veloped statements to assist practitioner and patient decisions about appro- priate health care for specific clinical circumstances" (IOM, 1990a, p. 8; 1992~. In this report the committee retains the term protocol, which is widely understood in the EMS community. Medical control-refers to physician oversight of care provided by prehospital personnel. That ove~ight is given in two ways: on-line, that is, directly by a physician (or a designated alternate) to emergency medical technicians (EMTs) and paramedics during their care of individual patients; and off- line, by physicians who participate in developing standardized procedures and planning for and ensuring the quality of prehospital services. Categorization offacilities and regionalization of care are usually closely linked. Categorization refers here to a variety of methods for evaluating and identifying the capabilities of hospitals and other facilities to provide adequate and appropriate care to patients. Because it is impossible for every facility to render the most sophisticated care for all types of patients, the few that can provide those services often become regional referral cen- ters. In this report, regionalization of care refers to deliberate efforts in predetermined geographic areas to identify facilities with special capabili- ties and to develop relationships between those facilities and the communi- ties and facilities that would look to them as a source of specialized care. EQUIPMENT The Right Kind and the Right Size Emergency care for children, especially very young ones, often requires equipment and medications specifically suited to children. Because of the traditional emphasis in EMS systems on adult trauma and cardiac care, standard equipment and supplies often do not include materials appropriate for treating children. Some adult equipment can be adapted for pediatric patients, but many items are too large or otherwise unsuitable. Other items that are unique in caring for children (such as papoose boards, bulb sy- ringes, pediatric IV equipment, or even cuddly toys) are likely to be missing altogether. The issue of equipment, medications, and supplies is not, how- ever, a simple dichotomy of "adult" and "pediatric." Because children, themselves, vary in size and development, pediatric equipment and supplies need to be available in a range of sizes so that proper care can be provided to all children, from infants to adolescents. The lesson that "children are not little adults" has been an important one to learn in many aspects of EMS, especially in defining essential equip- ment. For example, many ambulance units and hospital emergency depart

BEING READY TO DELIVER GOOD CARE 151 meets (EDs) do not have pediatric-sized cervical collars. This leads to children being placed in collars that are too large, often obscuring their faces and even impairing ventilation. Only recently have significant design changes been made by manufacturers, such as producing stiff collars suit- able for small children or babies. Lack of appropriate-sized IV needles may preclude obtaining vascular access and thus prevent the administration of a life-saving medication; lack of other pediatric IV equipment to control the rate of fluid administration exposes the child to inadvertent administration of potentially dangerous volumes of fluid; and use of adult bag-valve-mask devices can allow excessive ventilatory volumes and pressures to force air into the chest cavity causing pneumothorax. Some differences between children and adults are particularly sign~- cant (Mellick and Dierking, l991a,b). The proportions of children's bodies . are not the same as adults'. For instance, a young child's head is much larger relative to the rest of his or her body; this increases the risk of head injury and also means that techniques and equipment for achieving proper alignment and immobilization of the head and spine must accommodate these anatomic differences. Important anatomic structures, particularly in the upper airway, are not just smaller in children but are also located differently. Many medications used in the emergency care of adults are suitable for children, but the doses must be different. Pediatric drug carts are desirable, and when prefilled syringes are used, they should be available in pediatric dosages. Because the appropriate dosage varies across the pediatric age range, having prefilled syringes for all needed medications in all dosages is impractical. Therefore, personnel need to know how to determine appropri- ate doses and concentrations of solutions for their pediatric patients. De- vices such as the Broselow Tape (used to measure a child's length, from which it provides an estimate of weight and appropriate drug dosage) can help in making those determinations (Lubitz et al., 1988~. Finally, children also differ from adults in the nature of the emergencies they experience. For example, children rarely experience primary cardiac emergencies, but they are very likely to experience severe respiratory dis- tress or hypovolemia, which can lead to cardiopulmonary arrest if an adequate airway, ventilation, and oxygenation cannot be achieved. Thus, it is especially important for emergency care providers to have available equipment and supplies suitable for airway and respiratory management of children. Lack of Pediatric Equipment Deficiencies in equipment for treating pediatric patients exist through- out EMS systems and have been documented in various surveys over the past 10 to 15 years. Prehospital providers received some of the earliest attention. In 1978, the pediatric community in Los Angeles began working

52 EMERGENCY MEDICAL SERVICES FOR CHILDREN with the county EMS authority to develop pediatric equipment standards for county ambulances (Seidel, 1989~. In the early 1980s, a survey of 82 EMS agencies across the country demonstrated a widespread need to increase the availability of many kinds of basic equipment (Seidel, 1986a). For ex- ample, 79 percent of the responding agencies did not carry complete sets of masks for bag~valve~mask resuscitators. The survey also showed that, even when appropriate equipment guidelines were in place, ambulances did not always carry the recommended items. Various ED and critical care categorization programs tend to reveal the deficiencies in those settings. A survey by the Maine EMS-C project showed "considerable variation" among EDs in the airway management equipment available (Maine EMS-C Project, 1991, p. 23), and the project's physician advisory board expressed concern over the impact this might have on pa- tient care. A group of hospital EDs in Arkansas proved to be less well prepared for emergency care of newborns and infants than for older children (Scotter et al., 19901. Items not available in some hospitals included infra- red warming lights, infant oxygen masks, and tracheostomy tubes (sizes O to 5~. Some problems with lack of equipment can extend even to the pediatric wards and intensive care units (ICUs). Emergencies also arise in the office setting, but studies have found deficiencies among adult and pediatric providers in equipment and supplies needed to manage a variety of emergency conditions (Kobernick, 1986; Barth et al., 1989; Fuchs et al., 1989; Altieri et al., 1990; Schweich et al., 1991; Seidel et al., 1991a). A study focused specifically on the prepared- ness of pediatricians found that those in solo practice had the most limited equipment available, whereas health maintenance organizations (HMOs) were generally the most completely equipped (Schweich et al., 1991~. For spe- cific emergencies, the investigators found that all types of practices were best prepared to treat severe dehydration and least prepared to treat cardio- pulmonary arrest. Even so, among the solo practice group only 35 percent had all of the equipment deemed necessary to treat severe dehydration, and of the HMO practices only 58 percent were equipped to treat cardiopulmo- nary arrest. Pediatricians who had basic equipment available were more confident about managing emergencies, regardless of the practice setting, than those who had no such equipment on hand. Some ambulatory (or urgent) care centers also lack appropriate equipment for pediatric emergen- cies, even though they sometimes treat children for serious conditions such as seizures and anaphylaxis (Seidel et al., 1991 a). What Should Be There? The supplies needed to care appropriately for children range very widely. They can include standard medications needed for resuscitation that are

BEING READY TO DELIVER GOOD CARE 153 packaged in small amounts; infant stethoscopes that are not so large as to cover the entire torso; defibrillation paddles that fit on a child's chest; swaddling devices to keep children still when painful procedures are needed; and toys that can comfort children during transport or emergency room care. Many lists of pediatric equipment and supplies needed to provide emer- gency medical care for children exist. Several groups with EMS-C grants from the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (DHHS) developed such lists for a mix of prehospital providers, hospital EDs, and ICUs; a catalog summa- rizes products produced by the early EMS-C demonstration projects (Shaperman and Backer, 1991~. In California, Maine, Washington, Wisconsin, and New York City, those lists have been incorporated into official state or local requirements (California Code of Regulations, Title 13, § 1103.2; Wiscon- sin EMS-C Project, 1990; Maine EMS-C Project, 1991; Washington EMS-C Project, 1991~. Several professional societies have developed lists of equipment, sup- plies, and medications for different settings. For example, equipment lists for the ED and the ICU appear in the American Medical Association (AMA, 1990) categorization guidelines. The emergency care guidelines adopted in 1991 by the American College of Emergency Physicians (ACEP, 1990a, 1991) also include a list of suggested equipment for EDs for both adult and pediatric patients, and ACEP (1992a) has also approved guidelines for prehospital pediatric equipment. The Committee on Pediatric Emergency Medicine of the American Academy of Pediatrics (AAP) provides up-to-date suggestions for equipment, supplies, and medications for basic and advanced life sup- port for the pediatric age group and for newborns; the target settings are primary care physician offices, ambulances, and EDs (AAP, 1992e). Equip- ment lists for pediatric ICUs (PICUs) were published jointly by the AAP and the Society of Critical Care Medicine (SCCM) some years ago (AAP/ SCCM, 1983; SCCM, 1983~; development of revised standards, which may be available in 1993, is again a joint AAP and SCCM effort. Mellick and Dierking (1991a,b) review the kinds of pediatric equip- ment available and factors to consider in selecting specific items for prehospital care; they advocate taking into account significant characteristics of pediat- ric patients (particularly children under age 10), such as developmental level, basic temperament, health status and underlying conditions, environ- mental issues, anatomic considerations, and physiologic considerations. The authors argue for identifying "a standard core" (p. 35) of pediatric equip- ment needed to control airways; support breathing; maintain circulation; accomplish vascular access; monitor cardiac status; and immobilize patients, extremities, and head and cervical spine. They also suggest considering equipment protecting against exposure to infectious diseases as well as other

54 EMERGENCY MEDICAL SERVICES FOR CHILDREN items, such as obstetric packs, car seats, and a reference card for scoring severity of pediatric trauma. The lists cited above vary in their details, and many tend to be quite long. Generally, they represent simply opinions of the authors or a body of experts; data to demonstrate the importance of many pieces of equipment are scarce. Readers who wish to have more definitive and comprehensive information might best track the periodic updates of recommendations is- sued by the major professional societies, such as AAP, ACEP, and SC:CM. Some of this variation in recommendations for equipment and supplies reflects still-reasonable differences of opinion as to what interventions pro- viders with varying levels of training should be allowed to perform as well as unavoidable state and local differences in capabilities of and expectations for providers. For example, controversy still exists as to whether paramed- ics should be allowed to intubate children or perform needle thoracentesis and whether EMTs can start IV lines. The pediatric equipment available to providers should allow them to perform all authorized procedures. Differ- ences among the lists may also reflect uncertainty among experts about the effectiveness of certain kinds of equipment. Tsai (1990), for instance, points out conflicting views on the safety and effectiveness of prehospital use of four kinds of equipment: endotracheal tubes and supplies, pneumatic antishock garments, intraosseous needles, and pediatric backboards. Acquiring and maintaining equipment must be an ongoing process. Because many providers will encounter pediatric emergencies relatively infrequently, their equipment, medications, and supplies may deteriorate or become out- moded. Unless such products are monitored on a regular basis, they may be inadequate in the event of a true emergency or induce an inappropriate sense of security among practitioners and institutional providers. In sum, the committee did not attempt to create a definitive list of equipment and supplies necessary for treating pediatric emergencies in any particular practice setting. Instead, it states the following imperative: Each health care provider or agency must define the emergencies that occur in the patient populations that they serve, define the emergency care appropriately provided in that setting, and ensure that the equipment and supplies needed to provide such care for those emergencies are available and ready to treat critically ill or injured neonates, infants, children, and adolescents. To make this more concrete in the context of the recommendations in Chapter 8 about state EMS-C agencies, the committee recommends that all state regulatory agencies with jurisdiction over hospitals and emer- gency medical services systems require that hospital emergency depart- ments and emergency response and transport vehicles have available and maintain equipment and supplies appropriate for the emergency care of children. The objective is to repose responsibility and authority for

BEING READY TO DELIVER GOOD CARE 155 attention to EMS-C equipment and supplies in at least the prehospital and ED settings in a specific place, to two ends: first, that at least a minimal level of essential equipment is maintained in all hospital EDs and by all EMS systems; and, second, that a desirable level of consistency in require- ments is achieved while still permitting appropriate variation and flexibility needed ~n special (e.g.- geographic or financial) circumstances. Costs Financial considerations are, of course, a factor in determining what equipment for EMS-C is essential, but in general the cost of basic pediatric equipment and supplies is low. As a rule, the cost of individual items will not be higher for pediatric materials than for adult supplies; it is, however, necessary to maintain a wider variety of sizes owing to the substantial variability of the pediatric patient population. For example, an adult ambu- lance unit might need to carry only one size of central venous line catheter; a properly equipped unit taking care of children might need to carry four or five different sizes. A similar point can be made about a host of items (e.g., suction catheters, nasogastric tubes, laryngoscope blades) for most of the settings in which emergency care might be rendered to children. Monitor- ing equipment also needs to have a pediatric capability. For instance, sev- eral different sizes of pulse oximetry electrodes may be needed to cover the full pediatric age range, whereas only one size is needed for adults; simi- larly, monitors used to track the heart rates of infants require special pediat- ric algorithms in their software. Nevertheless, even these factors may not raise an insurmountable cost barrier for most systems. An estimate from Memphis, Tennessee, puts the additional cost of pediatric equipment for an ambulance at about $385 (Larry Youngman, City of Memphis Division of Fire Services, personal communi- cation, October 1992~. The San Diego Division of Emergency Medical Services estimated that additional equipment for a basic life support (BLS) ambulance would cost about $480; the equipment needed beyond that for an advanced life support (ALS) ambulance would cost about $295. Costs of stocking and replacing appropriate pediatric equipment and supplies also are low in comparison with the costs of similar goods for adults. For instance, Foltin and Cooper (forthcoming) point out that complete pediatric equipment and supplies for an ambulance are much less costly than a single semi-automatic defibrillator, which would be used for adult cardiac pa- tients. Altieri and colleagues (1990) estimated that basic equipment to contend with pediatric emergencies in office settings amounted to $1,200. Certainly, the cost of equipment and materials need not be high for EMS systems that already have a solid base from which to work.

156 EMERGENCY MEDICAL SERVICES FOR CHILDREN Not surprisingly, advanced pediatric emergency care does require more costly equipment than basic emergency services. As with the above discus- sion, however, these costs (or those for PICUs) need not exceed those for equivalent services to adults. To the extent that outlays for PICUs exceed what can be managed by many different hospitals, the argument for regionali- zation of that level of service is strengthened. This committee recognizes that along with costs for equipment and supplies come costs for personnel, special training (as discussed in Chapter 4), and similar "nonhardware" elements of EMS-C. Further, these aspects of financing EMS-C can be significant, especially in situations in which not much progress has been made in building a solid EMS-C element into the existing EMS system. The argument here, however, is focused on costs of specific equipment and material needed for pediatric care. Because this committee regards the aim of integrating EMS-C into the existing frameworks of EMS and child health care as crucial, it also believes that these costs should be seen as relatively small marginal investments on top of those already being incurred for the basic system. One argument for that view is that the much greater costs of staffing and capital equipment for overall system operation have already been incurred. A second argument is that having the proper equip- ment reduces the significant cost in morbidity and mortality that children might experience if they cannot receive needed care because only adult equipment is available or if they are treated with inappropriate equipment and supplies. In sum, the committee believes that the cost of essential pediatric equipment is minimal; thus, costs cannot and should not be ad- vanced as a justification for depriving children of necessary, basic emer- gency care. PROTOCOLS Value of Protocols Knowing what to do for each and every patient whom a provider sees is not an easy task. When that patient may be experiencing a life-threatening emergency, the need to make correct decisions quickly places even greater demands on providers. When that emergency patient is a child, much anec- dotal evidence suggests that anxiety levels are especially high. Moreover, except for those who specialize in pediatric emergency medicine, providers are likely to see seriously ill or injured children only infrequently, making it difficult for them to remain familiar with the special needs of children. Even more demanding are those emergencies that involve children with chronic illnesses or other special health care needs. Finally, as with equip- ment~ care appropriate for adults is often inappropriate for children.

BEING READY TO DELIVER GOOD CARE 157 To address these complexities for EMS-C, the value of reliable and valid protocols cannot be overstated. (The potential value of sound, defini- tive practice guidelines generally is discussed in two recent reports tIOM 1990a; 1992], and many of the points made there apply equally well to protocols in the EMS context.) The availability of protocols to guide decisionm~ing whether computerized algorithms' flow charts on wall posters' simple narrative guides, pocket-sized reminder or reference cards, or other types of guidelines allows the provider to benefit from a carefully consid- ered analysis of a broad range of experience. Protocols help ensure that providers examine all important information and perform the appropriate sequence of procedures. Protocols adopted by an EMS system help to standardize the care given by all of the system's providers around a mutually agreed-on set of steps and interventions. A goal might be to have the capability of dealing with 95 percent of the cases seen in typical EMS settings, since no planner or guide- line developer could possibly anticipate every emergency or develop defen- sible guidelines for them. The crucial grounds for developing and applying protocols lie in the area of improving the quality of EMS-C care throughout EMS systems, although ready access to and general compliance with high quality, authoritative guidelines and protocols may also offer some protec- tion from malpractice liability claims as well. The EMS-C demonstration projects sponsored by HRSA developed various kinds of protocols, including ones concerned with transport, triage, resusci- tation, and management of various pediatric conditions (e.g., trauma, car- diac rhythm disturbances or arrest, and suspected child abuse) in the prehospital and hospital settings (Shaperman and Backer, 1991~. Some of these guide- lines are lengthy and detailed, but they need not be so; protocols (as the term is understood in this field) may, in fact, be simple reminder cards or poster charts. The Washington State EMS-C project (1991), for example, produced laminated information cards for both BLS and ALS personnel to carry in their uniform pockets or in equipment boxes. These provide a rapid reference source for pediatric equipment size, drug dosages, and vital signs, and they are considered to be of special importance for providers and re- sponders whose contact with pediatric patients may be infrequent. Needs Throughout EMS Systems Protocols have a role to play in every phase of the EMS system. They help direct decisions about when and where care needs to be given as well as guide what care is given and how it is given. Each phase of care needs specific kinds of guidance, as discussed briefly in this section in terms of dispatch, prehospital services, EDs, and inpatient care.

158 Dispatchers EMERGENCY MEDICAL SERVICES FOR CHILDREN Children who enter the EMS system through a call to an emergency response system (often using 9-1-1) receive their first emergency services from the operator or other dispatch personnel answering such calls.2 The organization of dispatch systems and the training and skills of dispatchers vary widely (see Chapter 43. Many systems and personnel have little or no medical oversight even though they play a critical role in facilitating the delivery of urgent medical care; others may have had training in delivering emergency medical telephone instructions or long-time experience in dis- patching ambulances. Regardless of formal training or experience levels, however, dispatchers must be able to evaluate the nature of the problem and determine what sort of response is needed. These triage decisions may determine whether ambulances with ALS or BLS intervention skills are sent, whether air or ground units are used, or sometimes whether any EMS . . unit IS sent. Protocols exist in some systems to assist dispatchers in making these determinations in a systematic way. Those protocols must incorporate tools to evaluate pediatric cases. In a recent study, Foltin and colleagues (1992) determined from a retrospective evaluation of the appropriateness of ambu- lance dispatch in New York City that of nearly 100 children triaged by dispatchers as requiring ALS units, 45 percent warranted only BLS response and another 27 percent did not even require an ambulance; conversely, of about 145 children triaged as needing only BLS services, some 60 percent in fact needed ALS response. An assessment has not yet been made of the consequences for the child of these misassignments. These data do suggest that ALS resources are not being used efficiently. When an ALS unit is used for less serious cases, it will not be available for those who truly require that level of care; if an alternate ALS unit is avail- able, it may have a longer response time to the site of the emergency. The investigators suggest that protocol revisions and more training in the use of triage and dispatch protocols might enable the system to improve allocation of these prehospital resources. Their "Pediatric Ambulance Need Evalua- tion" (PANE) instrument may be one means of evaluating and identifying problems of both overtriage and undertriage (Foltin et al., 1992~. Appendix 7A reviews a variety of scoring instruments that have been devised to aid in triage decisions (in prehospital and other stages of emergency care) and to make retrospective assessments of the appropriateness of those decisions. Dispatchers also contribute to emergency care through "prearrival in- structions" to callers. Such instructions need to be appropriate to the condi- tion of the patient, and they need to be provided in a way that makes them useful to the caller. When the patient is a child, dispatchers often must deal with any special anxieties of their own and with the distress of the parent or other caller. Clawson and Hauert (1990) emphasize the need for guidelines

BEING READY TO DELIVER GOOD CARE 159 designed specifically for dispatchers, describing the unique conditions un- der which dispatchers provide BLS services: "Thrust in the role of 'instruc- tor,' the dispatcher must teach the caller (an unwilling student) a physical procedure in a matter of seconds, without visual aids of any kind or even any opportunity to practice" (p. 84~. Kellermann et al. (1989) have demon- strated the efficacy of d~spatcher-assisted cardiopulmonary resuscitation (CPR). at least for adults.3 Prehosp~tal Personnel Assessment and Initial Treatment Until the emergence of courses such as Pediatric Advanced Life Support (PALS), Advanced Pediatric Life Sup- port (APLS), and those developed by HRSA's EMS-C grantees, most EMTs and paramedics had little access to training in the care of children. Most also have little opportunity to gain hands-on experience because of the relatively small number of children cared for by the prehospital system. Protocols that guide EMTs and paramedics through the assessment and care of children can, to some extent, lessen the effect of these limitations. Protocols for prehospital care of children need to reflect sound medical judgment regarding the best forms of care, the levels of training among providers, and the setting in which the EMS system operates. They should be jointly developed by physicians and others with expertise in both emer- gency medicine and pediatrics. They should guide care given under an EMS system's standing orders (a product of off-line medical control) and specify when on-line direction from a base hospital or other medical control point is required. Medical control is discussed further in the next major section of this chapter and in Chapter 6. Protocols may be relatively easy to devise for "extreme" situations. As a case in point: In an urban area where rapid access to sophisticated hospi- tal care is possible, a system can emphasize quick transport to specific EDs and BLS-level care en route rather than extensive ALS care at the scene. New York City, for example, follows such an approach with provisions for ALS procedures in the event of delays in reaching the hospital (Foltin et al., 1990~. By contrast, protocols for EMS systems serving rural areas need to accommodate longer transport times and distances, various forms of trans- port (including helicopters, airplanes, intensive-care vans, or other means), and the problems posed by the relative scarcity of hospitals and the more limited resources of hospitals that are available. Thus, more ingenious solutions may be needed (e.g., a predesignated rendezvous-hospital ED) (Johnston, 1989~. These locale-specific policies may be easy to understand, but a large gray area exists in determining the appropriate choice between providing more extensive treatment at the scene and rapidly transporting a child to an

160 EMERGENCY MEDICAL SERVICES FOR CHILDREN emergency facility after providing only minimal on-scene treatment (Border et al., 1983; Pepe et al., 1986; Gold, 19871. The decision may depend on specific circumstances such as the nature of the child's injury or illness, the skills of the prehospital providers, and the transport time to reach definitive care. Even when time is taken to achieve initial resuscitation at the scene, other problems may arise if the team transporting the child is not well versed In ma~nta~n~rt~ resuscitation during the trip. Because the ava~le data do not clearly indicate which approach leads to better outcomes or which circumstances call for which approach, the committee urges further research on the optimal balance between on-scene treatment and more rapid transport to definitive care. Pediatric transport is one area, therefore, where local circumstances and resources, as well as situation-specific extrication time and assessment of a child's condition, all play a role. Guidelines appropriate for adults may not be entirely applicable, because of the greater number of different problems throughout the pediatric age range. For example, McCloskey and Orr (1991) cite "the 2-week-old with a cardiac defect, the 2-month-old with near-miss sudden infant death syndrome, the 2-year-old with epiglottitis, the 4-year- old with meningitis, and the 10-year-old with multiple trauma" (p. 476~. Ramenofsky and his colleagues (1983) raised the possibility that non-EMS transport might be appropriate when transit time to the ED is less than the time needed for an EMS unit to arrive at the scene. Further investigation is needed on the merits of such non-EMS transport. This committee did con- clude, however, that parents and others with responsibility for children gen- erally need better education on "when and where to go" in emergency situa- tions involving young persons (as already discussed in Chapter 4~. Although national guidelines for transport, developed by personnel with formal experience in pediatric critical care or EMS, will be helpful, hard and fast rules for every situation and locale may not be feasible. The aim should be protocols that emphasize patient and transport team safety, that are based on appropriate processes of care that have been demonstrated to lead to good patient outcomes, and that are in accordance with current medico-legal requirements and common sense. Additional research is needed to establish what approaches are best in what circumstances. Field Triage EMTs and other prehospital personnel must be able to determine rapidly the hospital destination and mode of transport appropriate to the patient's condition. Triage guidelines should prevent both undertriage (directing seriously ill or injured children to too low a level of care) and overtriage (directing them to a higher level of care than their condition requires). Developing guidelines and decision tools that can successfully achieve this balance is difficult for pediatric and adult cases (Kane, 1985; ACS, 1990, Chapter 31. In San Diego County, for example, triage effi

BEING READY TO DELIVER GOOD CARE 161 ciency for trauma patients has not been optimal owing to the system's reli- ance on "absolute" triage; directing virtually every injured patient to a trauma center to minimize undertriage resulted in a 35 to 40 percent overtriage rate (McArdle et al., 1990~. Kane and colleagues (1985) found in a systematic assessment of optimal components of trauma triage tools that no one tool or set of components could suc-~es-sfully identify at the s em-e time a large proportion of those patients who needed trauma center care and those who did not. Triage decisions can be based on various criteria that relate to physi- ologic disturbances (e.g., altered level of consciousness, cyanosis, respira- tory distress), anatomic disturbances (e.g., facial burns, penetrating thoracic wounds), or the origin of the disturbance (e.g., specific mechanisms of injury such as a fall from more than 15 feet or signs of a specific illness such as meningitis) (California EMS-C Project, 1989; ACS, 1990; Emerman et al., 1991~. Such variables can be dealt with singly or in combinations (e.g., with checklists). More complex, formal scales that summarize several factors are also used to triage patients. Most relate directly to trauma, some to illness, and most are based on adult experience. In applying these measures to children, several factors must be taken into account: the effect on the variables and on the scoring criteria of differences between adults and children in physi- ologic response to illness and injury; the necrologic and psychological de- velopment level of a child (e.g., assessment of very young children cannot rely on a variable such as verbal response); and tendencies for EMS person- nel not to collect complete data on pediatric patients (e.g., blood pressures for very young children). Some groups have developed child-specific trauma scores for example, the Pediatric Trauma Score (Tepas et al., 1987; Tepas, 1989), the Children's Trauma Tool (Kitchen and Haubner, 1989), and the Triage-Revised Trauma Score (Eichelberger et al., 1989b)-although all need additional reliability and validity testing insofar as field triage is concerned. Adequate scoring systems specifically for field triage for pediatric illness have not yet been developed; some experts believe, therefore, that a criteria-based approach (as mentioned just above) is the most feasible at the moment (Gioia et al.. 1989~. The Maryland EMS-C Project (1992) is attempting to address the triage of illness as well as injury with a new scoring system the Pediatric Severity Assessment Tool (PSAT - intended to be suitable for use by prehospital, ED, and primary care personnel. The PSAT appears promising, but further testing and evaluation are needed to confirm its usefulness. Emerman and colleagues (1991) argue that trauma systems might do better to educate prehospital personnel in recognizing when a patient should be transported to a trauma center (e.g., "patients with evidence of physi- ologic derangement, penetrating truncal injuries or . . . more than a trivial

62 EMERGENCY MEDICAL SERVICES FOR CHILDREN risk of death" tp. 1374]' than to require them to calculate trauma triage scores in the field. In the context of decisions about invoking a special transport team for severely injured or ill children, Orr and colleagues (1992) describe a "common sense" approach based on whether the patient will be admitted to a PICU, has a high potential to develop significant respiratory, cardiovascular' or neurologic detenorati-on during transport; or has multiple injuries and leas not yet been stabilized in a trauma center. To be useful in the prehospital setting, scoring systems must allow paramedics and EMTs to calculate a score easily and reliably. In many programs, however, prehospital personnel do not do the actual scoring of such scales in the field; rather, they provide the data to medical control personnel, who calculate the scores and then decide on the appropriate destination for the patient. To the extent that this off-the-field triage scor- ing preempts decisionmaking by experienced EMTs or delays appropriate action, the advantages of using such scales at one remove remain to be demonstrated. Clearly, the simpler such scoring systems are, the better, if they are to be useful in determining where the injured child should be taken for definitive resuscitation and hospital management. Most scoring sys- tems, however, are multifactorial and are more useful in predicting outcome than in directing field triage of the injured child. Chapter 7 (and its Appen- dix 7A) presents a further discussion of scoring systems, particularly their use in assessing inpatient acuity and predicting mortality risks, and also takes up the problems of collecting reliable data to use in calculating scores. ED Staff It is critical for an ED to be able, at a minimum, to assess and stabilize pediatric patients and to facilitate their access to definitive care. That is, EDs face at least two major triage decisions: one involves priority for treat- ment; the other the criteria and procedures for referring patients to higher levels of care. Most children who receive care in an ED will be seen in a general hospital where the staff are unlikely to be pediatric specialists and must treat patients of all ages for an extensive array of conditions. Various kinds of protocols can help ED staff recognize the urgency of conditions in children and treat them appropriately, including transfers to specialty cen- ters as needed (Foltin and Fuchs, 1991~. Insofar as possible, triage tools applicable in the prehospital setting should be the same as, or consistent with, those used in the ED to help decide whether the child needs to be transferred to a higher level of care. Medical Control In many EMS systems, the ED begins participating in the care of patients before they arrive at the hospital through radio or telephone contact with prehospital personnel. This on-line medical guid

BEING READY TO DELIVER GOOD CARE 163 ance may provide authorization for specific procedures or for deviations from standard practice. Because children generally will account for rela- tively few of these cases, the ED staff providing on-line direction are less likely to remain familiar with the details of pediatric care. Protocols can help ensure that consistently appropriate medical control is provided when no unusual care is Hated Centralized on-line medical control with one or a small number of hospitals responding to calls can concentrate the num- ber of pediatric cases managed and help maintain the skills of the medical direction staff. Triage Decisions Involving ED Care Busy EDs must have a means of identifying patients who have the most immediate need for care.4 Trauma patients arriving by ambulance are readily recognizable; however, seriously injured infants and children can be harder to identify than adult patients. Triage algorithms and other guidelines, often based on scoring systems or on specific mechanisms of injury, have been developed for use by a variety of ED personnel (Wiebe and Rosen, 1991~. Seriously ill infants and children can be more difficult to identify than those presenting with injury or trauma. For example, missed meningitis is commonly listed as one of the leading causes of medical malpractice suits for emergency physicians, and some serious clinical entities (e.g., intussus- ception) can have a very subtle presentation. One unique pediatric phenom- enon is the "quiet blanket," in which an arrested or agonal child can be completely obscured by wrappings. Severity of illness measures for chil- dren are far less common than are trauma measures, and the challenges of developing them are greater than for adults, in part because children, espe- cially younger children, may not manifest classic clinical findings of the illnesses they do in fact have. Chapter 7 presents a brief discussion of certain measures that have been proposed for children. Long waits for care in urban EDs, which are increasingly used for treatment of minor illness or are overstretched with patients presenting with severe problems related to urban violence, make this initial triage especially important for infants and very young children. As Wiebe and Rosen (1991, p. 496) observe: "ES]erious morbidity can result from delays in recognition of illness severity. It is this same group of very young children that differs the most from adults in terms of physiology and behavior, making their evaluation particularly difficult and anxiety provoking for the staff of gen- eral EDs. The signs and symptoms in this group are particularly subtle and difficult to recognize." Because many of the indicators of illness in infants are subjective, Wiebe and Rosen have suggested that EDs that see relatively few children should triage all infants less than six months old to the highest priority category. In contrast, some EDs may develop policies that will help triage nurses

64 EMERGENCY MEDICAL SERVICES FOR CHILDREN and other personnel refuse care in specified circumstances (Rivara et al., 1986; Derlet and Nishio, 19901. They may refer patients to more appropri- ate settings such as offices of primary care providers, community health centers and clinics, hospital outpatient clinics, or a special service in the ED for minor emergencies, perhaps using an "assistance desk" or a room adja- c-~t to flee emerger~cy room itself. These referrals are made- when vital signs (temperature. respirations, blood pressure, and pulse) fall within ac ceptable limits or when the presenting complaints are relatively minor. in other approaches, a primary-care management program may include a pedia- trician-gatekeeper empowered to authorize ED care (with unauthorized care permitted in life-threatening situations); one experience with this approach, however, seemed to result in a large fraction of pediatric patients with "urgent" conditions being seen neither by the ED physician nor by their primary care gatekeeper (Straw et al., 1990~. Finally, by virtue of long waiting times, children may experience de facto triage and leave without treatment. Generally, this situation involves children who clearly were not emergency cases, but in some small fraction the problems will turn out to be urgent or emergent (see, e.g., Dershewitz and Paichel, 1986~. Among adult patients leaving an ED without being seen, serious conditions were common; 46 percent were judged to have been in need of immediate care, and 11 percent were hospitalized within the next week (Baker et al., 1991~. Even absent serious adverse sequelae to such a "triage" mechanism, this is not a desirable approach to rationalizing the use of EDs and reducing inappropriate use. Pressures continue to mount on EDs to be sites where many children seek primary as well as emergency care well beyond the capacity of better triage systems to handle. In Chap- ter 9, this report returns to the question of the future of EDs. Triage Decisions Involving More Complex Care At its second triage point, the ILL must be prepared to identify those children who need care beyond the capacity of the local hospital. Many children can, of course, be successfully treated in the EDs of smaller community hospitals that lack extensive pediatric specialty services. Definitive care for more seriously ill and injured children, however, may require transferring them to referral center hospitals. Guidelines to identify those patients should be available. Factors such as transport time and available methods of transport (e.g., air or ground) may need to be considered as well as the severity of the illness or injury (Harris et al., 1992~. Guidelines for the transfer process itself should be available as well (AAP, 1986; ACEP, 1991; Seidel and Henderson, 1991~. These should ensure compliance with existing laws for the transfer of patients, particu- larly the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (Public Law [P.L.] 99-272) (see also the discussion in Chapter 91.

BEING READY TO DELIVER GOOD CARE 165 COBRA 1985 holds transferring hospitals (or physicians) responsible for the appropriateness of a patient's transfer, the suitability of the type of transport used, and the "medical integrity of the receiving hospital" (Orr and Kennedy, 1991, p. 35~. Preexisting transfer agreements between com- munity hospitals and referral centers facilitate the movement of patients and define the responsibilities off sending and receiving hospitals Patient trans- fer is discussed further in the section below on regionalization of care and in Chapter 6. Response to Crisis Finally, protocols are needed to guide care for patients with major trauma, cardiopulmonary arrest, or similar life-threaten- ing conditions that call for nearly instantaneous response and often for mobilization of large numbers of health care professionals for a single case. Seizures and upper airway obstruction are among the more common condi- tions among critically ill children for which clear protocols can facilitate prompt appropriate care (Kissoon and Walia, 19891. For pediatric resuscita- tion, a protocol for establishing emergency IV access (involving increas- ingly invasive techniques within approximately 5 minutes of an unsuccess- ful attempt to insert a catheter into a peripheral vein through the skin) has been reported (Kanter et al., 1986~. Disaster preparedness protocols should exist for unusual conditions or mass casualty incidents involving large num- bers of patients (Holbrook, 1991~. Child abuse and sexual assault also should receive attention in ED protocols. These cases require a careful and systematic response to ensure that the child receives proper medical and psychosocial care and that appro- priate legal and administrative steps are taken. The ED staff (and others who care for these children, such as primary care providers) must be alert to those cases in which the true nature of the problem is not reported to medi- cal personnel, as may happen if a family member is the abuser. Inpatient Hospital Staff An immensely varied set of hospital units and personnel may be called upon to provide further care for children whose emergency care needs ex- tend beyond its ED. These range from ICUs, PICUs, and special care units (e.g., for trauma or burns) to various types of wards and services including children's floors.5 The value of protocols in these settings lies in enabling clinicians and providers to make appropriate decisions in two situations: responding to immediate crisis and deciding when and where to refer patients for other or later care. In the first situation, transfer protocols can be important when the facility cannot provide the needed care. The AAP (1986) adopted guidelines for the transport of children in 1986; revised guidelines are expected to be

166 EMERGENCY MEDICAL SERVICES FOR CHILDREN issued in 1993. Orr and colleagues (1992) also have developed advice on transportation of critically ill children. In the second situation, referrals may be made to other programs or services in the same institutions, to services in community hospitals more appropriate or convenient for the particular patient, or to rehabilitation services outside the acute care setting. Facilities that care for few seriously ill children face special challenges. For them, practice scenarios allow ED and inpatient staff to reacquaint themselves with the specifics of pediatric care and to test their readiness to follow existing protocols (Reder, 1991~. Personnel in Outpatient Settings Pediatric emergencies are also encountered in outpatient settings, and providers in those settings must be able to ensure adequate interim care. Training (e.g., in PALS or APLS) and equipment need to be accompanied by office preparation (Ludwig and Selbst, 1990~. These settings have limi- tations like those noted above for other locations. In a study in the Wash- ington, D.C., area, only 50 percent of the pediatric practices surveyed had formal plans for managing emergencies in the office and only 25 percent had some member of the staff certified in advanced cardiac life support (Altieri et al., 1990~. Other studies of pediatricians and family practitioners have found that no more than half routinely used ambulances to transport ill children in their offices to the ED (Baker and Ludwig, 1991, Schweich et al., 19911. The findings for life-threatening illnesses are striking 64 per- cent of children with epiglottitis and 70 percent of patients with meningitis were transported from the physician's office by private automobile rather than by EMS vehicles (Baker and Ludwig, 19911. To address the implica- tions of these and other factors involving outpatient settings, the AAP (1992e) has produced a manual containing recommendations about preparing the physician office for emergency settings and about the relationships among the primary care provider, the family, and the EMS system. Comment As noted, this committee elected not to develop or endorse any specific set of guidelines or protocols for equipment, personnel, supplies, or other elements of parts of an EMS system. In the committee's view, many useful protocols are available to national, state, regional, and local organizations; adopting, monitoring, or enforcing conformance with such guidelines is regarded as a responsibility of those entities. This committee does take the stance, however, that adopting and implementing some authoritative proto- cols is crucial to the successful incorporation of EMS-C into broader EMS systems throughout the nation and, ultimately more importantly, to good

BEING READY TO DELIVER GOOD CARE 167 patient outcomes. It also expresses its view that state EMS agencies may be in the best position to balance local circumstances against the requirements or expectations of authoritative protocols and guidelines and to ensure ap- propriate pediatric input into guidelines ultimately adopted at the local level. MEDICAL CONTROL Extending the Physician's Care The prehospital care provided by EMS systems is intended to bring essential medical treatment to patients as quickly as possible. Because most prehospital agencies operate independently of hospitals or other medical facilities and with relatively few physicians among the providers, they need to incorporate into their operation medical control mechanisms that can help to ensure the appropriateness of the care they provide. More broadly, physician input into the design and operation of EMS systems across the range of services and agents typically involved (from prehospital through definitive treatment and rehabilitation) is essential. One authoritative state- ment defines three basic functions for medical control: "to ensure that field personnel have immediately available expert direction for emergency care"; "to ensure continuing high-quality field performance"; and "to provide the means for monitoring the quality of field performance and medical control itself" (Holroyd et al., 1986, p. 1027, citing NRC, 1981~. As stated earlier, medical control operates in two main ways. On-line control involves direct communication (voice and telemetry) with EMTs and paramedics to authorize and guide their care of patients at the scene and during transport to a hospital ED; it is largely but not exclusively a local function. Off-line control focuses on shaping the overall operation of the EMS system, often with special attention to the prehospital elements of the system; it operates through ongoing planning, training, and evaluation ac- tivities, ideally at the local, regional, and state levels of EMS systems. Some experts distinguish three forms of medical control: prospective (e.g., development of guidelines, protocols, procedures, and policies); on-line (as described above); and retrospective (quality assessment review and improve- ment of performance) (Holroyd et al., 19869. Conceptually, prospective and retrospective medical control correspond directly to the notion of off-line control, as used in this report. The need for medical control was initially recognized as paramedics and other prehospital providers were trained to perform invasive ALS pro- cedures such as endotracheal intubation and IV administration of fluids, irrespective of the age group involved. Both the ACEP and the National Association of EMS Physicians (George Foltin, Bellevue Hospital Center, personal communication, March 1992) advocate the extension of medical

168 EMERGENCY MEDICALSERVICES FOR CHILDREN control to BLS care as well. Increased attention to the care of pediatric patients and to the use of invasive procedures on patients in that age range has highlighted the need for pediatric expertise in all forms of medical control. Qn-Line Control: Immediate Care Prehospital personnel provide medical care, especially ALS procedures, under the authority of a responsible physician. Some EMS systems embody that authority in official standing orders that specify the actions authorized in the prehospital setting. Other systems require direct communication with a medical control point on every ALS case. Many lie in between, using standing orders as authorization for some procedures and requiring on-line approval and direction for others. On-line guidance also can aid in triage and destination assignment and assist on-scene personnel in managing such problems as patients who refuse care. In the committee's view, much stricter on-line medical control is needed in pediatric cases than in adult cases. Owing to the limited experience and assessment skills that prehospital care providers typically have in pediat- rics, allowing such personnel wide latitude to initiate treatment without contacting medical control can be unwise. Prehospital care protocols often identify the point at which the prehospital provider must contact medical control personnel before starting any additional therapy (given that they are already proceeding under a specific protocol). This point may be reached much sooner in protocols for pediatric patients than in those for adults. Adopting on-line medical control for BLS providers may bring a special benefit to pediatric patients because most of the prehospital care that chil- dren receive is at the BLS level. These providers are likely to have even less pediatric training and experience than the ALS providers for whom medical control is stressed (Foltin and Cooper, forthcoming). The personnel who provide on-line guidance should have special train- ing and should themselves have protocols to guide their actions (Holroyd et al., 1986; Foltin and Cooper, forthcoming). They, too, are likely to have only limited experience with pediatric cases. Because of the differences between children and adults in the kinds of emergencies they experience and in their physiologic responses, it is essential that these personnel have adequate training in pediatrics or ready access to sources of pediatric exper- tise. (Further discussion of the organization and operation of on-line medi- cal control appears in Chapter 6; education and training needs are discussed in Chapter 4.) Although comprehensive on-line control is preferred by many, others support much more selective use. They question whether it makes a signifi- cant contribution to the patient's care beyond what good written protocols

BEING READY TO DELIVER GOOD CARE 169 provide. For example, studies have found that on-line contact resulted in few deviations from standard care and led to longer time at the scene of the emergency (e.g., Erder et al., 1989; Hoffman et al., 1990~. Furthermore, many EMS systems do not have the financial or staff resources to provide on-line medical control, and these services are not reimbursed by insurers. Some expertly however support extending on-lir~e medical control to ir~- clude BLS providers because, as pointed out above, they are responsible for such a substantial portion of prehospital care (Henry and Stapleton, 1985; Holroyd et al., 19861. Further studies should specifically examine the ef- fectiveness of on-line control in improving outcomes of emergency care for children. Off-Line Control: Planning and Management Functions Any decision to limit on-line medical control emphasizes the impor- tance of off-line control because it becomes an even more vital channel through which medical judgment can be brought to bear on emergency care. Like on-line control, the involvement of professionals with pediatric experi- ence is crucial. In contrast to on-line control, however, the off-line role cannot be delegated to nonphysicians; it is the responsibility of physicians who serve as medical directors and advisors to EMS systems. Shaping the EMS System Off-line medical control contributes medical judgment to several pro- cesses that prepare an EMS system to provide care and to monitor and improve the quality of that care. One important function is to ensure that treatment protocols and equipment standards are consistent with the needs and capabilities of the system and with the current state of medical knowl- edge. By developing and conducting training programs, medical control physicians help to define a common knowledge base for a system's provid- ers and have an opportunity to work directly with prehospital staff. Medical judgment also should be reflected in the standards that states or localities establish for licensure, certification, scope of practice, equipment, and treat- ment protocols. Finally, any quality assurance or continuous quality im- provement program put in place for an EMS system must be able to draw on sources of medical expertise, including pediatrics. Need for Pediatric Input Because off-line medical control has such extensive influence on EMS systems, pediatricians and pediatric specialists must be involved to ensure that the special needs of children are considered. Planning for the care of

170 EMERGENCY MEDICAL SERVICES FOR CHILDREN children with disabilities or chronic illness is especially important, particu- larly for predictable emergencies; similarly important is planning for those whom geography or culture separate from the mainstream. Communities and regions that are beginning to address pediatric concerns, especially places with little or no immediate access to pediatric expertise, need a way to draw on the resources of the larger pediatric- community. More extensive regionalization of care (discussed later in this chapter), which could make the resources of specialty centers available to a larger population, might be one approach. Professional associations and indi- vidual institutions also have developed useful resources, particularly con- cerning pediatric aspects of prehospital care (Seidel and Henderson, 1987; Hemby Pediatric Trauma Institute, 1989; AAP, 1990b-, Eichelberger et al., 1992~. In addition, products developed by EMS-C demonstration grant projects can serve as a guide for other systems; further information on these materials is available from EMS-C resource centers and catalogs of grantee products (Shaperman and Backer, 1991; NERA, 1993~. Comment This committee strongly endorses the value of medical control in both its on-line and off-line applications. With respect to on-line operations, the committee reiterates its commitment to state and local decisions and proce- dures, believing that the relationships and reciprocal obligations built over time will be a significant positive factor in integrating EMS-C into EMS systems across the nation. With respect to off-line operations, the commit- tee views appropriate pediatric training, informed development of sound protocols and equipment standards, and evaluation as the major routes for ensuring adequate pediatric capabilities in EMS systems. In support of sound on- and off-line medical control for EMS-C, the committee strongly endorses the development, implementation, testing, and refinement of na- tional guidelines for adoption and implementation by regional and local EMS systems. CATEGORIZATION AND REGIONALIZATION A major theme of this report is that optimal emergency medical care of children requires systematic attention to the special needs of a complex patient population that ranges from infants through adolescents. Hospitals, EMS agencies, and individual emergency care providers must recognize both what they can do to provide needed care and what they cannot do. Many children can receive the care that they need from local providers and hospitals, but some will require the more advanced care available only at regional specialty centers.

BEING READY TO DELIVER GOOD CARE 171 To know where children can receive appropriate care, EMS-C systems need to make use of processes known as categorization and regionalization. Categorization encompasses two elements. First, qualifying criteria for a set of categories representing varying capabilities must be defined. The requirements must be balanced between being so stringent that they dis- courage hospitals from trying to meet them and being so lax that they do not ensure adequate care. Second, some process must be used to identify the category into which a facility falls. Options range from completely voluntary compliance with criteria for a specific category to strict assign- ment to a category by official agencies. Regionalization makes use of this information about the capabilities of local and regional facilities to make specialized services available to more patients and to limit inefficient duplication of services. This kind of orga- nized regional planning may develop successfully through the efforts of individual hospitals and EMS systems but often requires more formal over- sight to ensure that the needs of all communities are met, to balance com- peting interests among hospitals, and to overcome jurisdictional disputes among communities (e.g., regarding care for Medicaid or uninsured pa- tients). In the committee's view, categorization and regionalization are essen- tial for full and effective operation of EMS-C systems, but these processes cannot be left to evolve on their own. To ensure that children's needs are accounted for, categorization and regionalization must receive active atten- tion from the state EMS-C agencies that the committee proposes later in this report (see Chapter 8~. The remainder of this chapter examines catego- rization and regionalization, how they have been applied, and issues that they raise. Categorization: Identifying Appropriate Providers Categorization is essentially an effort to identify the readiness and ca- pability of a health care facility (typically a hospital) and its staff to provide optimal emergency care (AMA, 1989~. Over the past 20 years, three broad approaches have developed for defining categories of capabilities (Bern, 1987; AMA, 1989J. The first (described as horizontal categorization) em- phasized assessing broad capabilities for providing appropriate care "for any and all emergencies" (AMA, 1989, p. 1~. The second (vertical categori- zation) focused on capabilities for specialty care, such as for trauma, poi- soning, or acute medical conditions. The third to emerge (circular categori- zation) emphasizes arrangements for transferring patients among facilities that have differing levels of capability to provide comprehensive care, espe- cially for transfers to referral centers following initial stabilization in an- other facility (Bern, 19871.

72 EMERGENCY MEDICAL SERVICES FOR CHILDREN Once categories are created, they must then be applied to specific hos- pitals. The AMA's Commission on Emergency Medical Services (1989) cites four processes for doing this. First, categorization, which in addition to its use as a generic term is used to describe a specific process, refers to completely voluntary participation; facilities choose to comply with criteria, which qualifies them as providing ~ specific level of service-. Verification also allows for voluntary participation but adds a process for confirming that the hospital complies with the criteria for its declared capabilities. Accreditation allows voluntary participation but requires that a hospital ap- ply to and receive approval from a certifying group to qualify as a provider of a specific category of service. Designation is typically the most restric- tive approach. Facilities are selected to provide a specific level of care, often on the basis of formal evaluations by state or local governments. Some trauma systems use designation to restrict the number of trauma cen- ters so that each center can be expected to serve a certain minimum number of patients. Thus, the idea of categorization for pediatrics is not especially new or unique. It is widely used for trauma systems and neonatal intensive care in a mix of voluntary and mandated programs. The committee notes that deciding which approach is best depends on a variety of political and orga- nizational factors as much as on the strengths and weaknesses that any given approach might have. Some believe that a voluntary identification process that is carried out on a noncompetitive basis, such that any facility that can meet the criteria will be so classified, encourages both participation in the local EMS system and improvement in existing services. For some situations, more restrictive or demanding approaches may be appropriate. Regardless of the level of care a facility is capable of providing or the approach used to determine that capability, a strong commitment to provide that care is vital. . - , ~ . Capabilities for Emergency Care for Children Various schemes for classifying capabilities have been proposed (Bern, 1987; AMA, 1989; ACS, 1990; Seidel and Henderson, 1991~. The AMA (1990) has developed, and the AAP has endorsed, guidelines for a three- tiered categorization of pediatric emergency services, specifying which ele- ments are essential for each level of care.6 The guidelines include criteria for staffing, equipment, and auxiliary services for EDs, ICUs, and operating rooms. They also address quality assurance, community programs, and research activities. The Committee on Trauma of the American College of Surgeons (ACS, 1990) has established additional criteria to be met by Pedi- atric Trauma Regional Resource Centers and those adult trauma centers making an explicit commitment to care for pediatric patients. Specific

BEING READY TO DELIVER GOOD CARE 173 concerns include ED and ICU staffing and resources, composition of trauma teams, quality assurance, research, and injury prevention programs. These and other guidelines must be monitored to determine if they can be applied successfully in various settings and if they are effective in im- proving care. Periodic reviews should assess whether modifications are necessary. For example' requirements that call for ~ pediatric surgeon will prove d~- to meet because of the limited numbers of pediatric surgeons in the country. One trauma center has turned, with apparent success, to committed adult surgeons and pediatric intensive care specialists to provide trauma center care for children (Fortune et al., 1992~. An assessment of hospital capabilities in Maine based on the AMA categories found that some hospitals that provide essential pediatric care in rural areas would have difficulty meeting the requirements for the lowest AMA level (Maine EMS-C Project, 1991~. In addition, none of the hospitals in the state was likely to be able to meet the criteria for the most sophisticated level of pediatric care. That knowledge, however, makes clear that Maine is likely to need linkages with hospitals in other states that can offer more advanced care. In designing its new trauma system, Washington State used the three ACS categories and created two additional categories for facilities with more limited capabilities (Esposito et al., 1992~. Bringing these additional facilities into the trauma system recognizes the role they play in primary stabilization of patients, makes them eligible for grant funds for education and equipment, and imposes a requirement that they meet system standards and report data to the state trauma registry. In addition, the trauma system will provide for designation of three levels of pediatric and adult rehabilita- tion facilities. Implementing Categorization: One Approach One early program to categorize the pediatric capabilities of hospital EDs was implemented in Los Angeles County in 1984 (Seidel, 1989~. Two kinds of facilities are identified: emergency departments approved for pedi- atrics (EDAPs) and pediatric critical care centers (PCCCs). EDAPs, ap- proved to provide basic emergency services, agree to meet standards in- volving professional staff (physicians, nurses), policies and procedures, and equipment, trays, and supplies on hand. PCCCs, which can provide more specialized care, agree to meet requirements that include standards for pre- hospital EMS, EDs, consultation and interfacility transfer, access to a broad spectrum of specialized pediatric services and professionals, various sup- port services, and educational programs for professionals and the public. Participation in this system is voluntary and open to any hospital meet- ing the minimum system standards; an application process and site surveys

74 EMERGENCY MEDICAL SERVICES FOR CHILDREN are used to verify compliance with those standards. Currently, about three- quarters of the county's hospitals are EDAPs (Seidel, 1989~. The participa- tion of many organizations in the development of the EDAP-PCCC system has produced widespread acceptance and support. The pediatric transport protocols of the Los Angeles County EMS system, for example, are built around the hospital categorization. Implementing the system has also in- creased awareness ITS the counter of the needs of pediatric patients. This approach can be adapted to meet the needs of smaller or more rural areas, as other counties in California have done. For example, some hospitals may serve as "satellite EDAPs" by meeting a smaller set of re- quirements in collaboration with a hospital categorized as an EDAP. It has also been used in other states. The Arkansas EMS-C grantees, for example, introduced to the hospitals in their largely rural state a program for volun- tary adoption of EDAP-type guidelines (Scotter et al., 1990~. Even with the conclusion of the HRSA grant program and the lack of any formal adoption by state agencies, the EDAP activities continue to contribute to improving hospital readiness to provide basic pediatric emergency care. Comment In the view of this committee, improving ways to categorize the pediat- ric care capabilities of hospitals and other EMS system components is espe- cially important. Such categorization schemes should have a direct influ- ence on protocols for triage, transport, referral, and similar patient management processes at national, state, and local levels. Because these standards can have significant implications for both financial and human resources, better data are needed to show what resources are truly required to improve out- comes at each level of care. As with other elements of EMS-C systems, what seems to work best for the regional, state, or local professional, provider, and policy communities may be the best guide to which categorization approach to take. As indi- cated earlier, however, the committee recognizes a need for some oversight of categorization programs to ensure effective implementation. For ex- ample, it values the inclusivity of voluntary categorization programs, but it also recognizes that a voluntary program allows facilities to choose not to participate, which may, therefore, leave them inadequately prepared to care for children. Categorization programs also must guard against authorizing an excessive number of advanced care facilities such that no one center has sufficient numbers of patients to maintain staff expertise or to allow for efficient use of resources. Finally, the committee underscores the need to link categorization efforts with organized strategies for regionalization, which is the topic of the next section.

BEING READY TO DELIVER GOOD CARE 175 Regionalization: Making Effective Use of Pediatric Resources Relatively few patients (of any age) need the most sophisticated forms of medical care. Concentrating resources for such care in regional centers has long been proposed as the way to use those resources most efficiently and to provide patients with the services of the most highly skilled provid- ers. Regionalization of services has developed In various areas of health care for some patient populations and treatments, particularly high-technol- ogy invasive procedures such as heart, liver, and lung transplants. Access to appropriate transport to these regional centers from local hospitals be- comes an important concern. Where these centers serve regions that span state boundaries, administrative or jurisdictional barriers that might impede access to appropriate regional centers may need to be resolved. For EMS, many states have developed regional areas to support coordi- nation of referral, transport, and resource allocation. Regionalized services can include ground and air transport systems, ICUs, trauma centers, burn centers, and the like. Thus, the ways in which regionalization might be applied for EMS-C are, in principle, well understood in the professional and policy communities. The discussion that follows addresses elements of regionalized care of particular importance for EMS-C. Role of Regional Referral Centers Referral centers are often the focal points of regionalized systems of care. As such, they have a responsibility to develop good relationships with the community hospitals and EMS systems in the region and to promote the enhancement of community pediatric emergency care. Important roles for referral centers include consultation (including feedback to originating units and referring physicians), training, and similar activities. (Consultation and transfer agreements are discussed in more detail in Chapter 6.) Consultation services through telephone access to specialists at referral centers can provide community hospitals with essential information neces- sary to manage some pediatric emergencies. Some patients may then be able to receive the definitive care they need at the local hospital; others can be stabilized sufficiently that they can be transferred to the referral center for further care. When children are transferred, the referral center must ensure that appropriate information is made available to those remaining behind (e.g., family members) and to those who initiated the child's care (e.g., primary care provider, hospital ED). Formal transfer agreements between referral centers and community hospitals facilitate the expeditious transfer of seriously ill or injured chil- dren who require more extensive care. Referral centers and community hospitals should work together to implement such agreements. They should

176 EMERGENCY MEDICAL SERVICES FOR CHILDREN make clear the rights and responsibilities of both institutions, including costs and liability, and, as noted elsewhere, comply with federal regula- tions. A model transfer agreement for PICUs in northern and central Cali- fornia, covering PCCCs and pediatric trauma centers (PTCs), illustrates the elements that need to be taken into account (Seidel and Henderson, 1991, pp. 42-48~. Models such as this can be adapted by other hospitals (Q meet their specific requirements. Referral centers also should contribute to education and training for emergency care providers in community hospitals and EMS agencies. Pro- grams, such as courses on pediatric resuscitation, can be offered at the referral center or even in local communities. In addition, referral centers can serve as sites for more specialized training either through medical resi- dency and fellowship programs or other special clinical training programs for EMTs, nurses, and physicians. Referral centers also have an important role to play in education and training for the general public, including promoting an understanding of the emergency care capabilities of commu- nity and regional hospitals. Intensive Care Services In the 1970s, many states successfully developed regionalized perinatal services (Meyer, 1980; Stiles et al., 1991; AAP/ACOG, 1992), but PICU services have not received similar attention. According to the American Hospital Association (1991), about 2,900 dedicated PICU beds are available across the country. Data on the demand for these beds are limited, how- ever; the experience of the Pediatric Intensive Care Network of Northern and Central California suggests that annually 240 children per 100,000 will require intensive care (Pettigrew et al., 19861. According to Cuerdon and colleagues (1991), PICU beds are not evenly distributed across the coun- try the number of beds per 100,000 children in each state ranges from 0 to 13.2, and half of the states have no more than 2.6 beds per 100,000 chil- dren. These authors argue that, unlike adult ICU or neonatal ICU beds, the availability of PICU beds does not appear to be related to the health status of the state's population. With intensive care a major component of EMS-C systems, these extreme regional variations in availability of PICU beds may not be desirable. Research is needed to determine whether the numbers of existing PICU beds and their distribution are adequate to meet the intensive care needs of children in communities across the country. Pediatric Trauma Systems Efforts over the past 20 years to develop regionalized systems for trauma care have had mixed results. As of the late 1980s, only Maryland and

BEING READY TO DELIVER GOOD CARE 177 Virginia were recognized as having effective statewide or near-statewide systems (Mendeloff and Cayten, 1991), although in other states, city- or county-based systems are succeeding. Strong public controls over trauma center designation and prehospital services appear to contribute to trauma system success. Working toward trauma center designation (here meaning state selection of facilities hospital request' or a combination of both) is a complex matter [or the hospital and its stab. Meeting state and professional requirements can pose considerable challenges especially for community hospitals, which generally lack the organization, staffing, and other resources that university hospitals are likely to have (Clancy et al., 1992~. Trauma centers have proved effective in reducing mortality among adult patients. About 370 of some 6,600 hospitals in the United States function as trauma centers; they are concentrated in urban areas and serve only about one-quarter of the population (Champion and Mabee, 1990~. In recent years, however, individual trauma centers, and therefore systems of which they are a part, have faced serious problems from factors such as growing financial losses from unreimbursed costs and disruption of other hospital care by the unpredictable and immediate demands of trauma cases (see Champion and Mabee, 1990; GAO, 1991b). For some hospitals, these problems have led to a decision to withdraw from the trauma system. Experience with PTCs is more limited, chiefly because they are newer and far fewer in number. The earliest PTCs were established in the 1970s (Harris, 19891. Specific principles of pediatric trauma care advanced by the American Pediatric Surgical Association call for designation of PTCs by appropriate government authorities (Harris et al., 19921. Vane (1993) em- phasizes the value of a regional perspective in establishing PTCs; natural referral patterns can be identified and appropriate roles can be determined for all facilities in the area. Harris (1989) stresses that a regional pediatric trauma system must be "carefully tailored to respond to regional needs, be medically sound, well- organized, and have a solid fiscal base" (p. 149) all steps that require appreciable public education and involvement, financial support, and sus- tained commitment. Clearly, all the challenges facing, and pressures on, trauma centers and trauma systems in general afflict pediatric services as well; to the extent that EMS-C is Reemphasized relative to EMS generally, development of PTCs is likely to be impeded. Specialized Transport Resources Successful regionalization will depend heavily on the availability of high quality transport to referral centers. Because the patients who need to be transported are generally the most severely ill and injured, they require highly skilled care during the transfer to ensure that their condition does not

178 EMERGENCY MEDICAL SERVICES FOR CHILDREN deteriorate. Well-equipped vehicles (air or ground) with specially trained staff can make it possible to provide some advanced care even before reach- ing the destination hospital. Pediatric transport teams have generally in- cluded physicians, but it may prove possible to provide essential care with teams relying on other personnel (McCloskey et al., 1989~. Not all trans- fers to referral centers can be made by highly skilled and well-eqa~ipped transport teams, however, this fact makes it essential that local hospitals and ambulance services be able to provide tile minimum level of care neces- sary to maintain a patient's condition until more advanced care can be brought into play. Under the auspices of the AAP (AAP, 1986; Day et al., 1991), guide- lines are evolving to address training needs, transport team composition, and medico-legal issues. No one transport system will be appropriate for every setting or every case. Factors such as weather, geography, patient condition, and costs will affect the choice of vehicle (e.g., ground ambu- lance, helicopter, fixed-wing aircraft). Even more complex are decisions about aeromedical EMS programs, staffing, costs, and relationships to hos- pitals and trauma centers (Freilich and Spiegel, 19901. McCloskey and Orr (1991) and Orr and Kennedy (1991) both provide definitive overviews of pediatric transport issues. As in much of emergency medicine, research studies are needed to answer many questions about the effectiveness of transport practices, such as whether physicians are needed as members of transport teams and the relative value of rapid transport and arrival versus allowing greater time for on-scene stabilization. Improving Outcomes of Care A leading argument for regionalization of pediatric emergency services is the belief that children receiving care in a PICU or PTC will have better outcomes than those cared for in adult trauma or intensive care units, but few studies have been done to demonstrate differences in outcome. In one of the first such studies, Pollack and colleagues (1991) did find higher-than- expected mortality at nontertiary hospitals than at tertiary hospitals among children less than 18 years old who were "receiving care for head trauma, or who required intubation for respiratory support (for >12 thours] if post- operative)" (p. 151~. Another recent study compared children treated in PTCs, urban nonpediatric (general) trauma centers, and rural nonpediatric trauma centers (Nakayama et al., 19921. The investigators found higher mortality rates in the rural trauma centers, but no significant differences remained when comparisons were based on the probability of survival. They surmised that these data reflect an informal system that tends to direct younger children and children with head and neck injuries who are at great- est risk to the specialized care available at the PTC. Cooper and colleagues

BEING READY TO DELIVER GOOD CARE 179 (1993) concluded from analyses of New York data that patients with either brain or internal injuries and moderately severe skeletal injuries had better survival rates when they were treated in PTCs than when they were not; the investigators believe that triage of moderately to severely injured children to trauma centers with appropriate pediatric capabilities is not only practical and effective but also likely to increase survival of children with significant i. ~ . . . skeletal, brain, and ~nte-rnal Injuries. Additional studies are needed to verify these results and to identify factors that appear to make PICU or pediatric trauma care critical to better patient outcomes. In the meantime, this committee takes the position that when specialized pediatric centers are available, the most seriously ill and injured children should receive care in those centers. Special Concerns in Regionalization Implementing a system of regionalized services for pediatric care raises a number of concerns. Transferring children to regional centers removes them from relationships with the network of providers (e.g., pediatricians or family practitioners) from whom they and their families usually receive care (which should constitute a medical home). Thus, continuity and coor- dination of care for these children must be given special attention. Such transfers and shifts in the site of care, particularly to distant locations, can also cause substantial disruptions in the lives of children and their families. Efficiencies and costs in the system as a whole must also be considered. In particular, the likely volume of patients, especially transfers, must be con- sidered in the development of regional centers. Other, more political, issues must also be addressed, particularly resis- tance from hospitals to categorization and regionalization efforts. Resis- tance can occur for several reasons: if such programs are nonparticipatory (i.e., nonvoluntary), if they are heavily oriented to designation, if they might harm hospital reputations (by categorizing one hospital at a lower level than a competing hospital), if they might cost hospitals their patients (by hurting the hospital's reputation or by directing patients to other hospitals), or if they might impose an unacceptable financial burden (by increasing the number of uninsured patients requiring costly but unreimbursed care). No single response to these concerns is possible; specific local circumstances must be considered. Triage protocols that call for bypassing one hospital for another may be very difficult to develop and implement because of the need to coordinate plans with both the EMS agencies providing prehospital services and the hospitals in the area. Even when hospitals agree to bypass plans, EMTs may still take patients to the closest hospital. In some cases that decision may reflect parents' desires to have a child taken to a familiar local hospital

180 EMERGENCY MEDICAL SERVICES FOR CHILDREN rather than a more distant regional center. Thus, successful regionalization (or categorization-plus-regionalization) requires cooperation and collabora- tion across a wide set of professional, public, and policymaking entities- more so, perhaps, than for action involving equipment, guidelines and pro- tocols, or medical control. It calls also for mobilizing the political will to create a system based on a reasoned assessment of needs and capabilities. not one that ~s [based excIusT~ely ore `6sell-nam~ng.~' Finally, the scarcity of pediatric resources and experience make region- alization more critical in pediatrics than in many other areas of medicine. Even pediatricians well trained in taking care of many acute and critical situations can experience, with time and lack of exposure, erosion in critical care skills; this problem may be compounded by lack of resources and experience among other physicians, nurses, or support personnel at the hos- pital level. Although good undergraduate and graduate training and con- tinuing education efforts for all emergency care providers may ameliorate some of these problems (as discussed in Chapter 4), the solution to provid- ing definitive care for pediatric emergency patients may always lie more . . . ~ . . with reg~onal~zat~on. Interstate Issues Because some geographic areas do not have reasonable access to children's hospitals or PICU resources within their own state, natural referral patterns may cross state lines; this situation makes it necessary to consider issues of interstate coordination and cooperation if emergency medical care for chil- dren is to be successfully regionalized.7 Interstate issues also arise for metropolitan areas that serve more than one state. In some cases, interested parties may be able to develop official agreements under the auspices of state or local government agencies. In other cases, contractual or informal relationships develop between referral centers and community hospitals and EMS systems. The stability of both official and informal arrangements depends on meeting the needs of all groups involved and on addressing several key issues. Coordination of Professional, Legal, and Regulatory Requirements Neighboring states often differ in such matters as certification and licensing requirements for institutions or practitioners, procedures that providers are authorized to perform, and guidelines for triage. In working out interstate transfer or other arrangements, states must address these differences to en- sure that consistent and acceptable levels of care are rendered and that providers do not face liability risks from differences in practice standards. The liability risks for interstate transport services must also be addressed. At some level of complexity in working out interstate arrangements, a

BEING READY TO DELIVER GOOD CARE 181 threshold may be reached that argues for generalization beyond individual states to national standards. The immense variation in Medicaid services and regulations, and the resulting extreme unevenness in even basic care available to mothers and children, is poignant evidence of this point. Medicaid Reimbursement Medicaid policies and reimbursement levels are ~ concern for all providers; in the EMS context. hospitals may face the biggest problems. When care is provided to Medicaid patients from other states, hospitals must contend with several factors: the inadequacy of exist- ing Medicaid reimbursement levels per se, the unevenness of reimburse- ment levels across state lines, the willingness (or lack of it) of Medicaid agencies to pay for out-of-state care, and the possibility that a hospital may not be an approved Medicaid provider for other states or may be unaware of other states' Medicaid policies, such as prior authorization requirements, that affect eligibility for reimbursement. Where hospitals often serve a multistate population, considerable anec- dotal evidence of Medicaid payment problems exists. Those problems may be sufficient to discourage some hospitals from accepting out-of-state pa- tients or may, at least, lead them to consider how they might want to pro- ceed with such a step, as some District of Columbia hospitals have done for patients from Maryland. Problems similar to those that arise between states can also be found between cities and counties within states (e.g., New York City and Westchester County). Other complexities can arise when managed care programs for Medic- aid patients exclude nearby, but out-of-state, facilities that otherwise would provide considerable amounts of care, as happened when the Illinois I-Care program excluded children's hospitals in St. Louis, Missouri (Ron Morefeld, St. Louis Children's Hospital, personal communication, December 1992~. Long-standing subspecialty referral patterns for southern Illinois residents were disrupted, diverting them to other institutions as far away as Chicago. After termination of the program in 1991, a coalition of five children's hospitals in Chicago and St. Louis began working together with state gov- ernments on pediatric and Medicaid issues.8 These financial barriers to care make it difficult, if not impossible, to ensure that all children will have access to the care that they need. As part of their efforts to further the development of EMS-C programs, states and the federal government need to consider how to overcome reimbursement problems, especially for children who are uninsured or are covered by Med- icaid. This committee acknowledges the major shortfalls in insurance cov- erage for children that are now part of a significant debate about health care reform at the state and national levels. Broad questions of Medicaid or insurance reform are a significant backdrop to the EMS-C discussion; al- though extensive examination of these issues was clearly beyond its pur

82 EMERGENCY MEDICAL SERVICES FOR CHILDREN view, the committee briefly returns to them again in Chapter 9. Generally, however, the committee confined its discussion to interstate reimbursement issues that directly relate to EMS-C. Rural Issues Issues of categorization and regio-nal~ation are cruc~l for many rural providers particularly in the hospital sector. Many providers fear that they will be bypassed in the process of providing emergency care to patients. The key element in the entire system is the appropriate and adequate educa- tion that is provided to emergency personnel both on the emergency trans- port team and in the initial emergency room setting. If these individuals have been trained to handle pediatric (and adult) emergencies and have demonstrated this capability, the issue of categorization becomes less threatening and somewhat less of a concern in the process. Categorization and regionalization must continue to be pursued vigorously, but in the rural setting these factors need to be considered with appropriate sensitivity for the concerns of the parties involved. Encouraging Categorization and Regionalization As noted at the outset, categorization and regionalization are linked activities that, when pursued collaboratively, can make EMS-C, as part of larger EMS systems, more efficient as well as more effective. This commit- tee believes that they are critical elements in the development of EMS-C systems. It also believes that strong leadership from the federal and state governments, health departments, and professional societies will be needed to bring these many interests together successfully. Providing appropriate care for seriously ill and injured children re- quires special expertise and special commitment. The committee recog- nizes that ensuring the availability of expertise and commitment in pediatric care and access to that care will require a formal mechanism to identify facili- ties that can provide needed care, to develop protocols and other procedures to direct children to appropriate facilities, and to verify that those proce- dures are working successfully. The specific mechanisms may vary across EMS systems and states (some may emphasize voluntary participation whereas others may choose to designate specific facilities), but the result should ensure that appropriate care is available to children who need it. Therefore, the committee recommends that all state regulatory agencies with jurisdiction over hospitals and emergency medical services sys- tems address the issues of categorization and regionalization in oversee- ing the development of EMS-C and its integration into state and re- gional EMS systems. Beyond this, the committee explicitly refrains from

BEING READY TO DELIVER GOOD CARE 183 proposing specific steps to achieve categorization and regionalization be- cause of the diversity of approaches that states might want to use. Because of the range of interested parties professional groups, indi- vidual practitioners and institutional providers, public and patient advocacy groups, local and state governments, to name a few the special complexi- t~es of these efforts need to be appreciated. This commit~;~-e believes that steady, cooperative steps must be taken to establish a firm base for im- proved EMS-C programs. SUMMARY Despite impressive progress in recent years, EMS systems have particu- lar weaknesses in their ability to meet the needs of pediatric patients in five major areas: equipment, protocols and guidelines, medical control, catego- rization of facilities, and regionalization of care. This chapter argues, first of all, that more investment in supplies and equipment appropriate for chil- dren (across the entire pediatric age range) would significantly improve the capacity of EMS systems to discharge their responsibilities to children; the marginal cost (to the system) of having durable and disposable materials and supplies suitable for pediatric cases is quite low and should not be accepted as a reason for not providing those materials. The committee did not create definitive lists of equipment and supplies necessary for treating pediatric emergencies for various settings; rather it called for each health care provider and agency to define the emergencies that occur in the patient populations that they serve and to ensure that the necessary and proper equipment is available to treat critically ill and injured neonates, infants, children, and adolescents. To this end (and in line with later recommendations about the responsi- bilities of state agencies), the committee formally calls for all state regula- tory agencies with jurisdiction over hospitals and EMS systems to require that hospital EDs and emergency response and transport vehicles have available and maintain equipment and supplies appropriate for the emergency care of children (see Box 5-1~. The objectives are to ensure that (1) at least a minimal level of essential equipment is maintained in all hospital EDs and by all EMS systems and (2) consistency in these requirements be appropri- ately balanced with the flexibility needed in special circumstances (e.g., geographic or financial). Second, protocols have a solid place already in many areas of health care, including EMS for adults. What is desirable now is the development, dissemination, application, and evaluation of guidelines and protocols with tested pediatric elements and components. Such guidelines are needed for the full range of EMS-C activities dispatch, transport, prehospital care,

84 EMERGENCY MEDICAL SERVICES FOR CHILDREN ED services, hospital inpatient care, and emergency care in outpatient set- tings. Third, medical control (physician oversight, directly or indirectly, of the care provided by prehospital personnel) warrants attention. On-line medical control, which implies real-time direction of care for seriously in- jured or ill children, requires reliable input from personnel (particularly physicians) with experience and training in caring for infants, children, and adolescents. Local practices, personnel, and financial resources influence whether and how on-line medical control is implemented. Off-line medical control also requires active participation and leadership from health care professionals with pediatric expertise to ensure that children's needs are considered in an EMS system. It involves designing and implementing policies, training programs, quality assurance efforts, and the like. It is broader in scope and setting than on-line control and relates more to the long-term development of guidelines and protocols (to be used, often, in on- line situations). Categorization of institutions and regionalization of specialized services, often linked conceptually and practically, are the remaining areas in which this committee believes stronger involvement and investment are warranted. Although "local" as contrasted with "national" decisionmaking and solu- tions are generally preferred in thinking about steps to incorporate EMS-C into existing EMS systems and thus to categorize facilities accurately and designate regional referral centers for pediatric cases some guidance may be needed at the national and state level to foster appropriate identification and classification of referral centers and to overcome difficult interstate

BEING READY TO DELIVER GOOD CARE 185 questions of legal and regulatory matters, transfer policies, and reimburse- ment. The committee found these issues of sufficient significance to the successful development of EMS-C in EMS systems that it formally recom- mended that state EMS-C agencies (proposed in Chapter 8) address catego- rization and regionalization for EMS-C. NOTES 1. Information on physician offices in general is no more encouraging. For instance, a study in Dallas found that 25 percent of offices administering aerosols or epinephrine for asthma or allergic episodes did not have oxygen available, and nearly 20 percent of offices administering parenteral anticonvulsants did not have oxygen or bag-valve-mask capability (Barth et al., 1989). A survey of Michigan physicians (mainly those in family practice and secondarily in pediatrics) determined that only 11 percent had adequate equipment to manage common office emergencies such as chest pain and dyspnea, seizures, syncope, anaphylaxis, and behavioral emergencies (Kobernick, 1986). 2. The discussion about protocols for dispatchers is oriented toward EMS personnel. Brodsky (1990), however, calls attention to the problem of calls concerning fatal road accidents being directed first, or simultaneously, to police. Such practices result in delay before EMS services, such as an ambulance, are dispatched; in perhaps 15 percent of fatal accidents, a communica- tions officer has made the wrong decision by failing to notify an EMS program immediately. Some experts thus apparently believe that EMS dispatchers should be notified of all road accidents and have the responsibility of deciding whether ambulance rescue should be at- tempted based on the description of the crash. Such a policy might benefit from protocols for communications personnel and dispatchers that have been developed on the basis of informa- tion about the characteristics of road accidents and injuries in various geographic locales. 3. Dispatcher-delivered instruction in CPR by telephone has been proposed for at least 20 years as one approach for helping family members or bystanders cope with a victim of cardiac arrest. Although its utility has been demonstrated for adult patients (Kellermann et al., 1989), little if anything is known about such approaches when the patients are children. Dispatcher assistance to callers in situations involving airway emergencies and ingestions also warrants examination. Issues of telephone assistance, advice, and communication are taken up in Chap- ter 6. 4. "Emergent" and "most urgent" are not equivalent concepts in ED triage. Emergent re- quires the highest priority of care, for conditions that are life-threatening or will cause serious permanent physical impairment if not treated immediately; urgent cases may require rapid response (e.g., within 30 to 120 minutes) but not the highest priority interventions. 5. As noted elsewhere, this committee did not address questions of perinatal or neonatal emergencies. Generally, the same points concerning the utility of good guidelines and proto- cols will be true for those problems and settings. 6. The AMA (1990, p. 880) classifies pediatric emergency care facilities in three levels. Level I: "An institution capable of providing comprehensive, specialized pediatric care to any acutely ill or injured child. Usually a children's hospital or a large general hospital with a pediatric division providing comprehensive subspecialty pediatric medical and surgical ser- vices." Level II: "A hospital with a pediatric service capable of caring for the majority of pediatric patients, but with limited pediatric critical care and subspecialty expertise." Level III: "A hospital with a functioning Emergency Department capable of evaluation, stabilization, and transfer of seriously ill and injured pediatric patients. Such facilities should have formal- ized transfer agreements to higher levels of pediatric care. They should provide a vital service

86 EMERGENCY MEDICAL SERVICES FOR CHILDREN in stabilization and transfer in areas where level I and level II facilities are not readily acces- sible." 7. The discussion of interstate problems in regionalization focuses on one manifestation of broader problems of interjurisdictional cooperation and coordination. Intercounty difficulties can arise, for instance, if various county or other "local" governments cannot agree on funding responsibilities or other policies. At an even more disaggregated level, concerns on the part of incorporated cities or intercity rivalries can disrupt EMS programs within a single county. Committee discussions ~return-~:d Redly to ex~-~s In -which ~ ch~ld~s cam was compro mised by administrative and bureaucratic complications. McArdle and colleagues (1990) dis- cuss the strengths and limitations of a county-based EMS and regionalized trauma care system in San Diego, California, and provide useful lessons for other programs based at the county level or in a county department of health. 8. The consortium of children's hospitals that was formed after the I-Care program ended includes three Chicago hospitals (Wyler's, Children's Memorial, and LaRabida) and two hos- pitals in St. Louis, Missouri (Cardinal Glennon and St. Louis Children's).

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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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