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Emergency Medical Services for Children (1993)

Chapter: 6 CONNECTING THE PIECES: COMMUNICATION

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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.

6 Connecting the Pieces: Communication Communication is a critical element in the successful operation of sys- tems of emergency medical care. The many separate parts of these sys- tems individual health care providers, emergency medical services (EMS) agencies, emergency departments (EDs), critical care units, and various oth- ers must each perform their roles well, and they must also be able to work together. Communication, through formal and informal channels and through high-technology equipment and simple face-to-face conversations, is the thread that ties the separate pieces into a system. This chapter views communication from several perspectives. First, the context in which communication takes place creates special (perhaps even unique) communication needs. Delivery of services to specific patients raises different issues than do planning and information exchange that are independent of patient care. Second, the mechanisms by which communi- cation is achieved raise special questions. Some forms of communication- enhanced 9-1-1 emergency access systems and statewide microwave radio networks are cases in point- depend on the application of particular tech- nologies or equipment. Often, however, ordinary telephone calls can meet important communication needs. The third important factor is the partici- pants in the communication process. Patients and their families (or other bystanders), providers, and administrators need to interact in various com- binations and for various purposes. Fourth, better communication among all the providers who care for a patient is a special concern. "Follow-up" on patient outcomes and further care and "feedback" from other providers characterize two important forms of that communication. Through follow 187

188 EMERGENCY MEDICAL SERVICES FOR CHILDREN up efforts, providers actively seek information on the condition of patients whom they have treated and on whether recommended care has been re- ceived. Feedback gives providers valuable information on the consequences of their care. This chapter reviews the communication links that the committee views as most important {c': emergency medical services for children (EMS~C) and discusses ways in which those links should be strengthened. Several issues addressed in the previous two chapters (e.g., education In how to use the EMS system; the special training and guidance that dispatchers should have; on-line medical control; the interhospital links needed for regionalization of services) receive further attention here. Although the issues raised in this chapter are framed in terms of emergency care for children, they are not unique to children. The committee's observations point to ways to help make good emergency care available for all patients. PUBLIC ACCESS TO THE EMERGENCY CARE SYSTEM To benefit from the services of an EMS system, children who are ill or injured must first of all gain access to it. Many children initially receive such care at a hospital emergency room, where their parents have taken them without any prior contact with the EMS system. For children who need urgent care but not any of the services available in the prehospital setting, this can, in fact, be an appropriate way to reach emergency services. For many other children-those with major trauma or serious respira- tory distress, for example prehospital care from trained providers may be essential for a good outcome. The telephone (or equivalent media such as Citizen's Band radio) is the usual means of contacting the EMS system to obtain such assistance. Adoption of a universal emergency access num- ber namely, 9-1-1-is widely supported, to make it as easy as possible to request EMS assistance. ~ Sometimes it may not be clear whether emergency care is needed; in these situations, advice provided by telephone may help clarify what steps to take. Poison control centers are well-recognized sources of specialized information regarding situations that may range from harmless to life-threat- ening. Parents also seek advice from staff at EDs or from primary care providers on the care their children need. Although many in the medical community find this telephone advice valuable, sometimes in averting un- necessary ED visits, others are concerned that this indirect assessment of a child's condition may miss serious disorders. The discussion that follows reviews basic and augmented features of 9-1-1 telephone systems and the added features of enhanced 9-1-1 and pre- sents the committee's recommendation supporting universal adoption of the system. Following the examination of points relating to 9-1-1, this section

CONNECTING THE PIECES 189 presents a brief overview of the operation of poison control centers and discusses some issues related to other forms of telephone advice. Universal Access Through 9-1-1 For a quartex-century' nationwide adoption of a universal emergency access number such as 9-~-l has been recommended or endorsed by many groups (e.g., NASINRC, 1970a, 1972, 1978a,b; Brinegar, 1973; Whitehead, 1973; ACEP, 1976; AHA-ACEP-AMA, 1988; National Committee for In- jury Prevention and Control, 1989; NHTSA, 1990b; Seidel and Henderson, 1991~. Throughout much of the country today, a telephone call to 9-1-1 provides access to police, fire, and EMS services. Table 6-1 presents recent estimates of the proportion of each state's population covered by 9-1-1. Communities began working with their local telephone companies as long ago as 1968 to implement 9-1-1 service (Whitehead, 1973~.2 Accord- ing to the Advisory Commission on State Emergency Communications (un- published tables, August 1989), about 20 years later more than 40 states had legislation either authorizing or mandating adoption of 9-1-1. Various ap- proaches are used to fund these systems, including state or local telephone subscriber fees (especially the latter) and state or local taxes. Implementa- tion generally must be managed by individual counties or other local gov- ernmental units that can coordinate the interests and resources of the public, the public safety agencies, and the telephone company for financing and operating the system. Substantial progress has thus been made toward the goal of universal access enough that a National Emergency Number Association (NENA) was founded in 1982 to further the mission of "One Nation, One Number." As of mid-1992, NENA had nearly 2,000 members across all regions of the country; the association issues a quarterly magazine (NENA News, now in its tenth year of publication), offers an 800 number for updates and infor- mation on legislation and issues affecting the 9-1-1 field, and holds an annual conference. The Associated Public-Safety Communications Officers (APCO) organization also gives considerable attention to 9-1-1 issues (partly in collaboration with NENA); for instance, its journal (APCO Bulletin) pub- lishes an annual issue on 9-1-1 topics. Typically, more than 80 percent of the calls handled by 9-1-1 systems are for police services and about 10 percent are for EMS. For instance, NENA cites information from Orange County, Florida (population over 430,000), suggesting that of nearly 294,000 sheriff, fire, and rescue calls, 87 percent were to the sheriff and 11 percent were "medical patches"; for the city of Kissimmee (population 30,300), 66 percent of about 16,700 calls were for police, 17 percent were for the EMS system (NENA News, 1992~. Never- theless, it is the EMS community that is working through the American

190 EMERGENCY MEDICAL SERVICES FOR CHILDREN TABLE 6-1 Percentage of Population Covered by a 9-1-1 System, by State StatePercent _ State Percent Alabama60 Montana Alaska90 Nebraska 65 Arizona Nevada 95 Arkansas25-50 New Hampsh~re lob California100 New Jersey 35b Colorado85 New Mexico 75 Connecticut100 New York 80 Delaware100 North Carolina 76 District of Columbia100 North Dakota 33 Florida99 Ohio 60 Georgia76 Oklahoma 80 Hawaii95 Oregon 95 Idaho68 Pennsylvania 60 Illinois64 Rhode Island 100C Indiana49 South Carolina 72 Iowa South Dakota 70 Kansas80 Tennessee 83 Kentucky56 Texas 97 Louisianaa Utah 85 Maine25 Vermont 25 Maryland100 Virginia 75 Massachusetts38b Washington 40 Michigan60 West Virginia 43 Minnesota100 Wisconsin 78 Mississippi60 Wyoming 97 Missouri62 NOTE: , not reported. aExtent of coverage is unknown. bStatewide implementation of enhanced 9-1-1 is under wa C9-1-1 or similar access number. SOURCE: Emergency Medical Services ( 1992). Society for Testing and Materials (ASTM, 1991) to develop national con- sensus guidelines for planning and developing enhanced 9-1-1 systems. The National Highway Traffic Safety Administration (NHTSA, 1990a) also par- ticipates in the ASTM guidelines effort. Benefits of 9-1-1 Standard Capabilities The 9-1-1 systems provide a simple, easy-to- remember telephone number that callers, including young children, can use to make quick contact with emergency services of all kinds. A common

CONNECTING THE PIECES 191 number across the country eliminates the need to learn separate numbers for specific emergency services or in various communities. With such a sys- tem, callers do not waste valuable time trying to determine what number to use or waiting for a telephone operator reached through "O" to provide appropriate information about the correct agency (and relevant local tele- phone number) to contact. (To illustrate the profusion of numbers that has existed, in the early 1970s, a 21-~unty area in Nebraska had 184 separate ambulance service phone numbers tNAS/NRC, 1978b].) In short, the local benefits of a single, easy-to-dial telephone number for access to emergency services are multiplied in our highly mobile society, because people can rely on being able to use that same number no matter where they are and be confident that it will be answered by an "emergency-oriented" individual. The benefits of 9-1-1 and enhanced 9-1-1 do not accrue solely to the health field. Reduced response times are very important, for instance, in law enforcement and firefighting. A functioning 9-1-1 system can also be important in disaster situations, such as tornados. More generally, the fi- nancial, psychological, and public relations benefits (in terms of public regard for a "public good" agency) of simply having a more efficient, more cost-effective system of emergency services should not be underestimated. New Capabilities Certain new features have been developed to aug- ment standard 9-1-1 capabilities (other than enhanced 9-1-1 described be- low). A TDD keyboard (i.e., Telecommunications Device for the Deaf) has been developed that will meet the requirement of the Americans with Dis- abilities Act (ADA) that telephone emergency services provide direct access for persons with speech or hearing impairments (Lopez and Dion, 1991; Suchat, 1992~; with related advanced computer technologies, TDD calls can be displayed on a computer screen, enabling the call-taker to communicate with the individual calling in. Another advance for 9-1-1 lies in helping those who do not speak En- glish to use the 9-1-1 system successfully. EMS agencies can, by subscrib- ing to a telephone interpreter service available through AT&T ("Language Line Services"), obtain real-time access (all day, every day) to interpreters who can assist operators to communicate with callers in as many as 140 different languages (Moedinger, 19921. This kind of service makes it pos- sible to handle some calls strictly by telephone and to send response units (fire, police, or EMS) appropriate to the situation instead of every type of unit because of lack of understanding of the actual emergency. Enhanced 9-1-1 The original 9-1-1 service provides the benefit of simplified access to emergency services. Newer, enhanced 9-1-1 systems (E9-1-1) offer the ability to draw on computerized databases to identify automatically the

92 EMERGENCY MEDICAL SERVICES FOR CHILDREN telephone number and location of the caller respectively, Automatic Num- ber Identification (ANI) and Automatic Location Identification (ALI). The automatic availability of that information means that the EMS system can route calls to appropriate jurisdictions, when that is important in the par- ticular area. More significantly, it enables the EMS system to send assis- tance even if callers cannot speak English or communicate effcet~vely be- cause of their c-ond~on or for other reasons. AlI these factors mean that response times can be reduced, with presumably improved levels of inter- vention and, ultimately, of patient outcomes. The TDD and translation services noted above for standard 9-1-1 are also available for enhanced systems. New radio devices now make it possible for children or adults with chronic illnesses or other high-risk conditions to transmit a call to 9-1-1 by pressing the radio transmitter (Keller, 1992~. Some "Lifeline" systems based on radio transmitter systems are more complex. They are often monitored by hospitals, alarm companies, and other third parties, which keep data on subscribers' medical history and conditions and persons to reach in an emergency; when the subscriber triggers the transmitter, monitors call the residence or nearby family or friends before a call is initiated to 9-1-1 or the relevant EMS agency. Although such systems have obvious advantages, they also have some drawbacks. For example, if there is no answer, all resources and equipment may be sent to the home, for what often turns out to be a false alarm. Moreover, use of an intermediary may in fact delay entry into the EMS system. important Considerations for 9-1-1 Systems Despite progress in 9-1-1 technologies and as valuable as 9-1-1 systems are believed to be, some obstacles to complete adoption and implementation of these systems remain. Not all of these relate to EMS per se, and cer- tainly not to EMS-C, but they must be understood if the EMS and EMS-C fields are to be persuasive in arguing for comprehensive adoption of 9-1-1 and successful in helping to devise ways to bring that about. Installation and Operation Implementing an ALI component of an E9-1-1 system can require additional work in local areas, especially rural areas, that do not have "city-style" addresses. Converting to such addresses in various municipalities requires close collaboration with the U.S. Postal Service. The Postal Service has jurisdiction over the city, state, and ZIP code parts of a mailing address; a municipality has responsibility for street names and house numbers. The Postal Service believes that its guidelines on good addresses can be helpful to localities that are moving toward E9-1-1 but currently lack appropriate addresses to use in such a system (Pensabene,

CONNECTING THE PIECES 193 1991~. The increasing use of mobile cellular phones poses its own techno- logical challenge to the locator aspect of enhanced 9-1-1 since no fixed address is associated with them. The cost of installing and operating a 9-1-1 system, especially E9-1-1, may be an obstacle, especially given the current financial constraints that many states and 1Q081ilieS face- Old telephone switching -equipmer~t may need to be replaced to accommodate 9-~-1; additional andior different per- sonnel may be needed; and stand-alone databases may be required for E9-1-1 capabilities. Further, the costs of an E9-1-1 system will depend heavily on the amount of mapping and numbering that must be done for locations without street addresses. Developing and maintaining the database for tele- phone numbers and addresses will also contribute to installation and opera- tion costs. Patsey et al. (1992) report installation charges in North Carolina ranging from $18,000 to $160,000 for basic and enhanced 9-1-1, respec- tively, and monthly operating charges of $4,000 (basic) and $8,000 (en- hanced). One county in Iowa estimated that implementing an E9-1-1 sys- tem (for about 16,000 persons) would cost about $280,000 initially and require about $30,000 annually to operate (Petricca, 1992~. There are clear justifications for enhanced 9-1-1 in rural areas more rapid call-taking, better response times, better assistance for children who need emergency assistance but cannot describe where they live but the cost and logistical requirements lead some experts to question whether the benefits are suffi- cient to warrant outlays such as those quoted above. Some communities for a variety of reasons continue to rely on seven- digit phone numbers; further, they may have separate numbers for police, fire, and EMS. These arrangements continue, in some cases, because juris- dictional disputes have made it impossible to implement 9-1-1 a political factor that this committee finds unpalatable when public and patient safety is at stake. Communities may be unwilling to work together if doing so requires giving up local control of their public safety agencies. New call- routing technologies, however, now generally make it possible for a 9-1-1 system to direct calls to specific communities based on where the call origi- nates. Communities or public safety agencies themselves may resist giving up the separate phone numbers that provide direct access to each agency; one compromise position is to require such agencies to participate directly in the 9-1-1 system and also operate a separate phone number if they choose to do so, but experts worry that two separate phone numbers might be more confusing than helpful. Call Answering and Dispatch Services Once calls to 9-1-1 are placed, the EMS system needs to be prepared to answer them. Various approaches are used, depending on the particular needs of each system. All 9-1-1 calls are received at a public safety answering point (PSAP). In some systems,

94 EMERGENCY MEDICAL SERVICES FOR CHILDREN individual communities within a 9-1-1 area will maintain independent PSAPs, with calls routed to the appropriate point based on the caller's location or telephone exchange. The PSAP determines the kind of service needed (e.g., police, fire, medical) and either directs the call to the appropriate agency's dispatch center or performs the dispatch function itself. Because most 9-1-1 calls ~e pol~ce-relamd~ dispatch functions for all emergency services are frequently handled by employees of the police de- partment who may have little or no EMS training. All dispatchers who handle EMS calls should have minimum levels of training and access to medical guidance. (The committee's views on the training and protocols needed by dispatchers are presented in Chapters 4 and 5.) Some commer- cial programs are available, such as "Medical Priority Dispatch," that use set protocols to give police department employees appropriate questions to ask and appropriate responses to caller inquiries or statements. Finding that 80 percent of the paramedic runs dispatched in one year were for "false alarms" (essentially all calls, including bogus ones, in which paramedics did not evaluate or treat a patient at the scene) led Ramenofsky and col- leagues (1983) to conclude that better dispatch criteria were clearly needed. Brodsky's (1992) study on road accident reports points up some of the difficulties in making dispatch decisions. If callers do not provide specific information about the need for an ambulance, police dispatchers must de- cide whether to alert EMS, and those decisions may be delayed or incorrect. For example, although most highway collisions do not require ambulance service, in nearly 20 percent of fatal crashes in Missouri, the delays in notifying EMS were 5 minutes or longer. Brodsky also notes that specific policies on notifying EMS varied across the state; some local EMS systems believe that they, not the police, should detains whether to send an ambu- lance. He concludes that greater efforts should be made to link information on police dispatch with that on collisions to learn more about the impact of specific dispatch policies on morbidity and mortality. The impact of 9-1-1 systems on morbidity and mortality has not been adequately assessed. An analysis of trauma death rates in North Carolina counties before and after implementation of 9-1-1 showed that counties with 9-1-1 had a lower average trauma death rate than counties without 9-1-1, but the presence of 9-1-1 could not account for the difference after control- ling for other factors (Patsey et al., 19921. More significant than the ab- sence of 9-1-1 was the fact that those counties were more rural, less likely to have a trauma center, and less likely to have advanced life support (ALS) services available. These results suggest that a 9-1-1 system cannot by itself ensure better outcomes for trauma; other pieces of the EMS system must be available as well. This study does not, however, provide any insight into benefits that 9-1-1 might bring in other kinds of emergencies, perhaps by facilitating speedier response to cardiac emergencies or by pro- viding access to prearrival instructions for first aid.

CONNECTING THE PIECES 195 Public Access and Use One very practical concern, in both rural and urban areas, can be availability of telephone service. Some people in rural or remote areas may rely on radio communications, but others may have no local telecommunications resources at all. Factors that account for the lack of telephone services sparse population, terrain, poverty are likely to be of a long-standir~g nature and axe unlikely to succumb to remedial efforts based solely on arguments about 9-~-! service. Even ~n -urban areas, some households have no telephone service. One study found that families of 9 percent of the patients in a public assistance managed care plan who were seen in the pediatric ED of a major city hospital did not have a telephone (Glotzer et al., 1991~. Such families are likely to rely on neighbors' tele- phones or on nearby public telephones. Either way, some of the benefit of rapid access to EMS that 9-1-1 is intended to provide is compromised by delay in reaching a telephone, and the locator benefits of enhanced 9-1-1 are reduced because the caller is not at the scene of the emergency. Installing even the most sophisticated 9-1-1 system will not guarantee that the public will use the EMS system appropriately or that the EMS system will provide an appropriate response. Public education efforts are needed to prepare parents and others responsible for the care of children to recognize emergency conditions and to know how to respond, including how to contact the EMS system. (See Chapter 4 for a more extensive discussion of public education needs in this area.) As is the case with all emergency services, attention also must be given to when 9-1-1 should not be used. Inappropriate calls make it more difficult for those who really need emergency care to reach the EMS system; unnecessary dispatch of equipment risks squandering scarce staff and ambulance resources. Some inappropriate calls may, however, signal a need for other kinds of informa- tion and transportation services to assist people in getting to doctors' of- fices, clinics, and pharmacies for nonurgent medical care. In these situa- tions, having a "municipal services" or other nonemergency number may be useful. Managed Care Guidelines for Using 9-1-1 Efforts to promote use of 9-1-1 have received limited support from many managed care programs or health maintenance organizations (HMOs). Members of such programs may be requested, or required, to telephone the HMO offices first before call- ing 9-1-1 except in obviously life-threatening emergencies. Such policies are intended as an administrative mechanism to reduce unnecessary ED visits, which are a serious burden for some EDs and are costly for insurers. Given the difficulty with which parents or other responsible adults (or ado- lescents, siblings, or younger children) might have in discerning what is a life-threatening emergency in a child and what is not, requirements to con- tact the HMO first can pose problems if the definition of "emergency" is too narrow or too rigidly enforced.

196 EMERGENCY MEDICAL SERVICES FOR CHILDREN A study in the Chicago metropolitan area found that 15 of 16 large HMOs (accounting for 95 percent of HMO enrollees in the area) advised their members to contact the HMO (or gatekeeper physician) first in the event of an emergency; one advised going to the nearest hospital (some advised this as a secondary response in the most serious emergencies); none advised calling 9-1-1 as the first response (~ossfel`1 Ed Ryan, 1989~3 Similar policies were found among ~ representative sample of federally qualified HMOs (Kerr, 1989~. The vast majority allowed enrollees to pro- ceed to a hospital ED without permission when the problem was life-threat- ening and required permission when it was not; the mechanisms for acquir- ing permission from a gatekeeper by telephone varied across the HMOs. In some cases, patients would be allowed or directed to go only to a hospital in the HMO network (and not necessarily to the nearest one). If a true emer- gency exists, such policies run counter to EMS guidelines. Kerr (1989, p. 2763 notes that some "medical directors believed that telephone triage systems introduce undue delay in ED access and for that reason were not used by their HMOs," and he goes on to comment on the dearth of information about the safety of telephone gatekeeping systems of this sort in the EMS context. Others, however, have reported on advantages of a well-developed HMO telephone triage system (Daley et al., 1988; Leaning et al., 1991~. HMO staff have access to patient records during a call, can advise callers unaware of the seriousness of a condition how and where to seek appropriate emergency care (especially if no 9-1-1 system is avail- able), and can summon emergency transport for patients who might other- wise avoid seeking such assistance. The experience of the Harvard Com- munity Health Plan suggests that the participation of emergency physicians in HMO plans can provide greater appreciation within the organization of the need for efficient access to the EMS system (Daley et al., 1988~. Knopp (1986) argued for HMOs to take four steps to improve access to emergency services: (1) base reimbursement decisions on review of the initial presentation of the patient to an appropriate emergency facility or physician, not on the final diagnosis; (2) develop a cooperative relationship with the local EMS system, including providing enrollees with information on how to use it; (3) instruct HMO physicians and nurses to "err on the side of patient care, not cost containment" in making telephone triage decisions; and (4) develop better triage methods so that potential life-threatening situ- ations can be appropriately identified and the EMS system called into play in a timely fashion. Legal and Ethical Issues Privacy and confidentiality issues may be- come a concern precisely because of the caller identification capabilities that are at the heart of the E9-1-1 system. In principle, it does not seem reasonable to expect callers into an EMS system to object to this feature, as

CONNECTING THE PIECES 197 it arguably is always in their best interests. In practice, however, fears about invasion of privacy and breaches of confidentiality relating to sensi- tive medical information have reached quite high levels (as briefly explored in Chapter 7~. Such concerns may trouble even those who do not make direct use of the system because of the need to maintain a comprehensive database of telephone numbers and addresses for an entire service area. Another question that arises with E9-l-l is whether there is an obIiga- tion to dispatch response personnel or equipment (police, fire, or EMS) in response to very brief calls in which the location of the call is known but the caller has seemingly deliberately hung up before completing the call. In these situations, when the call-takers may suspect but not be certain that the call is a hoax, a decision must still be made as to whether to respond and, if so, with what kind of service. Frequently, 9-1-1 centers will call the num- ber back and send police to ensure that no emergency exists. Recommendation for 9-1-1 This study committee strongly believes that universal adoption of 9-1-1 must be a national goal. It recognizes that 9-1-1 systems in themselves cannot ensure that efficient and effective emergency services will be avail- able in response to a call; 9-1-1 systems are, instead, one part of the EMS system that needs to be in place to make such care available, and the capa- bilities of E9-1-1 make it especially valuable. Successful adoption of 9-1-1 is not necessarily simple; it will require communities to address a variety of interlocking challenges. In the committee's view, however, 9-1-1 is an essential EMS system element, for all the reasons and benefits offered above. Therefore, the committee recommends that all states ensure that 9-1-1 systems are implemented. The 9-1-1 system must be universally acces- sible and effectively linked to the emergency medical services system. Communities with 9-1-1 systems in place should move toward enhanced 9-1-1 capabilities. Communities with no 9-1-1 system should move di- rectly to an enhanced 9-1-1 system. More specifically, the committee advises that the federal center and state agencies described in Chapter 8 make the 9-1-1 issue one of their key priorities. For example, smaller communities that have not yet implemented 9-1-1 at all may need encouragement and assistance from federal or state bodies to overcome financial and administrative obstacles to adopting 9-1-1, and this help should be forthcoming at the earliest possible moment. Lo- calities that wish to move from standard to E9- 1-1 capabilities should also receive high priority attention or assistance. In all cases, attention should be directed at understanding and overcoming the various impedi- ments to 9-1-1 and enhanced 9-1-1 outlined above. The committee also believes that attention to these issues should proceed on a broad front relat

198 EMERGENCY MEDICAL SERVICES FOR CHILDREN ing to other parts of the EMS system, such as the education and training of dispatchers. Telephone Advice Poison Control Centers - Poison control centers fill a unique niche in pediatric emergency medi- cal care, providing the public and emergency care providers with telephone access to specialized information resources on treatment of poisonings. They are especially valuable for the pediatric population, which is the age group at greatest risk of unintentional poisonings. Data from 73 centers show that, in 1991, children under the age of 13 accounted for 66 percent of the reported cases; 54 percent were for children under the age of 4 (Litovitz et al., 1992~. Fortunately, only a few of these cases proved fatal: children under the age of 13 accounted for only 6 percent of deaths recorded by the centers. Deaths to adolescents (ages 13 through 19) were, however, 8 per- cent of the recorded deaths. These centers are an important adjunct of the EMS system. They re- duce the burden on EDs and the 9-1-1 system by handling the large number of calls about children who can be treated safely at home. One study com- pared rates of ED visits and home management of poison exposure between one state with no poison control center available and one with toll-free access to a center; the former had a much higher rate of unnecessary ED visits, resulting in nearly $1.4 million in unwarranted ED costs in less than one year (King and Palmisano, 19914. Poison control centers and EMS systems generally maintain close ties: emergency services can be activated quickly for calls that require them, and poisoning calls to 9-1-1 can be transferred to poison control centers. The centers also respond to calls from EMS systems and hospitals, which gener- ally involve the most serious cases. In some locales, EMS dispatchers will connect callers with poison control centers and stay on the line to act on the advice of the center (e.g., to trigger an EMS response if one is needed), rather than activate ambulance services immediately. Poison control centers are not available in all parts of the country. Of the 104 operating in 1990, 36 had been certified as regional centers by the American Association of Poison Control Centers (AAPCC) (Kearney, 19921. Only a few states have established their own standards or oversee the opera- tion of centers. Centers that have not met the AAPCC standards should, however, have sufficient oversight to ensure that they are giving sound guidance to the parents and health care providers whom they are serving. Poison control centers need reliable access to up-to-date information on both substances produced for a national market and specific local resources

CONNECTING THE PIECES 199 for managing individual cases. (Kearney t1992] provides a comprehensive overview of the origins and operations of poison control centers.) Hospital ED and Other Providers Telephone advice in pediatric and emergency medical Gal leas been subject of attention for at least 20 years (see, generally, Ott et al., 1974; Greitzer et al., 1976; Perrin and Goodman, 1978; Brown, 1980; Schmitt, 1980; Shah et al., 1980; Fosarelli, 1983; Knowles and Cummins, 1984; Selbst and Korin, 1985; Verdile et al., 1989; Kosower et al., 1991, forth- coming; Avner et al., 1992; Isaacman et al., 1992b; Yanovski et al., 1992~. It appears to be widely available from EDs and primary care physicians and is a specific component of the services of some HMOs. Only 8 of 61 EDs contacted in one study did not provide telephone advice services (Isaacman et al., 1992b). In another study, a group of pediatricians and family practi- tioners reported a weekly average of 45 telephone contacts for pediatric patients and an average of 65 office visits (Yanovski et al., 1992~. Accu- rately assessing the nature and severity of a child's condition on the basis of information obtained from parents or other untrained observers (and even from other medical personnel) can prove difficult, however. Furthermore, giving advice without examining a child directly may pose increased liabil- ity risks (Murray and Templeton, 1993), although few malpractice claims have been made (Avner et al., 19929. Calls do provide an opportunity to identify cases that do not require emergency attention and thus reduce the number of patients that crowded EDs must handle; moreover, telephone advice is valued by the community (Shah et al., 1980; Troutman et al., 1991~. One HMO has found that only about 10 percent of calls to their after-hours line result in ED visits; for these callers, the HMO is able to direct them to an appropriate hospital and can arrange for emergency transport if necessary (Leaning et al., 1991; Wilkinson et al., 1991). Clear protocols and thorough oversight help ensure that patients are receiving sound advice. Others, however, express concern that inappropriate advice may lead to a worsening of a child's condition and create a liability risk for the ED (Greitzer et al., 1976; Selbst and Korin, 1985; Verdile et al., 1989; Murray and Templeton, 1993~. Recent studies have found that both office-based physicians and ED personnel frequently provided inappropriate advice in response to calls on separate test scenarios for serious illness: about 55 percent of the physicians (Yanovski et al., 1992) and about 40 percent of the EDs (Isaacman et al., 1992b) failed to recommend the urgent attention deemed necessary by the researchers. In a similar study of freestanding urgent care centers, 83 of 100 centers contacted failed to provide advice deemed appro- priate by the investigators (O'Brien and Miller, 19901.

200 EMERGENCY MEDICAL SERVICES FOR CHILDREN The American College of Emergency Physicians (ACEP, 1990c) and the Emergency Nurses Association (ENA, 1991) have both issued position statements discouraging ED staff from offering diagnoses and recommending treatment over the telephone. If a life-threatening condition exists, directions regard- ing first aid and on seeking medical assistance are considered appropriate. Both organizations recognize' however' that telephone advice Is oDen re- quested Mom and provided by ED stab. They urge, therefore, that clear policies and protocols be developed to guide these activities, that all advice be documented, and that quality assurance programs be used to monitor the soundness of the advice given. Appropriate training and guidelines should be provided to physicians and nurses who are expected to respond to telephone calls for medical advice. Because they cannot observe the child directly, they must know what kind of descriptive information is essential and how to elicit it from the caller. Perrin and Goodman (1978) found, for example, that pediatric nurse practitioners with specific training in interviewing skills obtained more complete information from callers than practicing pediatricians who had little training of this sort. Some pediatric residency programs now include training in communication process skills (e.g., Kosower et al., 1991~. In its discussions the committee noted both benefits and risks associ ated with telephone advice and understands that it will be offered as a service in some hospitals. Consequently, it adopts the stance that all health care personnel who provide telephone advice should receive appropriate training for this task. Furthermore, the unevenness of telephone advice needs to be brought more forcefully to providers' attention; care must be taken to document and monitor all such calls when hospital EDs or others actually provide advice beyond simply telling the caller to seek care for the child. The committee also endorses the position of those in the health care field who advocate further development of guidelines for use by all clinical staff faced with making triage decisions over the phone. PREHOSPITAL COMMUNICATION Provided here is a brief discussion of some technical issues of concern in prehospital communication. Factors such as the nature of the informa- tion to be transmitted (e.g., voice, data, telemetry), the physical environ- ment, the numbers of transmissions expected, and the time frame within which contact and response are needed will influence the configuration of communications systems and the means of communication chosen in spe- cific instances. One distinctive aspect of prehospital communication on-line medical control is examined in somewhat more detail, since it is critical, yet only poorly understood and carried out. As in the related discussion in Chapter

CONNECTING THE PIECES 201 5, the committee seeks here to make clear the appreciable complexity of this aspect of EMS, in that systemwide and local issues surface in addition to those related simply to an individual emergency medical technician (EMT) or paramedic asking for and receiving medical guidance in the field. Communications Technologies EMS systems rely heavily on their communications networks in all phases of prehospital care. In the early 1970s, heightened concern over deficiencies in EMS communications capabilities led the Robert Wood Johnson (RWJ) Foundation to establish a grant program intended to support the establishment of regional emergency communications systems (NAS/NRC, 1978b). As noted in Chapter 3, the RWJ efforts had appreciable impact, for instance in establishing 9-1-1 systems. Since that time, considerable tech- nical progress has been made, but the basic needs remain similar and some gaps persist. For example, NHTSA's (1992) assessments of state EMS systems documented the need for more systems to develop up-to-date com- munications plans, to secure adequate funding so that old communications equipment can be replaced and additional equipment can be obtained to reduce coverage gaps, and to require training for dispatch personnel. Once notified that ambulance service is needed, EMS systems must be able to provide communications among the dispatch center, units dispatched on a specific call, other ambulance units, a base hospital or physician for medical direction, receiving hospitals, and other transport services. Addi- tionally the EMS system should be able to maintain voice contact with the originating caller, to provide instructions for cardiopulmonary resuscitation or other advice while the EMS units are en route. Communications capabilities allow ambulance units to request assis- tance from additional ground units or to request and communicate with air transport services. Receiving hospitals that are notified that a patient is on the way can prepare for any special services that might be needed. Small hospitals can alert appropriate physicians and other staff that they will be needed in the ED or begin arranging for a transfer to another hospital. Separate communications channels should be available to EMS to main- tain contact with fire and law enforcement services, which may need to respond to the same calls as EMS units. In some of these situations, the safety of EMS responders themselves is a concern. More generally, the point is that EMS personnel must function in joint response and incident command structures, so the availability of communications channels for contact with these other responders is important. Most prehospital communication is based on radio systems with equip- ment that can include fixed, mobile, portable, and hand-held radios; pagers also may be used. The specific frequency ranges available for EMS com

202 EMERGENCY MEDICAL SERVICES FOR CHILDREN munications have varying capabilities for distance and strength of signal (Keller, 1992~. Radio communication over large areas may require addi- tional equipment to boost signals to reach all the necessary locations. In urban areas, the concern is likely to be more with congestion of available frequencies than with communicating over substantial distances. New fre- quency ranges recently made available by the Federal Commux~icat~ox~s Com- m~ssio-n (FCC) may help relieve some of the congestion.4 Radio-frequency ranges are, however, finite, which argues for maximiz- ing efficient use of available communications channels. Efforts are being made to have the FCC designate the Emergency Medical Communications Service as a public safety communications service comparable to police or fire services (Ryan, 1992~. EMS would then be in a better position to participate in the development of consolidated public safety communica- tions services that can make efficient use of the newly released frequencies and the digital technologies designed to operate at those frequencies. For EMS, steps such as limiting or adapting on-line medical control protocols or using alternatives to voice communication (such as packet data transfer) may be needed. Radio systems also can be linked to telephone and microwave systems to extend the communications range. Microwave networks are used in states such as Idaho (Anderson, 1981a) and Wisconsin (Wisconsin EMS-C Project, 1990~5 to provide wide-area communications capabilities across large rural and remote areas. To illustrate, the communications center for Idaho's statewide network assists units that cannot make needed radio con- tact because of distance or interference. It can also serve as a dispatch center for special units in remote areas and can help coordinate transport services for patients needing transfers to specialty centers. Wisconsin was prompted to seek a more effective communications system because it found that rural EMS providers were often unable to establish medical control contact and thus lacked authorization to initiate important treatments. Other developments include the addition of cellular telephones to pre- hospital communications resources. This equipment offers two particular advantages: first, these phones can be used while in transit or at the scene of an emergency; second, because they can make connections with regular telephone lines, EMS personnel can reach a wider range of answer points than they can with radio alone. However, cellular communication depends crucially on system coverage, which can be spotty and unreliable even in urban areas and essentially nonexistent in many rural areas. In short, several technologies are needed to meet the communication demands created by regional variations in geography and operating condi- tions. Technologies suitable for the plains states of the Midwest may be ineffective for the mountainous states of the West. Localities will of neces- sity continue to adapt various methods such as microwave linkages, re

CONNECTING THE PIECES 203 peater schemes, and digital bunking to their particular circumstances; in sparsely populated rural areas, financial and technical support may be espe- cially critical. If the diffusion of high-capacity digital communication tech- nologies and infrastructure (e.g., fiber-optic telephone lines) is allowed to rest with market forces, poor and rural areas may be left without access to a valuable resource (O'Connor, 1992~. At the federal levels goals may in- cInde ensuring universal access to such technologies or developing mobile satellite communication systems that can overcome many of the constraints of conventional radio systems. On-line Medical Control On-line medical control depends on EMS communications capabilities to make direct medical guidance available to prehospital personnel caring for patients at the scene of an emergency and en route to an ED. In Chapter 5, on-line medical control was discussed principally in the context of apply- ing sound protocols to guide prehospital personnel in caring for children and to guide hospital personnel in directing that care. The discussion here addresses the organization and operation of communications systems to pro- vide on-line medical control. In general terms, on-line medical control is provided to prehospital personnel via radio or telephone contact with designated personnel at a "base hospital." Many EMS systems rely on physicians, typically with emergency training, to provide this on-line direction. Communications mecha- nisms exist that can bring an attending physician on-line very rapidly, no matter where he or she is in the hospital at the time. In some systems, nurses, paramedics, or other personnel are authorized to respond to calls while acting under the supervision of a physician who retains the ultimate responsibility for medical control (Holroyd et al., 1986; Dieckmann, 1992b). Nurses who specialize in providing base hospital services are known as mobile intensive care nurses (MICNs) in some EMS systems. Medical control for a transport team moving a critically ill or injured child from a referring hospital to a receiving hospital is a special case, in that the goal for interhospital transport is to provide care that resembles, as much as possible, the care expected from the receiving hospital. In this case, some experts recommend that the medical control director be a physi- cian trained in either pediatric emergency medicine or critical care medi- cine; be experienced in fielding transport calls and suggesting treatment until the patient and team arrive at the receiving hospital; and be able to direct training programs, develop guidelines and protocols, and provide or facilitate follow-up exchange of information between the receiving and the referring hospitals and physicians (Orr et al., 1992J. In all cases, meeting the needs of pediatric patients requires that on-line

204 EMERGENCY MEDICAL SERVICES FOR CHILDREN medical control reflect input by professionals with some training and expe- rience with pediatric patients. Until recently, only limited attention has been paid to developing specific guidance for treating pediatric patients, and participation by physicians with pediatric expertise in on-line direction has been similarly limited. Most prehospital providers have had only fairly narrow training or experience in using ALS procedures with children; they may, therefore, tend to use only basic life support (BLS) procedures, for which EMS systems generally do not require on-line direction. Even in an urban EMS system (Los Angeles) with strong emphasis on on-line guid- ance, paramedics made contact with the base hospital for only 28 percent of the pediatric cases (Seidel et al., l991b). The same study observed that, in more rural parts of California, base hospital contact ranged from 15 percent of pediatric cases (in a county that requires contact only for ALS proce- dures) to 89 percent. Direct physician-guided communication is the ideal but may not be feasible for all settings. In deciding how to provide medical control (e.g., standing orders versus direct communication or physician only versus phy- sician supervision of nurses or other surrogate personnel), EMS systems need to consider several factors: availability of qualified staff and staff costs for operating a base-hospital communications center, complexity of care that prehospital providers are authorized to deliver, and perceived need by the medical community and the EMS system for direct medical oversight of prehospital care (Dieckmann, 1992b). Use of MICNs, for example, can reduce personnel costs and improve protocol compliance but does not pro- vide immediate access to physician guidance. In rural areas, limited ED staffing and lack of expertise in emergency medicine among physicians in the area may make it especially difficult to provide on-line medical direc- tion of any kind (OTA, 19891. Communications systems that facilitate contact with more distant hospitals could provide rural areas with greater resources for medical direction. Two basic models are used to organize on-line medical control. Under one model, field personnel receive guidance directly from the hospital to which they expect to take their patient. Thus, each hospital operates its own commu- nications center. An alternative approach is to centralize medical control. In such a model, a small group of "base-station" physicians provides medical control for an entire region. EMS programs in cities such as Seattle, Dallas, and Houston employ this model, and it has been incorporated into state regula- tions in California (State of California, Health and Safety Code, Division 2.51. Clearly the centralized model can be extended to EMS-C efforts. An EMS-C variant is to have a regional tertiary center (e.g., children's hospital) moni- tor instructions between a receiving hospital and the prehospital EMS pro- viders; if those instructions are inappropriate, ED staff at the monitoring (base-station) hospital can supersede or countermand them.

CONNECTING THE PIECES 205 Centralized or regionalized on-line control permits standardization of instructions to paramedics and EMTs and some quality control over that guidance. It also makes more efficient use of scarce pediatric expertise in at least some areas of the country (both urban and rural). It may, however, create tensions between hospitals if non-base-station facilities come to be- lieve that base-station hospitals are ix~terfer~g in the management of pa- t~ent-s or are o~rertr~ng Stein to their own ~nst~ut~ons. Good commun~- tion between receiving hospitals and base stations, including perhaps indepen- dent review of triage decisions, is needed to limit such problems. As the need for specialized pediatric prehospital care has become more widely recognized, the participation of children's hospitals in on-line medi- cal direction is being considered. They have the potential to bring the most extensive range of pediatric expertise to on-line medical control. Dieckmann (1992c) suggests that well-established tertiary-care children's hospitals might successfully provide such services if they already function as major referral centers and have a knowledgeable full-time ED staff, and if other base hospitals in the system do not have strong pediatric resources. In whatever configuration an EMS system provides on-line medical control, it is critical that knowledgeable base-station physicians be available to provide guidance for care of pediatric patients. The pediatric community must help develop the system's resources for guiding the care of children. The committee here emphasizes its strong commitment to the creation, dis- semination, and evaluation of pediatric guidelines for prehospital and base- hospital providers. COMMUNICATION IN HOSPITAL CARE Hospital-based emergency care for children generally starts in the ED; successfully treating patients in this setting may ultimately require a variety of other services within the hospital or even at other hospitals. Good com- munication channels between EDs and those other hospital services play an important role in getting children the care they need in a timely way. Often, a centralized communication service within a hospital may be an asset, by enabling ED staff to contact other hospital resources quickly and reliably through "fast-track" high-priority calls that are isolated from usual ED com . . mun~cat~ons. In its discussions the committee focused on two specific concerns in this area: consultation to obtain advice from specialists (e.g., communica- tion between ED staff and internal hospital specialists, or between hospital staff and distant specialists), and contact between community hospitals and referral centers for patient transfers. For the most seriously ill and injured children, successful communication between these groups and facilities can be critical. For the many other children with less serious conditions who

206 EMERGENCY MEDICAL SERVICES FOR CHILDREN are treated in EDs, these communication needs may be less urgent, but they remain an important part of the overall care of those children. Consultation by the ED Staff focal Consultation An ED confronts a wide variety of illnesses and injuries. The special knowledge and skills that the ED staff bring to the care of these patients must be complemented by access to other services and sources of additional expertise. The extent of these resources beyond the ED will vary widely. EDs at the most sophisticated pediatric specialty hospitals will have available subspecialists in surgery, critical care, and a full range of medical fields (e.g., cardiology, neurology, pulmonology, infectious diseases) and the inpatient facilities to provide extensive and complex backup care. Many other hospitals can rely successfully on a less extensive array of specialists to provide essential assistance in pediatric emergency care. Physicians and other ED staff need to recognize when to seek assistance from these special- ists. Regardless of the size of the hospital or the community it serves, the ED needs to establish good working relationships with other parts of the hospital. The radiology department and laboratory services, for example, are two areas on which emergency care depends heavily. Access to surgical and inpatient services is needed for more serious cases. In the many hospi- tals with no special expertise in pediatric emergency care, advice and assis- tance from the hospital's pediatric staff will often be valuable. In the committee's view, two areas of consultation should receive spe- cial attention. The first derives from the concept of the "medical home" described in Chapter 1. That is, every child should have a source for primary care that is geographically and financially accessible, offers conti- nuity of care and comprehensive care, and organizes proper use of and linkages with community support services. Thus, the ED should be in contact with a child's primary care provider, because this physician will have the most extensive knowledge of the child's medical history and the responsibility for future care. Establishing this contact helps maintain the continuity of care that should ensure attention to all of a child's health needs (Seidel and Henderson, 1991~. For children with chronic illnesses or other special health care needs, involving primary care providers is even more important, for two reasons. These children are likely to require urgent care more often than other chil- dren, and treating them may be especially complex. Without such contact, important aspects of their care may easily be overlooked. Second, insofar as resources and time allow, emergency care providers

CONNECTING THE PIECES 207 should give early attention to their patients' rehabilitation needs. Early participation by physiatrists and other specialists, for instance, can reduce the disabling impact of some conditions and can facilitate planning for longer-term rehabilitation needs (NRC/TOM, 1985; IOM, l991b). Trauma care guidelines call specifically for this early integration of rehabilitation into patient care (A(;71~ 1987a; lIaller and Peavey I989~ Ha~s et al., I992~. The continuum of care for EMS-C must extend beyond acute care to ensuring that children receive appropriate rehabilitation services. Reaching Regional or National Specialists In cases where local expertise is inadequate to guide children's emer- gency care, some patients should be transferred to other hospitals with more extensive capabilities, a topic addressed below. Other patients can be treated successfully without being transferred when emergency care providers can draw on the expertise of specialists beyond the local community. Some of the sources of such guidance are described here. Regional Poison Control Centers These centers can provide telephone access to extensive toxicological expertise. Centers certified by the AAPCC are expected to serve a regional population of 1 million to 10 million people (Kearney, 1992~. Although many suspected poisonings in children can be managed without specialized care, the poison control center provides valu- able assistance to the ED staff in treating more serious cases and identifying children who require care beyond local capabilities. Pediatric Referral Centers Telephone access to a broad range of spe- cialists is often possible through major pediatric referral centers. Providing consultation services is an explicit component of some guidelines for criti- cal care services see especially work by the Commission on Emergency Medical Services (AMA, 1990), the Pediatric Emergency Medical Services Advisory Board (1988), and the Pediatric Intensive Care Network of North- ern and Central California (PICN, 1990~. The PICN provides 24-hour con- sultation services to the large area of California that it encompasses (Pettigrew, 1989~. Where such referral centers are the focal point for specialized care in a particular region, outreach programs can make regional medical communi- ties more aware of the resources available to them through the center. It still falls to local providers to recognize when to call upon those resources for consultation or transfer. Guidelines for critical care consultation or interfacility transfer may aid the many hospitals that rarely care for seri- ously ill and injured children. With funding from the federal EMS-C pro- gram, the California EMS Authority (1992) is working with the California Pediatric Emergency and Critical Care Coalition (PECCC) to develop guidelines

208 EMERGENCY MEDICAL SERVICES FOR CHILDREN of this sort that can be used by hospitals and EMS systems throughout the state. As part of a regional pediatric critical care system development project funded by the California EMS Authority, the Sierra-Sacramento Valley Emergency Medical Services Agency (1992) assembled consultation guide- lines that use specific physiologic criteria such as cardiac arrhythmias or evidence of shock (e.g., heart rate greater than 180 for a child two years old or y-ounger3, artatomTe criteria or types of injury (erg., spinal cord injury, burns to more than 15 percent of the body), and certain other indicators (e.g., severe electrolyte imbalance or metabolic disturbances, near-drown- ing). Telephone Hot Lines Some major hospitals across the country have encouraged telephone consultation with specialists on their staffs by devel- oping special telephone hot lines with toll-free numbers. Consultation is provided for emergency assessment and treatment of patients whether a transfer is necessary or not. The EMS-C demonstration grant project in Rochester, New York, specifically included development of such a tele phone hot line at the children's medical center at Strong Memorial Hospital (Shaperman and Backer, 1991~. In Florida, a network of five major pediat- ric referral centers is being created to provide telephone consultation ser- vices to physicians across the state. Facsimile Communication Facsimile (FAX) communication has proved to be a valuable addition to voice communication for EMS-C systems and emergency care providers (Yamamoto and Wiebe, 1989; Keller, 1992; Snyder, 1992~. It permits rapid transmission of written or graphic information and reduces errors that can arise from inaccurate recording of information trans- mitted orally. Cardiologists can, for example, view a patient's electrocar- diogram directly rather than rely on the caller's description of the tracing or delay treatment until it can be viewed in person. The ability of FAX tech- nology to transmit medical records between hospitals can be particularly valuable in providing consultants with more complete information for evaluat- ing a patient's condition and in ensuring that records for patients who must be transferred reach the referral hospital in a complete and timely manner. The Hawaii EMS-C project encouraged the installation of ED-based FAX equipment in hospitals throughout the state (Yamamoto and Wiebe, 1989~. Even within a hospital, FAX has proven useful for such tasks as transmit- ting medication orders to the pharmacy or sending laboratory results to the ED (Yamamoto and Wiebe, 1989; Snyder, 19921. More complex computer- based technologies are making it possible to use telephone lines to transmit radiographic images (e.g., from computerized tomography scans) to distant sites for interpretation by experts or in preparation for patient transfer (Yamamoto, 1992~.

CONNECTING THE PIECES Transfers to Other Facilities and Referral Centers 209 Some seriously ill or injured children need care that is beyond the capabilities of the local hospital. Scientific evidence indicates that children with the most serious conditions have the best outcomes when they are cared for in tertiary critical care facilities (Pollack et al., 1991~. To get children to those facilities' the local hospital and its medical staff must arrange an expeditious transfer to a referral center or another, more fully equipped facility with appropriate specialty and critical care capabilities. General medical principles guiding transfers include attention to the health and well-being of the patient, clear accountability on the part of physicians responsible for the patient, and transfer of necessary medical record docu- mentation (ACEP, 1990b). It is also necessary to comply with the growing body of federal and state law and regulations regarding patient transfers.6 When a child needs to be transferred, communication between the send- ing and receiving hospitals must be clear. The transferring hospital must establish where the child can be sent. It must provide enough information about the child's condition for the receiving hospital to determine the ap- propriate form of transport and to advise on further care until the referral center is reached. If a critical care transport team is dispatched to collect the patient, the transferring hospital needs to be prepared to work with team members to assure that the patient's condition is sufficiently stable to per- mit safe transport. Once the patient reaches the receiving hospital, information about the patient's condition and care should be sent back to the transferring hospital. This may be especially important when parents or other family members cannot immediately accompany the child during the transfer or reach the receiving hospital area promptly. McCloskey and Orr (1991) emphasize the need for all parties in the transfer process to communicate clearly and fully to avoid misunderstandings that might adversely affect a child's care. Be- yond information made available to a child's family, the receiving hospital should also inform the staff of the transferring hospital about the child's status and about the appropriateness of the care rendered, the timeliness of the referral, and any communication problems that occurred. Information should be provided in a constructive manner that will encourage a transfer- ring hospital to provide the optimal care possible within the context of its capabilities. Written Transfer Agreements Referrals can always be arranged on a case-by-case basis. In the most serious cases, however, when there may be considerable urgency in getting the patient to a higher level of care, addressing the administrative and fi

210 EMERGENCY MEDICAL SERVICES FOR CHILDREN nancial aspects of a transfer can be both time-consuming and distracting (McCloskey and Orr, 1991~. The committee agrees with many others that community hospitals and referral centers should have written transfer agree- ments in place before the need for transfer arises (ACEP, 1987a, 1990b; Pettigrew, 1989; AMA, 1990; Foltin and Fuchs, 1991; McCloskey and Orr, 1991; Seidel and Henderson, 1991; AMP, 1992e). It also endorses the view that community hospitals can and should establish agreements with more than one referral center when availability of beds or specialty services can- not be ensured by a single facility. As one variant on this point, guidelines for trauma systems call for trauma centers to establish written transfer agree- ments with rehabilitation facilities (ACEP, 1987a; Harris et al., 1992), a stand with which the committee concurs. In California, a model transfer agreement was originally developed by the PICN; it has been the basis for agreements put in place by various EMS systems in the state and has itself been revised on the basis of experience of some of those systems (Sierra-Sacramento Valley, 1992~. The California EMS Authority (1992) and the PECCC are developing a model transfer agreement that will be made available throughout the state. Hospitals can use these agreements to allocate responsibilities between the two facilities and to formalize arrangements for consultation, transport, payment, and liability. Arrangements for transferring patients back to their local hospital can be included as well. These agreements are not intended to govern medical decisions regarding patient care; community hospitals should have sound medical criteria for initiating the transfer process. (Chapter 5 in- cludes additional discussion of issues related to transfer agreements and protocols.) Centralized Communication System for Transfers In arranging to transfer children, physicians in community hospitals may need to rely on their personal knowledge of the capabilities of various referral centers or on working relationships developed with individual members of the medical staff. Even when a community hospital has standing transfer agreements, it must still establish in each individual case that a receiving hospital is willing to accept the patient. If space in pediatric intensive care units (PICUs) is limited or if a patient needs a special kind of care, staff at the original facility may need to contact more than one potential receiving hospital. The process can be time-consuming and may not produce the optimal match between the needs of the patient and the resources of the referral center. To facilitate the transfer process, some regional systems have estab- lished centralized communication services; these maintain information about the availability of beds in area referral centers and can assist in arranging

CONNECTING THE PIECES 211 patient transport (Seidel and Henderson, 1991~. The committee believes that the merits of this type of service should be investigated. It might give hospitals some of the same benefits in ease of system access that 9-1-1 systems provide to the public. By simplifying the process of arranging patient transfers, such a service might also save time that the medical staff of a local hospital could use more appropriately to care for seriously ill or injured patients. Further, centralized access to regional information on the availability of PICU beds and other services might make more efficient use of regional hospital facilities. A lengthy list of implementation issues would have to be considered: Would such a system be organized and operated by state or local govern- ments? Would regional referral centers establish voluntary networks? Can effective plans for patient referral be made when multiple centers are com- peting for business in the same geographic area? Are there situations in which facilities should, or should not, be bypassed? How would a system be financed? Who would have access to the system? Would the system handle patients of all ages? Would an interstate system be possible? Is such a service cost-effective? Given the diversity of local and regional needs and resources, no one answer to such questions is likely to be appro- priate everywhere. Nevertheless, the committee believes that the experi- ence of existing systems should be examined and their appropriateness in other parts of the country considered. FOLLOW-UP: ENHANCING CONTINUITY OF CARE An EMS-C system has within its scope services that reach from preven- tion to acute care and on to rehabilitation. This span is intended to ensure that the most seriously ill and injured children receive the full range of services needed to produce the best possible outcome. Because it focuses on providing speedy care for unanticipated problems, however, such a sys- tem is not designed to facilitate the continuity of care between patients and providers that is available in a well-functioning primary care setting. In fact, a successful outcome from emergency care may depend on ensuring that children reach those settings where longer-term care is available and that primary care providers participate in managing that care.7 Because emergency care, especially for children, should not be pro- vided in isolation from a patient's overall health care needs, an emergency care system must emphasize to its providers the importance of follow-up care. ACEP (1991) guidelines for emergency care establish a minimum level of responsibility. They call for identification of specific physicians who will accept responsibility for additional inpatient or outpatient care once patients are discharged from the ED. The interhospital transfers dis- cussed above create special follow-up obligations for both hospitals in

212 EMERGENCY MEDICAL SERVICES FOR CHILDREN valved to ensure that the shared responsibility for immediate care of these patients does not allow needs for short- or long-term care to be overlooked. The committee argues that, in addition to interhospital transfers, EMS-C systems must give special attention to follow-up in three areas: primary care, post-ED care, and rehabilitation. Primary Care Ideally, children have access to a regular source of health care that can ensure the continuity and coordination of care embodied in the medical home concept. That health care provider should also be able to facilitate access to and to monitor the progress of other, more specialized care. Treat- ment through the EMS system for sudden illness or injury should not occur in isolation. As noted above, primary care providers should be an important consultation resource in emergency care for children. It is equally impor- tant for the EMS-C system to ensure that primary care providers are kept informed about the care that children have received, the outcome of that care, and any need for further outpatient care related to the emergency. Mechanisms for communicating with primary care providers should be an integral part of the EMS-C system so that contact is made at every stage of care, from the ED to intensive care to general inpatient care to rehabilita- tion. Primary Care in the Emergency Department EDs provide care for children whose conditions could, in fact, be suc- cessfully and appropriately treated in a primary care setting. Many of these children reach the ED because primary care services are not available at all. Other children who have a regular source of care use the ED when those primary care services are unavailable (or perceived as unavailable) because of factors such as long waits for appointments, limited office or clinic hours, and insufficient coverage during those off hours. This committee is not comfortable with the extent to which so many children must rely on hospital EDs for routine care, but addressing this critical issue of access to health care in depth was beyond its charge. The committee does, however, return to some of these issues in Chapter 9, particularly as they relate to the future of EDs. Managed Care Plans and Medicaid A different form of communication with primary care providers is be- coming more frequent with the growth of managed care health insurance plans: securing approval from an appropriate representative of the plan for

CONNECTING THE PIECES 213 a child to be treated in the ED. Managed care plans generally require that patients pick a primary care physician who then serves as a gatekeeper to other forms of care, including ED care. Care received without prior autho- rization from this gatekeeper-physician or other designated representative may not be reimbursed. Under most plans, however, "unauthorized" ED care will be covered in the event of a serious emergency (as defined by the plan). (See al~so the discussion varier In this chapter on HMO policies on use of 9-1-1.) Managed care plans serve families with typical employer-based insur- ance and are covering increasing numbers of families participating in Med- icaid or other publicly funded health care programs. Implementation of these public programs is intended to provide low-income families with bet- ter access to more comprehensive services, particularly primary care. The focus on primary care may, however, be unfamiliar to many of these fami- lies. The ED has traditionally been their most accessible source of unsched- uled care, and some may continue to seek care there rather than from more appropriate primary care providers. When emergency care is needed, con- tact with the primary care provider may give the ED better access to infor- mation about the patient and facilitate arrangements for appropriate follow up care. Communication with a primary care provider or other plan representa- tive is a major feature of managed care plans. For some participants, par- ticularly in public assistance plans, this element may create problems in using services in intended ways. They may, for example, have difficulty contacting their primary care physician or using after-hours advice services if they lack reliable access to telephone service or cannot speak English well. One study found that the ED could reach by telephone only 21 per- cent of the families of a group of children whose publicly funded managed care plan had denied approval for ED care (Straw et al., 1990~. Also worri- some was evidence that only 60 percent of parents kept appointments that had been scheduled for their children when ED care was denied. Because families such as these can be difficult to contact and may not obtain the care recommended for their children, a decision to deny approval for ED care must be based on reliable communication between the ED and the primary care provider. On both sides, the responsibility for these com- munications should rest with personnel qualified to assess the clinical sig- nificance of information about the child's condition. Some observers have expressed concern that denying approval for ED care during hours when clinics and other primary care sites are not open may increase the possibil- ity that serious problems will be missed (Glotzer et al., 1991~. Both EDs and managed care plans should ensure that their mutual communication responsibilities receive serious and sufficient attention and that they are alert to lapses that may occur.

214 EMERGENCY MEDICAL SERVICES FOR CHILDREN Improving Follow-up Care Most children treated in EDs do not require admission to the hospital, but many do need further care at home or from a primary care provider. Too often, however, ED recommendations for such care are not followed (Jones et al., 1988; Nelson et al., 19911. Several factors appear to contrib- ute to th~s [allure -to comply -huh instructions. Jones and her colleagues (1988) found that patients who had no regular health care provider or who had difficulty arranging for temporary care of their children were signifi- cantly less likely to obtain recommended follow-up evaluations. For low- income families, the recommended treatment may prove too costly. Investi- gators in Boston found, for example, that the quantity of a commercial oral electrolyte solution needed to treat a seriously ill child would cost nearly 5 percent of a family's monthly grant from the city's Aid to Families with Dependent Children program (Meyers et al., 1991~. Patients and their families may also fail to remember or to understand the instructions given to them in the ED. A recent study found that, on leaving the ED, parents in the control group could recount accurately as little as 5 percent of the guidance they had received on "worrisome signs" that should prompt them to contact the ED again (Isaacman et al., 1992a). Language and cultural differences between patients and providers may make it notably difficult for ED physicians to communicate successfully with their patients. Interviews with Hispanic patients in one emergency room revealed that misunderstood instructions resulted not only in failure to seek recommended care but also in occasional adverse effects from mistaken care (Narita, 1991~. EDs and other parts of the EMS-C system need to explore ways to achieve better compliance with the care that they recommend. Compliance would be a chapter, if not a book, in itself, and communication skills of the health care provider are probably the most important factor. Nonetheless, the various parts of the EMS system can take positive steps. For example, mechanisms for routine follow-up contact with patients can be instituted or expanded. Telephone calls within a week of an ED visit have helped to increase the proportion of patients who seek recommended care (Jones et al., 1988; Nelson et al., 19913. Standardized delivery of simplified instructions has been shown to improve parents' ability to recall correctly the information they were given on medications and on positive and negative signs in their child's recovery (Isaacman et al., 1992a). For- mal programs have been developed by some pediatric EDs for instance, Bronx Municipal Hospital Center in New York and Children's Hospital of Philadelphia-to follow up on children about whom they are worried, such as those with abnormal laboratory results or those who failed to return for follow-up examinations. Such programs, successfully staffed by nurse prac

CONNECTING THE PIECES 215 titioners and physician assistants, can help foster compliance with treatment recommendations as well as identify possible deterioration in a child's con- dition before a crisis develops. EDs and other emergency care providers that serve a culturally diverse population may need to offer services such as trained interpreters. Staff may need better tra~x~ng in cultural differences related to expectations and understandings regarding health care. One model effort is the cultural di- versity training manual that the EMS-C demonstration program in Washing- ton State developed for use in a course for ED staff (Washington EMS-C Project, 1991~. It has received support from the state's hospital community and has generated interest in similar training for prehospital and primary care providers. Rehabilitation Services As improvements in EMS-C, including trauma centers and critical care facilities, lead to increased survival of more seriously injured children, the need for rehabilitation services increases. Children with spinal cord inju- ries and traumatic brain injuries account for a large portion of the patients needing rehabilitation; necrologic damage secondary to other injuries and illness adds to this population (IOM, 1991b). Burns may require substantial long-term rehabilitation and plastic surgery. Twenty percent of hospital admissions for burns involve children, most of whom are 2 to 4 years or 17 to 25 years of age (CDC, 1992b). Rehabilitation may benefit other injured children as well; fractures and other nonneurologic injuries can leave func- tional limitations for as long as six months after discharge from the hospital (Wesson et al., 1989~. The value of early and well-integrated rehabilitative care is supported by the success of the regional pediatric trauma program at Johns Hopkins University Hospital in Baltimore, Maryland; among the children more than 2 years of age, 88 percent have recovered without major motor or intellec- tual deficits (Hailer and Beaver, 1989~. Operational configurations for pe- diatric rehabilitation programs can differ; for instance, they can be based in a freestanding facility, a hospital-based freestanding program, or an inte- grated inpatient program. These differences can, in turn, lead to differences in the timing of rehabilitative interventions and in the mix of providers (acute care, primary care, outpatient specialists) who participate in manag- ing a child's care (Quint, 1992~. Regardless of the specifics of a particular program, a child's acute care providers must take into account the need for longer-term rehabilitative care. Early planning for such care and coordination between acute care services and rehabilitation providers will help ensure that a child gets ap- propriate care. The District of Columbia EMS-C Project (1991) focused on

216 EMERGENCY MEDICAL SERVICES FOR CHILDREN the residual effects of traumatic brain injury and developed tools to assess the rehabilitation needs of these children. This project also developed a guide that nurses and other case managers can use in arranging transfers of children to rehabilitation programs (Wright, 1990~. Physical rehabilitation may be the most obvious need. Nevertheless, children. need access to other services to address the psychological and behavioral consequences of injury. Social services that can assist families in managing the additional demands placed on them are an important ad- junct to care of the child (Quint, 19924. In sum, the range of services that contribute to rehabilitation is quite broad. Unfortunately, these services are often poorly coordinated, making it difficult to determine what resources are available and to realize the most effective use of them. Again, this may be an arena in which a federal center and, especially, state agencies (see Chapter 8) can play a helpful role. FEEDBACK Very early in its discussions, the committee agreed that more and better feedback throughout EMS and EMS-C systems would promote optimal pa- tient care and effective linkages between system components. Feedback takes many forms. Information on performance and patient outcomes should flow within the various components of these systems as well as between them. Communication needs to occur as an individual patient progresses through the system components; it also needs to take place in a more sys- tematic and comprehensive manner to address the overall aspects of system performance in the care of all patients. Feedback should reach individual providers and the organizational entities in which they work, and the child's private physician should not be overlooked in the feedback loop. It should be informative and constructive; successes should be acknowledged as well as problems. EMS-C systems should seek to develop a systemwide expectation for feedback. Within parts of the system, activities that can meet this need, such as hospital quality assurance or quality improvement programs, may already exist. Systems may, however, have to work at developing channels through which information can flow routinely from one part of the system to another between EDs and EMS agencies or between referral centers and community hospitals, for example. It is important that these information flows be seen as an integral part of the operation of an EMS-C system, not simply as a professional courtesy or an opportunity to assign blame. Feedback and systematic data collection are synergistic. For example, learning the frequency with which patients seek care for various conditions can help planners identify training or equipment needs; it can also help health care professionals target prevention activities more efficiently. In

CONNECTING THE PIECES 217 turn, being able to collect good data may depend on feedback: when data produce information that is useful to the people who collect it, they have a greater incentive to ensure that those data are accurate and complete. Issues such as these are discussed more extensively in Chapter 7. OTHER IMPORTANT FORMS OF COMMUNICATION Important communication about EMS-C takes place separately from the process of delivering care to children. Planning for and managing EMS-C systems need to bring together providers, administrators, and government officials to ensure that important issues are recognized and competing needs balanced. The participants in EMS-C should also have a good working relationship with the community in which they provide services. Good communication within the EMS-C professional community deserves atten- tion as well. System Planning and Coordination Providers with expertise in EMS-C should play an active role in the orga- nization and operation of EMS systems. They also need to develop working relationships with other influential individuals and organizations whose pri- mary focus is not EMS, such as hospital boards, regional planning groups, and local and state legislators. Only if EMS-C providers do so can they influ- ence system policies and priorities, make people aware of EMS-C concerns, and thus ensure that adequate attention is given to the needs of children. Vocal support for and involvement in the activities of the national and state EMS-C agencies proposed in Chapter 8 may help foster improved system planning and operations. Participation in advisory groups is another avenue at, say, the local or regional level; involvement in EMS councils will influence development of pediatric medical control guidelines, encour- age pediatric equipment purchases, and generally raise the level of under- standing about EMS-C issues. Closer to home, participation on hospital committees enables EMS-C advocates to assemble a "code team" that com- prises the best specialists from key departments in the institution and can respond quickly to an intrafacility crisis. Providing pediatric EMS training programs is often a useful "foot in the door" insofar as it influences the development of pediatric protocols and enhances awareness of special needs of pediatric patients. Communication with the Community Public education efforts are one of the more important forms of com- munication between the EMS-C system and the community it serves. Such

218 EMERGENCY MEDICAL SERVICES FOR CHILDREN programs should try to reach a broad audience so that they can educate the public about the need for an EMS system, use of the system, and implemen- tation of the system, as well as develop support for EMS-C activities per se. These efforts vary widely: for example, pediatricians teach parents about steps to prevent injury; EMS agencies promote the appropriate use of 9-1-1; and local EMTs, paramedics' nurses, and physicians teach CPR courses. Specific topics that public education should address are discussed at length in Chapter 4. Here, the committee's point is that public education is a significant form of communication that should be an integral part of the activities of EMS and EMS-C systems. An annual event such as National Emergency Medical Services Week, which has been held for several years and recognized by presidential proc- lamation since 1990, provides a valuable opportunity to focus broad com- munity attention on EMS and EMS-C issues. With federal agencies and professional organizations as sponsors, this program has received recogni- tion from state and local governments and has encouraged individual EMS agencies, fire departments, ambulance services, and hospitals to organize community activities. In addition to providing information about child safety to adults, many activities are designed for direct participation by children themselves (ACEP, no date). Injury prevention work with the community should receive an espe- cially high priority. The EMS-C system sees a broad range of injuries; it can identify those that occur most frequently and those that are especially serious. Providers can contribute their expertise and perspective to commu- nity efforts to reduce a variety of injury risks such as those related to automobiles, bicycles, residential hazards, and sports (Stevens, 1992~. As was cited in Chapter 4, for example, Harlem Hospital in New York City studied data on its admissions of injured children to develop an injury prevention program that targeted the specific risks that children in that community face (Barlow, 19921. Their emphasis has been on improving pedestrian and bicycle safety, upgrading playground equipment, and reduc- ing violence. An earlier program in New York City Children Can't Fly- substantially reduced falls from windows by promoting the use of window guards and supporting the passage of legislation requiring their installation (Speigel and Lindaman, 19771. One approach to linking prehospital providers with injury prevention is participation in programs such as the National SAFE KIDS Campaign, which has local, state, and national activities. A directory of violence and uninten- tional injury prevention projects funded by the Maternal and Child Health Bureau of the Health Resources and Services Administration, Department of Health and Human Services (DHHS), offers other models (NCEMCH, 1991~. For example, a New York State Department of Health project aims to reduce morbidity and mortality from childhood home injuries (falls, scalds, burns,

CONNECTING THE PIECES 219 and poisonings) by training EMTs in primary prevention and encouraging their participation in community efforts. Contact with the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention in DHHS will also be helpful.8 Professional Communication Opportunities for valuable communication among providers exist through various professional activities. Practitioners who are already active in EMS- C can make use of conferences and publications for the EMS-C community to share information in areas such as clinical observations in caring for children, EMS system planning and operation, and results of research. Con- ferences and publications with a broader focus offer the opportunity to bring EMS-C issues to the attention of colleagues who are not familiar with them. As the historical discussion in Chapter 3 emphasized, professional or- ganizations such as the American Academy of Pediatrics, American College of Emergency Physicians, American College of Surgeons, Emergency Nurses Association, and National Association of Emergency Medical Technicians have been important channels for informing providers about EMS-C. Other organizations whose efforts in this area must not be overlooked include the Ambulatory Pediatric Association, American Association of Critical Care Nurses, American Academy of Orthopaedic Surgeons, American Trauma Society, Association of Air Medical Services, National Association of EMS Physicians, and Society of Pediatric Nurses. Local and regional chapters of national organizations or other groups formed around a common interest give providers a more immediate chance to become acquainted with each other, perhaps facilitating cooperation when future cases require access to outside resources. Public safety and related organizations (such as NENA or APCO, and groups such as the International Association of Fire Chiefs)- even though their concerns extend beyond emergency medical services should also be seen as useful partners in communication about EMS and EMS-C to other groups, health care professionals, and the community at large. One collaborative effort that has developed is the Children's EMS Alli- ance, which began in 1990 as the Year of the Child in EMS. It brings together professional organizations and hospitals to inform the professional community and the public about EMS-C issues (Luten, 19911. The program seeks to educate the membership of participating organizations and to en- hance the operation of EMS systems by fostering cooperation among medi- cal and administrative organizations. The EMS-C demonstration grant program has placed particular empha- sis on information exchange among grantees and with other audiences as

220 EMERGENCY MEDICAL SERVICES FOR CHILDREN well. National conferences have brought grantees together periodically to share the results of their work. For a major conference in 1991, the grant- ees prepared a report, Emergency Medical Services for Children: A Report to the Nation, which presents their conclusions and recommendations re- garding areas where further work is needed (Seidel and Henderson, 1991~. One project (the National EMS-C Resource Alliance, or HERA) publishes EMSC News on a quarterly basis to bring information about EMS-C projects and innovations in pediatric emergency care to a broad audience. Another EMS-C effort (the EMS-C National Resource Center) provides information to grantees on legislative activities and possible funding sources. Many EMS-C projects have distributed samples of training materials and other grant products to other grantees, and catalogs of the materials produced by the grantees have been published (Shaperman and Backer, 1991; NERA, 1993~. For many of the projects, however, once EMS-C grant funding ends no other source of funds may be available to continue produc- ing copies of these materials; some materials may remain available if they have been adopted by state or local government or another sponsor such as a medical school. Even when materials continue to be available, organiza- tions may not be able to support the "marketing" necessary to make the EMS community aware of them or to undertake the appropriate updating as information increases and technologies change. am. . ~ . _ ~ ~-~ .r - - ~ ~ ~_ OF , the committee believes that post-M-(-grant difficulties such as these- for instance, in producing materials and informing people of their availabil- ity- argue for ongoing federal support for an organization that can provide clearinghouse services; these might include collecting and evaluating prod- ucts developed by the demonstration grants and by other groups. This work might be based within a federal agency such as the EMS-C center that the committee proposes in Chapter 8, or it might be performed by other organi- zations (public or private) under a federal contract or grant. (A variant on this idea is the creation of one or more "national resource centers"; for sim- plicity the term " clearinghouse" is retained here.) A clearinghouse might also help develop new materials that facilitate provider communication. For ex- ample, a prehospital resource guide produced by the AAP (1990b) and a re- cently published directory of injury prevention professionals (Children's Safety Network, 1992) might serve as models for other EMS-C publications. As proposed in Chapter 8, a federal center as well as state agencies might support other types of consultation. For instance, the federal office directly or indirectly could make materials or advice available to various community organizations and professional associations that wish to estab- lish EMS-C coalitions. Guidelines and consultation for public policy activ- ity at the state level are also needed, so that the public can be mobilized to support needed changes in EMS-C through legislation and regulatory change. Finally, a clearinghouse or resource center activity might be helpful in gen

CONNECTING THE PIECES 221 crating advice about long-term funding options, so that coordination of EMS- C activities does not falter upon the termination of the EMS-C demonstra- tion projects. SUMMARY This chapter explores the critical role that communication plays in the successful operation of systems of emergency medical care. It devotes considerable attention to issues of public access to the EMS system, espe- cially through promotion of 9-1-1 and E9-1-1 emergency response systems. The committee's firm belief in the advisability of universal adoption of 9-1-1 or E9-1-1 led to a formal recommendation that each state ensure implemen- tation of such systems (see Box 6-1~. Telephone access to poison control centers, especially those certified by the AAPCC, fills a need among the public and emergency care providers for specialized guidance for managing the care of children exposed to potentially toxic materials. Parents also seek telephone advice from hospital EDs; this service can provide benefits, but it also poses risks because no direct assessment of a child's condition can be made. The committee strongly advocates appropriate training, clear protocols, careful documentation, and routine monitoring in ED programs offering telephone advice. Prehospital services employ a range of communications technologies (e.g., standard telephone links, radio systems, microwave networks, and satellite links). On-line medical control requires direct communication be- tween designated medical personnel and prehospital providers. It is used for authorizing ALS procedures and advising on other aspects of prehospital patient management. EMS systems vary in the extent to which they use on- line medical control. In the hospital setting, good communication is critical. Emergency care may require ED consultation with specialists in the hospital or in the com ,"' ~ i"" ~ i'"', "I ' 'I'm "I ~ ~ ' " "' "~''~''~"'~''~-'~' ~"'~ "'' " "'' ~'~"~"'~'-~"' ~ I've '" ~'"""'~''~ "'"'''''" ~ ~ ~"'''~.' " '"'~''-"'"'~"'' ~ 2~'~'~'" " ''' ''I , ,: ~ ~ ~ ~ ~ ~ ~ ~: ~ ~ ~ , I, ~ ~ ~ ~ ~ ,~ ~ Aft"' "' "'"'""~'~"""'""'~'"'"''""'''""'"'"'"""'~;~""~''" """""'"'am'' "" ~ """',""'"'",,,,,,,,, " '',,"'',,

222 EMERGENCY MEDICAL SERVICES FOR CHILDREN munity as well as a child's primary care provider. Consultation with re- gional or national experts at pediatric referral centers or poison control centers may be needed and is facilitated by mechanisms such as telephone hot lines and facsimile communication. When children must be transferred to referral centers, clear communication between hospitals and health care providers involved is essential to ensure that v~1 cling and administra- t~e ~nforn,~tion is exchanged. Here the committee believes that written transfer agreements between hospitals make an important contribution to speeding the transfer process by settling many procedural and administra- tive matters in advance. Development of centralized communication ser- vices also may ease transfer arrangements and help make efficient use of regional resources. Communication plays an important role in ensuring that an ill or in- jured child obtains the full range of services, from prevention to acute care and on to rehabilitation, that comprise EMS-C. The committee thus argues that EMS-C systems must give special attention to follow-up in three areas: primary care, post-ED care, and rehabilitation. More and better feedback is needed throughout EMS and EMS-C sys- tems to promote optimal patient care and effective linkages between system components. Information regarding care for individual patients and regard- ing the overall pattern of care is needed. EMS systems may have to work at developing channels through which information on system performance and patient outcomes can flow routinely. Feedback needs to reach individual providers as well as managers and administrators and may require system- atic data collection. Important communication about EMS-C should occur independently of the delivery of care to children. Providers with pediatric expertise need to be active in the organization and operation of EMS systems, and public education should be an integral part of the activities of EMS and EMS-C systems. Public safety organizations, even though their concerns extend beyond EMS per se, should be viewed as useful partners in communication about EMS and EMS-C to other public agencies, health care professionals, and the community at large. The EMS-C demonstration grant program and the efforts of individual grantees have encouraged communication across the country. In the committee's view, the need to maintain and build on these activities argues for creation of a national EMS-C clearinghouse that can collect and evaluate EMS-C materials and serve as a focal point for information exchange. NOTES 1. Some experts in the public safety community argue that 9-1-1 should be thought of as a "response" number rather than an "emergency" number, for at least two reasons. First, many people have difficulty distinguishing an emergency from a nonemergency (i.e., they make

CONNECTING THE PIECES 223 erroneous distinctions about "real" emergencies); second, 9-1-1 is intended to provide access to potential dispatch of any type of public safety response unit (not just medical services). In certain situations, however, this can be problematic, as when the public uses 9-1-1 to access any city service and thereby clogs the telephone system with nonemergency calls. A single, communitywide seven-digit phone number, perhaps available 24 hours a day, should be estab- lished to handle the calls for nonemergency services. 2. One advantage of 9-1-1 apart from being easy to remember, is that it meets require- ments ~r num~g plans and switching conti=~rations of ~e telephone industry; 9-~! ~s unique, for instance, in that it has never been authorized as an area code or a service code (NENA, no date). 3. The potential dangers when HMOs do not properly advise members about 9-1-1 are illustrated by Kerr (1986). He reports on three adult HMO enrollees with severe cardiac symptoms who followed HMO procedures to call the triage physician and were directed to distant EDs; all patients endured considerable delay in reaching appropriate emergency and definitive care and suffered more serious sequelae than might otherwise have been the case. A later article (Kerr, 1989) gave the following examples of life-threatening events in the HMO context: heart attack, stroke, loss of consciousness, poisoning, uncontrolled bleeding, acute allergic reaction, shock, convulsions, and the like; non-life-threatening cases included rash, minor chest pain, high fever, vomiting, asthma, allergic reaction, and gas pains. Exactly where the main problems accounting for emergency situations for children would fit is not clear. 4. EMS communication systems are currently confronting limitations in the availability of radio frequency spectra. At present, eight med-channel pairings are allocated for regional EMS systems. Operating at frequencies in the 460 megahertz (MHz) range of the ultra-high frequency (UHF) spectrum, these channels are subject to significant "channel crowding" and "bleed over," especially in urban areas. Along the border with Mexico, some EMS radio systems encounter interference because allocation of frequencies is not covered by enforceable treaties with Mexico. Additional frequency spectra, dedicated to EMS use, must be authorized by the Federal Communications Commission (FCC); the FCC has recently released new 800 MHz and some 900 MHz spectra. 5. The EMS-C projects cited in this chapter are those of the federal demonstration grant program supported by the Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services. 6. In addition to the medical considerations in patient transfers, hospitals must be aware of legal obligations. Federal legislation the Consolidated Omnibus Budget Reconciliation Act of 1985 (P.L. 99-272) and the Omnibus Budget Reconciliation Act of 1989 (P.L. 101-239)- established regulations designed to ensure that patients receive appropriate assessment and stabilization before any transfer is made, to ensure that transfers are made in appropriate vehicles and to facilities that are able to provide necessary care, and to deter "dumping" of patients from one hospital to another on the basis of the patient's ability to pay. 7. Care for children with severe burns and the use of burn centers illustrate the critical need in EMS-C for attention to optimal sites for care and to long-term follow-up. Burn centers might, for example, have direct linkages with emergency departments and community hospi- tals, so that children in this situation would be triaged directly to them rather than to the hospital's intensive care unit. EMS-C systems should promote early planning for the extended follow-up care that many of these children will need for procedures such as plastic surgery. Ideally, this planning should look to a medical home or other source of primary care to assure continuing attention to the special health care needs of children with severe burns. (We thank one of our anonymous reviewers for elucidating this particular example.) 8. The National Center for Injury Control and Prevention was established at the Centers for Disease Control and Prevention in June 1992. Previously, injury prevention activities were the responsibility of the Division of Injury Control of the National Center for Environmental Health and Injury Control.

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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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