Emergency Medical Services for Children (1993) / Chapter Skim
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5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE
5 BEING READY TO DELIVER GOOD CARE: PUTTING ESSENTIAL TOOLS IN PLACE
Pages 149-186
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From page 149... ...
This chapter cites advances that have been made to date, identifies persistent problems, and presents the committee's conclusions about appropriate steps to overcome those problems and to strengthen emergency medical services for children (EMS-C)
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From page 150... ...
to emergency medical technicians (EMTs) and paramedics during their care of individual patients; and offline, by physicians who participate in developing standardized procedures and planning for and ensuring the quality of prehospital services.
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From page 151... ...
For example, children rarely experience primary cardiac emergencies, but they are very likely to experience severe respiratory distress or hypovolemia, which can lead to cardiopulmonary arrest if an adequate airway, ventilation, and oxygenation cannot be achieved. Thus, it is especially important for emergency care providers to have available equipment and supplies suitable for airway and respiratory management of children.
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From page 152... ...
A group of hospital EDs in Arkansas proved to be less well prepared for emergency care of newborns and infants than for older children (Scotter et al., 19901. Items not available in some hospitals included infrared warming lights, infant oxygen masks, and tracheostomy tubes (sizes O to 5~.
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From page 153... ...
Mellick and Dierking (1991a,b) review the kinds of pediatric equipment available and factors to consider in selecting specific items for prehospital care; they advocate taking into account significant characteristics of pediatric patients (particularly children under age 10)
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From page 154... ...
Instead, it states the following imperative: Each health care provider or agency must define the emergencies that occur in the patient populations that they serve, define the emergency care appropriately provided in that setting, and ensure that the equipment and supplies needed to provide such care for those emergencies are available and ready to treat critically ill or injured neonates, infants, children, and adolescents. To make this more concrete in the context of the recommendations in Chapter 8 about state EMS-C agencies, the committee recommends that all state regulatory agencies with jurisdiction over hospitals and emergency medical services systems require that hospital emergency departments and emergency response and transport vehicles have available and maintain equipment and supplies appropriate for the emergency care of children.
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From page 155... ...
An estimate from Memphis, Tennessee, puts the additional cost of pediatric equipment for an ambulance at about $385 (Larry Youngman, City of Memphis Division of Fire Services, personal communication, October 1992~. The San Diego Division of Emergency Medical Services estimated that additional equipment for a basic life support (BLS)
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From page 156... ...
A second argument is that having the proper equipment reduces the significant cost in morbidity and mortality that children might experience if they cannot receive needed care because only adult equipment is available or if they are treated with inappropriate equipment and supplies. In sum, the committee believes that the cost of essential pediatric equipment is minimal; thus, costs cannot and should not be advanced as a justification for depriving children of necessary, basic emergency care.
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From page 157... ...
These provide a rapid reference source for pediatric equipment size, drug dosages, and vital signs, and they are considered to be of special importance for providers and responders whose contact with pediatric patients may be infrequent. Needs Throughout EMS Systems Protocols have a role to play in every phase of the EMS system.
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From page 158... ...
Many systems and personnel have little or no medical oversight even though they play a critical role in facilitating the delivery of urgent medical care; others may have had training in delivering emergency medical telephone instructions or long-time experience in dispatching ambulances. Regardless of formal training or experience levels, however, dispatchers must be able to evaluate the nature of the problem and determine what sort of response is needed.
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From page 159... ...
Protocols for prehospital care of children need to reflect sound medical judgment regarding the best forms of care, the levels of training among providers, and the setting in which the EMS system operates. They should be jointly developed by physicians and others with expertise in both emergency medicine and pediatrics.
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From page 160... ...
Field Triage EMTs and other prehospital personnel must be able to determine rapidly the hospital destination and mode of transport appropriate to the patient's condition. Triage guidelines should prevent both undertriage (directing seriously ill or injured children to too low a level of care)
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From page 161... ...
; and tendencies for EMS personnel not to collect complete data on pediatric patients (e.g., blood pressures for very young children)
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From page 162... ...
presents a further discussion of scoring systems, particularly their use in assessing inpatient acuity and predicting mortality risks, and also takes up the problems of collecting reliable data to use in calculating scores. ED Staff It is critical for an ED to be able, at a minimum, to assess and stabilize pediatric patients and to facilitate their access to definitive care.
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From page 163... ...
Protocols can help ensure that consistently appropriate medical control is provided when no unusual care is Hated Centralized on-line medical control with one or a small number of hospitals responding to calls can concentrate the number of pediatric cases managed and help maintain the skills of the medical direction staff. Triage Decisions Involving ED Care Busy EDs must have a means of identifying patients who have the most immediate need for care.4 Trauma patients arriving by ambulance are readily recognizable; however, seriously injured infants and children can be harder to identify than adult patients.
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From page 164... ...
Many children can, of course, be successfully treated in the EDs of smaller community hospitals that lack extensive pediatric specialty services. Definitive care for more seriously ill and injured children, however, may require transferring them to referral center hospitals.
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From page 165... ...
35~. Preexisting transfer agreements between community hospitals and referral centers facilitate the movement of patients and define the responsibilities off sending and receiving hospitals Patient transfer is discussed further in the section below on regionalization of care and in Chapter 6.
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From page 166... ...
Facilities that care for few seriously ill children face special challenges. For them, practice scenarios allow ED and inpatient staff to reacquaint themselves with the specifics of pediatric care and to test their readiness to follow existing protocols (Reder, 1991~.
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From page 167... ...
One authoritative statement defines three basic functions for medical control: "to ensure that field personnel have immediately available expert direction for emergency care"; "to ensure continuing high-quality field performance"; and "to provide the means for monitoring the quality of field performance and medical control itself" (Holroyd et al., 1986, p. 1027, citing NRC, 1981~.
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From page 168... ...
Adopting on-line medical control for BLS providers may bring a special benefit to pediatric patients because most of the prehospital care that children receive is at the BLS level. These providers are likely to have even less pediatric training and experience than the ALS providers for whom medical control is stressed (Foltin and Cooper, forthcoming)
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From page 169... ...
Further studies should specifically examine the effectiveness of on-line control in improving outcomes of emergency care for children. Off-Line Control: Planning and Management Functions Any decision to limit on-line medical control emphasizes the importance of off-line control because it becomes an even more vital channel through which medical judgment can be brought to bear on emergency care.
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From page 170... ...
CATEGORIZATION AND REGIONALIZATION A major theme of this report is that optimal emergency medical care of children requires systematic attention to the special needs of a complex patient population that ranges from infants through adolescents. Hospitals, EMS agencies, and individual emergency care providers must recognize both what they can do to provide needed care and what they cannot do.
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From page 171... ...
Categorization: Identifying Appropriate Providers Categorization is essentially an effort to identify the readiness and capability of a health care facility (typically a hospital) and its staff to provide optimal emergency care (AMA, 1989~.
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From page 172... ...
has established additional criteria to be met by Pediatric Trauma Regional Resource Centers and those adult trauma centers making an explicit commitment to care for pediatric patients. Specific
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From page 173... ...
One trauma center has turned, with apparent success, to committed adult surgeons and pediatric intensive care specialists to provide trauma center care for children (Fortune et al., 1992~. An assessment of hospital capabilities in Maine based on the AMA categories found that some hospitals that provide essential pediatric care in rural areas would have difficulty meeting the requirements for the lowest AMA level (Maine EMS-C Project, 1991~.
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From page 174... ...
The Arkansas EMS-C grantees, for example, introduced to the hospitals in their largely rural state a program for voluntary adoption of EDAP-type guidelines (Scotter et al., 1990~. Even with the conclusion of the HRSA grant program and the lack of any formal adoption by state agencies, the EDAP activities continue to contribute to improving hospital readiness to provide basic pediatric emergency care.
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From page 175... ...
Role of Regional Referral Centers Referral centers are often the focal points of regionalized systems of care. As such, they have a responsibility to develop good relationships with the community hospitals and EMS systems in the region and to promote the enhancement of community pediatric emergency care.
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From page 176... ...
Referral centers also should contribute to education and training for emergency care providers in community hospitals and EMS agencies. Programs, such as courses on pediatric resuscitation, can be offered at the referral center or even in local communities.
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From page 177... ...
Clearly, all the challenges facing, and pressures on, trauma centers and trauma systems in general afflict pediatric services as well; to the extent that EMS-C is Reemphasized relative to EMS generally, development of PTCs is likely to be impeded. Specialized Transport Resources Successful regionalization will depend heavily on the availability of high quality transport to referral centers.
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From page 178... ...
Not all transfers to referral centers can be made by highly skilled and well-eqa~ipped transport teams, however, this fact makes it essential that local hospitals and ambulance services be able to provide tile minimum level of care necessary to maintain a patient's condition until more advanced care can be brought into play. Under the auspices of the AAP (AAP, 1986; Day et al., 1991)
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From page 179... ...
Additional studies are needed to verify these results and to identify factors that appear to make PICU or pediatric trauma care critical to better patient outcomes. In the meantime, this committee takes the position that when specialized pediatric centers are available, the most seriously ill and injured children should receive care in those centers.
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From page 180... ...
Although good undergraduate and graduate training and continuing education efforts for all emergency care providers may ameliorate some of these problems (as discussed in Chapter 4) , the solution to providing definitive care for pediatric emergency patients may always lie more .
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From page 181... ...
When care is provided to Medicaid patients from other states, hospitals must contend with several factors: the inadequacy of existing Medicaid reimbursement levels per se, the unevenness of reimbursement levels across state lines, the willingness (or lack of it) of Medicaid agencies to pay for out-of-state care, and the possibility that a hospital may not be an approved Medicaid provider for other states or may be unaware of other states' Medicaid policies, such as prior authorization requirements, that affect eligibility for reimbursement.
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From page 182... ...
, but the result should ensure that appropriate care is available to children who need it. Therefore, the committee recommends that all state regulatory agencies with jurisdiction over hospitals and emergency medical services systems address the issues of categorization and regionalization in overseeing the development of EMS-C and its integration into state and regional EMS systems.
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From page 183... ...
To this end (and in line with later recommendations about the responsibilities of state agencies) , the committee formally calls for all state regulatory agencies with jurisdiction over hospitals and EMS systems to require that hospital EDs and emergency response and transport vehicles have available and maintain equipment and supplies appropriate for the emergency care of children (see Box 5-1~.
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From page 184... ...
Although "local" as contrasted with "national" decisionmaking and solutions are generally preferred in thinking about steps to incorporate EMS-C into existing EMS systems and thus to categorize facilities accurately and designate regional referral centers for pediatric cases some guidance may be needed at the national and state level to foster appropriate identification and classification of referral centers and to overcome difficult interstate
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From page 185... ...
Level I: "An institution capable of providing comprehensive, specialized pediatric care to any acutely ill or injured child. Usually a children's hospital or a large general hospital with a pediatric division providing comprehensive subspecialty pediatric medical and surgical services." Level II: "A hospital with a pediatric service capable of caring for the majority of pediatric patients, but with limited pediatric critical care and subspecialty expertise." Level III: "A hospital with a functioning Emergency Department capable of evaluation, stabilization, and transfer of seriously ill and injured pediatric patients.
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From page 186... ...
discuss the strengths and limitations of a county-based EMS and regionalized trauma care system in San Diego, California, and provide useful lessons for other programs based at the county level or in a county department of health.
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