Emergency Medical Services for Children (1993) / Chapter Skim
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6 CONNECTING THE PIECES: COMMUNICATION
6 CONNECTING THE PIECES: COMMUNICATION
Pages 187-223
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From page 187... ...
agencies, emergency departments (EDs) , critical care units, and various others must each perform their roles well, and they must also be able to work together.
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From page 188... ...
Poison control centers are well-recognized sources of specialized information regarding situations that may range from harmless to life-threatening. Parents also seek advice from staff at EDs or from primary care providers on the care their children need.
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From page 189... ...
Implementation generally must be managed by individual counties or other local governmental 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)
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From page 190... ...
bStatewide implementation of enhanced 9-1-1 is under wa C9-1-1 or similar access number. SOURCE: Emergency Medical Services ( 1992)
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From page 191... ...
has been developed that will meet the requirement of the Americans with Disabilities 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.
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From page 192... ...
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.
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From page 193... ...
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.
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From page 194... ...
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 department who may have little or no EMS training.
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From page 195... ...
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 information and transportation services to assist people in getting to doctors' offices, clinics, and pharmacies for nonurgent medical care.
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From page 196... ...
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 available)
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From page 197... ...
The 9-1-1 system must be universally accessible 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.
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From page 198... ...
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 generally involve the most serious cases.
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From page 199... ...
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, forthcoming; Avner et al., 1992; Isaacman et al., 1992b; Yanovski et al., 1992~.
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From page 200... ...
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.
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From page 201... ...
assessments of state EMS systems documented the need for more systems to develop up-to-date communications 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.
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From page 202... ...
EMS would then be in a better position to participate in the development of consolidated public safety communications 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)
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From page 203... ...
In this case, some experts recommend that the medical control director be a physician trained in either pediatric emergency medicine or critical care medicine; 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
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From page 204... ...
In deciding how to provide medical control (e.g., standing orders versus direct communication or physician only versus physician 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)
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From page 205... ...
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.
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From page 206... ...
Second, insofar as resources and time allow, emergency care providers
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From page 207... ...
Providing consultation services is an explicit component of some guidelines for critical care services see especially work by the Commission on Emergency Medical Services (AMA, 1990) , the Pediatric Emergency Medical Services Advisory Board (1988)
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From page 208... ...
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 transmitted orally.
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From page 209... ...
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 permit 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.
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From page 210... ...
(Chapter 5 includes 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.
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From page 211... ...
Because it focuses on providing speedy care for unanticipated problems, however, such a system 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 provided 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.
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From page 212... ...
Treatment 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.
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From page 213... ...
When emergency care is needed, contact with the primary care provider may give the ED better access to information about the patient and facilitate arrangements for appropriate follow up care. Communication with a primary care provider or other plan representative is a major feature of managed care plans.
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From page 214... ...
found that patients who had no regular health care provider or who had difficulty arranging for temporary care of their children were significantly less likely to obtain recommended follow-up evaluations. For lowincome families, the recommended treatment may prove too costly.
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From page 215... ...
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.
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From page 216... ...
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.
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From page 217... ...
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, encourage pediatric equipment purchases, and generally raise the level of understanding about EMS-C issues. Closer to home, participation on hospital committees enables EMS-C advocates to assemble a "code team" that comprises the best specialists from key departments in the institution and can respond quickly to an intrafacility crisis.
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From page 218... ...
An annual event such as National Emergency Medical Services Week, which has been held for several years and recognized by presidential proclamation since 1990, provides a valuable opportunity to focus broad community attention on EMS and EMS-C issues. With federal agencies and professional organizations as sponsors, this program has received recognition from state and local governments and has encouraged individual EMS agencies, fire departments, ambulance services, and hospitals to organize community activities.
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From page 219... ...
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.
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From page 220... ...
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)
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From page 221... ...
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.
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From page 222... ...
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 administrat~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 administrative matters in advance.
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From page 223... ...
Burn centers might, for example, have direct linkages with emergency departments and community hospitals, 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.
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