Emergency Medical Services for Children (1993) / Chapter Skim
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7 KNOWING WHAT IS HAPPENING AND WHAT IS NEEDED: PLANNING, EVALUATION, AND RESEARCH
7 KNOWING WHAT IS HAPPENING AND WHAT IS NEEDED: PLANNING, EVALUATION, AND RESEARCH
Pages 224-279
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From page 224... ...
The information resources that are currently available are too limited, scattered, and unconnected to support the planning and evaluation that EMS-C needs. Without a broad and reliable base of information, it is hard for anyone emergency care providers, administrators, parents, policymakers to determine in any systematic way how successful EMS-C systems are in providing appropriate, timely care or what they ought to do to improve performance and patient outcomes.
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From page 225... ...
· For what is the system used? Data on the illnesses and injuries that bring children into the emergency medical services (EMS)
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From page 226... ...
Some individual hospitals, state and local EMS agencies, and emergency dispatch centers that are parts of EMS systems do have sophisticated data collection and analysis programs that generate valuable information. EMS systems, however, depend on successful coordination of services from many separate components; only rarely are these individual components able to link their data together to learn more about the complete course of a patient's emergency care.
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From page 227... ...
Much of the needed research demands specialized data, but some work might be done with better EMS and EMS-(: data on system structures operat~onal processes, and patient outcomes. Assessing the costs and cost-effectiveness of erne-rgency care and EMS systems must be a priority in times of fiscal constraint, but accurate, comprehensive, and meaningful data are difficult to obtain.
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From page 228... ...
EMS-C evaluation must address at least three concerns. First, it should seek to know whether the system is "doing things right": for example, whether the existing full range of services, from prehospital care through definitive inpatient and outpatient care through rehabilitation and counseling, as well as prevention, has been of high quality and whether certain practices or interventions could be improved.
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From page 229... ...
EMS-C research questions cover a wide spectrum: for instance, elucidating biologic factors that contribute to the success or failure of basic or advanced life support (BLS, ALS) interventions in children, developing improved injury and illness acuity measures for children, investigating the etiology and epidemiology of childhood trauma or illnesses that account for the major part of EMS calls, predicting the emergency care needs of children with chronic or disabling illnesses, assessing outcomes of emergency care over time, or investigating factors that make public education campaigns about safety and healthy lifestyles successful.
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From page 230... ...
UNDERSTANDING CURRENT AND EMERGING SOURCES OF DATA AND DATA SYSTEMS Strengths and Weaknesses In principle, data on emergency medical care for children and the systems through which it is provided are available from an assortment of sources. Those different data systems have different advantages and disadvantages, and in no case can one source provide the full range of information needed for the planning, evaluation, and research activities discussed earlier.
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From page 231... ...
Hospitals Emergency Departments EDs are an especially important source of information about emergency medical care for children. They have the potential to produce the broadest array of data on emergency care because many patients receive no prehospital or inpatient services.
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From page 232... ...
. Adding E-codes to discharge data enables researchers, policymakers, and others to use the data in planning and assessing injury prevention efforts.
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From page 233... ...
The CDC advises inclusion of core data elements in seven categories (Pollock and McClain, 1989~: demographic and identifying data; incident description; prehospital care; ED care; surgical care; anatomic diagnosis; and outcome data. Software packages are now available that permit hospitals to manage their registries on personal computers.4 Two long-term efforts have been made to collect data on an even broader basis to help evaluate trauma care.
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From page 234... ...
As valuable as trauma registries are in studying the nature and quality of trauma care, they capture data on only a limited portion of the children who suffer serious injury. As with discharge data, information on children who die outside the hospital is not incorporated into these files.
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From page 235... ...
. Mandatory Ecoding in vital statistics records for injury-related deaths may make them a valuable resource for assessing the contribution of injury to mortality and for injury prevention studies (although it should be recognized that "traumatic injury" is no longer acceptable as a cause of death)
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From page 236... ...
The National Accident Sampling System, also based on police reports, captures information on nonfatal motor vehicle collisions, including those involving pedestrians and bicycles (National Committee for Injury Prevention and Control, 1989~. The detail that these data systems
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From page 237... ...
Software has been developed to facilitate reporting by prehospital provider agencies and hospital EDs. The state of Maine has computerized its prehospital run sheets, and it has also established electronic linkages with computerized police accident report data and hospital discharge summaries, allowing officials to monitor data from the scene of injury through hospital discharge.
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From page 238... ...
Planning is also under way by NHTSA for a national consensus development conference on EMS data elements (as part of an EMS-MIS) , which is expected to be convened by fall 1993 (NHTSA, 1991a; Ryan, 1992~.
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From page 239... ...
The committee has taken preliminary steps to establish a data set by identifying some of the data elements that it sees as essential (see below and Appendix 78~. (Certain of tile elements proposed should help address some of the other significant limitations to existing data and data sources discussed below, especially linking and aggregating data over patients, settings, and time.
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From page 240... ...
The committee discussed the need for unique individual identifiers and strongly endorsed the concept that individuals should be assigned such an identifier at birth or as close after birth as possible. One prominent option Is the social security numbers It has been raised in proposals for revisions to the Uniform Hospital Discharge Data Set (CHDDS)
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From page 241... ...
As noted earlier in this chapter, only six states currently require that hospital discharge data include Encodes for injury diagnoses (CDC, 1992a)
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From page 242... ...
Retrospective identification of inpatients who received emergency care for illness-related conditions is much more problematic, and the obstacles to doing so deserve more attention than they have received to date. Evidence of admission through the ED might be helpful, but it is not always available in discharge data sets; moreover, not all patients requiring emergency care come to the hospital through the ED, so they might be missed altogether.
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From page 243... ...
The difficulties in developing scoring systems for pediatric illness in particular have led to a suggestion to establish a medical registry, along the lines of the trauma registries discussed above, which would make it possible to accumulate the large volumes of data needed to support development of a broadly valid assessment measure (Buchert and Yeh, 1992~. A different kind of response has emerged from observations of the inability of adult scoring systems to predict outcome accurately: Civetta (1991)
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From page 244... ...
Is the appropriate time to evaluate outcomes of prehospital care upon arrival at the ED or at some later point? For children suffering significant trauma requiring intensive inpatient and outpatient care and rehabilitation, when in the sequence of events should outcomes be assessed?
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From page 245... ...
In another vein, facilities and agencies collecting routine information may be reluctant to share data with institutional, physician, or other provider identifiers intact; they may fear potential malpractice liability or public disclosure of unflattering information about performance and patient outcomes. Here, too, an understanding of the need for evaluation and con
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From page 246... ...
Thus, the committee recommends that states implement a program to collect, analyze, and report data on emergency medical services; those data should include all the elements of a national uniform data set and describe the nature of emergency medical services provided to children. Further, the committee recommends that mechanisms be developed to link all data on a specific case, where those data are generated by separate parts of the emergency medical services system.
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From page 247... ...
Priority Data Elements Appendix 7B outlines the data elements on prehospital and ED care that this committee has determined should have highest priority for inclusion in a national uniform data set for EMS-C. The rationale for including each item is given.
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From page 248... ...
At these levels, in contrast with national-level analysis, it becomes possible to make meaningful use of a much broader range of data captured in greater detail to assess and guide improvements in local performance or to identify specific circumstances that may require special study. In short, the committee's proposed data elements should be thought of as a beginning and not an end a core and not a constraint.
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From page 249... ...
Disposition: Left at scene or transported Transported to: Hospital identification number, possibly hospital zip code Zip code for site of EMS encounter Prehospital provider identification number Prehospital run report number Type of responder (e.g., ALS, BLS) Emergency Departments Date of birth Gender Race/ethnicity Mode of transport (e.g., self, EMS, interfacility, air, ground)
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From page 250... ...
develop guidelines for a national uniform data set on emergency medical services for children. Much additional work must be done on many fronts to achieve the committee's goal.
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From page 251... ...
Furthermore, in all settings the direct impact of data collection efforts on care delivery and patient-provider interaction must be minimized, or all parties are likely to become frustrated or anxious (or both) about the health encounter itself.
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From page 252... ...
, which could support research related to EMS-C and EMS more generally, were not considered by the committee. Instead, the focus was on a proposed federal center for EMS-C (see Chapter 8)
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From page 253... ...
Because each of these topics could generate a long list of research projects, particularly important issues must be identified. Therefore, the committee recommends that research in emergency medical services for children be expanded and that priority attention be given to seven areas: clinical aspects of emergencies and emergency care; indices of severity of injury and, especially, severity of illness; patient outcomes and outcome measures; costs;
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From page 254... ...
It would be desirable if the data elements in the proposed core data set discussed above could be used in research efforts. The committee recognizes, however, that primary data collection will likely be needed to address many of the issues presented below and that broader secondary analyses of existing databases may prove helpful.
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From page 255... ...
System Organization, Configuration, and Operation Effective and practical ways to upgrade EMS system components Effectiveness, efficiency, and other outcomes of various EMSIEMS-C arrangements for different populations and settings Extent to which children who need emergency medical services receive them, with particular attention to care received (or not received) in hospital EDs continued
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From page 256... ...
For injured children, the merits of operative versus nonoperative management of blunt hepatic, splenic, and pancreatic injuries and use of blood products and synthetic blood products remain significant concerns. Critical elements for evaluating minor head trauma need to be established, including indications for CT (computed tomography)
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From page 257... ...
costs of improving EMS systems sufficiently to be able to handle the pediatric age group adequately; investigation of the economic consequences of pediatric trauma or severe illness for families and for taxpayers; and, finally, evaluation of the cost-effectiveness of different EMS-C program configurations, with particular attention to a broad set of program benefits (i.e., patient and system outcomes)
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From page 258... ...
As to the former, effective ways, in all settings and at all levels, to educate and train EMS professionals initially and throughout careers, were regarded as especially important. Particular attention to improved practice patterns, patient outcomes, and skill acquisition and retention is warranted.
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From page 259... ...
A more specific concern is patterns of musculoskeletal injury from motor vehicle crashes and the biomechanics of injury in restrained and unrestrained children. Attention also should be given to characteristics of firearm injuries.
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From page 260... ...
develop guidelines for a national uniform data set. As a first step toward this data set, the committee proposes data elements for prehospital and ED care.
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From page 261... ...
; and prevention. Other areas warranting targeted research efforts include the epidemiology of illness and injury, skills needed in prehospital care, and rehabilitation services.
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From page 262... ...
The reliability of hospital discharge data, for example, was examined in the late 1970s by study committees of the Institute of Medicine (IOM, 1977, 1980b) ; the situation has improved some since the introduction of Medicare's DiagnosisRelated Groups Prospective Payment System for hospitals, but the problems are by no means solved.
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From page 263... ...
8. The literature on functional outcomes, health status, and health-related quality of life is quite large certainly too comprehensive to review here.
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From page 264... ...
. In 1992, privacy and confidentiality of personal health data was also to one degree or another the subject of debate by three IOM committees considering, respectively, employment-based health benefits (IOM, 1993c)
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From page 265... ...
TRAUMA AND INJURY MEASURES Many measures and scoring systems have been developed for trauma and injury. Some are intended especially for field or later triage; this involves identifying injured patients who should be transported by, for instance, aeromedical services, transported directly to and treated in trauma centers, transported from one hospital to another that has more sophisticated facilities, or in other ways managed with services that imply considerable resource use because of increased medical need.
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From page 266... ...
generates a probability of survival from a mathematical formula that combines a patient's Trauma Score (or Revised Trauma Score) , Injury Severity Score, and age.
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From page 267... ...
developed the Pediatric Trauma Score (PTS) specifically for children.
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From page 268... ...
a triage tool in the field, and some advocate that EMS systems routinely collect its component data elements (Morris et al., 1986~. A related tool, the Triage Decision Scheme, is a flow-chart instrument designed to help emergency medical technicians (EMTs)
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From page 269... ...
that the TS, PTS, and unweighted RTS have an acceptable sensitivity for triage decisions (e.g., whether to transport a child to a pediatric trauma center) , although the last-named may have a less acceptable specificity.
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From page 270... ...
Generally, the state of the art of mortality prediction among injured children, which relates directly to ongoing debates about the adequacy of trauma scoring systems for pediatric patients, remains in flux. Questions about mortality measures are pertinent to efforts to evaluate pediatric trauma programs.
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From page 271... ...
that is designed to be appropriate for prehospital providers as well as clinicians in community hospital EDs and physicians' offices. Its designers intend that it quickly identify patients who need various levels of emergency care without having to resort to much in the way of laboratory data (except perhaps for an electro
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From page 272... ...
In addition, measures otherwise considered reasonably applicable to the pediatric age group tend to be unreliable in infants under 2 months.
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From page 273... ...
Far less has been done to try to apply existing measures in any program evaluation or quality assurance effort. Thus, an appreciable amount of investigation and validation lies ahead to provide the EMS-C field with reliable and valid instruments related to illnesses across the pediatric age range that can be employed in research and evaluation activities.
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From page 274... ...
The committee felt very strongly that getting started on defining a core data set and collecting data was critical. To that end, it has proposed an initial set of data elements for EMS-C, which is described in detail in this appendix.
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From page 275... ...
(The data elements relevant for interfacility transports may differ from those presented below for prehospital reporting; the committee did not attempt to develop a list of data elements specifically for interfacility transports.) Emergency Departments The committee noted that several parameters that are markers for the physiologic status of the child should be collected routinely in EDs (even if they are not now so collected)
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From page 276... ...
Zip Code for Site of EMS Encounter Relationship of age to number and nature of emergency events and to outcomes; facilitate linkage between ED and EMS records; may not be routine part of current Prehospital data collection; the committee encourages use of date of birth, which is a better tool for record matching. Distinguish differences in types of emergencies (and therefore service needs)
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From page 277... ...
Dead on Scene/ Alive on Arrival at ED Resuscitation Needed Medical/Surgical/Other Facilitate linkage between ED and EMS records. Qualifications of responders.
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From page 278... ...
Bye opening Best motor response Vital Signs (initial readings) Pulse Respiratory rate Systolic blood pressure Temperature Basis for Selection, Consideration, or Rejection Relationship of age to number and nature of emergency events and to outcomes; facilitate linkage between ED and EMS records.
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From page 279... ...
Communication Barriers Between Provider and Patient (or Family) Prior Health Status Rejected Data Elements Loss of Consciousness (history at time of arrival)
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