Emergency Medical Services for Children (1993) / Chapter Skim
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8 LEADERSHIP FOR DEVELOPING EMERGENCY MEDICAL SERVICES FOR CHILDREN
8 LEADERSHIP FOR DEVELOPING EMERGENCY MEDICAL SERVICES FOR CHILDREN
Pages 280-320
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From page 280... ...
Many can be attributed to insufficient integration of EMS-C with other areas of health care. In particular, we note inadequate attention to the needs of children on the part of an emergency care system developed to meet the needs of adults from emergency dispatch centers to emergency transport systems, emergency departments (EDs)
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From page 281... ...
education and training for the public, for health professionals generally, and for emergency care providers specifically; ~ organization and delivery of care' especially regarding equipment' protocols and guidelines, medical control, categorization of facilities, and regionalization of care; · communication, including universal adoption of 9-1-1 for telephone access to the emergency system and movement toward enhanced 9-1-1; and · planning and evaluation, including efforts to institutionalize a national uniform data set appropriate for EMS-C and to require reporting of ICD-9-CM E-codes for injury diagnoses, and augmented research activities. As a way to focus attention and resources on efforts to improve EMSC, the committee sets forth in this chapter recommendations for establishing EMS-C agencies at the federal and state levels and discusses the rationale for its position.
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From page 282... ...
to establish and maintain links among the many federal activities related either to emergency care or to child health (although it has promoted informal networking among state EMS-C programs)
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From page 283... ...
Thus, the responsibility for promoting more cohesive and comprehensive EMS-C efforts cannot rest entirely on the shoulders of professional groups. A FOCUS FOR EMERGENCY MEDICAL SERVICES FOR CHILDREN In sum, progress in improving the quality of emergency care given to children and the readiness of EMS systems to provide that care depends on ensuring that essential EMS-C components become an integral part of both EMS in general and the broader realm of child health care.
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From page 284... ...
Because the organization and delivery of emergency care services rest not with the federal government but with state and local governments and health care providers in the private sector, action at the federal level alone is not sufficient. Therefore, the committee further recommends that states establish a lead agency to identify specific needs in emergency medical services for children and to address the mechanisms appropriate to meeting those needs.
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From page 285... ...
Developing a National Strategy Perhaps the highest priority for the federal EMS-C center is to develop a clear national strategy for ensuring that the emergency care needs of children are met. As a nationally recognized entity that can represent or respond to many interests, the EMS-C center together with its national advisory council would be able to speak to such a broad need in an authoritative voice not always available to other groups.
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From page 286... ...
, the newly created National Center for Injury Prevention and Control is intended to provide leadership in a broad national program related to nonoccupational injury prevention and control, with the aim of preventing premature death and disability from intentional injuries resulting from violent and abusive behavior and from unintentional injuries. Activities at the National Institutes of Health include research and education programs in asthma and emergency cardiac care at the National Heart, Lung, and Blood Institute; work on injury and injury surveillance at the National Institute of Arthritis and Musculoskeletal and Skin Diseases; work on child health, injuries, and medical rehabilitation at the National Institute of Child Health and Human Development; and shock and trauma research at the National Institute for Neurological Disorders and Stroke.
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From page 287... ...
Improving Access to Care Numerous factors can limit the availability of appropriate emergency medical care for children and can otherwise distort patterns of seeking and receiving nonemergency care, which in turn impinges on the EMS system. The EMS-C center should identify ways in which actions at the federal level can overcome some of those limitations or help states and municipalities to do so.
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From page 288... ...
These issues must be a serious concern because, as hospitals face increasing burdens from underand uncompensated care, access to emergency care is threatened as well. Drawing Attention to Illness-Related Emergencies Emergencies from serious illness have, overall, received less attention than injury, yet illness is a major reason for young children, especially the very young, to require emergency care and hospitalization.
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From page 289... ...
Finally' the federal c-enter could also develop ways to act as or support ~ clearinghouse through which proven, or innovative, curricular programs and other teaching materials might be shared. Collecting and Analyzing Data The committee believes that assembling a core of nationally comparable data on pediatric emergency care is essential.
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From page 290... ...
For this reason, the committee advises that the federal center give early and strong priority to developing methods for generating good cost and cost-effectiveness data and to making the case to the states that they, in turn, will need to find ways to obtain these data. Both the federal and state advisory councils can be used to carry this message to the broad set of interested parties in both the public and private sectors.
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From page 291... ...
Creating Incentives for State Action Because the federal government has only limited responsibilities for the direct operation of EMS systems, its efforts to improve their services must operate through states and localities and the various health care providers who do deliver those services. States are an especially important target because of their frequent role as funders of EMS and as regulators through standards for provider training and practice, facilities, and equipment.
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From page 292... ...
For example, the center might undertake to increase access to training or to help finance purchases of additional equipment. Providing Technical Assistance States and localities may not have available the kinds of expertise they need either to assess shortcomings in their ability to provide emergency care for children or to develop the new programs that would improve their capabilities.
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From page 293... ...
Finally, it might investigate whether future federal efforts could facilitate interstate reimbursements under Medicaid or other programs, particularly in the context of state agency efforts to develop written transfer agreements and other interstate cooperative initiatives. A special form of coordination to which the federal center ought to direct some attention is international, especially relationships between states of the United States and neighboring countries.
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From page 294... ...
. ODPHP was established in 1976 to coordinate DHHS policies and programs in the health promotion arena, and it has considerable responsibility within the PHS to implement various health promotion and disease prevention strategies (such as those advanced in Healthy People 2000 [DHHS, 19911~.
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From page 295... ...
Cheaters on Pediatric Emergency Care Some elements of other programs more directly associated with EMS-C might also serve as models for a national center. The two examples noted here are part of the EMS-C Resource Network, although based in the private sector, both are funded by MCHB in HRSA.
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From page 296... ...
Advisory Board, 19911: coordinating federal programs through an interagency task force; conducting research (including data collection and analysis) and making research grants; awarding grants to states and localities to develop or enhance services; providing technical assistance; and supporting the operation of an information clearinghouse (at the Kempe Center, noted above tClearinghouse, 19921~.
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From page 297... ...
These experts should be able to address operational and clinical concerns for illness and injury, but the general point is that the council must have broader EMS and child health perspectives in order to further the aim of integrating EMS-C better into these two fields. Private Sector Membership Voting members should include representatives across a broad spectrum of health care providers.
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From page 298... ...
STATE AGENCIES AND ADVISORY COUNCILS ON EMERGENCY MEDICAL SERVICES FOR CHILDREN The committee's second major pair of recommendations in this chapter is that each state establish a lead agency for EMS-C and a corresponding advisory council. The committee takes no position on whether these should
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From page 299... ...
State Agency Structure These lead EMS-C agencies in the states are, in the committee's view, likely to have a much more direct impact on the organization and delivery of services to patients within each state's borders than the federal EMS-C agency can hope to have. Each state will have a unique mix of opportunities and constraints based on factors such as population, geography, culture, political system, economics, and health care policies and resources and each state agency must formulate programs suited to its specific circumstances.
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From page 300... ...
State Agency Charge and Agenda The committee sees at least eight areas on which a state EMS-C agency ought to place high priority: 1. planning state programs; enhancing education and training; 3.
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From page 301... ...
Finally, these EMS-C agencies might support high-technology communications programs that would permit volunteer EMS personnel or those in remote areas to participate in educational activities without disruption of local emergency care services or personal lives.
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From page 302... ...
In the committee's view the state agencies should treat data collection and analysis capabilities as early and major priorities, much as it has advised that the federal center do.
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From page 303... ...
EMS agencies may also become involved in interstate operations. Where local facilities are lacking, they may need to arrange transport for patients to facilities in other states; alternatively, the emergency care providers may come from another state to provide services that are not available locally.
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From page 304... ...
They might also undertake development of regional communication systems and protocols for prehospital care and medical control. The agencies and their-respective advisory councils should seek out any and all positive factors that can motivate states to seek greater interstate cooperation.
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From page 305... ...
Apart from fiscal auditing procedures, a state agency might discharge its public accountability duties in. several ways Among the tasks that might be pursued are formal quality assurance for providers, rigorous program evaluation, citizen review panels for complaints, and review of training and continuing education materials and programs.
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From page 306... ...
program will not pay for pediatric critical care services in hospitals that do not have a PICU, and neonatal intensive care will not be rein bursed unless rendered in an appropriate facility. Relationships with "Local" Public Sector Entities Clearly, a concern of any state agency is how its work relates (or should relate)
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From page 307... ...
One factor that has hindered recognition of pediatric emergency care needs has been a lack of input from pediatricians and others with pediatric expertise in EMS planning and advisory groups. In many cases, neither side has appreciated that a patient population with distinct emergency care needs was being overlooked.
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From page 308... ...
The value of obtaining data to make a thorough needs assessment may be an especially important message for states that have, as yet, done little to address issues of emergency medical care for children. Potential Limitations to "New" Agencies and Councils In proposing these new agencies and advisory groups, the committee recognizes that simply "establishing entities" is only part of the response that is needed to develop the emergency care capabilities to which children across the country should have access.
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From page 309... ...
Reasons for such hostility may reflect a general resistance to regulation or the view that enough opportunities exist within routine procedures to make any changes that are needed. Fiscal Constraints Another source of likely resistance stems, of course, from fiscal considerations.
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From page 310... ...
THE CASE FOR NEW ENTITIES TO ADDRESS EMERGENCY MEDICAL SERVICES FOR CHILDREN While fully aware that its recommendations for new federal and state entities may face some obstacles, the committee nonetheless firmly believes that ensuring adequate emergency medical care for children is of such significance that those obstacles must be understood, met, and overcome. In seeking to bring major attention to children's needs, the committee is not proposing to establish a new entitlement for children's medical care.
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From page 311... ...
Substantial areas of overlap exist between national and state concerns for example, using federal funding to create incentives for state action, collecting and analyzing data, or disseminating the results of research and this factor should lead to coordination of efforts between federal and state agencies or advisory councils or both. The proposed structures might in many respects be a model for the sort
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From page 312... ...
By contrast, the proposed federal center, plus state lead agencies, are intended to stimulate rather than impose requirements for state actions. This approach recognizes the extraordinary diversity in state capacity to fund effective EMS-C programs as well as the tremendous interstate variation in the challenges that EMS-C providers face.
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From page 313... ...
Thus, these agencies and advisory councils can help ensure that services relating to prevention of injury and illness, disability prevention, and rehabilitation for children are included in the state EMS plan and are linked to more general planning for child health needs. More broadly, they can work to guarantee that these and related emergency services are universally available to all children residing in the state.
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From page 314... ...
The committee advocates congressional appropriations of new federal monies for each of the ensuing five years for federal and federally sup: ported activities related to emergency care for children. Part of this funding would directly support federal center efforts; most of the funds would be made available to support state agency programs (and perhaps, through the states, some local activities)
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From page 315... ...
Such an effort may thus waste the resources that are provided, lead to a false sense of security about the state of EMS for children today and tomorrow, and be unable to demonstrate any meaningful effect on the planning and delivery of emergency care for children. Barr- to this two-part, five-~ar strategy might be considered.
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From page 316... ...
information and serving a clearin~o.~-se function, improving access,.to-~care, underscoring medical illness as a special concern in EMS-C, assisting education and training efforts, collecting and analyzing data, supporting enhanced research efforts, creating incentives for state action, providing technical assistance, and encouraging regional coordination. At the state level, the following matters are paramount: planning state programs, enhancing education and training, strengthening structural elements of the EMS-C system, collecting and analyzing data, improving access to.
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From page 317... ...
Although DOD provides medical care, including emergency care, to children of service personnel, its principal focus in research and training is on care of active-duty personnel, particularly for combat casualties. The health care system of the ' Department of Veterans Affairs also delivers some EMS care but obviously does little if anything in' the pediatric 'EMS arena.
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From page 318... ...
or even formal guidance could be difficult and drawn out. Second, it is not a given that such statutory language, regulations, or guidance could be made sufficiently flexible that the EMS-C office could respond adequately to the quite varied circumstances of pediatric emergency care across the states.
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From page 319... ...
12. For the discussion of lead EMS-C agencies at the state level, "state agency" refers specifically to the recommended "lead agency" in each state's executive branch; to avoid confusion, other elements of state government are designated as departments, offices, units, or by some other rubric.
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From page 320... ...
federal program for children might be considered. For the RICH block grant program to the states, which is administered by MCHB/HRSA, approximately $547 million was available in FY 1992 for direct block grants, approximately $96 million for SPRAINS grants (Special Playacts of Regional and National Significance)
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