social problems. Much of the service provided to these difficult patients is compensated poorly or not at all. This situation places tremendous financial pressure on safety net hospitals, some of which have closed or are in danger of closing as a result.

The problems faced by children in the current emergency care system are even more daunting. Although children represent 27 percent of all ED visits, many hospitals are not well prepared to handle pediatric patients. For example:

  • Only about 6 percent of EDs in the United States have all of the supplies deemed essential for managing pediatric emergencies; only half of hospitals have at least 85 percent of those supplies.

  • Of the hospitals that lack the capabilities to care for pediatric trauma patients, only half have written transfer agreements with other hospitals.

  • Although pediatric skills deteriorate quickly without practice, continuing education in pediatric care is not required or is extremely limited for many prehospital emergency medical technicians (EMTs).

  • Many medications prescribed for children are “off label,” meaning they have not been adequately tested or approved by the U.S. Food and Drug Administration (FDA) for use in pediatric populations.

  • Disaster preparedness plans often overlook the needs of children, even though their needs during a disaster differ from those of adults.

  • Evidence indicates that pediatric treatment patterns vary widely among emergency care providers, that many of these providers do not properly stabilize seriously injured or ill children, that many undertreat children in comparison with adults, and that many fail to recognize cases of child abuse.

  • These shortcomings are often exacerbated in rural areas, where dedicated, well-intentioned prehospital and ED providers often make do without the specialized pediatric training and resources that most of us would expect to be in place.

As a result of the above problems, many children with an emergency medical condition do not receive appropriate care under the current system. Many urban areas have children’s hospitals or hospitals with pediatric EDs staffed by pediatric emergency medicine specialists and equipped with the latest technologies for the care and treatment of children. However, the vast majority of ED visits made by children are not to children’s hospitals or those with a pediatric ED, but to general hospitals, which are less likely to have pediatric expertise, equipment, and policies in place.

The Institute of Medicine’s (IOM) Committee on the Future of Emergency Care in the United States Health System was formed in September 2003 to examine the emergency care system in the United States; explore its strengths, limitations, and future challenges; describe a desired vision of

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