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Emergency Care for Children: Growing Pains
Index
A
Accidental Death and Disability: The Neglected Disease of Modern Society,17, 36–37, 105
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Emergency Care for Children: Growing Pains
Index
A
Accidental Death and Disability: The Neglected Disease of Modern Society, 17, 36–37, 105
Accountability
fragmentation of EMS system and, 135
importance of, 5, 115
model EMS systems, 121, 123, 124, 125
new lead agency for EMS system and, 138, 140
obstacles to, 5, 115
performance measurement and, 5
recommendation for, 117
strategies for enhancing, 116
Accreditation
disaster drill requirements, 238
EMS system components, 116–117
pediatric emergency care, 162–163
Adolescent patients, 211–212
Advanced life support (ALS)
field stabilization vs. transport, 112–113
pediatric, 158
role of emergency medical technicians, 152
in rural areas, 79–80
shortcomings of pediatric care capabilities, 50–51
training for, 154, 155, 164–165
Adverse events
current state of pediatric emergency care, 193–194
language difference as cause of, 210
mandated reporting, 198
in prescription or administration of drugs, 196–197
recommendations for reducing, 198, 212
risk in EDs, 188–190
risks for children in emergency care, 190–193
strategies for reducing, 197–198
Agency for Healthcare Research and Quality, 27, 132, 141, 195, 197, 201, 227, 249, 261
Airbags, 254–255
Ambulance services
appropriateness of dispatch, 63–64
diversion, 71–72, 115, 129
origins and development, 37
payer mix, 82
pediatric utilization, 62, 63–64
response times, 75
shortcomings of pediatric care capabilities, 50–51
See also Transport of patients
American Academy of Pediatrics, 39, 227, 247, 265, 268
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American Board of Emergency Medicine, 41
American Board of Pediatrics, 41
American College of Emergency Physicians (ACEP), 39, 105, 165, 264
American College of Surgeons, 13, 110–111, 271, 273
American Pediatric Surgical Association, 43
American Trauma Society, 43
Anthrax, 229
Asthma management, 176
Atropine, 237
Automated external defibrillator, 202–203
Automobile crashes, 39, 52, 54
airbag research, 254–255
B
Bag mask ventilation, 158
Balanced Budget Act, 80
Bar code technology, 199–200
Basic life support
role of emergency medical technicians, 152
shortcomings of pediatric care capabilities, 50
training for, 154, 155
Best Pharmaceuticals for Children Act, 195–196
Bicycle accidents, 54
Biochemical events
antidotes, 237
health care system preparedness, 227–22
training for, 238
vulnerability of children, 25
Boarding, 71–72
Bomb injuries, 225
C
Carbon monoxide poisoning, 191–192
Cardiac arrest, 202–203
Cardiopulmonary resuscitation, 253
Categorization of emergency medical services
goals, 111
implementation, 113–115
pediatric acute care facilities, 47, 49
recommendations for, 4, 111–112, 146
regionalization of pediatric emergency care, 109–110, 111
shortcomings of current system, 24, 51
trauma centers, 43
trauma system, 110–111
Causes of ED visits, 18–19, 55–59, 59
Causes of prehospital calls, 20, 63, 79
Centers for Disease Control and Prevention (CDC)
National Center for Injury Prevention and Control, 40, 132, 262
new lead agency for EMS system and, 141
recent funding cuts, 135–137
research activities, 27, 262, 268
structure and operations, 262
transition to new lead agency for EMS system, 143
Centers for Medicare and Medicaid Services (CMS)
EMTALA review, 130
payment system, 128–129
public reporting activities, 119
research support from, 263
See also Medicaid;
Medicare
Centers of excellence, 266–267
Child, defined, 29
Child abuse/neglect
ED utilization related to, 69–70
risk, 54, 55
Children’s hospitals
capacity and utilization, 19
Medicaid reimbursement, 85
teaching in, 86–87
Children’s Oncology Network, 268
Clinical Practice Guidelines for Pediatric Emergency Care, 176
Committee on the Future of Emergency Care, 2–3, 27–28
Communication, interpersonal, cultural competency of providers, 210–211
Communications technologies and systems
current shortcomings, 3, 103, 222
for disaster response, 222
to improve coordination of care, 107–108
model EMS systems, 120–121, 123
risk of error in emergency care, 189
Computed tomography, 201–202
Congress, recommendations for, 6, 7, 13, 14, 126, 139, 142–143, 144, 146–147, 257, 273
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Coordination of care
communications system for, 107–108
current shortcomings, 3–4, 102–104
establishment of new lead agency for EMS system, 7, 138
goals, 4, 106
model systems, 106–107, 120–121, 122, 123, 124
previous efforts to improve, 105–106
regulatory impediments to, 129–130
County Hospital Alert Tracking Systems, 121
Crossing the Quality Chasm: A New Health System for the 21st Century, 10, 204, 251
Crowding, ED, 70–72, 75
payment incentives to reduce, 129
Cultural competency, 210–211
D
Data Elements for Emergency Department Systems (DEEDS), 116
Decontamination equipment, 224, 229
Defibrillators, automated external, 202–203
Dehydration treatment, 176
Demonstration program
funding, 6, 127
granting agency, 127–128
grant recipients, 126
proposals, 126
purposes, 126–127
rationale, 125–126
recommendations for, 6, 126, 146
Department of Defense, 263
Department of Health and Human Services (DHHS)
in categorization of emergency services, 4, 111–112, 146
in development of clinical practice guidelines, 176–177, 179
disaster preparedness funding, 223
new lead agency for EMS system in, 7, 139, 140, 146
recommendations for, 4, 5, 7, 8, 9, 11, 12–13, 111–112, 117, 131, 139, 146, 176, 179, 195, 197, 212, 229–230, 239, 257
research program, 9, 27, 261–263
structure of EMS system oversight and support, 131, 132, 135
See also Agency for Healthcare Research and Quality;
Centers for Disease Control and Prevention;
Health Resources and Services Administration
Department of Homeland Security (DHS)
disaster preparedness funding, 223
FEMA, 132, 263–264
recommendations for, 229–230, 239
research support from, 263–264
role of, 132, 263
structure of EMS system oversight and support, 6, 131, 140
Department of Transportation (DOT)
structure of EMS system oversight and support, 6, 131, 140, 263
training standards for EMS providers, 155
See also National Highway Traffic Safety Administration
Depression, 195
Disaster Medical Assistance Teams (DMATs), 12, 132, 232–234, 238, 239
Disaster preparedness
challenges in, 221–222
definition of “disaster,” 221
drills, 12, 238–239, 239
enhancing pediatric expertise for, 232–234
establishment of new lead agency for EMS system, 7, 139, 141, 146
federal funding, 223
goals for pediatric care, 12, 230, 239
minimizing family separation in, 230–232
needs of children in, 11, 25, 30, 223–224, 236–238
pediatric considerations in planning, 11, 12, 25, 104, 223, 226–227, 236–238
recommendations for, 11–12, 229–230, 239
shortcomings of current system, 2, 11, 16, 25, 51, 222–223, 227–229
studies, 224–226
surge capacity, 234–236
Disease and illness, pediatric
causes of hospital ED visits, 55–59
epidemiology, 52, 55–59
preventive efforts, 40–41
Dispatch of emergency services
appropriateness, 63–64
establishment of new lead agency for EMS system, 7, 139, 141, 146
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model EMS systems, 120–121
research needs, 112
See also Ambulance services;
Transport of patients
Diversion, ambulance, 71–72
accountability for, 115
economic incentives to reduce, 129
E
Economics
demonstration program funding, 6, 126, 127, 146
disaster preparedness funding, 223
efficiency of care, 76–77
EMS-C funding and grant distribution, 38, 44–46
establishment of new lead agency for EMS system oversight and support, 138, 142–143
funding for researcher training, 266, 267
hospital ED payer mix, 67–69
nonurgent care in ED, 66
origins and early development of EMS system, 36, 37, 38
payment incentives to improve provider performance, 128–129
problems of current EMS system, 1–2
recommendations for EMS-C funding, 14, 144–145
regionalization outcomes, 108–109
research funding, 12, 51, 251, 257–264, 266
rural EMS systems, 80
rural poverty, 78
teaching hospital funding, 86–87
See also Reimbursement
EDs. See Hospital emergency departments
Effectiveness of pediatric emergency care, 73–74, 252
Efficiency of emergency care, 76–77, 252
Emergency care, defined, 29
Emergency care system, defined, 29
Emergency Department: A Regional Medical Resource, 17
Emergency departments approved for or accepting pediatrics, 109–110
Emergency ID Net, 268
Emergency Medical Services Agenda for the Future, 137, 250
Emergency Medical Services at Midpassage, 17
Emergency medical services (EMS), 190.
See Prehospital care
Emergency medical services (EMS) system
coordination of care in, 3–4
current shortcomings, 1–2, 16, 17, 24–26
definition, 29
demonstration program recommendations, 6, 126, 146
establishment of new lead agency for, 137–143, 146–147
future reforms, 14
goals, 3, 24, 101
linkage with other medical care providers, 104–105
model systems, 120–125
origins and development, 36–37, 131–132
performance measurement, 116–117, 118
public health agencies and, 104–105
readiness for reform, 18
recent efforts to improve, 17–18
status of pediatric care in, 20–24
structure, 249
Emergency Medical Services for Children, 3, 18, 35, 49–51, 108, 246–247
Emergency Medical Services for Children (EMS-C) program
accomplishments, 13, 47–49, 51
administration, 44
clinical practice guidelines, 113, 176
coordinators, 51
disaster preparedness in, 228
five-year plan, 46
funding and grant distribution, 44–46, 46–47, 132, 144, 147
in future of pediatric emergency care system, 13–14
new lead agency for EMS system and, 138, 141
origins, 38, 44, 246
purpose, 3, 38, 44, 144
recommendations for funding, 14, 144–145, 147
research support from, 46, 246, 256
Emergency Medical Services for the Future, 106
Emergency Medical Services Systems Act, 37, 106
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Emergency medical technicians (EMTs)
classifications, 152, 153
continuing education and skills maintenance, 2, 157–158, 159, 160
hospital ED staff, 170
recruitment and retention, 153–154
risk of error in emergency care, 190
in rural areas, 154
training and certification, 154–158
volunteers, 153, 154
working conditions, 153
See also Paramedics
Emergency Medical Treatment and Active Labor Act (EMTALA)
implications for coordination of care, 129–130
purpose, 129
recommendations for, 130–131, 146
revisions, 130
Emergency Medicine Cardiac Research and Education Group International, 268
Emergency Medicine Foundation, 264
Emergency Medicine Network, 268
Emergency Nurses Association, 259–264
Emergency pediatric centers, 109–110
EMS. See Emergency medical services;
Prehospital care
EMS-C. See Emergency Medical Services for Children (EMS-C) program
EMS Performance Measures Project, 116
Endotracheal intubation, 1, 172–173
Equity in care access and outcomes, 77–78, 252
F
Family-centered care
barriers to, 208
conceptual development, 205
cultural competency, 210–211
defining characteristics, 10–11, 74, 205
effectiveness, 205
in emergency care, 205–210
family presence during medical procedures, 206–207, 208
implementation, 208
rationale, 10, 11
recommendations for, 11, 204–205, 212
shortcomings of current system, 26, 74–75, 204
staff attitudes, 207–208
Federal Emergency Management Agency (FEMA), 132, 263–264
Federal government
establishment of new lead agency for EMS system, 7, 137–143, 146–147
interagency collaboration in EMS system, 132–133, 135
research funding, 257–258, 260
strategies for improving EMS system leadership, 135
structure of EMS oversight and support, 6–7, 131–132, 133–135
See also specific governmental entity
Federal Interagency Committee on EMS (FICEMS)
mission, 133
new lead agency for EMS system and, 142
prospects for EMS system leadership, 135–137
Fire departments, EMS personnel and, 104
First responders, 151–152, 155.
See also Emergency medical technicians
Florida, model EMS system, 124–125
Fluoxetine, 195
Food and Drug Administration (FDA), 195, 197, 201
Fostering Rapid Advances in Health Care: Learning from System Demonstrations, 125–126
Fragmentation of EMS system, 1, 24, 102–103
accountability and, 5
effects, 3–4, 6–7, 103, 134–135
sources of, 103–104
structure of government oversight and support, 6–7, 131–132, 133–134, 135–137
See also Coordination of care
H
Health Insurance Portability and Accountability Act (HIPAA)
implications for coordination of care, 129, 130
purpose, 130
recommendations for, 130–131, 146
Health Plan Employer Data and Information Sets (HEDIS), 119
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Health Resources and Services Administration (HRSA)
demonstration program administration, 6, 128, 146, 261
in development of EMS system, 41, 176
disaster planning, 228
interagency collaborations, 132
mission, 261
recommendations for, 6, 126, 146
research activities, 27, 195, 197, 261–262
structure and operations, 261
trauma registry, 270
See also Emergency Medical Services for Children (EMS-C) program
Health Services, Preventive Health Services, and Home Community Based Services Act, 44
Health status of children in U.S., 52
insurance status and, 59, 83
neonatal health problems, 59
with special health care needs, 61
Hill-Burton Act, 36
Hospital-Based Emergency Care: At the Breaking Point, 167
Hospital emergency departments (EDs)
causes of ED visits, 18–19, 55–59
characteristics of pediatric patients, 18–19
community service obligations, 36, 105
design, 209
disease surveillance role, 104–105
establishment of new lead agency for EMS system, 7, 139, 141, 146
family-centered care in, 208
hospital admissions from, 19, 70–71
Medicaid reimbursement, 83–85
non-physician care providers, 170–171
nonurgent care in, 105
nursing staff, 168–170
origins and development, 36, 37
payer mix, 84
pediatric emergency coordinators, 8, 177–179
pediatric visits, 2, 15
pharmacists in, 171–172
physicians’ pediatric training, 161–165
physician supply, 160, 164
provider skill maintenance, 172–173
public health linkages, 104
risk of adverse events in, 188–190, 193
shortcomings of pediatric care capabilities, 2, 16, 50
specialized pediatric EDs, 19, 37
surge capacity, 234–236
utilization, 65, 249, 256
See also Causes of ED visits
Hospital Quality Alliance, 119
Hurricanes, 225
Katrina, 11, 221–222, 226, 230–231
Hypothermia/hyperthermia, 191
I
Indian Health Service, 262
Infants, 29, 65
Infectious disease
causes of ED visits, 18, 55
population surveillance, 104–105
vulnerability of pediatric EMS system, 42
Information technologies and systems
clinical information systems, 107, 118
for continuity of care, 107, 251
current shortcomings, 3, 251
future prospects, 250
goals, 250
Health Insurance Portability and Accountability Act effects, 130
to improve patient safety, 199–200
model EMS systems, 121, 123
pediatric considerations in emerging technologies, 10, 203–204
risk of error in emergency care, 189–190
role of new lead agency for EMS system, 140
special needs children, 61–62
trauma registries, 13, 39, 270–273
utilization of EMS and EDs, 249–250
See also Communications technologies and systems;
Outcomes research;
Performance measurement
Infusion pump, 26, 200–201
Injury, pediatric
causes of ED visits, 18–19
causes of prehospital calls, 63
data sources, 52
early prevention efforts, 40
epidemiology, 52–55
goals of EMS-C program, 44
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mortality, 39, 43–44, 52, 54, 270
prehospital calls, 20
preventive interventions, 254–255
recommendations for trauma registry, 13, 272–273
research needs, 13
trends, 54–55
vulnerabilities of children, 25
Injury in America: A Continuing Health Problem, 40
Insight (clinical information system), 107
Insurance
coverage in rural areas, 78–79
health status and, 59, 83
hospital ED payer mix, 67–69
hospital utilization and, 36, 81
pediatric emergency care payer mix, 81
See also Medicaid;
Medicare;
Uninsured children
Intensive care units, pediatric, 106–107
origins and early development, 37
tertiary-level, 108
Interagency Committee on Emergency Medical Services for Children Research, 133
J
Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 238
Josiah Macy, Jr. Foundation, 27
K
Korean conflict, 36
L
Language differences, 210–211
Legal liability
medication errors, 197
shortage of on-call specialists and, 167
Licensure and certification
emergency medical technician training and credentialing, 154
emergency medicine specialty, 161, 163
nurses, 168–169, 171
pediatric surgery, 165
recommendations for, 7–8, 174
M
Major Trauma Outcome Study, 271
Maryland, 37
EMS and trauma system, 106, 120–122
Medicaid
coverage, 82–83
enrollment, 83
features, 82
hospital ED utilization and reimbursement, 67–68, 83–84
prehospital service reimbursement, 63–64, 85–86, 128–129
reimbursement problems, 84–86, 103–104
significance of, for emergency care, 81
Medicare
graduate medical education funding, 86–87
prehospital service reimbursement, 128–129
purpose, 86
reimbursement system, 86
Medicare Rural Hospital Flexibility Program, 80
Meningococcemia, 191
Mental health problems
causes of ED visits, 55–59
disaster preparedness, 12, 224, 237
pediatric risks, 54
pharmacotherapy for, 195
prevalence, 59
quality of ED care, 60–61
shortcomings of pediatric emergency care, 59–60
training of EMS providers for, 60
trends, 59
Metropolitan Medical Response System (MMRS), 132
Military medicine, 36
Model Pediatric Protocols, 113
Mortality
early pediatric EMS research, 38
leading causes, 55
neonatal intensive care, 109
pediatric injury, 39, 43–44, 52, 54, 158–159, 270
N
National Advisory Committee on Children and Terrorism, 227–228
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National Association of Children’s Hospitals and Related Institutions, 166
National Association of Emergency Medical Technicians, 156–157, 259–264
National Association of EMS Physicians, 113
National Association of State EMS Officials (NASEMSO), 49
National Bioterrorism Hospital Preparedness program, 132
National Cancer Institute, 268
National Disaster Medical System, 232
National Emergency Medicine Association, 264–265
National EMS Data Analysis Resource Center, 247
National EMS Education Standard, 156
National EMS Information System, 49, 131–132, 250
National EMS Research Agenda, 49
National Highway Traffic Safety Administration
EMS-C program support, 44, 46, 49
enhanced 9-1-1 system, 138
recommendations for, 4, 5, 9, 111–112, 113, 146, 197, 212, 229–230, 239
research program, 27, 263
structure of EMS system oversight and support, 131–132, 135
transition to new lead agency for EMS system, 143
National Hospital Ambulatory Medical Care Survey, 249, 250
National Institutes of Health (NIH), 12, 141, 201, 258, 260, 265, 266
National Pediatric Trauma Registry, 39, 270–271
National Surgical Care Improvement Project, 116
National Trauma Data Bank, 13, 271–272
National Trauma Registry for Children, 272
Neonatal care, 109
9-1-1 system
establishment of new lead agency for EMS system and, 7, 138, 139, 141, 146
utilization, 62
Nonurgent utilization of EMS, 65–67
causes of, 105
wait times, 192
Nurse practitioners, 170–171
Nurses
advanced practice, 171
current ED staffing, 168
demographic patterns, 168
family presence policies and attitudes, 207
job stress, 168
pediatric emergency coordinators, 178
roles and responsibilities, 168
staffing challenges, 169–170
training and certification, 168–169, 174
O
Omnibus Budget Reconciliation Act (OBRA), 83
On-call specialists
legal liability concerns, 167
quality-of-life concerns of, 167
reimbursement problems, 85, 166–167
roles and responsibilities, 165–166
strategies for improving supply, 167–168
supply problems, 72, 166–167
Outcomes research
current state, 250–251
early pediatric EMS research, 38, 39, 41
obstacles to, 251
pediatric ED visits, 19
pediatric pharmacotherapy, 195
pediatric prehospital care, 158–159
performance indicators, 5
performance measurement data, 117–118
regionalization outcomes, 108
trauma registries, 270–273
P
Pain management, 75–76
Paramedics
risk of medication errors, 194
roles and responsibilities, 152–153
training and certification, 154, 155–156
Paroxetine, 195
Patient-centered care
adolescent patients, 211–212
characteristics of, 10, 74, 204
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current state of pediatric emergency care, 252
See also Family-centered care
Pediatric Academic Societies, 259
Pediatric Advanced Life Support, 39, 208
Pediatric Disaster Life Support, 232
Pediatric Education for Prehospital Providers, 155
Pediatric emergency care
child abuse–related visits, 69–70
current state, 2, 16–17, 29–30, 35–36, 41–42, 72–78
defined, 29
disparities in equity, 77–78
effectiveness, 73–74
efficiency of care, 76–77
family-centered care in, 74–75
findings of 1993 study, 49–51, 248–249
goals, 30, 44, 101
historical and technical development, 35, 37, 38–41
model systems, 120
nonurgent utilization, 65–67
obstacles to improvement, 101–102, 128
patient leaving before being seen, 75
payer mix, 67–69, 81–82
recommendations for practice guidelines and standards, 8, 175–177, 179
recommendations for protocol development, 5, 113, 146
research needs, 26
rural areas, 69, 78–80
safety concerns, 8–9, 30, 73, 188, 190–193
special demands of, 1, 86
timeliness of care, 75–76
trends, 87
utilization, 19–20, 26, 62–63, 64–65, 69
See also Prehospital care
Pediatric Emergency Care Applied Research Network, 25–26, 46, 141, 145, 247–248, 257, 269
Pediatric emergency coordinator(s)
current implementation, 178, 179
recommendations for appointment of, 8, 177
roles and responsibilities, 8, 177–179
Pediatric emergency medical services. See Pediatric emergency care
Pediatric Emergency Medical Services Training Program (PEMSTP), 39
Pediatric Prehospital Care course, 156–157
Pediatric Research Equity Act, 195–196
Pediatric Trauma Score, 39
Performance measurement
access to data, 6
to build accountability, 5
collaborative entity for, 117
current efforts, 116–117, 121, 250, 251
data collection and analysis, 118, 250
goals, 117–119
pediatric information systems, 204
public reporting, 5–6, 119–120
recommendations for, 5, 117, 146
shortcomings of current efforts, 117
system-wide, 117, 118
Pharmacotherapy
clinical pharmacy specialists, 171–172
disaster preparedness, 236–237
dosing errors, 196
infusion pumps, 26, 200–201
medication errors in EDs, 73
off label use, 2, 9, 16, 194
pain management, 75–76
pharmacists in ED, 171–172
recommendations for improving pediatric care, 9, 195, 197, 212
research needs, 9, 197, 212
shortcomings in pediatric emergency care, 2, 9, 16, 26
strategies for improving safety, 198, 199–200
threats to patient safety in, 194–195, 196–197
Physician assistants, 170
Physicians
current emergency department staffing, 160, 164
moonlighting in EDs, 161
pediatric emergency care training, 161–165, 173–175
psychiatric training, 60
referrals to EDs for nonurgent care, 105
risk of error in emergency care, 188–190
skills for emergency department, 160
See also Specialties, medical
Physiology of children
pharmacotherapy considerations, 195
risks in emergency care, 190–193
special medical considerations, 1, 20–24
vital signs, 1
vulnerability in disasters, 11, 25, 223–224
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Plane crash, 225–226
Poisoning, 54
Poison Prevention Packaging Act, 40
Post-traumatic stress, 237
Potassium iodide, 236
Pralidoxime, 237
Prehospital care
categorization for regionalization, 111
child abuse identification and treatment, 70
emerging technologies, 9–10
EMT training, 154–158
family-centered care in, 205–208
field stabilization vs. transport, 112–113
historical and technical evolution, 36–37, 38
Medicaid reimbursement problems, 85–86
model EMS information systems, 123–124
new lead agency for EMS system and, 7, 139, 141, 146
payer mix, 82
pediatric. See Pediatric emergency care
pediatric percentage, 158
recommendations for protocol development, 5, 113, 146
in rural areas, 79–80
threats to patient safety in, 190, 193–194
utilization, 249–250
wait times, 75
workforce, 151–160
See also Ambulance services;
Dispatch of emergency services;
9-1-1 system;
Training of EMS providers
Prehospital Trauma Life Support, 155
Preventive Health and Health Services Block Grant, 38
Preventive interventions
with adolescents, 212
automated external defibrillator, 202–203
early efforts, 40
pediatric illness, 40–41
public health agency resources for, 104
rationale, 254
research needs, 255–256
role of EMS, 254–255
Private research, 264–265
Public health and safety
communications shortcomings, 3
EMS linkages, 104–105
preventive interventions, 254–256
surveillance, 222
Public Health Security and Bioterrorism Preparedness and Response Act, 227–228
Public perceptions and understanding
accountability in health care and, 115
EMS system performance, 15
expectations for EMS system performance, 15
Public reporting
access to data, 119
aggregation of performance data for, 6, 119
current efforts, 119, 121
forms of, 119
goals, 5–6, 119–120
obstacles, 119
rationale, 119
Q
Quality of care
ambulance diversion and, 71
challenges in pediatric emergency care, 26, 70–72
family-centered care, 10–11
infrastructure for, 26, 187
mental health interventions, 60–61
pediatric prehospital care, 158–159
primary care delivered in ED, 66
recommendations for guidelines and standards, 8, 175–177, 179
regionalization and, 108
role of pediatric emergency coordinator(s), 8, 177
shortcomings of pediatric emergency care, 2, 16–17, 18–19, 72–78
skill maintenance among ED providers, 172–173
variation in physician practice patterns, 74, 173
workforce interventions to improve, 173–179
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R
Race/ethnicity
cultural competency of providers, 210–211
disparities in care access and outcomes, 77–78
hospital ED utilization, 65
wait times and, 77
Radiation exposure, 202, 236
Regionalization of EMS
categorization of emergency medical services and, 4, 111
concerns, 110
goals, 4, 108
implementation, 109–110
model systems, 109, 110–111, 121, 122, 123–125
quality of care and, 108
rationale, 4, 108
transport protocol development, 113, 146
Regional variation in EMS systems
current state, 15–16, 41–42, 125
emergency medical technician training and credentialing, 154
Reimbursement
characteristics of pediatric EMS system, 80–81
fragmentation of EMS system and, 103–104
incentives to improve provider performance, 128–129
Medicaid system, 83–86
Medicare system, 86
payer mix, 67–69, 81–82
resource-based relative value scale, 86
shortage of on-call specialists related to, 85, 166–167
Research
barriers to, 257
basic, 252
benefits, 245
in centers of excellence, 266–267
cross-cutting nature of emergency care research, 258–259
development of clinical practice guidelines, 175–176
disaster preparedness and response, 224–226
dissemination of findings, 248, 259–264
early pediatric EMS research, 39, 245–248
EMS-C program, 46
establishment of new lead agency for EMS system and, 141
funding, 12, 51, 257–264
infrastructure development, 247–248
medical technology development, 10, 201, 203, 204, 212
needs. See Research needs
network approach, 12, 13, 267–270
organizational collaboration and coordination, 259
organizational leadership, 256
potential sources of support, 260–264
private support for, 264–265
rationale for increasing, 256
recommendations for improving, 12–13, 201, 257, 273
shortcomings of current data collection, 51, 248, 251–252, 252, 267
shortcomings of current evidence base, 12, 25–26, 73–74, 195
training for, 13, 258, 264–267
translational, 253
trauma data collection for, 270–273
Research needs
basic research, 252
effects of preventive interventions, 255–256
organization and delivery of emergency care, 253–254
for patient safety improvement, 9
pediatric pharmacotherapy, 9, 195–196, 197, 212
pediatric trauma, 13, 270
technology-related risks, 201–202
translational research, 253
transport protocols, 112
Reye’s syndrome, 40
Rhode Island night club fire, 235
Robert Wood Johnson Foundation, 176
Rural areas
barriers to care, 78
causes of prehospital care, 79
challenges for emergency care providers, 80
demographic characteristics, 78
ED utilization, 69, 79–80
EMS workforce problems, 154, 174
shortcomings of pediatric emergency care, 2, 19, 78–80
volunteer EMS providers, 80
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S
Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users (SAFETEA-LU), 133
Safety, patient
current state of pediatric emergency care, 73, 193–194, 251
goals, 187
medical technologies to improve, 199–204
in prescription and administration of drugs, 9, 194–195, 212
provider policies to improve, 198
provider training to improve, 198–199
radiation exposure, 201–202
recommendations for improving, 9, 195–196, 197, 212
research needs, 9, 201–202, 212
risks in emergency care, 188–190
risks in pediatric care, 8, 30, 188, 190–193
strategies for improving, 197–198
Safety net providers
burdens on hospitals, 72
hospital EDs as, 105
Medicaid reimbursement, 85
San Francisco Community Clinic Consortium, 107
Seat belts, 40, 104
Severe acute respiratory syndrome (SARS), 42
Shock, 191
Smoke inhalation, 191–192
Society for Academic Emergency Medicine (SAEM), 248, 259, 264, 265
Special Children’s Outreach and Prehospital Education, 157
Specialties, medical
acute care surgical specialist, 167–168
clinical pharmacy specialists, 171–172
emergency medicine specialists, 160–162, 163
origins of pediatric EMS specialties, 39, 41
surgical, 165
suture technicians, 172
variation in physician practice patterns, 74, 173
See also On-call specialists
Stand-by emergency departments approved for pediatric, 109–110
State Children’s Health Insurance Program, 81–82, 83, 85
State Emergency Department Databases, 249, 250
State governments
demonstration program grants, 6, 126
disaster preparedness, 228–229
EMS-C grants, 44–46
EMS-C-supported programs and policies, 47–49
EMS information collection systems, 250
evolution of EMS funding, 38
Medicaid administration, 82, 83
model EMS systems, 120–125
trauma registries, 270
Strategic national stockpile, 236–237
Sudden infant death syndrome, 40
Suicide, 54–55, 60
Supplies and equipment for pediatric emergency care
disaster preparedness, 11, 222–223, 224, 236–238
findings of 1993 study, 50–51
shortcomings of hospital EDs, 2, 16, 187
Surge capacity, 12, 222, 234–236
Surveillance, public health, 104–105, 107, 222
T
Teaching Resource for Instructors in Prehospital Pediatrics, 156
Technology development and adoption
dissemination of research findings, 259–264
future prospects, 9–10, 200
to improve patient safety, 199–204
recommendations for, 10, 201, 212
shortcomings in pediatric emergency care, 26, 201, 202–203
Terrorist threat, 227–228, 238.
See also Biochemical events
Tertiary-level pediatric intensive care, 108
Texas, model EMS system, 122–123
Timeliness of care, 75–76, 252
risks in pediatric emergency care, 190–193
Training of emergency care providers
child abuse identification and treatment, 70
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children with special health care needs and, 157
continuing education in pediatric care, 2, 8, 16, 25, 42, 157–158, 172–173, 174–175, 179
disaster preparedness, 222, 232–234, 238–239
early pediatric-focused programs, 37, 39–40
emergency department physicians, 162–165
emergency medical technicians, 154–158
emergency medicine specialty, 160–161, 163
EMS-C efforts, 47
for family-centered care, 208
findings of 1993 study on pediatric EMS, 49–50
first responders, 151–152, 155
goals, 173–175
graduate medical education, 85, 86–87
to improve patient safety, 198–199
instructor support, 156
National Standard Curricula, 155–156
nurses, 168–169
origins of pediatric specialties and subspecialties, 39, 41
pediatric emergency medicine subspecialty, 161–162
pediatric surgery, 165
psychiatric, 60
recommendations for, 8, 174, 179
for research, 13, 258, 264–267
shortcomings of current system, 7, 16, 25, 73, 157–158
simulation exercises, 199
teamwork training, 198–199
Transfer agreements, 2
accountability and, 5, 115
shortcomings of current EMS system, 16, 24, 51, 103
Transport of patients
developments in history of, 36
disaster response, 225–226
Emergency Medical Treatment and Active Labor Act and, 129–130
field stabilization and, 112–113
interfacility transfers, 19
Medicaid/Medicare reimbursement, 63–64, 85–86, 128–129
model EMS systems, 121, 123–124
parental involvement, 206–207
payer mix, 82
recommendations for protocol development, 5, 112–113, 146
research needs, 112
role of emergency medical technicians, 152
See also Ambulance services
Trauma care
defined, 29, 42–43
development of pediatric trauma care, 43–44
establishment of new lead agency for EMS system, 139, 141, 146
historical development, 36
pediatric, 109
trauma registries, 13, 39, 270–273
Trauma center
defined, 29
features, 43
pediatric, 109
Trauma registries, 13, 39, 270–273
Trauma system
defined, 29
as model of regionalization, 110–111
origins and development, 37
regionalization, 109
Triage, pediatric, 192
disaster response, 228
U
Uninsured children
emergency transports, 82
health status, 59
prevalence, 81
Utilization
data sources, 249–250
deterrents to ED use, 68–69
early research, 245–246
historical trends, 36
insurance coverage and, 36, 81
Medicaid patient ED visits, 67–68, 81
nonurgent ED care, 65–67, 105
pediatric ED visits, 2, 15, 18, 19, 64–65, 256
prehospital care, 19–20, 62–64, 158
rural EDs, 69, 79–80
surge capacity, 222
trends, 70
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V
Vaccines, 40–41
Vermont Oxford Network, 268
Vietnam conflict, 36
Violence, exposure to, 52, 54, 192–193
Vision, of committee, 3–7, 30
Vital signs, 1
Volunteer EMS providers
credentialing within regional EMS system, 122
emergency medical technicians, 153, 154
in rural areas, 80, 154
Vomiting, 192, 223
W
Wait times, 71, 77
average ED wait, 192
nonurgent care in ED, 66
patient departure before being seen, 75
risks for children, 192–193
Workforce, 30
credentialing within regional EMS system, 122
cultural competency, 210–211
current shortcomings in pediatric emergency care, 7, 8, 24–25, 151
family presence during medical interventions, attitudes toward, 206–207, 208
friction within EMS system, 104
goals for pediatric EMS system, 7–8
knowledge required for pediatric care, 24
non-physician care providers in hospital EDs, 170–171
pediatric disaster expertise, 232–234
pediatric emergency coordinators, 8, 177–179
prehospital care, 151–160
risk of error in emergency care, 190
in rural areas, 80
skill maintenance among ED providers, 172–173
strategies to improve pediatric care, 173–179
See also Emergency medical technicians (EMTs);
Nurses;
On-call specialists;
Physicians;
Training of emergency care providers
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