Index

A

Accidental Death and Disability: The Neglected Disease of Modern Society, 17, 3637, 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, 116117

pediatric emergency care, 162163

Adolescent patients, 211212

Advanced life support (ALS)

field stabilization vs. transport, 112113

pediatric, 158

role of emergency medical technicians, 152

in rural areas, 7980

shortcomings of pediatric care capabilities, 5051

training for, 154, 155, 164165

Adverse events

current state of pediatric emergency care, 193194

language difference as cause of, 210

mandated reporting, 198

in prescription or administration of drugs, 196197

recommendations for reducing, 198, 212

risk in EDs, 188190

risks for children in emergency care, 190193

strategies for reducing, 197198

Agency for Healthcare Research and Quality, 27, 132, 141, 195, 197, 201, 227, 249, 261

Airbags, 254255

Ambulance services

appropriateness of dispatch, 6364

diversion, 7172, 115, 129

origins and development, 37

payer mix, 82

pediatric utilization, 62, 6364

response times, 75

shortcomings of pediatric care capabilities, 5051

See also Transport of patients

American Academy of Pediatrics, 39, 227, 247, 265, 268



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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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Emergency Care for Children: Growing Pains 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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Emergency Care for Children: Growing Pains 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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Emergency Care for Children: Growing Pains 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 Care for Children: Growing Pains 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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Emergency Care for Children: Growing Pains 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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Emergency Care for Children: Growing Pains 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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Emergency Care for Children: Growing Pains 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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Emergency Care for Children: Growing Pains 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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Emergency Care for Children: Growing Pains 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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Emergency Care for Children: Growing Pains 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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Emergency Care for Children: Growing Pains 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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Emergency Care for Children: Growing Pains 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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Emergency Care for Children: Growing Pains 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