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s Being Ready to Deliver Good Care: Putt.i.ng Essential Wo.is in Place Training members of the public and providers of health care how to respond to emergencies in children and how to use the emergency medical services (EMS) system is not enough in itself. Those providers need to have system resources available that enable them to use their training and skills successfully. The committee identified specific areas in which EMS systems warrant redoubled efforts to meet the needs of pediatric patients: equipment, protocols, medical control, categorization of facilities, and region- alization of care. This chapter cites advances that have been made to date, identifies persistent problems, and presents the committee's conclusions about appropriate steps to overcome those problems and to strengthen emergency medical services for children (EMS-C). DEFINITIONS Equipment refers to both reusable and disposable items that are used in providing emergency care. It includes supplies such as intravenous (IV) catheters, blood pressure cuffs, endotracheal tubes, medication charts, and field-to-hospital communications devices, as well as medications. Protocols are standardized sets of procedures or decision algorithms that are developed to guide patient care. They exist, and are generally needed, for all phases of emergency care. In some cases, protocols direct the process of care in the EMS system (e.g., logistics and procedures, such as determining the hospital to which a patient is taken). In other cases, they direct the content of care (e.g., specific interventions and medications). The 149

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150 EMERGENCY MEDICAL SERVICES FOR CHILDREN concept of protocols overlaps considerably with that of "clinical practice guidelines," which the Institute of Medicine defines as "systematically de- veloped statements to assist practitioner and patient decisions about appro- priate health care for specific clinical circumstances" (IOM, 1990a, p. 8; 1992~. In this report the committee retains the term protocol, which is widely understood in the EMS community. Medical control-refers to physician oversight of care provided by prehospital personnel. That ove~ight is given in two ways: on-line, that is, directly by a physician (or a designated alternate) to emergency medical technicians (EMTs) and paramedics during their care of individual patients; and off- line, by physicians who participate in developing standardized procedures and planning for and ensuring the quality of prehospital services. Categorization offacilities and regionalization of care are usually closely linked. Categorization refers here to a variety of methods for evaluating and identifying the capabilities of hospitals and other facilities to provide adequate and appropriate care to patients. Because it is impossible for every facility to render the most sophisticated care for all types of patients, the few that can provide those services often become regional referral cen- ters. In this report, regionalization of care refers to deliberate efforts in predetermined geographic areas to identify facilities with special capabili- ties and to develop relationships between those facilities and the communi- ties and facilities that would look to them as a source of specialized care. EQUIPMENT The Right Kind and the Right Size Emergency care for children, especially very young ones, often requires equipment and medications specifically suited to children. Because of the traditional emphasis in EMS systems on adult trauma and cardiac care, standard equipment and supplies often do not include materials appropriate for treating children. Some adult equipment can be adapted for pediatric patients, but many items are too large or otherwise unsuitable. Other items that are unique in caring for children (such as papoose boards, bulb sy- ringes, pediatric IV equipment, or even cuddly toys) are likely to be missing altogether. The issue of equipment, medications, and supplies is not, how- ever, a simple dichotomy of "adult" and "pediatric." Because children, themselves, vary in size and development, pediatric equipment and supplies need to be available in a range of sizes so that proper care can be provided to all children, from infants to adolescents. The lesson that "children are not little adults" has been an important one to learn in many aspects of EMS, especially in defining essential equip- ment. For example, many ambulance units and hospital emergency depart

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BEING READY TO DELIVER GOOD CARE 151 meets (EDs) do not have pediatric-sized cervical collars. This leads to children being placed in collars that are too large, often obscuring their faces and even impairing ventilation. Only recently have significant design changes been made by manufacturers, such as producing stiff collars suit- able for small children or babies. Lack of appropriate-sized IV needles may preclude obtaining vascular access and thus prevent the administration of a life-saving medication; lack of other pediatric IV equipment to control the rate of fluid administration exposes the child to inadvertent administration of potentially dangerous volumes of fluid; and use of adult bag-valve-mask devices can allow excessive ventilatory volumes and pressures to force air into the chest cavity causing pneumothorax. Some differences between children and adults are particularly sign~- cant (Mellick and Dierking, l991a,b). The proportions of children's bodies . are not the same as adults'. For instance, a young child's head is much larger relative to the rest of his or her body; this increases the risk of head injury and also means that techniques and equipment for achieving proper alignment and immobilization of the head and spine must accommodate these anatomic differences. Important anatomic structures, particularly in the upper airway, are not just smaller in children but are also located differently. Many medications used in the emergency care of adults are suitable for children, but the doses must be different. Pediatric drug carts are desirable, and when prefilled syringes are used, they should be available in pediatric dosages. Because the appropriate dosage varies across the pediatric age range, having prefilled syringes for all needed medications in all dosages is impractical. Therefore, personnel need to know how to determine appropri- ate doses and concentrations of solutions for their pediatric patients. De- vices such as the Broselow Tape (used to measure a child's length, from which it provides an estimate of weight and appropriate drug dosage) can help in making those determinations (Lubitz et al., 1988~. Finally, children also differ from adults in the nature of the emergencies they experience. For example, children rarely experience primary cardiac emergencies, but they are very likely to experience severe respiratory dis- tress or hypovolemia, which can lead to cardiopulmonary arrest if an adequate airway, ventilation, and oxygenation cannot be achieved. Thus, it is especially important for emergency care providers to have available equipment and supplies suitable for airway and respiratory management of children. Lack of Pediatric Equipment Deficiencies in equipment for treating pediatric patients exist through- out EMS systems and have been documented in various surveys over the past 10 to 15 years. Prehospital providers received some of the earliest attention. In 1978, the pediatric community in Los Angeles began working

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52 EMERGENCY MEDICAL SERVICES FOR CHILDREN with the county EMS authority to develop pediatric equipment standards for county ambulances (Seidel, 1989~. In the early 1980s, a survey of 82 EMS agencies across the country demonstrated a widespread need to increase the availability of many kinds of basic equipment (Seidel, 1986a). For ex- ample, 79 percent of the responding agencies did not carry complete sets of masks for bag~valve~mask resuscitators. The survey also showed that, even when appropriate equipment guidelines were in place, ambulances did not always carry the recommended items. Various ED and critical care categorization programs tend to reveal the deficiencies in those settings. A survey by the Maine EMS-C project showed "considerable variation" among EDs in the airway management equipment available (Maine EMS-C Project, 1991, p. 23), and the project's physician advisory board expressed concern over the impact this might have on pa- tient care. A group of hospital EDs in Arkansas proved to be less well prepared for emergency care of newborns and infants than for older children (Scotter et al., 19901. Items not available in some hospitals included infra- red warming lights, infant oxygen masks, and tracheostomy tubes (sizes O to 5~. Some problems with lack of equipment can extend even to the pediatric wards and intensive care units (ICUs). Emergencies also arise in the office setting, but studies have found deficiencies among adult and pediatric providers in equipment and supplies needed to manage a variety of emergency conditions (Kobernick, 1986; Barth et al., 1989; Fuchs et al., 1989; Altieri et al., 1990; Schweich et al., 1991; Seidel et al., 1991a). A study focused specifically on the prepared- ness of pediatricians found that those in solo practice had the most limited equipment available, whereas health maintenance organizations (HMOs) were generally the most completely equipped (Schweich et al., 1991~. For spe- cific emergencies, the investigators found that all types of practices were best prepared to treat severe dehydration and least prepared to treat cardio- pulmonary arrest. Even so, among the solo practice group only 35 percent had all of the equipment deemed necessary to treat severe dehydration, and of the HMO practices only 58 percent were equipped to treat cardiopulmo- nary arrest. Pediatricians who had basic equipment available were more confident about managing emergencies, regardless of the practice setting, than those who had no such equipment on hand. Some ambulatory (or urgent) care centers also lack appropriate equipment for pediatric emergen- cies, even though they sometimes treat children for serious conditions such as seizures and anaphylaxis (Seidel et al., 1991 a). What Should Be There? The supplies needed to care appropriately for children range very widely. They can include standard medications needed for resuscitation that are

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BEING READY TO DELIVER GOOD CARE 153 packaged in small amounts; infant stethoscopes that are not so large as to cover the entire torso; defibrillation paddles that fit on a child's chest; swaddling devices to keep children still when painful procedures are needed; and toys that can comfort children during transport or emergency room care. Many lists of pediatric equipment and supplies needed to provide emer- gency medical care for children exist. Several groups with EMS-C grants from the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (DHHS) developed such lists for a mix of prehospital providers, hospital EDs, and ICUs; a catalog summa- rizes products produced by the early EMS-C demonstration projects (Shaperman and Backer, 1991~. In California, Maine, Washington, Wisconsin, and New York City, those lists have been incorporated into official state or local requirements (California Code of Regulations, Title 13, 1103.2; Wiscon- sin EMS-C Project, 1990; Maine EMS-C Project, 1991; Washington EMS-C Project, 1991~. Several professional societies have developed lists of equipment, sup- plies, and medications for different settings. For example, equipment lists for the ED and the ICU appear in the American Medical Association (AMA, 1990) categorization guidelines. The emergency care guidelines adopted in 1991 by the American College of Emergency Physicians (ACEP, 1990a, 1991) also include a list of suggested equipment for EDs for both adult and pediatric patients, and ACEP (1992a) has also approved guidelines for prehospital pediatric equipment. The Committee on Pediatric Emergency Medicine of the American Academy of Pediatrics (AAP) provides up-to-date suggestions for equipment, supplies, and medications for basic and advanced life sup- port for the pediatric age group and for newborns; the target settings are primary care physician offices, ambulances, and EDs (AAP, 1992e). Equip- ment lists for pediatric ICUs (PICUs) were published jointly by the AAP and the Society of Critical Care Medicine (SCCM) some years ago (AAP/ SCCM, 1983; SCCM, 1983~; development of revised standards, which may be available in 1993, is again a joint AAP and SCCM effort. Mellick and Dierking (1991a,b) review the kinds of pediatric equip- ment available and factors to consider in selecting specific items for prehospital care; they advocate taking into account significant characteristics of pediat- ric patients (particularly children under age 10), such as developmental level, basic temperament, health status and underlying conditions, environ- mental issues, anatomic considerations, and physiologic considerations. The authors argue for identifying "a standard core" (p. 35) of pediatric equip- ment needed to control airways; support breathing; maintain circulation; accomplish vascular access; monitor cardiac status; and immobilize patients, extremities, and head and cervical spine. They also suggest considering equipment protecting against exposure to infectious diseases as well as other

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54 EMERGENCY MEDICAL SERVICES FOR CHILDREN items, such as obstetric packs, car seats, and a reference card for scoring severity of pediatric trauma. The lists cited above vary in their details, and many tend to be quite long. Generally, they represent simply opinions of the authors or a body of experts; data to demonstrate the importance of many pieces of equipment are scarce. Readers who wish to have more definitive and comprehensive information might best track the periodic updates of recommendations is- sued by the major professional societies, such as AAP, ACEP, and SC:CM. Some of this variation in recommendations for equipment and supplies reflects still-reasonable differences of opinion as to what interventions pro- viders with varying levels of training should be allowed to perform as well as unavoidable state and local differences in capabilities of and expectations for providers. For example, controversy still exists as to whether paramed- ics should be allowed to intubate children or perform needle thoracentesis and whether EMTs can start IV lines. The pediatric equipment available to providers should allow them to perform all authorized procedures. Differ- ences among the lists may also reflect uncertainty among experts about the effectiveness of certain kinds of equipment. Tsai (1990), for instance, points out conflicting views on the safety and effectiveness of prehospital use of four kinds of equipment: endotracheal tubes and supplies, pneumatic antishock garments, intraosseous needles, and pediatric backboards. Acquiring and maintaining equipment must be an ongoing process. Because many providers will encounter pediatric emergencies relatively infrequently, their equipment, medications, and supplies may deteriorate or become out- moded. Unless such products are monitored on a regular basis, they may be inadequate in the event of a true emergency or induce an inappropriate sense of security among practitioners and institutional providers. In sum, the committee did not attempt to create a definitive list of equipment and supplies necessary for treating pediatric emergencies in any particular practice setting. Instead, it states the following imperative: Each health care provider or agency must define the emergencies that occur in the patient populations that they serve, define the emergency care appropriately provided in that setting, and ensure that the equipment and supplies needed to provide such care for those emergencies are available and ready to treat critically ill or injured neonates, infants, children, and adolescents. To make this more concrete in the context of the recommendations in Chapter 8 about state EMS-C agencies, the committee recommends that all state regulatory agencies with jurisdiction over hospitals and emer- gency medical services systems require that hospital emergency depart- ments and emergency response and transport vehicles have available and maintain equipment and supplies appropriate for the emergency care of children. The objective is to repose responsibility and authority for

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BEING READY TO DELIVER GOOD CARE 155 attention to EMS-C equipment and supplies in at least the prehospital and ED settings in a specific place, to two ends: first, that at least a minimal level of essential equipment is maintained in all hospital EDs and by all EMS systems; and, second, that a desirable level of consistency in require- ments is achieved while still permitting appropriate variation and flexibility needed ~n special (e.g.- geographic or financial) circumstances. Costs Financial considerations are, of course, a factor in determining what equipment for EMS-C is essential, but in general the cost of basic pediatric equipment and supplies is low. As a rule, the cost of individual items will not be higher for pediatric materials than for adult supplies; it is, however, necessary to maintain a wider variety of sizes owing to the substantial variability of the pediatric patient population. For example, an adult ambu- lance unit might need to carry only one size of central venous line catheter; a properly equipped unit taking care of children might need to carry four or five different sizes. A similar point can be made about a host of items (e.g., suction catheters, nasogastric tubes, laryngoscope blades) for most of the settings in which emergency care might be rendered to children. Monitor- ing equipment also needs to have a pediatric capability. For instance, sev- eral different sizes of pulse oximetry electrodes may be needed to cover the full pediatric age range, whereas only one size is needed for adults; simi- larly, monitors used to track the heart rates of infants require special pediat- ric algorithms in their software. Nevertheless, even these factors may not raise an insurmountable cost barrier for most systems. An estimate from Memphis, Tennessee, puts the additional cost of pediatric equipment for an ambulance at about $385 (Larry Youngman, City of Memphis Division of Fire Services, personal communi- cation, October 1992~. The San Diego Division of Emergency Medical Services estimated that additional equipment for a basic life support (BLS) ambulance would cost about $480; the equipment needed beyond that for an advanced life support (ALS) ambulance would cost about $295. Costs of stocking and replacing appropriate pediatric equipment and supplies also are low in comparison with the costs of similar goods for adults. For instance, Foltin and Cooper (forthcoming) point out that complete pediatric equipment and supplies for an ambulance are much less costly than a single semi-automatic defibrillator, which would be used for adult cardiac pa- tients. Altieri and colleagues (1990) estimated that basic equipment to contend with pediatric emergencies in office settings amounted to $1,200. Certainly, the cost of equipment and materials need not be high for EMS systems that already have a solid base from which to work.

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156 EMERGENCY MEDICAL SERVICES FOR CHILDREN Not surprisingly, advanced pediatric emergency care does require more costly equipment than basic emergency services. As with the above discus- sion, however, these costs (or those for PICUs) need not exceed those for equivalent services to adults. To the extent that outlays for PICUs exceed what can be managed by many different hospitals, the argument for regionali- zation of that level of service is strengthened. This committee recognizes that along with costs for equipment and supplies come costs for personnel, special training (as discussed in Chapter 4), and similar "nonhardware" elements of EMS-C. Further, these aspects of financing EMS-C can be significant, especially in situations in which not much progress has been made in building a solid EMS-C element into the existing EMS system. The argument here, however, is focused on costs of specific equipment and material needed for pediatric care. Because this committee regards the aim of integrating EMS-C into the existing frameworks of EMS and child health care as crucial, it also believes that these costs should be seen as relatively small marginal investments on top of those already being incurred for the basic system. One argument for that view is that the much greater costs of staffing and capital equipment for overall system operation have already been incurred. A second argument is that having the proper equip- ment reduces the significant cost in morbidity and mortality that children might experience if they cannot receive needed care because only adult equipment is available or if they are treated with inappropriate equipment and supplies. In sum, the committee believes that the cost of essential pediatric equipment is minimal; thus, costs cannot and should not be ad- vanced as a justification for depriving children of necessary, basic emer- gency care. PROTOCOLS Value of Protocols Knowing what to do for each and every patient whom a provider sees is not an easy task. When that patient may be experiencing a life-threatening emergency, the need to make correct decisions quickly places even greater demands on providers. When that emergency patient is a child, much anec- dotal evidence suggests that anxiety levels are especially high. Moreover, except for those who specialize in pediatric emergency medicine, providers are likely to see seriously ill or injured children only infrequently, making it difficult for them to remain familiar with the special needs of children. Even more demanding are those emergencies that involve children with chronic illnesses or other special health care needs. Finally, as with equip- ment~ care appropriate for adults is often inappropriate for children.

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BEING READY TO DELIVER GOOD CARE 157 To address these complexities for EMS-C, the value of reliable and valid protocols cannot be overstated. (The potential value of sound, defini- tive practice guidelines generally is discussed in two recent reports tIOM 1990a; 1992], and many of the points made there apply equally well to protocols in the EMS context.) The availability of protocols to guide decisionm~ing whether computerized algorithms' flow charts on wall posters' simple narrative guides, pocket-sized reminder or reference cards, or other types of guidelines allows the provider to benefit from a carefully consid- ered analysis of a broad range of experience. Protocols help ensure that providers examine all important information and perform the appropriate sequence of procedures. Protocols adopted by an EMS system help to standardize the care given by all of the system's providers around a mutually agreed-on set of steps and interventions. A goal might be to have the capability of dealing with 95 percent of the cases seen in typical EMS settings, since no planner or guide- line developer could possibly anticipate every emergency or develop defen- sible guidelines for them. The crucial grounds for developing and applying protocols lie in the area of improving the quality of EMS-C care throughout EMS systems, although ready access to and general compliance with high quality, authoritative guidelines and protocols may also offer some protec- tion from malpractice liability claims as well. The EMS-C demonstration projects sponsored by HRSA developed various kinds of protocols, including ones concerned with transport, triage, resusci- tation, and management of various pediatric conditions (e.g., trauma, car- diac rhythm disturbances or arrest, and suspected child abuse) in the prehospital and hospital settings (Shaperman and Backer, 1991~. Some of these guide- lines are lengthy and detailed, but they need not be so; protocols (as the term is understood in this field) may, in fact, be simple reminder cards or poster charts. The Washington State EMS-C project (1991), for example, produced laminated information cards for both BLS and ALS personnel to carry in their uniform pockets or in equipment boxes. These provide a rapid reference source for pediatric equipment size, drug dosages, and vital signs, and they are considered to be of special importance for providers and re- sponders whose contact with pediatric patients may be infrequent. Needs Throughout EMS Systems Protocols have a role to play in every phase of the EMS system. They help direct decisions about when and where care needs to be given as well as guide what care is given and how it is given. Each phase of care needs specific kinds of guidance, as discussed briefly in this section in terms of dispatch, prehospital services, EDs, and inpatient care.

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158 Dispatchers EMERGENCY MEDICAL SERVICES FOR CHILDREN Children who enter the EMS system through a call to an emergency response system (often using 9-1-1) receive their first emergency services from the operator or other dispatch personnel answering such calls.2 The organization of dispatch systems and the training and skills of dispatchers vary widely (see Chapter 43. Many systems and personnel have little or no medical oversight even though they play a critical role in facilitating the delivery of urgent medical care; others may have had training in delivering emergency medical telephone instructions or long-time experience in dis- patching ambulances. Regardless of formal training or experience levels, however, dispatchers must be able to evaluate the nature of the problem and determine what sort of response is needed. These triage decisions may determine whether ambulances with ALS or BLS intervention skills are sent, whether air or ground units are used, or sometimes whether any EMS . . unit IS sent. Protocols exist in some systems to assist dispatchers in making these determinations in a systematic way. Those protocols must incorporate tools to evaluate pediatric cases. In a recent study, Foltin and colleagues (1992) determined from a retrospective evaluation of the appropriateness of ambu- lance dispatch in New York City that of nearly 100 children triaged by dispatchers as requiring ALS units, 45 percent warranted only BLS response and another 27 percent did not even require an ambulance; conversely, of about 145 children triaged as needing only BLS services, some 60 percent in fact needed ALS response. An assessment has not yet been made of the consequences for the child of these misassignments. These data do suggest that ALS resources are not being used efficiently. When an ALS unit is used for less serious cases, it will not be available for those who truly require that level of care; if an alternate ALS unit is avail- able, it may have a longer response time to the site of the emergency. The investigators suggest that protocol revisions and more training in the use of triage and dispatch protocols might enable the system to improve allocation of these prehospital resources. Their "Pediatric Ambulance Need Evalua- tion" (PANE) instrument may be one means of evaluating and identifying problems of both overtriage and undertriage (Foltin et al., 1992~. Appendix 7A reviews a variety of scoring instruments that have been devised to aid in triage decisions (in prehospital and other stages of emergency care) and to make retrospective assessments of the appropriateness of those decisions. Dispatchers also contribute to emergency care through "prearrival in- structions" to callers. Such instructions need to be appropriate to the condi- tion of the patient, and they need to be provided in a way that makes them useful to the caller. When the patient is a child, dispatchers often must deal with any special anxieties of their own and with the distress of the parent or other caller. Clawson and Hauert (1990) emphasize the need for guidelines

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BEING READY TO DELIVER GOOD CARE 159 designed specifically for dispatchers, describing the unique conditions un- der which dispatchers provide BLS services: "Thrust in the role of 'instruc- tor,' the dispatcher must teach the caller (an unwilling student) a physical procedure in a matter of seconds, without visual aids of any kind or even any opportunity to practice" (p. 84~. Kellermann et al. (1989) have demon- strated the efficacy of d~spatcher-assisted cardiopulmonary resuscitation (CPR). at least for adults.3 Prehosp~tal Personnel Assessment and Initial Treatment Until the emergence of courses such as Pediatric Advanced Life Support (PALS), Advanced Pediatric Life Sup- port (APLS), and those developed by HRSA's EMS-C grantees, most EMTs and paramedics had little access to training in the care of children. Most also have little opportunity to gain hands-on experience because of the relatively small number of children cared for by the prehospital system. Protocols that guide EMTs and paramedics through the assessment and care of children can, to some extent, lessen the effect of these limitations. Protocols for prehospital care of children need to reflect sound medical judgment regarding the best forms of care, the levels of training among providers, and the setting in which the EMS system operates. They should be jointly developed by physicians and others with expertise in both emer- gency medicine and pediatrics. They should guide care given under an EMS system's standing orders (a product of off-line medical control) and specify when on-line direction from a base hospital or other medical control point is required. Medical control is discussed further in the next major section of this chapter and in Chapter 6. Protocols may be relatively easy to devise for "extreme" situations. As a case in point: In an urban area where rapid access to sophisticated hospi- tal care is possible, a system can emphasize quick transport to specific EDs and BLS-level care en route rather than extensive ALS care at the scene. New York City, for example, follows such an approach with provisions for ALS procedures in the event of delays in reaching the hospital (Foltin et al., 1990~. By contrast, protocols for EMS systems serving rural areas need to accommodate longer transport times and distances, various forms of trans- port (including helicopters, airplanes, intensive-care vans, or other means), and the problems posed by the relative scarcity of hospitals and the more limited resources of hospitals that are available. Thus, more ingenious solutions may be needed (e.g., a predesignated rendezvous-hospital ED) (Johnston, 1989~. These locale-specific policies may be easy to understand, but a large gray area exists in determining the appropriate choice between providing more extensive treatment at the scene and rapidly transporting a child to an

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176 EMERGENCY MEDICAL SERVICES FOR CHILDREN make clear the rights and responsibilities of both institutions, including costs and liability, and, as noted elsewhere, comply with federal regula- tions. A model transfer agreement for PICUs in northern and central Cali- fornia, covering PCCCs and pediatric trauma centers (PTCs), illustrates the elements that need to be taken into account (Seidel and Henderson, 1991, pp. 42-48~. Models such as this can be adapted by other hospitals (Q meet their specific requirements. Referral centers also should contribute to education and training for emergency care providers in community hospitals and EMS agencies. Pro- grams, such as courses on pediatric resuscitation, can be offered at the referral center or even in local communities. In addition, referral centers can serve as sites for more specialized training either through medical resi- dency and fellowship programs or other special clinical training programs for EMTs, nurses, and physicians. Referral centers also have an important role to play in education and training for the general public, including promoting an understanding of the emergency care capabilities of commu- nity and regional hospitals. Intensive Care Services In the 1970s, many states successfully developed regionalized perinatal services (Meyer, 1980; Stiles et al., 1991; AAP/ACOG, 1992), but PICU services have not received similar attention. According to the American Hospital Association (1991), about 2,900 dedicated PICU beds are available across the country. Data on the demand for these beds are limited, how- ever; the experience of the Pediatric Intensive Care Network of Northern and Central California suggests that annually 240 children per 100,000 will require intensive care (Pettigrew et al., 19861. According to Cuerdon and colleagues (1991), PICU beds are not evenly distributed across the coun- try the number of beds per 100,000 children in each state ranges from 0 to 13.2, and half of the states have no more than 2.6 beds per 100,000 chil- dren. These authors argue that, unlike adult ICU or neonatal ICU beds, the availability of PICU beds does not appear to be related to the health status of the state's population. With intensive care a major component of EMS-C systems, these extreme regional variations in availability of PICU beds may not be desirable. Research is needed to determine whether the numbers of existing PICU beds and their distribution are adequate to meet the intensive care needs of children in communities across the country. Pediatric Trauma Systems Efforts over the past 20 years to develop regionalized systems for trauma care have had mixed results. As of the late 1980s, only Maryland and

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BEING READY TO DELIVER GOOD CARE 177 Virginia were recognized as having effective statewide or near-statewide systems (Mendeloff and Cayten, 1991), although in other states, city- or county-based systems are succeeding. Strong public controls over trauma center designation and prehospital services appear to contribute to trauma system success. Working toward trauma center designation (here meaning state selection of facilities hospital request' or a combination of both) is a complex matter [or the hospital and its stab. Meeting state and professional requirements can pose considerable challenges especially for community hospitals, which generally lack the organization, staffing, and other resources that university hospitals are likely to have (Clancy et al., 1992~. Trauma centers have proved effective in reducing mortality among adult patients. About 370 of some 6,600 hospitals in the United States function as trauma centers; they are concentrated in urban areas and serve only about one-quarter of the population (Champion and Mabee, 1990~. In recent years, however, individual trauma centers, and therefore systems of which they are a part, have faced serious problems from factors such as growing financial losses from unreimbursed costs and disruption of other hospital care by the unpredictable and immediate demands of trauma cases (see Champion and Mabee, 1990; GAO, 1991b). For some hospitals, these problems have led to a decision to withdraw from the trauma system. Experience with PTCs is more limited, chiefly because they are newer and far fewer in number. The earliest PTCs were established in the 1970s (Harris, 19891. Specific principles of pediatric trauma care advanced by the American Pediatric Surgical Association call for designation of PTCs by appropriate government authorities (Harris et al., 19921. Vane (1993) em- phasizes the value of a regional perspective in establishing PTCs; natural referral patterns can be identified and appropriate roles can be determined for all facilities in the area. Harris (1989) stresses that a regional pediatric trauma system must be "carefully tailored to respond to regional needs, be medically sound, well- organized, and have a solid fiscal base" (p. 149) all steps that require appreciable public education and involvement, financial support, and sus- tained commitment. Clearly, all the challenges facing, and pressures on, trauma centers and trauma systems in general afflict pediatric services as well; to the extent that EMS-C is Reemphasized relative to EMS generally, development of PTCs is likely to be impeded. Specialized Transport Resources Successful regionalization will depend heavily on the availability of high quality transport to referral centers. Because the patients who need to be transported are generally the most severely ill and injured, they require highly skilled care during the transfer to ensure that their condition does not

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178 EMERGENCY MEDICAL SERVICES FOR CHILDREN deteriorate. Well-equipped vehicles (air or ground) with specially trained staff can make it possible to provide some advanced care even before reach- ing the destination hospital. Pediatric transport teams have generally in- cluded physicians, but it may prove possible to provide essential care with teams relying on other personnel (McCloskey et al., 1989~. Not all trans- fers to referral centers can be made by highly skilled and well-eqa~ipped transport teams, however, this fact makes it essential that local hospitals and ambulance services be able to provide tile minimum level of care neces- sary to maintain a patient's condition until more advanced care can be brought into play. Under the auspices of the AAP (AAP, 1986; Day et al., 1991), guide- lines are evolving to address training needs, transport team composition, and medico-legal issues. No one transport system will be appropriate for every setting or every case. Factors such as weather, geography, patient condition, and costs will affect the choice of vehicle (e.g., ground ambu- lance, helicopter, fixed-wing aircraft). Even more complex are decisions about aeromedical EMS programs, staffing, costs, and relationships to hos- pitals and trauma centers (Freilich and Spiegel, 19901. McCloskey and Orr (1991) and Orr and Kennedy (1991) both provide definitive overviews of pediatric transport issues. As in much of emergency medicine, research studies are needed to answer many questions about the effectiveness of transport practices, such as whether physicians are needed as members of transport teams and the relative value of rapid transport and arrival versus allowing greater time for on-scene stabilization. Improving Outcomes of Care A leading argument for regionalization of pediatric emergency services is the belief that children receiving care in a PICU or PTC will have better outcomes than those cared for in adult trauma or intensive care units, but few studies have been done to demonstrate differences in outcome. In one of the first such studies, Pollack and colleagues (1991) did find higher-than- expected mortality at nontertiary hospitals than at tertiary hospitals among children less than 18 years old who were "receiving care for head trauma, or who required intubation for respiratory support (for >12 thours] if post- operative)" (p. 151~. Another recent study compared children treated in PTCs, urban nonpediatric (general) trauma centers, and rural nonpediatric trauma centers (Nakayama et al., 19921. The investigators found higher mortality rates in the rural trauma centers, but no significant differences remained when comparisons were based on the probability of survival. They surmised that these data reflect an informal system that tends to direct younger children and children with head and neck injuries who are at great- est risk to the specialized care available at the PTC. Cooper and colleagues

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BEING READY TO DELIVER GOOD CARE 179 (1993) concluded from analyses of New York data that patients with either brain or internal injuries and moderately severe skeletal injuries had better survival rates when they were treated in PTCs than when they were not; the investigators believe that triage of moderately to severely injured children to trauma centers with appropriate pediatric capabilities is not only practical and effective but also likely to increase survival of children with significant i. ~ . . . skeletal, brain, and ~nte-rnal Injuries. Additional studies are needed to verify these results and to identify factors that appear to make PICU or pediatric trauma care critical to better patient outcomes. In the meantime, this committee takes the position that when specialized pediatric centers are available, the most seriously ill and injured children should receive care in those centers. Special Concerns in Regionalization Implementing a system of regionalized services for pediatric care raises a number of concerns. Transferring children to regional centers removes them from relationships with the network of providers (e.g., pediatricians or family practitioners) from whom they and their families usually receive care (which should constitute a medical home). Thus, continuity and coor- dination of care for these children must be given special attention. Such transfers and shifts in the site of care, particularly to distant locations, can also cause substantial disruptions in the lives of children and their families. Efficiencies and costs in the system as a whole must also be considered. In particular, the likely volume of patients, especially transfers, must be con- sidered in the development of regional centers. Other, more political, issues must also be addressed, particularly resis- tance from hospitals to categorization and regionalization efforts. Resis- tance can occur for several reasons: if such programs are nonparticipatory (i.e., nonvoluntary), if they are heavily oriented to designation, if they might harm hospital reputations (by categorizing one hospital at a lower level than a competing hospital), if they might cost hospitals their patients (by hurting the hospital's reputation or by directing patients to other hospitals), or if they might impose an unacceptable financial burden (by increasing the number of uninsured patients requiring costly but unreimbursed care). No single response to these concerns is possible; specific local circumstances must be considered. Triage protocols that call for bypassing one hospital for another may be very difficult to develop and implement because of the need to coordinate plans with both the EMS agencies providing prehospital services and the hospitals in the area. Even when hospitals agree to bypass plans, EMTs may still take patients to the closest hospital. In some cases that decision may reflect parents' desires to have a child taken to a familiar local hospital

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180 EMERGENCY MEDICAL SERVICES FOR CHILDREN rather than a more distant regional center. Thus, successful regionalization (or categorization-plus-regionalization) requires cooperation and collabora- tion across a wide set of professional, public, and policymaking entities- more so, perhaps, than for action involving equipment, guidelines and pro- tocols, or medical control. It calls also for mobilizing the political will to create a system based on a reasoned assessment of needs and capabilities. not one that ~s [based excIusT~ely ore `6sell-nam~ng.~' Finally, the scarcity of pediatric resources and experience make region- alization more critical in pediatrics than in many other areas of medicine. Even pediatricians well trained in taking care of many acute and critical situations can experience, with time and lack of exposure, erosion in critical care skills; this problem may be compounded by lack of resources and experience among other physicians, nurses, or support personnel at the hos- pital level. Although good undergraduate and graduate training and con- tinuing education efforts for all emergency care providers may ameliorate some of these problems (as discussed in Chapter 4), the solution to provid- ing definitive care for pediatric emergency patients may always lie more . . . ~ . . with reg~onal~zat~on. Interstate Issues Because some geographic areas do not have reasonable access to children's hospitals or PICU resources within their own state, natural referral patterns may cross state lines; this situation makes it necessary to consider issues of interstate coordination and cooperation if emergency medical care for chil- dren is to be successfully regionalized.7 Interstate issues also arise for metropolitan areas that serve more than one state. In some cases, interested parties may be able to develop official agreements under the auspices of state or local government agencies. In other cases, contractual or informal relationships develop between referral centers and community hospitals and EMS systems. The stability of both official and informal arrangements depends on meeting the needs of all groups involved and on addressing several key issues. Coordination of Professional, Legal, and Regulatory Requirements Neighboring states often differ in such matters as certification and licensing requirements for institutions or practitioners, procedures that providers are authorized to perform, and guidelines for triage. In working out interstate transfer or other arrangements, states must address these differences to en- sure that consistent and acceptable levels of care are rendered and that providers do not face liability risks from differences in practice standards. The liability risks for interstate transport services must also be addressed. At some level of complexity in working out interstate arrangements, a

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BEING READY TO DELIVER GOOD CARE 181 threshold may be reached that argues for generalization beyond individual states to national standards. The immense variation in Medicaid services and regulations, and the resulting extreme unevenness in even basic care available to mothers and children, is poignant evidence of this point. Medicaid Reimbursement Medicaid policies and reimbursement levels are ~ concern for all providers; in the EMS context. hospitals may face the biggest problems. When care is provided to Medicaid patients from other states, hospitals must contend with several factors: the inadequacy of exist- ing Medicaid reimbursement levels per se, the unevenness of reimburse- ment levels across state lines, the willingness (or lack of it) of Medicaid agencies to pay for out-of-state care, and the possibility that a hospital may not be an approved Medicaid provider for other states or may be unaware of other states' Medicaid policies, such as prior authorization requirements, that affect eligibility for reimbursement. Where hospitals often serve a multistate population, considerable anec- dotal evidence of Medicaid payment problems exists. Those problems may be sufficient to discourage some hospitals from accepting out-of-state pa- tients or may, at least, lead them to consider how they might want to pro- ceed with such a step, as some District of Columbia hospitals have done for patients from Maryland. Problems similar to those that arise between states can also be found between cities and counties within states (e.g., New York City and Westchester County). Other complexities can arise when managed care programs for Medic- aid patients exclude nearby, but out-of-state, facilities that otherwise would provide considerable amounts of care, as happened when the Illinois I-Care program excluded children's hospitals in St. Louis, Missouri (Ron Morefeld, St. Louis Children's Hospital, personal communication, December 1992~. Long-standing subspecialty referral patterns for southern Illinois residents were disrupted, diverting them to other institutions as far away as Chicago. After termination of the program in 1991, a coalition of five children's hospitals in Chicago and St. Louis began working together with state gov- ernments on pediatric and Medicaid issues.8 These financial barriers to care make it difficult, if not impossible, to ensure that all children will have access to the care that they need. As part of their efforts to further the development of EMS-C programs, states and the federal government need to consider how to overcome reimbursement problems, especially for children who are uninsured or are covered by Med- icaid. This committee acknowledges the major shortfalls in insurance cov- erage for children that are now part of a significant debate about health care reform at the state and national levels. Broad questions of Medicaid or insurance reform are a significant backdrop to the EMS-C discussion; al- though extensive examination of these issues was clearly beyond its pur

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82 EMERGENCY MEDICAL SERVICES FOR CHILDREN view, the committee briefly returns to them again in Chapter 9. Generally, however, the committee confined its discussion to interstate reimbursement issues that directly relate to EMS-C. Rural Issues Issues of categorization and regio-nal~ation are cruc~l for many rural providers particularly in the hospital sector. Many providers fear that they will be bypassed in the process of providing emergency care to patients. The key element in the entire system is the appropriate and adequate educa- tion that is provided to emergency personnel both on the emergency trans- port team and in the initial emergency room setting. If these individuals have been trained to handle pediatric (and adult) emergencies and have demonstrated this capability, the issue of categorization becomes less threatening and somewhat less of a concern in the process. Categorization and regionalization must continue to be pursued vigorously, but in the rural setting these factors need to be considered with appropriate sensitivity for the concerns of the parties involved. Encouraging Categorization and Regionalization As noted at the outset, categorization and regionalization are linked activities that, when pursued collaboratively, can make EMS-C, as part of larger EMS systems, more efficient as well as more effective. This commit- tee believes that they are critical elements in the development of EMS-C systems. It also believes that strong leadership from the federal and state governments, health departments, and professional societies will be needed to bring these many interests together successfully. Providing appropriate care for seriously ill and injured children re- quires special expertise and special commitment. The committee recog- nizes that ensuring the availability of expertise and commitment in pediatric care and access to that care will require a formal mechanism to identify facili- ties that can provide needed care, to develop protocols and other procedures to direct children to appropriate facilities, and to verify that those proce- dures are working successfully. The specific mechanisms may vary across EMS systems and states (some may emphasize voluntary participation whereas others may choose to designate specific facilities), but the result should ensure that appropriate care is available to children who need it. Therefore, the committee recommends that all state regulatory agencies with jurisdiction over hospitals and emergency medical services sys- tems address the issues of categorization and regionalization in oversee- ing the development of EMS-C and its integration into state and re- gional EMS systems. Beyond this, the committee explicitly refrains from

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BEING READY TO DELIVER GOOD CARE 183 proposing specific steps to achieve categorization and regionalization be- cause of the diversity of approaches that states might want to use. Because of the range of interested parties professional groups, indi- vidual practitioners and institutional providers, public and patient advocacy groups, local and state governments, to name a few the special complexi- t~es of these efforts need to be appreciated. This commit~;~-e believes that steady, cooperative steps must be taken to establish a firm base for im- proved EMS-C programs. SUMMARY Despite impressive progress in recent years, EMS systems have particu- lar weaknesses in their ability to meet the needs of pediatric patients in five major areas: equipment, protocols and guidelines, medical control, catego- rization of facilities, and regionalization of care. This chapter argues, first of all, that more investment in supplies and equipment appropriate for chil- dren (across the entire pediatric age range) would significantly improve the capacity of EMS systems to discharge their responsibilities to children; the marginal cost (to the system) of having durable and disposable materials and supplies suitable for pediatric cases is quite low and should not be accepted as a reason for not providing those materials. The committee did not create definitive lists of equipment and supplies necessary for treating pediatric emergencies for various settings; rather it called for each health care provider and agency to define the emergencies that occur in the patient populations that they serve and to ensure that the necessary and proper equipment is available to treat critically ill and injured neonates, infants, children, and adolescents. To this end (and in line with later recommendations about the responsi- bilities of state agencies), the committee formally calls for all state regula- tory agencies with jurisdiction over hospitals and EMS systems to require that hospital EDs and emergency response and transport vehicles have available and maintain equipment and supplies appropriate for the emergency care of children (see Box 5-1~. The objectives are to ensure that (1) at least a minimal level of essential equipment is maintained in all hospital EDs and by all EMS systems and (2) consistency in these requirements be appropri- ately balanced with the flexibility needed in special circumstances (e.g., geographic or financial). Second, protocols have a solid place already in many areas of health care, including EMS for adults. What is desirable now is the development, dissemination, application, and evaluation of guidelines and protocols with tested pediatric elements and components. Such guidelines are needed for the full range of EMS-C activities dispatch, transport, prehospital care,

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84 EMERGENCY MEDICAL SERVICES FOR CHILDREN ED services, hospital inpatient care, and emergency care in outpatient set- tings. Third, medical control (physician oversight, directly or indirectly, of the care provided by prehospital personnel) warrants attention. On-line medical control, which implies real-time direction of care for seriously in- jured or ill children, requires reliable input from personnel (particularly physicians) with experience and training in caring for infants, children, and adolescents. Local practices, personnel, and financial resources influence whether and how on-line medical control is implemented. Off-line medical control also requires active participation and leadership from health care professionals with pediatric expertise to ensure that children's needs are considered in an EMS system. It involves designing and implementing policies, training programs, quality assurance efforts, and the like. It is broader in scope and setting than on-line control and relates more to the long-term development of guidelines and protocols (to be used, often, in on- line situations). Categorization of institutions and regionalization of specialized services, often linked conceptually and practically, are the remaining areas in which this committee believes stronger involvement and investment are warranted. Although "local" as contrasted with "national" decisionmaking and solu- tions are generally preferred in thinking about steps to incorporate EMS-C into existing EMS systems and thus to categorize facilities accurately and designate regional referral centers for pediatric cases some guidance may be needed at the national and state level to foster appropriate identification and classification of referral centers and to overcome difficult interstate

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BEING READY TO DELIVER GOOD CARE 185 questions of legal and regulatory matters, transfer policies, and reimburse- ment. The committee found these issues of sufficient significance to the successful development of EMS-C in EMS systems that it formally recom- mended that state EMS-C agencies (proposed in Chapter 8) address catego- rization and regionalization for EMS-C. NOTES 1. Information on physician offices in general is no more encouraging. For instance, a study in Dallas found that 25 percent of offices administering aerosols or epinephrine for asthma or allergic episodes did not have oxygen available, and nearly 20 percent of offices administering parenteral anticonvulsants did not have oxygen or bag-valve-mask capability (Barth et al., 1989). A survey of Michigan physicians (mainly those in family practice and secondarily in pediatrics) determined that only 11 percent had adequate equipment to manage common office emergencies such as chest pain and dyspnea, seizures, syncope, anaphylaxis, and behavioral emergencies (Kobernick, 1986). 2. The discussion about protocols for dispatchers is oriented toward EMS personnel. Brodsky (1990), however, calls attention to the problem of calls concerning fatal road accidents being directed first, or simultaneously, to police. Such practices result in delay before EMS services, such as an ambulance, are dispatched; in perhaps 15 percent of fatal accidents, a communica- tions officer has made the wrong decision by failing to notify an EMS program immediately. Some experts thus apparently believe that EMS dispatchers should be notified of all road accidents and have the responsibility of deciding whether ambulance rescue should be at- tempted based on the description of the crash. Such a policy might benefit from protocols for communications personnel and dispatchers that have been developed on the basis of informa- tion about the characteristics of road accidents and injuries in various geographic locales. 3. Dispatcher-delivered instruction in CPR by telephone has been proposed for at least 20 years as one approach for helping family members or bystanders cope with a victim of cardiac arrest. Although its utility has been demonstrated for adult patients (Kellermann et al., 1989), little if anything is known about such approaches when the patients are children. Dispatcher assistance to callers in situations involving airway emergencies and ingestions also warrants examination. Issues of telephone assistance, advice, and communication are taken up in Chap- ter 6. 4. "Emergent" and "most urgent" are not equivalent concepts in ED triage. Emergent re- quires the highest priority of care, for conditions that are life-threatening or will cause serious permanent physical impairment if not treated immediately; urgent cases may require rapid response (e.g., within 30 to 120 minutes) but not the highest priority interventions. 5. As noted elsewhere, this committee did not address questions of perinatal or neonatal emergencies. Generally, the same points concerning the utility of good guidelines and proto- cols will be true for those problems and settings. 6. The AMA (1990, p. 880) classifies pediatric emergency care facilities in three levels. Level I: "An institution capable of providing comprehensive, specialized pediatric care to any acutely ill or injured child. Usually a children's hospital or a large general hospital with a pediatric division providing comprehensive subspecialty pediatric medical and surgical ser- vices." Level II: "A hospital with a pediatric service capable of caring for the majority of pediatric patients, but with limited pediatric critical care and subspecialty expertise." Level III: "A hospital with a functioning Emergency Department capable of evaluation, stabilization, and transfer of seriously ill and injured pediatric patients. Such facilities should have formal- ized transfer agreements to higher levels of pediatric care. They should provide a vital service

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86 EMERGENCY MEDICAL SERVICES FOR CHILDREN in stabilization and transfer in areas where level I and level II facilities are not readily acces- sible." 7. The discussion of interstate problems in regionalization focuses on one manifestation of broader problems of interjurisdictional cooperation and coordination. Intercounty difficulties can arise, for instance, if various county or other "local" governments cannot agree on funding responsibilities or other policies. At an even more disaggregated level, concerns on the part of incorporated cities or intercity rivalries can disrupt EMS programs within a single county. Committee discussions ~return-~:d Redly to ex~-~s In -which ~ ch~ld~s cam was compro mised by administrative and bureaucratic complications. McArdle and colleagues (1990) dis- cuss the strengths and limitations of a county-based EMS and regionalized trauma care system in San Diego, California, and provide useful lessons for other programs based at the county level or in a county department of health. 8. The consortium of children's hospitals that was formed after the I-Care program ended includes three Chicago hospitals (Wyler's, Children's Memorial, and LaRabida) and two hos- pitals in St. Louis, Missouri (Cardinal Glennon and St. Louis Children's).