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Explores why emergency care for children--from infants through adolescents--must differ from that for adults and describes what seriously ill or injured children generally experience in today's EMS systems. Points the way to integrating EMS-C into current and emergency programs and into broader aspects of health care for children. Gives recommendations for ensuring access to emergency care through the 9-1-1 system; training health professionals, from paramedics to physicians; educating the public; and more.
Copyright © 1993 National Academy of Sciences
All right reserved.
Emergency care for children's serious illnesses and injuries is a part of the health care system that parents hope never to need. Unfortunately, many families will need such care for their children, and they will want the best care possible. Life-threatening emergencies arise in many forms-motor vehicle crashes, drownings, poisonings, burns, pneumonia, meningitis, and asthma only begin a long list. Each year, injury alone claims more lives of children between the ages of 1 and 19 than do all forms of illness. Most admissions to pediatric intensive care units, however, are due to acute illness. Overall, some 21,000 children and young people under the age of 20 died from injuries in 1988. Nearly 21,000 more deaths occurred because of illness and other disorders (excluding congenital anomalies and birth-related conditions). Thousands more children were hospitalized and millions more were treated in emergency departments (EDs). Clearly, preventing emergencies is the best "cure" and must be a high priority, but as yet, prevention is far from foolproof. When prevention fails, families should have access to timely care by trained personnel within a well-organized emergency medical services (EMS) system. Services should encompassprevention, prehospital care and transport, ED and inpatient care at local hospitals and specialty centers, and assistance in gaining access to appropriate follow-up care including rehabilitation services.
For too many children and their families, however, these resources have not been available when they were needed. Although EMS systems and hospital EDs are widely assumed to be equally capable of caring for children and adults, this is not true. In many EMS systems, children's needs have been overlooked as services developed for adult trauma and cardiac patients. Progress has been made in recent years to improve emergency care for children, but much work remains to be done. This report identifies essential steps to be taken to make available to children the high quality emergency care they need and deserve.
RECOGNIZING A NEED FOR EMERGENCY MEDICAL SERVICES FOR CHILDREN
Origins of the Study and Report
In 1984, Congress approved a demonstration grant program to expand access to and improve the quality of emergency medical services for children (EMS-C) available through existing EMS systems and to generate knowledge and experience that other states and localities could draw on in their efforts to enhance EMS-C capabilities. This ongoing program is operated by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (DHHS).
In response to continuing congressional interest, HRSA requested that the Institute of Medicine (IOM) undertake a study of pediatric emergency medical services to look at the issues more broadly than individual demonstration projects could. The IOM study was guided by a 19-member committee with expertise in pediatrics, emergency medicine, trauma, nursing, prehospital emergency services, injury prevention, hospital administration, public policy, and local government (see roster), and it benefited from the contributions of others who met with the committee.
The committee's report examines the nature and extent of acute illness and injury among children, reviews the origins and organization of EMS systems, describes the current state of effective care, addresses data and standards needed for surveillance and evaluation of services and outcomes, and recommends policy mechanisms to promote development of better systems of care. The committee took into account system components needed to reduce the negative consequences of pediatric emergencies, the full spectrum of facilities involved in pediatric emergencies, particular problems and capabilities of urban and rural settings, and experience gained from the demonstration projects.
The report is addressed to a wide audience: health policymakers; health professionals, including physicians in pediatrics, family practice, surgery, and emergency medicine, nurses in emergency, critical care, and pediatric settings, and prehospital care providers at all levels; hospital administrators; members of voluntary organizations concerned with public safety; parents and the concerned public; and the officials responsible for organizing and operating EMS systems at the national, state, and local levels.
A Vision of Emergency Medical Services for Children
Public policies and programs for children are often fragmented, with special initiatives devised ad hoc or de novo to meet special needs. The committee finds this unacceptable for EMS-C. It adopted a broad vision of an ideal EMS-C system as part of overall EMS and as part of a comprehensive and coherent approach to children's health care (which should include a "medical home" for routine care). The connections between primary care, emergency care, tertiary (i.e., specialty) care, and rehabilitation should be as seamless as possible.
EMS-C systems must be prepared to care for all children: regardless of age (infants, toddlers, schoolchildren, or adolescents); condition (ill, injured, or with special health care needs); or economic resources (insured, uninsured, or in a public assistance program). The committee also emphasizes that EMS systems should view ensuring high quality emergency care for children as a further step in the same process that has led them to develop increasingly sophisticated care for adults.
The committee concluded that, if children's needs in emergency care are to be met, EMS-C must establish three important linkages. First, the separate components of EMS-C must be connected to form a system. Second, EMS-C must be integrated into the larger EMS system. Third, EMS-C must develop strong ties to the broader elements of child health care. Two approaches are needed to fashion these linkages. First, a "top down" approach-reflected in recommendations for federal and state action-is essential to ensure that the needs of all children are addressed in a comprehensive, efficient, and equitable manner. Second, a "bottom up" approach, which depends on the efforts of concerned and committed individuals and communities, is a vital element in making sure that EMS-C is recognized as a priority and receives the attention it requires at the local level. The committee's examination of EMS-C issues proceeds from the position that both approaches are essential.
Children and Why They Need Special Attention
Because no consensus exists regarding the age at which childhood ends and adulthood begins, the committee declined to fix a specific age range to define the "children" to be served by EMS-C. Instead, the committee emphasizes its concern for the entire span of childhood: infants, toddlers and preschoolers, schoolchildren, and adolescents. The one exclusion deemed appropriate for this report is newborns and the intensive care that they may require immediately after birth.
Care for seriously ill and injured children cannot presume that they are simply "little adults." It can, in fact, be more difficult to assess the severity of illness or injury in children than in adults. Important anatomic, physiologic, and developmental differences exist between children and adults: children are smaller and proportioned differently; normal respiratory rates, heart rates, and blood pressure differ; characteristic changes in vital signs that signal deterioration in adults may not occur in children; and stages in children's physiologic, emotional, and behavioral development affect their responses to medical care and their risk of injury and illness.
Limited data make it difficult to determine in detail how many children need emergency care, the kinds of illness and injury they experience, and the nature and outcome of the care they receive. What is clear is that injury is the leading cause of death among children over the age of 1 year. Overall, injuries associated with motor vehicles account for the largest number of deaths. Drowning, burns, and fire-related injuries are significant contributors to deaths, especially among younger children. Among adolescents, many deaths are due to homicide and suicide. In anatomic terms, brain injuries (caused directly by trauma or as a secondary result of illness or other injury) contribute to many deaths and long-term impairments for survivors.
Fewer children die from acute illnesses than from injuries, but many more are hospitalized. In 1990, for example, children experienced about 266,000 hospitalizations principally for injury and 701,000 for respiratory conditions (which represents nearly a third of all hospitalizations among children less than 15 years old). Respiratory, circulatory, or neurologic crises, which can have a variety of causes, characterize many illness-related emergencies. With no commonly accepted set of diagnoses defining illness-related emergencies, however, determining specific numbers of cases from available mortality and hospitalization data is difficult. Some deaths attributed to sudden infant death syndrome, the second leading cause of death among infants, may be due to child abuse or inadvertent suffocation.
Children with chronic illnesses or other special health care needs are especially vulnerable to serious injury and illness. They are likely to need specialized emergency care, to need care more frequently than other children, and to need care for complaints that would be less serious in fundamentally healthy children.
Several other factors are also of special concern. Adolescent girls may require emergency care for pregnancy-related problems, including premature labor. Children experiencing psychiatric or behavioral emergencies require care from mental health professionals as well as from medical and surgical providers. Violence, in the form of homicide, suicide, assault, and child abuse, is a special threat to children's physical and emotional well-being.
Increasingly, firearms are used in homicide and suicide among children.
Data on ED visits and prehospital care, for injury or illness, are especially weak. Estimates are that children account for 25 to 35 percent of all ED visits (about 30 million in 1990) and appear to make up about 10 percent of patients receiving prehospital services. The most seriously ill and injured children may require care in pediatric specialty centers and access to rehabilitation services.
Demands on EMS-C are being increased by factors other than simply the frequency of illness and injury among children: inadequate access to (or use of) primary care; increased survival and home care of children who have chronic illnesses or are technology-dependent; and staff, facility, and other resource limitations. Office-based physicians encounter children requiring emergency care, but many offices may not be adequately prepared to provide the immediate treatment that those children need.
Lifetime costs associated with injury have been estimated at $13.8 billion for children under age 15 and $39.1 billion for 15- to 24-year-olds. Asthma is one of the few major illnesses for which costs have been estimated: annual direct and indirect costs for children under age 18, excluding medications, amounted to $1.3 billion. Both injury and illness carry nonmonetary costs in pain and distress for children and their families.
Key Historical Developments
Two developments in the mid-1960s brought EMS to the attention of federal, state, and local governments and the medical community. First, the landmark report Accidental Death and Disability: The Neglected Disease of Modern Society, published in 1966, highlighted the need for better trauma care. Second, work by physicians in Ireland demonstrated that rapid treatment of cardiac emergencies could improve survival. Trauma and emergency cardiac care continue to be significant priorities for EMS systems.
Federal funding was first made available to support development of EMS systems through the National Highway Traffic Safety Administration of the Department of Transportation and through the Department of Health, Education, and Welfare (now DHHS) under the 1973 Emergency Medical Services Systems (EMSS) Act. A grant program underwritten by the Robert Wood Johnson Foundation provided further resources at this important developmental stage. The DHHS role decreased in 1981 when EMS funding was folded into a block grant program that allowed states to decide how to distribute funds among seven preventive health and health services programs. EMS was allocated substantially less support, but over time, many states and localities increased their own funding for EMS.
Resources for emergency care were developing within the health care community, including training programs for physicians, nurses, and prehospital providers (i.e., emergency medical technicians [EMTs] and paramedics) and specialized trauma units. During the 1970s, however, pediatricians and pediatric surgeons recognized that children's emergency care needs were not receiving adequate attention. To correct this oversight, they began working with hospitals, EMS agencies, their colleagues, and their communities to improve the ability of EMS systems to care for children.
Early successes such as creation of a regional pediatric trauma center as part of Maryland's statewide EMS system and the Los Angeles program to identify EDs qualifying as "emergency departments approved for pediatrics" or "pediatric critical care centers" have served as models for similar efforts elsewhere. Training in pediatric emergency care became available through locally developed programs and nationally recognized courses (e.g., Pediatric Emergency Medical Services Training Program, Pediatric Advanced Life Support [PALS], and Advanced Pediatric Life Support [APLS]).
Awareness of EMS-C issues increased with the start of the EMS-C demonstration grant program in HRSA. Since it began, the program has supported 20 demonstration projects, 11 implementation programs, and 5 special projects. Grantees have created a variety of products including training materials, treatment protocols, and system guidelines. Two EMS-C resource centers have also been established to assist grantees and others interested in emergency care for children.
PRIORITY ISSUES IN IMPROVING EMERGENCY MEDICAL SERVICES FOR CHILDREN
The EMSS Act did much to shape the development of EMS systems by specifying 15 essential functions, including training, communications, transportation, critical care facilities, and standard record keeping. For EMS-C, this committee sees seven essential areas of system responsibility: identifying emergencies; ensuring access to the services of the system (e.g., through 9-1-1 telephone service) with dispatch of equipment and personnel; providing appropriate prehospital care; transporting patients; providing definitive medical care; communicating among emergency care providers and with others, including parents and primary care providers; and using information systems and feedback to assess and improve patient care, to enhance system performance, and to identify injury prevention needs.
Achieving these goals involves medical and administrative considerations and requires the participation and cooperation of a variety of individuals and institutions. No one agency or institution has authority over all the elements involved. Thus, efforts to address the EMS needs of children must consider all the elements that constitute EMS systems, understand the specific channels through which change can be implemented, and make EMS-C a genuine priority with decisionmakers in a position to influence the future direction of emergency medical care. With this report, the committee identifies issues of special concern for EMS-C and presents recommendations for specific actions that should be taken.
Excerpted from Emergency Medical Services for Children Copyright © 1993 by National Academy of Sciences. Excerpted by permission.
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|2||Risking Our Children's Health: A Need for Emergency Care||38|
|3||Emergency Medical Services Systems: Origins and Operations||66|
|4||Learning How to Provide Good Care: Education and Training||108|
|5||Being Ready to Deliver Good Care: Putting Essential Tools in Place||149|
|6||Connecting the Pieces: Communication||187|
|7||Knowing What is Happening and What is Needed: Planning, Evaluation, and Research||224|
|8||Leadership for Developing Emergency Medical Services for Children||280|
|9||Improving Emergency Medical Services for Children: Looking to the Future||321|
|App. A Acronyms||369|
|App. B Biographies of Committee Members||373|