Emergency Medical Services for Children: The Report From the Institute of Medicine

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PEDIATRICS Vol. 93 No. 5 May 1994 821

COMMENTARIES

Op inions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

Emergency

Medical

Services

for

Children:

The

Report

From

the

Institute

of

Medicine

ABBREVIATIONS. EMS-C, emergency medical services for

chil-dren; IOM, Institute of Medicine.

The scope and complexity of the problems posed by

attempting to provide emergency medical services for

children

(EMS-C)

are great. Of the 90 million

emer-gency department visits in the United States each

year, one third, or 30 million, are by children. Many

of these are due to injury. In 1990, 266 000 injured

children were admitted to hospitals; >20 000 children

died of injuries in 1988 and many more were disabled

permanently. In addition to this human cost, the

mon-etary cost of childhood injuries has been estimated to

be $7.5 billion annually.1

Most emergency department visits by children,

however, are for illnesses, many of which may be

se-rious, such as asthma, pneumonia, or bacterial

men-ingitis. Indeed, the majority of acute admissions to

pediatric intensive care units from emergency

depart-ments are due to illness, infection, or ingestion.

There-fore, the solution to these problems must include the

ability to care for emergencies caused by both illness

and injury in children. These emergencies occur in

every locale, including urban centers and rural areas.

The outcome for these children with

life-threatening conditions depends on the prompt

rec-ognition by their caregivers of the seriousness of the

situation, and on having prompt access to

appropri-ately trained medical care providers and the

neces-sary equipment and facilities.

Although the foregoing numbers are an indication

of the scope of the great need for EMS-C, they are also

an indication of the fragmentary nature of currently

available information. There is no comprehensive,

systematic, nationwide effort to obtain information

essential to the successful development of EMS-C;

The Institute of Medicine’s Committee on Pediatric Emergency Medical Services completed 396-page report or the 25-page executive summary can be purchased from the National Academy Press, 2101 Constitution Avenue,

NW, Washington, DC 20418. Additional information for the practicing phy-sician is available from the American Academy of Pediatrics by requesting

the manual Emergency Medical Services for Children: The Role of the Primary Care Provider.

Received for publication Jul 12, 1993; accepted Oct 21, 1993.

Reprint requests to (J. A. W.) Division of Emergency Services, Le Bonheur Children’s Medical Center, 848 Adams Ave. Memphis, TN 38103.

Acad-emy of Pediatrics.

that information is essential not only for planning but

also for evaluating and improving services, and, very

importantly, for prevention services.

The recently issued report by the Institute of

Medi-cine (IOM), Emergency Medical Services for Children,2

however, does provide an excellent blueprint for

be-ginning to solve these problems and developing an

effective

EMS-C

system.

EMS-C has received increasing attention during the

past several years. This effort started as individual

initiatives by volunteers. The recognition of the com-plexity of the factors involved in delivering pediatric

emergency care led to the development of a concept

of the delivery system needed to adequately meet the emergency care needs of children. That system should ensure that (1) critically ill and injured infants,

chil-dren, and adolescents can be appropriately

resusci-tated and stabilized by their initial emergency care

providers; and (2) those pediatric patients needing

more specialized care are rapidly identified and safely

transported to such care. The ultimate goal is that all

children should be returned to their family and

medi-cal home after having been given optimal care and,

therefore, the maximal opportunity to return to their

highest possible level of functioning.

The development and implementation of an ideal

EMS-C

system is complex and difficult. There are chil-dren in need of emergency care at all times in every

neighborhood, in every county, in every state in the

nation. However, not every locale will have sufficient

demand to justify producing all the pediatric

emer-gency physicians, pediatric surgeons, pediatric

inten-sivists, pediatric critical care and emergency nurses to

meet its local need. Deaths numbering 40 000 to 50 000

are distributed across the thousands ofjurisdictions in

the nation.

Pediatric cases comprise only some 10% of the runs

made by an average ambulance service. Indeed, the

individual primary care provider, emergency medical

technician, paramedic, or emergency physician will

seldom confront the problem of a critically ill or

in-jured pediatric patient. This imbalance creates a

se-rious problem. All too often, needed care is not given

because the need is not recognized or the appropriate

and expert pediatric care is not available. The result

is death or disability that could be prevented.

The solution must begin with pediatric primary

care providers working together to create an

emer-gency and critical care system that meets the needs of

their patients. There already exists, in most places, an

emergency care system with emergency medical

tech-nicians, nurses, physicians, ambulances, and

hospi-tals, but the special needs of children have been

over-looked too often by this system. It is too often

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822 COMMENTARIES

overwhelmed by the many adult patients with cardiac

and trauma problems. Moreover there already exists

in most places a child health care delivery system of

pediatricians, family practitioners, nurse

practition-ers, health department and hospital clinics. But

in-cipient emergencies too often are overlooked in the

pressures created by preventive health exams,

immu-nizations, minor illnesses, allergies, feeding, and

learning problems. EMS-C must link its two

progeni-tors; it must be an integrated part of both the

emer-gency care system and the child health system.

These dangers to our children and the need for

im-provements spawned increasing concern from

pro-fessional societies such as the American Academy of

Pediatrics and the American College of Emergency Physicians and Congress. Through the leadership of

Senator Daniellnouye of Hawaii, the EMS-C program

of the Maternal and Child Health Bureau of the

Health Resources and Services Administration was

established in 1984. Demonstration and

implementa-tion projects have now been funded in 31 states.

Sub-sequently the Maternal and Child Health Bureau

commissioned a study by the IOM of the National

Academy of Sciences to address the broad problem of

pediatric emergency medical services. The IOM

Committee on Pediatric Emergency Medical Services

published its findings in July 1993.

That Committee, composed of 19 individuals with diverse professional expertise and interests, worked for 18 months to produce its report, Emergency Medical

Servicesfor Children.2 The Committee was asked: (1) to provide an overview of the current state of emergency care to children; (2) to study the impact of emergen-cies on child health; (3) to define the characteristics of a system to meet these emergency care needs; (4) to

develop criteria and data requirements for

surveil-lance and evaluation of such a system; and (5) to make specific recommendations to the government on ways

to reduce the impact of childhood emergencies. The

report, with >600 citations, is one of the most com-prehensive reviews of the subject available. Most im-portantly, it contains specific recommendations for

action.

EDUCATION AND TRAINING

Seven recommendations involve training. The

Committee expressed great concern regarding the un-dereducation of the general public and health pro-fessionals of all types in pediatric emergencies, car-diopulmonary resuscitation, and injury prevention.

The ability of the current approach of special 1- or 2-day courses to overcome basic curricular

deficien-cies was questioned. Skill retention for vital, but in-frequently used, beneficial interventions poses a

sig-nificant problem for EMS-C educators; therefore,

regular retraining is necessary.

The Committee recommended that “states and

lo-calities develop and sustain programs to provide to

the general public of all ages adequate and

age-appropriate levels of education and training in safety

and prevention, in first aid and cardiopulmonary

re-suscitation, and in when and how to use the

emer-gency medical services system appropriately for

chil-dren.” The primary curricula for all health care

professionals should include basic resuscitation skills and the use of the EMS system. The curricula for pre-hospital care providers, graduate nurses and

emer-gency medicine, family practice, pediatric, and

sur-gical residents should include the emergency care of children including resuscitation.

CREATING A DELIVERY SYSTEM-NECESSARY EQUIPMENT AND

SUPPLIES-SYSTEMS DEVELOPMENT

Several studies documented deficiencies in the

availability of equipment and supplies appropriate

for pediatric patients on ambulances and in

emer-gency departments. Equipment lists are available

from the major professional societies (the American

Academy of Pediatrics,3’4 the American College of

Emergency Physicians,5 the Society of Critical

Medi-cine,4 and the American Heart Association6). The

Committee rejected the argument that cost was a valid deterrent to stocking pediatric supplies, because the actual marginal cost of these supplies is low and there

are significant savings realized by decreasing

mor-bidity and mortality. The Committee stressed the

im-portance of regionalization and systems development

to overcome the serious problem posed by the

avail-ability of a relatively small number of specialized fa-cilities and providers and the low frequency of critical events in any one locale. It is impractical, if not im-possible, to develop the needed expertise in every

lo-cale. Therefore, the Committee recommended the

states (1) address the issues of regionalization and

cat-egorization in developing EMS-C systems (and

inte-grating them into the EMS system); and (2) require

emergency departments and emergency response

ye-hides in these regions be appropriately equipped for

children’s emergencies.

COMMUNICATIONS

The

Committee

realized that communication sys-tems for EMS-C could not and should not be separate

from EMS in general. Enhanced 911 service allows

the address of the caller to be identified. This enables even children with minimal verbal skills to access the

system. Accordingly, the Committee recommended

universal access to enhanced 91 1 systems.

PLANNING, EVALUATION AND RESEARCH

Currently insufficient data create significant

prob-lems in analyzing and planning EMS-C efforts.

Con-founding issues include the lack of uniformity in data collection, the inability to link data elements across providers and facilities, and the lack of outcome stud-ies. The Committee recommended that International Classification of Diseases (ICD)-9-CM-E-codes be re-ported for all injury diagnoses on hospital and

emer-gency department discharges, the creation of an

EMS-C data base including a uniform minimum data

set, and the linkage of data across all the encounters with each patient.

Research in EMS-C should be expanded with

pri-ority

given to the following seven areas: clinical

as-pects of emergencies and emergency care; indices of severity of injury and, especially, severity of illness;

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1 .Guyer B, Ellers B. Childhood injuries in the United States. Mortality, morbidity and cost. A/DC. 1990;144:649-652

2. Institute of Medicine. Emergency Medical Services for Children.

Washing-ton, DC: National Academy of Sciences; 1993

3. American Medical Association Commission on Emergency Medical Ser-vices. Pediatric emergencies. Pediatrics 1990;85:879-887

4. American Academy of Pediatrics: Committee on Hospital Care. Guide-lines and levels of care for pediatric intensive care units. Crit Care Med. 1993;21 :1077-1086

5. American College of Emergency Physicians. Pediatric supply and

equipment guidelines for general emergency departments. Pediatr Emerg Med Section Newsletter. August 1990;1

6. American Heart Association. Emergency Cardiac Care Committee and Subcommittees. Guidelines for cardiopulmonary resuscitation and emergency cardiac care, VI pediatric advanced life support. JAMA.

1992;268:2262-2275

COMMENTARIES 823

patient outcomes and outcome measures; costs;

sys-tem organization, configuration, and operation;

effec-tive approaches to education and training, including retraining and

skill

retention; and, very importantly,

prevention.

FEDERAL AND STATE AGENCIES

AND FUNDING

The Committee endorsed both a “bottom-up” and

“top-down” approach to EMS-C. Local, state, and

fed-eral government leadership and support is necessary

to promulgate guidelines and standards, develop a

systems approach involving multiple jurisdictions,

coordinate research and planning, create training

mandates and curricula, and promote research. The

Committee believed that a high-level, public-private

sector approach will ensure adequate attention to the

problems of emergency care for children. Therefore,

the Committee recommended that federal and state

EMS-C offices with advisory councils be created with

the assistance of federal funding of 30 million dollars

annually for 5 years.

The IOM report provides an excellent blueprint for

action to improve pediatric emergency care. The

re-sponsibility for advocacy for these recommendations

now passes to all concerned with children’s health.

Pediatricians and other child health care advocates

must promote these recommendations within their

practices, their communities, their states, their

pro-fessional societies, and their organizations. The

enor-mous and tragic toll of serious injury and illness can

be significantly reduced through the development of

EMS-C

systems encompassing prevention, acute care,

critical care, and rehabilitation coordinated with the

child’s medical home. The pediatric community must

lead the effort to ensure that these systems are

avail-able to all of our children.

JOSEPH A. WEINBERG, MD Division of Emergency Services Le Bonheur Children’s Medical Center

Memphis, TN 38103

DONALD N. MEDEARIS, MD

Children’s Service

Massachusetts General Hospital

Boston, MA 02114

REFERENCES

Video-Assisted

Thoracoscopic

Surgery

for

Patent

Ductus

Arteriosus

ABBREVIATIONS. PDA, patent ductus arteriosus; NEC,

necrotiz-ing enterecolitis; TEE, transesophageal echocardiography; VATS,

video-assisted thoracoscopy.

Therapeutic options for the treatment of patent

ductus arteriosus (PDA) continue to evolve. Gross

and Hubbard reported the first surgical interruption

in 1939.’ Transcatheter occlusion was achieved by

Portsmann et al in 1971,2 and indomethacin therapy

for premature newborns was described in 1976.

Al-though preliminary results have been reported for

several transcatheter PDA devices, none currently

have Food and Drug Administration approval.

Trans-catheter coils are being placed in many institutions,4

and some patients are awaiting the availability of

transcatheter devices. In an effort to reduce surgical

trauma, advanced endoscopic imaging technology

has been adapted for use in pediatric cardiothoracic surgery, enabling an interruption of the PDA with a

minimally invasive transthoracic technique.5

Clini-cians face the daunting task of selecting an option

from a variety of procedures, without the advantage

of a prospective, randomized trial comparing the

risks and benefits.

Open surgical PDA division is a safe and reliable

procedure. The incidence of operative mortality, even

in premature newborns, approaches zero.6

Compli-cations are rare, but do reflect the trauma of a

tho-racotomy incision. Chest wall and spine deformity,

recurrent nerve injury, and, rarely, ligation of the left

pulmonary artery or aorta, have been described. In

large series (>600 patients), residual ductal patency

has been infrequent, occurring in 0.4 to 3.1% of

pa-tients undergoing ligation.7’8 Although open surgical interruption can be performed safely, with excellent

results on a wide range of patients, chest wall

se-quelae have been the driving force behind search for

a less traumatic approach.

Indomethacin effectively produces duct closure in

79% of premature newborns, and has become the

mainstay of therapy.9 Problems include

nephrotoxic-ity, bleeding, and an association with necrotizing

en-terocolitis (NEC). A prospective, randomized trial has

demonstrated that indomethacin therapy followed by

surgery for treatment failures is a reasonable

ap-proach,6 but the ideal treatment algorithm remains

elusive.

Variable results have been reported for elective

transcatheter device interruption of PDA. Depending

on the method of assessment (usually physical

ex-amination or angiography), these devices have

re-sidual patency rates as high as 34%4 Procedural

com-plications relate to anesthesia, catheterization,10 and

Received for publication Feb 3, 1994; accepted Feb 3, 1994.

Reprint requests to (R. P. B.) Dept of Pediatric Cardiac Surgery, The Chil-dren’s Hospital, 300 Longwood Avenue, Boston, MA 0211g.

Acad-emy of Pediatrics.

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1994;93;821

Pediatrics

Joseph A. Weinberg and Donald N. Medearis

Emergency Medical Services for Children: The Report From the Institute of Medicine

Services

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1994;93;821

Pediatrics

Joseph A. Weinberg and Donald N. Medearis

Emergency Medical Services for Children: The Report From the Institute of Medicine

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Emergency Medical Services for Children: The Report From the Institute of Medicine

COMMENTARIES

822 COMMENTARIES

Senator Daniellnouye of Hawaii, the EMS-C program

EDUCATION AND TRAINING

sig-nificant problem for EMS-C educators; therefore,

CREATING A DELIVERY SYSTEM-NECESSARY EQUIPMENT AND

im-portance of regionalization and systems development

children’s emergencies.

COMMUNICATIONS

EMS-C data base including a uniform minimum data

pri-ority

COMMENTARIES 823

skill

DONALD N. MEDEARIS, MD

REFERENCES

Pediatrics

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Pediatrics

American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.