Pediatric
Emergencies
in Office
Practices:
Prevalence
and Office
Preparedness
Susan
Fuchs,
MD, David M. Jaffe,
MD, and
Katherine
K. Christoffel,
MD, MPH
From the Department of Pediatrics, University of Pittsburgh Medical School, Children’s Hospital of Pittsburgh, and the Department of Pediatrics, Northwestern University Medical School, Children’s Memorial Hospital, Chicago
ABSTRACT. Because of a nationally apparent increased
interest in emergency medical services for children and the need for a greater understanding of the relationship
between office pediatric and emergency department care of children, a questionnaire was mailed to practitioners to (1) describe office physician involvement with emer-gent conditions, and (2) evaluate physician office
prepar-edness for pediatric emergencies. Responses were
re-ceived from 280 pediatricians and family practitioners,
including information regarding the availability of
equip-ment and medication, physician training, and practice characteristics. Of the responding physicians, 62% re-ported that they assessed in their offices more than one child each week who required hospitalization or urgent
treatment. A preparedness score was developed and
mul-tiple regression analysis was used to investigate the
re-lationship between this score and physician and practice
characteristics. The mean overall preparedness score was 53.7 of a possible 156 (range 5 to 136, SD = 31.3).
Characteristics related to this score were type of practice
and advanced cardiac life support certification. Large
multispecialty practices and practices with physicians
trained in advanced cardiac life support tended to have better preparedness scores. Family practitioners tended to have more complete stock of medications than
pedia-tricians. The data presented suggested that critically ill
children who enter the medical system via the office setting may have a better than even chance of finding the office unprepared to treat the emergency: in fewer than one third of the offices in which it was reported that at least one patient was seen weekly with asthma, ana-phylaxis, sickle cell vasoocclusive crisis, status epilepti-cus, and sepsis were they fully equipped to treat
emergen-cies related to these conditions. This finding suggests a
need for further study of office-based care of life-threat-ening conditions and for the development of guidelines
for office emergency preparedness. Pediatrics 1989;83:
Received for publication July 11, 1988; accepted Aug 15, 1988. Reprint requests to (S.F.)Ambulatory Care Center/Emergency Department, Children’s Hospital of Pittsburgh, 3705 Fifth Ave at Desoto St, Pittsburgh, PA 15213-2583
PEDIATRICS (ISSN 0031 4005). Copyright © 1989 by the American Academy of Pediatrics.
931-939; emergency, prehospital care, emergency medical
services, office practice, health care.
ABBREVIATIONS. BLS, basic life support; ACLS, advanced cardiac life support; ATLS, advanced trauma life support.
The primary care office in pediatrics or family practice is organized to provide well-child care and to care for children with chronic diseases and acute minor problems, both medical and surgical. Yet patients occasionally seek care in office settings with urgent and emergent conditions that can re-quire different equipment, medication, and skills than those generally used in this setting. In these circumstances, the physician may need to provide for basic life support, stabilization, and transport to emergency care facilities, although it is likely that not all offices are well equipped to do this. Kobernick’ recently reported that more than 50% ofphysicians have seen adult patients with anaphy-laxis, dyspnea, shock, and syncope one or more times in their offices, but only 11% had adequate equipment to manage these emergencies. Similar research has not been reported regarding the pre-paredness of office practices for pediatric emergen-cies.
TABLE 1. Equipment List* 89.3 84.3 53.9 50.7 47.9 44.6 42.1 40.0 36.1 31.1 30.7 28.6 28.2 27.5 26.8 25.4 25.4 25.0 20.7 20.0 16.8 7.1 6.1 2.5 87.9 85.7 84.6 73.9 71.1 68.9 62.9 57.1 55.4 53.9 52.1 49.6 45.7 41.1 25.0 24.6 23.2 21.1 19.3 18.9 10.0 8.2 5.4 1.1 0.7 0 0 research relevant to the development of guidelines
for office preparedness.
MATERIALS
AND METHODS
A questionnaire was designed to obtain infor-mation concerning the availability of office emer-gency equipment and medication (51 and 56 items, respectively) and physician and practice character-istics. It was mailed to a sample of pediatricians and family practitioners in the Chicago area. The sample was obtained from a list of 963 practitioners practicing within a 64.5-km (40-mile) radius of Chicago who had made referrals to Children’s Me-mona! Hospital, a tertiary care pediatric hospital in Chicago. Hospital-based and academic physi-cians were excluded. The 64.5-km (40-mile) radius included the city, surrounding suburbs, and few, if any, rural areas.
The information requested in the questionnaire concerned specific equipment (presence and sizes), specific medication (type), physician characteristics (specialty, board certification, number of years in practice, training, age, sex, basic life support (BLS) and advanced cardiac life support (ACLS) certifi-cation and advanced trauma life support (ATLS) certification), and practice characteristics (type of practice, age of patients seen, number of ill patients with specific diagnoses seen per week [eg, acute asthma, sepsis, trauma], number of severely ill chil-dren seen in the last week and last 3 months, number of patients seen per week, and number of active patients in the practice). The equipment and medication items in the questionnaire are listed in Tables 1 and 2.
One week after the first mailing, a follow-up postcard was sent to all physicians; 2 weeks later, a second copy of the questionnaire was mailed to physicians who had not responded.2
Demographic data were recorded for each re-sponding physician. Data concerning equipment and medication were recorded only once for each office. When responses from two or more physicians in an office differed concerning office equipment, discrepancies were resolved by telephone.
Preparedness scores were developed as follows: at least one point was given for each specified item that was present in the office, and items essential for pediatric emergencies received two points. Two-point items were selected by the investigators and compared with those recommended in standard pe-diatric and pediatric emergency texts.3’#{176} Separate scores for equipment and medications were calcu-lated for each office (maximum scores 75 and 81, respectively). The total maximum possible score was 156 (58 one-point and 49 two-point items, Tables 1 and 2).
Offices With
Items the Item
(%)
2 Point
BP equipment Antiseptic solutions Extremity splints
Ped needles (small gauge)
Eye flush device
Ped scalp vein needles Oxygen delivery system Ped oxygen masks Bag-valve-mask
ECG
Ped suction catheters Ped laryngoscope & blades
Ped nasogastric tubes
Suction system
IV administration sets Ped endotracheal tubes Ped IV catheters
Ped resuscitation drug list
Chest cardiopulmonary resuscitation
board
Ped cervical collar
Lumbar puncture set
Tracheostomy
Ped defibrillator and paddles Cricothyroidotomy set 1 Point
Suture removal equipment
Wound dressing
Nonocclusive
Occlusive
Sterile gloves
Ped urine specimen collection bag
Suture material
Fluorescein tapes Eye shields
Gynecologic examination table Vaginal specula
Ped oral airway
Blue (Wood’s) lamp Face mask
Urine pregnancy test
Iv
polePed urine catheters X-ray capabilities
Ped nasopharyngeal airway Sterile gowns
Stylet
Cutdown tray for venous access Magill forceps
Ped tracheostomy tray Ped central venous pressure
catheters
Thoracotomy trays
Pod chest tube
Water suction for chest tube
* Abbreviation: Ped, pediatric.
epilep-87.9 60.4 51.8 48.9 46.4 44.6 43.9 36.1 30.0 29.6 27.9 25.7 25.4 22.9 23.6 22.1 20.0 18.9 17.9 14.3 12.5 11.4 10.7 5.0 77.9 74.3 72.9 60.9 37.7 30.4 30.0 29.3 27.5 26.1 26.1 20.0 19.3 17.9 16.1 16.1 16.1 11.8 10.0 9.6 8.6 8.6 7.9 7.1 4.6 3.9 2.5 1.8 1.1 1.1
item were considered fully prepared. These results were used to calculate frequencies of illness-specific full preparedness among all responding offices.
The
x2
test was used to evaluate bivariate asso-ciations among categorical variables and the Stu-dent’s t test was used for continuous variables.20 The Statistical Package for the Social Sciences program2’ was used to calculate multiple regression equations for analysis of characteristics related to scores for overall preparedness, equipment, and medication.22 For bivariate associations, the signif-icance level was set at P < .01 to correct for multiple comparisons. For multiple regression, the signifi-cance level was set at P < .05.RESULTS
Questionnaires were successfully delivered to 780 of the 963 eligible recipients. Responses were re-ceived from 280 physicians in 252 offices for an overall response rate of 36%. Of these 280 physi-cians, 204 pediatricians and 76 family practitioners answered, response rates of 47% and 22%, respec-tively.
Physician Respondent Characteristics (Table 3)
The mean respondent age was 50 years; 77% of the respondents were men and 84% were board certified or eligible. They averaged 19 years in practice. Training in BLS had been taken by 88%, in ACLS by 16%, and in ATLS by 1%. There were several statistically significant differences between pediatrician and family practitioner respondents: pediatricians included in more women, were more likely to be board certified or eligible, but were less likely to have advanced cardiac life support train-ing. The sex distributions among our respondents reflect the national sex distributions in the respec-tive fields as indicated by membership in the Amer-ican Academy ofPediatrics (75% men, 25% women) and in the American Academy of Family Physicians (82.3% men, 17.5% women).
Practice Characteristics (Table 4)
Because of the location and referral patterns at Children’s Memorial Hospital, nearly all respond-ing physicians practiced in the city or suburbs. Two thirds of offices were situated less than 3.2 km (2 miles) from the nearest hospital, and paramedic or ambulance response time was less than five minutes for 63% of the practices; these characteristics were similar for pediatricians and family practitioners. A significantly larger percentage of family practi-tioners were in solo practice.
TABLE 2. Medication List
Items Offices With
the Item (%)
2 Point
Epinephrine (1:1000)
Ipecac
Sterile eye flush Epinephrine (1:10,000) Phenobarbital Diazepam (Valium) Inhalant medication Aminophylline (IV) 25% Dextrose Sodium bicarbonate Atropine sulfate Glucagon (intramuscular) Insulin
Normal saline (0.9)
Digoxin
Phenytoin sodium (Dilantin) Lactated Ringers Parenteral analgesic Activated charcoal Antibiotics (IV) Dopamine Naloxone
5% Dextrose/0.2 normal saline
Mannitol 1 Point
Theophylline (P0) Topical burn medication Lidocaine hydrochloride (1%) Impregnated gauze dressing Ophthalmic analgesic (Ophthaine) Lidocaine hydrochloride (IV)
Nonstick dressing 5% Dextrose/water Furosemide (Lasix) Calcium gluconate Corticosteroid (IV) Calcium chloride Isoproterenol Parenteral sedative Potassium chloride Mydriatics Propranolol Cycloplegics
5% Dextrose/0.45 normal saline
Other asthma medication
5% Dextrose/normal saline
Heparin Cathartic Paraldehyde Other drugs
Dobutamine
Other diabetes medication Other seizure medication Other IV fluids Glycerol
TABLE 3. Physician Respondent Characteristics
Characteristics No. (%) of No. (%) of Family P Value
Pediatricians Practitioners
(n= 204) (n= 76)
Age (yr) 49 53 NS
Yr in practice 18 21 NS
Sex
M 147 (72) 68 (89) .002
F 56 (27) 7 (9)
Board certified or eligible 183 (90) 56 (75) .004
Life support training
Basic 180 (88) 65 (86) NS
Advanced cardiac 26 (13) 19 (25) .01
Advanced trauma 1 (0.4) 3 (4) NS
TABLE 4. Practice Characteristics
Characteristics No. (%) of Both No. (%) of No. (%) of Family P Value*
(n = 280) Pediatricians Practitioners
(n= 204) (n= 76)
Type of practice
Solo 123 (44) 74 (36) 49 (64) .001
Small group (2-3 persons) 79 (28) 65 (32) 14 (18)
Large single specialty 29 (10) 27 (13) 2 (3)
Large multispecialty 34 (12) 27 (13) 7 (9)
Other 15 (6) 11 (6) 4 (6)
Location of practice
City 104 (37) 78 (38) 26 (34) .001
Suburb 168 (60) 125 (61) 43 (57)
Rural 7 (3) 0 (0) 7 (9)
Distance from hospital
3.2 km (<2 mi) 189 (68) 144 (71) 45 (59) NS
3.2-7.9 km (2-4.9 mi) 65 (23) 46 (22) 19 (25)
8 km (5 mi) 26 (9) 14 (7) 12 (16)
Paramedic or ambulance
response time
<5 mm 175 (63) 130 (64) 45 (59) NS
5-9 mm 70 (22) 46 (22) 24 (32)
10-20 mm 18 (6) 15 (7) 3 (4)
>20 mm 1 (0.4) 0 (0) 1 (1)
Variable 5 (2) 4 (2) 1 (1)
None 0 (0) 0 (0) 0 (0)
* Result of x2 comparisons of distribution for pediatricians v family practitioners.
Item Preparedness (Tables I and 2)
The following items were present in more than
75% of the offices: BP machine, suture removal equipment, wound dressings, antiseptic solution, epinephrine (1:1,000), and theophylline (oral).
Equipment present in 25% or fewer of the offices
included: pediatric cervical collar, defibrillator, pe-diatric endotracheal tube, surgical airway access equipment (cricothyroidotomy set), surgical IV ac-cess equipment (cut-down set), chest tube, lumbar puncture set, and x-ray capability. Drugs available in 25% or fewer offices included: IV fluids (lactated
Ringer’s or normal saline), IV antibiotics, insulin, parentera! analgesics, activated charcoal, naloxone, calcium chloride, mannitol, and IV vasopressors.
Because many pediatric emergencies involve dis-turbance in respiration and most cardiopulmonary
arrests in children are the result of hypoxia, equip-ment and medications related to airway manage-ment are of particular interest. Oxygen and bag-valve-mask capabilities were available in 42% and 36% of practices, respectively. Epinephrine (1:1,000) and inhalation agents (bronchodilators) were available in 88% and 44% of offices, respec-tively. Epinephrine (1:10,000), probably the single most essential cardiopulmonary arrest medication, was available in 49% of offices. There were no significant differences between pediatricians and family practitioners with respect to these items.
fu-TABLE 5. Multiple Regression An alysis-Ov erall Preparedn ess Score*
Variable Points Significance Multiple R R2
Large multispecialty 55.0 0 .5310 .2820
Other 45.5 0 .6070 .3685
Advanced cardiac life support 19.7 0 .6382 .3990
Single specialty
Large 20.8 0.003 .6514 .4243
Small 9.5 0.016 .6632 .4398
Constant 38.1
* Maximum score = 156. Analysis of variance: F = 33.44; significance of F = 0. Multiple
regression equation: predicted score = 38.1 (constant) + type of practice (points) + advanced cardiac life support certification (points).
TABLE 6. Multiple Regression Analysis-Equipment
Score*
Variable Points Signifi-cance
Multiple
R R2
Large multispecialty 26.2 0 .4952 .2453
Other 21.6 0 .5652 .3195
Advanced cardiac life 8.9 0 .5906 .3488
support
Single specialty
Large 12.3 0 .6106 .3728
Small 5.7 0 .6288 .3954
Constant 21.8
* Maximum score = 75. Analysis of variance: F = 27.87; significance of F = 0. Multiple regression equation: pre-dicted score = 26.8 (constant) + type of practice (points) + advanced cardiac life support certification (points).
TABLE 7. Multiple Regression Analysis-Medication
Score*
Variable Points Signifi-cance
Multiple
R R2
Large multispecialty 30.2 0 .5284 .2729
Other 24.2 0 .6048 .3658
Advanced cardiac life 9.4 0 .6391 .4084 support
Specialty 5.6 0.006 .6494 .4218
Single specialty
Large 9.6 0.011 .6584 .4335
Small 4.7 0.029 .6680 .4462
Constant 14.3
* Maximum score = 81. Analysis of variance: F = 28.34; significance of F = 0. Multiple regression equation: pre-dicted score = 14.3 (constant) + type of practice (points) + advanced cardiac life support certification (points) +
specialty (points).
rosemide, lidocaine, parenteral analgesics, and
sed-atives.
Preparedness
Score
The mean overall preparedness score was 53.7 of a possible 156 (range 5 to 136, SD = 31.3). (Mean equipment score = 29.6 of a possible 75; mean medication score = 24.1 of a possible 81). Multiple regression analysis was used to evaluate the rela-tionship of several factors with each of the prepar-edness scores (overall preparedness, Table 5;
equip-ment, Table 6; and medication, Table 7) in an
attempt to determine which factors contributed to better preparedness scores among responding phy-sicians. The two factors found to contribute
signif-icantly to overall preparedness scores were type of practice and ACLS certification. Specialty was a third significant factor in the medication score regression equation, with family practitioners tend-ing to receive better scores than pediatricians. The multiple correlation coefficients ranged from .62 to
.67, and the significant characteristics accounted for 40% to 45% of the variability in the respective preparedness scores.
Scores for nonsolo practices of all types were better than for solo practices. The largest increment in score was attributed to being in a large multispe-cialty practice, followed by “other” types of prac-tice. (The category “other” [n = 15] included small multispecialty groups, three; board of health clinics, two; HMOs, six; and unspecified groups, four.) ACLS-certified physicians also had better scores. According to the regression equation, the best scores predicted were those of large multispecialty practices in which physicians were ACLS certified (ie, score = 38.1 + 55 + 19.7 = 112.8), and the least scores were predicted for solo practices in which the physician lacked ACLS certification (score =
38.1).
None of the following variables contributed sig-nificantly to any of the three preparedness scores: distance to hospital, paramedic response time, number of years in practice, number of critically ill patients seen per week or in a 3-month period, and BLS or ATLS certification.
Illness Preparedness
Physicians Who See Physicians With All Offices With All Offices With All
>1 Patient/wk Essential Items
Who See >1 Patient/wk
Essential Items Essential Items
in Which >1 Patient/wk Is
Seen
91.0 25.8
81.0 52.5
71.0 32.4
26.4 19.7
22.5 29.8
7.5 10.5
25.4 92.2
44.0 88.4
35.3 64.0
9.9 57.0
27.4 26.1
11.1 7.1
TABLE 8. Illness Preparedness*
Illness and Essential Drugs or Equipment
Asthma
Oxygen delivery system Oxygen mask
Epinephrine (1:1000)
or
Inhalant
Theophylline (P0) or aminophyl-line (IV)
Trauma (minor) Antiseptic solution
Wound dressing (occlusive or
non-occlusive) Suture material
Sterile gloves Extremity splints
1% lidocaine
Allergy injections (possible
anaphy-laxis)
Oxygen delivery system Oxygen mask
Epinephrine (1:1000)
Sepsis (meningitis)
BP machine
IV catheter or scalp vein needle IV antibiotics
Status epilepticus
Oxygen delivery system Bag valve mask apparatus
Valium (or other anticonvulsant)
Sickle cell vasoocclusive crisis IV catheter
or
Scalp vein needle
IV fluid administration set
IV fluids
Parenteral analgesia
* All values are given as percentages.
reported that one or more patients with asthma, allergy injections (possible anaphylaxis), sepsis, status epilepticus, and sickle cell vasoocclusive
cri-sis was seen weekly were fully equipped to treat emergencies related to these problems. For four conditions the proportion of offices seeing such patients regularly was much greater among pre-pared compared with unprepared offices: asthma, 92% V 26%; trauma, 88% v 53%; anaphylaxis, 64%
V 32%; sepsis, 57% v 20%. By contrast, for two conditions this proportion was actually less for prepared than unprepared offices: status epilepti-cus, 26% v 30%, and sickle cell vasoocclusive crisis,
7% v 11%. Thus, there was a relationship between clinical need and preparedness, but the relationship
was inconsistent both qualitatively and
quantita-tively.
DISCUSSION
As our ability to save lives is advanced by medical technology and increasing consumer expectations set ever greater standards for health care delivery, it is important for health care providers and poli-cymakers to understand the services available to desperately ill children outside tertiary care set-tings. Our study is a first step toward that under-standing.
Methods
addition, response bias may be present, in view of the relatively small response rates. However, nei-ther of these factors is likely to lead to misinterpre-tation of the data. We would have expected, if anything, a response bias favoring those practition-ers who were better prepared. Although we found wide ranges of actual preparedness (scores ranging from 5 to 136), such a response bias suggests that, if anything, office preparedness is overestimated in our sample. The true situation in the Chicago area may be that office practitioners are less completely equipped than we are reporting. We have no reason to suspect a response bias in which preparedness is underestimated.
The proportion ofphysicians who see one or more patients per week with a specific illness may have been overestimated because of the choices available in our questionnaire. Given the options of selecting
zero v one to five patients per week, some physi-cians may have chosen one to five because they do indeed see these patients occasionally but not every week.
Because of these limitations, we consider this report to be provocative and exploratory rather than definitive. Systematic nationwide research is needed and may indicate local and regional differ-ences in office preparedness.
Review of Results
For there to be appropriate response to pediatric emergencies from the health care system, the Ca-pabilities of and relationships between hospital-based emergency services and prehospital health care facilities (both the primary care office and the transport system) are vitally important. Although it is unreasonable to expect the primary care office to be as fully equipped as a hospital emergency department, it is reasonable for parents and par-amedics to expect that basic life support and sta-bilization will be provided pending the arrival of timely and competent transport services. The data presented provide information relevant primarily to the office practice portion of the system. They suggest that urgently ill children who enter the medical system via the office setting may have a better than even change of finding the office unpre-pared to treat the emergency. Fewer than one third of the offices in which physicians seeing at least one patient weekly with asthma, anaphylaxis, sickle cell vasoocclusive crisis, status epilepticus, and sep-sis were fully equipped to treat emergencies related to these conditions.
Compared with an adult study by Kobernick,’ our results are similar in terms of both the lack of specific emergency equipment and drugs and the
poor correlation between office preparedness and illness treatment frequency.
Correlates of Preparedness and Their
Implications
Family practitioners tended to have better stocks of medications than pediatricians. Large multispe-cialty practices and practices with physicians trained in ACLS tended to have better prepared-ness scores in all categories. This suggests that factors sometimes seen by parents as disadvantages of multispecialty practices, (eg, different physicians at different visits, less personal attention) may be counterbalanced by a safety advantage.
Office preparedness scores were not affected by distance to the hospital or paramedic response time, suggesting that offices far from a hospital and/or with slow paramedic response time are no better equipped than those with more rapid access to emergency services. Most physicians in this survey reported having a rapid paramedic response time and/or being near to a hospital. Perhaps physicians in these practices rely on these resources to assist in the stabilization of their emergently ill patients and to provide missing equipment and medication. If so, there may be some reason for concern.
The paramedic transport system is an integral part of a community’s emergency response capabil-ities; however, deficiencies in paramedic prepared-ness for pediatric emergencies have been docu-mented. Seidel23 surveyed US emergency medical service provider agencies and Los Angeles County Fire Department emergency medical service squads, which have a recommended pediatric equipment list. Both were found inadequately equipped to treat pediatric emergencies. In addition, many of the Los Angeles County paramedics did not have all of the required pediatric items. Physicians who rely on rapid and competent paramedic response for defin-itive treatment of pediatric emergencies must crit-ically assess the preparedness of their local emer-gency medical service providers, and, if necessary, become actively involved in establishing and en-forcing standards.
Unassessed Factor
stocks of medication and equipment that are rarely, if ever, used, would be prohibitive in many offices. The presence of a modest set of essential
medica-tions and equipment (as suggested in Table 8), if coupled with a skilled physician response and a timely and competent paramedic response, is likely to yield the optimal outcome in a true pediatric emergency.
Several approaches are available for physicians to obtain skills for emergency situations. In our sample, 88% of pediatricians and 86% of family practitioners had BLS training. Only 13% of pedia-tricians and 25% of family practitioners had ACLS training, and few had ATLS training. Advanced pediatric life support training was not available at the time the survey was distributed. Soon, however, two national courses (one jointly sponsored by the American Academy of Pediatrics and the American College of Emergency Physicians, the other by the American Heart Association and The American Academy of Pediatrics) will be available and may provide more relevant advanced training in emer-gency life support for children.
However, the availability of courses does not eliminate the need to specifically assess the critical physician factor when evaluating emergency pedi-atric services. The duration of skills acquired in such courses is unknown. It is possible that, if rarely used, skills that are not freshly learned may be relied on inappropriately.
Study Implications
We are beginning to examine the role of office practitioners in the management of pediatric emer-gencies. Clearly, that role will vary with practice
circumstances, including office location, availabil-ity of paramedic and hospital support services, phy-sician training and skill, office equipment, local and regional custom, and practitioner preference.
The data indicate that children with both actual and potential urgent and emergent illnesses are assessed regularly in office practices. A majority of pediatricians and family practitioners have basic life support training and timely access to paramedic and ambulance services. However, a prevalent lack of equipment and medications often needed in emergency stabilization were also demonstrated.
The data suggest the need for further study to broaden the generalizability of available informa-tion to office emergency care and also to clarify specific aspects (eg, the relationship of patients seen to preparedness, the relationship of emergency training to equipment and skills). In addition, the data suggest the need for guidelines for office pre-paredness, similar in concept but possibly different
in content from those established for paramedic preparedness. Such guidelines could address issues of physician training and regional and local varia-tions, as well as specifying office equipment and medications necessary and desirable for effective intervention in unexpected pediatric emergencies.
ACKNOWLEDGMENTS
The authors thank John Hewitt, PhD, for assistance in data processing, Christopher Winship, PhD, for
statis-tical consultation, and Lucy Koutsavlis for preparation of the manuscript.
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SAT SCORES
More than 1.7 million high school students will take the Scholastic Aptitude Test this academic year, mostly because the Educational Testing Service and the College Board - the nation’s two largest nonprofit testing organizations
-have done a masterful job of convincing colleges and universities that requiring the test is a good thing.
But while ETS and the College Board have succeeded at public relations, they still fail to demonstrate that they provide a useful service. After six years of research drawing on three national surveys, hundreds of studies conducted by colleges, and analyses prepared by ETS itself, I have concluded that ETS and the College Board have promoted the SAT on three grounds. And I have found that they have not disclosed evidence that undermines each one:The SAT helps colleges. ETS’s own data show that the SAT changes very few admissions decisions in American colleges. At least 84% of the decisions to admit or reject applicants would be the same if the policy were based on the high school record alone. The percentage is in the mid-nineties at many colleges and for many programs within individual universities.
Furthermore, the SAT does not improve admissions decisions appreciably in the few cases where it changes them. Consequently, the typical gain to colleges from adding the SAT to the high school record is an increase in average freshman grades of only 0.02 on the usual four-point scale. The SAT is even less useful in predicting which students will graduate from college...
Mr. Crouse is a professor of educational studies and sociology at the Univer-sity of Delaware. He is co-author with Dale Trusheim of “The Case Against the SAT” (University of Chicago Press).
Noted by J.F.L., MD
