Taking Care of the Injured Child

The Role of EMSC

Elizabeth A. Edgerton, MD, MPH, FAAP

Branch Chief for EMSC and Injury Prevention

Department of Health and Human Services

Health Resources and Services Administration

The goal of prehospital care is to minimize

further systemic insult or injury and

manage life-threatening conditions through

a series of well defined and

appropriate interventions, and to

embrace principles that ensure patient

safety.

Considerations

• On average, 10% of EMS runs involve children and

adolescents

• According to a survey published in the December

2010 issue of Pediatrics:

• Only 11 % of ED visits by children occur in hospitals

specifically designed to treat children. The rest end up in

general EDs

• Only 6 % of EDs in the United States have all the

equipment needed to treat children

• Studies indicate pre-hospital providers are less comfortable caring for children, particularly infants, than for adults. • Paramedics report being very comfortable about terminating

CPR on adults, ... but very uncomfortable terminating resuscitation of children (Hall et al., 2004).

• A job satisfaction study of paramedics found that they view pediatric calls as among the most stressful • because of the low volume of such cases they typically

encounter (Federiuk et al., 1993).

• There are few well designed clinical trials of interventions performed in the pre-hospital setting. • Even worse for children where only 1 randomized controlled

trial—the gold standard for research-- has ever been conducted.

Considerations

Pediatric Recognition System

Pediatric Critical Care Center (PCCC)

Emergency Department

Approved for Pediatrics (EDAP)

Standby Emergency Department

for Pediatrics (SEDP)

Not all hospitals are

the same for children

Data from Illinois

Pre-EDAP

Patients Deaths Death

Rate

21,249 290 13.6

Post-EDAP

Patients Deaths Death

Rate

29,875 321 10.7

Mortality Rates per 1,000 Inpatient Injury-Related

Admissions from the ED,

0-15 Year Olds, 1994-2009*

*Records were restricted to facilities participating as EDAP

• Before 1984, no specialized

pre-hospital care of children.

• Realized that children are not

“little adults” and have different

anatomy, physiology, and

development than adults.

• Acknowledged the gap in care.

Why EMSC?

The Emergency Medical Services for Children

(EMSC) Program under section 1910 of the

Public Health Service Act (42 U.S.C. 300w–9) is

the only Federal program that focuses

specifically on improving the pediatric

components of emergency medical care.

Challenges for Emergency

Care for Children

• Of the 119 million emergency department (ED) visits, approximately 23 million are children.

• There are 3,833 EDs in the United States.• Fewer than 10% of EDs are fully equipped and trained to handle

pediatric emergencies.

• “Children who are injured or ill have different medical needsthan adults with the same problems.”

• They often need equipment that is smaller than what is used for adults.

• They require medication in much more carefully calculateddoses.

• They have special emotional needs as well, often reacting very differently to an injury or illness than adults do.

Quality Improvement

• State Partnership Grants

Knowledge Generation

• Targeted Issues Grants

• Pediatric Emergency Care Applied Research

Network-PECARN

Support & Dissemination

• Resource Centers

EMSC National Resource Center

NEDARC-National EMSC Data Analysis CenterAnalysis

Resource Center

What is EMSC doing?

EMSC State

Partnership Program

Provides funding to 49 states, DC, and 5

territories to improve pediatric care through

performance measures:

• Medical direction

• Pediatric equipment

• Facility recognition

• Inter-facility transfer

• Institutionalization of EMSC in the State

system

State Performance Measures Data

PM Number Brief Description

71* On-line pediatric medical direction

72* Off-line pediatric medical direction

73* Pediatric equipment and supplies

74 Hospital recognition system for medical emergencies

75 Hospital recognition system for traumatic emergencies

76 Inter-facility transfer guidelines

77 Inter-facility transfer agreements

78* Pediatric emergency education

79 EMSC Permanence – Advisory Committee

80* EMSC Priorities – state statutes and regulations

Collecting the Data

EMSC Program

Integral to this process is medical

oversight of prehospital care by:

• using preexisting protocols (indirect

medical oversight), which are

evidence-based when possible

• by medical control via voice and/or

video communication (direct medical

oversight).

Prehospital Access to

Medical Oversight

Medical Direction*

Online

2007-09 2010-11

BLS 69% BLS 87%

ALS 71% ALS 91%

Offline-Protocols

2007-09 2010-11

BLS 56% BLS 63%

ALS 83% ALS 90%

*Preliminary data from survey analysis by NEDARC

Equipment for Ambulances

• ACS-COT original list for

ambulances

• 1988 ACEP develops lists

• 2000 joint effort

• 2005 NAEMSP joins

• 2006 EMSC stakeholders

add pediatric components

Equipment Type

• Ventilation and Airway Equipment

• Monitoring and Defibrillation

• Immobilization Devices

• Bandages

• Communication

• Obstetrical Kit (commercially

• packaged is available)

• Miscellaneous

• Infection Control*

• Injury Prevention Equipment

• Ventilation and Airway Equipment

• Vascular Access

• Cardiac

• Medications (pre-loaded

syringes when available)

BLS (35 items) ALS (70 items)

Equipment on Vehicles*

2007-09 2010-11

BLS 16% BLS 23%

ALS 18% ALS 34%

• At a glance

*Respond to 911 calls and transport patients to hospitals

Equipment on Vehicles*

Equipment on Vehicles*

2010-11

Complete list

2010-11

Nearly complete

(>90%)**

BLS 23% BLS 91%

ALS 34% ALS 96%

• The rest of the story

*Respond to 911 calls and transport patients to hospitals

Equipment on Vehicles*

**Initial analysis of survey data by NEDARC

Improving Knowledge about

Pediatric Emergency Care

Targeted Issue Grants

• Issues of national significance with potential to

improve practice in the field.

• Many focus on the pre-hospital environment.

Pediatric Emergency Care Applied

Research Network (PECARN)

• Creating an infrastructure to conduct rigorous

studies in pediatric emergency care.

• Use of medications in the pre-hospital settingg.

Targeted Issue Grants

• FY2011 Funded Grants Focusing on Prehospital Care:

• Integrating Evidence Based Pediatric PrehospitalProtocols into Practice

• (Manish Shah, MD—Texas Children’s Hospital)

• Refining Pediatric Triage Algorithms and Education in the Prehospital Setting

• (Mark Cicero, MD—Yale University)

• EMS and Pediatric Trauma: A North Carolina Population Based Performance Improvement and Evaluation Using Multiple Linked Healthcare Databases

• (Greg Mears, MD—University of NC)

PECARN

• Consists of approximately 20 Emergency Departments

across the United States

• HRSA has provided infrastructure support to participating

EDs since 2001

• Represents approximately one million pediatric emergency

department visits annually

• Over 100 publications from research protocols

• Over 52 million dollars in external funding for projects

EMSC Network Development Demonstration Project

Lessons Learned

PECARN

• Determine the epidemiology of prehospital care

• Worked with local EMS agencies to collect prehospital data

linked to EDs in the research network

• Over 2 years of data collected

• minimal standardization of forms

• incomplete data collected

• unable to analyze to provide an overview of prehospital

care

Other Pediatric Initiatives

• Evaluating ED Readiness

• Only 6% of EDs ready to take care of children?

• Re-survey of EDs using 2008 national guidelines to

reassess pediatric preparedness

• Helicopter transport of pediatric patients

• Analysis of MEIMSS data using field triage criteria

• Helicopter transport, pediatric pain assessment

• NIH funding for prehospital research

• Working with NICHD to re-issue a program

announcement

• Previously funded work in pediatric patient safety

Emergency Care for Children

Future Steps

• Improve pediatric infrastructure at the State/Territory level

• Equipment for ambulances

• Regionalized systems of hospital care

• Improved ED preparedness

• Increase research efforts

in pre-hospital emergency care• Standardization in prehospital

setting

• Champions among prehospital

providers

• EMSC remains a part of the larger EMS system

• Children represent a small proportion of runs, but care

needs to be specialized

• Pediatric specialist need to be included in protocol

development and implementation

• Maintain benchmarks to assure the delivery of quality care

for children in all settings

Next steps to success

Contact Information

Elizabeth Edgerton, MD, MPH, FAAP

Branch Chief EMSC and Injury Prevention

MCHB/HRSA

eedgerton@hrsa.gov