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2 History and Current State of Pediatric Emergency Care
Pages 35-100

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From page 35...
... report Emergency Medical Serices for Children, which represented the first comprehensive look at the need for and effectiveness of pediatric emergency care services in the United States. An understanding of the development of pediatric emergency care provides a sense of progress, as well as greater insight into the system's resources, challenges, successes, and failures.
From page 36...
... Experience in Vietnam led to advances in trauma care. Surgeons returning to the United States from Korea and Vietnam recognized that the systems developed by the Army for triage, transport, and field surgery could surpass anything available to civilians at home (Rosen, 1995)
From page 37...
... Dedicated pediatric emergency departments (EDs) began to develop, staffed by pediatricians who were willing to devote their full attention to emergency care.
From page 38...
... In the 1980s, several cities designated pediatric trauma centers. Advocates for pediatric emergency care in Los Angeles developed a new two-tiered approach for organizing such care.
From page 39...
... Some courses were also developed locally. An example is the Pediatric Emergency Medical Services Training Program (PEMSTP)
From page 40...
... Much as the NAS/NRC report Accidental Death and Disability led to the passage of the EMSS Act of 1973, Injury in America: A Continuing Health Problem led to the creation of an injury prevention program at the Centers for Disease Control and Prevention (CDC) , which later became CDC's National Center for Injury Prevention and Control (IOM, 1993)
From page 41...
... . In 1998, pediatric emergency medicine fellowships became accredited.
From page 42...
... While data on system performance are not routinely collected, it appears that where a child lives has an important impact on whether the child can survive a serious illness or injury. The day-to-day presentation of pediatric patients is challenging enough for emergency care systems in some areas; addressing new and emerging threats to children's health may be beyond the capabilities of the current system.
From page 43...
... . Given that the development of pediatric emergency care has lagged behind that of adult emergency care, it is surprising that the first pediatric trauma center was established in 1962 -- 5 years before the first adult trauma center was established (Ramenofsky, 2006)
From page 44...
... The Emergency Medical Services for Children Program The creation of the federal EMS-C program in 1984 grew at least in part out of policy makers' personal experiences with the pediatric emergency care system. Several congressional staff members had had disturbing experiences with the emergency care system's ability to care for their children.
From page 45...
...  HISTORY AND CURRENT STATE Emergency Medical Services for Children FIGURE 2-1 Continuum of care of the Emergency Medical Services for Children program. 2-1 hospital and hospital-based providers, establishing logo collection processes data with new type in to identify significant pediatric issues in the EMS system, and developing tools for assessing critically ill or injured children (CPEM, 2001)
From page 46...
... In 2001, the program collaborated with the Research Branch of HRSA's MCHB to develop the Pediatric Emergency Care Applied Research Network (PECARN) , the first federally funded multi-institutional network for research in pediatric emergency care.
From page 47...
... It has improved the availability of child-size equipment in ambulances and EDs; initiated hundreds of programs to prevent injuries; and provided thousands of hours of training to EMTs, paramedics, and other emergency medical care providers. Educational materials covering every aspect of pediatric emergency care have been developed under the EMS-C program, and a formal partnership (the EMS-C Partnership for Children Stakeholder Group)
From page 48...
... Demonstration • Five cooperative agreements at $700,000 each Targeted Issues • Grants to demonstrate the effectiveness of a model $3.1 million Grants system that may be helpful to the field • 16 grants funded at $200,000 per year National • Contract with Children's National Medical Center $2.2 million Resource in Washington, D.C., for establishment of a center Center to provide technical assistance to EMS-C grant recipients, prepare special reports and educational materials on EMS-C issues, plan national meetings, collect and disseminate EMS-C products and related resources, and encourage collaboration among national organizations to promote improvements in pediatric emergency care National EMSC • Advises grantees and state EMS offices on data $1.2 million Data Analysis collection and analysis issues; conducts workshops in Resource data analysis, grant writing, and other technical areas; Center assists with research design; and provides other types (NEDARC) of technical assistance to grantees Interagency • Funding to the Centers for Disease Control and $800,000 Agreements Prevention for a pediatric emergency care data collection effort associated with the National Hospital Ambulatory Medical Care Survey • Funding to the National Highway Traffic Safety Administration to support projects that include the development of the National EMS Research Agenda and the National EMS Information System (NEMSIS)
From page 49...
... . Previously the National Academy of Sciences, National Research Council, and IOM had conducted several other studies related to emergency care, but few had given much attention to pediatric emergency care.
From page 50...
... , which are less likely than specialized facilities to have providers specifically trained in pediatric emergency medicine. Anecdotal accounts of physicians expressing doubt about their skills to care for a critically ill or injured child are not uncommon (Frush and Hohenhaus, 2004)
From page 51...
... . Certainly there has been some expansion of pediatric emergency care research since 1993, but efforts to track patient outcomes have been hampered by the absence of an infrastructure for the systematic collection of a uniform set of data elements and by the inability to link datasets of different providers (prehospital, ED, others)
From page 52...
... The result is that millions of Americans rely on the emergency medical system to provide care for children when they need it most. Injury Statistics on childhood injury are available from a variety of sources, but perhaps the most comprehensive are from CDC's National Vital Statistics Reports and ACS's National Trauma Data Bank (NTDB)
From page 53...
... TABLE 2-3 Percentage of Total Pediatric Patients Presenting at a Trauma Center, by Mechanism of Injury Mechanism of Injury Percentage of Total Patients Motor Vehicle Traffic 43.3 Fall 19.7 Struck by, against 7.4 Transport, Other 6.4 Firearm 5.0 Pedal Cyclist, Other 3.7 Fire/Burn 3.1 Cut/Pierce 3.1 Natural/Environmental 1.3 Unspecified 1.2 Machinery 0.6 Pedestrian, Other 0.5 Drowning/Submersion 0.5 Poisoning 0.3 Overexertion 0.3 Suffocation 0.2 Other 3.4 NOTE: The data include patients that were seen at one of the 474 trauma centers in 43 states that participate in the National Trauma Data Bank.
From page 54...
... Motor vehicle crashes are most likely to occur among teenaged drivers, particularly during the first year behind the wheel; teenagers are more likely to speed, ride with an intoxicated driver, or drive after using alcohol or drugs than those in other age groups (National Center for Injury Prevention and Control, 2001)
From page 55...
... Healthcare Cost and Utilization Project (HCUP) State Emergency Department Database (SEDD)
From page 56...
... Respiratory Septicemia Septicemia Chronic lower Chronic lower distress 79 42 respiratory respiratory 943 disease disease 95 192 8. Bacterial Chronic lower Chronic lower Cerebrovascular HIV sepsis respiratory respiratory disease 178 749 disease disease 58 65 41 9.
From page 57...
... , Healthcare Cost and Utilization Project (HCUP) , aggregate of 2002 State Emergency Department Databases from Connecticut, Georgia, Maine, Maryland, Massachusetts, Minnesota, Missouri, Nebraska, South Carolina, Tennessee, Utah, and Vermont (http://www.hcup-us.ahrq.gov)
From page 58...
... , Healthcare Cost and Utilization Project (HCUP) , aggregate of 2002 state inpatient databases from Connecticut, Georgia, Maine, Maryland, Massachusetts, Minnesota, Missouri, Nebraska, South Carolina, Tennessee, Utah, and Vermont (http://www.hcup-us.ahrq.gov)
From page 59...
... Near-poor and poor children were three times as likely to have unmet health care needs as nonpoor children, and uninsured children were three times as likely to have unmet needs as privately insured children (Newacheck et al., 2000)
From page 60...
... Standardized psychiatric training is not required of residents in emergency medicine and pediatric emergency medicine. Fewer than onequarter of emergency medicine residency programs provide formal psychiatric training (Santucci et al., 2003)
From page 61...
... In fact, these children are the most rapidly growing subset of pediatric patients (Sacchetti et al., 2000)
From page 62...
... However, some data are available on the use of prehospital EMS by children, revealing that in general, their use of such services is relatively low compared with that of adults. The vast majority of pediatric patients under age 15 come to the ED by private vehicle or public transportation and therefore do not receive prehospital emergency care.
From page 63...
... . A study of pediatric ambulance transports in Cleveland that excluded patients needing immediate resuscitation or trauma care found
From page 64...
... . Children's Use of the ED Data from CDC's National Hospital Ambulatory Medical Care Survey (NHAMCS)
From page 65...
... Nonurgent Use of the ED Many pediatric visits to the ED are preventable or avoidable. Compared with adults, children make more visits to EDs that can be classified as ambulatory sensitive, meaning that patients do not require care within 12 hours, that immediate care is needed but could be provided in a typical primary care setting, or that immediate care is needed but could have been avoided with timely and effective primary care.
From page 66...
... Second, the literature is unclear as to whether providing nonurgent care in the ED is cost-effective. To some extent, EDs and trauma centers welcome the revenue generated by nonurgent pediatric visits if the hospital would otherwise serve a very low volume of emergent or urgent patients in the ED.
From page 67...
... NOTE: SCHIP = State Children's Health Insurance Program. SOURCE: 2002 NHAMCS data, calculations by IOM staff.
From page 68...
... Additionally, Medicaid enrollees may have difficulty seeing primary care providers during regular office hours. According to one study, Medicaid providers who offer evening hours have patients who are less likely to use the ED (Lowe et al., 2005)
From page 69...
... In fact, abuse is often not recognized until severe injury or death occurs. A review of child abuse fatalities indicates that more than a quarter of the children involved had old fractures consistent with prior abuse and/or recent contact with health care providers (King et al., 2004)
From page 70...
... First, identification of child abuse is poor. Although emergency medicine physicians do receive didactic training in child abuse, a survey of residents found that many believed the training was not sufficient (Wagh and Heon, 1999)
From page 71...
... Diversion delays lifesaving care to seriously ill and injured children and adults. By redirecting ambulances to a hospital farther away, it causes valuable time for treating patients to be lost (Neely et al., 1994)
From page 72...
... It is within this difficult environment that the emergency care system struggles to meet the unique needs of pediatric patients. Pediatric Emergency Care and the Six Quality Aims One way to assess how the current emergency care system is meeting the needs of children is to consider each of the six quality aims for care
From page 73...
... . In fact, in many parts of the country, the physicians who staff EDs are not residency trained in emergency medicine or pediatric emergency medicine (Moorhead et al., 2002)
From page 74...
... . Physician practice patterns for pediatric patients also vary widely, and examples of these variations are numerous.
From page 75...
... . Specific data on prehospital response times for pediatric patients based on acuity are not currently available.
From page 76...
... Regardless, for the many patients who use the ED for nonurgent care because they lack access to other sources of care, restricting use of the ED would jeopardize their health. As noted earlier, under the current system, emergency care providers lack access to patients' medical histories, which can result in the ordering of diagnostic tests that the patient has already received (Cordell et al., 1998)
From page 77...
... However, of the small number of studies that have looked at equity in emergency care and the still fewer that have examined equity in pediatric emergency care, many indicate that inequities in treatment and access exist. As discussed above relative to effectiveness, not all patients with the same condition receive the same type of treatment, a fact that indicates a lack of equity in the receipt of care.
From page 78...
... Issues related to rural pediatric emergency care are explored below. Not all studies indicate disparities in treatment, however.
From page 79...
... However, many studies have shown differences in the use of pediatric emergency care between rural and urban areas. In an examination of pediatric coroners' cases in both rural and urban California counties, rural children were found to be less likely to use EMS provider services than their urban counterparts (66 versus 84 percent)
From page 80...
... REIMBURSEMENT FOR PEDIATRIC EMERGENCY CARE The costs of providing emergency care services reflect not just the operational costs of responding to each emergency call, but also the costs associated with having personnel available around the clock. Appropriate reimbursement for pediatric emergency care services is of obvious importance.
From page 81...
... As a result, this section is intended to highlight some of the difficulties related to reimbursement for pediatric emergency care services rather than to suggest immediate changes to payment and policies. Payer Mix Although some emergency care providers may receive financial support through public subsidies or private donations, their primary source of income is reimbursement for services.
From page 82...
... uninsured. Data on payer mix for prehospital care at the national level are unavailable, but as noted earlier, data from regional ambulance services confirm the heavy reliance of pediatric patients on Medicaid or SCHIP for health insurance coverage.
From page 83...
... . Children represent approximately 50 percent of Medicaid enrollees (Kaiser Family Foundation, 2004a)
From page 84...
... In addition, the Medicaid payment cycle can be twice as long as that of most private insurance payers, so providers do not receive timely reimbursement. Third, some Medicaid programs do not reimburse for a variety of services that are provided to pediatric patients in the ED.
From page 85...
... Clearly, there are a number of problems associated with Medicaid payment for pediatric emergency care services. While coverage expansions through SCHIP may aid in offsetting the costs of uncompensated care, the low reimbursement rates and poor payment policies of both programs may not meet the financial needs of operating a pediatric ED.
From page 86...
... In fact, there are several reasons why pediatric emergency care requires greater physician time and attention than adult emergency care. First, emergency providers must respond to childrens' fear and anxiety prior to examinations or treatment, which tends to add to the time and stress involved.
From page 87...
... 2000. Committee on Pediatric Emergency Medicine.
From page 88...
... 2004. Association between infant continuity of care and pediatric emergency department utilization.
From page 89...
... :172–178. CPEM (Center for Pediatric Emergency Medicine)
From page 90...
... 2005. Resident efficiency in a pediatric emergency department.
From page 91...
... :1125–1132. Glaser NS, Barnett P, McCaslin I, Nelson D, Trainor J, Louie J, Kaufman F, Quayle K, Roback M, Malley R, Kuppermann N, Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics.
From page 92...
... 2001. Comparative practice patterns of emergency medicine physicians and pediatric emergency medicine physicians managing fever in young children.
From page 93...
... 2002. Variables associated with medication errors in pediatric emergency medicine.
From page 94...
... 2005. Pediatric emergency medicine fellowships adopt a new application process.
From page 95...
... Pediatric Emergency Care 14(1)
From page 96...
... 1995. Pediatric emergency medicine.
From page 97...
... 1999. Disturbing trends: The epidemiology of pediatric emergency medical services use.
From page 98...
... 1999, March. Pediatric emergency medicine: Past, present, and future.
From page 99...
... 2005. Cost and utilization analysis of a pediatric emergency department diversion project.


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