pediatric readiness in emergency medical services systems · mary fallat, md, facs, faap,q...

TECHNICAL REPORT

Pediatric Readiness in EmergencyMedical Services SystemsSylvia Owusu-Ansah, MD, MPH, FAAP,a Brian Moore, MD, FAAP,b Manish I. Shah, MD, MS, FAAP,c Toni Gross, MD, MPH, FAAP,d

Kathleen Brown, MD, FAAP,e,f Marianne Gausche-Hill, MD, FACEP, FAAP, FAEMS,g Katherine Remick, MD, FACEP, FAAP, FAEMS,h,i,j

Kathleen Adelgais, MD, MPH, FAAP,k Lara Rappaport, MD, MPH, FAAP,l Sally Snow, RN, BSN, CPEN, FAEN,m

Cynthia Wright-Johnson, MSN, RNC,n Julie C. Leonard, MD, MPH, FAAP,o John Lyng, MD, FAEMS, FACEP, NRP,p

Mary Fallat, MD, FACS, FAAP,q COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE, SECTION ON EMERGENCY MEDICINE, EMSSUBCOMMITTEE, SECTION ON SURGERY

abstractIll and injured children have unique needs that can be magnified when thechild’s ailment is serious or life-threatening. This is especially true in the out-of-hospital environment. Providing high-quality out-of-hospital care to childrenrequires an emergency medical services (EMS) system infrastructuredesigned to support the care of pediatric patients. As in the emergencydepartment setting, it is important that all EMS agencies have the appropriateresources, including physician oversight, trained and competent staff,education, policies, medications, equipment, and supplies, to provide effectiveemergency care for children. Resource availability across EMS agencies isvariable, making it essential that EMS medical directors, administrators, andpersonnel collaborate with outpatient and hospital-based pediatric experts,especially those in emergency departments, to optimize prehospitalemergency care for children. The principles in the policy statement “PediatricReadiness in Emergency Medical Services Systems” and this accompanyingtechnical report establish a foundation on which to build optimal pediatriccare within EMS systems and serve as a resource for clinical andadministrative EMS leaders.

DEFINITIONS

• Emergency medical services (EMS): An intricate and comprehensivesystem, which in a coordinated response, provides the arrangements ofpersonnel, facilities, and equipment for the effective, coordinated, andtimely delivery of health and safety services to provide emergencycare.1,2

• Out of hospital: A term used in emergency medicine to mean “in thefield,” “in the community,” “at the patient’s home or workplace,” or“prehospital.” Assessments performed and treatments given out of

aDivision of Emergency Medical Services, Department of Pediatrics andEmergency Department, University of Pittsburgh Medical Center Children’sHospital of Pittsburgh, Pittsburgh, Pennsylvania; bDepartment of EmergencyMedicine, University of New Mexico Health Sciences Center, Albuquerque,New Mexico; cSection of Emergency Medicine, Department of Pediatrics,Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas;dDepartment of Emergency Medicine, Children’s Hospital New Orleans andLouisiana State University Health New Orleans, New Orleans, Louisiana;eDepartments of Pediatrics and Emergency Medicine, School of Medicineand Health Sciences, The George Washington University, Washington,District of Columbia; fDivision of Emergency Medicine, Children’s NationalMedical Center, Washington, District of Columbia; gDepartments ofEmergency Medicine and Pediatrics, David Geffen School of Medicine,University of California, Los Angeles and Harbor–University of California, LosAngeles Medical Center, Los Angeles, California; hSan Marcos Hays CountyEmergency Medical Services, San Marcos, Texas; iAustin-Travis CountyEmergency Medical Services System, Austin, Texas; jDepartment ofPediatrics, Dell Medical School, The University of Texas at Austin, Austin,Texas; kDepartment of Pediatrics, School of Medicine, University of Colorado,Aurora, Colorado; lDepartment of Pediatric Emergency Medicine and UrgentCare Center, Denver Health Medical Center, Denver, Colorado; mPediatricEmergency and Trauma Nursing, Fort Worth, Texas; nEmergency MedicalServices for Children, Maryland Institute for Emergency Medical ServicesSystems, Baltimore, Maryland; oDivision of Emergency Medicine,Department of Pediatrics, Nationwide Children’s Hospital and College ofMedicine, The Ohio State University, Columbus, Ohio; pLevel I Adult TraumaCenter and Level II Pediatric Trauma Center, North Memorial HealthHospital, Minneapolis, Minnesota; and qDivision of Pediatric Surgery,University of Louisville and Norton Children’s Hospital, Louisville, Kentucky

To cite: Owusu-Ansah S, Moore B, Shah MI, et al. AAPCOMMITTEE ON PEDIATRIC EMERGENCY MEDICINE, SECTIONON EMERGENCY MEDICINE, AAP EMS SUBCOMMITTEE,SECTION ON SURGERY. Pediatric Readiness in EmergencyMedical Services Systems. Pediatrics. 2020;145(1):e20193308

PEDIATRICS Volume 145, number 1, January 2020:e20193308 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on March 26, 2020www.aappublications.org/newsDownloaded from

hospital often stabilize a patient orinitiate critically needed care.3

INTRODUCTION

Emergency care for children occursalong a continuum from primaryprevention to prehospital, hospital-based acute care, and rehabilitationservices. In 2009, the AmericanAcademy of Pediatrics (AAP), theAmerican College of EmergencyPhysicians (ACEP), and theEmergency Nurses Associationcollaborated to produce a documentfocused on the emergencydepartment (ED), “Guidelines for Careof Children in the EmergencyDepartment,”4 recently revised andpublished as “Pediatric Readiness inthe Emergency Department.”5

Alongside the ED policy statement,the National Association of EMSPhysicians (NAEMSP) and NationalAssociation of Emergency MedicalTechnicians (NAEMT) joined thoseorganizations in authoring a policystatement6 on pediatric readiness inEMS systems. This technical reportsupports these policies with evidencefor the need for pediatric services tobe embedded into the EMS segmentof the continuum of emergency carefor children. This report identifiesareas where improvements can bemade in EMS systems and providesresources and references for clinicaland administrative EMS leaders touse to transform health care forpediatric patients. Recommendationsfor integrating pediatric-specificcomponents into EMS systems arenoted in Table 1.

BACKGROUND

In 2011, the National Association ofState EMS Officials (NASEMSO)published the results of the NationalEMS Assessment. At the time,826 111 credentialed EMSprofessionals in 19 971 licensed EMSagencies cared for more than 35million patients annually in theUnited States.7 Children represented

only 10% of EMS encounters,8 raisingconcerns that even well-trained EMSproviders can face challenges in themaintenance of their cognitiveknowledge and psychomotor skillsgiven the range of acuity in pediatricpatients they encounter.8–19 Thesechallenges underscore theimportance of establishing activitiesin EMS agencies and systems toensure pediatric readiness in the EMSenvironment.19–24

Pediatric Readiness

In 2006, the Institute of Medicine(IOM), now called the NationalAcademies of Sciences, Engineering,and Medicine, published a reporttitled, “Emergency Care for Children:Growing Pains,” which describedmultiple deficiencies and gaps in theability of our emergency care systemto meet the needs of children.25 Forexample, the IOM noted that theworkforce providing emergency caremust have the knowledge and skillsto take care of children to minimizedevastating health consequences. Asevidence of deficiencies in thisnecessary knowledge and skill, theauthors noted significant gaps in bothclinical and administrative areas aswell as a paucity of research on bestpractices, clinical outcomes, andpatient safety for the prehospitalcare of children. The report hadseveral recommendations includingthe need for the EMS industryto establish defined pediatricemergency care competencies andprovide initial and continuingpediatric-specific education forproviders.4–25

The 2013 National PediatricReadiness Project assessmentevaluated various foundationalelements based on the joint policystatement “Guidelines for Care ofChildren in the ED.” The fundamentalelements of readiness includedadministration and coordination;physicians, nurses, and other healthcare providers; quality improvement(QI); patient safety; policies,

procedures, and protocols; supportservices; and equipment, supplies,and medications.4,26 This studydemonstrated that although pediatricreadiness had improved in EDs, 80%still reported some barriers toimplementing the recommendationsin the guidelines. Studies examiningpediatric readiness and a pediatricfacility verification program foundthat activities in EDs that achievehigher scores of pediatric readinessare linked to improved outcomessuch as a decreased pediatricmortality rate, timeliness of painmanagement and reduced radiationfor fractures, and improvedsimulation care for pediatricsepsis.4,26–30

Evidence from the National PediatricReadiness Project supports that EDsare more prepared to care forchildren when guidelines are adheredto for the care of children in EDs.26,27

Several of the elements of pediatricreadiness assessed recommendeda pediatric liaison in the EMSenvironment. EMS medicine hasthe potential to see similar benefitsin readiness to care for childrenwith established guidelines forthe care of children in EMSsystems.5,24

The Impact of Population-SpecificOversight Practices on ImprovingCare

Attention to sufficient cognitive andpsychomotor training, providerexperience, and physician oversightaids EMS success. An example ofsuccess for a condition-specificpopulation is advanced airwaymanagement, in which focusedoversight has been shown to improveperformance.31,32 Researchers inRochester, New York, studied theeffect of a redesigned rapid sequenceintubation program that wasconsistent with recommendationspublished by the NAEMSP.33

They were able to demonstratesignificant gains in cognitiveperformance, most notably proper

2 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on March 26, 2020www.aappublications.org/newsDownloaded from

patient selection.33 This serves asan example of the effect thatrecommendations from professionalorganizations can have on increasingEMS agency attention towardspecial populations or conditionsand how adding close physicianoversight can improve providerperformance.

ADMINISTRATION AND COORDINATIONFOR THE CARE OF CHILDREN IN EMSSYSTEMS

Many publications have called for thecoordination and integration ofpatient care throughout EMS systems.In 1993, the NASEMSO and NAEMSPpublished a position statement onphysician oversight, emphasizing thatquality patient care depends ona commitment to the developmentand operation of an integrated andcomprehensive EMS system.34 High-quality leadership is a critical elementin developing such a high-functioningEMS agency or system, especially

with regard to physician oversight ofEMS. In 2017, the NAEMSP providedclear descriptions of the role andduties of the EMS medical director,which were intended to help systemadministrators integrate medicaldirection throughout EMS systems.35

The NAEMSP has published a positionstatement specifically outlining thecritical elements of “PhysicianOversight of Pediatric Care in EMS.”36

In another policy statement thatdiscussed the role of pediatricians inrural communities, the AAP describedhow pediatricians’ expertise can helpclose gaps in pediatric care for EDsand EMS agencies that have limitedresources.37 In the EMS Agenda 2050document, which is a collaborativeeffort to create a plan for the nextseveral decades, there is an emphasison patient-centered care, as follows:“EMS medical oversight for specificpatients and populations includesclose collaboration with thephysicians who make up the patients’medical home,” including input from

various specialists such aspediatricians. Collaboration is anintrinsic component to system-wideEMS care tailored to the individualpatient.38

Pediatric Leadership in EMS

As previously noted, the 2006 IOMreport stated the importance ofhaving a pediatric emergency carecoordinator (PECC) designated at theEMS agency level to facilitatecontinued pediatric emergencyeducation; ensure QI for pediatricpatients; enhance the availability ofpediatric medications, equipment,and supplies; represent the pediatricperspective in the development ofEMS protocols; and participate inpediatric research.25 The 2017NAEMSP position statement on theimportance and oversight of pediatriccare in EMS also discussed how PECCoversight could be incorporated intoexisting roles (eg, an agency’s EMSphysician medical director) orestablished as a new role that is

TABLE 1 Integration of Pediatric Components Into EMS Systems

Medical oversightEnsure pediatric representation in EMS planning, operations, and oversight as outlined in the NAEMSP position statement “Physician Oversight of Pediatric

Care in EMS”Provide direct and indirect medical oversight that integrates pediatric-specific elements into the global EMS system

OperationsInclude pediatric-specific guidance and expertise in the development and improvement of EMS operationsHave pediatric-specific equipment and supplies available and ensure that prehospital providers are competent in their useDevelop processes for evaluating pediatric-specific psychomotor and cognitive competencies of prehospital providersHave policies that ensure the safe transport of children and families in emergency vehiclesCollaborate with outpatient and hospital-based pediatric experts, especially those in EDsFacilitate destination determination of patients by weighing the risks and benefits of transport to a higher level of careCollaborate with local EDs to promote basic pediatric readiness of all facilitiesInclude considerations for care of children and families in emergency preparedness planning and exercises, including family repatriation, in time of disastersProvide situational awareness to caregivers by encouraging providers to designate a person to narrate and preempt actions to the bystander on the scene,

using lay terms to communicate with patients and families, and allowing bystanders to maintain a line of sight with the child as long as they are notinterfering with patient care

EducationEnsure that prehospital providers receive periodic pediatric-specific educationEnsure pediatric assessment and recognition of respiratory distress or failure, cardiac failure, and shockCompetency in neonatal and pediatric resuscitationEnsure updated psychomotor skills and practice in pediatric airway management (focusing on basic airway management) and venous and intraosseous

placement and accessProvide education tools to improve proper pain and wt assessment and pain management

Research, data management, and QIImplement practices to reduce pediatric medication errorsInclude pediatric-specific measures in QI and quality assurance processesSubmit data to a statewide database that is compliant with the most recent version of the NEMSIS and work with local hospitals to track pediatric patient-

centered outcomes across the continuum of care

Adapted from National Association of Emergency Medical Services Physicians. Physician oversight of pediatric care in emergency medical services. Prehosp Emerg Care. 2017;21(1):88 andAyub EM, Sampayo EM, Shah MI, Doughty CB. Prehospital providers’ perceptions on providing patient and family centered care. Prehosp Emerg Care. 2017;21(2):233–241.

PEDIATRICS Volume 145, number 1, January 2020 3 by guest on March 26, 2020www.aappublications.org/newsDownloaded from

collaborative within the EMSleadership team (eg, PECC or EMSsystem pediatric advisorycommittee).36 The PECC could beincorporated into an EMS system asa single provider or team ofproviders. A person and/or team inthis role would be expected tooversee the system-based care ofpediatric patients and would promotethe integration of pediatric elementsinto day-to-day services as well aslocal and/or regional disasterplanning.25,36 The PECC also canserve as a pediatric health care liaisonamong the EMS agency, communitypediatricians, and medical home inaddition to the local health carefacilities. The recommendedqualifications and responsibilities ofan EMS PECC are noted in Table 2,which as previously noted, can beincorporated into an existing rolealready within the EMS agency orestablished as a stand-alonerole.5,25,36 The importance of a PECCwithin EMS agencies was furtherexemplified by the EmergencyMedical Services for Children (EMSC)program adding this supportive roleas a performance measure.39 Analysisof pediatric readiness assessmentdata demonstrated that havinga PECC in an ED increased thelikelihood of a higher readiness scoreoverall and improved pediatric QIprocesses.40 A recent study showedinterest among EMS agencyadministrators in integrating a PECCinto their systems, and in addition,pediatric-specific psychomotor skillstesting was more common in EMSagencies that respond to a higherpediatric call volume and havea PECC. The presence of a PECC canpotentially increase providerconfidence and safety for all pediatricprehospital patients regardless ofvolume and location.41 Regardless ofhow this role is incorporated into thestructure of EMS, it is important thateach agency include pediatric-specificguidance and expertise in thedevelopment and improvement oftheir operations.

Pediatric Emergency CareCoordinator Learning Collaborative

There is currently an initiative tostrategize integrations of PECCswithin EMS agencies, known as thePediatric Emergency CareCoordinator Learning Collaborative.This initiative is being led by theEmergency Medical Services forChildren Innovation andImprovement Center (EIIC). Thepurpose of this project is to forma cohort of EMSC state partnershipgrant recipients to participate ina learning collaborative that willdemonstrate effective and replicablestrategies for local EMS agencies witha PECC. Results from this project willinform and advance efforts within all58 EMSC state partnership recipientsites to increase the adoption ofPECCs within local EMS agencies.42

COMPETENCIES FOR PROVIDERS

Considering the challenges associatedwith low patient volumes, a numberof experts in the field haverecommended mandated skillstesting or ongoing education inpediatric emergency care programssuch as Pediatric Advanced LifeSupport, Pediatric Education forPrehospital Professionals (PEPP),Advanced Pediatric Life Support, andthe Emergency Nursing PediatricCourse.9–19,43–46

EMS Education

EMS agencies have an important rolein integrating pediatric-specificelements into all aspects ofprehospital care, including oversight,education, protocol development, andperformance improvement. Only 10%of the EMS patient volume involvespediatric patients,8 underscoring therecognition that additional methodsof exposure are needed to help EMSproviders maintain clinically relevantcognitive and psychomotorcompetencies. One of thesealternatives includes an annualeducational and skill assessment of

provider competency in the followingdomains:

• pediatric assessment, includingrecognition of respiratory distressor failure, shock, and cardiacfailure43,47–49;

• neonatal and pediatriccardiopulmonaryresuscitation43–46;

• pediatric airway management withan emphasis on basic airwayintervention skills10–14,17;

• pediatric vascular access, includingintravenous access andintraosseous access;

• pain assessment and management,using age-appropriate pain scales;and

• pediatric weight assessment,equipment sizing, and medicationdosing.48–51

Pediatric Clinical Care Within EMS:Pediatric Assessment

Critical illness and injury do notalways manifest in children in thesame way as they do in adults. EMSagencies should ensure that providershave access to tools that can helpthem recognize critically ill or injuredpediatric patients. Structuredpediatric assessment tools, such asthe Pediatric Assessment Triangle(PAT),47–49 which is taught in thePEPP course,44 allow EMS providersto develop a standardized approachto pediatric assessment. Evidence hasshown that the PAT is a proven triagetool for EMS and has becomea foundation for rapid pediatricassessment.46,49–51 Such assessmenttools have been incorporated intomost standardized life supportcourses in the United States,including Pediatric Advanced LifeSupport, Advanced Pediatric LifeSupport, and the Emergency NursingPediatric Course.43–46 The PATincludes an observational assessmentof a child’s respiratory status,circulatory status, and mental statusand, when paired with measurementof a child’s vital signs, can help


a provider rapidly identify a childwith significant illness or injury.47–49

The PEPP course and textbook is anadditional EMS resource for pediatricassessment of abnormal respiratoryand circulatory status and includesevaluating a child’s lung sounds andwork of breathing, noting the oxygenconcentration and route of deliveryrequired to improve oxygenation, andsigns of perfusion such as skin colorand capillary refill time.44 Assessmentof mental status can be achieved by

using the “alert-verbal-pain-unresponsive” (also known as AVPU)scale or the Glasgow Coma Scale.44

Age-related changes in ranges ofnormal pediatric vital signs can addto the challenges EMS providers facein recognition of critically ill orinjured children.15 Initial and ongoingassessment and documentation ofpediatric vital signs includeevaluation of respiratory rate, heartrate, blood pressure, temperature,pulse oximetry, mental status, weight,

and pain.43–49 Current weightassessment tools in EMS includelength-based tape52 and age-basedweight applications standardized inkilograms.45,50–52 Pain assessmentwith age-appropriate tools anddocumentation before and aftermedication administration isconsistent with evidence-basedguidelines and defined EMS Compassquality metrics.53,54 Understandingand recognizing critical departuresfrom normal values can guideproviders in detecting unstable

TABLE 2 Responsibilities of an EMS PECC

Recommended Qualifications Responsibilities

A clinical provider (physician, nurse, physician assistant, or nursepractitioner) with experience in EMS medicine and who works in an ED withactive clinical practice in pediatric emergency medicine or a paramedicwith some experience in pediatric prehospital or pediatric emergencymedicine

Education

Strong interest in and desire to improve pediatric emergency care within theEMS system

To enhance pediatric proficiency for all EMS providers by facilitating both initialand continuing pediatric education for all providers

Experience in emergency medical care of children as demonstrated bytraining, clinical experience, and/or focused continuing education

To verify and promote EMS provider competency in providing pediatricemergency care through periodic training and evaluation of both cognitiveand psychomotor competencies

Maintenance of competency in pediatric emergency care To provide resuscitation skills training that includes concepts related to bothtrauma and medical care for neonates through adolescents

Provider may already be working within the EMS system To promote opportunities for additional pediatric emergency care educationand advancement within the EMS organization including, where available,collaboration with academic institutions

Clinical careTo actively provide pediatric-based input in the development and revision of

EMS protocolsTo assess compliance with pediatric emergency care protocols and policiesTo observe and measure the quality of pediatric emergency careTo equip the EMS agency to care for all children through the availability of

pediatric-sized equipment and supplies, including medications required totreat common conditions in children

To integrate pediatric needs into EMS disaster and emergency preparednessplans

To serve as a liaison between hospitals, the local community, and EMS toestablish local destination determination guidelines that ensure thatpediatric patients are transported to appropriate regional facilities on thebasis of the patient’s clinical needs

Research and QITo oversee pediatric QI, patient safety, injury and illness prevention, and

clinical care initiativesTo identify potential sources of funding for pediatric EMS research at local,

state, or federal levelsTo integrate pediatric-specific quality metrics into the EMS agency that are

either based on the national EMS Compass Initiative or are evidence basedTo establish a mechanism for electronic data collection that captures

pediatric-relevant information in accordance with the most recent versionof the NEMSIS data dictionary

To analyze system efficacy and cost-effectiveness with respect to pediatricpatient outcomes

To identify local pediatric public health and operational issues in need ofscientific evaluation and provide leadership to develop pediatric EMSresearch


children early.15 Processes foridentifying abnormal vital signs andreporting them to receiving facilitiesas part of prearrival notification canenhance patient care and should beincorporated into EMS-based policiesand clinical protocols.

In addition to these vital assessmentfindings, pediatric readiness alsoincludes developing processes toinclude training on the recognition ofchild sex trafficking and interventionsin cases of suspected child physicaland/or sexual abuse and/orneglect.5,55 Such processes should beincorporated into each EMS agency’spediatric-specific policies andprotocols.

QI AND PERFORMANCE IMPROVEMENT

In 2006, the federal EMSC programestablished performance measures toevaluate the status of pediatricemergency care capabilities in eachstate and territory. The performancemeasures included benchmarks forEMS access to direct and indirectpediatric-specific medical oversightand suggested pediatric equipmentguidelines for ground ambulances.This document also recommendedhospital benchmarks to establishstandardized systems for identifyingfacilities that are equipped to stabilizeand manage children with medical ortraumatic emergencies and toestablish interfacility transferguidelines and agreements amonghospitals.39

A 2013 assessment of the EMSCperformance measures revealed thatapproximately 90% of basic lifesupport (BLS) and Advanced LifeSupport (ALS) agencies have directpediatric-specific medical oversight.Indirect medical oversight, providedas written pediatric protocols, wasavailable to 72% of BLS and 94% ofALS EMS agencies. In addition, bothBLS and ALS agencies carried morethan 90% of the nationallyrecommended pediatric equipment.39

After this assessment, the EMSCprogram worked with the NationalEMS for Children Data AnalysisResource Center to develop the nextgeneration of “EMS for Children”performance measures, which wereimplemented for assessment in201739:

• submission of National EmergencyMedical Services InformationSystem (NEMSIS)–compliantversion 3 data,

• pediatric emergency carecoordination at the EMS agencylevel, and

• evaluation of psychomotorcompetencies using pediatricequipment.

PEDIATRIC-SPECIFIC ELEMENTS OF EMSQI

EMS QI involves the continuousmonitoring of EMS systemperformance by using measures toidentify opportunities for improvingpatient care. Such improvements caninclude changes in policies, additionor revision of clinical protocols, andensuring access to appropriateresources and health care facilities.

Pediatric EMS QI includes severalimportant elements, starting with theintegration of pediatric-relevantcontent into prearrival dispatchinstructions. Other components arethe inclusion of pediatric dataelements into prehospital patient carecharts and data-reporting technologyand collaboration with pediatriccontent-matter experts in off-lineprotocol development. Of criticalimportance are the development ofrelationships and a communicationprocess between EMS and hospitalsto facilitate the exchange of QIinformation including patientoutcomes and case reviews and toinclude both EMS and hospitals insystem data analysis.5,56 The EIIC isspearheading a QI collaborative toassist state programs in acceleratingtheir progress in improving thepediatric readiness of EDs through

new interventions. The EIIC hopes todemonstrate how leveraging QIscience and the expertise of multipleprofessional societies and federalorganizations can improve andtransform health care outcomes forchildren in the United States.57

Evaluation of EMS as part of thetrauma QI program is a requirementfor trauma centers by statedesignation, the American College ofSurgeons verification process, orboth. Integration of prehospital careand children’s hospital transportservices in the QI process is also anessential component of the AmericanCollege of Surgeons OptimalResources for Children’s Surgical CareVerification Program.58

Pediatric-specific EMS QI programsshould consider the following clinicalareas for inclusion in both concurrentreporting and peer review withmedical oversight and in a writtenplan that incorporates quality metricsthat use NEMSIS-based dataelements:

• neonatal assessment, resuscitation,and transport;

• respiratory distress and failure,including airway management;

• cardiovascular assessment andmanagement;

• trauma, including burns and headinjury;

• child abuse and neglect;

• pain assessment and management;

• hypoglycemia and hyperglycemiaassessment and management;

• seizure assessment andmanagement;

• environmental exposurehypothermia and hyperthermia;and

• toxicology assessment andmanagement.

In 2014, NASEMSO launched aninitiative known as EMS Compass.This initiative was funded througha cooperative agreement with theNational Highway Traffic Safety


Administration with the focused goalof helping EMS systems (local,regional, and state) measure EMScare delivery and improve the qualityof care at all 3 levels.54 The qualitymetrics proposed by this program arelinked to NEMSIS data variables toallow individual EMS agencies toassess quality and benchmark theircare against other EMS agencies. Aspediatric-relevant quality metrics aredeveloped through EMS Compass, it isimportant to integrate them into localQI processes at the EMS agency level.The first pediatric-specific qualitymetrics focus on pediatric respiratoryassessment, the administration ofb-agonists for asthma, and thedocumentation of weight in kilogramswith the use of various methods andapplications, such as length-basedtape. To ensure sustainability of theinitial work of the EMS Compassinitiative, the Joint NationalEmergency Medical ServicesLeadership Forum is working withthe National Highway Traffic SafetyAdministration to create the NationalEMS Quality Alliance.59

POLICIES, PROCEDURES, ANDPROTOCOLS

Use of prehospital guidelines willassist EMS entities in achievingrecommendations from the IOM that“EMS systems should implementevidence-based approaches to reduceerrors in emergency and trauma carefor children.”25 Integration of theseguidelines into operational practicerequires the involvement of EMSmedical directors and administrators,EMS educators, state health entities,emergency physicians, pediatricians,and nurses who are involved in theprehospital care of children.5,36,56

Pediatric Refusals

Refusal of medical aid is a challengingelement of EMS care for patients ofany age and can be especially difficultwhen the refusal of aid involvespediatric patients. A NAEMSP andACEP joint position statement

recommends that each EMS agencyand system include key elements intheir policies surrounding refusal ofmedical aid and that such policiesspecifically address the issue ofnontransport of minors. It alsorecommends that nontransport occuronly in the presence of online medicaldirection or detailed off-lineprotocols.60 These specific guidelinesare useful tools to help EMS systemsprepare for the special needs of theirpediatric population.

Existing Guidelines for Policies,Procedures, and Protocols

Local or statewide EMS policies,procedures, and protocols lay thefoundation for providing optimal careto ill and injured pediatric patients inthe prehospital setting. Thedevelopment of policies, procedures,and protocols that are evidencebased, when possible, and inclusiveof EMS system stakeholders at thelocal, regional, and state levels willmake EMS care more effective forchildren.

Implementation of procedures thatintegrate QI activities and includeeducation within the system has thepotential to enhance care. Suggestedprehospital pediatric policies,procedures, and protocols couldinclude, but are not limited to, thefollowing:

• appropriate level of care (BLS, ALS,or critical care);

• appropriate mode of transport(ground, rotor wing, or fixed wing);

• pediatric field triage and facilitydestination decision-making;

• refusal of medical aid(nontransport decision-making anddocumentation);

• prehospital determination of deathand withholding of resuscitation;

• physician medical direction;

• dispatch prearrival instructions forchildren and families;

• children with special health careneeds;

• child maltreatment, includingrecognition and criteria andprocesses for mandated reporting;

• evidence-based guidelines forclinical care and, when notavailable, vetted consensus-basedguidelines, such as the NASEMSOModel EMS Clinical Guidelines61;

• development of new guidelinesbased on the pediatric community’shealth care needs by using rigorousmethods for guidelinedevelopment;

• children and disaster managementplanning62–67; and

• key support services.

PATIENT AND MEDICATION SAFETY

Unlike adults, for whom a “one-dose-fits-most” approach can be aneffective method of dosingmedications, dosage of medicationsfor pediatric patients requires anaccurate assessment of a child’sweight to avoid significant over- andunderdosing.45,50–52 Estimation ofchildren’s weight by using a specificpediatric validated tool for weightand documenting the weight inkilograms in the EMS record canenhance safety.45,50–52 Medicationdosages are based on weight inkilograms, and adjuncts, such assmartphone applications that providedecision support for precalculateddoses, can minimize dosingerrors.50–52 Online medical directionfrom a physician with pediatricexpertise can provide importantguidance when EMS personnelhave reached the limit of what isspecified in their agency’s protocols.A method to identify, prevent, andreport medication errors, includinga policy for timely reporting andtracking of adverse events, canenhance safety.68 Including pediatricweight measurement tools, useof weight-based dosing tools,education in the use of those tools,and developing QI projectssurrounding the accuracy ofpediatric-based medication dosing


are necessary components ofpediatric readiness that shouldbe incorporated in the activitiesof each EMS agency.45,50–52,68–70

Patient- and Family-Centered Care inEMS

Policies and/or protocols thatpromote family presence,participation in care, and safetransport of children have beenrecommended by the NAEMT.71

Methods for the identification of thechild receiving treatment andtransport during a disaster thatincludes contact information fora responsible adult can enhance theability of EMS systems and/orhospitals to reunify children withadult caregivers. Planning for thereunification of children and familiesis often an overlooked element ofdisaster planning but is an importantconsideration in disaster responseplans for both EMS and receivingfacilities.67,72

Part of providing patient- and family-centered care also involves usingeffective communication strategiesand technology. In a qualitative studyof EMS providers who participated insimulated resuscitations of pediatricpatients, providers identified severalstrategies to promote patient- andfamily-centered care. These includedproviding emotional support tocaregivers, maintaining a calmdemeanor, empowering familiesto feel involved, designatinga person to narrate and preemptivelydescribe interventions in layterms, summarizing betweeninterventions, allowing a line ofsight between the caregiver andchild, and allowing the bystanderthe opportunity to return iftemporarily removed for interferingwith patient care.72

The diversity of languages thatEMS providers encounter continuesto grow, and methods for accessinglanguage services can enhancethe ability of EMS personnelto communicate with

non–English-speaking patientsand family members. Organizationssuch as the NAEMT haverecommended that EMS agenciesadopt procedures to ensureeffective communication in culturallydiverse communities.71

Policies on advanced directives forwithholding or terminatingprehospital resuscitation efforts inchildren are also an importantconsideration for local protocols andshould be considered as part of anEMS agency’s pediatric readinessactivities. State protocols for thedeclaration of death in the field andtermination of resuscitation varywidely and often differ betweenadults and children. For childhoodvictims of out-of-hospital cardiacarrest attributable to blunttrauma, there is evidence thatchildren and adults have similaroutcomes, although the currentrecommendations for terminationof resuscitation in children aremore conservative, recommendingat least 30 minutes of resuscitationefforts compared with 15 minutesin adults. The recommendationsin children also advocate fora family-centered approachunder guidance from medicalcontrol, especially in remoteareas that are far from ahospital.73–77

Guidance for prehospital providerson how to disclose that a childis dead of any cause, next stepsin the care of the family, andprevention of secondary traumain themselves are all challengesof encountering pediatric death inthe field.75

Pediatric Safe Transport

Safe transport for children has beena significant problem that is nowbeing recognized. Given the uniquefeatures of children, including theirsmaller size and different anatomicproportions, the National HighwayTraffic Safety Administrationpublished guidelines for the safe

transport of children in groundambulances, including specificguidance regarding requirements forpediatric-passenger restraint.78

Previously, there were no federalstandards or protocols for the bestmethod of pediatric transport inambulances. It is estimated that up to1000 ambulance crashes involvepediatric patients per year, withapproximately 4 fatalities occurringper year.79 In addition, in a collisionat 35 mph, an unrestrained 15-kgchild is exposed to the same forces asin falling from a fourth-storywindow.79 The NASEMSO releasedinterim guidance in 2017 on the safetransport of children by EMS, and thisorganization specifically highlightedthe need for further research toestablish a Society of AutomotiveEngineers standard for pediatricrestraint recommendations throughcrash testing of different types ofequipment.80 The interim guidanceemphasized that safe transport forchildren should be consideredstandard of care equivalent toEMS airway, breathing, andcirculation maintenance. Theguidance strongly states thatall EMS agencies should havepediatric safe transport policiesand procedures for evidence-basedand appropriately sized andpositioned child-restraint systems.Children should not be transportedin ambulances unrestrained(eg, held in laps and/or arms).80

Children With Special Health CareNeeds

Children with special health careneeds are defined as “children whohave or are at increased risk fora chronic physical, developmental,behavioral, or emotional conditionand who also require health andrelated services of a type or amountbeyond that required by childrengenerally.”81 Given that the number ofchildren with special health careneeds or dependence on healthtechnologies has been steadilyincreasing, EMS systems have always


faced the need to provide qualityprehospital care to children withspecial needs. A report from Utahfound that these children were morelikely to receive ALS and prehospitalclinical interventions than childrenwho are not technology dependent.82

Up to 78% of ED encounters forchildren with special health careneeds are also more likely to use EMSfor interfacility transport.83

It is important to have access to keyinformation to care for patients,especially those with special needs.Professional organizations such as theACEP and AAP have recommendedthat families maintain an emergencyinformation form (EIF).84 Paper andelectronic versions of the form areavailable from both organizations’Web sites. The development ofelectronic, remotely accessible health-information exchanges available toEMS providers in real time maysomeday reduce the need for papercopies of EIFs. Until then, EMS-applicable patient-specific care plans,EIFs, and off-line guidelines are eachimportant elements of pediatricprehospital readiness programs. Inaddition to key information andmedical history for this population, itis equally important to ensurespecific training for pediatrictechnology such as ventilators,tracheostomies, and gastrostomytubes.84

Health Disparities in PediatricPrehospital Care

Significant health disparities exist inpediatric prehospital care. EMSpersonnel are often the initial contactfor many children who do not haveinsurance or access to emergencycare. EMS serves as a health caresafety net for this population. Ruralareas are a setting in which EMS canact as a primary source of health care.Rural EMS systems face operationaland clinical challenges in meeting theprehospital needs of theircommunities and more specificallythe vulnerable population of children.

These challenges include geographicisolation, lack of qualified physiciansto serve as medical directors,insufficient staffing of EMS providers,substandard road conditions,inadequate landing areas for airtransport, and radio communicationdead zones.85–87

In addition, the health disparity gap iswidened for pediatric minoritypopulations such as AfricanAmerican, American Indian, Alaskannative, and Hispanic children.Children of minority populationsexperience myriad disparities inprehospital care, medical care, accessto health care, and use of health careservices. Some of these healthdisparities include suboptimal healthstatus; higher levels of obesity,asthma, and behavioral problems;lack of mental health services andmedical insurance; transportationbarriers to care; and increasedfrequency of ED visits. Language andcultural differences can lead tobarriers to care in the prehospitalenvironment. African Americanchildren and children in urbanresidences are more likely to arrive atthe ED by EMS.86,87 In a recentlypublished abstract, pediatric patientswith severe asthma who weretransported by regional EMS agencieswere predominantly older, of malesex, and African American.88 Inaddition, in a recent study assessingstatewide EMS management ofpediatric asthma, 49% of the patientswere African American, and there wasa geographic disparity of EMS asthmaencounters involving AfricanAmerican children living in ruralareas.89 American Indian and Alaskannative children are disproportionatelyburdened by injuries and diseasesand often live in rural areasgeographically far fromhospitals.90–92 A study focusing onprehospital care for rural AmericanIndian children concluded that IndianHealth Service EMS agencies do nothave the infrastructure to treatpediatric patients during day-to-day

operations as well as disastersituations. Indian Health Serviceagencies were markedlyoverwhelmed and unable to providepediatric continued medicaleducation.93 Mobile integrated health(MIH) and community paramedicineis a way for EMS systems to providepatient-centered and integratedhealth care with social services,subsequently improving the overallhealth of the community. MIHprograms improve and enhance careby sending EMS personnel topatients’ home to aide in chronicdisease management (eg, asthma)and education, follow-up, andrehabilitation care as well aspreventive care.94 A PECC can serveas a pediatric liaison within an EMSMIH system to provide much neededhealth care to children in minorityand rural populations where theylive. Integration of PECCs within EMSsystems could help to overcomehealth care barriers and obstacles forthese patients and serve as a possiblesolution to help coordinate pediatricemergency care for these particularlyvulnerable populations.

Mental Health and PediatricPrehospital Care

Mental health disorders are one of themost common diseases of childhood.Children with mental health disordersare at increased risk for substanceuse, residing in juvenile detention,and suicide and homicide. Therecontinues to be an increasing numberof children with mental healthdisorders seen in the ED anda decreasing number of availablemental health facilities.95 As a result,there is growing evidence revealingincreased use of EMS services forchildren with mental health disordersto obtain care related to thesedisorders.95 In a study of a statewideEMS system, a large proportion ofpediatric patients with behavior-related disorders within mentalhealth disorders was associatedwith an increase in EMS resourceuse because of limited behavioral


health infrastructure.96 Interventionsare key to training EMS providerson the recognition and managementof pediatric mental healthdisorders.

INTERACTION WITH SYSTEMS OF CARE

Trauma

Trauma accounts for approximately20% of pediatric EMS encounters.97

The care of the pediatric traumapatient in the prehospital settinginvolves rapid assessment ofhemodynamic status; focused andmeasured assessment andmanagement of airway patency,oxygenation, and ventilation;evaluation of pain and provision ofanalgesia; consideration of cervicalspine injury and provision ofappropriate spinal motion restriction;and making appropriate destinationdetermination decisions.98–100

Verification or state designation ofa trauma center does not mean thatthe facility has also achieved a highdegree of overall pediatricreadiness.101 In regions where bothtrauma center and pediatric facilitydesignation programs exist, a traumacenter does not equate to pediatricreadiness, further highlighting thepotential benefits of regionalizingpediatric care.101 Pediatric readinessin EMS systems will therefore need toinclude an assessment of appropriatedestination facilities with respect topediatric-focused protocols,equipment, and training to optimallymanage the pediatric trauma patient.5

Most children’s hospitals that are alsopediatric trauma centers will have therequisite resources for the care of theinjured child, and EMS providers whouse a destination determinationtriage tool such as the one developedby the Centers for Disease Controland Prevention will triage children toa pediatric trauma center if one isavailable.102 Coordination with theregional trauma system as well as anypediatric facility verification program,where it exists, will be critical.102,103

Mass Casualties and Disasters

Few position statements regardingmass casualty events address infantsand children. The NAEMSP hasposition statements on both the roleof EMS in disaster response and massgathering medical care,64,65 withneither document specificallyaddressing children. In a survey ofEMS agencies, only 13% hadpediatric-specific mass casualtyincident plans.66 Severalorganizations have worked or arenow working to develop resources forEMS agencies to incorporate childreninto their disaster preparednessplans, including educationalresources.67–69 These resources canbe leveraged by EMS agencies toprepare for the care of children andfamilies during disasters as part oftheir prehospital pediatric readinessactivities.

EQUIPMENT, SUPPLIES, ANDMEDICATIONS

Even with the best leadership andwell-trained providers, withoutappropriate equipment, optimal carecannot be provided to pediatricpatients in the field. The policystatement “Equipment for GroundAmbulances” addresses this issue andserves as a standard for the minimumequipment and supplies needed forboth ALS and BLS ground ambulancesin the United States.104

CONCLUSIONS

Numerous publications haveindicated the need for improvedintegrated pediatric care within theprehospital setting.4,5,25,26,36 EMSsystems can adopt policies, practices,and procedures that guide providerprehospital pediatric emergency care.Pediatric-specific components thatwill aid in improving care includepediatric-specific education,equipment, QI, data collection andmanagement, and research.Designation of a PECC, EMS provideraccess to pediatric direct and indirectmedical direction, and safe transport

of pediatric patients are particularlyimportant components of a well-integrated pediatric prehospital caresystem.

LEAD AUTHORS

Sylvia Owusu-Ansah, MD, MPH, FAAPBrian Moore, MD, FAAPManish Shah, MD, MS, FAAPToni Gross, MD, MPH, FAAPKathleen Brown, MD, FAAPMarianne Gausche-Hill, MD, FACEP, FAAP,FAEMSKatherine Remick, MD, FACEP, FAAP, FAEMSKathleen Adelgais, MD, MPH, MSPH, FAAPLara Rappaport, MD, PhD, MPH, FAAPSally Snow, RN, BSN, CPEN, FAENCynthia Wright-Johnson, MSN, RNCJulie C. Leonard, MD, MPH, FAAPJohn Lyng, MD, FAEMS, FACEP, NRP(Paramedic)Mary Fallat, MD, FACS, FAAP

AMERICAN ACADEMY OF PEDIATRICSCOMMITTEE ON PEDIATRIC EMERGENCYMEDICINE, 2018–2019

Joseph Wright, MD, MPH, FAAP, ChairpersonJames Callahan, MD, FAAPJavier Gonzalez del Rey, MD, MEd, FAAPToni Gross, MD, MPH, FAAPMadeline Joseph, MD, FAAPNatalie Lane, MD, FAAPLois Lee, MD, MPH, FAAPElizabeth Mack, MD, MS, FAAPJennifer Marin, MD, MSc, FAAPSuzan Mazor, MD, FAAPNathan Timm, MD, FAAP

LIAISONS

Andrew Eisenberg, MD, MHA – AmericanAcademy of Family PhysiciansCynthia Wright-Johnson, MSN, RNC –National Association of State EMS OfficialsCynthiana Lightfoot, BFA, NRP – AmericanAcademy of Pediatrics Family PartnershipsNetworkCharles Macias, MD, MPH, FAAP – EmergencyMedical Services for Children Innovation andImprovement CenterBrian Moore, MD, MPH, FAAP – NationalAssociation of EMS PhysiciansDiane Pilkey, RN, MPH – Maternal and ChildHealth BureauKatherine Remick, MD, FACEP, FAAP, FAEMS– National Association of Emergency MedicalTechniciansMohsen Saidinejad, MD, MBA, FAAP, FACEP –American College of Emergency PhysiciansSally Snow, RN, BSN, CPEN, FAEN –Emergency Nurses AssociationMary Fallat, MD, FAAP – American College ofSurgeons


FORMER AMERICAN ACADEMY OFPEDIATRICS COMMITTEE ON PEDIATRICEMERGENCY MEDICINE MEMBERS,2016–2018

Terry Adirim, MD, MPH, FAAPMichael S.D. Agus, MD, FAAPThomas Chun, MD, MPH, FAAPGregory Conners, MD, MPH, MBA, FAAPEdward Conway Jr, MD, MS, FAAPNanette Dudley, MD, FAAPNatalie Lane, MD, FAAPCharles Macias, MD, MPH, FAAPPrashant Mahajan, MD, MPH, MBA, FAAPBrian Moore, MD, FAAPJoan Shook, MD, MBA, FAAP, Chair(2012–2016)

STAFF

Sue Tellez

ABBREVIATIONS

AAP: American Academy ofPediatrics

ACEP: American College ofEmergency Physicians

ALS: Advanced Life SupportBLS: basic life supportED: emergency departmentEIF: emergency information formEIIC: Emergency Medical Services

for Children Innovation andImprovement Center

EMS: emergency medical servicesEMSC: Emergency Medical

Services for ChildrenIOM: Institute of MedicineMIH: mobile integrated health

NAEMSP: National Association ofEMS Physicians

NAEMT: National Association ofEmergency MedicalTechnicians

NASEMSO: National Association ofState EMS Officials

NEMSIS: National EmergencyMedical ServicesInformation System

PAT: Pediatric AssessmentTriangle

PECC: pediatric emergency carecoordinator

PEPP: Pediatric Education forPrehospital Professionals

QI: quality improvement

Technical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However,

technical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they

represent.

Dr Owusu-Ansah served as the lead author of the draft statement; Drs Moore and Shah collaborated on the draft statement; Drs Gross, Brown, Gausche-Hill, Remick,

Adelgais, Rappaport, Leonard, Lyng, and Fallat, Ms Snow, and Ms Wright-Johnson provided input; members of the Committee on Pediatric Emergency Medicine,

Section on Emergency Medicine Emergency Medical Services Subcommittee, and Section on Surgery provided guidance on content and key edits; and all authors

reviewed and approved the final manuscript as submitted.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual

circumstances, may be appropriate.

All technical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before

that time.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements

with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of

Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

DOI: https://doi.org/10.1542/peds.2019-3308

Address correspondence to Sylvia Owusu-Ansah, MD, MPH, FAAP. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2020 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: Dr Shah has disclosed the following: Health Resources and Services Administration, EMSC Program. Relationship: Pediatric Prehospital

Readiness Steering Committee member. Amount: $2000 per year maximum for travel reimbursement only. All other authors indicated they have no financial

relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds2019-3307.

REFERENCES

1. Moore L. Measuring quality andeffectiveness of prehospital EMS.Prehosp Emerg Care. 1999;3(4):325–331

2. National Highway Traffic and SafetyAdministration Office of EMS. What isEMS? Available at: https://www.ems.gov/whatisems.html. Accessed May 14, 2019

3. Medical Dictionary. Out-of-hospital.Available at: https://medical-dictionary.thefreedictionary.com/out-of-hospital.August 29, 2018


https://doi.org/10.1542/peds.2019-3308

https://www.ems.gov/whatisems.html

https://www.ems.gov/whatisems.html

https://medical-dictionary.thefreedictionary.com/out-of-hospital

https://medical-dictionary.thefreedictionary.com/out-of-hospital

4. American Academy of Pediatrics,Committee on Pediatric EmergencyMedicine and Section on Surgery;American College of EmergencyPhysicians, Pediatric EmergencyMedicine Committee; EmergencyNurses Association, PediatricEmergency Medicine Committee. Jointpolicy statement guidelines for careof children in the emergencydepartment. Pediatrics. 2009;124(4):1233–1243. Reaffirmed February 2016

5. Remick K, Gausche-Hill M, Joseph MM,Brown K, Snow SK, Wright JL;American Academy of PediatricsCommittee on Pediatric EmergencyMedicine and Section on Surgery;American College of EmergencyPhysicians Pediatric EmergencyMedicine Committee; EmergencyNurses Association PediatricCommittee. Pediatric readiness in theemergency department [publishedcorrection appears in Pediatrics.143(3):e20183894]. Pediatrics. 2018;142(5):e20182459

6. American Academy of Pediatrics,Committee on Pediatric EmergencyMedicine; American College ofEmergency Physicians, EmergencyMedical Services Committee;Emergency Nurses Association,Pediatric Committee; NationalAssociation of Emergency MedicalServices Physicians, Standards andClinical Practice Committee; NationalAssociation of Emergency MedicalTechnicians, Emergency Pediatric CareCommittee. Policy statement: pediatricreadiness in emergency medicalservices systems. Pediatrics. 2019;145(1):e20193307

7. National Highway Traffic SafetyAdministration. Federal InteragencyCommittee on Emergency MedicalServices. 2011 National EMSAssessment. Publication No. DOT HS811 723. Washington, DC: USDepartment of Transportation,National Highway Traffic SafetyAdministration; 2012. Available at:https://www.nhtsa.gov/staticfiles/nti/ems/pdf/811723.pdf. Accessed May 14,2019

8. Seidel JS, Hornbein M, Yoshiyama K,Kuznets D, Finklestein JZ, St Geme JWJr.. Emergency medical services andthe pediatric patient: are the needs

being met? Pediatrics. 1984;73(6):769–772

9. Hill MG, Fuchs S, Sirbaugh P.Prehospital emergencies. PediatrEmerg Care. 2004;20(2):135–140

10. Garza AG, Algren DA, Gratton MC, Ma OJ.Populations at risk for intubationnonattempt and failure in theprehospital setting. Prehosp EmergCare. 2005;9(2):163–166

11. Gausche M, Lewis RJ, Stratton SJ, et al.Effect of out-of-hospital pediatricendotracheal intubation on survival andneurological outcome: a controlledclinical trial. JAMA. 2000;283(6):783–790

12. Hubble MW, Brown L, Wilfong DA,Hertelendy A, Benner RW, Richards ME.A meta-analysis of prehospital airwaycontrol techniques part I: orotrachealand nasotracheal intubation successrates. Prehosp Emerg Care. 2010;14(3):377–401

13. Youngquist ST, Henderson DP, Gausche-Hill M, Goodrich SM, Poore PD, Lewis RJ.Paramedic self-efficacy and skillretention in pediatric airwaymanagement. Acad Emerg Med. 2008;15(12):1295–1303

14. Kovacs G, Bullock G, Ackroyd-Stolarz S,Cain E, Petrie D. A randomizedcontrolled trial on the effect ofeducational interventions in promotingairway management skill maintenance.Ann Emerg Med. 2000;36(4):301–309

15. Su E, Mann NC, McCall M, Hedges JR.Use of resuscitation skills byparamedics caring for critically injuredchildren in Oregon. Prehosp EmergCare. 1997;1(3):123–127

16. Su E, Schmidt TA, Mann NC, Zechnich AD.A randomized controlled trial to assessdecay in acquired knowledge amongparamedics completing a pediatricresuscitation course. Acad Emerg Med.2000;7(7):779–786

17. Henderson DP, Gausche-Hill M, GoodrichSM, Poore PD, Michael WB, Lewis RJ.Education of paramedics in pediatricairway management: effects of differentretraining methods on self-efficacy andskill retention. Acad Emerg Med. 1998;5(5):429

18. Gausche-Hill M, Henderson DP,Brownstein D, Foltin G. The educationof out-of-hospital medical personnelin pediatrics: report of a national

task force. Ann Emerg Med. 1998;31(1):58–63

19. Baker TW, King W, Soto W, Asher C, StolfiA, Rowin ME. The efficacy of pediatricadvanced life support training inemergency medical service providers.Pediatr Emerg Care. 2009;25(8):508–512

20. Gausche-Hill M, Schmitz C, Lewis RJ.Pediatric preparedness of USemergency departments: a 2003 survey.Pediatrics. 2007;120(6):1229–1237

21. Gausche-Hill M. Integrating childreninto our emergency care system:achieving the vision. Ann Emerg Med.2006;48(2):131–134

22. Hansen M, Meckler G, Dickinson C, et al.Children’s safety initiative: a nationalassessment of pediatric educationalneeds among emergency medicalservices providers. Prehosp EmergCare. 2015;19(2):287–291

23. Institute of Medicine, Committee on theFuture of Emergency Care in the USHealth System. Hospital BasedEmergency Care at the Breaking Point.Washington, DC: National AcademiesPress; 2006

24. Institute of Medicine, Committee on theFuture of Emergency Care in the USHealth System. Emergency MedicalServices at the Crossroads.Washington, DC: National AcademiesPress; 2006

25. Institute of Medicine, Committee on theFuture of Emergency Care in the USHealth System. Emergency Care forChildren: Growing Pains. Washington,DC: National Academies Press; 2007

26. Gausche-Hill M, Ely M, Schmuhl P, et al.A national assessment of pediatricreadiness of emergency departments.JAMA Pediatr. 2015;169(6):527–534

27. Remick K, Kaji AH, Olson L, et al.Pediatric readiness and facilityverification. Ann Emerg Med. 2016;67(3):320–328.e1

28. Ball JW, Sanddal ND, Mann NC, et al.Emergency department recognitionprogram for pediatric services: does itmake a difference? Pediatr Emerg Care.2014;30(9):608–612

29. Kessler DO, Walsh B, Whitfill T, et al;INSPIRE ImPACTS Investigators.Disparities in adherence to pediatricsepsis guidelines across a spectrum of


https://www.nhtsa.gov/staticfiles/nti/ems/pdf/811723.pdf

https://www.nhtsa.gov/staticfiles/nti/ems/pdf/811723.pdf

emergency departments: a multicenter,cross-sectional observational in situsimulation study. J Emerg Med. 2016;50(3):403–415–e3

30. Rice A, Dudek J, Gross T, St Mars T,Woolridge D. The impact of a pediatricemergency department facilityverification system on pediatricmortality rates in Arizona. J EmergMed. 2017;52(6):894–901

31. Wang HE, Davis DP, O’Connor RE,Domeier RM. Drug-assisted intubationin the prehospital setting (resourcedocument to NAEMSP positionstatement). Prehosp Emerg Care. 2006;10(2):261–271

32. National Association of EMS Physicians.Drug-assisted intubation in theprehospital setting position statementof the National Association ofEmergency Physicians. Prehosp EmergCare. 2006;10(2):260

33. Cushman JT, Zachary Hettinger A,Farney A, Shah MN. Effect of intensivephysician oversight on a prehospitalrapid-sequence intubation program.Prehosp Emerg Care. 2010;14(3):310–316

34. National Association of State EMSDirectors and National Association ofEMS Physicians. Joint positionstatement on emergency medicalservices and emergency medicalservices systems. National Associationof State EMS Directors and NationalAssociation of EMS Physicians. PrehospDisaster Med. 1993;8(4):285, 288–289

35. National Association of EmergencyMedical Services Physicians. Physicianoversight of emergency medicalservices. Prehosp Emerg Care. 2017;21(2):281–282

36. National Association of EmergencyMedical Services Physicians. Physicianoversight of pediatric care inemergency medical services. PrehospEmerg Care. 2017;21(1):88

37. Moore B, Sapien R; American Academyof Pediatrics, Committee on PediatricEmergency Medicine. Policy statement:the role of the pediatrician in ruralemergency medical services forchildren. Pediatrics. 2012;130(5):978–982. Reaffirmed September 2015

38. EMS Agenda. 2050, Technical ExpertPanel. EMS Agenda 2050: A People-

Centered Vision for the Future ofEmergency Medical Services Report No.DOT HS 812 664. Washington, DC:National Highway Traffic SafetyAdministration; 2019. Available at:https://www.ems.gov/pdf/EMS-Agenda-2050.pdf. Accessed May 14, 2019

39. Morrison-Quinata T, Edgerton EA.National EMS for Children Data AnalysisResource Center. EMSC performancemeasures: implementation manual forstate partnership grantees. EMSCNatural Resource Center. 2017.Available at: www.nedarc.org/performanceMeasures/documents/EMS%20Perf%20Measures%20Manual%20Web_0217.pdf. Accessed May 14, 2019

40. National EMS for Children Data AnalysisResource Center. National pediatricreadiness project. Available at: https://www.pedsready.org/. Accessed May 14,2019

41. Hewes H, Ely M, Richards R, et al. Readyfor children: assessing pediatric carecoordination and psychomotor skillsevaluation in the prehospital setting.Prehosp Emerg Care. 2019;23(4):510–518

42. US Department of Health and HumanServices. Health resources and servicesadministration and maternal and childhealth services. Pediatric EmergencyCare Coordinator (PECC) learningcollaborative demonstration project.Available at: https://mchb.hrsa.gov/fundingopportunities/?id=e9870d04-acb5-4d5b-a85d-bdfd26d85132.Accessed May 14, 2019

43. de Caen AR, Berg MD, Chameides L,et al. Part 12: pediatric advanced lifesupport: 2015 American heartassociation guidelines update forcardiopulmonary resuscitation andemergency cardiovascular care.Circulation. 2015;132(18, suppl 2):S526–S542

44. American Academy of Pediatrics. In:Gausche-Hill M, Brownstein D,Dieckmann R, eds., et al PediatricEducation for PrehospitalProfessionals, 3rd ed. Sudbury, MA:Jones and Bartlett Learning LLC; 2016

45. American Academy of Pediatrics,American College of EmergencyPhysicians. Advanced Pediatric LifeSupport (APLS): The PediatricEmergency Medicine Resource Book,

5th ed. Sudbury, MA: Jones and BartlettLearning LLC; 2011

46. Emergency Nursing Association.Emergency Nursing Pediatric CourseBook, 4th ed. Schaumburg, IL:Emergency Nurses Association; 2012

47. Fuchs S, Terry M, Adelgais K, et al.Definitions and assessment approachesfor emergency medical services forchildren. Pediatrics. 2016;138(6):e20161073

48. Dieckmann RA, Brownstein D, Gausche-Hill M. The pediatric assessmenttriangle: a novel approach for the rapidevaluation of children. Pediatr EmergCare. 2010;26(4):312–315

49. Gausche-Hill M, Eckstein M, Horeczko T,et al. Paramedics accurately apply thePediatric Assessment Triangle to drivemanagement. Prehosp Emerg Care.2014;18(4):520–530

50. Heyming T, Bosson N, Kurobe A, Kaji AH,Gausche-Hill M. Accuracy of paramedicBroselow tape use in the prehospitalsetting. Prehosp Emerg Care. 2012;16(3):374–380

51. Graves L, Chayen G, Peat J, O’Leary F. Acomparison of actual to estimatedweights in Australian childrenattending a tertiary children’s’ hospital,using the original and updated APLS,Luscombe and Owens, Best Guessformulae and the Broselow tape.Resuscitation. 2014;85(3):392–396

52. Young KD, Korotzer NC. Weightestimation methods in children:a systematic review. Ann Emerg Med.2016;68(4):441–451.e10

53. Gausche-Hill M, Brown KM, Oliver ZJ,et al. An Evidence-based Guideline forprehospital analgesia in trauma.Prehosp Emerg Care. 2014;18(suppl 1):25–34

54. National Association of State EMSOfficials. EMS compass-improvingsystems of care through meaningfulmeasures. Available at: http://www.nemsqa.org/completed-quality-measures/. Accessed November 22,2019

55. Greenbaum J, Bodrick N; Committee onChild Abuse and Neglect; Section onInternational Child Health. Globalhuman trafficking and childvictimization. Pediatrics. 2017;140(6):e20173138


https://www.ems.gov/pdf/EMS-Agenda-2050.pdf

https://www.ems.gov/pdf/EMS-Agenda-2050.pdf

http://www.nedarc.org/performanceMeasures/documents/EMS%20Perf%20Measures%20Manual%20Web_0217.pdf




https://www.pedsready.org/

https://www.pedsready.org/

https://mchb.hrsa.gov/FUndingopportunities/?id=e9870d04-acb5-4d5b-a85d-bdfd26d85132



http://www.nemsqa.org/completed-quality-measures/



56. American Academy of Pediatrics,Committee on Pediatric EmergencyMedicine and American College ofEmergency Physicians, and PediatricCommittee. Care of children in theemergency department: guidelines forpreparedness. Pediatrics. 2001;107(4):777–781

57. EMSC Improvement and InnovationCenter. Pediatric readiness qualitycollaborative. Available at: https://emscimprovement.center/collaboratives/PRQuality-collaborative/.Accessed May 14, 2019

58. American College of Surgeons,Committee on Trauma. Resources foroptimal care of the injured patient.2014. Available at: https://www.facs.org/-/media/files/quality-programs/trauma/vrc-resources/resources-for-optimal-care.ashx. Accessed November22, 2019

59. National EMS Quality Alliance. NationalEMS Quality Alliance. Available at: http://www.nemsqa.org/about/. AccessedNovember 22, 2019

60. American College of EmergencyPhysicians. Clinical practice andmanagement joint position statement:refusal of medical aid. Available at:https://naemsp.org/resources/position-statements/joint-position-documents/.Accessed November 22, 2019

61. National Association of EMS StateOfficials. National Model EMS clinicalguidelines. Version 2.2, January 2019.Available at: https://nasemso.org/wp-content/uploads/National-Model-EMS-Clinical-Guidelines-2017-PDF-Version-2.2.pdf. Accessed November 22, 2019

62. National Association Of Ems Physicians.Role of emergency medical services indisaster response. Prehosp EmergCare. 2010;14(4):543

63. Schwartz B, Nafziger S, Milsten A, Luk J,Yancey A II. Mass gathering medicalcare: resource document for theNational Association of EMS PhysiciansPosition Statement. Prehosp EmergCare. 2015;19(4):559–568

64. Shirm S, Liggin R, Dick R, Graham J.Prehospital preparedness for pediatricmass-casualty events. Pediatrics. 2007;120(4). Available at: www.pediatrics.org/cgi/content/full/120/4/e756

65. US Department of Health and HumanServices, Federal EmergencyManagement Agency. Ready Kids.Available at: https://www.fema.gov/children-and-disasters. Accessed May14, 2019

66. US Department of Health and HumanServices. Children in disasters andemergencies: health information guide.Available at: https://disasterinfo.nlm.nih.gov/dimrc/children.html. AccessedMay 14, 2019

67. Chung S, Shannon M. Reuniting childrenwith their families during disasters:a proposed plan for greater success.Am J Disaster Med. 2007;2(3):113–117

68. Krug SE, Frush K; Committee onPediatric Emergency Medicine,American Academy of Pediatrics.Patient safety in the pediatricemergency care setting. Pediatrics.2007;120(6):1367–1375

69. Hoyle JD Jr., Sleight D, Henry R, ChasseeT, Fales B, Mavis B. Pediatric prehospitalmedication dosing errors: a mixed-methods study. Prehosp Emerg Care.2016;20(1):117–124

70. Kaji AH, Gausche-Hill M, Conrad H, et al.Emergency medical services systemchanges reduce pediatric epinephrinedosing errors in the prehospitalsetting. Pediatrics. 2006;118(4):1493–1500

71. National Association of EmergencyMedicine Technicians. Emergencypediatric care. Available at: https://www.naemt.org/education/epc.Accessed May 14, 2019

72. Ayub EM, Sampayo EM, Shah MI,Doughty CB. Prehospital providers’perceptions on providing patient andfamily centered care. Prehosp EmergCare. 2017;21(2):233–241

73. Fallat ME; American College ofSurgeons Committee on Trauma;American College of EmergencyPhysicians Pediatric EmergencyMedicine Committee; NationalAssociation of EMS Physicians;American Academy of PediatricsCommittee on Pediatric EmergencyMedicine. Withholding or termination ofresuscitation in pediatric out-of-hospital traumatic cardiopulmonaryarrest. Pediatrics. 2014;133(4). Availableat: www.pediatrics.org/cgi/content/full/133/4/e1104

74. Jordan KA, Fallat ME. Prehospitalresuscitation decisions in cases oftraumatic cardiopulmonary arrest:assessing the risk of legal liability &the impact of TOR guidelines. J Leg Med.2015;36(2):159–213

75. Hopson LR, Hirsh E, Delgado J, DomeierRM, McSwain NE, Krohmer J. Guidelinesfor withholding or termination ofresuscitation in prehospital traumaticcardiopulmonary arrest: joint positionstatement of the National Association ofEMS Physicians and the AmericanCollege of Surgeons Committee onTrauma. J Am Coll Surg. 2003;196(1):106–112

76. Barbee AP, Fallat ME, Forest R, McClureME, Henry K, Cunningham MR. EMSperspectives on coping with child deathin an out of hospital setting. J LossTrauma. 2016;21(6):455–470

77. Fallat ME, Barbee AP, Forest R, McClureME, Henry K, Cunningham MR. Familycentered practice during pediatricdeath in an out of hospital setting.Prehosp Emerg Care. 2016;20(6):798–807

78. National Traffic Highway SafetyAdministration, Office of EMS. Workinggroup best-practice recommendationsfor the safe transportation of childrenin emergency ground ambulances.2012. Available at: www.ems.gov/pdf/811677.pdf. Accessed May 14, 2019

79. Pediatric Safety Net. Finally – a steptowards safe transport for kids inambulances. Available at: https://www.pediatricsafety.net/2012/09/finally-safe-transport-for-kids-in-ambulances-thanks-nhtsa/. Accessed May 14, 2019

80. National Association of State EMSOfficials. Safe transport of children byEMS: interim guidance. 2017. Availableat: https://nasemso.org/wp-content/uploads/Safe-Transport-of-Children-by-EMS-InterimGuidance-08Mar2017-FINAL.pdf. Accessed November 22, 2019

81. McPherson M, Arango P, Fox H, et al. Anew definition of children with specialhealth care needs. Pediatrics. 1998;102(1, pt 1):137–140

82. Suruda A, Vernon DD, Diller E, Dean JM.Usage of emergency medical servicesby children with special health careneeds. Prehosp Emerg Care. 2000;4(2):131–135


https://emscimprovement.center/collaboratives/PRQuality-collaborative/



https://www.facs.org/-/media/files/quality-programs/trauma/vrc-resources/resources-for-optimal-care.ashx




http://www.nemsqa.org/about/

http://www.nemsqa.org/about/

https://naemsp.org/resources/position-statements/joint-position-documents/

https://naemsp.org/resources/position-statements/joint-position-documents/

https://nasemso.org/wp-content/uploads/National-Model-EMS-Clinical-Guidelines-2017-PDF-Version-2.2.pdf




http://www.pediatrics.org/cgi/content/FUll/120/4/e756


https://www.fema.gov/children-and-disasters

https://www.fema.gov/children-and-disasters

https://disasterinfo.nlm.nih.gov/dimrc/children.html

https://disasterinfo.nlm.nih.gov/dimrc/children.html

https://www.naemt.org/education/epc

https://www.naemt.org/education/epc



http://www.ems.gov/pdf/811677.pdf

http://www.ems.gov/pdf/811677.pdf

https://www.pediatricsafety.net/2012/09/finally-safe-transport-for-kids-in-ambulances-thanks-nhtsa/




https://nasemso.org/wp-content/uploads/Safe-Transport-of-Children-by-EMS-InterimGuidance-08Mar2017-FINAL.pdf




83. Lerner CF, Kelly RB, Hamilton LJ, KlitznerTS. Medical transport of children withcomplex chronic conditions. Emerg MedInt. 2012;2012:837020

84. American Academy of Pediatrics;Committee on Pediatric EmergencyMedicine and Council on ClinicalInformation Technology; AmericanCollege of Emergency Physicians;Pediatric Emergency MedicineCommittee. Policystatement–emergency informationforms and emergency preparednessfor children with special health careneeds. Pediatrics. 2010;125(4):829–837.Reaffirmed October 2014

85. Freeman VA, Patterson D, Slifkin RT.Issues in Staffing Emergency MedicalServices: Results from a NationalSurvey of Local Rural and Urban EMSDirectors. Report No. 93. Chapel Hill, NC:University of North Carolina at ChapelHill, US Department of Health andHuman Services; 2008

86. Flores G, Tomany-Korman SC. Racial andethnic disparities in medical and dentalhealth, access to care, and use ofservices in US children. Pediatrics.2008;121(2). Available at: www.pediatrics.org/cgi/content/full/121/2/e286

87. Shah MN, Cushman JT, Davis CO,Bazarian JJ, Auinger P, Friedman B. Theepidemiology of emergency medicalservices use by children: an analysis ofthe National Hospital AmbulatoryMedical Care Survey. Prehosp EmergCare. 2008;12(3):269–276

88. Owusu-Ansah S, Ramgopal S, Martin-GillC. Prehospital management of pediatricasthma patients. Abstracts for the 2019NAEMSP Scientific Assembly. PrehospEmerg Care. 2019;23(1):133

89. Fishe JN, Palmer E, Finlay E, et al. Astatewide study of the epidemiology ofemergency medical services’management of pediatric asthma[published online ahead of print

February 14, 2019]. Pediatr Emerg Care.doi:10.1097/PEC.000000000000174

90. Mark D. Community-associated MRSA:disparities and implications for AI/ANcommunities. IHS Prim Care Provid.2007;32(12):1–88

91. Indian Health Service. Chapter 17 -emergency medical services. Availableat: https://www.ihs.gov/ihm/pc/part-3/p3c17/. Accessed November 22, 2019

92. McGinnis K. Rural and Frontier.Emergency Medical Services. Agendafor the Future. Kansas City, MO: NationalRural Health Association; 2004

93. Genovesi AL, Hastings B, Edgerton EA,Olson LM. Pediatric emergency carecapabilities of Indian Health Serviceemergency medical service agenciesserving American Indians/AlaskaNatives in rural and frontier areas.Rural Remote Health. 2014;14(2):2688

94. Goodwin J, Zavadsky M, Hagen T, et al.Mobile integrated healthcare andcommunity paramedicine. NationalAssociation of Emergency MedicalTechnicians. Available at: https://www.naemt.org/docs/default-source/community-paramedicine/naemt-mih-cp-report.pdf?sfvrsn=df32c792_4.Accessed May 14, 2019

95. Perou R, Bitsko RH, Blumberg SJ, et al;Centers for Disease Control andPrevention (CDC). Mental healthsurveillance among children–UnitedStates, 2005-2011. MMWR Suppl. 2013;62(2):1–35

96. Fishe JN, Lynch S. Pediatric behavioralhealth-related EMS Encounters:a statewide analysis. Prehosp EmergCare. 2019;23(5):654–662

97. Committee on Pediatric EmergencyMedicine, Council on Injury; Violence,And Poison Prevention, Section onCritical Care, Section on Orthopaedics,Section on Surgery, Section onTransport Medicine, Pediatric TraumaSociety, and Society of Trauma Nurses

Pediatric Committee. Management ofpediatric trauma. Pediatrics. 2016;138(2):e20161569

98. Nance ML, Carr BG, Branas CC. Accessto pediatric trauma care in the UnitedStates. Arch Pediatr Adolesc Med. 2009;163(6):512–518

99. MacKenzie EJ, Rivara FP, Jurkovich GJ,et al. A national evaluation of the effectof trauma-center care on mortality.N Engl J Med. 2006;354(4):366–378

100. Fischer PE, Perina DG, Delbridge TR,et al. Spinal motion restriction in thetrauma patient – a joint positionstatement. Prehosp Emerg Care. 2018;22(6):659–661

101. Walther AE, Falcone RA, Pritts TA,Hanseman DJ, Robinson BR. Pediatricand adult trauma centers differin evaluation, treatment, andoutcomes for severely injuredadolescents. J Pediatr Surg. 2016;51(8):1346–1350

102. Centers for Disease Control andPrevention. Guidelines for field triage ofinjured patients: Recommendations ofthe national expert panel on fieldtriage, 2011. MMWR Morb Mortal WklyRep. 2012;61(1):1–21

103. Lerner EB, Cushman JT, Drendel AL,et al. Effect of the 2011 revisions to thefield triage guidelines on under- andover-triage rates for pediatric traumapatients. Prehosp Emerg Care. 2017;21(4):456–460

104. American Academy of Pediatrics;American College of EmergencyPhysicians; American College ofSurgeons Committee on Trauma;Emergency Medical Services forChildren; Emergency NursesAssociation; National Association ofEMS Physicians; National Association ofState EMS Officials. Equipment forground ambulances. Prehosp EmergCare. 2014;18(1):92–97





https://www.ihs.gov/ihm/pc/part-3/p3c17/

https://www.ihs.gov/ihm/pc/part-3/p3c17/

https://www.naemt.org/docs/default-source/community-paramedicine/naemt-mih-cp-report.pdf?sfvrsn=df32c792_4




originally published online December 19, 2019; Pediatrics SURGERY

EMERGENCY MEDICINE and EMS SUBCOMMITTEE, SECTION ON COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE, SECTION ON

Snow, Cynthia Wright-Johnson, Julie C. Leonard, John Lyng, Mary Fallat, SallyMarianne Gausche-Hill, Katherine Remick, Kathleen Adelgais, Lara Rappaport,

Sylvia Owusu-Ansah, Brian Moore, Manish I. Shah, Toni Gross, Kathleen Brown,Pediatric Readiness in Emergency Medical Services Systems

ServicesUpdated Information &

019-3308http://pediatrics.aappublications.org/content/early/2019/12/17/peds.2including high resolution figures, can be found at:

References

019-3308#BIBLhttp://pediatrics.aappublications.org/content/early/2019/12/17/peds.2This article cites 72 articles, 14 of which you can access for free at:

Subspecialty Collections

subhttp://www.aappublications.org/cgi/collection/emergency_medicine_Emergency Medicinefollowing collection(s): This article, along with others on similar topics, appears in the

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtmlin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or

Reprintshttp://www.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:

by guest on March 26, 2020www.aappublications.org/newsDownloaded from

http://http://pediatrics.aappublications.org/content/early/2019/12/17/peds.2019-3308

http://http://pediatrics.aappublications.org/content/early/2019/12/17/peds.2019-3308

http://pediatrics.aappublications.org/content/early/2019/12/17/peds.2019-3308#BIBL

http://pediatrics.aappublications.org/content/early/2019/12/17/peds.2019-3308#BIBL

http://www.aappublications.org/cgi/collection/emergency_medicine_sub

http://www.aappublications.org/cgi/collection/emergency_medicine_sub

http://www.aappublications.org/site/misc/Permissions.xhtml

http://www.aappublications.org/site/misc/reprints.xhtml

originally published online December 19, 2019; Pediatrics SURGERY

EMERGENCY MEDICINE and EMS SUBCOMMITTEE, SECTION ON COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE, SECTION ON

Snow, Cynthia Wright-Johnson, Julie C. Leonard, John Lyng, Mary Fallat, SallyMarianne Gausche-Hill, Katherine Remick, Kathleen Adelgais, Lara Rappaport,

Sylvia Owusu-Ansah, Brian Moore, Manish I. Shah, Toni Gross, Kathleen Brown,Pediatric Readiness in Emergency Medical Services Systems

http://pediatrics.aappublications.org/content/early/2019/12/17/peds.2019-3308located on the World Wide Web at:

The online version of this article, along with updated information and services, is

ISSN: 1073-0397. 60007. Copyright © 2019 by the American Academy of Pediatrics. All rights reserved. Print the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

by guest on March 26, 2020www.aappublications.org/newsDownloaded from

http://pediatrics.aappublications.org/content/early/2019/12/17/peds.2019-3308

pediatric readiness in emergency medical services systems · mary fallat, md, facs, faap,q...

Documents