taking care of the injured child the role of emsc · resuscitation of children (hall et al., 2004)....
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Taking Care of the Injured Child
The Role of EMSC
Elizabeth A. Edgerton, MD, MPH, FAAP
Branch Chief for EMSC and Injury Prevention
Department of Health and Human Services
Health Resources and Services Administration
The goal of prehospital care is to minimize
further systemic insult or injury and
manage life-threatening conditions through
a series of well defined and
appropriate interventions, and to
embrace principles that ensure patient
safety.
Considerations
• On average, 10% of EMS runs involve children and
adolescents
• According to a survey published in the December
2010 issue of Pediatrics:
• Only 11 % of ED visits by children occur in hospitals
specifically designed to treat children. The rest end up in
general EDs
• Only 6 % of EDs in the United States have all the
equipment needed to treat children
• Studies indicate pre-hospital providers are less comfortable caring for children, particularly infants, than for adults. • Paramedics report being very comfortable about terminating
CPR on adults, ... but very uncomfortable terminating resuscitation of children (Hall et al., 2004).
• A job satisfaction study of paramedics found that they view pediatric calls as among the most stressful • because of the low volume of such cases they typically
encounter (Federiuk et al., 1993).
• There are few well designed clinical trials of interventions performed in the pre-hospital setting. • Even worse for children where only 1 randomized controlled
trial—the gold standard for research-- has ever been conducted.
Considerations
Pediatric Recognition System
Pediatric Critical Care Center (PCCC)
Emergency Department
Approved for Pediatrics (EDAP)
Standby Emergency Department
for Pediatrics (SEDP)
Not all hospitals are
the same for children
Data from Illinois
Pre-EDAP
Patients Deaths Death
Rate
21,249 290 13.6
Post-EDAP
Patients Deaths Death
Rate
29,875 321 10.7
Mortality Rates per 1,000 Inpatient Injury-Related
Admissions from the ED,
0-15 Year Olds, 1994-2009*
*Records were restricted to facilities participating as EDAP
• Before 1984, no specialized
pre-hospital care of children.
• Realized that children are not
“little adults” and have different
anatomy, physiology, and
development than adults.
• Acknowledged the gap in care.
Why EMSC?
The Emergency Medical Services for Children
(EMSC) Program under section 1910 of the
Public Health Service Act (42 U.S.C. 300w–9) is
the only Federal program that focuses
specifically on improving the pediatric
components of emergency medical care.
Challenges for Emergency
Care for Children
• Of the 119 million emergency department (ED) visits, approximately 23 million are children.
• There are 3,833 EDs in the United States.• Fewer than 10% of EDs are fully equipped and trained to handle
pediatric emergencies.
• “Children who are injured or ill have different medical needsthan adults with the same problems.”
• They often need equipment that is smaller than what is used for adults.
• They require medication in much more carefully calculateddoses.
• They have special emotional needs as well, often reacting very differently to an injury or illness than adults do.
Quality Improvement
• State Partnership Grants
Knowledge Generation
• Targeted Issues Grants
• Pediatric Emergency Care Applied Research
Network-PECARN
Support & Dissemination
• Resource Centers
EMSC National Resource Center
NEDARC-National EMSC Data Analysis CenterAnalysis
Resource Center
What is EMSC doing?
EMSC State
Partnership Program
Provides funding to 49 states, DC, and 5
territories to improve pediatric care through
performance measures:
• Medical direction
• Pediatric equipment
• Facility recognition
• Inter-facility transfer
• Institutionalization of EMSC in the State
system
State Performance Measures Data
PM Number Brief Description
71* On-line pediatric medical direction
72* Off-line pediatric medical direction
73* Pediatric equipment and supplies
74 Hospital recognition system for medical emergencies
75 Hospital recognition system for traumatic emergencies
76 Inter-facility transfer guidelines
77 Inter-facility transfer agreements
78* Pediatric emergency education
79 EMSC Permanence – Advisory Committee
80* EMSC Priorities – state statutes and regulations
Collecting the Data
EMSC Program
Integral to this process is medical
oversight of prehospital care by:
• using preexisting protocols (indirect
medical oversight), which are
evidence-based when possible
• by medical control via voice and/or
video communication (direct medical
oversight).
Prehospital Access to
Medical Oversight
Medical Direction*
Online
2007-09 2010-11
BLS 69% BLS 87%
ALS 71% ALS 91%
Offline-Protocols
2007-09 2010-11
BLS 56% BLS 63%
ALS 83% ALS 90%
*Preliminary data from survey analysis by NEDARC
Equipment for Ambulances
• ACS-COT original list for
ambulances
• 1988 ACEP develops lists
• 2000 joint effort
• 2005 NAEMSP joins
• 2006 EMSC stakeholders
add pediatric components
Equipment Type
• Ventilation and Airway Equipment
• Monitoring and Defibrillation
• Immobilization Devices
• Bandages
• Communication
• Obstetrical Kit (commercially
• packaged is available)
• Miscellaneous
• Infection Control*
• Injury Prevention Equipment
• Ventilation and Airway Equipment
• Vascular Access
• Cardiac
• Medications (pre-loaded
syringes when available)
BLS (35 items) ALS (70 items)
Equipment on Vehicles*
2007-09 2010-11
BLS 16% BLS 23%
ALS 18% ALS 34%
• At a glance
*Respond to 911 calls and transport patients to hospitals
Equipment on Vehicles*
Equipment on Vehicles*
2010-11
Complete list
2010-11
Nearly complete
(>90%)**
BLS 23% BLS 91%
ALS 34% ALS 96%
• The rest of the story
*Respond to 911 calls and transport patients to hospitals
Equipment on Vehicles*
**Initial analysis of survey data by NEDARC
Improving Knowledge about
Pediatric Emergency Care
Targeted Issue Grants
• Issues of national significance with potential to
improve practice in the field.
• Many focus on the pre-hospital environment.
Pediatric Emergency Care Applied
Research Network (PECARN)
• Creating an infrastructure to conduct rigorous
studies in pediatric emergency care.
• Use of medications in the pre-hospital settingg.
Targeted Issue Grants
• FY2011 Funded Grants Focusing on Prehospital Care:
• Integrating Evidence Based Pediatric PrehospitalProtocols into Practice
• (Manish Shah, MD—Texas Children’s Hospital)
• Refining Pediatric Triage Algorithms and Education in the Prehospital Setting
• (Mark Cicero, MD—Yale University)
• EMS and Pediatric Trauma: A North Carolina Population Based Performance Improvement and Evaluation Using Multiple Linked Healthcare Databases
• (Greg Mears, MD—University of NC)
PECARN
• Consists of approximately 20 Emergency Departments
across the United States
• HRSA has provided infrastructure support to participating
EDs since 2001
• Represents approximately one million pediatric emergency
department visits annually
• Over 100 publications from research protocols
• Over 52 million dollars in external funding for projects
EMSC Network Development Demonstration Project
Lessons Learned
PECARN
• Determine the epidemiology of prehospital care
• Worked with local EMS agencies to collect prehospital data
linked to EDs in the research network
• Over 2 years of data collected
• minimal standardization of forms
• incomplete data collected
• unable to analyze to provide an overview of prehospital
care
Other Pediatric Initiatives
• Evaluating ED Readiness
• Only 6% of EDs ready to take care of children?
• Re-survey of EDs using 2008 national guidelines to
reassess pediatric preparedness
• Helicopter transport of pediatric patients
• Analysis of MEIMSS data using field triage criteria
• Helicopter transport, pediatric pain assessment
• NIH funding for prehospital research
• Working with NICHD to re-issue a program
announcement
• Previously funded work in pediatric patient safety
Emergency Care for Children
Future Steps
• Improve pediatric infrastructure at the State/Territory level
• Equipment for ambulances
• Regionalized systems of hospital care
• Improved ED preparedness
• Increase research efforts
in pre-hospital emergency care• Standardization in prehospital
setting
• Champions among prehospital
providers
• EMSC remains a part of the larger EMS system
• Children represent a small proportion of runs, but care
needs to be specialized
• Pediatric specialist need to be included in protocol
development and implementation
• Maintain benchmarks to assure the delivery of quality care
for children in all settings
Next steps to success
Contact Information
Elizabeth Edgerton, MD, MPH, FAAP
Branch Chief EMSC and Injury Prevention
MCHB/HRSA