Emergency Medical Services for Children PDF

Emergency Medicine, Critical PART Care, and Anesthesia...

Emergency Medicine, Critical PART Care, and Anesthesia VII The federal Emergency Medical Services for Children (EMSC) Chapter 77 program of the Health Resources and Services Administration Mater- nal and Child Health Bureau has stewarded improvements in the care Emergency Medical of children in the context of the continuum-­of-­care model. The pro- grammatic mission of the EMSC program is as follows: To ensure U.S. emergency care systems across the continuum of care Services for Children are pediatric-­ready, meaning pediatric-­specific needs are incorpo- rated into every aspect of patient care, including patient safety prac- Charles G. Macias, Katherine E. Remick, tices, equipment and supplies, competency requirements, policies and procedures, quality improvement efforts, and administrative and Steven E. Krug oversight and coordination of care. To ensure access to high-­quality emergency medical care for ill or injured children and adolescents of all ages regardless of geographic The overwhelming majority of the 27 million children who present location. annually for emergency care in the United States are seen at community-­ To ensure that pediatric services are well integrated into an emer- based general emergency departments (EDs). Visits to children’s hospital gency medical services (EMS) system and backed by optimal re- EDs account for just 10% of initial ED encounters. Additionally, across sources. emergency medical services, children account for approximately 10% of To ensure that the entire spectrum of emergency services—includ- all transports. This distribution suggests that the greatest opportunity to ing primary prevention of illness and injury, acute care, and reha- optimize care for acutely ill or injured pediatric patients, on a population bilitation—is provided to infants, children, and adolescents at a level basis, occurs broadly as part of a systems-­based approach to emergency equal to that of adults. services, an approach that incorporates the unique needs of children at every level. Conceptually, emergency medical services for children are characterized by an integrated, continuum-­of-­care model (Fig. 77.1). The model is designed such that patient care flows seamlessly from the PRIMARY CARE PHYSICIAN AND OFFICE primary care medical home through transport and on to hospital-­based PREPAREDNESS definitive care. It includes the following five principal domains of activity: The primary care physician (PCP) has multiple important roles in the 1. Prevention, both primary and secondary EMS system. Through anticipatory guidance, the PCP can help shape 2. Out-­of-­ hospital care, both emergency response and prehospital the attitudes, knowledge, and behaviors of parent and child, with the transport primary goal of preventing acute medical events, such as injury and 3. Hospital-­based care: ED and inpatient, including critical care exacerbations of illness. The point-­of-­care initiation for many acute 4. Interfacility transport, as necessary, for definitive or pediatric medi- problems is often the PCP office. From the standpoint of personnel, cal and surgical subspecialty care (see Chapter 77.1) equipment, training, and protocols, the PCP office setting must be 5. Rehabilitation adequately prepared to initially manage acute and emergency exacer- bations of common pediatric conditions, such as respiratory distress and seizures. Furthermore, on rare occasion, the PCP office environ- ment may be confronted with a child in clinical extremis who requires resuscitation and stabilization. It is therefore incumbent on the PCP Em not only to ensure access to EMS, that is, 911 system activation, but erg also to ensure that there is adequate equipment and supplies and on-­ en site cognitive and psychomotor skill preparation to deal with such an cy Injury prevention emergency. Office preparedness requires training and continuing res po education for staff members, protocols for emergency interventions, ns ready availability of appropriate resuscitation drugs and equipment, e and knowledge of local EMS resources and ED capabilities. PCPs can are also play a pivotal role in informing and advocating for pediatric emer- n tio lc gency and disaster readiness for families (especially those of children ita ita and youth with special healthcare needs) and in local EMS agencies, bil p os ha schools and childcare programs, and community hospitals. In all com- eh Re Pr Emergency Medical munities, the medical home plays a vital role in promoting family read- Services for Children iness for emergencies and disasters. Int erf Staff Training and Continuing Education a Hospital care It is a reasonable expectation that all office staff, including reception- cili ty ists and medical assistants, be trained in cardiopulmonary resuscita- tra tion (CPR) with recertification maintained every 2 years. Nurses and ns physicians should also have training in a systematic approach to pedi- p ort atric resuscitation that optimizes performance of high-­quality CPR. Fig. 77.1 The emergency medical services for children (EMSC) contin- Core knowledge may be obtained through standardized courses in uum of care. Seriously ill and injured children interface with a large num- advanced life support (ALS) offered by national medical associa- ber of healthcare personnel as they move through the EMSC system. tions and professional organizations. Frequent practice and timely 534 Downloaded for mohamed ahmed ([email protected]) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.  Chapter 77 u Emergency Medical Services for Children 535 recertification are important for knowledge retention and skill main- tenance. Examples include the Pediatric Advanced Life Support Table 77.1  Recommended Drugs and Equipment for (PALS) and Pediatric Emergency Assessment, Recognition and Sta- Pediatric Office Emergencies bilization (PEARS) courses sponsored by the American Heart Asso- DRUGS/EQUIPMENT PRIORITY ciation (AHA), the Advanced Pediatric Life Support (APLS) course sponsored by the American Academy of Pediatrics (AAP) and Ameri- DRUGS Oxygen E can College of Emergency Physicians (ACEP), and the Emergency Albuterol for inhalation E Nurses Pediatric Course (ENPC) sponsored by the Emergency Nurses Epinephrine (1:1,000 [1 mg/mL]) E Association (ENA). Activated charcoal S Antibiotics S Protocols Anticonvulsants (diazepam/lorazepam) S Standardized protocols for telephone triage of seriously ill or injured Corticosteroids (parenteral/oral) S children are essential. When a child’s clinical status is guarded and pre- Dextrose (25%) S hospital care is available, ambulance transport in the care of trained Diphenhydramine (parenteral, 50 mg/mL) S personnel is always preferable to transport by other means (e.g., pri- Epinephrine (1:10,000 [0.1 mg/mL]) S vate vehicle). This obviates the potentially serious medical conse- Atropine sulfate (0.1 mg/mL) S Naloxone (0.4 mg/mL) S quences of relying on distraught, often untrained, parents who lack Sodium bicarbonate (4.2%) S essential equipment and supplies to provide even basic life support (BLS) measures to an unstable child during transport. Practitioners INTRAVENOUS FLUIDS can work with their regional pediatric emergency care resource cen- Normal saline (0.9 NS) or lactated Ringer solution S (500-­mL bags) ter (e.g., children’s hospital, academic medical center, trauma center) 5% dextrose, 0.45 NS (500-­mL bags) S to develop and maintain written protocols for office-­based manage- ment of a range of conditions, including anaphylaxis, cardiopulmo- EQUIPMENT FOR AIRWAY MANAGEMENT nary arrest, head trauma, ingestions, shock, status asthmaticus, status Oxygen and delivery system E epilepticus, extremity injuries, and upper airway obstruction. Regular Bag-­valve-­mask (450 mL and 1,000 mL) E Clear oxygen masks, breather and non-­rebreather, with E practice using mock code scenarios improves office-­based practitioner reservoirs (infant, child, adult) and staff performance and self-­efficacy in managing these problems. Suction device, tonsil tip, bulb syringe E Nebulizer (or metered-­dose inhaler with spacer/mask) E Resuscitation Equipment Oropharyngeal airways (sizes 00-­5) E Availability of necessary equipment is a vital part of an emergency Pulse oximeter E response. Every physician’s office should have essential resuscitation Nasopharyngeal airways (sizes 12-­30F) S equipment and medications packaged in a weight-­based pediatric Magill forceps (pediatric, adult) S resuscitation cart or kit (Table 77.1). This cart or kit should be checked Suction catheters (sizes 5-­16F and Yankauer suction tip) S on a regular basis and kept in an accessible location known to all office Nasogastric tubes (sizes 6-­14F) S staff. Outdated medication, a laryngoscope with a failed light source, Laryngoscope handle (pediatric, adult) with extra S batteries, bulbs or an empty oxygen tank represents a potential catastrophe in a resus- Laryngoscope blades (straight 0-­2; curved 2-­3) S citation scenario. Such an incident can be easily avoided if an equip- Endotracheal tubes (uncuffed 2.5-­5.5; cuffed 6.0-­8.0) S ment checklist and regular maintenance schedule are implemented. A Stylets (pediatric, adult) S pediatric kit that includes posters to reinforce clinical management and Esophageal intubation detector or end-­tidal carbon S procedures, a drug-­dosing formulary, and a color-­coded length-­based dioxide detector resuscitation tape specifying weight and emergency equipment size are EQUIPMENT FOR VASCULAR ACCESS AND FLUID invaluable in avoiding critical therapeutic errors during resuscitation. MANAGEMENT To facilitate emergency response when a child needs rapid interven- Butterfly needles (19-­25 gauge) S tion in the office, all personnel should have designated roles. Organiz- Catheter-­over-­needle device (14-­24 gauge) S ing a “rapid response team” within the office ensures that necessary Arm boards, tape, tourniquet S equipment is made available to the physician in charge, an appropriate Intraosseous needles (16 and 18 gauge) S medical record detailing all interventions and the child’s response is Intravenous tubing, micro-­drip S generated, and the 911 call for EMS response or a critical care transport MISCELLANEOUS EQUIPMENT AND SUPPLIES team is made in a timely fashion. Regular practice for these infrequent Color-­coded tape or preprinted drug doses E events will promote timely response when needed. Cardiac arrest board/backboard E Sphygmomanometer (infant, child, adult, thigh cuffs) E Transport Splints, sterile dressings E Once efforts to stabilize the child have begun, a decision must be made Automated external defibrillator with pediatric S capabilities on how best to transport a child to a facility capable of providing defini- Spot glucose test S tive care. If a child requires airway or cardiovascular support, has an Stiff neck collars (small/large) S altered mental state or unstable vital signs, or has significant potential Heating source (overhead warmer/infrared lamp) S to deteriorate en route, it is not appropriate to send the child via pri- vately owned vehicle, regardless of proximity to a hospital. Even when E, essential; S, strongly suggested. From Frush K, American Academy of Pediatrics, Committee on Pediatric Emergency an ambulance is called, it is the PCP’s responsibility to initiate essen- Medicine. Policy statement-­preparation for emergencies in the offices of pediatricians tial life support measures and to attempt to stabilize the child before and pediatric primary care providers. Pediatrics. 2007;120:200-­212. Reaffirmed in transport. Pediatrics. 2011;128:e748. In metropolitan centers with numerous public and private ambu- lance agencies, the PCP must be knowledgeable about the scope of service provided by each. The availability of BLS vs ALS services, whereas others may have a two-­tiered system, providing both BLS and the configuration of the transport team, and pediatric expertise vary ALS. It may be appropriate to consider medical air transport when greatly among agencies and across jurisdictions. BLS services provide definitive or specialized care is not available within the community or basic support of airway, breathing, and circulation, whereas ALS units when ground transport times are prolonged. In that case, initial trans- are capable of providing resuscitation drugs and procedural interven- port via ground to an appropriate helicopter landing zone or a local tions as well. Some communities may have only BLS services available, hospital for interval stabilization may be undertaken, pending arrival Downloaded for mohamed ahmed ([email protected]) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. 536 Part VII u Emergency Medicine, Critical Care, and Anesthesia of the air transport team. Independent of whether a child is to be protocols, quality improvement, patient safety, family-­centered care, transported by air or ground, copies of the pertinent medical records staff competencies, and equipment and supplies. Although children and any imaging or laboratory studies should be sent with the patient represent a minority population in the prehospital setting, the joint and a call made to the physician at the receiving facility to alert them policy statement, Pediatric Readiness in Emergency Medical Services to the referral and any treatments administered. Such notification is Systems, provides a comprehensive overview of how EMS systems can not merely a courtesy; direct physician-­to-­physician communication address the needs of children throughout all aspects of care. The iden- is essential for optimal care quality and to ensure adequate transmis- tification of a PECC and physical demonstration of pediatric-­specific sion of patient care information, to allow mobilization of necessary skills represent two of the reference standards that the federal EMSC resources in the ED, and to redirect the transport if the emergency program has adopted as performance measures for state-­level opera- physician believes that the child would be more optimally treated at tional readiness to care for children in an EMS system. an alternative facility. First responders may be law enforcement officers or firefighters, who are dispatched to provide emergency medical assistance, or bystanders. PEDIATRIC PREHOSPITAL CARE Public safety personnel have a minimum of 40 hours of training in first Prehospital care refers to emergency assistance rendered by trained aid and CPR. Their role is to provide rapid response and stabilization emergency medical personnel before a child reaches a treating medi- pending the arrival of more highly trained personnel. In some smaller cal facility. The goals of prehospital care are to further minimize sys- communities, this may be the only prehospital emergency medical temic insult or injury through a series of well-­defined and appropriate response available. interventions and serve as the first link in high-­quality emergency care. In the United States the bulk of emergency medical response is pro- Prehospital emergency care services embrace patient safety, family-­ vided by EMTs, who may be volunteers or paid professionals. Basic centered care, and timely and effective interventions as core tenets. EMTs may staff an ambulance after undergoing a training program of Most U.S. communities have a formalized EMS system; the organi- approximately 100 hours. They are licensed to provide BLS services zational structure and nature of emergency medical response depend but may receive further training in some jurisdictions to expand their greatly on local demographics and population base. EMS may be pro- scope of practice to include intravenous catheter placement and fluid vided by volunteers or career professionals working in a fire depart- administration, management of airway adjuncts, and use of an auto- ment–based or independent third-­service response system. All EMS mated external defibrillator (AED). and fire-­based agencies have an identified medical director who defines Paramedics, or EMT-­Ps, represent the highest level of EMT provider competencies and scope of practice. Key points to recognize response, with medical training and supervised field experience of at in negotiation of the juncture between the community physician and least 1,000 hours. Paramedic skills include advanced airway manage- the local EMS system include access to the system, provider capability, ment, including endotracheal intubation; placement of peripheral vas- and destination determination. cular or intraosseous lines; intravenous administration of drugs and blood products; administration of nebulized aerosols; needle and fin- Access to the EMS System ger thoracostomy; and cardioversion, cardiac pacing, and manual defi- Virtually all Americans have access to the 911 telephone service that brillation. These professionals provide ALS services, functioning out provides direct access to a dispatcher who coordinates police, fire, of an ambulance equipped as a mobile intensive care unit (ICU). The and EMS responses. Many communities have a next-­generation 911 joint position statement Recommended Essential Equipment for Basic system, in which the location of the caller is automatically provided Life Support and Advanced Life Support Ground Ambulances 2020 pub- to the call taker and/or dispatcher regardless of landline or mobile lished by the AAP, ACEP, American College of Surgeons Committee on device use, permitting emergency response even if the caller, such Trauma, EMSC Innovation and Improvement Center, ENA, National as a young child, cannot give an address. Next-­generation 911 also Association of EMS Physicians, and National Association of EMS Offi- provides text-­messaging capabilities. The extent of medical training cials outlines national standards for essential equipment, medications, for call takers and dispatchers varies among communities, as do the and supplies necessary to provide BLS and ALS care across the age protocols by which they assign an emergency response level (BLS spectrum. vs ALS). Many dispatch centers have adopted the Medical Priority Both basic EMTs and paramedics function under the delegated Dispatch System (MPDS) to use standardized protocols and prear- licensing authority of a supervisory EMS medical director. This physi- rival/postdispatch instructions. MPDS requires emergency medical cian oversight of prehospital practice is broadly characterized under dispatchers to ask a series of questions that determine the appropri- the umbrella term medical control. Direct, or online, medical control ate level of priority and EMS response. In some smaller communi- refers to medical direction either at the scene or in real time via voice ties, no coordinated dispatch exists, and emergency medical calls or video transmission. Indirect, or offline, medical control refers to are handled by the local law enforcement agency or fire department. the administration of medical direction before and after the provision When activating the 911 system, the physician must make clear to of care (i.e., clinical protocols). Offline activities, such as provider edu- the dispatcher the nature of the medical emergency and the condi- cation and training, protocol development, and medical leadership of tion of the child. quality assurance/quality improvement programs, represent areas in need of greater pediatric input. Whether in the presence or absence of Provider Capability a PECC, a pediatric advisory committee may provide additional pedi- There are many levels of training for prehospital EMS providers, rang- atric knowledge and expertise. Evaluation and tracking of pediatric ing from individuals capable of providing only first aid to those trained performance is critical to ensuring high-­quality care for children in a and licensed to provide ALS. All EMS personnel, whether basic emer- community. The National EMS Information System (NEMSIS) serves gency medical technicians (EMTs) or paramedics, receive some ini- as a registry for standardized EMS data collection. EMS agency par- tial training in pediatric emergencies; however, in most programs the ticipation in NEMSIS-­compliant data submission is one of the federal dedicated time allotted to pediatric emergencies is minimal. Further- EMSC performance measures. The National EMS Quality Alliance more, state requirements vary for pediatric continuing education, and (NEMQA) and the National EMS Model Clinical Guidelines comple- exposure to critically ill or injured children in the prehospital setting is ment the NEMSIS program by providing evidence-­derived pediatric infrequent, even in urban settings. PCPs should recognize that prehos- quality measures for adoption in any EMS agency. As a measure of the pital providers may need additional consultation or support, especially degree to which EMSC permanence is being established in state EMS when managing children with uncommon medical conditions. PCPs systems, the federal EMSC program has required demonstration of can support maintenance of pediatric knowledge by EMS providers by the presence of an EMSC advisory committee at the state level. These serving as or working closely with an identified pediatric emergency advisory bodies are well positioned to support EMS agencies in their care coordinator (PECC) within the EMS agency to fully integrate pediatric readiness and provide a forum for the active engagement of the needs of children into every aspect of system-­based care: policies, pediatric care experts at a system level. Downloaded for mohamed ahmed ([email protected]) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.  Chapter 77 u Emergency Medical Services for Children 537 Destination Determination ACS-­verified trauma centers to adhere to specific pediatric readiness The destination to which a pediatric patient is transported may be criteria. defined by parental preference, provider preference, or jurisdictional In communities that do not have a hospital with the equipment protocol, which is typically predicated on field assessment and, in the and personnel resources to provide definitive pediatric inpatient care, case of trauma, mechanism of injury. The 2021 National Guidelines interfacility transport of a child to a regional pediatric center should for the Field Triage of Injured Patients relies on injury patterns, physi- be undertaken after initial stabilization (see Chapter 77.1). In the end, ologic criteria, mechanism of injury, and other special considerations all emergency care facilities must stand ready to provide care to ill and (e.g., suspicion for child maltreatment). Based on these criteria, EMS injured children of all ages. providers determine the optimal trauma center destination in the set- ting of injury. In communities served by an organized trauma system THE EMERGENCY DEPARTMENT that incorporates pediatric designation based on objectively verified The ability of EDs to respond to critically ill and injured children hospital capabilities (i.e., pediatric readiness), seriously injured chil- depends on all aspects of pediatric readiness: administrative over- dren may be triaged by protocol to the highest-­level pediatric-­capable sight, staff competencies, pediatric-­specific policies and procedures, trauma center reachable within a reasonable amount of time. Other patient and medication safety, quality improvement, and equipment communities have established state or regional emergency care systems and supplies. Training, awareness, and experience of the staff as well that use pediatric readiness criteria to recognize EDs appropriate for as access to support services, pediatricians, and medical and surgi- pediatric patients. A high level of pediatric readiness in both medical cal subspecialists also play a key role. The majority of children who and trauma centers is linked to decreased mortality in critically ill and require emergency care are evaluated in community EDs. Emergency injured children. The mantra is to deliver the child to the right care in care staff, including physicians, nurses, and advanced practice provid- the right time, even if it requires bypassing closer hospitals. ers, may have variable degrees of pediatric training and experience. Regionalization in the context of EMS is defined as a geographi- Although children account for approximately 25% of all ED visits, only cally organized system of services that ensures access to care at a level a fraction of these encounters represents true emergencies. Because appropriate to patient needs while maintaining efficient use of avail- the volume of critical pediatric cases is low, emergency physicians and able resources. This system concept is especially germane in the care nurses working in lower-­volume EDs often have limited opportunity of children, given the relative scarcity of facilities and their associated to reinforce and sustain their knowledge and skills in the assessment providers that are capable of managing the full range and scope of and stabilization of severely ill or injured children. Indeed, nearly 70% pediatric conditions (Fig. 77.2). Regionalized systems of care coordi- of U.S. EDs provide care for 30 adult V Respiratory verbal stimuli Immediate rate 45 PEDI Responds to 2sec (Adult) Unresponsive to Perfusion Immediate U noxious stimuli No palpable pulse (PEDI) Yes “P” (inappropriate; e.g, posturing) or “U” (Pediatric) Does not obey commands Mental status (Adult) Immediate Obeys commands (Adult) Delayed “A”, “V” or “P” (Appropriate) (Pediatric) Fig. 77.3 Combined START/Jump START triage algorithm. (Copyright 2002, Lou Romig, MD.) complexity to a pediatric tertiary center may be unable to do so during (https://emscimprovement.center), U.S. Centers for Disease Con- a disaster. Mechanisms for remote consultation and support of pedi- trol and Prevention (https://emergency.cdc.gov), U.S. Department of atric care, leveraging community pediatricians and tertiary pediatric Health and Human Services (https://www.phe.gov/preparedness/Page subspecialists via telemedicine, should be considered. s/default.aspx), U.S. HHS ASPR Technical Resources, Assistance Cen- Beyond acute medical treatment needs, pediatric planning must also ter, and Information Exchange (TRACIE) (https://asprtracie.hhs.gov/), consider the typically broad mental and behavioral health impact disas- U.S. Federal Emergency Management Agency (https://www.fema. ters have on children and families. Mental and behavioral health con- gov), HHS ASPR Western Regional Alliance for Pediatric Emergency cerns commonly represent the largest impact of disasters on children Management (WRAPEM) (https://www.wrap-em.org/index.php/ and adolescents. Pediatric plans must also be in place for locations where resources-edocman-public), and HHS HRS Pediatric Network (PPN) children congregate, such as schools and childcare; these plans must be (https://pedspandemicnetwork.org/). aligned with local jurisdiction planning and communicated to families. Community practice and healthcare system readiness and resiliency Triage in Disaster Pediatric Medical Care begin with personal and family readiness planning engaged by health- Mass causality events (hurricanes, bombings, gas leaks, bus or plane care providers and support staff; these efforts should also include atten- crashes, earthquakes, mass shootings, fires, others) require scene-­based tion to provider wellness. assessment, assignment, and tagging (Figs. 77.3 and 77.4). Assessment The AAP’s Children and Disasters website* (https://www.aap.org/ must be rapid (∼30 seconds) and includes breathing, circulation, and en/community/aap-­councils/council-­on-­disaster-­preparedness-­and-­ mental status. These parameters are incorporated in the START (simple recovery-­codpr/) contains toolkits, checklists, and other resources triage and rapid treatment) triage tool for adolescent and adults and the pertinent to pediatric readiness within the community, schools, the Jump START assessment for 0-­to 14-­year-­old children. The combined medical home, and hospitals; educational materials are also available algorithm is noted in Figure 77.3. The “jump” in Jump START relates to for families. Reliable information and excellent disaster readiness one difference between pediatric and adult approaches wherein children resources are also located on the websites of the EMSC Innovation and are given a rescue breath if they remain apneic with a pulse after posi- Improvement Center and U.S. Department of Health and Human Ser- tioning the airway (see Fig. 77.3). Triage categories are color coded (see vices (HHS) and Assistant Secretary for Preparedness and Response Fig. 77.4) at the site of the disaster based on risk. Red – immediate life-­ (ASPR) Eastern Great Lakes Pediatric Disaster Center of Excellence threatening injury; Yellow – potentially stable for a short period; Green – minor injury, walking wounded; Black – dead or not expected to survive. * https://www.aap.org/en-­us/advocacy-­and-­policy/aap-­health-­initiatives/Children-­and-­ Disasters/Pages/default.aspx. Visit Elsevier eBooks+ at eBooks.Health.Elsevier.com for Bibliography. 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All rights reserved. 540 Part VII u Emergency Medicine, Critical Care, and Anesthesia Triage categories Expectant Black triage tag color Delayed Yellow triage tag color Victim unlikely to survive given severity Victim’s transport can be delayed of injuries, level of available care, or both Includes serious and potentially Palliative care and pain relief should life-threatening injuries, but status not be provided expected to deteriorate significantly over several hours Immediate Red triage tag color Minor Green triage tag color Victim can be helped by immediate Victim with relatively minor injuries intervention and transport Status unlikely to deteriorate over days Requires medical attention within May be able to assist in own care: minutes for survival (up to 60) “Walking wounded” Includes compromises to patient’s Airway, Breathing, Circulation Fig. 77.4 Triage categories. (From US Department of Health and Human Services: https://chemm.hhs.gov/startpediatric.htm.) 77.1 Interfacility Transport of the Seriously and procedures that guarantee safe, state-­of-­the-­art, and timely pediat- ric critical care transport; and a database for quality and performance Ill or Injured Pediatric Patient assessment. Corina Noje, Mary Beth Howard, and Bruce L. Klein* COMMUNICATIONS AND DISPATCH CENTER Patients often seek treatment at facilities that lack sufficient expertise to Communications are one of the most vital components of a regional treat their conditions, necessitating transfer to more appropriate spe- transport system. Treating a critically ill or injured child is generally an cialty centers. This is especially pronounced in pediatrics. Emergency uncommon event for most community physicians. Therefore they need medical services (EMS) providers or parents usually take children to to know whom, how, and when to call for assistance in the stabilization local emergency departments (EDs) first, where their conditions and and transfer of a pediatric patient. The communications and dispatch physiologic stabilities are assessed. Although bringing a child directly center provides a single telephone number for such calls. to the local ED may be proper logistically, community-­based local EDs The communications and dispatch center coordinates communica- can be less than ideal for pediatric emergencies. Children have been tions among the outlying facility, receiving unit, MCP, transport team, reported to account for about 20% of all ED visits, but not all EDs have and other consultants. This center may be part of a hospital unit (e.g., the necessary supplies for pediatric emergencies. Also, general EDs are ED, PICU), self-­contained in a single institution (e.g., emergency com- less likely to have pediatric expertise or policies in place for the care of munications and information center), or based off-­site as a freestand- children. Outcomes for critically ill children treated in pediatric inten- ing center coordinating communications and dispatch for multiple sive care units (PICUs) are better than for those treated in adult ICUs. transport programs. When pediatric critical care is required, transport to a regional PICU is Staffing varies depending on the type of center. On-­duty nurses indicated. In addition, often the type of subspecialty care needed (e.g., or physicians may receive calls at unit-­based models with low vol- pediatric orthopedics) is available only at the pediatric center. umes. In contrast, dedicated communications specialists usually staff Pediatric transport medicine consists of the interfacility transfer of self-­contained or freestanding centers, which tend to be busier. The infants, children, and adolescents from community facilities to pedi- communications specialist has numerous responsibilities, including atric centers that can provide the needed level of expertise. Transport answering the referring physician’s call promptly; documenting essen- is performed by professionals proficient in pediatric transport using tial patient demographic information; arranging for immediate consul- age-­equipped ground, rotorcraft, or fixed-­wing ambulances. Pediat- tation with the MCP; dispatching the transport team to the referring ric transport medicine is a multidisciplinary field comprising pediat- facility expeditiously; updating the referring facility with any changes ric critical care and pediatric emergency medicine (PEM) physicians in the arrival time; and coordinating medical control and other neces- (and, sometimes for newborn infants, neonatologists); nurses, respira- sary transport-­related calls. The transport team must be able to contact tory therapists, and paramedics with advanced training for pediatric the receiving and referring facilities immediately, when necessary. Fur- transport; and communications specialists. The goal is to deliver qual- thermore, with advances in technology and wireless communication ity pediatric care to the region’s children, while optimizing the use of systems, telemedicine—either interactive (synchronous) or store and regional resources. For the individual child, the aim is to stabilize and, forward (asynchronous)—is being used during pediatric transport, when appropriate, begin treating as soon as possible—that is, at the and certain programs have incorporated it into their routine transport local ED and during transport, well before arrival at the referral center. operations. Models for pediatric transport services vary depending on the needs and available resources in a geographic region, but all should have cer- MEDICAL CONTROL PHYSICIAN tain basic components: a network of community hospitals and regional The MCP is involved in the clinical care and safe transport of the pediatric centers; an established communications and dispatch system patient from the time of referral through arrival at the receiving hospi- that easily facilitates transfer to the pediatric center; ground and/or air tal unit. The MCP’s oversight increases once the transport team arrives ambulances; medical and nursing leadership from pediatric critical at the referring facility. The MCP should have expertise in pediatric care or PEM (or neonatology); experienced pediatric medical control critical care or PEM (or sometimes neonatology). Besides having the physicians (MCPs); a multidisciplinary team of pediatric transport knowledge required to stabilize a critically ill or injured child, the MCP professionals specially trained and equipped to provide the appropriate must be familiar with the transport environment; the transport team level of care required during transport; operational and clinical policies members’ resources and capabilities; the program’s policies and pro- cedures; and the region’s geography, medical resources, and regula- * Adapted initially from Dr. Lorry R. Frankel’s chapter in the 18th edition of this book. We tions regarding interhospital transport. The MCP must possess good also want to thank Dr. Beth Edgerton, who co-­authored a prior version of this chapter. interpersonal and communication skills and must be able to maintain Downloaded for mohamed ahmed ([email protected]) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.  Chapter 77 u Emergency Medical Services for Children 541 collegiality with the referring hospital’s staff during a potentially dif- The receiving unit must be updated before arrival so it can finalize ficult and stressful situation. preparations for the patient. Once a transport call is received, the MCP must be immediately available to confer with the referring physician. Although the MCP may GROUND VS AIR AMBULANCE have other responsibilities, these transport responsibilities take priority Transport vehicle options include ground, rotorcraft, and fixed-­wing in order to avoid undue delays when transferring a critically ill child. ambulances. Vehicle selection depends on the child’s emergency needs, Often the MCP recommends further testing or therapeutic interven- transport team’s capabilities, any out-­of-­ordinary staffing or equipment tions that can be delivered by the referring hospital before the transport requirements (e.g., extracorporeal membrane oxygenation, inhaled team arrives. The MCP may seek additional guidance from other spe- nitric oxide, heliox), referring facility’s abilities, distance, terrain, traffic cialists, as necessary. Because the child’s condition may change rapidly, patterns, ground or air ambulance availability, helicopter landing pad the MCP must remain ready to give additional advice. All conversa- or airport access, weather conditions, and expense. tions and recommendations regarding the care of the patient should be The transport vehicle must be equipped with electrical power, oxy- documented. Some centers record these conversations. gen, and suction and must have sufficient space for the equipment and After discussion with the referring physician—and when warranted, supplies that the team brings along—stretcher or isolette, monitor, with the transport staff—the MCP determines the best team composi- ventilator, oxygen tank(s), medication pack(s), infusion pumps, and tion and vehicle for transport. The MCP usually does not accompany more. Compared with helicopters, ambulances typically are more spa- the team but remains available to supervise care. With advances in cious and able to carry more weight, so they can accommodate larger video conferencing capabilities, there has been increased use of tele- teams and more equipment. Another advantage of ground ambulance medicine in the pediatric transport medical direction process. For transport is the ability to stop en route if the patient’s condition dete- some acutely ill patients or those requiring visual diagnoses, telemedi- riorates; this may facilitate the performance of certain interventions or cine has been reported to improve disposition at the receiving hospital, procedures, such as intubation. potentially leading to improved clinical outcomes. An airplane may be able to fly to an area when distance (>150 miles), altitude, or weather precludes helicopter use. However, the use of an TRANSPORT TEAM airplane necessitates several ambulance transfers, with their attendant Transport team composition varies greatly among programs—and delays and additional risks. There also are delays when the plane must sometimes within an individual program. The team’s composition is fly from a remote base to the program’s jurisdiction. based on a variety of factors, including the child’s age; the severity of the illness or injury; the distance to the referring facility; the transport TRANSPORT PHYSIOLOGY vehicle used; the team members’ advanced practice scope and abili- When possible, the transport team tries to provide the same care dur- ties; the referrer’s insistence that a physician be present; the program’s ing transport as the patient would receive in the specialty center. This historical professional makeup; and the region’s staffing regulations. can be difficult, however, because of limitations in personnel, equip- The pediatric transport workforce may include physicians, advanced ment, and space, as well as other environmental challenges. practice providers, nurses, respiratory therapists, and paramedics who The team and child are subjected to variable intensities of back- have expertise in pediatric critical care, PEM, or neonatology (in some ground noise and vibration while traveling in the vehicle cabin. Noise cases), as well as advanced education and training in those cognitive can impair the team’s ability to auscultate breath sounds and heart and procedural areas important for pediatric critical care transport. sounds or accurately measure the blood pressure manually—another Physician trainees—usually fellows and, less often, residents—may also reason for monitoring vital signs mechanically and relying on other participate in transport in some capacity. There is a lower incidence assessment modalities, such as the level of mentation, skin color, and of transport-­related morbidity for critically ill and injured children capillary refill. For rotor transports in particular, the crew and patient transported by pediatric specialty teams than for those transported by should wear helmets or headphones (or another wearable noise atten- generalist teams. Nevertheless, in-­transit critical events occur in ∼10% uator) to mitigate noise. Motion and vibration are additional trans- of pediatric critical care transports. port hazards and can lead to increased metabolic rate, shortness of Various scoring systems that can help guide team composition and/ breath, and fatigue in the patient, as well as motion sickness in the or mode of transport have been developed to aid in transport planning. patient and staff. A team member’s training, experience, and skill in treating critically ill On fixed-­wing or certain rotary-­wing transports, the patient may patients are more important considerations than that team member’s suffer adverse physiologic effects from altitude. With increasing professional degree. Team members must understand basic pediatric altitude, the barometric (atmospheric) pressure decreases, and gas pathophysiology and collectively must be able to assess and monitor expands to occupy a greater volume due to the decreased pressure a critically ill or injured child; manage the airway and provide respi- exerted on it. Therefore, as barometric pressure drops with altitude, ratory support; obtain vascular access; perform point-­of-­care testing; the partial pressures of inspired oxygen (Pio2) and, consequently, arte- and administer fluids and medications (including infusions) typically rial oxygen (Pao2) decrease, as does the arterial oxygen-­hemoglobin used in pediatric critical care transport. They must be familiar with the saturation (Spo2). For example, at 8,000 feet—an elevation at which physiologic alterations and practical difficulties of the transport envi- unpressurized airplanes may fly, as well as the effective cabin altitude ronment and, importantly, must be comfortable working in an out-­of-­ for many pressurized airplanes flying at 35,000-­40,000 feet—the baro- hospital setting. Physicians are less often deployed on transport teams metric pressure, Pio2, Pao2, and Spo2 fall to 565 mm Hg, 118 mm Hg, in part because of the advanced training that other healthcare profes- 61 mm Hg, and 93%, respectively. In comparison, the barometric pres- sionals on the transport team receive. sure, Pio2, Pao2, and Spo2 are 760 mm Hg, 159 mm Hg, 95 mm Hg, The transport team should have a designated team leader who, in and 100% at sea level. Although healthy individuals usually tolerate addition to the team leader’s many other responsibilities, interacts these changes well, patients with respiratory insufficiency, pulmonary with the MCP during the transport. Once the team arrives at the refer- hypertension, significant blood loss, or shock may decompensate and ring facility, the team should reassess the child’s condition, review all should receive supplemental oxygen and/or have the cabin pressurized the pertinent diagnostic studies and therapies, and discuss the situa- at sea level. tion with the referring staff and parents. If the patient’s condition has Gases expand up to 10% at the few thousand feet where helicopters changed significantly, the team leader may need to contact the MCP for typically fly, and approximately 30–40% at 8,000 feet. Gases within the additional advice. Otherwise, the team leader should generally notify body itself also expand as the altitude increases. The degree of gas expan- the MCP before starting to bring the child to the receiving facility. Any sion must be considered during transport via air of any patient with care delivered by the team during transport should be documented, pneumocephalus, pneumothorax, bowel obstruction, or another condi- and copies of all medical records—including laboratory data, radio- tion involving entrapped gas. Before transport, a pneumothorax should graphs, and scans—should accompany the child to the pediatric center. generally be decompressed and a nasogastric tube inserted for ileus. Downloaded for mohamed ahmed ([email protected]) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. 542 Part VII u Emergency Medicine, Critical Care, and Anesthesia SAFETY Each hospital needs to review its facility’s guidelines; if estab- Safety is of paramount importance and mandates constant vigilance by lished guidelines do not exist, the Emergency Medical Services for everyone involved. Accident rates for pediatric air and ground trans- Children National Resource Center in partnership with the Emer- port have been estimated at approximately 1 in 1,000 transports. The gency Nurses Association and the Society of Trauma Nurses has team should routinely attend pilot briefs and perform safety inspections developed the “Interfacility Transfer Tool Kit for the Pediatric of the vehicles and equipment, aided by checklists. When in doubt, the Patient” (available at: https://emscimprovement.center/education-­ MCP should solicit input from the staff about whether to transport via and-­resources/toolkits/interfacility-­transfer-­toolbox/). This tool kit air or ground ambulance or to employ lights and sirens, decisions that includes the essentials for comprehensively and safely transferring cannot be taken lightly. The pilot’s or driver’s judgment as to the safety the pediatric patient to the most appropriate level of care in a timely of proceeding during inclement weather or with a mechanical problem manner. must not be overruled. Organizations such as the Federal Aviation Administration (FAA) EDUCATIONAL OUTREACH and the National Transportation Safety Board (NTSB) play a role in Besides safe and rapid transport, regional pediatric transport programs ensuring safe interfacility transport. The Commission on Accredi- (and their specialty centers) have an obligation to provide educational tation of Medical Transport Systems (CAMTS) is an independent, opportunities to community healthcare providers so that these provid- peer-­review organization established in 1990 in response to the num- ers can acquire the necessary skills to evaluate and stabilize a critically ber of air medical accidents in the 1980s. CAMTS, through voluntary ill or injured child until the transport team arrives. These learning participation, audits and accredits fixed-­wing, rotary-­wing, and ground activities may include transport case reviews; lectures on pediatric interfacility medical transport services. acute care topics; resuscitation and related programs such as the Pedi- atric Advanced Life Support (PALS) course, Advanced Pediatric Life Support (APLS) course, Pediatric Education for Prehospital Profes- FAMILY-­CENTERED CARE sionals (PEPP) course, and S.T.A.B.L.E. (sugar and safe care, tempera- Family-­centered care represents a philosophy that respects the impor- ture, airway, blood pressure, lab work, emotional support) program; tant role that family members play in a child’s care. It recognizes family and rotations through the specialty center’s pediatric ED and PICU. members and healthcare providers as partners in caring for the child. These activities also help cement relationships with the referring facil- Family presence during transport is beneficial because it provides sup- ity’s staff. port to both children and parents in stressful situations and assists healthcare providers in delivering care to patients with complex and Visit Elsevier eBooks+ at eBooks.Health.Elsevier.com for Bibliography. chronic medical problems. As care is transitioned from the referring hospital, it is the transport team’s responsibility to maintain culturally sensitive, family-­centered care. The team meets with family members to explain the transport 77.2 Risk Adjustment and Outcomes process, help obtain consent, and discuss anticipated management. Measurement of Pediatric Emergency When possible, the transport team should attempt to accommodate a Medical Services family member’s presence onboard. However, the family member and Anna K. Weiss child may need to be separated when the child is critically ill and rapid transport is essential, or in case of space or weight limitations in the air Health services research has demonstrated wide variation in imple- or ground ambulance. In these situations, it is important that family mentation of equitable, evidence-­based care for pediatric patients in members have a clear understanding of how the child will be cared for U.S. hospitals, a reality that can negatively affect the health of children during the separation. and youth (see Chapter 2). The complexities of delivering high-­quality, evidence-­based care are magnified in the emergency department (ED), REFERRING HOSPITAL RESPONSIBILITIES where patients are often in crisis, patient-­physician interactions are Transfer of a child to another facility requires written documentation brief, and the variety and volume of complaints and diagnoses are by the referring physician of the need and reasons for transfer, includ- immense. In the context of this frenetic environment, practitioners can ing a statement that the risks and benefits, as well as any alternatives, only assess their local system relative to recognized benchmarks and have been discussed with the parents. Informed consent should be standards of care if there are clear guidelines for measurement of per- obtained from the parent/legal guardian before transfer. formance. However, no two places of practice are the same, and a single Federal law under the Emergency Medical Treatment and Active ED may differ significantly from a theoretical “best practice” standard. Labor Act (EMTALA), part of the Consolidated Omnibus Budget To reflect this, practitioners seeking to make local improvements must Reconciliation Act (COBRA), imposes specific requirements that a assess not only raw outcomes (e.g., throughput times, mortality, patient patient presenting to an ED be given a medical screening examina- satisfaction) but must also adjust for severity of illness, case mix, and tion without regard for ability to pay. If on examination an emer- risk of morbidity. gency medical condition is found, the hospital is required to stabilize the patient or to transfer the patient to another facility if unable to stabilize the patient (or if requested by the patient in writing after OUTCOME MEASURES IN EMERGENCY MEDICAL being informed of the risks). The primary requirement is that the SERVICES FOR CHILDREN referring physician must certify that the medical risks of transfer To ensure delivery of equitable, evidence-­based care in the ED, pediat- are outweighed by its potential benefits. The receiving hospital must ric emergency medical systems must support the use of national stan- agree to accept the patient if it has the space and staff to provide the dards for emergency care performance measurement. The Donabedian necessary level of care. The transferring hospital is responsible for structure-­process-­outcome model provides a framework for most con- arranging for the transfer and ensuring that it is performed by quali- temporary quality measurement and improvement activities. In this fied medical personnel with appropriate equipment. The transfer- framework, structural elements provide indirect quality-­of-­care mea- ring hospital must also send copies of the patient’s medical records sures related to a physical setting and resources (e.g., available staff, and test results, even those that become available after the transfer equipment, and supplies). Process indicators provide a measure of the is complete. quality of care and services by evaluating the method or process by Some referring hospitals have entered into transfer agreements with which care is delivered, including both technical and interpersonal specialty centers to facilitate the smooth and safe transfer of pediatric components. Outcome elements describe valued results related to patients. Having prepared forms for all the purposes noted earlier also lengthening life, relieving pain, reducing disabilities, and satisfying the aids in the transfer process. consumer. Downloaded for mohamed ahmed ([email protected]) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.  Chapter 77 u Emergency Medical Services for Children 543 A true outcome-­based approach to performance improvement In the ED, the choice of a risk adjustment tool depends on ED-­ describes observable measures such as mortality, risk of organ sys- specific outcomes of interest. Two general risk adjustment tools have tem failure, and disability. An alternative approach is a resource-­based been developed specifically for PEM, the second-­generation Pediatric outcome measure with a definition that is relative to the level of care Risk of Admission (PRISA II) score and the Revised Pediatric Emer- required. Children who are more ill generally require more resources; gency Assessment Tool (RePEAT). therefore resource use across groups of patients reflects relative sever- ity of illness within the groups, provided clinicians have a similar Pediatric Risk of Admission II approach to practice. Examples of resource-­based outcomes include PRISA II uses components of acute and chronic medical history as need for hospital admission (ED disposition), ED length of stay, costs, well as acute physiology to determine the probability of hospitaliza- and diagnostic and therapeutic interventions performed in the ED. tion. The outcome measure of interest is mandatory hospital admission Although this approach provides a measurement of clinical activity, (admissions using therapies that are best delivered in the inpatient when used in a vacuum it does not indicate whether the patient receiv- setting). Table 77.4 lists the patient-­related attributes contributing to ing the therapeutic interventions or resources actually needed them the PRISA II risk adjustment score. Analytic models, including the (i.e., data may also reflect physician behavior and/or [lack of] expe- PRISA II score, have good calibration (how well the probabilities pre- rience). Therefore some other assessment is needed that incorporates dicted from the model correlated with the observed outcomes in the information on how sick the patient is or their specific diagnosis. population) and discrimination (the ability to categorize subjects cor- Table 77.3 provides a list of performance measures for pediatric rectly into the categories of interest) with respect to mandatory hospital ED care developed by the Emergency Medical Services for Chil- admission. Construct validity of the PRISA II score has been demon- dren Innovation and Improvement Center supported by the Health strated by measuring rates of the secondary outcomes: mandatory Resources and Services Administration of the U.S. Department of admission, PICU admission, and mortality. As the probability of hos- Health and Human Services. pital admission rises, the proportion of patients with these increasing care requirements also increases. This finding supports the use of the RISK ADJUSTMENT PRISA II score as a measure of illness severity. PRISA II has also been The purpose of measuring outcomes in the ED is to evaluate per- used to demonstrate racial/ethnic differences in severity-­adjusted hos- formance—offering EDs and other components of the healthcare pitalization rates, as well as variation in hospitalization rates between system the opportunity to make meaningful improvements over teaching and nonteaching hospitals. time using benchmarks within and between units. When making comparisons over time, one must ensure that patient-­related attri- Revised Pediatric Emergency Assessment Tool butes (e.g., age, preexisting conditions, severity of illness) have not RePEAT uses a limited set of data collected at the time of ED triage to changed; otherwise, one may be looking at changes in demography model severity of illness as reflected by the level of care provided in and case mix rather than at true change in performance. To ensure the ED—for example, routine assessment (clinical examination only fair and meaningful measurement across time, risk adjustment is ± nonprescription medicine) vs specific ED care (ED diagnostics and/ necessary to level the playing field. As an example, illness severity or therapeutics) vs hospital admission. In this model, it is assumed typifies the concept of risk—the higher the severity, the higher the that patients needing a higher level of care have a higher severity of risk of a given outcome. Without risk adjustment, EDs with sicker illness. Table 77.5 lists the patient-­related attributes contributing to patients may appear to have poorer outcomes. Risk Adjustment Tools in the ED Table 77.4  Elements of the PRISA II Score Although other risk adjustment scoring systems—such as the PRISM score for pediatric critical care—use mortality and morbidity as pri-  ge A mary outcomes, this approach is not appropriate for the ED setting. Injury severity Across U.S. EDs, pediatric mortality is low, and a patient’s presenting Temperature physiology may reflect interventions performed in the prehospital set- Referral status (e.g., self-­referral vs referral from physician’s office ting. Similarly, eventual morbidity and/or mortality may reflect what or from another ED) Presence of: happens in the PICU or during hospital ward care.  bdominal pain in an adolescent A Immunodeficiency Indwelling medical device Controller asthma medication Decreased mental status Table 77.3  Stakeholder-­Endorsed Performance Measures Low systolic blood pressure (80 mg/dL) Presence of on-site pediatric coordinator(s) High white blood cell count (>20,000/mm3) Oxygen therapy other than during inhaled bronchodilator treatments Parent/caregiver understanding of discharge instructions Low bicarbonate and high potassium values Door to provider time Total length of stay Reducing pain in children with acute fractures Children with minor head trauma receiving a head CT scan Protocol for suspected child abuse in place Table 77.5  Elements of the RePEAT Score Systemic corticosteroids in asthma patients with acute exacerbation  ge A Evidence-based guideline for bronchiolitis Chief complaint Reducing antibiotic use in children with viral illnesses Triage category Return visits within 48 hours resulting in admission Current use of prescription medications Medication error rates Arrival via EMS (ground/air) Heart rate (relative to age-­based norms) ACEP, American College of Emergency Physicians; AAP, American Academy of Respiratory rate (relative to age-­based norms) Pediatrics; ENA, Emergency Nurses’ Association; GCS, Glasgow Coma Score; CT, Temperature computed tomography. Downloaded for mohamed ahmed ([email protected]) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. 544 Part VII u Emergency Medicine, Critical Care, and Anesthesia the RePEAT risk adjustment score. Analytic models such as RePEAT strategies have proved effective, the data are based on U.S. research and have good calibration and discrimination with respect to predict- may not be generalizable to other countries. ing ED care and hospital admission. Furthermore, analytic models that compare costs and length of stay between EDs are improved by Out-­of-­Hospital Care adjusting for severity of illness using the RePEAT score. RePEAT is a Out-­of-­hospital care comprises access to emergency services, pre- reasonable objective marker of severity of illness that could be used in hospital care, and interfacility transport of patients. Morbidity and the administrative process comparing outcomes between EDs. With mortality arise from delayed or limited access to emergency care, implementation of scoring systems such as PRISA II and RePEAT, lack of prehospital care, transport without proper monitoring or U.S. EDs can benchmark the care that they provide to children and trained personnel, or delayed transport to a higher level of care. make meaningful improvements to ensure that this care is equitable Safe transport of seriously ill children is a neglected global health and evidence-­based. issue. An emergency response system must address the following links in the patient’s care: a communication system with prompt Visit Elsevier eBooks+ at eBooks.Health.Elsevier.com for Bibliography. activation of emergency medical services (EMS), the correct assess- ment and initial treatment of the patient, and the rapid transport to definitive care. 77.3 Principles Applicable to the Access to Care Developing World When a child is injured or ill, a parent or caretaker must be able to David M. Walker and Victorio R. Tolentino Jr. access help and activate EMS. In the majority of low-­and middle-­ income countries, no universal emergency numbers have been estab- The maturity of pediatric emergency medicine (PEM) in any given lished, requiring access by direct dialing to an ambulance, if such area depends on the healthcare priorities and resources of that geo- private services exist. In countries that have a universal emergency graphic or physical setting. The places in which emergency care takes number, barriers remain related to absence of phones in some house- place range from the community (especially for those with no access holds, unclear addresses in rural areas, and insufficient reach of the to organized medical care) to state-­of-­the-­art pediatric emergency emergency system. departments (EDs), typically in larger population centers. The scope In most low-­and middle-­income countries, the family must bring ranges from the care of the individual patient to the management of the ill or injured child to the health facility for stabilization and populations of children involved in large-­scale disasters. Barriers to treatment. For this to occur, families must also overcome financial quality care vary in each situation and in each part of the world, with and geographic barriers, which can result in delayed presentation the implication for the PEM practitioner that the care provided must for care. This delay predictably increases the likelihood of associ- be relevant to the local context of healthcare. ated complications and decreases the likelihood of full recovery and survival. CONTINUUM-­OF-­CARE MODEL This Emergency Medical Services for Children (EMSC) framework can Prehospital Care also be applied to discussion of emergency care for children on a global In regions with maturing EMS systems, there must be adequately level (see Chapter 77). Although medical infrastructure in some parts trained personnel to stabilize and transport the child to a medical facil- of the developing world may not be consistent or well organized, or ity. The quality and level of training of such prehospital personnel vary has been weakened by civil strife, natural disasters, or economic loss, among countries and within regions of the same country. In urban the EMSC framework can still apply generally to individual healthcare areas, there is a greater concentration of medical care and therefore systems. a greater opportunity to have strong prehospital training. In most of Asia and sub-­Saharan Africa, trained personnel are used primarily to Prevention transfer patients between health facilities, not from the initial site of Infectious Diseases illness or injury. In most high-­income countries, medical services are International child health has focused mainly on reducing the inci- dispatched to the patient. dence of preventable childhood illnesses, primarily through immuni- Around the world, the effort to establish standardized approaches zation initiatives. Enormous advances have been realized in measles, to prehospital care exists primarily in the form of courses to edu- neonatal tetanus, and polio; wild-­type smallpox was eradicated in cate EMS and hospital personnel in the emergency management of 1978. Although there are advocates for providing primary care inter- patients. The WHO manuals Prehospital Trauma Care Systems and ventions (e.g., vaccinations) in the ED, the role of the PEM practitioner Guidelines for Essential Trauma Care focus on guidelines for prehos- in this area of prevention has been limited. pital and trauma care systems that are affordable and sustainable. The American Academy of Pediatrics (AAP) course “Pediatric Education Injuries for Prehospital Professionals” is a dynamic, modularized teaching tool Injuries are a leading cause of childhood morbidity and mortality. designed to provide specific pediatric prehospital education that can Unintentional injuries constitute 90% of injury mortality to chil- be adapted to any EMS system. Table 77.6 describes additional pre- dren 5-­19 years old and are the cause of 9% of the world’s mortality hospital resources. (see Chapter 14). Intentional injuries, which remain underrecog- Although most middle-­and high-­income countries have a system nized and underreported, make a smaller but significant contribu- of trained EMS workers, lower-­income countries lack this advanced tion. Unintentional injuries cause more than 2,000 childhood deaths tier of emergency care. In these countries, commercial drivers, vol- daily, or 950,000 annually worldwide. The burden of these deaths is unteers, and willing bystanders provide the first line of care. Training borne disproportionately by children in middle-­and lower-­income a cadre of first responders can rely on existing networks of aid or countries, where >95% of all injury-­related deaths occur. For each can be drawn from specific populations, such as students, soldiers, of these deaths, many more children are permanently disabled, and or public servants. Training needs to emphasize basic lifesaving and an even larger number are treated and released without permanent limb-­saving interventions, including how to stop bleeding and sup- sequelae. port breathing, access advanced care, and splint broken limbs. In Traffic-­related injuries, burns, and drowning are the main causes of Ghana, for example, taxi drivers participated in a first-­aid course that injury-­related mortality in children. The World Health Organization relied heavily on demonstration and practice rather than knowledge (WHO) and United Nations Children’s Fund (UNICEF) have out- transfer through didactic sessions. Taxi drivers were selected because lined several proven injury prevention strategies of which child health they already provided much of the transport for injured patients. Two practitioners in the global community must be aware. Although these years after the course, external evaluators favorably rated the quality Downloaded for mohamed ahmed ([email protected]) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.  Chapter 77 u Emergency Medical Services for Children 545 Table 77.6  Pediatric Emergency Care Resources PREHOSPITAL CARE Manual for the Health Care of Children in Humanitarian Emergencies Emergency Pediatric Care WHO publication that provides comprehensive guidance on childcare Course developed by the National Association of Emergency in emergencies; includes information on care of traumatic injuries Medical Technicians (NAEMT) focused on field treatment of sick and mental health emergencies. and injured children. Course is open to physicians, nurses, EMTs, Website: https://www.who.int/publications/i/item/9789241596879 and paramedics. Pediatric Disaster Care Centers of Excellence (United States) Website: https://www.naemt.org/education/epc Coalition of medical centers and government agencies established to Pediatric Trauma Life Support for Prehospital Care Providers guide the delivery of pediatric healthcare services in a disaster. An 8-­hour pediatric prehospital course sponsored by the global Website: https://emscimprovement.center/domains/preparedness/asprcoe/ organization International Trauma Life Support (ITLS) MENTAL HEALTH EMERGENCIES Website: https://www.itrauma.org/education/itls-­pediatric/ The Mental Health & Psychosocial Support Network Pediatric Education for Prehospital Professionals (PEPP) A hosted online practice network organized around crowdsourcing Curriculum designed specifically to teach prehospital professionals of mental health and psychosocial support resources for use in how to assess and manage ill or injured children. emergencies and ongoing humanitarian crises in the developing world. Website: https://www.peppsite.com/ Website: https://mhpss.net/ HOSPITAL CARE Save the Children Psychological First Aid Training Pocket Book of Hospital Care for Children: Second Edition Practitioner training manual dedicated to the provision of WHO publication providing guidelines for the management of psychological first aid to children exposed to trauma. common illnesses in resource-­limited settings; incorporates Website: https://resourcecentre.savethechildren.net/document-­ both the Emergency Triage Assessment and Treatment (ETAT) collections/save-­children-­psychological-­first-­aid-­training and Integrated Management of Childhood Illness (IMCI)