Goal:  By 2026, 90 percent of EMS agencies in the state or territory have a designated individual who coordinates pediatric emergency care.

Significance of the Measure:

The Institute of Medicine (IOM) report “Emergency Care for Children: Growing Pains”1 recommends that EMS agencies and emergency departments (EDs) appoint a pediatric emergency care coordinator to provide pediatric leadership for the organization. This individual need not be dedicated solely to this role and could be personnel already in place with a special interest in children who assumes this role as part of their existing duties.

 

Gausche-Hill et al.2 in a national study of EDs found that the presence of a physician or nurse pediatric emergency care coordinator was associated with an ED being more prepared to care for children. EDs with a coordinator were more likely to report having important policies in place and a quality improvement plan that addressed the needs of children than EDs that reported not having a coordinator.

 

The IOM report further states that pediatric coordinators are necessary to advocate for improved competencies and the availability of resources for pediatric patients. The presence of an individual who coordinates pediatric emergency care at EMS agencies may result in ensuring that the agency and its providers are more prepared to care for ill and injured children.

The Pediatric Emergency Care Coordinator (PECC) should be a member of the EMS agency and be familiar with the day-to-day operations and needs at the agency. However, some states or territories may use a variety of models to coordinate pediatric emergency care at the county or regional levels. If there is a designated individual who coordinates pediatric activities for a county or region, that individual could serve as the PECC for one or more individual EMS agencies within the county or region.

 

Some of the roles that the individual who coordinates pediatric emergency care might oversee at an EMS agency include:

 

• Ensuring that the pediatric perspective is included in the development of EMS protocols.
• Ensuring that fellow providers follow pediatric clinical-practice guidelines.
• Promoting pediatric continuing-education opportunities.
• Overseeing pediatric-process improvement.
• Ensuring the availability of pediatric medications, equipment, and supplies.
• Promoting agency participation in pediatric-prevention programs.
• Promoting agency participation in pediatric-research efforts.
• Liaises with the emergency department pediatric emergency care coordinator.
• Promoting family-centered care at the agency.

1 Institute of Medicine Committee on the Future of Emergency Care in the U. S. Health System (2007). Emergency care for children: growing pains.

2 Gausche-Hill, M., Ely, M., Schmuhl, P., Telford, R., Remick, K. E., Edgerton, E. A., & Olson, L. M. (2015). A national assessment of pediatric readiness of emergency depart­ments. JAMA Pediatrics, 169(6), 527–534.

Goal:  By 2026, 90 percent of EMS agencies will have a process that requires EMS providers to physically demonstrate the correct use of pediatric-specific equipment.

Significance of the Measure:

The Institute of Medicine (IOM) report “Emergency Care for Children: Growing Pains”1 states that because EMS providers rarely treat seriously ill or injured pediatric patients, providers may be unable to maintain the necessary skill level to care for these patients. For example, Lammers et al.2 reported that paramedics manage an adult respiratory patient once every 20 days compared to once every 625 days for teens, once every 958 days for children, and once every 1,087 days for infants. As a result, skills needed to care for pediatric patients may deteriorate. Another study by Su et al.3 found that EMS provider knowledge rose sharply after a pediatric resuscitation course, but when providers were retested six months later, their knowledge was back to baseline.

Continuing education such as the Pediatric Advance Life Support (PALS) and Pediatric Education for Prehospital Professionals (PEPP) courses are vitally important for maintaining skills and are considered an effective remedy for skill atrophy. These courses are typically required only every two years. More frequent practice of skills using different methods of skill ascertainment are necessary for EMS providers to ensure their readiness to care for pediatric patients when faced with these infrequent encounters.

Demonstrating skills using EMS equipment is best done in the field on actual patients, but in the case of pediatric patients, this can be diffi­cult given how infrequently EMS providers see seriously ill or injured children. Other methods for assessing skills include simulation, case scenarios and skill stations. In the absence of pediatric patient en­counters in the field, there is no definitive evidence that shows that one method is more effective than another for demonstrating clinical skills. But, Miller’s Model of Clinical Competence4 posits via the skills complexity triangle that performance assessment can be demonstrat­ed by a combination of task training, integrated skills training, and integrated team performance. In the EMS environment this can be translated to task training at skill stations, integrated skills training during case scenarios, and integrated team performance while treating patients in the field.

1 Institute of Medicine Committee on the Future of Emergency Care in the U. S. Health System (2006). Emergency care for children: growing pains.

2 Lammers, R. L., Byrwa, M. J., Fales, W. D., & Hale, R. A. (2009). Simulation-based assessment of paramedic pediatric resuscitation skills. Prehospital Emergency Care, 13(3), 345–356.

3 Su, E., Schmidt, T. A., Mann, N. C., & Zechnich, A. D. (2000). A randomized controlled trial to assess decay in acquired knowledge among paramedics completing a pediatric resuscitation course. Academic Emergency Medicine, 7(7), 779-786.

4 Miller, G. E. (1990). The assessment of clinical skills/competence/performance. Academic Medicine, 65(9), S63-7.  

Goal:  By 2022, 25 percent of hospitals are recognized as part of a statewide, territorial, or regional standardized program that are able to stabilize and/or manage pediatric medical emergencies.

Significance of the Measure:

The performance measure emphasizes the importance of the existence of a standardized statewide, territorial, or regional system of care for children that includes a recognition program for hospitals capable of stabilizing and/or managing pediatric medical emergencies. A standardized recognition and/or designation program, based on compliance with the current published pediatric emergency and trauma care guidelines,1 contributes to the development of an organized system of care that assists hospitals in determining their capacity and readiness to effectively deliver pediatric emergency, trauma, and specialty care.

This measure helps to ensure essential resources and protocols are available in facilities where children receive care for medical and trauma emergencies. A recognition program can also facilitate EMS transfer of children to appropriate levels of resources.

Additionally, a pediatric recognition program that includes a verification process to identify facilities meeting specific criteria has been shown to increase the degree to which EDs are compliant with published guidelines and improve hospital pediatric readiness statewide.2

Performance Measure EMSC 04 does not require that the recognition program be mandated. Voluntary facility recognition is accepted.

Recognition programs and criteria should be based upon the most current version of the “Guidelines for Care of Children in the Emergency Department,”1 a joint policy statement by the American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Committee, and the Emergency Nurses Association Pediatric Committee. These guidelines include criteria that address:

• Administration and coordination of pediatric care
• The qualifications of physicians, nurses, and other ED staff
• A formal pediatric quality-improvement or monitoring program
• Patient safety
• Policies, procedures, and protocols
• The availability of pediatric equipment, supplies, and medications

The 2013 National Pediatric Readiness Assessment (see the National Pediatric Readiness Project below) scored EDs on their readiness to care for pediatric medical or trauma events, based on the “Guidelines for Care of Children in the Emergency Department.”1 EDs were scored on a scale from 0 to 100 based on a modified Delphi method by a group of clinical experts. Throughout the nation, emergency departments received a median score of 69 out of 100, indicating a need for improvement in the emergency care of children.

A recognition program should be monitored by the state or territory or some other governing body, and it needs to include a process for on-site verification of hospital emergency department capabilities for treating children.

1 American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Committee, & Emergency Nurses Association Pediatric Committee (2009). Joint policy statement—guidelines for care of children in the emergency department. Pediatrics, 124(4), 1233–1243.

2 Remick, K. E, Kaji, A. H., Olson, L. M., Ely, M., Schmuhl, P., McGrath, N., Edgerton, E. A., & Gausche-Hill, M. (2016). Pediatric readiness and facility verification. Annals of Emergency Medicine, 67(3), 320–328.

Goal:  By 2022, 50 percent of hospitals are recognized as part of a statewide, territorial, or regional standardized system that recognizes hospitals that are able to stabilize and/or manage pediatric trauma.

Significance of the Measure:

The performance measure emphasizes the importance of the existence of a standardized statewide, territorial, or regional system of care for children that includes a recognition program for hospitals capable of stabilizing and/or managing pediatric trauma emergencies. A standardized recognition and/or designation program, based on compliance with the current published pediatric emergency and trauma care guidelines,1 contributes to the development of an organized system of care that assists hospitals in determining their capacity and readiness to effectively deliver pediatric emergency, trauma, and specialty care.

This measure addresses the development of a pediatric trauma recognition program. Recognition programs are based upon state-defined criteria and/or adoption of national current published pediatric emergency and trauma care consensus guidelines1 that address administration and coordination of pediatric care; the qualifications of physicians, nurses, and other ED staff; a formal pediatric quality-improvement or monitoring program; patient safety; policies, procedures, and protocols; and the availability of pediatric equipment, supplies, and medications.

Additionally, EMSC 05 does not require that the recognition program be mandated. Voluntary facility recognition is accepted. However, the preferred status is to have a program that is monitored by the state or territory.

This measure emphasizes the need for state and territory trauma systems to have a process in place that assures facilities providing pediatric trauma care have been verified as having integrated appropriate resources addressing the unique needs of children.

State trauma systems have existed in the United States in some organized fashion since the early 1970s and have been championed by the Institute of Medicine as a model for delivery of care for traumatic injury.2 Considering that traumatic injury is one of the most significant public health issues facing children, disparities in equipment, supplies, and training is concerning. Currently available research has not conclusively determined what the best type of trauma system or center is; however, research has identified “current gaps and disparities in the care of injured children that can be remedied through education and training.”3

The 2013 National Pediatric Readiness Assessment (see National Pediatric Readiness Project below) identified that not all emergency departments in the United States have the essential guidelines and resources in place to provide effective care to children.4 This assessment, based on “Guidelines for Care of Children in the Emergency Department,”1 scored hospitals on a scale from 0 to 100 based on a modified Delphi method developed by a group of clinical experts. Throughout the nation, emergency departments received a median score of 69 out of 100, indicating a need for improvement in the emergency care of children.

The Emergency Medical Services for Children Program continues to champion efforts to ensure that the ability to stabilize and/or manage pediatric trauma is fully integrated into all trauma systems. Most states have trauma systems in place that are either verified by the American College of Surgeons (ACS) Committee on Trauma (COT) or that are based on similar criteria.

1 American Academy of Pediatrics Committee on Pediatric Emergency Medicine, Amer­ican College of Emergency Physicians Pediatric Committee, & Emergency Nurses Association Pediatric Committee (2009). Joint policy statement—guidelines for care of children in the emergency department. Pediatrics, 124(4), 1233–1243.

2 Carr, B. G. & Nance, M. L. (2010). Access to pediatric trauma care: alignment of providers and health systems. Current Opinion in Pediatrics, 22(3), 326–331.

3 Petrosyan, M., Guner, Y. S., Emami, C. N., & Ford, H. R. (2009). Disparities in the delivery of pediatric trauma care. Journal of Trauma, 67(2 Suppl), S114–119.

4 Gausche-Hill, M., Ely, M., Schmuhl, P., Telford, R., Remick, K. E., Edgerton, E. A., & Olson, L. M. (2015). A National assessment of pediatric readiness of emergency departments. JAMA Pediatrics, 169(6), 527–534.

Goal:  By 2021, 90 percent of hospitals in the state or territory have written interfacility transfer guidelines that cover pediatric patients and that include specific components of transfer.

Significance of the Measure:

In order to assure that children receive optimal care, timely transfer to a specialty care center is essential. Such transfers are better coordinated through the presence of interfacility transfer agreements and guidelines.

Timely access to pediatric specialty services for a child in the acute stages of illness or injury is critical to reducing morbidity and mortality. Most children are treated first in a local community hospital, which may not have all of the processes, staff, and equipment needed to provide specialty pediatric care.1 When this is the case, a critically ill or injured child will need to be transferred rapidly from the referring facility to a more specialized receiving facility, such as a pediatric-specialty hospital or a trauma center that has additional resources needed to treat children. The development of written interfacility transfer guidelines promotes effective working relationships between referring hospitals and specialized receiving facilities.2 Facilities are more prepared to receive and care for children when the interfacility transfer guidelines include the eight recommended components endorsed by the American Academy of Pediatrics (AAP), American College of Emergency Physicians (ACEP), and Emergency Nurses Association (ENA).3

Interfacility transfer guidelines combined with the recommended components solidify the patient-transfer process through written steps and procedures among hospitals. This helps to ensure that critically ill and injured children receive needed services, that appropriate consultation services are available, and that children are rapidly transported to specialized centers.

The adoption of interfacility transfer guidelines at pediatric-specialty hospitals or other specialty-receiving facilities is also important in cases where specialty treatment such as burns is not available at the referring facility or in cases of surge capacity in the event of a disaster or mass-casualty event. In the case of regional disasters, pediatric-specialty hospitals and tertiary-level hospitals should have interfacility transfer guidelines to manage transfers to other hospitals within and across state lines.

 

EMSC 06 and 07

This measure is closely aligned with EMSC 07 – interfacility transfer agreements. Both of these measures ensure that the process for interfacility transfers are already in place through written interfacility transfer documentation. Your time may be best served by working on these two measures simultaneously. Both measures ensure virtually the same outcome— that when children need to be transferred to a more specialized facility, the proper guidelines are in place and the relationship for transfer between facilities are established in writing. This can reduce delays in care as well as the loss of important patient information.

NOTE: Compliance with the Emergency Medical Treatment and Labor Act (EMTALA) does not constitute having interfacility transfer guidelines.4

1 Gausche-Hill, M., Ely, M., Schmuhl, P., Telford, R., Remick, K. E., Edgerton, E. A., & Olson, L. M. (2015). A national assessment of pediatric readiness of emergency departments. JAMA Pediatrics, 169(6), 527–534.

2 Arora, V., Johnson, J., Lovinger, D., Humphrey, H. J., Meltzer, D. O. (2005). Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Quality & Safety in Health Care, 14(6), 401–407.

3 American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Committee, & Emergency Nurses Association Pediatric Committee (2009). Joint policy statement—guidelines for care of children in the emergency department. Pediatrics, 124(4), 1233–1243.  

4 CMS Manual System, Department of Health & Human Services, Centers for Medi­care & Medicaid Services (PDF). Retrieved in July 2016 from www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R46SOMA.pdf.  

Goal:  By 2021, 90 percent of hospitals in the state or territory have written interfacility transfer agreements that cover pediatric patients.

Significance of the Measure:

In order to assure that children receive optimal care, timely transfer to a specialty care center is essential. Such transfers are better coordinated through the presence of interfacility transfer agreements and guidelines.

Timely access to pediatric specialty services for a child in the acute stages of illness or injury is critical to reducing morbidity and mortality. Most children are first treated in a local community hospital that may not have all of the processes, staff, and equipment needed to provide specialty pediatric care.1 When this is the case, a critically ill or injured child will need to be rapidly transferred from the referring facility to a more specialized receiving facility, such as a pediatric-specialty hospital or a trauma center that has the additional resources needed to treat children.

The development of written interfacility transfer agreements promotes effective working relationships between referring hospitals and specialized receiving facilities.2 Interfacility transfer agreements solidify the patient-transfer process through written contracts between hospitals, helping to ensure that critically ill and injured children receive needed services, that appropriate consultation services are available, and that children are rapidly transported to specialized centers.

The adoption of interfacility transfer agreements at pediatric-specialty hospitals or other specialty-receiving facilities is also important in cases where specialty treatment such as burns is not available at the referring facility or in cases of surge capacity in the event of a disaster or mass-casualty event. In the case of regional disasters, pediatric-specialty hospitals and tertiary-level hospitals should have agreements with other hospitals within and across state lines.

 

EMSC 06 and 07

This measure is closely aligned with EMSC 06 – interfacility transfer guidelines. Both of these measures ensure that the process for interfacility transfers are already in place through written interfacility transfer documentation. Your time may be best served by working on these two measures simultaneously. Both measures ensure virtually the same outcome—that when children need to be transferred to a more specialized facility, the proper guidelines are in place and the relationship for transfer between facilities are established in writing. This can reduce delays in care as well as the loss of important patient information.

NOTE: Compliance with the Emergency Medical Treatment and Labor Act (EMTALA) does not constitute having interfacility transfer agreements.3

1 Gausche-Hill, M., Ely, M., Schmuhl, P., Telford, R., Remick, K. E., Edgerton, E. A., & Olson, L. M. (2015). A national assessment of pediatric readiness of emergency departments. JAMA Pediatrics, 169(6), 527–534.

2 Arora, V., Johnson, J., Lovinger, D., Humphrey, H. J., & Meltzer, D. O. (2005). Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Quality & Safety in Health Care, 14(6), 401–407.

3 CMS Manual System, Department of Health & Human Services, Centers for Medicare & Medicaid Services (PDF). Retrieved in July 2016 from www.cms.gov/ Regulations-and-Guidance/Guidance/Transmittals/downloads/R46SOMA.pdf.  

Goal: To increase the number of states and territories that have established permanence of EMSC in the state or territory EMS system.

Each year:

• The EMSC Advisory Committee has the required members as per the implementation manual.
• The EMSC Advisory Committee meets at least four times a year.
• Pediatric representation incorporated on the state or territory EMS Board.
• The state or territory requires pediatric representation on the EMS Board.
• One full-time EMSC Manager is dedicated solely to the EMSC Program.

 

Goal:  By 2027, EMSC priorities will have been integrated into existing EMS, hospital, or healthcare facility statutes or regulations.

 

Significance of the Measure:

 

For the EMSC Program to be sustained in the long-term and reach permanence, it is important for the Program’s priorities to be integrated into existing state or territory mandates. Integration of the EMSC priorities into mandates will help ensure pediatric emergency care issues and/or deficiencies are being addressed state- or territory-wide for the long-term.

 

The EMSC Program Priorities:

1. EMS agencies are required to submit NEMSIS-compliant data to the state EMS Office.
2. EMS agencies in the state or territory have a designated individual who coordinates pediatric emergency care.
3. EMS agencies in the state or territory have a process that requires EMS providers to physically demonstrate the correct use of pediatric-specific equipment.
4. A statewide, territorial, or regional standardized system that recognizes hospitals that are able to stabilize and/or manage pediatric medical emergencies and pediatric trauma.
5. Hospitals in the state or territory have written interfacility trans­fer guidelines that cover pediatric patients and that include the following components of transfer:
   • Defined process for initiation of transfer, including the roles and responsibilities of the referring facility and referral center (including responsibilities for requesting transfer and communication).
   • Process for selecting the appropriate care facility.

• Process for selecting the appropriately staffed transport service to match the patient’s acuity level (level of care required by patient, equipment needed in transport, etc.).
• Process for patient transfer (including obtaining informed consent).
• Plan for transfer of patient medical record.
• Plan for transfer of a signed copy of transport consent.
• Plan for transfer of personal belongings of the patient.
• Plan for provision of directions and referral-institution information to family.

6. Hospitals in the state or territory have written interfacility trans­fer agreements that cover pediatric
7. Basic life support (BLS) and advanced life support (ALS) prehos­pital provider agencies in the state or territory have on-line and off-line pediatric medical direction available.
8. BLS and ALS patient-care units in the state or territory have the essential pediatric equipment and supplies, as outlined in the na­tionally recognized and endorsed guidelines.
9. Requirements adopted by the state or territory for pediatric con­tinuing education prior to the renewal of BLS and ALS licensing and/or certification.​