INTRODUCTION

Background

Responding to a 1993 Institute of Medicine Report (IOM) on emergency medical services for children, the Federal Emergency Medical Services for Children (EMSC) Program developed a comprehensive long-range strategy – the EMSC Five-year Plan, 1995-2000. By 1997, the EMSC Program completed many of the Plan’s proposed activities and collected baseline data for each objective. In 1998, the EMSC Five-year Plan: Midcourse Review was published as an update to the 1995 edition. The new data offered in this document presented a picture of unmet pediatric emergency care needs and revealed that yet more work needed to be done. In anticipation of the expiration of the first five-year plan, a new plan was developed in 2000 for the years 2001-2005. This report serves as a midcourse review of the EMSC Five-Year Plan, 2001-2005. Its purpose is to collect updated information and report on the progress made to date.

The EMSC Program has developed many elements of a model EMSC system, including prehospital protocols for triage and treatment of children and standards for hospital facilities accepting pediatric patients. While the EMSC Five-Year Plan, 2001-2005 continues to target the more traditional aspects of pediatric EMS system development, it also addresses, for the first time, such contemporary and emerging issues as telehealth applications, mental health issues, research, economic analyses, program evaluation, and cultural competency.

Development of the Current Five-Year Plan

During an 18-month period, numerous organizations and individuals – including Federal agencies, national health care professional organizations, parents, health care payors, researchers, educators, and others – were involved in developing the new plan that established the goals, objectives, and action steps to be pursued on behalf of EMSC.

The EMSC National Resource Center (NRC), with direction from its National Steering Committee, established a framework for the new plan – one that would flow from the previous five-year plan and incorporate objectives that are measurable for the Federal EMSC Program, yet meaningful to the Nation. It was the Committee’s intention that this document would provide guidance to the EMSC Program, prioritize national activities, and guide the integration of EMS for children into the vision of the broader EMS system.

To assist the NRC with plan development, the Committee established six task forces:

• Human Resources, System Finance, Legislation and Regulation
• Communications, Public Access
• Public Education, Professional Education
• Medical Direction, Clinical Care, Integration of Health Services
• Research, Evaluation, Information Systems
• Health Promotion, Prevention

Each task force included a minimum of three topic-related experts and one NRC staff member. Convening twice in 1999, experts reviewed existing objectives for revision or deletion, and also developed new objectives.

Coinciding with events surrounding the 2000 National Congress on Childhood Emergencies, a newly developed five-year draft plan was posted to the EMSC web site for a 60-day public comment period. In addition, 200 targeted reviewers received hard copies of the plan for their consideration. Immediately following the comment period, public recommendations were integrated, baseline data were collected for each objective, and the final EMSC Five-year Plan, 2001-2005 was produced.

Leadership and Responsibility

Although many of the objectives and action steps included in the second five-year plan were intended to be carried out through the EMSC Program, the improvements the pediatric experts envisioned could only be accomplished through the coordinated efforts of many other groups and organizations. Therefore, this plan should be considered a strategic plan for both the EMSC Program and the Nation.

Taking this into account, the EMSC Five-Year Plan Task Forces and the National Steering Committee offered recommendations on leadership and responsibility for each objective, indicating for which objectives the EMSC Program should have primary leadership or responsibility and for which objectives other agencies or organizations should have primary leadership or responsibility.

Architects of the current five-year plan recognized that the EMSC Program and the EMSC community should work in harmony with the existing efforts of other entities to ensure a coordinated, cooperative approach – one that seeks to avoid duplication of effort and remain consistent with priority issues and activities identified by EMSC’s partner agencies and organizations.

Below is a breakout of the 45 objectives that make up the current five-year plan with the corresponding recommendation of the EMSC Five-Year Plan Task Forces and the EMSC National Steering Committee on primary leadership and responsibility:

Objectives for which the Five-Year Plan Task Forces and the National Steering Committee assigned the EMSC Program primary leadership or responsibility:

A-1, A-2, A-3, A-6, A-7, A-8, B-1, B-2, B-6, C-1, C-2, C-3, C-4, D-1, D-2, E-1, E-2, F-1 , F-3, F-6, F-8, F-9, G-1, G-2, H-1, K-1, K-2

Objectives for which the Five-Year Plan Task Forces and the National Steering Committee assigned other agencies/organizations primary leadership or responsibility, but advised strong support of these entities by the EMSC Program and/or the EMSC community:

A-4, A-5, B-3, B-4, B-5, B-7, B-8, F-2, F-4, F-5, F-7, I-1, I-2, I-3, I-4, J-1, J-2, K-3

Progress At-a-Glance

At the time of the midcourse review, progress on the plan’s objectives and related activities varied greatly – with some objectives achieving significant or moderate progress and others gaining little or no advancement.

Concerning some objectives for which little or no progress was made – it is important to keep in mind that the current five-year plan was developed prior to the events of September 11, 2001. Consequently, agency and organization resources and activities may have been redirected in response to the changing priorities and issues that came about as a result of this Nation-altering experience.

SIGNIFICANT PROGRESS: A-1, A-3, A-6, A-7, B-1, B-6, C-1, E-1, E-2, F-1, F-3, F-4, F-5, F-8, G-1, G-2, H-1, J-1, K-1

MODERATE PROGRESS: A-2, B-2, B-8, C-3, C-4, D-2, I-1, J-2, K-2, K-3

LITTLE OR NO PROGRESS: A-4, A-5, A-8, B-3, B-4, B-5, B-7, C-2, D-1, F-2, F-6, F-7, F-9, I-2, I-3, I-4

How Progress Is Measured

For the purposes of evaluating progress made thus far on the goals and objectives of the five-year plan, the following criteria were established:

Significant Progress: Attributed to objectives for which either (a) at least 75% of the recommended activities were accomplished and/or (b) the objective was achieved completely as measured by the indicator.

Moderate Progress: Attributed to objectives for which either (a) at 50% of the recommended activities were accomplished and/or (b) the objective was not achieved fully as measured by the indicator, but efforts to reach this objective were initiated.

Little or No Progress: Attributed to objectives for which either (a) less than 50% of the recommended activities were accomplished and/or (b) the objective was not achieved as measured by the indicator.

Definitions for the Purposes of this Document

Baseline Data: Objectives need a target (the desired end point or amount of change, reflected by a number or percentage) and a baseline (where the community is now). Exceptions include policy or organizational objectives that can be measured simply by being established. If data are not available about a particular priority area, it is important to determine if there are alternative types of data available or ones that realistically can be developed. (Athey, J., Report on EMSC 5-Year Plan, 1995-2000; 2001). Baseline data were collected and reported in 2000 and 2003.

EMSC Partnership Grant: Through its Partnership grants, the EMSC Program funds activities that represent the next logical steps to improve, refine and institutionalize EMSC in a state.

EMSC Targeted Issue Grant: The EMSC Program-funded “Targeted Issues” grants focus on special pediatric EMS system development issues that are of regional or national concern. These grants have addressed such topics as quality improvement, the development of multimedia EMS training materials, managed care, and children with special health care needs (CSHCN). More recently, research grants have also supported national EMSC interests.

EMS Partnership for Children: In 1996, the EMSC Program developed a new initiative, the EMS Partnership for Children (PFC), a multi-disciplinary consortium of national and professional organizations contracted by the Health Resources and Services Administration's Maternal and Child Health Bureau to help implement the Program's Five-Year Plan.

Indicator: The method or measurement that is used to evaluate achievement of the objective.

Objective: An objective narrows the goal by specifying who, what, when, and where or clarifies by how much, how many, or how often. It offers measurable milestones or targets. An objective is very specific–it clearly identifies what is to be achieved. (Athey, J., Report on EMSC 5-Year Plan, 1995-2000; 2001)

OBJECTIVE A-1: Increase to 100% the number of hospital emergency departments (EDs) that have the essential equipment and resources for the stabilization of ill and injured children.

Indicator: Percentage of hospital EDs with the essential equipment and resources for the stabilization of ill and injured children (as defined by the EMSC/U.S. Consumer Product Safety Commission or CPSC survey).

2000 Baseline Data: Most U.S. hospital EDs surveyed reported having all the basic equipment needed for monitoring a child. However, some hospital EDs reported not having the following equipment: pulse oximeter with newborn sensor size (12%), neonatal-size blood pressure cuffs (14%), 19-gauge butterfly needles (11%), 24-gauge long catheter-over-needle devices (43%), intraosseous needles, Seldinger vascular access kit–size 3Fr (75%), umbilical vein catheters–size 3.5 Fr (41%) and size 5Fr (37%), preterm-size oxygen masks (37%), infant-size mask (9%), infant-size rebreathing mask (31%) and child-size rebreathing mask (13%), infant-size nasal cannulae (25%), pediatric Magil forceps (31%), smallest size nasogastric tube (25%), several sizes of chest tubes (48%), all sizes of tracheostomy tubes (38%), and infant cervical immobilization equipment (33%).

2003 Baseline Data: Of those responding to the 2001 and 2003 National EMSC Grantee Assessments, 14 States and Territories (AZ, CO, DC, DE, GA, HI, IA, MN, MS, NH, NJ, NY, UT, and WI) indicated having at least 44% of EDs approved for pediatrics of the total number of EDs in the State or Territory.^[1]

Current Status of Objective A-1: In 2001, EMSC and the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) developed, tested, and applied the EMSC Survey Supplement to the National Hospital Ambulatory Medical Care Survey (NHAMCS) instrument, allowing for a larger, more general sample than the previous National Electronic Injury Surveillance System (NEISS) studies. Piloted in 2001, the instrument allowed for formal data collection for two years, 2002 through 2003. A draft report was developed in March 2004.

Other efforts in support of this objective include:

• The EMSC Program funded three new EMSC Special Initiative grants; two “Clinical Practice Guidelines for Emergency Care of Children” and one “Enhancing Pediatric Patient Safety,” which provides training programs in the safe use of pediatric-specific equipment;
• The Program identified and distributed available pediatric ED equipment and medication guidelines, including the equipment guidelines developed by the American College of Emergency Physicians (ACEP);
• Through its PFC project, the American Academy of Pediatrics (AAP) and ACEP convened a consensus meeting to review/revise the “1998 Guidelines for Pediatric Equipment and Supplies for Emergency Departments;"
• Through its PFC project, the AAP and ACEP implemented ED care of children guidelines and organized a joint AAP-ACEP meeting;
• The EMSC Program provided support to help the AAP and ACEP evaluate and release Care of Children in the ED: Guidelines for Preparedness (RE069904), 2001.
• The EMSC Program provided assistance to the American Trauma Society to develop and evaluate a program that is designed to improve the communications and support provided to families stricken by life-threatening injury or sudden illness;
• The Program supported the National Association of Social Workers’ (NASW) efforts to disseminate and implement bereavement practice guidelines for social workers providing services in the ED; and
• The EMSC Program provided support to NASW to revise, implement, and evaluate a bereavement practice guidelines training program for social workers in the ED.

Progress of Objective A-1: Significant

OBJECTIVE A-2: Increase to 100% the number of hospitals that have written interfacility transfer agreements and guidelines for ill and injured pediatric patients consistent with EMTALA (Emergency Medical Treatment and Active Labor Act).

Indicator: Percentage of hospitals with EDs with written interfacility transfer agreements for pediatric patients.

2000 Baseline Data: Fifty-one percent of the hospitals with EDs surveyed reported having written interfacility transfer agreements.

2003 Baseline Data: Of those responding to the 2003 National EMSC Grantee Assessment, 13 States and Territories (AK, DC, DE, HI, ID, MD, MN, MS, MT, NH, NM, UT, and WA) indicated that 51% of hospitals with EDs had pediatric interfacility transfer agreements.^[2]

Current Status of Objective A-2: Through two EMSC-funded Targeted Issues grants (PA, IL), information on existing interfacility transfer agreements and research on transport team composition was compiled and analyzed, and model interfacility transfer agreements and transport team composition guidelines were disseminated. Looking ahead to 2004, the EMSC Program plans to convene an ED diversion meeting that may consider the development of an assessment tool/decision tree.

Progress of Objective A-2: Moderate

OBJECTIVE A-3: Increase to 56 the number of States, Tribal Reservations, or Federal Territories that have adopted and disseminated pediatric guidelines that categorize acute care facilities with the equipment, drugs, trained personnel, and facilities necessary to provide varying levels of pediatric emergency and critical care.

Indicator: Number of States that have implemented pediatric guidelines for acute care facility identification.

2000 Baseline Data: In 1996, 11 States had adopted and disseminated pediatric guidelines that categorize acute care facilities with the equipment, drugs, trained personnel, and facilities necessary to provide varying levels of pediatric emergency and critical care.

2003 Baseline Data: In 2003, 18 States and Territories (AR, CA, GA, HI, IA, IL, MA, MO, MS, NE, NH, NJ, NY, OK, PA, TN, UT, and WA) had adopted and disseminated pediatric guidelines that categorize acute care facilities with the equipment, drugs, trained personnel, and facilities necessary to provide varying levels of pediatric emergency and critical care.^[3]

Current Status of Objective A-3: EMSC funding of an AAP-ACEP project is addressing integration of pediatric facilities categorization guidelines and implementation of the guidelines by hospitals and the EMS system.

Other activities in support of this objective include:

• Through the NRC, the Program provided technical assistance to States and other entities on implementation of the guidelines; and
• The NRC also disseminated documents that identify existing guidelines and implementation methods (e.g., definitions of recognition, designation, and verification), including State guidelines such as those developed by California.

Progress of Objective A-3: Significant

OBJECTIVE A-4: Increase by 10 the number of telehealth projects focused on pediatric trauma and medical care.

Indicator: Number of telehealth projects focused on pediatric trauma and medical care.

2000 Baseline Data: The Health Resources and Services Administration’s (HRSA) Office for the Advancement of Telehealth (OAT) required all 18 of its rural telemedicine grantees to have an emergency medicine services component. Of these, 12 telehealth projects (CA, KY, HI, MA, ME, MO, NC, ND, NE, NV, OK, and WA) addressed aspects of pediatric trauma and medical care.

2003 Baseline Data: In FY 2002, 23 OAT grant programs provided or planned to provide emergency/trauma telehealth services and, of these, 14 provided or planned to provide pediatric and emergency care. These programs were in AL, AK (2), CA, IL, KY, HI, MT, NC, PA, SD, UT, WA, and WI. Thirty-one programs provided or planned to provide pediatric care using telehealth technologies. These programs were in AL, AK (2), AR, CA (2), GA, HI, IL, KS, KY, LA, ME, MI, MO, MT (2), NC, NE, NM, NY, OK, PA (2), SC, SD, TN, VA, VT, WA (2), and WI.^[4] In 2003, OAT no longer required grantees to provide emergency/trauma care and did not explicitly track which programs provided pediatric versus adult emergency care via telehealth.

Current Status of Objective A-4: EMSC-supported activities related to this objective were limited to offering a training session on telehealth at the 2002 National Congress. However, the EMSC Program has designated specific telehealth-related work for the NRC, beginning in FY 2004.

Progress of Objective A-4: Little

OBJECTIVE A-5: Develop an evidence-based practice guideline for referral of pediatric patients to rehabilitation during the acute care phase.

Indicator: Practice guideline is developed.

2000 Baseline Data: No known practice guideline existed.

2003 Baseline Data: As of 2003, the American Academy of Physical Medicine and Rehabilitation did not know of specific guidelines concerning referral of pediatric patients to rehabilitation during the acute care phase. The Academy indicated that national standards did exist for trauma centers, which mandated referral to physical medicine and rehabilitation. According to other national experts on this topic, neither evidence-based guidelines nor significant study reports existed on this particular issue.^[5]

Current Status of Objective A-5: In FY 2002, EMSC funded the Targeted Issues grant (AR), “Coordinating Discharge Care for Children with Injury and Special Health Care Needs.”

Progress of Objective A-5: Little

OBJECTIVE A-6: Develop for primary care providers a consensus guideline on pediatric equipment, medication, supplies, and training, for the stabilization of ill and injured children.

Indicator: Consensus guideline is developed.

2000 Baseline Data: No consensus guideline existed.

2003 Baseline Data: In FY 2002, the EMSC Program funded the Outcomes Based Office Practice Emergency Self Assessment Tool. The Program also helped to fund the production of the Preparedness for Emergency Response to Children (PERC) CD-ROM, which is available through the EMSC Clearinghouse.^[6]

Current Status of Objective A-6: PERC project coordinators convened a consensus meeting to identify barriers to emergency preparedness and to define essential guidelines for pediatric emergency equipment, medication, supplies, and training for the office setting and initiated dissemination of educational programs that address primary care office practices during unexpected, acute pediatric illnesses and injuries.

Other activities in support of this objective include:

• The EMSC Program provided support to help the Ambulatory Pediatric Association develop guidelines on parent/caretaker presence during procedures and cardiopulmonary resuscitation (CPR); and
• The Program provided support to help ACEP promote the process for the development of evidence-based clinical guidelines on pediatric sedation and analgesia in the ED.

Progress of Objective A-6: Significant

OBJECTIVE A-7: Develop model emergency department protocols to treat the variety of child and adolescent mental health problems.

Indicator: Number of model protocols developed.

2000 Baseline Data: No known protocols existed.

2003 Baseline Data: The CPSC Children's Mental Health Survey collected pilot data on children presenting to EDs for mental health reasons using NEISS hospitals for a pilot sample. Final data results were reported to HRSA’s Maternal and Child Health Bureau (MCHB) in October 2001. Data were also presented at the 3rd National Congress on Childhood Emergencies, and a paper on this data will be submitted for publication.^[7]

Current Status of Objective A-7: Through the NEISS mental health survey, an analysis of ED records may be conducted to determine the type and frequency of mental health problems presenting in EDs.

Other efforts in support of this objective include:

• Through its PFC project, the National Association of EMS Physicians’ (NAEMSP) convened a consensus group to determine appropriate emergency treatments and follow-up and to develop model protocols for various mental health problems;
• The EMSC Program initiated Federal interagency collaborations to support mental health priorities, particularly EMSC-related research activities in partnership with the National Institute of Mental Health;
• The Program funded Targeted Issue grants (PA, DC) that focused on educating EMS professionals on the need for long-term follow up for mental health problems; and
• The Program promoted resources developed by organizations and individuals not affiliated with the EMSC Program, including “Detecting Suicide Risk in a Pediatric Emergency Department: Development of a Brief Screening Tool.” Horowitz, LM et al. Pediatrics 107(5): 1133–1137, May 2001.

Progress of Objective A-7: Significant

OBJECTIVE A-8: Develop tools for assessing the competence of health care providers* who provide emergency care to children assisted by technology. *Including, but not limited to: school nurses, home health nurses, emergency physicians, out-of-hospital providers, emergency nurses, and camp nurses.

Indicator: Number of tools developed for different health care provider groups.

2000 Baseline Data: No known tools existed.

2003 Baseline Data: No known tools existed.^[8]

Current Status of Objective A-8: As of 2003, EMSC had not sponsored any activity in support of this objective.

Progress of Objective A-8: None

OBJECTIVE B-1: Pediatric clinical experts shall participate in the process of developing core content, scope of practice, and education standards for out-of-hospital providers.

Indicator: Pediatric clinical experts are official representatives on all education committees outlined in the EMS Education Agenda for the Future.

2000 Baseline Data: In 1998, representatives from the National Highway Traffic Safety Administration (NHTSA) and HRSA-MCHB met to coordinate the process for developing the primary components of the EMS education system for the future as outlined in the EMS Education Agenda for the Future. In 2000, NHTSA work groups began development of the National EMS Core Content, National EMS Scope of Practice Model, and the National EMS Education Standards. Pediatric clinical experts had not yet been designated.

2003 Baseline Data: In 2003, the task forces for the National EMS Core Content and the Model Scope of Practice Model included pediatric representatives. A statement concerning pediatric input was included in the National EMS Education Standards. Development of the National EMS Education Standards had not yet begun.^[9]

Current Status of Objective B-1: In 2003, activities initiated in support of this objective included plans to: convene a multi-disciplinary consensus panel to review literature and practice to identify pediatric core content and core competencies in association with the revision cycle of the EMS Education Agenda for the Future; provide funding for pediatric clinical experts to participate on education committees outlined in the EMS Education Agenda for the Future; and include pediatric skills and knowledge in core content for out-of-hospital providers at all levels.

Other activities in support of this objective include:

• The EMSC Program provided support to help the AAP promote the development of uniform pediatric first aid, safety, and CPR training materials for child-care providers;
• The Program provided support to help the National Council of State EMS Training Coordinators (NCSEMSTC) analyze available data and current literature on degradation of skills to assess the status of national pediatric prehospital continuation education as it relates to certificate/license renewal training requirements and retention of skills;
• The Program provided support to help NCSEMSTC organize a consensus meeting to develop recommendations for future pediatric continuing education requirements; and
• The Program helped NCSEMSTC to develop recommendations for refresher training and continuing medical education on such pediatric skills and knowledge.

Progress of Objective B-1: Significant

OBJECTIVE B-2: Develop tools for assessing the competence of out-of-hospital providers in pediatric emergency care.

Indicator: Number of tools developed.

2000 Baseline Data: No known tools existed.

2003 Baseline Data: Of those responding to the 2003 National EMSC Grantee Assessment, 11 States and Territories (CT, LA, MI, NV, OH, TX, VI, VT, WA, WI, and WY) indicated pediatric education requirements as a condition of recertification for first responders; 24 (AL, AR, CT, FL, IL, LA, MD, MI, MS, NC, NV, OH, OK, OR, RI, SD, TN, TX, VA, VI, VT, WA, WI, and WY) indicated these requirements for EMT-B; 23 (AL, AR, CT, DC, IL, LA, MD, MI, MS, NC, NV, OH, OK, RI, SD, TN, TX, VA, VI, VT, WA, WI, and WY) for EMT-I; and 31 (AL, AR, CT, DC, DE, FL, ID, IL, IN, LA, MD, MI, MS, NC, NH, NM, NV, OH, OK, OR, RI, SD, TN, TX, UT, VA, VI, VT, WA, WI, and WY) for EMT-P.^[10]

Current Status of Objective B-2: NCSEMSTC’s PFC contract will assess current recertification programs and practices.

Other activities in support of this objective include:

• The EMSC Program provided funds to help produce and distribute the Paramedic TRIPP (Teaching Resources in Prehospital Pediatrics) CD-ROM in FY 2002; and
• NHTSA’s EMS Education for Future Model Scope of Practice work plan includes a recommendation to convene a task force to identify core pediatric competency measures.

Progress of Objective B-2: Moderate

OBJECTIVE B-3: Specific objectives for pediatric emergency care shall be integrated into pediatric nursing core curricula.

Indicator: Learning objectives for pediatric emergency care developed by nursing leadership.

2000 Baseline Data: In 2000, the Board of Certification for Emergency Nursing required learning objectives in pediatric emergency care.

2003 Baseline Data: In 2003, the Board of Certification for Emergency Nursing required learning objectives in pediatric emergency care.^[11]

Current Status of Objective B-3: The core curriculum for pediatric emergency nursing was published in 2003. The International Council on Disaster Nursing Education included some pediatric disaster-related content. However, national experts on this issue are not aware of any efforts to study, include, or expand on pediatric emergency care in undergraduate or graduate curriculum.

Other activities in support of this objective include:

• The EMSC Program provided funds to help the National Association of School Nurses (NASN) extend pediatric emergency medical training to school nurses in rural areas;
• With EMSC Program support, NASN advanced the process for the development and evaluation of a disaster preparedness curriculum for school nurses and the development of a tool to track injuries that occur in school settings; and
• The Program provided support to help NASN to: disseminate the Disaster Preparedness School Nurses’ course nationally using current instructors; educate 20 school nurses as new Disaster Preparedness for School Nurses instructors/facilitators; and pilot its injury-tracking tool for school injuries.

Progress of Objective B-3: Little

OBJECTIVE B-4: Specific objectives for pediatric emergency care shall be integrated into physician and dental residency and fellowship programs*. *Including family practice, surgery (orthopedics, plastics, general, and trauma), anesthesia, radiology, psychiatry, obstetrics, orthopedics, physiatry, pediatrics, emergency medicine, and neurology.

Indicator: Objectives developed by physician leadership.

2000 Baseline Data: In 2000, the Accreditation Council for Graduate Medical Education (ACGME) approved 35 pediatric emergency medicine fellowships. ACGME required pediatric emergency care as part of the Program Requirements for Residency Education in Emergency Medicine, Pediatrics.

2003 Baseline Data: In 2003, ACGME accredited seven pediatric emergency medicine programs. ACGME required pediatric emergency care as part of the Program Requirements for Residency Education in Emergency Medicine, Pediatrics.^[12]

Current Status of Objective B-4: In 2003, the program requirements for pediatric surgery training only required the availability of a pediatric emergency room where the pediatric surgeons serve as consultants, especially for pediatric trauma patients and children with burns. Requirements for rotations in the pediatric ED for pediatric surgery residents or general surgery residents did not exist.

Other efforts in support of this objective include:

• The EMSC Program supported the Pediatric Emergency Medicine Fellows Annual Meeting; and
• The AAP’s Committee on Pediatric Emergency Medicine worked to determine the status of pediatric emergency management training in residency and fellowship programs.

Progress of Objective B-4: Little

OBJECTIVE B-5: Specific objectives for pediatric emergency care shall be integrated into core curricula for nurse practitioner and physician assistant health professionals caring for children.

Indicator: Educational objectives for pediatric emergency care developed by nurse practitioner and physician assistant health leadership.

2000 Baseline Data: In 2000, learning objectives existed within nurse practitioner core curricula approved by the Association of Faculties of Pediatric Nurse Practitioner Programs. Physician assistants’ programs accredited by the Commission on Accreditation of Allied Health Education Programs did not include pediatric emergency care learning objectives.

2003 Baseline Data: Learning objectives existed within nurse practitioner core curricula approved by the Association of Faculties of Pediatric Nurse Practitioner Programs.^[13]

Current Status of Objective B-5: In 2003, the Accreditation Review Commission for the Physician Assistant did not require pediatric emergency care learning objectives.

Progress of Objective B-5: None

OBJECTIVE B-6: Convene a biennial national conference on EMSC topics.

Indicators: (1) Documentation of meetings. (2) Evaluation summary.

2000 Baseline Data: The EMSC Program has convened two national conferences since 1998: the National Congress on Childhood Emergencies, “Community Partnerships, Clinical Care, and Policy,” in Washington, DC, 1998 and the National Congress on Childhood Emergencies, “Giving America’s Children Our Best,” in Baltimore, MD, 2000.

2003 Baseline Data: The EMSC Program convened a third National Congress on Childhood Emergencies, Taking Action Saving Lives, in Dallas, TX, 2002.^[14]

Current Status of Objective B-6: For the 2002 National Congress, a master plan was developed and implemented, a national planning committee was convened to identify the educational priorities for the biennial conference, and the program was marketed to all target audiences. Work to utilize an evaluation tool to assess overall meeting objectives was initiated. No further plans for a biennial National Congress exist, but the EMSC Program plans for a special 20-year anniversary celebration in 2005.

Progress of Objective B-6: Significant

OBJECTIVE B-7: Increase by 10 the number of pediatric emergency telehealth education opportunities.

Indicator: Number of telehealth opportunities.

2000 Baseline Data: In 2000, HRSA-OAT funded six telehealth projects that focused on educational training in pediatric trauma and/or medical care in seven States: AK, CA, KY, MO, ND, NE, and WA.

2003 Baseline Data: In FY 2002, 24 HRSA-OAT grantees (AL, AK, CA, GA, HI, IL, KS, LA, ME, MI, MO, MT, NC, NM, OK, PA, SC, SD, TN, UT, VT, VA, and WA^[15]) provided both pediatric care and distance education programs using telehealth technologies.

Current Status of Objective B-7: EMSC-supported activity related to this objective was limited to offering a training session on telehealth at the 2002 National Congress. However, the EMSC Program has designated specific telehealth-related work for the NRC, beginning in FY 2004.

Progress of Objective B-7: Little

OBJECTIVE B-8: Improve the education of EMS providers in injury prevention by integrating injury prevention into the National EMS Education System.

Indicators: (1) Injury prevention is included in the National EMS Core Content. (2) Injury prevention is included in the National EMS Scope of Practice Model. (3) Injury prevention is included in the National EMS Education Standards.

2000 Baseline Data: The National EMS Core Content is a comprehensive list of skills and knowledge needed for out-of-hospital emergency care. The document’s first draft, developed in 1999, included information on illness and injury prevention under the section “Preparatory and Operations”. Its inclusion assures that injury prevention will be integrated into the primary training courses for EMS out-of-hospital providers of all levels. In 2000, NHTSA began to develop courses based on National EMS Core Content.

2003 Baseline Data: Of those responding to the 2003 National EMSC Grantee Assessment, 49 States and Territories (AL, AK, AZ, AR, CA, CO, CT, DE, FL, GA, GU, HI, IA, ID, IL, IN, LA, MA, MD, ME, MI, MN, MO, MP, MS, MT, NC, ND, NE, NH, NJ, NM, NY, OH, OK, OR, PA, PR, RI, SC, SD, TN, TX, UT, VT, VA, WA, WI, and WY) indicated that EMS providers are utilized for injury prevention activities.^[16]

Current Status of Objective B-8: In 2003, injury prevention for EMS providers was included in the National EMS Core Content, and was under consideration for inclusion in the National Scope of Practice Model. Work to integrate injury prevention into the National EMS Education Standards has not yet begun.

Other efforts in support of this objective include:

• Through its National Heroes Award Program, EMSC established an award recognizing injury prevention community outreach by out-of-hospital EMS providers; and
• The NRC initiated the collection and dissemination of model injury prevention primary training and continuing education courses for EMS providers.

Progress of Objective B-8: Moderate

OBJECTIVE C-1: Increase the infrastructure for conducting research and evaluation of pediatric emergency services.

Indicators: During a 12-month period: (1) Number of publications. (2) Number of research grant applicants. (3) Number of new investigators. (4) Amount of Federal funding awarded.

2000 Baseline Data: In 1996, 63 research studies on pediatric emergency medicine were published. Approximately 218 researchers were involved in conducting these studies. As of FY 2000, Federal funding for EMSC research priorities had not been established.

2003 Baseline Data: Between 2001 and 2003, 266 research studies on pediatric emergency medicine were published. In FY 2001, $1.8 million was set aside to develop the Network Development Demonstration Projects (NDDP).^[17] The projects support regional pediatric EMS research nodes in California, Michigan, New York, and Washington, DC. To facilitate data sharing between regions, representatives from each node serve on the Pediatric Emergency Care Applied Research Network (PECARN). To date, two manuscripts and three abstracts have been published and six grant applications have been submitted through PECARN. An additional six abstracts are awaiting publication. One project funded by the National Institute of Child Health and Human Development and HRSA-MCHB is underway. Fifty-one new investigators have joined PECARN. Twenty-five collaborating EDs also participate in the Network.

Current Status of Objective C-1: As of FY 2003, EMSC has convened three Interagency Committee on EMSC Research (ICER) meetings, held annually.

Other activities in support of this objective include:

• The EMSC Program supported the Ambulatory Pediatric Association to evaluate the results of a conference on pediatric emergency medicine outcomes research and organize a consensus meeting to plan a validation study of new outcomes measures.
• Through its PFC project, the Emergency Nurses Association (ENA) developed and evaluated a research curriculum for nurses associated with the four NDDPs;
• The Program funded the development of the Central Data Management Coordinating Center;
• EMSC worked with NHTSA to ensure that the National EMS Research Agenda included priority research issues relating to EMSC;
• The EMSC Program provided support to NAEMSP to develop and evaluate a curriculum for a pediatric emergency care research workshop;
• The National EMSC Data Analysis Resource Center (NEDARC) conducted a three-day scientific grant writing workshop to help grantees and EMS researchers become more familiar with the grant writing process and to receive feedback on their grant proposals;
• NEDARC conducted an EMSC research workshop in conjunction with the Annual EMSC Grantee Meeting, which featured in-depth discussions and interactive exercises on research design, statistics, writing techniques, and current trends in EMSC-related literature; and
• NAEMSP conducted a new investigator research workshop at its 2004 Annual Meeting.

Progress of Objective C-1: Significant

OBJECTIVE C-2: Increase by 5 the number of studies that identify the impact of payment mechanisms on the cost and quality of pediatric emergency medical services.

Indicator: Number of studies.

2000 Baseline Data: Five studies were conducted to identify the impact of payment mechanisms on the cost and quality of pediatric emergency medical services.

2003 Baseline Data: As of 2003, one additional study was conducted, EMSC Targeted Issues grant “Economic Evaluation of Intensive Care Services for Pediatric Trauma Injury Patients” (AR).^[18]

Current Status of Objective C-2: The NRC initiated efforts to promote uniformly defined quality indicators for pediatric emergency medical services through National Committee for Quality Assurance. The Center also started to develop Pediatric Health Plan Employer Data and Information Set (HEDIS) indicators.

Progress of Objective C-2: Little

OBJECTIVE C-3: Increase by 5 the number of economic analyses of pediatric emergency medical services.

Indicator: Number of economic analyses published in peer-reviewed journals.

2000 Baseline Data: Three economic analyses of pediatric emergency medical services were conducted.

2003 Baseline Data: No new studies were conducted to identify the impact of payment mechanisms on the cost and quality of pediatric emergency medical services.^[19]

Current Status of Objective C-3: The EMSC Program recruited new Federal agency partners to participate in the EMSC research Program Announcement to make EMSC research a funding priority.

Other activities in support of this objective include:

• The EMSC Program will address current knowledge and needs concerning pediatric emergency medical system economic issues when it convenes a national ED diversion meeting through ACEP in 2004; and
• The EMSC Program and its resource centers initiated collaborations between EMSC and economic researchers to conduct studies.

Progress of Objective C-3: Moderate

OBJECTIVE C-4: Increase by 5 the number of evaluations of components and care processes of the pediatric emergency system.

Indicator: Number of research studies published in peer-reviewed journals.

2000 Baseline Data: In 2000, the Federal EMSC Program Funding Announcement included Targeted Issue grant funding to evaluate the components of the EMS system for children and two evaluations of components and care processes of the pediatric emergency system.

2003 Baseline Data: Two manuscripts were published with official PECARN authorship.^[20]

Current Status of Objective C-4: For FY 2004, a new Program Announcement in support of EMSC research will include support for evaluation of the components of the EMS system for children.

Other efforts in support of this objective include:

• The EMSC Program initiated support for studies that examine system continuity/transfer between components;
• Through its Clinical Practice Guideline grants, the EMSC Program supported the development of clinical practice guidelines and analyses of their impact on outcome in pediatric emergency services;
• By supporting work to define core pediatric data elements, the EMSC Program encouraged analysis of the impact of regional trauma systems on pediatric outcome;
• The EMSC Program provided support to the AAP and ACEP to evaluate the impact of their jointly published policy statement titled, “Care of Children in the Emergency Department: Guidelines for Preparedness,” as well as the reasons some hospitals may not wish to implement the guidelines;
• The Program provided support to help the American Pediatric Surgical Association develop specific national, evidence-based quality measures that are applicable across the continuum of care for certain injuries common among children;
• The EMSC Program supported NAEMT’s efforts to direct the process for the evaluation of the JumpSTART Pediatric Triage Algorithm; and
• The 2002 and 2003 Annual EMSC Grantee Meetings included sessions on program evaluation methodology.

Progress of Objective C-4: Moderate

OBJECTIVE D-1: Produce a tool for EMS providers that will enhance their abilities to provide culturally and linguistically appropriate emergency medical services.

Indicator: Tool is developed.

2000 Baseline Data: No known tool.

2003 Baseline Data: No known tool.^[21]

Current Status of Objective D-1: In 2003, HRSA sponsored the Cross Cultural Communication in Health Care: Building Organizational Capacity Broadcast, which included information on "Errors in Medical Interpretation and Their Potential Clinical Consequences in Pediatric Encounters". Flores, G, et al., Pediatrics, 2003, 111: 6-14. The Robert Wood Johnson Foundation sponsored regional workshops, titled A Practical Guide to Culturally and Linguistically Appropriate Services in Health Services Delivery.

Other activities in support of this objective include:

• The EMSC Program supported NAEMT’s efforts to develop “On the Same Team,” a CD-ROM to assist prehospital care providers in becoming more proficient in engaging family members in the care of their loved ones;
• The American Trauma Society created “2nd Trauma,” which focuses on how to provide support to families when a child suffers a life-threatening injury or sudden illness; and
• The AAP’s National Center of Medical Home Initiatives included topics on cultural and linguistic awareness.

Progress of Objective D-1: None

OBJECTIVE D-2: Increase to 56 the number of States, Tribal Reservations, or Federal Territories that have established critical incident stress management programs for EMS providers caring for children.

Indicators: (1) Number of States having critical incident stress management programs for out-of-hospital providers. (2) Number of trauma centers caring for children having critical incident stress management programs for hospital staff.

2000 Baseline Data: In 2000, nine States (CT, IL, LA, MD, ND, TN, WA, WI, and WY) reported having established critical incident stress management programs for EMS providers caring for children.

2003 Baseline Data: In 2003, 20 States report having established critical incident stress management programs for EMS providers caring for children: CA, CT, ID, IL, LA, MD, ME, MN, MT, ND, NE, NJ, NY, OK, PA, TN, VA, WA, WI, and WY.^[22]

Current Status of Objective D-2: In FY 2002, an American Psychological Association’s PFC project convened a consensus panel to review literature on the impact and effectiveness of critical incident stress management.

Other activities in support of this objective include:

• Paramedic TRIPP includes a section on critical incident stress management for EMS providers; and
• A Point-Counterpoint session conducted at NAEMSP’s January 2004 meeting focused on the education of out-of-hospital and hospital-based EMS providers as it relates to the need for and benefits of critical incident stress management.

Progress of Objective D-2: Moderate

OBJECTIVE E-1: Increase to 56 the number of States, Tribal Reservations, or Federal Territories that have conducted an EMSC needs assessment within the last 5 years.

Indicator: Number of States with completed needs assessments within the last 5 years.

2000 Baseline Data: In 2000, 24 States, Tribal Reservations, or Federal Territories had conducted an EMSC needs assessment within the last five years.

2003 Baseline Data: Of those responding to the 2003 National EMSC Grantee Assessment, 36 States and Territories (AK, AL, AR, AZ, CO, CT, DE, FL, GU, HI, IA, ID, IL, IN, LA, MD, MI, MN, MS, MT, NE, NJ, NM, NV, NY, NC, ND, OH, OR, SD, TN, UT, VA, VI, WA, and WI) indicated they had conducted an EMSC needs assessment with in the last five years. ^[23]

Current Status of Objective E-1: The EMSC Program requires all EMSC State System grantees to complete the EMSC needs assessment and identify pediatric emergency care gaps.

Other efforts in support of this objective include:

• The NRC provided ongoing technical assistance to States to support needs assessment activities;
• The EMSC Program required its State System grantees to collect new core assessment data elements; and
• NEDARC provided ongoing technical support to State System grantees on data collection and analysis activities.

Progress of Objective E-1: Significant

OBJECTIVE E-2: Increase to 56 the number of States, Tribal Reservations, or Federal Territories that disseminate information about pediatric issues using statewide EMS data collection systems.

Indicator: Number of States reporting pediatric EMS data.

2000 Baseline Data: Ten States disseminated information about pediatric issues using statewide EMS data collection systems.

2003 Baseline Data: According to the 2001 National EMSC Grantee Assessment Annual Report, 42 States and Territories (AK, AL, AR, CA, CO, CT, DC, DE, FL, GA, IA, ID, IL, IN, KS, KY, LA, MI, MN, MO, MS, MT, NC, ND, NE, NH, NM, NY, OH, OK, OR, PA, RI, SC, SD, TN, UT, VA, VT, WA, WV, and WY) reported having a standardized EMS run sheet and a statewide, computerized EMS data collection system. Thirty-six States and Territories (AL, AR, CA, CO, DC, DE, GA, IA, ID, IL, IN, KS, KY, LA, MI, MN, MO, MS, MT, NC, ND, NE, NH, NM, NY, OK, PA, RI, SC, SD, TN, UT, VT, WA, WV, and WY) reported producing reports on pediatric issues using statewide EMS data collection systems.^[24]

Current Status of Objective E-2: In FY 2002, EMSC funded NEDARC to provide technical assistance in how to use statewide EMS data collection systems and to support the development of NEMSIS, a national EMS database.

Other activities in support of this objective include:

• NEDARC conducted three Quality Improvement workshops to teach attendees about the quality improvement process, from problem identification and research design to data analysis and data communication;
• NEDARC participated in and taught the NHTSA EMS Information Systems (EMSIS) courses;
• NEDARC collaborated with the CDC to promote pediatric issues within Data Elements for Emergency Department Systems (DEEDS) 2.0;
• With Office of Management and Budget clearance, the EMSC Program required its grantees to complete a survey on their data reporting activities in 2001 and 2003;
• NEDARC compiled statistics on EMSC data issues and disseminated a report; and
• The Program established EMSC data issues as priority areas for FY 2002 and 2003 Partnership grants.

Progress of Objective E-2: Significant

OBJECTIVE F-1: Increase to 56 the number of States, Tribal Reservations, or Federal Territories participating in annual multi-State EMSC meetings for the promotion of interstate collaboration.

Indicators: (1) Number of multi-State EMSC meetings per year. (2) Number of States participating in at least one EMSC-focused multi-State meeting per year.

2000 Baseline Data: In 2000, five multi-State meetings were held: Central America Regional EMSC, Heartland EMS for Children, Intermountain Regional EMSC Coordinating Council, New England EMSC Region, and Southeastern EMSC Regional Conference. Thirty-four States (AL, AZ, CO, CT, FL, GA, ID, IL, IN, IA, KS, KY, ME, MA, MI, MN, MS, MO, MT, NE, NV, NH, NM, NC, ND, OH, RI, SC, SD, TN, VT, UT, WI, and WY) participated in these meetings.

2003 Baseline Data: In 2003, eight multi-State meetings were held – Pacific Rim EMSC, Central America Regional EMSC, Heartland EMS for Children, Mid-Atlantic Regional EMSC, Red River EMSC Alliance, Intermountain Regional EMSC Coordinating Council, New England EMSC Region, Southeast EMSC Regional Conference – representing all States and Territories.^[25]

Current Status of Objective F-1: In support of multi-State EMSC meetings, the EMSC Program established a program planning committee and a menu of priority EMSC topics from which meeting planners may select. The EMSC Program requested that States conducting multi-State EMSC meetings identify important decision-makers to attend multi-State meetings; disseminate information from multi-State meetings (web site, listserv) to stakeholders and decision-makers; invite Federal, regional office staff, and national EMSC program staff to attend meetings and provide updates; investigate Federal funding options for multi-State EMSC meetings; and seek supplemental funding (State, corporate, foundation) for the meetings.

Progress of Objective F-1: Significant

OBJECTIVE F-2: Pediatric emergency care shall be an integrated component of all health care delivery systems.

Indicator: Number of health plan report cards that include pediatric emergency care indicator(s).

2000 Baseline Data: No standardized Health Plan Employer Data and Information Set (HEDIS) 2000 measures existed for evaluating pediatric emergency care.

2003 Baseline Data: In 2003, the National Committee for Quality Assurance Health Plan Report Card’s standards for accreditation do not require pediatric emergency care indicators.^[26]

Current Status of Objective F-2: EMSC-related activity in support of this objective is limited to the NRC efforts to partner with health care providers, public health groups, consumers, health plans, payors, policy makers, and others to increase knowledge about the availability and appropriate use of EMS; and to collaborate with health plans, public and private payors, consumers, and providers to ensure that EMSC issues are addressed in emerging models of health care finance and delivery.

Other activities in support of this objective include:

• The EMSC Program provided support to help NAEMT direct the process for developing guidelines for pre-hospital care professionals responding to emergencies in the school setting.

Progress of Objective F-2: Little

OBJECTIVE F-3: Develop model emergency care plans for families of children with special health care needs (CSHCN) with 3 specific conditions. * *i.e., severe asthma, bronchopulmonary dysplasia, ventilator-assisted, tracheostomies, shunts and latex allergies, severe cardiac anomalies, brain injuries.

Indicator: Model emergency care plans exist for 3 specific conditions.

2000 Baseline Data: No known condition-specific emergency care plans existed.

2003 Baseline Data: In FY 2001, the EMSC Program developed the Special Initiative Grant on Clinical Practice Guidelines.^[27]

Current Status of Objective F-3: In FY 2001, the National Association of Children’s Hospitals and Related Institutions’ (NACHRI) PFC project convened a consensus group to identify essential elements of emergency care plans. The project also included work to compile and review emergency care plans for existing conditions and to disseminate these plans to the NACHRI network.

Other activities in support of this objective include:

• The EMSC Program funded a secondary NACHRI project that is charged with developing form templates reflecting the recommended components of emergency care plans for children with special health care needs – prevention and preparation for an emergency situation and identification and initial response to escalating symptoms;
• The EMSC Program funded a Targeted Issue grant on cardiac disease, titled “Emergency Preparedness for Infants with Significant Heart Disease” (MN); and
• The AAP supported a National Center of Medical Home Initiatives for CSHCN.

Progress of Objective F-3: Significant

OBJECTIVE F-4: Increase to 56 the number of States, Tribal Reservations, or Federal Territories that address pediatric aspects of care in their State trauma plans or system implementation guidelines.

Indicators: (1) Number of State trauma registries that include pediatric-specific elements data. (2) Number of States with plans for care of pediatric trauma patients within their trauma systems.

2000 Baseline Data: Twenty States and the District of Columbia reported having designated pediatric trauma centers. Twenty-four States and the District of Columbia had triage destination protocols. Twenty-eight States and the District of Columbia had pediatric interfacility transfer guidelines. Twenty States and the District of Columbia reporting have trauma registries that collect pediatric data.

2003 Baseline Data: In 2003, three States (IL, MO, and WA) reported having trauma registries that include pediatric-specific data elements. Five States (CA, IL, MO, NH, and WA) had plans for the care of pediatric trauma patients within their trauma systems, and three States (MI, NE, and WI) were in the process of completing their plans. ^[28] Of those responding to the 2003 National EMSC Grantee Assessment, 13 States and Territories (AK, DC, DE, HI, ID, MD, MN, MS, MT, NH, NM, UT, and WA) indicated that at least 51% of their hospitals with EDs have pediatric interfacility transfer agreements.^[29]

Current Status of Objective F-4: In FY 2002, EMSC funded two Special Initiative grants, titled National Trauma Registry for Injured Children (NTRC).

Other efforts in support of this objective include:

• The EMSC Program convened a consensus group to define the essential components of a coordinated system of pediatric injury care in December 2000. Proceedings from the meeting included recommendations to initiate the development of uniform pediatric trauma data elements for trauma registries, to promote utilization of uniform pediatric data elements in all trauma registries, and to encourage dissemination and adoption of essential pediatric injury care components to States and national organizations;
• In FY 2001, EMSC grantees received supplemental funding from the newly created Trauma-EMS Program to convene multidisciplinary groups of trauma stakeholders and to conduct three comprehensive statewide trauma-EMS surveys;
• The EMSC Program actively participated in the development of NHTSA’s Trauma Vision for the Future; and
• NEDARC worked with trauma registry representatives, researchers, and federal agencies to compare the uniformity of statewide and regional pediatric trauma registry inclusion criteria in all 50 states.

Progress of Objective F-4: Significant

OBJECTIVE F-5: Increase to 100% the number of States, Tribal Reservations, or Federal Territories that include pediatric issues in State emergency disaster plans.

Indicator: Number of States that include pediatric issues in their emergency disaster plans.

2000 Baseline Data: No States included pediatric issues in their State emergency disaster plans.

2003 Baseline Data: In 2003, at least 13 States (AK, IA, IL, IN, MI, MO, ND, NH, OH, RI, SD, VT, and WI) were formally assigned to their State disaster preparedness committees).^[30]

Current Status of Objective F-5: The EMSC Program co-sponsored the Pediatric Preparedness for Disasters and Terrorism: A National Consensus Conference and published the findings.

Other efforts in support of this objective include:

• The EMSC Program funded a Targeted Issue project (NY) to initiate development, validation, and dissemination of model pediatric components for disaster plans;
• The EMSC Program co-sponsored a pre-conference workshop at the 23rd Annual International Disaster Management Conference;
• The Program disseminated educational programs that address pediatric disaster issues, including Virginia’s JumpSTART Pediatric Triage Algorithm and Massachusetts’ Pediatric Disaster Life Support (PDLS);
• The AAP and ACEP identified priorities and established activities to support disaster preparedness;
• The Program encouraged pediatric representation on State emergency disaster management advisory boards; and
• The Federal Emergency Management Agency developed and disseminated multi-lingual fact sheets about pediatric disaster preparedness and the special needs of children and their families during disasters.

Progress of Objective F-5: Significant

OBJECTIVE F-6: Develop model critical incident stress management guidelines for use with school-aged children.

Indicator: Model critical incident stress management guidelines are developed.

2000 Baseline Data: No known models of critical incident stress management guidelines for school-aged children existed.

2003 Baseline Data: No known models of critical incident stress management guidelines for school-aged children existed.^[31]

Current Status of Objective F-6: In FY 2002, the CDC established the National Advisory Committee on Children and Terrorism, which included liaison representatives of the EMSC community and provided a listing of resources for children suffering from traumatic stress.

Other activities in support of this objective include:

• In FY 2002, the Substance Abuse and Mental Health Services Administration (SAMHSA) funded the National Child Traumatic Stress Network;
• NASN and the American Red Cross developed a partnership to address resiliency and stress management issues for children; and
• In 2003, the Departments of Education and Homeland Security launched a new website ­ http://www.ed.gov/emergencyplan – to help school officials plan for natural disasters, violent incidents and terrorist acts.

Progress of Objective F-6: Little

OBJECTIVE F-7: Increase to 50% the number of States, Tribal Reservations, or Federal Territories that have an EMS representative participating on an established child death investigation and review system.

Indicator: Number of States with EMS representation on established child death investigation and review systems.

2000 Baseline Data: Two States (IL, MT) included EMS representation as part of an established child death investigation and review system.

2003 Baseline Data: In 2003, the AAP indicated that two States (IL, MT) included EMS representation as part of an established child death investigation and review system.^[32]

Current Status of Objective F-7: In 2003, an EMS representative participated as a referral resource for the National Center on Child Fatality Review.

Other activities in support of this objective include:

• The NRC initiated work to compile and disseminate information on existing State child death investigation and review systems; and
• The NRC encouraged EMS providers and child advocates to support the establishment of child death investigation and review systems.

Progress of Objective F-7: Little

OBJECTIVE F-8: Develop a model emergency care plan for child care providers.

Indicator: A model plan exists.

2000 Baseline Data: No known emergency care plans for child care providers existed.

2003 Baseline Data: Of those responding to the 2003 National EMSC Grantee Assessment, 36 States and Territories (AK, AZ, CA, CO, CT, DE, FL, GA, GU, IA, ID, IL, IN, LA, MA, MD, ME, MN, MO, MP, MS, MT, NC, ND, NH, NJ, NM, OH, OK, PA, SD, TN, TX, UT, VI, and WA) indicated requirements for first aid training for child care providers; 32 States and Territories (AK, CA, CT, DE, FL, GA, IA, IL, LA, MA, MD, ME, MN, MO, MP, MS, MT, NC, ND, NE, NH, NJ, NM, OH, OK, OR, PA, SD, TN, UT, VI, and WA) indicated requirements for rescue breathing training for child care providers; and 35 States and Territories (AK, AZ, CA, CT, DE, FL, GA, GU, HI, IA, ID, IL, LA, MA, MD, ME, MN, MO, MP, MS, MT, NC, ND, NE, NH, NJ, NM, OH, OR, SD, TN, TX, UT, VI, and WA) indicated requirements for CPR training for child care providers.^[33]

Current Status of Objective F-8: An EMSC-funded Targeted Issue grant (PA) compiled and reviewed existing emergency care plans, convened a consensus group to define essential elements of an emergency care plan, and developed and implemented a model emergency care plan for child care providers.^[34]

Other efforts in support of this objective include:

• In FY 2002, the AAP PFC project included development of uniform pediatric first aid, safety, and CPR training materials for child care providers.

Progress on Objective F-8: Significant

OBJECTIVE F-9: Pediatric emergency care issues shall be addressed within the national center for patient safety.

Indicator: Number of EMSC Program representatives participating on committees of the national center for patient safety.

2000 Baseline Data: In FY 2001, it was recommended that $20 million be allocated to create the Center for Quality Improvement and Patient Safety within the Association for Health Care Research and Quality. The Center will fund research on medical errors. It will work with private sector entities and public sector partners to develop national goals for patient safety; issue an annual report on the state of patient safety nationally; promote the translation of research findings into improved practices and policies; and educate patients, consumers, and health care providers about patient safety.

2003 Baseline Data: As of 2003, a designated national center for patient safety was not established. The US Department of Health and Human Services created a Patient Safety Task Force to coordinate a joint effort among several department agencies to improve existing systems to collect data on patient safety. As of 2003, EMSC Program representatives did not participate on the Patient Safety Task Force. ^[35]

Current Status of Objective F-9: In FY 2001, EMSC convened a meeting to examine issues related to pediatric patient safety and ultimately funded two Special Initiative grants, titled “Enhancing Pediatric Patient Safety.”

Progress on Objective F-9: Little

OBJECTIVE G-1: Increase to 56 the number of States, Tribal Reservations, or Federal Territories that have developed a specific mechanism for pediatric input in the EMS lead agency.

Indicators: (1) Number of States with pediatric representation on State EMS/trauma advisory boards. (2) Number of States with EMSC laws or pediatric emergency care-related regulations or rules.

2000 Baseline Data: In 1999, four States required pediatric representation on State EMS/trauma advisory boards. Eighteen States had EMSC laws or pediatric emergency care-related rules or regulations.

2003 Baseline Data: Of those responding to the 2003 National EMSC Grantee Assessment, 51 State and Territories (AK, AL, AR, AZ, CA, CT, DC, DE, FL, GA, GU, HI, IA, ID, IL, IN, LA, MA, ME, MD, MI, MN, MO, MP, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, PR, RI, SC, SD, TN, TX, UT, VA, VI, VT, WA, WI, and WY) indicated having a specific mechanism for providing pediatric input to the EMS lead agency. Thirty-one States and Territories (AL, CA, CO, CT, DE, FL, GA, ID, IL, IN, LA, MA, MD, ME, MI, MN, MP, NC, ND, NJ, NV, NY, OH, OR, PA, PR, SC, TN, UT, VA, and WI) indicated having an active EMSC advisory board that reports to the EMS lead agency. Thirty-eight States and Territories (AL, AZ, CA, CO, CT, DC, FL, GA, GU, HI, IA, ID, IL, IN, LA, MA, MD, ME, MI, MN, MO, MP, NC, NE, NH, NJ, NV, NY, OH, OR, PA, PR, SC, TN, TX, UT, VA, and WA) indicated having pediatric representation on the State’s EMS board or advisory committee.^[36] Twenty States and Territories (AR, CA, CO, FL, HI, IL, KY, LA, MD, NE, NH, NJ, OK, OR, PR, RI, SC, TN, TX, and UT) had EMSC laws or pediatric emergency care-related rules or regulations.^[37]

Current Status of Objective G-1: The NRC provides technical assistance to EMSC grantees on identifying optimal methods for sustaining a pediatric emergency care focus in the State, ensuring inclusion of pediatric input to EMS lead agencies and developing broad-based membership on State EMSC advisory councils during project funding.

Other activities in support of this objective include:

• The EMSC Program provided support to the National Association of State EMS Directors to build the foundation of a national EMS information system by revising NHTSA’s data set to better document and capture important aspects of patient care. The project included efforts to develop a plan for data collection and transmission from local, state, and national systems; to develop database schema that will promote timely and accurate data submission to state and national systems; and to coordinate efforts to promote a national standard model for adoption by EMS systems, devise manufacturers, and software vendors.

Progress on Objective G-1: Significant

OBJECTIVE G-2: Increase to 56 the number of States, Tribal Reservations, or Federal Territories that require all essential EMSC-recommended pediatric equipment and supplies on transport units.

Indicators: (1) Number of States with rules/regulations listing essential pediatric equipment and supplies. (2) Commission on Accreditation of Ambulance Services (CAAS)-recommended equipment lists include all essential EMSC-recommended pediatric equipment and supplies.

2000 Baseline Data: Two States required all essential EMSC-recommended pediatric equipment and supplies on basic life support (BLS) transport units. Five States required all essential EMSC-recommended pediatric equipment and supplies on advanced life support (ALS) transport units. In 2000, CAAS-recommended equipment lists did not include all essential EMSC-recommended pediatric equipment and supplies.

2003 Baseline Data: Of those responding to the 2003 National EMSC Grantee Assessment, 46 States and Territories (AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, GU, HI, ID, IL, IN, LA, MA, MD, ME, MI, MN, MP, MS, MT, NC, ND, NH, NJ, NM, NV, NY, OK, OR, PA, RI, SC, TN, TX, UT, VA, VI, VT, WA, WI, and WY) indicated having requirements for all essential EMSC-recommended pediatric equipment and supplies for prehospital ground transport units; 39 States and Territories (AK, AL, AZ, CA, CO, CT, DC, DE, FL, GA, GU, HI, IL, IN, LA, MA, MD, ME, MI, MN, MS, MT, NC, ND, NH, NM, NY, OK, PA, RI, SC, TN ,TX, UT, VA, VT, WA, WI, and WY) indicated these requirements for interfacility ground transport units; 30 States and Territories (AK, AR, AZ, CA, DC, FL, HI, ID, IL, IN, MD, ME, MI, MN, MS, MT, NC, NH, NM, NV, NY, OK, OR, SC, TN, TX, UT, VA, VT, and WA) indicated these requirements for fixed-wing air ambulance units; and 32 States and Territories (AK, AR, AZ, CA, DC, DE, FL, HI, IL, IN, MA, MD, ME, MI, MN, MS, MT, NC, NH, NJ, NM, NV, NY, OK, PA, SC, TN, TX, UT, VA, VT, and WA) indicated these requirements for rotor-wing air ambulance units.^[38] In 2003, CAAS-recommended equipment lists did not include all essential EMSC-recommended pediatric equipment and supplies.^[39]

Current Status of Objective G-2: In 2003, 46 States and Territories had requirements for all essential EMSC-recommended pediatric equipment and supplies for prehospital ground transport units; 39 States and Territories had similar requirements for interfacility ground transport units; 30 States and Territories also had requirements for fixed-wing air ambulance units; and 32 States and Territories required all essential EMSC-recommended pediatric equipment and supplies for rotor-wing air ambulance units.

Other activities in support of this objective:

• The NRC encouraged the adoption of essential equipment and supplies lists; and
• The EMSC Program supported National Strategic Stockpile activities.

Progress on Objective G-2: Significant

OBJECTIVE H-1: Increase to 56 the number of State, Tribal Reservation, or Federal Territory EMS agencies that have pediatric protocols for both online medical direction of emergency medical technicians (EMTs) and paramedics at the scene of an emergency and overall medical direction in the development of written pediatric protocols, medical policies, and guidelines.

Indicator: (1) Number of States with pediatric protocols for online medical direction. (2) Number of States with pediatric protocols for written medical direction.

2000 Baseline Data: In 1996, 18 States indicated having pediatric protocols for both online medical direction of EMTs and paramedics at the scene of an emergency and overall medical direction in the development of written pediatric protocols, medical policies, and guidelines.

2003 Baseline Data: Of those responding to the 2003 National EMSC Grantee Assessment, 32 States and Territories (AK, AL, AR, AZ, CO, CT, DC, DE, GA, HI, IA, IL, MD, MD, MI, MN, MO, MS, MT, NC, NM, NY, OK, OR, PA, RI, TN, UT, VA, VI, VT, and WI) indicated having pediatric protocols for online medical direction. Thirteen States and Territories (CA, GU, ID, IN, KS, KY, MA, MP, ND, NH, NJ, SC, and SD) indicated having specific written pediatric protocols). ^[40]

Current Status of Objective H-1: Forty-five States and Territories indicate having on-line (radio or phone) and/or written pediatric medical direction available to EMS providers.

Other efforts in support of this objective include:

• NAEMSP promoted the NHTSA Medical Directors course and, in 2003, updated its national pediatric prehospital guidelines;
• An EMSC-funded Targeted Issues grant (MN) disseminated model pediatric protocols for infants and children with severe cardiac disease;
• The EMSC Program established implementation of quality improvement (QI) programs to monitor and improve patient outcomes and protocol adherence as a grant priority area;
• NEDARC provided technical assistance for implementation of an EMS QI program; and
• The EMSC Program initiated work to support multi-State meetings to ensure consistency in protocols and provision of care.

Progress on Objective H-1: Significant

OBJECTIVE I-1: Increase by 50% the number of States, Tribal Reservations, or Federal Territories with established injury prevention programs.

Indicator: Number of State Departments of Health having injury prevention staff, programs, and funding.

2000 Baseline Data: In 1999, 33 States and Territories indicated having an MCH Injury Prevention Coordinator. Of those States and Territories, 18 reported having a full-time MCH Injury Prevention Coordinator. Forty-four States and Territories reported having programs that address one or more of the following areas: traffic (bike, pedestrian, occupant); violence (youth, weapons, family); residential (fire, poisoning); recreation/sports/drowning; school/playground/childcare; and suicide. Twenty-six States reported using Title V funding for injury control.

2003 Baseline Data: Of those responding to the 2003 National EMSC Grantee Assessment, 34 States and Territories (AK, AZ, CA, CO, CT, DE, FL, GA, GU, HI, IA, IL, IN, LA, MD, MS, MT, NC, ND, NH, NJ, NM, NY, OH, OK, OR, SC, TN, TX, UT, VT, WA, WI, and WY) indicated having injury prevention staff, programs, and funding.^[41]

Current Status of Objective I-1: The EMSC Program promotes interagency collaboration, attends interagency meetings, and initiates work to develop guidelines and protocols for the collection and use of injury data.

Other activities in support of this objective include:

• The NRC continued its collaboration with the MCHB Children’s Safety Network to support injury prevention efforts at the State and Federal levels providing technical assistance on identifying potential State partners for injury prevention programs and on injury data analysis, program planning, implementation, and evaluation.

Progress on Objective I-1: Moderate

OBJECTIVE I-2: Increase to 35 the number of States, Tribal Reservations, or Federal Territories with programs for prevention of unintentional and intentional injuries in children with special health care needs (CSHCN).

Indicator: Number of States with programs.

2000 Baseline Data: Fifteen States reported having injury prevention programs for CSHCN to address the following risk areas: bicycle safety, car seats, drowning, falls, motor vehicles, and appropriate transport of CSHCN.

2003 Baseline Data: Of those responding to the 2003 National EMSC Grantee Assessment, 12 States and Territories (AK, AZ, CA, CO, FL, GA, HI, LA, MD, NC, UT and WA) indicated that their EMS lead agency had injury prevention programs specifically for CSHCN.^[42]

Current Status of Objective I-2: Through activities of the Family Advocacy Network (FAN), the EMSC Program encourages the inclusion of parents of CSHCN in State planning efforts and injury prevention coalitions.

Other activities in support of this objective include:

• The EMSC Program funded a Targeted Issue grant (CT) on car seat safety for CSHCN; and
• The NRC supported efforts to disseminate information about the new MCHB standard definition of CSHCN that includes children with behavioral disorders.

Progress on Objective I-2: Little

OBJECTIVE I-3: Develop model discharge instructions on reducing injury-related risk-taking behavior for computerized discharge instruction systems.

Indicators: (1) Number of model instructions developed. (2) Number of vendors integrating injury-related risk-taking behavior instructions.

2000 Baseline Data: No known model instructions developed.

2003 Baseline Data: No EMSC-developed instructions existed.^[43]

Current Status of Objective I-3: To date, EMSC-supported efforts toward this objective do not exist.

Progress on Objective I-3: None

OBJECTIVE I-4: Increase by 50% the number of States, Tribal Reservations, or Federal Territories in which injury-related hospitalizations are coded for external cause of injury.

Indicator: Number of States mandating external cause of injury codes.

2000 Baseline Data: As of September 1998, 42 States indicated having statewide hospital discharge data systems (HDDS). Of those States, 36and the District of Columbia routinely collected external cause of injury codes. Of these 36, 23 States reported having mandatory external cause of death injury code reporting. Eight of the 36 States and the District of Columbia recorded one code; six States recorded two codes; 21 States recorded from three to 21 codes; and one State responded unknown. As of September 1998, 12 States and Puerto Rico reported having a statewide hospital emergency discharge data system (HEDDS). Of these, 11 States routinely collected these codes in their statewide HEDDS. Nine of the 11 States have mandated coding for external cause of injury for their statewide HEDDS.

2003 Baseline Data: In 2003, 23 states (AZ, CA, CT, DE, FL, GA, KY, MD, MA, MO, NE, NH, NJ, NY, PA, RI, SC, TN, UT, VT, VA, WA, and WI) reported having mandatory hospital discharge E-coding. ^[44]

Current Status of Objective I-4: EMSC-funded NTRC grants will devise strategies for collecting uniform data elements characterizing pediatric trauma.

Other efforts in support of this objective include:

• The American Public Health Association’s Injury Control and Emergency Health Services section replicated its survey on hospital E-coding. A pilot survey was conducted through the State and Territorial Injury Prevention Directors Association. Findings were released in spring 2004.

Progress on Objective I-4: Little

Objective J-1: Increase to 100% the number of communities that have access to a certified poison control system.

Indicators: (1) Number of States with access to a certified poison control center. (2) Percentage of population with access to a certified poison control center.

2000 Baseline Data: In 2000, certified poison control centers provided services to all residents of 32 States and the District of Columbia. In addition, five States have certified poison control centers that serve some residents but not all. Eighty-four percent of the U.S. population is served by a certified poison control center.

2003 Baseline Data: A nationwide 24-hour, toll-free telephone number (1-800-222-1222) activated in 2001 provided access to U.S. poison control centers for 50 states, the District of Columbia, the U.S. Virgin Islands, and Puerto Rico. In 2003, 89% of the U.S. population was served by a certified center. Overall, 100% of U.S. population is served by general poison control centers. Of the certified centers in 2003, two have pediatric advice lines and four have 24-hour bilingual staff. ^[45]

Current Status of Objective J-1: Through the American Association of Poison Control Centers’ (AAPCC) PFC project, the EMSC Program collaborates with stakeholders to: promote poison control centers’ long-term economic viability; encourage poison control center representation on EMSC advisory groups, task forces, councils, and other policy-forming committees; foster dissemination of information about the incidence of pediatric poisonings; and partner with other stakeholders (Federal, State, and local) to promote a national toll-free telephone number.

Other activities in support of this objective include:

• The EMSC Program provided for AAPCC to conduct a pilot project to determine whether site visits incorporated into the certification review process of poison control centers add value or change the certification process and whether site visits are feasible on an on-going basis; and
• EMSC Program support of AAPCC advanced the development of continuing education modules and efforts to determine whether site visits incorporated into the certification review process of poison control centers add value or change certification outcome.

Progress on Objective J-1: Significant

Objective J-2: Increase to 100% the U.S. population having access to a comprehensive* 9-1-1 system. *Emergency medical dispatch, training, quality assurance, special needs population, technology addressing, public education, professional education, and resource allocation.

Indicator: Percentage of the U.S. population with access to a comprehensive 9-1-1 system.

2000 Baseline Data: Some type of 9-1-1 services covered about 93% of the U.S. population and 50% of its geographic area. Ninety-five percent of that coverage is Enhanced 9-1-1.

2003 Baseline Data: In 2003, 99% of the U.S. population was covered by at least basic 9-1-1 as is 96% of the geographic U.S. ^[46] According to a Department of Transportation database, as of October 2003, nearly 65% of Public Safety Answering Points (PSAP) had Phase I wireless E9-1-1 service, which provides the approximate location of the caller, while only 18% had Phase II, which provides a more precise location and is the ultimate goal of wireless E9-1-1 service. Twenty-four state 9-1-1 contacts said in response to a Government Accounting Office survey that their state will have Phase II implemented by 2005 or sooner; however, all other state contacts estimated dates beyond 2005 or were unable to estimate a date. ^[47]

Current Status of Objective J-2: The EMSC Program attends Federal interagency meetings and advocates for the needs of children.

Other activities in support of this objective include:

• Through its partnership with NHTSA, the EMSC Program encouraged linkage of Intelligent Transportation Systems to be inclusive of the needs of children; supported development and dissemination of educational strategies (i.e., Basic Emergency Lifesaving Skills, Make the Right Call) on 9-1-1, E 9-1-1, and Intelligent Transportation Systems; and fostered dissemination of multi-lingual fact sheets on the needs of children and their families in emergency public access systems (9-1-1, Intelligent Transportation Systems), such as NHTSA’s Make the Right Call and Bystander Care Spanish resources.

Progress on Objective J-2: Moderate

Objective K-1: Increase to 56 the number of States, Tribal Reservations, or Federal Territories that promote public awareness of pediatric EMS issues.

Indicators: (1) Number of grantees utilizing media resources from the national EMSC media campaign. (2) List of media resources developed for the national EMSC media campaign.

2000 Baseline Data: In 2000, a CD-ROM containing EMSC products and a list of other resources was produced for the National EMSC Public Information and Education (PIE) Campaign for use by decision-makers.

2003 Baseline Data: Phase II of the PIE Campaign was launched in October 2002 as part of DHHS’ national observance of Child Health Month. EMSC developed a brochure on how to prevent and handle emergency situations; a drop-in article; public service advertisements (PSAs) for radio, television, and all print mediums; a poster; and fact sheets. The guide and consumer materials were contained in an electronic toolkit located at: http://mchb.hrsa.gov/child/childhealthday.html. More than 1,500 local and national media outlets throughout the nation were asked to run either the 30-second television or radio spot or a camera-ready, black and white print ad. Both English and Spanish versions were distributed. In March 2003, the EMSC Program received its first report from a PSA distribution and tracking service. According to the report, more than 177 television stations in 146 markets ran the 30-second PSA a total of 720 times between February 1- June 30, 2003. During this same time period, the radio spot played more than 45,280 times on 416 radio stations in 223 cities. A total of 540 million impressions were made. Since the February kickoff through the end of June 2003, the estimate dollar value of the PSA campaign is $3.48 million ($842,000 for television and $2.64 million for radio). ^[48]

Current Status of Objective K-1: Through the NRC, the EMSC Program developed media resources to conduct the PIE campaign; convened a national task force to provide advice to the campaign, which includes research, planning, implementation, and evaluation; presented the plan at annual national and multi-State meetings, and to national organizations and groups; and implemented the campaign at national, State, and local levels.

Progress on Objective K-1: Significant

Objective K-2: Increase to 20 the number of States, Tribal Reservations, or Federal Territories implementing the Basic Emergency Lifesaving Skills (BELS) curriculum template to teach children to respond to a medical emergency.

Indicator: Number of States implementing the BELS curriculum template.

2000 Baseline Data: The BELS curriculum template was completed and published in March 2000 and is now available online at the EMSC web site.

2003 Baseline Data: In FY 2002, EMSC funded a Target Issue grant (WI) to promote implementation of BELS.^[49]

Current Status of Objective K-2: An EMSC-funded Targeted Issue grant (WI) established partnerships with the education community to promote BELS’ implementation; initiated work to identify, compile, and distribute existing resources for teaching the content; and promoted State and local partnerships between the education community and EMS providers to teach basic emergency lifesaving skills.

Other efforts in support of this objective include:

• An EMSC Targeted Issue project (WI) and the National Center for Early Defibrillation (NCED) developed a CD to raise awareness about the need for bystander care, CPR, and automatic external defibrillator (AED) use by high school students.

Progress on Objective K-2: Moderate

Objective K-3: Develop model tools to assist school-based personnel* to recognize medical and mental health emergencies and provide short-term emergency interventions. *Teachers, secretaries, coaches, principals, building service personnel, counselors, instructional assistants.

Indicator: Number of model tools developed for medical and mental health emergencies’ recognition and intervention.

2000 Baseline Data: In 1998, NASN published Emergency Guidelines for Schools.

2003 Baseline Data: NASN updated its School Nurse Emergency Care Course, Emergency Guidelines for Schools. The EMSC Program supported school health activities through the Association’s PFC contracts. An EMSC Targeted Issue grant (IL) produced the School Nurse Emergency Care Course (CD-ROM), 2003.^[50]

Current Status of Objective K-3: Through its EMSC-funded PFC project, NASN initiated work to: convene a consensus group with EMS and education leaders to identify essential skills; review and revise existing tools for recognition of medical emergencies and short-term interventions; develop a course chapter for recognition of mental health emergencies and short-term interventions; promote dissemination of model tools; and encourage school personnel to obtain and use the tools.

Other activities in support of this objective:

• The EMSC Program provided support to NAEMT to develop Guidelines for Prehospital Response to Medical Emergencies at Schools.

Progress on Objective K-3: Moderate

^[1] National EMSC Grantee Assessment, NEDARC, Salt Lake City, UT, 2003, 2001

^[2] National EMSC Grantee Assessment, NEDARC, Salt Lake City, UT, 2003

^[3] National EMSC Grantee Assessment, NEDARC, Salt Lake City, UT, 2003

^[4] Interview data, Puskin, D. HRSA-Office for the Advancement of Telehealth, Washington, DC, January 2004

^[5] Interview data, Coult, J., AAPMR and Carney, N., OHSU, January 2004

^[6] EMSC Program Highlights, FY 2002, HRSA-MCHB, Rockville, MD

^[7] EMSC Program Highlights, FY 2002, HRSA-MCHB, Rockville, MD

^[8] Interview data, Ball, J., EMSC National Resource Center, Silver Spring, MD, December 2003

^[9] Interview data, Dawson, D. and Bryson, D., NHTSA, Washington, DC, December 2003

^[10] National EMSC Grantee Assessment, NEDARC, Salt Lake City, UT, 2003

^[11] Interview data, Bernardo, L., January 2004

^[12] Accreditation Council for Graduate Medical Education website, December 2003

^[13] Association of Faculties of Pediatric Nurse Practitioner Programs website, December 2003

^[14] Taking Action, Saving Lives: Syllabus of the 3rd National Congress on Childhood Emergencies, 2002

^[15] Interview data, Puskin, D. HRSA-Office for the Advancement of Telehealth, Washington, DC, January 2004

^[16] National EMSC Grantee Assessment, NEDARC, Salt Lake City, UT, 2003

^[17] Interview data, Carter, S., EMSC National Resource Center, Silver Spring, MD, January 2004

^[18] List of Targeted Issue Grants, EMSC National Resource Center, Silvers Spring, MD, January 2004

^[19] Interview data, Miller, T., December 2003

^[20] Interview data, Carter, S., EMSC National Resource Center, Silver Spring, MD, January 2004

^[21] Interview data, Ball, J., EMSC National Resource Center, Silver Spring, MD, January 2004

^[22] JEMS website, January 2004

^[23] National EMSC Grantee Assessment, NEDARC, Salt Lake City, UT, 2003

^[24] National EMSC Grantee Assessment, NEDARC, Salt Lake City, UT, 2001

^[25] EMSC Program Highlights, FY 2002, HRSA-MCHB, Rockville, MD

^[26] National Committee for Quality Assurance website, December 2003

^[27] EMSC Program Highlights, FY 2002, HRSA-MCHB, Rockville, MD

^[28] Interview data, Fendya, D., EMS-Trauma Technical Assistance Center, Silver Spring, MD, December 2003

^[29] National EMSC Grantee Assessment, NEDARC, Salt Lake City, UT, 2003

^[30] Interview data, Fendya, D., EMS-Trauma Technical Assistance Center, Silver Spring, MD, December 2003

^[31] Interview data, Ball, J., EMSC National Resource Center, Silver Spring, MD, January 2004

^[32] Interview data, Glasstetter, M., American Academy of Pediatrics, Elk Grove Village, IL, December 2003

^[33] National EMSC Grantee Assessment, NEDARC, Salt Lake City, UT, 2003

^[34] Interview data, Ball, J., EMSC National Resource Center, Silver Spring, MD, January 2004

^[35] US DHHS Patient Safety Task Force Participant List, AHRQ website, January 2004

^[36] National EMSC Grantee Assessment, NEDARC, Salt Lake City, UT, 2003

^[37] Public Policy Section, EMSC website, January 2004

^[38] National EMSC Grantee Assessment, NEDARC, Salt Lake City, UT, 2003

^[39] Interview data, Hogue,T., CAAS, December 2003

^[40] National EMSC Grantee Assessment, NEDARC, Salt Lake City, UT, 2003, 2001

^[41] National EMSC Grantee Assessment, NEDARC, Salt Lake City, UT, 2003

^[42] National EMSC Grantee Assessment, NEDARC, Salt Lake City, UT, 2003

^[43] Interview data, Ball, J., EMSC National Resource Center, Silver Spring, MD, January 2004

^[44] Interview data, Weiss, H., Center for Injury Research and Control, Pittsburgh, PA, January 2004

^[45] Interview data, Soloway, R., American Association of Poison Control Centers, January 2004

^[46] NENA 9-1-1 Fast Facts, October 2003

^[47] Highlights of GAO-04-55 Report: Uneven Implementation of Wireless E911 Raises Prospect of Piecemeal Availability for Years to Come: GAO, Washington, DC, November 2003

^[48] EMSC Program Highlights, FY 2003 DRAFT, EMSC National Resource Center, Silver Spring, MD

^[49] EMSC Program Highlights, FY 2002, HRSA-MCHB, Rockville, MD

^[50] EMSC Product List, EMSC website, January 2004