Emergency Medical Services for Children
A 10-year Retrospective Based on the Recommendations of the Committee on Pediatric Emergency Medical Services of
the National Academy of Sciences Institute of Medicine

Introduction and Background

The Emergency Medical Services for Children Program

In 1984, under Section 1910 of the Public Health Service Act, the U.S. Congress enacted legislation authorizing the development of the Emergency Medical Services for Children (EMSC) Program. Its purpose is to ensure that all ill and injured children and adolescents receive state-of-the-art emergency care, including primary prevention, prehospital care, emergency care, acute care, and rehabilitation.

Administered by the U.S. Department of Health and Human Services' (HHS) Health Resources and Services Administration (HRSA) in collaboration with the U.S. Department of Transportation's (DOT) National Highway Traffic Safety Administration (NHTSA), the EMSC Program provides grants to States and U.S. territories to improve existing emergency medical services (EMS) systems and to develop and evaluate improved procedures and protocols for treating children. The EMSC Program is the only Federal program that focuses specifically on improving the quality of children's emergency care.

In its first year of funding, EMSC received $2 million to support four State demonstration projects in California, Alabama, Oregon, and New York. These States developed some of the first strategies for addressing pediatric emergency care issues, such as disseminating educational programs for prehospital and hospital-based providers, establishing data collection processes to identify significant pediatric-related problems within the EMS system, and developing tools for assessing critically ill and injured children.

Since its establishment, the EMSC Program has allocated $138 million to fund 851 grant awards. All 50 States, the District of Columbia, and five U.S. territories have received funding to improve the way children receive emergency services.

States obtaining program funds initially received a demonstration grant. In later years States received a planning grant for needs assessment, which was followed by an implementation grant. As funding levels grew, however, new grant categories evolved to meet the more challenging aspects of improving systems for pediatric emergency care. In 1997, State Partnership Grants were introduced to help grantees sustain change and to assure a continuing focus on pediatric EMS issues. Regional Symposia and Targeted Issues Grants (initially called State Enhancement Grants) also were added.

A description for the latter four grant categories follows. All States and territories received one or more of these grants between 1995 and 2004 and are thus the focus of this report.

• Implementation Grants: A 3-year grant to help States initiate the development of a special pediatric focus within their EMS system. The state identifies specific objectives for the grant funding. States are encouraged to use resources and strategies that have been developed by other states. States are eligible for only one implementation grant.
• State Partnership Grants: A 3-year grant to help States sustain the significant system changes that had been accomplished with previous EMSC funding.
• Regional Symposia Grants: Many issues for improving an EMS system for children require collaboration between states. This grant supplement is awarded to a State Partnership Grant recipient to organize a workshop or meeting to promote the exchange of knowledge and information between EMSC grant recipients and key partners within a geographic region. Participants often share information about emerging technologies, network building, data collection, and public policy.
• Targeted Issues Grants: A 2 or 3 year grant to help States develop and evaluate a model product, program, or strategy with regional or national significance. In most cases, the grant is responsive to a special need that has been identified by EMSC Program staff.

To receive grant funding, interested professionals need to adhere to specific requirements outlined in the grant guidance. The guidance describes the guidelines for each section of the project proposal, including the problem statement, goals and objectives, methodology, evaluation, project management, and budget. An independent objective review panel evaluates each application and submits its recommendations to Federal program staff.

The Institute of Medicine

The Institute of Medicine (IOM) was established in 1970 as an arm of the National Academy of Sciences, and was charged with the responsibility of recruiting nationally recognized experts to scrutinize topics of concern regarding public health in the United States. IOM serves as an adviser to the Federal government and identifies progress and deficiencies in areas of medical care, research, and education.

In 1991, the 19-member Committee on Pediatric Emergency Medical Services was convened. Two years later, the National Academy Press published the committee's recommendations in the book Institute of Medicine Report on Emergency Medical Services for Children.¹ As described by Committee Chair Donald Medearis, Jr., MD, in the book's preface, the charge of the IOM committee was "to review the nature and extent of pediatric emergencies and the emergency care available to children and to define the characteristics of an emergency medical services system for children, the elements of a data system needed for planning and evaluation, and the role of government in that system." (p. vi)

The committee's work resulted in a set of recommendations in five key areas:

1. Education and Training
2. Putting Essential Tools in Place
3. Communication and 9-1-1 Systems
4. Planning, Evaluation, and Research
5. Federal and State Agencies and Funding

This 10-year retrospective review is organized according to these five areas. It addresses the progress made towards the achievement of the recommendations within each area since the release of the 1993 IOM Report. These achievements are organized by the entity responsible for the effort, i.e., EMSC resource centers and grantees, EMSC national or Federal partners, or EMSC allied organizations. A definition of each entity is provided below.

EMSC Resource Centers and Grantees. The Federal EMSC Program's efforts are primarily achieved through its resource centers and grant activities. The EMSC Program funds two national centers: the EMSC National Resource Center (NRC) in Washington, DC, and the National EMSC Data Analysis Resource Center (NEDARC) in Salt Lake City, UT. The NRC assists States on a variety of topics, manages a collection of EMSC resources and the EMSC Program Web site, promotes public understanding of EMSC issues, and works with professional organizations to improve the quality of pediatric care. NEDARC provides assistance to EMSC projects and State EMS offices in developing capabilities to effectively collect, analyze, and utilize EMS data. (For a comprehensive description of each resource center, see Section E.)

EMSC National Partners. In 1996, the EMSC Program developed the EMS Partnership for Children (PFC), a multi-disciplinary consortium of 17 national and professional organizations that contribute to the EMSC Program's mission -- saving kid's lives -- by developing resources of regional and national significance. In 2003, PFC member organizations included: the Ambulatory Pediatric Association (APA), the American Academy of Pediatrics (the AAP), the American Association of Poison Control Centers (AAPCC), the American College of Emergency Physicians (ACEP), the American Pediatric Surgical Association (APSA), the American Psychological Association, the American Trauma Society (ATS), the Brain Injury Association of America, the Emergency Nurses Association (ENA), the National Association of Children's Hospitals and Related Institutions (NACHRI), the National Association of EMS Physicians (NAEMSP), the National Association of Emergency Medical Technicians (NAEMT), the National Association of School Nurses (NASN), the National Association of Social Workers (NASW), the National Association of State EMS Directors (NASEMSD), the National Association of State Head Injury Administrators, and the National Council of State EMS Training Coordinators (NCSEMSTC).

Each PFC member is responsible for implementing activities that support the EMSC Program's 5-Year Plan. This strategic plan guides EMSC program planning and funding decisions, and it includes numerous objectives, each with specific action steps and evaluation measures. Given the commitment and dedication of these national organizations to preventing and treating childhood illness and injury, their active participation makes a tremendous contribution to the nationwide successes of the EMSC Program.

PFC members address issues that encompass the entire spectrum of care -- from illness and injury prevention, to prehospital and acute care, to rehabilitation and reintegration into the community. A sample of these issues include:

• Increased availability of and access to injury prevention programs;
• Pediatric education and training for health care professionals;
• Child-sized equipment on ambulances and in hospitals;
• Interfacility transfer agreements to ensure that children are treated at facilities best prepared to meet their needs;
• Protocols, practice guidelines, and minimum standards for managing pediatric emergencies;
• Research in identifying "best practices" for clinical care and system development;
• Protocols for treating children who are the victims of sexual assault;
• Guidelines for the management of school emergencies;
• First aid and cardiopulmonary resuscitation (CPR) training for teachers; and
• Mental health services for adolescents at risk for suicide or violence.

EMSC Federal Partners. EMSC has partnered with many Federal agencies during the last decade to promote EMSC Program development. NHTSA, for example, has been a consistent partner since the Program's establishment in 1984. Partnerships have been formally and informally established with several other federal agencies to accomplish specific activities. Some of these partnerships involve direct administrative or financial support from the EMSC Program.

EMSC Allied Organizations. An allied organization is any Federal, national, or professional entity that developed an EMSC-related activity or product without the use of EMSC Program funds. The efforts of these organizations further promote the EMSC Program mission.

EMSC Program Strategic Planning

In response to the IOM Report, the Federal EMSC Program developed a comprehensive long-range strategy: the EMSC 5 Year Plan, 1995-2000.² In 1997, the EMSC Program had completed many of the proposed activities listed in the plan and was able to collect baseline data for each objective. In 1998, the EMSC 5-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 2000, in anticipation of the expiration of the first 5-Year plan, a new plan was developed for the years 2001-2005. In 2003, the second 5-Year plan underwent a midcourse review to collect updated information and to 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 5-Year Plan, 2001-2005 targets the more traditional aspects of pediatric EMS system development, it also addresses contemporary and emerging issues, such as telehealth applications, mental health issues, research, economic analyses, program evaluation, and cultural competency.³

A. Education and Training

EMSC Resource Centers and Grantees

In support of Recommendations A.1 and A.2, the EMSC resource centers and grantees initiated the following activities:

In 1995, the EMSC resource centers released Emergency Medical Services for Children: A 10-Year Report.⁴ The document summarized the accomplishments of those States that received EMSC grant funds between 1985 and 1995, and demonstrated how the Program enabled many States to begin the process of enhancing the system to meet children's needs. The report included information about each state's public education activities, such as the development of videos, fact sheets, and special events designed to educate the general public about first aid, CPR, injury prevention, and how and when to contact EMS. It was distributed to all grantees and made available through the federal clearinghouses.

In 1995, the NRC produced Saving Kids' Lives: Emergency Medical Services for Children.⁵ Through the dramatic life-saving story of young Kacey McCallister, this educational video examines the origins of the EMSC Program and the major developments and milestones made by State EMS systems in serving the needs of children. Topics addressed in the video include: training and education, systems development, public awareness, injury prevention, and research and evaluation. Saving Kids' Lives was produced to commemorate the tenth anniversary of Congress enacting legislation to improve pediatric emergency medical care. This product was designed as a companion document to the 10-Year report.

A year later, the NRC produced seven public service announcements (PSAs) that featured several stars of the hit drama "ER," including Ellen Crawford, Connie Marie Brazelton, Vanessa Marquez, Lily Mariye, and Deezer D.⁶ Produced in 20- or 30-second lengths, the Saving Kids' Lives PSAs addressed five topics:

• Knowing where to take your child in an emergency;
• The importance of learning CPR and first aid;
• The role prevention plays in protecting children;
• The importance of pediatric training; and
• The importance of having a system in place that recognizes the differences between children and adults in medical emergencies.

In 1997, the EMSC Program supported the development of How to Prevent and Handle Childhood Emergencies: A Handbook for Parents and People Who Care for Children.⁷ Developed by the Florida EMSC State project, this resource remains one of the most popular items disseminated by the Federal Program.

At the request of HRSA's Maternal and Child Health Bureau (MCHB), the NRC established the EMSC National Heroes Award Program in 1998 to recognize and reward outstanding achievement in EMSC and to encourage continued excellence in the field. The award categories provide an opportunity to honor individuals, state teams, and organizations dedicated to advancing the goals of the EMSC Program. It creates awareness within the EMSC community that is inspiring to the thousands of individuals who participate in this field of health care. Awards have recognized EMSC project coordinators, State projects, EMSC products, community partnerships, family volunteers, State policymakers, and researchers. In addition, selected individuals have been honored with a lifetime achievement award.

In 1998, the Ohio EMSC project based in the State's Department of Public Safety released Emergency Guidelines for Schools to serve as an emergency care resource for school staff without full-time medical or nursing support.⁸ These color-coded, first-aid flowcharts provide guidelines for more than 40 of the most common pediatric illnesses or injuries and are arranged alphabetically for quick reference. The guidelines also include a list of recommended first aid equipment and supplies for schools, and universal precautions to prevent or reduce the spread of infectious diseases. Ohio received the 2000 Innovation in EMSC Product Award. In 2001, the guidelines were revised and expanded to include sections on infection control, behavioral emergencies, child abuse and neglect, and communicable disease.

In 1999, the Oklahoma EMSC State project produced the CD-ROM, Oklahoma EMSC Emergency First Care and Injury Prevention Curriculum.⁹ This 280-page curriculum for child care providers contains modules on injury prevention, child care provider well-being, emergency action principles, airway and breathing emergencies, bleeding, shock, and soft tissue injuries, among others. It includes an instructor manual, instructor resource kit, and a student handbook.

In 1999, the EMSC Web site (www.ems-c.org) received the Gold Award for "best government health care Web site." According to the Health Information Resource Center, the organization that sponsors the international awards program, the EMSC Web site is one of the world's best health information sites on the Internet. The range of topics covered on the site includes EMSC products and resources, national and State activities, public policy, data collection and research, family information, injury and illness prevention, health care finance, quality improvement, education and training, funding opportunities, EMS/EMSC system development, rehabilitation, and children with special health care needs. It also addresses other areas of interest, including child care, cultural competence, disasters, mental health, and school health.

That same year, the NRC developed Working to Improve Child Care, a two-page fact sheet that describes the EMSC Program's efforts to improve the safety and well-being of children in child care settings.¹⁰ The fact sheet is distributed through the EMSC Web site and at national meetings.

In 2000, HRSA/MCHB's Children's Safety Network worked in collaboration with the NRC to publish the Basic Emergency Lifesaving Skills (BELS) curriculum template.¹¹ The curriculum includes guidelines for implementing age-appropriate actions to help teach children how to respond to a medical emergency. It also includes guidelines for teaching and evaluating the program. In FY 2002, EMSC funded a Targeted Issues Grant to develop and evaluate a model for bystander care education to children in school settings using the BELS curriculum template.

From 2000 to 2003, the NRC worked with grantees and PFC members on the EMSC National Public Information and Education (PIE) campaign to raise public awareness about pediatric EMS issues. The first phase of the campaign targeted medical professionals and included the production of a CD-ROM containing more than 2,000 pages of critical information on pediatric injury and illness prevention, treatment, and rehabilitation.¹² Its goal was to help evaluate and bring organizations, communities, and states into compliance with accepted standards for pediatric emergency care.

The second phase of the campaign, which targeted parents, caregivers, and children, was launched in October 2002 as part of the HHS national observance of Child Health Month. The NRC helped to develop a range of consumer materials focused on pediatric emergency preparedness. Resources included: 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. EMSC worked with HHS and HRSA communications staff to develop a promotional guide for the observance. The guide and consumer materials were contained in an electronic toolkit located on the HRSA Web site (http://mchb.hrsa.gov). English and Spanish versions of the PSAs in standard-broadcast format, and of the consumer brochure and poster in hard-copy format are available by calling 1-888-ASK-HRSA.

As a follow-up to Child Health Month, EMSC initiated its long-awaited PSA campaign in December 2002 to heighten awareness about the importance of parents and caregivers being prepared for pediatric medical emergencies. 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 print a camera-ready, black and white print ad. Both English and Spanish versions were distributed.

In July 2003, the EMSC Program received its final report from PCS Broadcast Services, 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 and June 30, 2003. During this same time period, the radio spot played more than 45,280 times on 416 radio stations in 223 cities, including the top 10 media markets: New York, NY; Los Angeles, CA; Chicago, IL; Philadelphia, PA; San Francisco, CA; Boston, MA; Dallas-Ft. Worth, TX; Washington, DC; Detroit, MI; and Atlanta, GA. 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 was $3.48 million ($842,000 for television and $2.64 million for radio).

EMSC National and Federal Partnerships

Through the PFC consortium several significant documents have been developed in support of Recommendations A.1 and A.2, including:

• "Guidelines for Providing Family-Centered Prehospital Care," developed by NAEMT and published in the June 2001 issue of EMS;¹³
• Uniform pediatric first aid, safety, and CPR training materials for child care providers, developed by the AAP in 2002;¹⁴ and
• On the Same Team: Involving the Family in Prehospital Care CD-ROM, developed by NAEMT in 2002 and disseminated to 4,000 prehospital care providers (all attendees of EMS Expo 2002).¹⁵

In 1999, NHTSA embarked on its Make the Right Call program, providing educational information to the public, especially children, on how to use the 9-1-1 emergency call system. (See Section C: Communication and 9-1-1 Systems.)

In 2000, ACEP included information about the first-ever National EMSC Day in its National EMS Week promotional materials. Working in partnership with the NRC, EMSC Day is now annually recognized on the third Wednesday of each May. By designating a specific day within the EMS celebration, the Program hopes to draw national attention to the essential need for specialized emergency care for pediatric patients.

EMSC Allied Organizations

In 2000, NHTSA released English and Spanish versions of its First There, First Care program, a concise, 1 hour course in emergency first aid designed to teach laypersons with no prior medical training how to render help to victims on the scene of a highway crash. High schools also are using the program to teach students how to serve as first responders for emergencies involving their family and friends.

In 2002, the AAP published the Family Readiness Kit: Preparing to Handle Disasters, a resource designed to help prepare families for most types of natural disasters, including hurricanes, earthquakes, and floods.¹⁶ The kit was developed using data from focus groups involving more than 250 families. It is available on-line at www.aap.org (not a U.S. Government Web site).

In 2003, the U.S. Department of Education issued Practical Information on Crisis Planning: A Guide for Schools and Communities.¹⁷ The U.S. Departments of Education and Homeland Security also have a web site to help school officials plan for natural disasters, violent incidents, and terrorist acts (www.ed.gov/emergencyplan).

In 2003, NHTSA established WHALE: We Have A Little Emergency, an identification program that provides emergency and law enforcement personnel with vital information about a child involved in a crash in the event that the adults in the vehicle are incapacitated.¹⁸ The emergency information is found in a plastic identification card holder attached to the child safety seat or booster seat. Two WHALETM stickers attached to the vehicle's rear side windows alert EMS and law enforcement personnel to the emergency information.

EMSC Resource Centers and Grantees

Great strides have been made in educating prehospital providers about pediatric emergency care. Listed below are a few of the many educational programs and resources that the EMSC resource centers and grantees have developed.

• Pediatric Airway Management was developed in 1993 with a Targeted Issues grant awarded to California's Harbor UCLA Medical School.¹⁹ This book and video set was later revised in 1997 and expanded to include a basic and advanced provider tool kit, instructor manual, and case studies. In 2004, Jones and Bartlett published Pediatric Airway Management with an accompanying DVD, authored by Marianne Gausche-Hill, MD.
• Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP) was developed in 1998 with a Targeted Issues grant awarded to the Center for Pediatric Emergency Medicine (CPEM) in New York City.²⁰ This CD-ROM is an 850-page encyclopedic resource for emergency medical technician (EMT) instructors. TRIPP received an EMSC Outstanding Product of the Year Award in 1998. One hundred copies of the CD were provided, free of charge, to each State Department of Health's EMS Division for distribution within their States. It is available for free downloading from the CPEM Web site (www.cpem.org not a U.S. Government Web site).
• Children with Special Health Care Needs: Technology-Assisted Children (TAC) was developed in 1998 by the Utah State Department of Health's Bureau of EMS with EMSC Targeted Issues grant support.²¹ This "how-to" book combines detailed graphics with written objectives and guidelines for prehospital personnel caring for children with special health care needs, specifically technology-assisted children. TAC received an EMSC Outstanding Product of the Year Award in 1998. Also produced was the companion interactive CD-ROM, A Child in Need.²²
• The Pediatric Disaster Life Support Course was created in 1999 by the University of Massachusetts Medical School with EMSC Targeted Issues grant support.²³ This course was based on a 1995 EMSC-sponsored workshop and is designed to help physicians, nurses, and EMTs provide better care to children victimized by a disaster.
• Helping Kids Survive was developed in 1999 by the Idaho EMSC project with input from the Connecticut and New York State EMSC projects.²⁴ This three-volume interactive CD-ROM program is designed to help basic and advanced life-support prehospital personnel sharpen their critical decision-making skills by viewing short scenarios and being taught in an interactive manner how to make assessment and treatment decisions about pediatric medical and respiratory emergencies. Pediatric emergency procedures also are presented through step-by-step demonstrations.
• SCOPE (Children's Outreach and Prehospital Education) was developed in 2001 by the Children's National Medical Center in Washington, DC with EMSC Targeted Issues funding.²⁵ This prehospital education program addresses the emergency care of children with special health care needs (CSHCN). It received the Innovation in EMSC Product of the Year Award in 2002. Protocols for the care of the special needs children were published in 2003 in Prehospital Emergency Care.²⁶ These protocols have been integrated into the NAEMSP 2003 Model Pediatric Protocols.
• Paramedic TRIPP was developed in 2002 by CPEM with EMSC Targeted Issues funding.²⁷ This 1,450-page encyclopedic resource for paramedic instructors is designed to support the expanded pediatric portions of the National Standard Curriculum for Paramedics. It contains the most recent recommendations of the American Heart Association (AHA). Fifty copies of the CD were shipped, free of charge, to each State Department of Health's EMS Division for distribution within their States, and it was made available for free downloading from the CPEM Web site (www.cpem.org not a U.S. Government Web site).
• Child Abuse & Neglect: A Continuing Education and Teaching Resource was developed in 2003 by CPEM.²⁸ This resource is based on recommendations gathered from a 2001 EMSC-sponsored National Blue Ribbon Panel that brought together, for the first time, members of Child Protection Services and the EMSC community to discuss the knowledge and education of prehospital personnel in child abuse and neglect. Meeting proceedings were published in Pediatric Emergency Care in 2002.²⁹ This resource includes handouts, slides, and medical illustrations to help instructors teach prehospital providers about the recognition, treatment, documentation, and reporting of child abuse and neglect.
• It's Time to Ask was developed in 2003 at Children's Mercy Hospital in Kansas City, MO with funding by an EMSC Targeted Issues grant.³⁰ This instructional program is designed to help providers identify and intervene in intimate partner violence in the pediatric acute care setting.

EMSC National and Federal Partnerships

Organizational members of the PFC consortium created numerous documents pertaining to IOM Recommendations A.3 and A.4. Several of these include:

• Education of Out-of Hospital Emergency Personnel in Pediatrics: Report of a National Task Force, developed by ACEP in 1998;³¹
• Model Pediatric Protocols, developed by NAEMSP in 1999 and revised in 2003;³²,³³
• Skill Degradation and Future Pediatric Continuing Education Requirements, assessment and recommendations developed by NCSEMSTC in 2004;³⁴ and
• Refresher and CE Education on Pediatric Skills and Knowledge, recommendations developed by NCSEMSTC in 2004.³⁵

In 1993, the National Registry of Emergency Medical Technicians created the consensus-based document National EMS Education and Practice Blueprint.³⁶ The blueprint led to several EMS system and education activities that were subsequently initiated by NHTSA. These activities are described below.

In 1996, NHTSA and HRSA/MCHB released the EMS Agenda for the Future, a strategic plan for building the next millennium's EMS system.³⁷ EMS of tomorrow will be a community-based health management system that provides surveillance, identification, intervention and evaluation of injury and disease. EMS will be integrated with other health care providers and public health and public safety agencies. This role strengthens the essential value of EMS as the community's emergency medical safety net. The EMS Agenda for the Future: Implementation Guide (1998), a companion to the EMS Agenda for the Future, is intended to be used as a tool for EMS providers, administrators, and medical directors; health care providers and payers; public health and safety officials; local, State, and Federal government officials; organization and community leaders; and all other entities and people with a potential interest or influence on the structure or function of the Nation's system for providing emergency medical care.³⁸

Between 1994 and 2002, NHTSA developed several additional documents for the national standardization of EMT and paramedic education, including:

• Revised National Standard Curriculum for EMT-Basic (1994), with an increased pediatric content;³⁹
• First Responder: National Standard Curricula (1995);⁴⁰
• EMT-Basic Refresher: National Standard Curriculum (1996);⁴¹
• First Responder Refresher: National Standard Curriculum (1996);⁴²
• Revised National Standard Curriculum for EMT Paramedic (1998), with an increased pediatric content;⁴³
• Emergency Medical Technician-Intermediate: National Standard Curriculum (1999);⁴⁴
• EMT-Paramedic Refresher: National Standard Curriculum (2001);⁴⁵
• EMT-Intermediate Refresher: National Standard Curriculum (2001);⁴⁶ and
• Supplemental Airway Modules for the 1994 EMT-Basic National Standard Curriculum (2002).⁴⁷

Most EMT and paramedic training in the U.S. is based on NHTSA's National Standard Curricula, although the curriculum is frequently adapted to meet specific State requirements.

EMSC Allied Organizations

In 2000, the AAP published Pediatric Education for Prehospital Professionals (PEPP) ? a comprehensive course for EMTs and paramedics based on the California EMSC project's Pediatric Education for Paramedics program.⁴⁸ With the development of PEPP, States were no longer required to maintain or update individual prehospital pediatric education courses. The AAP assumed responsibility for establishing training standards and keeping the program content current. PEPP received the EMSC Product of the Year Award in 2001.

In 2001, NAEMT published its own EMT and paramedic course, Pediatric Prehospital Care (PPC), and assumed responsibility for standardizing pediatric prehospital education by making a commitment to keep program content up-to-date.⁴⁹

EMSC Resource Centers and Grantees

In 1998, an EMSC-funded conference to create consistency among pediatric prehospital educational products resulted in the publication of Education Of Out-Of-Hospital Emergency Medical Personnel In Pediatrics: Report of A National Task Force.³¹

That same year marked the beginning of the biennial National Congress on Childhood Emergencies, an event that brings together experts (physicians, nurses, prehospital professionals, social workers, parent advocates, EMS system managers) from throughout the U.S. to share information during various educational forums. The EMSC resource centers have conducted three National Congress conferences. These include:

• 1st National Congress on Childhood Emergencies: "Kids: The Right Care When It Counts," March 22-24, 1998, Washington DC;
• 2nd National Congress on Childhood Emergencies: "Giving America's Children Our Best," March 27-29, 2000, Baltimore MD; and
• 3rd National Congress on Childhood Emergencies: "Taking Action, Saving Lives," April 15-17, 2002, Dallas TX.

Relevant products of distinction that EMSC-funded programs have developed include:

• Pediatric Pain Management in the Emergency Department (2002);⁵⁰
• Injury Prevention for Medical Personnel -- Reach for the Sky CD-ROM (2003);⁵¹ and
• Tube Tools: RSI Technique and Related Emergent Procedures, an interactive CD for the emergency management of the pediatric airway (2004).⁵²

EMSC National and Federal Partnerships

In 1997, the EMSC Program brought together representatives from the AAP and ACEP, two of the largest physician organizations that advocate for improved pediatric emergency care, to form the EMSC AAP/ACEP Coordinating Committee. The committee's primary purpose is to encourage professional collaboration, uniform educational concepts, and improved pediatric emergency care. Prior to the committee's establishment, policy statements and programs released by the AAP and ACEP were sometimes inconsistent and therefore much less effective.

In 1998, the American Psychological Association released its Training EMSC Providers in Violence Prevention.⁵³ Three years later, NASW created the training curriculum Bereavement Practice Guidelines for Social Workers in the ED.⁵⁴

In 1998, the Society of Pediatric Nurses, one of the early EMSC partnership organizations, incorporated key concepts of pediatric emergency care into its Standards and Guidelines for Pre-Licensure and Early Professional Education for the Nursing Care of Children and Their Families, the national guidelines for undergraduate nursing education.⁵⁵

EMSC Allied Organizations

In 2001, an ad hoc group consisting of physicians, nurses, and prehospital providers representing each of the following nationally recognized courses and educational resources united to form the Pediatric Emergency Care Education Collaborative.

• AAP's Pediatric Emergencies for Prehospital Providers course;
• AAP's Division of Life Support Programs;
• ACEP's Advanced Pediatric Life Support course;
• AHA's Advanced Cardiac Life Support, Pediatric Advanced Life Support, and Neonatal Resuscitation Program courses;
• CPEM's Teaching Resources for Instructors in Prehospital Pediatrics;
• EMSC National Resource Center;
• ENA's Emergency Nursing Pediatric Curriculum course; and
• NAEMT's Pediatric Prehospital Care course.

In 2003, the collaborative began work on its first task: to enhance communication among medical professionals by promoting the consistent terminology usage by the wide range of emergency health care providers.

EMSC Resource Centers and Grantees

Through an EMSC Targeted Issue Grant awarded in 1994, University of Connecticut developed and distributed the School Nurse EMSC Program.⁵⁶ In 2001, New Mexico received a Targeted Issue Grant to update the program. Through its current State Partnership Grant, New Mexico will develop and distribute instructional support materials for a School Nurse EMSC train-the-trainer workshop and pay for rural school nurse representation.

In 2003, the Illinois EMSC project produced the School Nurse Emergency Care Course (CD-ROM).⁵⁷ The CD contains a course manual, instructor manual, and slide guide to help instruct school nurses in emergency care education and guidelines that can be used when caring for ill or injured students.

EMSC National and Federal Partnerships

From 1998 to 2002, NASN created the following:

• Managing School Emergencies I: Respiratory, Cardiovascular, and Neurological Emergencies; Instructor and Student Manuals (1998-1999);⁵⁸
• Preparing a Response to Emergency Problems (1998);⁵⁹
• Managing School Emergencies II: Musculoskeletal, Facial, and Mental Health Emergencies; Instructor and Student Manuals (1999-2000);⁶⁰
• Managing School Emergencies III: Multiple Trauma and Mass Casualty Incident; Instructor and Student Manual (2000);⁶¹
• Managing School Emergencies Courses (revised, 2002);⁶² and
• Disaster Preparedness Curriculum for School Nurses and Tracking Tool for School Injuries (2002).⁶³

In 2001, NASN extended the reach of its pediatric emergency medical training to include rural school nurses.

ENA published the results of its Assessment of Family-Centered Care in the Emergency Department on its Web site (www.ena.org not a U.S. Government Web site) and in the Journal of Emergency Nursing.⁶⁴

EMSC Allied Organizations

In 1994, ENA released its Emergency Nursing Pediatric Course (ENPC), a 16-hour class designed to provide the core-level pediatric knowledge and psychomotor skills needed to care for pediatric patients in the emergency setting. Since that time, the ENPC Provider Manual has been updated twice, once in 1998 and again in 2004. Additionally, ENA has published the following:

• ENA Position Statement: Educational Recommendations for Nurses Providing Pediatric Emergency Care (2001);⁶⁵
• ENA Position Statement, Family Presence at the Bedside During Invasive Procedures and Resuscitation (2001);⁶⁶
• ENA Position Statement, Prevention and Treatment of Burns in the Pediatric Population (2003);⁶⁷ and
• Core Curriculum for Pediatric Emergency Nursing in 2003.⁶⁸

NOTE: The Board of Certification for Emergency Nursing (BCEN) is a nonprofit organization responsible for the Certified Emergency Nurse (CEN) and Certified Flight Registered Nurse (CFRN) exams. Certification is for four years, with renewal examination required to maintain certification. As of 2000, BCEN requires learning objectives in pediatric emergency care.

The International Council on Disaster Nursing Education includes some pediatric disaster-related content.

In 1997, AHA published its Guidelines for Parent Support Groups to provide information about the needs, function, and structure of support groups for children with heart disease and their families. Some of these children are at high risk for a medical emergency.

EMSC Resource Centers and Grantees

In 2003, a Texas Targeted Issues grantee produced Office PERC: Preparedness for Emergency Response to Children, a CD-ROM designed to train primary care office personnel how to recognize and stabilize an ill or injured child in need of emergency care.⁶⁹ It also includes printable lists of recommended equipment, supplies, and medications for the office, algorithms for treating common pediatric emergencies, and the AAP/ACEP Emergency Information Form.

In 2004, a Missouri Targeted Issues grantee received support for the education of pediatric emergency fellows in pediatric emergency research skills.

EMSC National and Federal Partnerships

In 1998, EMSC funded a national meeting in Naples, FL, to encourage AAP state chapters to develop committees on pediatric emergency medicine. Representatives from 80 percent of AAP's state chapters attended the meeting, and most established a state Committee on Pediatric Emergency Medicine.

Through its participation in the PFC Consortium, ACEP created evidenced-based clinical guidelines on pediatric sedation and analgesia in the emergency department (ED).⁷⁰

In 2004, the EMSC Program collaborated with NAEMSP to sponsor a workshop for emergency physicians in fellowship training to enhance their research skills.

EMSC Allied Organizations

The AAP's national Committee on Pediatric Emergency Medicine (COPEM) has issued several policy statements during the last 10 years, including:

• First Aid for the Choking Child (1993);⁷¹
• Pediatrician's Role in Advocating Life Support Courses for Parents (1994);⁷²
• Guidelines for Pediatric Emergency Care Facilities (1995, 1998, 2000);⁷³
• Pediatrician's Role in Disaster Preparedness (1997);⁷⁴
• Role of the Pediatrician in Rural EMSC (1998);⁷⁵
• Emergency Physician and the Office-Based Pediatrician: An EMSC Team (1998);⁷⁶
• Emergency Preparedness for Children with Special Health Care Needs (1999);⁷⁷
• Pediatric Care Recommendations for Freestanding Urgent Care Facilities (1999);⁷⁸
• Access to Pediatric Emergency Medical Care (2000);⁷⁹and
• Pediatricians' Liability During Disasters(2000);⁸⁰ and
• Consent for Emergency Medical Services for Children and Adolescents (2003).⁸¹

The AAP also created a Neonatal Resuscitation Program (1997);⁸² the Visual Diagnosis of Child Abuse on CD-ROM, 2nd Edition (2003);⁸³ and the subspecialist fact sheet "What is a Pediatric Emergency Physician?" (2003).⁸⁴

In collaboration with ACEP, the AAP developed the Emergency Information Form for Children with Special Health Care Needs (1997),⁸⁵ and position statements on Care of Children in the ED: Guidelines for Preparedness (2001),⁸⁶ and Death of a Child in the Emergency Department (2002).⁸⁷

ACEP published the following position statements:

• Rapid Sequence Intubation of the Pediatric Patient (1996);⁸⁸
• Role of Emergency Physicians in EMSC 2000;⁸⁹
• Immunization of Pediatric Patients in the ED (2000);⁹⁰
• Role of Emergency Physicians in the Care of Children (updated in 2001);⁹¹ and
• Role of Emergency Physicians in the Prevention of Pediatric Injury (2001).⁹²

ACEP also developed and updated the educational program Advanced Pediatric Life Support, 4th Edition (2003).⁹³

AHA's International Liaison Committee on Resuscitation (ILCOR) issued the following:

• Advisory Statement on Pediatric Resuscitation (1997);⁹⁴
• Advisory Statement on Resuscitation of the Newly Born Infant (1999);⁹⁵ and
• Use of AEDs for Children: An Update (2003).⁹⁶

AHA also published the "Response to Cardiac Arrest and Selected Life-Threatening Medical Emergencies: The Medical Emergency Response Plan for Schools" in 2004.⁹⁷

NOTE: In 2000, the Accreditation Council for Graduate Medical Education (ACGME) approved 34 pediatric emergency medicine fellowships. AGCME requires pediatric emergency care as part of the program requirements for residency education in Emergency Medicine and Pediatrics. In 2003, ACGME accredited seven pediatric emergency medicine programs.

In 2003, the program requirements for pediatric surgery training only specify that there be a pediatric emergency room, where the pediatric surgical fellow serves as a consultant, especially for pediatric trauma patients and children with burns. There is no requirement for rotations in the pediatric emergency department for pediatric surgery or general surgery residents.

The AAP Committee on Pediatric Emergency Medicine, through its Future of Pediatric Education project, worked to determine the status of pediatric emergency management training in residency and fellowship programs. (2001-2002)

According to the ACEP Fact Sheet: Emergency Care of Children, emergency medicine residents generally receive 4 to 6 months of training in the emergency care of children. In addition, during the second and third year of their residencies, they spend 6 months in emergency departments under the supervision of attending emergency physicians. During that time, 20 to 30 percent of their patients are children.

B. Putting Essential Tools in Place

EMSC Resource Centers and Grantees

EMSC funded two Special Initiative Grants in 2002 focused on pediatric emergency care patient safety. The grants were awarded to:

• Duke University Medical School — to decrease medical errors in the pediatric emergency center, project staff developed and evaluated an educational course and training program for emergency providers to increase the appropriate use of the Broselow-Luten Pediatric System. This resulted in the 2004 publication of "Pediatric Patient Safety: Common Problems in the Use of Resuscitative Aids for Simplifying Pediatric Emergency Care," in the Journal of Emergency Nursing.⁹⁸
• Utah State Department of Health — to reduce medical errors in the pediatric ED, project staff demonstrated the impact of education in color-coding pediatric system design. A report is forthcoming.

EMSC National and Federal Partnerships

In 1996, ACEP published Guidelines for Pediatric Equipment and Supplies on Ambulances.⁹⁹

In 2001, the AAP and ACEP released Care of Children in the ED: Guidelines for Preparedness, which was published that same year in Pediatrics. 87 Evaluation of these implementation guidelines is currently being supported with EMSC funding.

In 2001, the results of an EMSC-funded study "Ability of Hospitals to Care for Pediatric Emergency Patients" was published in Pediatric Emergency Care.¹⁰⁰ The EMSC Program collaborated with the Consumer Product Safety Commission to collect data about the ED care of children using the National Electronic Injury Surveillance System (NEISS). A self-report survey of 101 hospital EDs revealed that the emergent and critical care of infants and children are not well integrated and regionalized within our health care system. For example, a large majority of surveyed U.S. hospital EDs had most of the basic pediatric emergency equipment available. However, equipment for infants and children was more likely to be missing than adult-sized equipment. This study strongly suggests that there is room for improvement in the quality of care for children encountering emergent illness and trauma.

In 2001, EMSC and the Centers for Disease Control and Prevention's (CDC) National Center for Health Statistics developed, tested, and applied the EMSC Survey Supplement to the National Hospital Ambulatory Medical Care Survey instrument, allowing for a larger, more generalizable sample than the previous NEISS studies. Piloted in 2001, the instrument allowed for formal data collection for 2 years, 2002 through 2003. A publication is in process.

EMSC Allied Organizations

In 2000, ACEP and the American College of Surgeons (ACS) established a joint policy on pediatric equipment for ambulances.¹⁰¹

In 2002, the AAP published "The State of Pediatric Interfacility Transport: Consensus of the Second National Pediatric and Neonatal Interfacility Transport Medicine Leadership Conference" in Pediatric Emergency Care.¹⁰²

EMSC Resource Centers and Grantees

According to an EMSC Grantee Assessment, in 1996 11 States had adopted and disseminated pediatric guidelines that categorized acute care facilities with the equipment, drugs, trained personnel, and facilities necessary to provide varying levels of pediatric emergency and critical care.¹⁰³ In 2003, the number had risen to 18 States and U.S. territories.

In 1998, emergency physicians, pediatricians, nurses, EMS and disaster planners, school representatives, and mental health professionals gathered at the Children's Emergencies in Disasters: A National EMSC Workshop in Orlando, FL, to develop the Consensus Recommendations for Responding to Children's Emergencies in Disasters.¹⁰⁴ Recommendations include information on medical capabilities, managed care, mental health, community planning, data collection, volunteer services, school and child care, public awareness, and family empowerment.

In 1998, the Illinois EMSC project implemented a pediatric facility recognition program, utilizing the California EDAP (Emergency Department Approved for Pediatrics) model.¹⁰⁵ Two levels of recognition were made available ? EDAP and Standby Emergency Department for Pediatrics. In 2003, a third recognition level was offered for Pediatric Critical Care Centers. To date, more than 100 facilities have received recognition by their State health department.

Of those responding to the 2001 and 2003 National EMSC Grantee Assessments, 44 percent of State and territory grantees reported having specifically designated pediatric emergency care facilities (pediatric critical care or trauma centers with pediatric capabilities).¹⁰⁴

In 2000, the NRC released State-by-State Profiles: The Integration of Pediatric Care Components into the EMS System.¹⁰⁶ The document summarizes the gains and accomplishments of each State and territory that had received EMSC funding. The document serves as an update to the 1995 EMSC 10-year Report. Each state profile includes the following data (when available):

• Pediatric age breakdown;
• A racial/ethnic distribution;
• Childhood health and social indicators that are relevant to children's need for emergency care;
• A listing of key clinical resources that exist in each state or territory; and
• Data from the 1997 Youth Risk Behavior Surveillance System.

In addition, the following components of EMSC were assessed: systems development; training and education, including public education; injury prevention; and data collection. State EMSC coordinators were given an opportunity to provide a brief narrative highlighting their progress since 1995.

In 2003, an agreement between HRSA/MCHB and the Indian Health Service to facilitate EMSC Program goals resulted in the following:

• Coordinating Tribal/Indian Health Service human and organization resources with EMSC-related resources to promote and develop EMSC activities;
• Strengthening the basic infrastructure within the Native American EMS Association as related to pediatric EMS issues through improvement in technical assistance, training, and injury and illness prevention;
• Promoting the benefits of establishing a relationship between Tribal/Indian Health Service EMS programs and State EMS programs; and
• Enhancing opportunities for pediatric EMS training.

EMSC National and Federal Partnerships

In 1997, NASEMSD surveyed State EMS directors on the status of EMSC as it relates to the following: lead EMS agency and regulatory issues; education, training, and certification; children with special health care needs; injury prevention, training, and certification; and data collection and evaluation.

NASW released the following documents:

• Mental Health Treatment for Self-Injurious Behaviors: Clinical Practice Guidelines for Children & Adolescents in the ED (1997);¹⁰⁷
• Risk-Taking Behaviors in the ED: The Social Worker's Role with Children and Their Families (1998);¹⁰⁸
• Family-Centered Care Approaches to Families After a Child's Death/Emotional Reactions to the Sudden Death of a Child: The Family and the Emergency Care Provider (1998);¹⁰⁹ and
• Bereavement Practice Guidelines for Health Care Professionals in the Emergency Department (1999).⁵⁴

In 1999, the following PFC projects were completed:

• NAEMT's Child and Adolescent Health Care Services: A Community Assessment Guide;¹¹⁰
• AAP/ACEP's Emergency Preparedness for Children with Special Health Care Needs Kit;¹¹¹ and
• NACHRI's EMSC Standards and Guidelines of Public and Private Sector Agencies and Organizations.¹¹²

In 2001, NACHRI released Recommendations for Emergency Care Plans for Children with Special Health Care Needs.¹¹³

In 2002, EMSC and the Agency for Healthcare Research and Quality (AHRQ) co-sponsored the Pediatric Preparedness for Disasters and Terrorism: A National Consensus Conference. Seventy experts from throughout the Nation gathered to discuss the particular vulnerabilities of children to terrorist attacks or disasters and the possible emergency medical responses. A year later, EMSC and AHRQ published the document Pediatric Preparedness for Disasters and Terrorism: A National Consensus.¹¹⁴

In 2002, EMSC and the International Disaster Management Center held a joint conference concerning the unique needs of children in disasters.

In 2002, the American Psychological Association released Mental Health Needs for Providers of EMSC: A Report of a Consensus Panel.¹¹⁵

In 2002, APSA's "Outcome Studies and Practice Guidelines in Trauma" was published in Seminars in Pediatric Surgery.¹¹⁶

In 2003, NAEMT evaluated the utility of the JumpSTART Pediatric Triage Algorithm. Publication of the results in Pediatric Emergency Care is pending.

EMSC Allied Organizations

Recognizing that no published or commonly used multiple casualty incident triage system adequately addressed the unique anatomy and physiology of children, Lou Romig, MD, developed the JUMPStart Triage System for Children in Disasters.¹¹⁷ The 1995 tool parallels the START (Simple Triage And Rapid Treatment) system, developed by the Newport Beach Fire and Marine Department and Hoag Hospital in Newport Beach, CA. JUMPStart utilizes decision points appropriate to the wide variations of normal physiology within the pediatric age group. It is widely used throughout the U.S. and Canada and actively advancing throughout the world. French, Spanish, and Japanese translations of the algorithms are available for download at www.jumpstarttriage.com/ (not a U.S. Government Web site).

In January 2000, "A Consensus Report for Regionalization of Services for Critically Ill or Injured Children" was published in Pediatrics as a joint venture of the AAP and the American College of Critical Care Medicine.¹¹⁸

C. Communication and 9-1-1 Systems

EMSC Resource Centers and Grantees

Although no independent EMSC activities have been specifically focused on this recommendation, the EMSC Program and resource centers have worked collaboratively with the Federal agencies and national organizations that have primary responsibility for this issue.

EMSC National and Federal Partnerships

In 1999, NHTSA embarked on its Make the Right Call program, providing educational information to the public, especially children, on how to effectively use the 9-1-1 emergency call system. Program materials focus on who to call, when to call, and what information to have ready before calling 9-1-1. A tool kit that includes media items, youth materials, workshop pamphlets, and PSAs is available in both English and Spanish.¹¹⁹

Through its partnership with NHTSA, the EMSC Program encourages links to Intelligent Transportation Systems that are inclusive of the needs of children; supports development and dissemination of educational strategies about 9-1-1, Enhanced 9-1-1, and Intelligent Transportation Systems; and fosters dissemination of multi-lingual fact sheets on the needs of children and their families in emergency public access systems (i.e., Make the Right Call and Bystander Care Spanish resources).

NHTSA is aggressively pursuing implementation of wireless E 9-1-1 systems. DOT provides funding for the National Emergency Number Association (NENA) to provide technical assistance to local public safety answering points (PSAP). NHTSA has an ongoing cooperative relationship with the Federal Communication Commission to assure coordination of Federal efforts.

EMSC Allied Organizations

According to NENA's 9-1-1 Fast Facts, 99 percent of the U.S. population and 96 percent of the geographic U.S. is covered by at least basic 9-1-1. According to a DOT database, as of October 2003, nearly 65 percent of PSAP had Phase I wireless E 9-1-1 service, which provides the approximate location of the caller, while only 18 percent had Phase II, which provides a more precise location and is the ultimate goal of wireless E 9-1-1 service. Twenty-four State 9-1-1 contacts responded to a Government Accounting Office (GAO) survey that they expect to have Phase II implemented by 2005 or sooner.

The GAO recommends that DOT work with State E 9-1-1 officials, NENA, and other public safety groups to determine which PSAP will need to have their equipment upgraded. The information would then be reflected in a NENA-managed PSAP database, and would serve as a baseline to measure progress toward the goal of full nationwide deployment of wireless E 9-1-1 service.

D. Planning, Evaluation, and Research

EMSC Resource Centers and Grantees

Injuries are a major cause of mortality, morbidity, and disability. In the U.S., the care of patients who suffer intentional and unintentional injuries and poisonings contributes significantly to the increase in medical care costs. External causes of injury and poisoning codes (E-codes) are intended to provide data for injury research and evaluation of injury prevention strategies. E-codes capture how the injury or poisoning happened (cause), the intent (unintentional or intentional, such as suicide or assault injuries), and the place where the event occurred. Some major categories of E-codes include: traffic and transport accidents; poisoning and adverse effects of drugs, medicinal substances, and biologicals; falls; injuries caused by fire and flames; injuries due to natural and environmental factors; late effects of unintentional injuries, assaults, or self injury; assaults or purposely inflicted injury; and suicide or self inflicted injury.

While Recommendation D.1 is listed as an objective in the EMSC 5 Year Plan, the Program recognizes that other organizations will take lead responsibility for this activity.

EMSC National and Federal Partnerships

No activities to report.

EMSC Allied Organizations

In 1997, the Children's Safety Network (CSN) reported that 20 states used E-coding for hospital discharge. In 2003, that number rose to 26 States that routinely collected E-codes requiring external cause of death. (See http://www.childrenssafetynetwork.org for more information.) (not a U.S. Government Web site)

In 1998, the Injury Control and Emergency Health Service Section of the American Public Health Association issued a status report regarding how states were collecting and examining injury data using E-codes. The report identified those States using E-codes routinely in hospital discharge, trauma system, and emergency medical system data.¹²⁰

EMSC Resource Centers and Grantees

In 1995, to address "the need for more and better data on the volume, nature, and outcomes of pediatric emergency care," HRSA/MCHB funded NEDARC to help EMSC grantees and State EMS offices develop their own capabilities to collect, analyze, and utilize EMS and other healthcare data that could improve the quality of care in State EMS and trauma systems. NEDARC provides technical assistance, conducts workshops and educational forums, and provides support to the Federal EMSC Program.

Between 2001 and 2003, NEDARC studied the characteristics of State-level EMS data systems and developed indicators for evaluating their capacity to collect and analyze such data. A basic profile of each State's data system is available on NEDARC's Web site (www.nedarc.org not a U.S. Government Web site), with more extensive descriptions for some of the model State systems. NEDARC studied 43 States regarding collection of the 81 NHTSA uniform EMS data elements. It was determined that 79 percent of the elements were being collected. Results from this study were published in Prehospital Emergency Care in 2004.¹²¹

In September 2002, the EMSC Program announced the availability of National Trauma Registry for Children (NTRC) Planning Grants. The purpose of the NTRC project is to devise innovative strategies for collecting uniform data elements characterizing pediatric trauma and clinical management of pediatric injuries. EMSC awarded two NTRC grants, which are listed below by title, organization, and principal investigator:

• Registry Design and Technology Planning Grant ? awarded to the University of Pittsburgh, Laura Cassidy Schall, PhD, principal investigator, to develop a scheme for a pediatric trauma information system that collects standardized, representative pediatric trauma data into a centralized national trauma registry for children.
• Data Identification, Collection, and Use Planning Grant ? awarded to the Medical College of Wisconsin, Karen Guice, MD, MPP, principal investigator, to plan and design a national data registry for children in the United States.

EMSC National and Federal Partnerships

Since the early 1970s, numerous publications and legislation have contributed to the development of EMS information systems and databases. EMS systems vary in their ability to collect patient and systems data and to put these data to use. No method currently exists to easily link disparate EMS databases and allow analysis at a local, State, and national level. This effort became more challenging with the implementation of the Health Insurance Portability and Accountability Act of 1996.

In 1994, NHTSA developed its 81-element Uniform Pre-hospital Dataset. This dataset helped standardize EMS data elements and definitions. During the next decade, it became apparent that a national EMS registry would be valuable.

In 2001, NHTSA and HRSA's programs for Trauma/EMS Systems and EMSC provided funds for NASEMSD to develop a national EMS information system (NEMSIS) database framework.¹²² The planned information system would be used to develop national EMS training curricula, evaluate patient and EMS system outcomes, facilitate research efforts, determine national fee schedules and reimbursement rates, address resources for disaster and domestic preparedness, and provide valuable information on other issues or areas of need related to EMS care. Numerous professional organizations and Federal agencies have been involved in the development of NEMSIS data definitions and the database framework.

In 2000, HHS released Healthy People 2010.¹²³ This document includes objectives for improving health and tracking healthy people. It includes six EMS and trauma specific objectives, three of which are related to pediatrics:

1.14 Increase the number of States and the District of Columbia that have implemented guidelines for prehospital and hospital pediatric care.

1-14a. Increase the number of States and the District of Columbia that have implemented statewide pediatric protocols for online medical direction. (Baseline: 18 states had implemented statewide pediatric protocols for online medical direction in 1997.)

1-14b. Increase the number of States and the District of Columbia that have adopted and disseminated pediatric guidelines that categorize acute care facilities with the equipment, drugs, trained personnel, and other resources necessary to provide varying levels of pediatric emergency and critical care. (Baseline: 11 states had adopted and disseminated pediatric guidelines that categorize acute care facilities with the equipment, drugs, trained personnel, and other resources necessary to provide varying levels of pediatric emergency and critical care in 1997.)¹⁰⁴

EMSC Allied Organizations

In 1991, representatives from AHA, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council released Recommended Guidelines for Uniform Reporting of Data From Out-of-Hospital Cardiac Arrest: The Utstein Style. In 1995, AHA issued a pediatric version of this document, titled Recommended Guidelines for Uniform Reporting of Pediatric Advanced Life Support; The Pediatric Utstein Style.¹²⁴

In 2003, AHA's ILCOR issued Recommended Guidelines for Uniform Reporting of Data From Drowning: The "Utstein Style."¹²⁵ This document presents the consensus of a group of international investigators who met to establish guidelines for the uniform reporting of data from drowning incident studies. The principal purpose of the recommendations is to establish consistency in the reporting of drowning-related incidents, both in terms of nomenclature and guidelines for reporting data.

In 2003, the CDC and HHS announced the availability of funds for the Cooperative Agreement Program Linkages of Acute Care and Emergency Medical Services to State and Local Public Health Programs. The program is designed to support collaboration between national organizations of professionals in acute medical care, trauma, and emergency medical services with State and local public health programs and CDC in efficiently and effectively responding to mass trauma events resulting from terrorism.

EMSC Resource Centers and Grantees

In 1999, NRC's "Priorities for Research in Emergency Medical Services for Children: Results of a Consensus Conference" was published in the Annals of Emergency Medicine.¹²⁶ This article provided an overview of the topics that were prioritized by a consensus group for future EMSC research. Participants were asked to rate each topic from the 1993 IOM Report on the significance of its research and its potential for improving general knowledge, altering behavior, improving health, decreasing costs of care, or reforming public policy. Injury prevention was among the highest ranked priorities along with clinical aspects of emergency care and systems organization, configuration, and operation.

In 2001, the EMSC Program funded the Network Development Demonstration Projects (NDDP) to demonstrate the value of a multi-centered research network in conducting investigations on the efficacy of pediatric treatments, transport, and care responses, including those preceding the arrival of children to hospital EDs. This project is a collaboration between HRSA/MCHB Division of Research, Training, and Education (DRTE) and the EMSC program. Those receiving NDDP Grants collectively form the Pediatric Emergency Care Applied Research Network (PECARN). PECARN is governed by a steering committee, which formulates and monitors policies and procedures guiding all research activities.

A Central Data Management Coordinating Center cooperative agreement was awarded to the University of Utah in 2002 to manage the data collection and analysis for the research network, as well as to assure the scientific integrity of the research studies. The HRSA/MCHB DRTE and EMSC Program created this infrastructure to help overcome present difficulties in assessing efficacy and quality of care and ensuring accountability in state EMSC programs that derive from the relatively small incidence rates of critical pediatric emergency events and the lack of a current mechanism to pool sites and treatment experiences.

Each NDDP grantee is responsible for creating a regional network of EDs or node for research. The four nodes include: the Academic Centers Research Node, the Chesapeake Applied Research Network, the Great Lakes Regional Node, and the Pediatric Emergency Department North East Team. The principle investigators of these nodes work collaboratively to develop and submit nodal research proposals to PECARN and to conduct PECARN-approved research at their respective institutions. Each regional network is comprised of hospital emergency department affiliates whose tasks are to:

• Conceive and develop protocols for trials and observational studies;
• Participate in observational studies and controlled trials;
• Recruit patients required for studies;
• Maintain patient records for each study protocol; and
• Collect clinical and laboratory data studies.

Each year, PECARN collectively averages more than 800,000 pediatric patient visits to the ED. PECARN is conducting observational and randomized studies on a variety of issues related to EMSC, including processes involved in translating research results to treatment settings. Studies to date have included a core data project, a bronchiolitis study, mild head injury decision rule, and hypothermia for cardiac arrest.

In 2000, the EMSC-funded study "A Randomized, Controlled Trial to Assess Decay in Acquired Knowledge Among Paramedics Completing A Pediatric Resuscitation Course" was published in Academy Emergency Medicine ¹²⁷The study concluded that although intensive prehospital pediatric education enhances knowledge, that knowledge rapidly decays due to the infrequent occurrence of critical pediatric illness or injury in the out-of-hospital setting. The authors of the study recommend that EMS programs find novel ways to increase retention and assure paramedic readiness.

From 2001 to 2004, CPEM conducted the Pediatric PHASE (Prehospital Arrest Survival Evaluation) Project, a one-year prospective study of all children who were resuscitated by ambulance personnel in the New York City 9-1-1 system. Data are being analyzed and peer review papers are being prepared for submission for publication in 2004.

EMSC National and Federal Partnerships

In 2001, the NIH Guide to Grants and Contracts included the "Research on Emergency Medical Services for Children" research announcement PA-01-044. The announcement was developed by the Interagency Committee on EMSC Research, an EMSC-supported collaboration involving eight Federal agencies ? HRSA/MCHB's Research Branch (lead agency); AHRQ; and CDC's National Institute for Occupational Safety and Health, National Heart, Lung and Blood Institute, National Institute for Child Health and Human Development, National Institute on Drug Abuse, National Institute of Mental Health, and National Institute for Nursing Research.

The program announcement could be found on each partner's Web site, as well as on the EMSC Web site (www.ems-c.org) and the National Institutes of Health Guide to Grants and Contracts Web site (grants1.nih.gov/grants/guide/index.html). The EMSC Program is working with this committee to revise and extend this historic interagency achievement, which expired in 2004.

In 1996, AHRQ, in partnership with HRSA/MCHB, supported a study to determine whether endotracheal intubation (ETI), a technique often used for airway management of children in the out-of-hospital setting, had a positive effect on survival or neurological outcome. In a controlled clinical trial, the survival and neurological outcome of pediatric patients treated with bag-valve-mask ventilation (BVM) were compared with those of patients treated with BVM followed by ETI in two large, urban, rapid-transport EMS systems. The study results indicated that the addition of out-of-hospital ETI to a paramedic scope of practice that already includes BVM did not improve survival or neurological outcome of pediatric patients treated in an urban EMS system. In 2000, "Effect of Out-of-Hospital Pediatric Endotracheal Intubation on Survival and Neurological Outcome: A Controlled Clinical Trial" was published in JAMA.¹²⁸

In 2001, NHTSA and HRSA funded NASEMSD to develop a NEMSIS database.¹²⁹ (See "EMSC National and Federal Partnerships," under Recommendation D.2-3 for further details.)

In 2003, NHTSA and HRSA/MCHB released the National EMS Research Agenda, a template for EMS and EMSC researchers interested in studying the clinical and system aspects of prehospital care. The Agenda identifies obstacles to the growth of scientific investigation in the EMS field, and suggests strategies for improving the quality and quantity of EMS research, with the goal of providing a scientific foundation upon which to base current and future prehospital care.

EMSC Allied Organizations

Below is a sample of the latest research articles that pertain to Recommendation D.5.

Functional outcome in children with multiple trauma without significant head injury, as study conducted by Aitken ME. Jaffe KM. DiScala C. Rivara FP. was published in 1999.¹³⁰ The objective of this retrospective cohort study was to assess functional outcome and describe disability at discharge in children who have had trauma without significant head injury. The study concluded that functional dependence is present in a large proportion of injured children, even without significant head injury. Rehabilitation and other services may be underused in this population. Further study is required to fully assess the degree and duration of disability in these patients.

A prospective population based study of the demographics, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest, a study conducted by Sirbaugh P, Pepe P, et al. was published in 1999.¹³¹ The objective was to perform a prospective, population-based study addressing the demography, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest (PCPA) in a large urban municipality who were treated by EMS personnel for apneic, pulseless conditions. Data were collected prospectively for 3 years using a comprehensive data collection tool and on-line computerized database. Each child received standard pediatric advanced cardiac life support. During the 3-year period, 300 children presented with PCPA (annual incidence of 19.7/100,000 at risk). Compared with the population at risk (32 percent black patients, 36 percent Hispanic patients, 26 percent white patients), a disproportionate number of arrests occurred in black children (51.6 percent versus 26.6 percent in Hispanics, and 17 percent in white children; P <.0001). Over 60 percent of all cases (n=181) occurred in the home with family members present, and yet those family members initiated basic CPR in only 31 (17 percent) of such cases. Only one factor, endotracheal intubation, was correlated positively with return of spontaneous circulation (P =.032). This population-based study underscored the need to investigate new therapeutic interventions for PCPA, as well as innovative strategies for improving the frequency of bystander CPR for children.

E. Federal and State Agencies and Funding

In 1991, HRSA/MCHB established two resource centers, the EMSC National Resource Center at Children's National Medical Center in Washington, DC and the National EMSC Resource Alliance (NERA) at Harbor UCLA Medical Center in Torrance, CA. In 1995, NEDARC was established; and in 1997 the activities of the NRC and NERA were consolidated with a Federal contract awarded to Children's National Medical Center. (See below and "EMSC Resource Centers and Grantees" under the "Introduction and Background" section for more information.)

The EMSC Program has sought input from national experts for strategic planning through various mechanisms. The EMSC PFC Stakeholder Group consists of 20 member organizations, including: APA, America's Health Insurance Plans, the American Academy of Family Physicians, the AAP, AAPCC, ACEP, the American College of Osteopathic Emergency Physicians, APSA, ATS, ENA, Family Voices, the International Association of Fire Fighters, NACHRI, NAEMSP, NAEMT, NASN, NASW, NASEMSD, NCSEMSTC, and the National SAFE KIDS Campaign. General partnership members include: CDC's National Center for Injury Prevention and Control, NEDARC, PECARN, and EMSC State Partnership and Targeted Issues grantee representatives.

EMSC National Resource Center (NRC)

Funded since 1991, the NRC was established at Children's National Medical Center in Washington, DC. NRC staff members have expertise in the following areas:

• strategic planning and problem solving;
• project development, management, and evaluation;
• coalition building;
• media relations;
• funding;
• injury prevention;
• children with special health care needs;
• public policy;
• managed care;
• quality improvement; and
• research development.

Consultation is available by telephone, e-mail, meetings, and technical assistance visits. The NRC also collects and catalogs products developed by EMSC grantees and other organizations. These products are available through the EMSC Clearinghouse and/or on-line at www.ems-c.org.

Publications created by the NRC that were produced specifically for use by EMSC grantees in project management include the following:

• Reaching Out: A Guide to Effective Coalition Building (1997);¹³²
• Working with Families to Enhance Emergency Medical Services for Children (1997);¹³³
• Managed Care and EMSC: A Practical Guide to Resources in Managed Care (2000);¹³⁴
• Meeting the Needs of Children: A Guide to Funding EMSC Projects (1997);¹³⁵
• Pounding the Pavement: Getting the Media to Work for You (2000);¹³⁶
• Preventing Childhood Injuries: A Guide to Developing Effective Injury Prevention Initiatives (1998);¹³⁷ and
• EMSC's Role in Shaping Policy: A Practical Guide to Changing Minds and Saving Lives (2000).¹³⁸

From 1997 to 2000, the EMSC Program worked with the Robert Wood Johnson Foundation on the development of EMSC Managed Care "white papers." The partnership resulted in the 1999 publication of the EMSC Managed Care Task Force List of Recommendations and Priorities,¹³⁹ The document identifies 11 managed care priorities with recommendations for addressing each issue. The priorities relate to access, development of national guidelines and performance measures, continuity of care, reimbursement, definition of medical necessity, and development of parent and caregiver resources.

Several papers were published in the Annals of Emergency Medicine as a result of this partnership, including:

• "Emergency Medical Services for Children Managed Care White Paper Series: Introduction;"¹⁴⁰
• "Practice Guidelines and Performance Measures in Emergency Medical Services for Children;"¹⁴¹
• "Quality and Accountability: Children's Emergency Medical Services in A Managed Care Environment;"¹⁴²
• "Twenty-Four Hour Access to Emergency Care for Children in Managed Care;"¹⁴³
• "Injury Prevention and Emergency Medical Services for Children in A Managed Care Environment;"¹⁴⁴ and
• "The Impact of Managed Care on Access to Emergency Services: An Analysis of Managed Care Contracts on State Medicaid and Federal Employee Health Benefit Plans."¹⁴⁵

National EMSC Data Analysis Resource Center (NEDARC)

NEDARC was established in 1995 in Salt Lake City, UT, to help EMSC grantees and State EMS offices develop capabilities to collect, analyze, and utilize EMS and other healthcare data to improve the quality of care in State EMS and trauma systems. NEDARC provides the following services:

• Data Collection: which elements to collect, hardware/software issues, survey/database design, confidentiality issues, XML assistance;
• Data Analysis: statistics, general analysis, probabilistic linkage, database access;
• Data Communication: data communication methods, fact sheets/presentations, serving data on the Web, Web site design issues;
• Quality Improvement (QI): using EMS data for QI, statistics in QI, program evaluation, trauma system evaluation;
• Research Design: research consultation, reducing bias/confounding, statistical testing, design/analysis of surveys; and
• Grant Writing: outlining the idea, proofreading and critique, Institutional Review Boards.

To date, all 50 States and five U.S. territories have received EMSC funding. The State's lead EMS agency manages the EMSC State Partnership Grants. Project coordinators oversee the day-to-day activities of each grant. Advisory groups are required as a prerequisite for all EMSC grant funding. Both the NRC and NEDARC have advisory groups overseeing their activities.

EMSC Funding History:

Acronym Glossary

Refereneces

¹ J.S. Durch and K.N. Lohr, Institute of Medicine Report on Emergency Medical Services for Children, Washington, DC: National Academy Press, 1993.
² EMSC National Resource Center, EMSC Five Year Plan, 1995-2000, Washington, DC: author, 1995.
³ EMSC National Resource Center, EMSC Five Year Plan, 2001-2005, Washington, DC: author, 2001.
⁴ H.B. Feely and J.L. Athey, Emergency Medical Services for Children: 10 Year Report, Arlington, VA: National Center for Education in Maternal and Child Health, 1995.
⁵ H.B. Feely and Rohrer Video Production, Saving Kids Lives Video, Washington, DC: Rohrer Video Production , 1995.
⁶ H.B. Feely and Rohrer Video Production, Saving Kids'Lives Public Service Announcements, Washington, DC: Rohrer Video Production, 1995.
⁷ D. Mulligan-Smith, How to Prevent and Handle Childhood Emergencies: A Handbook for Parents and People Who Care for Children, Tallahassee, FL: Florida EMSC, 1997.
⁸ Ohio Department of Health, Emergency Guidelines for Schools, Columbus, OH: Ohio Department of Health, 1998.
⁹ Oklahoma EMSC Resource Center, Emergency First Care and Injury Prevention CD-ROM, Oklahoma City, OK: Children's Hospital of Oklahoma, 1999.
¹⁰ Emergency Medical Services for Children National Resource Center, Working to Improve Child Care, Washington, DC: EMSC National Resource Center, 2000.
¹¹ Maternal and Child Health Bureau, Basic Emergency Lifesaving Skills (BELS): A Framework for Teaching Emergency Lifesaving Skills to Children and Adolescents, Rockville, MD: Health Resources and Services Administration, 1999.
¹² EMSC National Resource Center, EMSC Pediatric Emergency Care Resource Kit, Washington, DC: EMSC National Resource Center, 2000.
¹³ National Association of Emergency Medical Technicians, Guidelines for Providing Family-Centered Prehospital Care, Clinton, MS: National Association of Emergency Medical Technicians, 2000, http://www.ems-c.org/downloads/doc/Guidelines.doc (accessed August 4, 2004).
¹⁴ American Academy of Pediatrics, Uniform Pediatric First Aid, Safety, and CPR Training Materials for Child-Care Providers, Elk Grove Village, IL: American Academy of Pediatrics, 2002.
¹⁵ National Association of Emergency Medical Technicians, On the Same Team: Involving the Family in Prehospital Care (CD-ROM), Clinton, MS: National Association of Emergency Medical Technicians, 2002.
¹⁶ American Academy of Pediatrics, Family Readiness Kit: Preparing to Handle Disasters, Elk Grove Village, IL: American Academy of Pediatrics, 2002, http://www.aap.org/family/frk/frkit.htm (not a U.S. Government Web site) (accessed August 4, 2004).
¹⁷ Department of Education, Practical Information on Crisis Planning: A Guide for Schools and Communities, Washington, DC: Department of Education, 2003.
¹⁸ National Highway Traffic Safety Administration, Car Safety Seat Occupant ID Program: WHALE: We Have a Little Emergency, Washington, DC: National Highway Traffic Safety Administration, 2003.
¹⁹ M. Gausche-Hill, Pediatric Airway Management book and video, Torrance, CA: Harbor UCLA Medical Center, 1993, Case Studies in Pediatric Airway Management, 1997; Pediatric Airway Management (book and DVD), Sudbury, MA: Jones and Bartlett Publisher, 2004.
²⁰ G. Foltin, M. Tunik, A.Cooper, D. Markenson, M. Treiber, R. Phillips, T. Karpeles, Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP), New York, NY: Center for Pediatric Emergency Medicine, New York University School of Medicine, 1998.
²¹ M. Witte and B. Rushton, Children with Special Health Care Needs: Technology-Assisted Children, Salt Lake City, UT: Utah Department of Health, 1998.
²² Critical Illness and Trauma Foundation, A Child in Need, Bozeman, MT: Critical Illness and Trauma Foundation, 1998.
²³ R. Aghababian, MD, Pediatric Disaster Life Support Course, Worcester, MA: University of Massachusetts Medical School, 1999.
²⁴ P. Anderson, Helping Kids Survive: Interactive Training for Prehospital Providers, interactive 3-CD ROM set, Boise, ID: Idaho Emergency Medical Services for Children, 1999.
²⁵ B. Smith, J. Wright, and T. Adirim, SCOPE (Children's Outreach and Prehospital Education), Washington, DC: Children's National Medical Center, 2002.
²⁶ T. Singh, J. Wright, and T. Adirim, Children with Special Health Care Needs: A Template for Prehospital Protocol Development, Prehospital Emergency Care, 7 (3): 336-351, 2003.
²⁷ G. Foltin, M. Tunik, A. Cooper, D. Markenson, M. Treiber, and A. Skomorowsky, Paramedic TRIPP (Teaching Resource for Instructors in Prehospital Pediatrics), New York, NY: NYU School of Medicine Center for Pediatric Emergency Medicine, 2002.
²⁸ D. Markenson, G. Foltin, M. Tunik, A. Cooper, H. Matza-Haughton, L. Olson, and M. Treiber, Knowledge and Attitude Assessment and Education of Prehospital Personnel in Child Abuse and Neglect: Report of a National Blue Ribbon Panel, Pediatric Emergency Care, 18(3): 238-246, 2002.
²⁹ New York University School of Medicine, Center for Pediatric Emergency Medicine, Child Abuse and Neglect: A Prehospital Continuing Education and Teaching Resource, New York, NY: NYU School of Medicine Center for Pediatric Emergency Medicine, 2003.
³⁰ M. D. Dowd, It's Time to Ask, Children's Mercy Hospital: Kansas City, MO, 2003.
³¹ M. Gausche, et al. and the Pediatric Education Task Force, Education of Out-of-Hospital Emergency Medical Personnel in Pediatrics: Report of a National Task Force, Annals of Emergency Medicine, 31(1): 58-64, 1998.
³² National Association of Emergency Medical Service Physicians, Model Pediatric Protocols, Lenexa, KS: National Association of Emergency Medical Service Physicians, 1999, http://www.ems-c.org/downloads/pdf/ModelPed.pdf (accessed August 5, 2004).
³³ National Association of Emergency Medical Service Physicians, Model Pediatric Protocols, revised, Lenexa, KS: National Association of Emergency Medical Service Physicians, 2003, http://www.naemsp.org (not a U.S. Government Web site) (accessed August 5, 2004).
³⁴ D. Wood, E.J. Kalinowski, D. Miller, and T. Newton, Pediatric Continuing Education for Emergency Medical Technicians, Pediatric Emergency Care, 20(4): 261-268, 2004.
³⁵ D. Miller, E.J. Kalinowski, D. Wood, Pediatric Continuing Education for EMTs: Recommendations for Content, Method, and Frequency, Pediatric Emergency Care, 20(4): 269-272, 2004.
³⁶ National Registry of Emergency Medical Technicians, National Emergency Medical Services Education and Practice Blueprint, Washington, DC: Department of Transportation, National Highway Traffic Safety Administration, 1993.
³⁷ National Association of EMS Physicians, EMS Agenda for the Future, NTS-42, Washington, DC: Department of Transportation, National Highway Traffic Safety Administration, 1996.
³⁸ National Highway Traffic Safety Administration, EMS Agenda for the Future: Implementation Guide, Washington, DC: Department of Transportation, 1998. http://www.nhtsa.dot.gov/people/injury/ems/agenda/index.html (accessed August 5, 2004).
³⁹ National Highway Traffic Safety Administration, Emergency Medical Technician-Basic: National Standard Curriculum, Instructor's Course Guide, Washington, DC: National Highway Traffic Safety Administration, 1994, http://www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pdf (accessed August 5, 2004).
⁴⁰ National Highway Traffic Safety Administration, First Responder: National Standard Curriculum, Washington, DC: National Highway Traffic Safety Administration, 1995, http://www.nhtsa.dot.gov/people/injury/ems/pub/frnsc.pdf (accessed August 5, 2004).
⁴¹ National Highway Traffic Safety Administration, Emergency Medical Technician: Basic Refresher Curriculum, Instructor Course Guide, Washington, DC: National Highway Traffic Safety Administration, 1996, http://www.nhtsa.dot.gov/people/injury/ems/pub/basicref.pdf (accessed August 5, 2004).
⁴² National Highway Traffic Safety Administration, First Responder Refresher: National Standard Curriculum, Instructor Course Guide, Washington, DC: National Highway Traffic Safety Administration, 1996, http://www.nhtsa.dot.gov/people/injury/ems/pub/refresh2.pdf (accessed August 5, 2004).
⁴³ National Highway Traffic Safety Administration, EMT-Paramedic National Standard Curriculum, Washington, DC: National Highway Traffic Safety Administration, 1998, http://www.nhtsa.dot.gov/people/injury/ems/EMT-P/disk_1%5B1%5D/ (accessed August 5, 2004).
⁴⁴ National Highway Traffic Safety Administration, EMT-Intermediate: National Standard Curriculum, Washington, DC: National Highway Traffic Safety Administration, 1998, http://www.nhtsa.dot.gov/people/injury/ems/EMT-I/index.html (accessed August 5, 2004).
⁴⁵ National Highway Traffic Safety Administration, 2001 EMT-Paramedic NSC Refresher Curriculum, Instructor Course Guide, Washington, DC: National Highway Traffic Safety Administration, 2001, http://www.nhtsa.dot.gov/people/injury/ems/ems2001/Paramedic.htm (accessed August 5, 2004).
⁴⁶ National Highway Traffic Safety Administration, 2001 EMT-Intermediate NSC Refresher Curriculum, Instructor Course Guide, Washington, DC: National Highway Traffic Safety Administration, 2001, http://www.nhtsa.dot.gov/people/injury/ems/ems2001/IntRefresher.html (accessed August 5, 2004).
⁴⁷ National Highway Traffic Safety Administration, 2002 Supplemental Airway Modules for the 1994 Emergency Medical Technician-Basic: NSC, Washington, DC: National Highway Traffic Safety Administration, 2002, http://www.nhtsa.dot.gov/people/injury/ems/2002AirwayModules.pdf (accessed August 5, 2004).
⁴⁸ American Academy of Pediatrics, Pediatric Education for Prehospital Professionals (PEPP), Sudbury, MA: Jones and Bartlett, 2000.
⁴⁹ National Association of Emergency Medical Technicians, Pediatric Prehospital Care Course, National Association of Emergency Medical Technicians, Clinton, MS, 2001, http://naemt.org/mary-ann/ppc/ (not a U.S. Government Web site).
⁵⁰ Illinois EMSC, Pediatric Pain Management in the Emergency Department, Chicago, IL: Loyola University, 2002.
⁵¹Illinois EMSC, Injury Prevention for Medical Personnel - Reach for the Sky (CD-ROM), Chicago, IL: Loyola University, 2002.
⁵² K. Gnauck, et al., Tube Tools: Rapid Sequence Intubation and Related Pediatric Airway Techniques, Landover, MD: Power Train, Inc., 2004.
⁵³ American Psychological Association, Training EMSC Providers in Violence Prevention, Washington, DC: American Psychological Association, 1998, http://www.apa.org/pi/pii/trainems.html (not a U.S. Government Web site) (accessed August 5, 2004).
⁵⁴ National Association of Social Workers, NASW Bereavement Practice Guidelines for Social Workers in the ED: Trainee Manual, Washington, DC: National Association of Social Workers, 2001, http://www.ems-c.org/PFC/Downloads/DOC/911trainee.doc (accessed August 5, 2004).
⁵⁵ Woodring, B. (Ed.), Standards and Guidelines for Pre-Licensure and Early Professional Education for the Nursing Care of Children and Their Families, Washington, DC: U.S. Government Printing Office. 1998.
⁵⁶ Department of Pediatrics, School Nurse EMSC Program, Hartford, CT: University of Connecticut, 1997.
⁵⁷ Illinois EMSC, School Nurse Emergency Care Course (CD-ROM), Springfield, IL: Emergency Medical Services for Children, 2003.
⁵⁸ National Association of School Nurses, Managing School Emergencies: Instructor and Student Manuals, Scarborough, ME: National Association of School Nurses, 1999.
⁵⁹ L.M. Bernardo and L. Anderson, Preparing a Response to Emergency Problems, Scarborough, ME: National Association of School Nurses, 1998.
⁶⁰ National Association of School Nurses, Managing School Emergencies II: Musculoskeletal, Facial, and Mental Health Emergencies, Instructor and Student Manuals, Scarborough, ME: National Association of School Nurses, 2000.
⁶¹ National Association of School Nurses, Managing School Emergencies III: Multiple Trauma and MCI Instructor Manual, Scarborough, ME: National Association of School Nurses, 2000, http://www.nasn.org/education/mse.htm(not a U.S. Government Web site).
⁶² National Association of School Nurses, Managing School Emergencies Update, Scarborough, ME: National Association of School Nurses, 2002.
⁶³ National Association of School Nurses, Develop Disaster Preparedness Curriculum for School Nurses and Create Tracking Tool for School Injuries, Scarborough, ME: National Association of School Nurses, 2002.