EMSC Performance Measures
2007 Edition
Implementation Manual for State Partnership Grantees

Table of Contents

Introduction

• Performance Measures Background
• Process for Developing the Performance Measures
• List of Performance Measures
• Description of Revised Implementation Manual
• Program Contacts

General Considerations

• Definitions
• Implementation Considerations

Performance Measures

• Performance Measure #66a
• Performance Measure #66b
• Performance Measure #66c
• Performance Measure #66d
• Performance Measure #66e
• Performance Measure #67
• Performance Measure #68a
• Performance Measure #68b
• Performance Measure #68c
• Performance Measure #68d

Appendix A: Annotated Bibliography

Appendix B: Case Studies

Appendix C: Crosswalk of IOM Report Recommendations to EMSC Performance Measures

Implementation Manual Writing Team

Introduction

Performance Measures Background

With the implementation of the Government Performance and Results Act (GPRA), public sector agencies are increasingly being held accountable for achieving outcomes. GPRA focuses on a results-oriented approach, requiring Federal agencies to develop performance measures that inform and guide organizational decisions and communicate to a broad constituency about their success. As a result of GPRA, all Federal agencies are obligated to provide information to Congress on the effectiveness of their programs.

In an effort to continue its focus on accountability and performance, the Emergency Medical Services for Children (EMSC) Program tasked the National Resource Center (NRC) to develop a set of performance measures for the EMSC Program. The development of the performance measures complement the Program’s current performance management activities and can be integrated into existing reporting structures.

The purpose of the EMSC Program performance measures is to document activities and accomplishments of the Program in improving the delivery of emergency services to children. Additionally, information from the measures will provide guidance to the Program on future areas for improvement.

Specifically, the set of measures will:

• Provide an ongoing, systematic process for tracking progress towards meeting the goals of the EMSC Program;
• Allow for continuous monitoring of the effectiveness of key EMSC Program activities;
• Identify potential areas of performance improvement among the EMSC State Partnership grantees;
• Determine the extent to which the grantees are meeting established targets and standards; and
• Allow the EMSC Program to demonstrate its effectiveness and “tell its story” to the Health Resources and Services Administration (HRSA), Congress, and other stakeholders.

Process for Developing the Performance Measures

The process for developing the performance measures was an iterative one informed by various activities, including a comprehensive document review of EMSC Program materials to identify the “universe” of measures; the selection of a subset of measures using a set of five criteria; the convening of a consensus group meeting and follow-up conference calls to identify three core performance measures; and site visits to three betatest grantees to further refine the three performance measures

List of Performance Measures

The three overarching performance measures and their respective sub-measures are listed in the table below:

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Description of Revised Implementation Manual

The purpose of this revised Implementation Manual (herein referred to as Manual) is to provide the EMSC Program State Partnership Grantees with a more streamlined manual and to improve the ease, accuracy, and consistency of data collection and reporting for the performance measures across all grantees. This manual takes into account the feedback that the EMSC Program and the EMSC resource centers have received from the State Partnership Grantees, as well as an analysis and assessment of data entered into the HRSA Electronic Handbook (EHB) by grantees.

In an effort to streamline the contents of the revised Manual, a new format has been used. The remainder of this revised Manual includes the following information for each performance measure:

• Performance Measure: Lists the performance measure.
• Significance of Measure: Explains the importance of the measure and the rationale for implementing the measure. In addition, a list of resources, publications, and other scientific references including articles, reports, and expert testimonies is included.
• Definition(s): Provides definitions of key terms in the measure.
• Data Collection Methods: Provides: 1) a description of the appropriate data collection methods for the measure and 2) a description of supporting documentation that may be requested by HRSA and should be made available to support EHB entries.
• Data Entry: Includes: 1) a sample of the form grantees will be required to complete in the EHB for the measure and 2) information on the new online worksheet that grantees will be required to complete on the NEDARC website every year. This data worksheet will ask grantees to answer questions (e.g., response rates, specific data points not entered in EHB) on how they collected data for each of the measures.
• Prehospital: This term is generally used to define any setting apart from and prior to the access of any definitive care facility (such as a private residence or public location) where 911 services are requested for assessment, intervention, and transportation of a patient to a definitive care facility.
• Strategic Planning:: Includes: 1) advice to grantees on specific strategies and tools they should undertake after reviewing their data in order to effect system changes in their State/Territory to help meet the performance measures and 2) guidance for annual targets for the measure (based on the baseline data collected in 2006-2007).

The Appendices include the following:

• Appendix A: An annotated bibliography that includes an annotation for each reference listed in the “Significance of Measure” section for each performance measure.
• Appendix B: Case studies that highlight best practices, including lessons learned, for implementing some of the performance measures.
• Appendix C: A crosswalk that maps each performance measure to the relevant 2006 Institute of Medicine (IOM) Report Emergency Care for Children: Growing Pains recommendation(s).

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EMSC Program Contacts:

Dan Kavanaugh, MSW, LCSW-C
CAPT. USPHS
Senior Program Manager
(301) 443-1321 or
DKavanaugh@hrsa.gov

Christina Turgel, BSN, RN, BC
Nurse Consultant
(301) 443-5599 or
CTurgel@hrsa.gov

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Resource Center Contacts:

EMSC National Resource Center (NRC),
Tasmeen Singh, NREMT, MPH, Executive Director,
202-476-6866
tsingh@cnmc.org

National EMSC Data Analysis Resource Center (NEDARC),
Michael Ely, MHRM, Director,
801-585-9761
michael.ely@hsc.utah.edu

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General Considerations

The “General Considerations” section addresses a broad spectrum of issues that are applicable to all performance measures. This section includes definitions for terms used throughout the Manual, as well as implementation considerations for the various data collection methods described in the Manual for the performance measures.

Definitions

ALS Providers: Among other procedures, Advanced Life Support (ALS) providers administer higher life and limb saving assessment and interventions including the administration of medications, advanced airway procedures, and cardiac rhythm analysis as well as interpretation and electrical interventions. ALS personnel will include the EMT-Paramedic (EMT-P) and all intermediate level providers between the EMT-Basic (EMT-B) and EMT-P including EMT-Intermediate (EMT-I) and Advanced Cardiac Rescue certifications/ratings. For purposes of data collection, levels in between Paramedic Life Support (PLS) and Basic Life Support (BLS) should be counted as ALS providers.

BLS Providers: BLS providers provide basic life saving assessment and interventions before and during transportation of a patient to a definitive care facility. They include EMT-B only. For purposes of data collection, levels in between ALS and BLS should be counted as ALS providers.

EMSC: The component of emergency medical care that addresses the infant, child, and adolescent needs, and the Program that strives to ensure the establishment and permanence of that component. EMSC includes emergent at the scene care as well as care received in the emergency department, surgical care, intensive care, long-term care, and rehabilitative care. EMSC extends far beyond these areas yet for the purposes of this manual this will be the extent currently being sought and reviewed.

Hospitals: Facilities that provide definitive medical and/or surgical assessment, diagnoses, and life and/or limb saving interventions for the ill and injured, excluding the highest-level pediatric facilities in the State/Territory. Military and Indian Health Service hospitals are not required for data collection, but may be helpful in assuring all children in the State/Territory have access to needed resources. A State/Territory can obtain information from these hospitals if they are able to do so.

Mandate: A mandate is defined as a State/Territory statute, rule, regulation, or State/Territory developed policy issued by a legally authorized entity with enforcement rights to ensure compliance.

Patient Care Unit: A patient care unit is broadly defined as a vehicle staffed with EMS providers (BLS and/or ALS) dispatched in response to a 911 call to provide patient care. Examples include an ambulance, fire truck, hazardous materials (hazmat) vehicle, or a rapid/emergent response vehicle/unit. This definition includes non-transport vehicles (such as chase cars) to provide additional personnel resources. It EXCLUDES air ambulances, exclusively defined specialty care units, water ambulances/units, and any other vehicle/unit not exclusively designated to respond to any and all patient emergencies short of a mass casualty situation in which most any unit may actually be requested to respond for purpose of transportation only.

Pediatric: Even though it has been discovered that across the nation and territories a wide variance exists regarding the age of a pediatric patient for the purposes of this manual a pediatric patient will be defined as any person up to 18 years of age. States/Territories should provide answers to the performance measures based on their definition of a pediatric patient. However, if a State/Territory’s definition for a pediatric patient differs from the EMSC Program definition (i.e., persons up to 18 years old), the State/Territory is still required to provide in their supporting documentation an explanation of how care for all persons up to 18 years old is provided with respect to each measure. If the State/Territory is unable to collect and report data on the entire pediatric population as defined by this manual, the State/Territory should submit whatever data it does have and provide a justification for not being able to submit data on all persons up to 18 years old.

Pre-hospital Providers: For the purposes of data collection, prehospital providers are defined as those who provide medical care during a 911 call and staff patient care units (as defined in this manual).

Implementation Considerations

General Data Collection Considerations

• The changes to the performance measures are in effect starting with the 2007 State Partnership cycle (March 1, 2007 to February 29, 2008). If 2007 data has already been collected (e.g., sent out surveys), contact the National EMSC Data Analysis Resource Center (NEDARC) immediately. NEDARC will work with the survey that was distributed. All other States/Territories should contact NEDARC to begin data collection for the 2007 cycle. Note that data must be collected by February 29, 2008. EHB entry will occur in July 2008 for this data.
• Data must be collected every year for each performance measure; the EMSC Program is interested in measuring change for these performance measures over time.
• If a grantee has met a performance measure 100%, contact the State/Territory NRC representative to discuss whether data collection should continue.

Survey Considerations

• Grantees must use surveys either developed or approved by NEDARC. A response rate of at least 80% is required; 100% is the ideal standard.
• Grantees are encouraged to use the NEDARC survey templates because they have been rigorously reviewed and tested. Unless surveys have already been previously developed and approved by NEDARC it is suggested that grantees avoid developing individual surveys on their own. Grantees must have their surveys reviewed by NEDARC each year even if the surveys were used the previous year because NEDARC utilizes the experience from the previous year to revise/update surveys. It is hoped that grantees will go beyond the required questions for data analysis by NEDARC and if grantees add questions to the NEDARC template, NEDARC has to approve the additional questions. This information can assist a grantee to exceed beyond the performance measure as written and assist any State/Territory in achieving greater excellence, validity, reliability, and quality of life from the information obtained.
• Grantees must conduct annual surveys in order to report on yearly progress. This means that the same individuals may need to be re-surveyed each year. If grantees wish to conduct a random sample of the surveys, they must consult NEDARC.

Inspection Report Considerations

• For those grantees that plan to use inspection reports as their data collection method, they can either aggregate electronic data or collect and review data for 100% of available paper reports. If grantees have a large number of reports, they should contact NEDARC to discuss the feasibility of conducting a random sample. However, in order for a random sample to be feasible, data to generate a random sample must be available.
• Grantees must collect and report data every year for each performance measure. However, because many inspections are conducted every other year, data from one year may be used to report on a performance measure for the following year as well. Therefore, the same data may be submitted for two years in a row for those measures that have inspection reports as their data source.

State/Territory Mandate Considerations

• If a State/Territory mandate exists, the grantee may not need to collect data for certain performance measures. To be exempt from data collection, the State/Territory must have a mandate that contains clear and specific requirements, and the State/Territory must have strong enforcement policy. If a grantee thinks that his or her State/Territory might be eligible for an exemption, contact your NRC representative as soon as possible. Provide the representative with a copy of the State/Territory mandate and an explanation of how the mandate is being used to obtain written approval for an exemption from data collection. The NRC will send a written response to the exemption request within two weeks of receiving the State’s supporting documentation.
• If approved, the grantee will not need to resubmit additional requests in subsequent years unless directed so by the NRC or unless the State/Territory mandate has an expiration date. It is imperative that the grantee submit supporting documentation for the exemption from data collection as soon as possible. In so doing, the State/Territory will ensure it has ample time to collect data if the exemption is not granted.

Supporting Documentation Considerations

• Grantees are not required to submit supporting documentation for each performance measure during the continuation application process. However, note that HRSA may request supporting documentation at any time. Supporting documentation also should be available to support EHB entries. Guidance as to where to submit this supporting documentation (if requested by HRSA) will be provided in the grant guidance or in a separate memo distributed by the EMSC Program.

Performance Measures

Significance of Measure

This performance measure focuses on the importance of the EMSC system in the State/Territory having on-line and off-line pediatric medical direction available at the scene of all emergencies for both BLS and ALS providers. Medical direction provides EMS personnel with guidance and assistance at the scene of an emergency to ensure optimal care.

On-line and off-line pediatric medical direction is needed to assist and direct pre-hospital providers in the assessment, emergent intervention(s), and both timely and appropriate transportation of the pediatric patient at the scene of an emergency. Off-line medical direction helps to standardize pediatric patient care for prehospital care providers to assist in providing appropriate and quality assessment and care based on current pediatric clinical recommendations and evidence-based guidelines. This measure will help ensure prehospital providers have access to direction facilitating the provision of quality assessment and care in an emergent event.

For additional information on the importance of this measure, refer to the web resources, web casts, and journal articles listed below. Appendix A includes an annotated bibliography for each reference.

Web Resources

• Direction of Pre-hospital Care at the Scene of Medical Emergencies. Visit http://www.acep.org/, click on “ACEP Policy Statements” under “Practice Resources” and select document from the list.
• Example of Children with Special Healthcare Needs Protocols. Visit http://health.state.ga.us/programs/ems/emsc/, and then click on “Children with Special Health Care Needs” on the left menu.
• NRC Toolbox—Medical Direction. Visit http://bolivia.hrsa.gov/emsc/, click on “Previous Toolboxes,” and then click on “March 2007, Medical Direction.”
• Pre-hospital Systems and Medical Oversight, 3rd Edition by Alexander Kuehl. Visit http://www.naemsp.org, click on “Publications” to find the book, and then order the form.

Web Casts

• Kavanaugh, Dan, Improving EMS Medical Direction for Pediatric Patients. An Internet Archive. Visit http://www.mchcom.com/, click on “Archived Webcasts”, click on “Trauma EMS Webcasts”, and then select the document from the list.

Journal Articles

• American Academy of Pediatrics, Committee on Pediatric Emergency Medicine and American College of Emergency Physicians, Pediatric Committee, Care of Children in Emergency Departments, Guidelines for Preparedness. Pediatrics, 2001, 107: 777-781.
• Committee on Pediatric Emergency Medicine, The Role of the Pediatrician in Rural EMSC, Policy Statement. Pediatrics, 2005, 116:1553-1556.
• Scribano, Philip, Baker, D., Holms, J., and Shaw, K., Use of Out-of-hospital Interventions for the Pediatric Patient in an Urban Emergency Medical Services System. Academic Emergency Medicine, 2000; 7: 745-750.
• Shelton, Steve, Sewor, R., Domeier, R., and Lucas, R. Position Paper, National Association of EMS Physicians, Medical Direction of Inter-facility Transports. Prehospital Emergency Care, 2000; 4: 361-364.
• Thomas, Stephen, Williams, K., Claypool, D. Position Paper National Association of Emergency Medical Services Physicians — Medical Direction for Air Transport Program. Prehospital Emergency Care, 2002; 6:455-457.

Definitions

On-line pediatric medical direction: An individual is available 24/7 on the telephone, radio, or other telecommunication method to EMS providers who need on-line medical direction when transporting a pediatric patient to a hospital. This person must be a medical professional (e.g., nurse, physician, physician assistant [PA], nurse practitioner [ARNP], RN, or EMT-P) deemed to have pediatric expertise by the hospital in which they work and must have a higher level of pediatric training/expertise than the EMS provider to whom he/she is providing medical direction.

Note that grantees will be permitted to use either the definition provided above or the one established by their State/Territory. This definition is purposefully broad to allow for the wide variation in resources available at a hospital in each State/Territory. The intent of this measure is to ensure that EMS providers in the field (e.g., EMT, EMT-P) have access to a higher level of medical care for direction in treating a pediatric patient during an emergency.

For survey purposes, if the EMS provider does not know the pediatric expertise of the person providing medical direction, the EMS provider should answer based on his/her confidence in the information given by the medical professional.

Although some States/Territories would like to see the EMSC Program require specific pediatric training courses — such as Pediatric Advanced Life Support (PALS) or Pediatric Education for Pre-hospital Professionals (PEPP) — these courses are not the only way to have pediatric expertise. For example, a hospital could have a nurse who has several years of experience working in a pediatric emergency department (ED), but has never taken PALS. The hospital also could have a nurse who has recently graduated from nursing school, but has taken PALS. This example highlights that these nurses could not be counted as having equivalent pediatric expertise. By restricting the definition of online medical direction to a certain number of years of experience or specific training courses, we would not account for the permutations of choices that are available in a particular State/Territory. Therefore, the EMSC Program recommends that States consider adopting a specific definition of pediatric medical direction that includes requiring pediatric emergent care experience.

Off-line pediatric medical direction: Treatment guidelines and protocols used by EMS providers to ensure the provision of appropriate pediatric patient care, available in written or electronic (e.g., laptop/tablet computer) form in the patient care unit or with a provider, at the scene of an emergency. Treatment guidelines and protocols located at the EMS station or agency are not considered to be available at the scene of an emergency. The intent of this measure is to ensure that EMS providers have a resource available to them during and at the scene of an emergency should they need to refer to it given that EMS providers do not treat pediatric patients often.

At the scene of an emergency: For on-line and off-line pediatric medical direction, “at the scene of an emergency” will be defined as medical direction available to the EMS provider from the time the patient care unit is dispatched through patient transport to a definitive care facility.

Data Collection Methods

The two acceptable data collection methods for Performance Measure #66a are inspection reports (preferred data collection method) and surveys. If a grantee has an alternate source for gathering data, he/she must contact NEDARC and gain approval for this method to answer the EHB.

Inspection Reports. Grantees that plan to use inspection reports as their data collection method can either review compiled aggregate electronic data or collect and review data for 100% of available paper reports as based on the inspection cycle of the State/ Territory. (Note: If grantees have a large number of reports, they can contact NEDARC to discuss the feasibility of conducting a random sample; however, the data to generate a random sample must be available.)

HRSA may request supporting documentation for this measure. Supporting documentation also should be available to support the following EHB entries:

• If using aggregate data:
  • List of the data elements available in the dataset and a data dictionary;
  • Query parameters used to generate final results; and
  • Copy of final results.
• If reviewing inspection reports:
  • Copy of an inspection report to represent how on-line or off-line medical direction is checked as defined in this manual; and
  • Copy of tabulations from data collected.

Surveys. Grantees must use surveys either developed or approved by NEDARC. Note that this performance measure does not look at access to pediatric medical direction as being specific to communication issues (e.g., non-working radios), but more broadly to the availability of pediatric expertise. States/Territories have the option to add additional questions to a survey if there are specific issues in the State/Territory that they want to explore further.

If a grantee is unclear about whom to survey, he/she should contact NEDARC for help in determining the best person to survey. Acceptable individuals to survey include:

• A representative of the EMS agency (e.g., EMS administrator, EMS manager) that has oversight of the day-to-day operations and/or management of the individual EMS agency. This excludes agency EMS directors, medical directors, regional directors, or other representatives who are not involved in the day-to-day operations of the EMS agency
  • Note: in some small States or Territories, the state/territory-wide EMS director has day to day oversight due to the small size of the jurisdiction. This is acceptable but the state/territory should confirm with NEDARC that their director is appropriate.
• If for some reason a single point of contact cannot be identified at an agency, a representative sample of ground level 911EMS providers from the agency may be surveyed. (Grantees should consult NEDARC on sampling ground level EMS providers.)

HRSA may request supporting documentation for this measure. Supporting documentation also should be available to support the following EHB entries:

• Survey results/analysis from the NEDARC on-line survey tool (provided by NEDARC), or
• Raw data and survey analysis if utilizing paper surveys or another (non-NEDARC) on-line tool

Exemption from Data Collection

Grantees may be exempt from data collection due to either a State/Territory mandate for on-line pediatric medical direction or the existence of State/Territory-wide pediatric protocols/guidelines for off-line pediatric medical direction.

For On-line Pediatric Medical Direction: A State/Territory may qualify for an exemption from data collection if the State/Territory meets both of the following criteria:

• A State/Territory mandate exists that includes specific language directed at online pediatric medical direction during an EMS event.
• The State/Territory must have an enforcement process that ensures that on-line pediatric medical direction is available. An enforcement process for the purposes of this measure is a mechanism by which pediatric on-line medical direction is ensured in the State/Territory. Examples include:
  • Use of base stations that are available to 100% of the EMS providers in the State/Territory.
  • EMS licensing requirements that stipulate the provision of on-line pediatric medical direction that is available to 100% of the providers in the State/Territory.

Grantees should consult with their NRC representative as soon as possible. Provide the representative with a copy of the State/Territory mandate and an explanation of how the mandate is being used to obtain written approval for an exemption from data collection. The NRC will send a written response within two weeks of receiving the State’s exemption request.

If approved, the grantee will not need to resubmit additional requests in subsequent years unless directed so by the NRC or unless the State/Territory mandate has an expiration date. Note that this exemption applies only to on-line pediatric medical direction and that grantees will still be required to collect data for off-line pediatric medical direction. Supporting documentation for this measure will be a letter of approval from the NRC granting an exemption from data collection.

The following decision tree should help grantees determine if they are eligible for an exemption from data collection due to a State/Territory mandate for on-line pediatric medical direction.

Decision Tree for Exemption from Data Collection
Due to State/Territory Mandate for On-line
Pediatric Medical Direction

[d]

For Off-line Pediatric Medical Direction: A State/Territory may qualify for an exemption from data collection if State/Territory-wide pediatric protocols/guidelines exist and the State/Territory has all of the following in place:

• All EMS patient care units in the State/Territory are required to use the State/Territory approved and required pediatric protocols/guidelines. Note that protocols/ guidelines do not need to be consistent across the State. Individual agencies can have agency or regional specific protocols as long as 100% of the agencies are required to have pediatric protocols.
• A training and/or testing program is in place to ensure that the content of State/Territory approved and required pediatric protocols/guidelines is known by all pre-hospital providers required to utilize them. Note that this training and testing program is only needed if a grantee is seeking an exemption from data collection as such an exemption assumes assurance that ground providers know that protocols exist and utilize them.
• Copies of the State/Territory approved and required pediatric protocols/guidelines are available in all patient care units (in paper or electronic form).

Note that if pediatric protocols/guidelines are available in the entire State/Territory (even if they are inconsistent between regions) and the other requirements for an exemption from data collection are met, a grantee can contact the NRC describing your State/Territory-wide pediatric protocols/guidelines to determine if the State qualifies for an exemption from data collection.

Grantees should consult with their NRC representative as soon as possible. Provide the representative with a copy of the State/Territory approved and required pediatric protocol/guideline and a description of the State/Territory process that allows it to meet the measure. Written responses will be sent within two weeks of submission.

If approved, the grantee will not need to resubmit additional requests in subsequent years unless directed so by the NRC or unless the State/Territory approved and required pediatric protocols/ guidelines have an expiration date. Note that this exemption applies only to off-line pediatric medical direction and that grantees will still be required to collect data for on-line pediatric medical direction.

Supporting documentation for this measure will be a letter of approval from the NRC granting an exemption from data collection.

The following decision tree should help grantees determine if they are eligible for an exemption from data collection due to the existence of State/Territory approved and required pediatric protocols/guidelines for off-line pediatric medical direction.

Decision Tree for Exemption from Data Collection
Due to State/Territory-wide Pediatric Protocols/
Guidelines for Off-line Pediatric Medical Direction

[d]

Data Entry

A template of the form grantees will be required to complete in the HRSA Electronic Handbook is provided below.

The numerator and denominator that should be used for the percentage calculations in the form above are listed below:

Numerator

• The number of emergency (911) agencies in the State/Territory that have on-line pediatric medical direction at the scene of an emergency for all of their BLS providers.
• The number of emergency (911) agencies in the State/Territory that have on-line pediatric medical direction at the scene of an emergency for all of their ALS providers
• The number of emergency (911) agencies in the State/Territory that have off-line pediatric medical direction at the scene of an emergency for all of their BLS providers.
• The number of emergency (911) agencies in the State/Territory that have off-line pediatric medical direction at the scene of an emergency for all of their ALS providers

Denominator

• The total number of BLS emergency (911) agencies in the State/Territory
• The total number of ALS emergency (911) agencies in State/Territory

Online Worksheet Data Entry

In addition to EHB reporting, grantees will be required to complete an online worksheet each year. The new sheet is located on the NEDARC website at http://www.nedarc.org. The purpose of this worksheet is to help ensure accurate, rigorous, and consistent data collection for the measure among all State/Territory grantees and to allow grantees to provide more detail about individual performance measure results. For Performance Measure #66a, the data worksheet will ask grantees the following questions:

General Questions

1. Total number of licensed pre-hospital provider agencies in the State/Territory:
2. Total number of hospitals with an emergency department in the State/Territory:
3. Does the State/Territory have intermediate (ILS) or some type of licensed ambulances other than BLS or ALS?
   • Yes. If yes, how were these other types of licensed ambulances classified for baseline data collection?
     • Grouped with ALS ambulances for baseline data collection
     • Grouped with BLS ambulances for baseline data collection
     • Excluded from baseline data collection
     • Other (please explain)
   • No

Performance Measure 66a: On-line Pediatric Medical Direction

4. How did data collection occur for EHB entry of on-line medical direction?
   • Survey
   • Ambulance/Agency Inspection Process
   • Exemption from data collection from the NRC
   • Did not collect data
   • Other (please specify)
5. If an exemption from data collection was not received, which pediatricspecific definition of on-line medical direction was used?
   • EMSC Program definition
   • Other (please enter the definition here)

If you used a survey

6. If a survey was used, did NEDARC provide or approve the survey instrument?
   • YES
   • NO (please explain). If no, submit a copy of the survey to NEDARC for review.
7. Who was the survey sent to for completion?
   • Licensed pre-hospital provider agency managers/directors/administrators
   • Pre-hospital provider personnel within an agency
   • EMS agency medical officers/directors
   • Regional or county EMS liaison personnel
   • Other (please describe)
8. Describe the oversight role(s) that the individual(s) who responded to the survey plays for the EMS agency
9. Was a survey sent to a representative of all of the State’s/Territory’s pre-hospital provider agencies?
   • Yes. If yes, what was the total number of individuals it was sent to?
   • No. If no, did NEDARC help to develop a representative sample?
     • Yes
     • No. If no, how were the agencies selected to survey? How many agencies received the survey?
10. What is the total number of respondents that completed the survey?

If grantees used an agency/ambulance inspection process:

11. What do inspectors check for to determine whether pre-hospital provider agencies have pediatric on-line medical direction?
12. Did the grantee (or other authorized personnel) personally review individual inspection reports from all pre-hospital provider agencies to obtain performance measure data?
    • Yes
    • No. If no, how did the grantee decide which agencies to review inspection reports from? How many did the grantee review?
13. If individual inspection reports were not reviewed, were some type of summarized results from all pre-hospital provider agencies of inspections reviewed to obtain performance measure data?
    • Yes. Please describe the source of the summarized results.
    • No. If no, how did the grantee decide which agencies to review inspection reports from? How many were reviewed?

Performance Measure 66a: Off-line Pediatric Medical Direction

14. How was data collected for the EHB entry of off-line medical direction?
    • Survey
    • Ambulance/Agency Inspection Process
    • Exemption from data collection from the NRC
    • Did not collect data
    • Other (please specify)
15. If an exemption from data collection was not received, which pediatricspecific definition of off-line medical direction was used?
    • EMSC Program definition
    • Other (please enter the definition here)

If grantees used a survey:

16. If a survey was used, did NEDARC provide or approve the survey instrument?
    • YES
    • NO (please explain). If no, submit a copy of the survey to NEDARC for review.
17. Who was the survey sent to for completion?
    • Licensed pre-hospital provider agency managers/directors/administrators
    • Pre-hospital provider personnel within an agency
    • EMS agency medical officers/directors
    • Regional or county EMS liaison personnel
    • Other (please describe)
18. Describe the oversight role(s) that the individual(s) who responded to the survey plays for the EMS agency.
19. Was a survey sent to a representative of all of the State’s/Territory’s pre-hospital provider agencies?
    • Yes. If yes, what was the total number of individuals it was sent to?
    • No. If no, did NEDARC help to develop a representative sample?
      • Yes
      • No. If no, how were agencies selected to survey? How many agencies received the survey?

If grantees used an agency/ambulance inspection process:

21. What is the total number of respondents that completed the survey?
22. What do inspectors check for to determine whether pre-hospital provider agencies have pediatric off-line medical direction?
23. Did the grantee (or other authorized personnel) personally review individual inspection reports from all pre-hospital provider agencies to obtain performance measure data?
    • Yes
    • No. If no, how did the grantee decide which agencies to review inspection reports from? How many were reviewed?
24. If individual inspection reports were not reviewed, was some type of summarized results from all pre-hospital provider agencies of inspections reviewed to obtain performance measure data?
    • Yes. Please describe the source of the summarized results.
    • No. If no, how did the grantee decide which agencies to review inspection reports from? How many were reviewed?

Strategic Planning

Using the 2006 data, the State/Territory should assess their compliance with having online and off-line pediatric medical direction. Data should be presented to the EMSC Advisory Committee to develop a strategy for meeting the performance measure.

Some specific strategic planning activities grantees can undertake to effect system changes in their States/Territories, which are needed to meet this measure, include:

Online Pediatric Medical Direction

• Review baseline data for the measure, and discuss system gaps with the EMS director and medical director.
• Dialogue with agencies lacking pediatric medical direction to discuss barriers that exist (e.g., communication issues in the field versus availability of pediatric staff at local hospitals).
• Engage hospitals in the State/Territory having pediatric medical expertise available to elicit assistance in establishing such for other agencies.
• Discuss the feasibility or appropriateness of a centralized pediatric medical direction system.
• Consider providing PALS, PEPP, PPC, APLS, or other pediatric emergency care courses to all ED staff that are providing pediatric medical direction.
• Contact the NRC for examples of protocols developed and adopted in many States/Territories.

Off-line Pediatric Medical Direction

• Review baseline data for the measure, and discuss system gaps with the EMS director and/or medical director.
• Assess the reasons why EMS agencies do not have access to pediatric protocols/ guidelines (e.g., protocols/guidelines do not exist in the agency paper copies are not available in the unit, etc.).
• Engage regional/agency medical directors to discuss barriers/challenges to implementing off-line pediatric medical direction. Brainstorm with these medical directors and the EMSC Advisory Committee to determine possible solutions.
• Determine the feasibility of State/Territory-wide pediatric protocols/guidelines.
• Provide model protocol/guideline templates to facilitate the development process.

Guidelines for annual targets for this measure are provided below:

[back to introduction]

Significance of Measure

This performance measure targets the availability of essential pediatric equipment and supplies for BLS and ALS patient care units. Prehospital providers must have the appropriate pediatric equipment and supplies to care for ill and injured children in order to achieve optimal pediatric outcomes. Consequently, in 1996 ACEP Guidelines were developed as an essential pediatric equipment and supply list for pre-hospital providers based on current evidence and expert opinion¹. This measure is an important indicator of prehospital provider preparedness to care for children.

The EMSC Program is working with several national organizations to update the pediatric equipment list used for these performance measures. This is one of the reasons why we need to collect detailed data from States/Territories on what equipment patient care units are carrying and why some pieces may be lacking and/or unnecessary.

For additional information on the importance of this measure, refer to the web resources, publications, and guidelines/protocols listed below. Appendix A includes an annotated bibliography for each reference.

Web Resources

• NRC Toolbox — Prehospital Education. Visit http://bolivia.hrsa.gov/emsc/ click on “Toolbox” from the left menu, and then select “Prehospital Education.”

Publications

• American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, Pediatric Care Recommendations for Free Standing Urgent Care Facilities, 2007.
• Institute of Medicine Committee, Future of Emergency Care in the United States Health System, Report Brief. National Academy of Sciences, 2006.
• Krug, Steve, Emergency Care Crisis: A Nation Unprepared for Public Health Disasters. Testimony for Homeland Security Subcommittee on Emergency Preparedness, Science, and Technology, 2006.
• Seidel J.S, et al. EMS and the Pediatric Patient: Are the Needs Being Met? Pediatrics, Volume 73, June, 1984.
• Seidel, J.S., et al. EMS and the Pediatric Patient. Are the Needs Being Met II? Training and Equipping EMSC Providers for Pediatric Emergency Care. Pediatrics, Volume 78, December 1986.

Guidelines/Protocols

• American Academy of Pediatrics, Committee on Pediatric Emergency Medicine and American College of Emergency Physicians, Pediatric Committee, Care of Children in Emergency Departments, Guidelines for Preparedness. Pediatrics, 2001; 107: 777-781.
• ACEP Equipment Guidelines 1996. Contact the NRC Library at 202-476-6847 for more information.
• Peckinpaugh, Karen, Izsak, E., Lindstrom, D., Orlow, G., Contour, T., and Rice, M., The Advanced Pedi-Bag Program: A Hospital-EMS Partnership to Implement Prehospital Training, Equipment and Protocols. Pediatric Emergency Care, 2000, 16: 409-412.

¹ Siedel et al. Committee on Ambulance, Equipment, and Supplies. National Emergency Medical Services for Children Resource Alliance. (1996). Guidelines for pediatric equipment and supplies for Basic and Advanced Life Support Ambulances. Annals of Emergency Medicine, 28(6), 699-701.

Definitions

Essential: The item is necessary and should be carried by a patient care unit. Some equipment items such as an oropharyngeal airway have several sizes. Patient care units need to have at least one of every size in the range for all required pediatric items. Suction catheters are only available in even number sizes. Refer to the list of essential pediatric equipment and supplies for BLS and ALS in the section titled “Online Worksheet Data Entry” (page 34). Note that ALS includes all provider levels above BLS, such as ILS and PLS.

For States/Territories with patient care units that do not have their own set of pediatric equipment, paramedic jump kits (i.e., portable pediatric equipment kits that can be brought to the scene of an emergency) can be used as long as the State/Territory can provide supporting evidence that the jump kit is always and immediately available on every EMS response. States/Territories should work with their Advisory Committees, key partners, and the NRC to determine the best way to confirm that this system consistently works. In addition, States/Territories should conduct regular quality improvement monitoring to ensure that the necessary number of portable jump kits is available to adequately handle pediatric emergencies. Completely stocked paramedic jump kits may not necessarily include all essential pediatric equipment and supplies. Each patient care unit should be inspected for routinely carried pediatric equipment that supplements paramedic jump kits.

ACEP Guidelines: The 1996 ACEP Guidelines, which include a list of equipment and supplies that should be stocked on BLS and ALS patient care units to effectively provide pediatric patient care. Refer to the “Online Worksheet Data Entry” for the list of essential pediatric equipment and supplies for BLS and ALS patient care units.

Data Collection Methods

Grantees will be required to collect and report data on each piece of equipment, including individual sizes of equipment. Missing items (including missing sizes) of pediatric equipment, as well as the number or percent of patient care units that carry pediatric equipment by each specific item of equipment are to be noted in the online worksheet.

An “out-of-scope” answer choice also will be provided when entering data on the measure into the NEDARC online worksheet. Out-of-scope equipment is defined as equipment that cannot be used because an agency’s off-line pediatric protocols/guidelines do not allow for its use or the equipment is out-of-scope of practice for the EMS provider in the State/Territory. Items that are excluded because of cost or political reasons (e.g., EMS medical director or EMSC Advisory Committee does not like or allow the equipment) cannot be counted as “out-of-scope.”

A list of all equipment that will be considered “out-of-scope” should be sent to the NRC with an explanation of why it is out-of-scope to ensure that the correct interpretation of out-of-scope is being used. If the NRC verifies that an item can be considered out-ofscope, this item does not need to be included in the survey. In addition, report this item as “out-of-scope” in the online worksheet (see Data Entry section).

The two acceptable data collection methods for acquiring information for EHB data entry are inspection reports (preferred data collection method) and surveys. If a grantee has an alternate source for gathering data, he/she must contact NEDARC for approval of the data collection method. Note that the proposed data collection method must be as rigorous as the two methods listed above.

Inspection Reports: Grantees that plan to use inspection reports as their data collection method can either review electronic data (individual reports or aggregated inspection results as long as aggregate data contains the detail necessary to determine whether each piece of pediatric equipment in the 1996 ACEP Guidelines was present or missing) or collect and review data for 100% of available paper reports as based on the inspection cycle of the State/Territory. If the State/Territory has an inspection process that covers 100% of the patient care units, it doesn’t matter whether it takes one, two, or three years to inspect all patient care units. Grantees can still use the data, but he/she must review all of the available reports. All patient care units should be included in this data collection.

Note that if grantees have a large number of reports, they can contact NEDARC to discuss the feasibility of conducting a random sample. However, for a random sample to be feasible, the data to generate a random sample must be available.

HRSA may request supporting documentation for this measure. Supporting documentation also should be available to support the following EHB entries:

• If using aggregate data:
  • List of the data elements available in the dataset and a data dictionary;
  • Query parameters used to generate final results; and
  • Copy of final results.
• If reviewing inspection reports:
  • Copy of the inspection report indicating a 1:1 match with the 1996 ACEP Guidelines; and
  • Copy of tabulations from data collected.

Surveys: Grantees must use surveys either developed or approved by NEDARC. If a grantee is unclear about whom to survey, he/she should contact NEDARC for help in determining the best person to survey. Acceptable individuals to survey include:

• A representative of the EMS agency (e.g., EMS administrator, EMS manager,) that has oversight of the day-to-day operations and/or management of the individual EMS agency. This excludes state EMS directors, medical directors, regional directors, or other representatives who are not involved in the day-to-day operations of the EMS agency
  • Note: in some small States or Territories, the state/territory-wide EMS director has day to day oversight due to the small size of the jurisdiction. This is acceptable but the state/territory should confirm with NEDARC that their director is appropriate.
• If for some reason a single point of contact cannot be identified at an agency, a representative sample of ground level (not air) EMS providers from the agency may be surveyed. (Grantees should consult NEDARC on sampling ground level EMS providers.)

HRSA may request supporting documentation for this measure. Supporting documentation also should be available to support EHB entries. Supporting documentation for this measure includes:

• Survey results/analysis from the NEDARC online survey tool (provided by NEDARC)
• Raw data and survey analysis if utilizing paper surveys or another (non-NEDARC) online tool

Exemption from Data Collection

Exemption from data collection for Performance Measure #66b will require that the State/Territory mandate meets all of the following criteria.

• The State/Territory must have an inspection process that verifies a 1:1 match with the 1996 ACEP Guidelines (for all equipment and supply sizes; excluding out-ofscope equipment/supply). Remember to verify with the NRC if a piece of equipment can be legitimately considered “out-of-scope.”
• The inspection process must be regular (as defined by the State/Territory; this typically occurs every year or every two years) and must cover all patient care units in the State/Territory in the given inspection cycle.
• A documented enforcement process (as defined by the State/Territory) must exist that covers all patient care units and removes a patient care unit from service if any pediatric inspection deficiencies are not met in a State-defined time limit.

If requesting an exemption from data collection grantees should contact their NRC representative as soon as possible. Provide a copy of the State/Territory mandate and an explanation of how the mandate is being used to obtain written approval for an exemption from data collection. Written responses will be sent within two weeks of submission.

If approved, the grantee will not need to resubmit additional requests in subsequent years unless directed so by the NRC or unless the State/Territory-wide pediatric protocols/guidelines have an expiration date. Note that many inspection reports will likely not meet all of the aforementioned criteria, and thus, it is important to consult the NRC immediately to discuss your inspection process.

Supporting documentation for this measure will be a letter of approval from the NRC granting an exemption from data collection.

The following decision tree should help grantees determine if they are eligible for an exemption from data collection due to a State/Territory mandate.

Decision Tree for Exemption from Pediatric Equipment
Data Collection Due to State/Territory Mandate

[d]

Data Entry

A template of the form grantees will be required to complete in the HRSA Electronic Handbook is provided below.

The numerator and denominator that should be used for the percentage calculations in the form above are listed below:

Numerator

• The number of BLS patient care units in the State/ Territory that have all of the essential pediatric equipment and supplies as outlined in the 1996 ACEP Guidelines
• The number of ALS patient care units in the State/ Territory that have all of the essential pediatric equipment and supplies as outlined in the 1996 ACEP Guidelines

Denominator

• The total number of BLS patient care units in the State/Territory
• The total number of ALS patient care units in State/Territory

Online Worksheet Data Entry

In addition to EHB reporting, grantees will be required to complete an online worksheet each year. The new sheet is located on the NEDARC website at http://www.nedarc.org. The purpose of this worksheet is to help ensure accurate, rigorous, and consistent data collection for the measure among all State/Territory grantees and to allow grantees to provide more detail about individual performance measure results. For Performance Measure #66b, the data worksheet will ask grantees the following questions:

General Questions

1. What is the total number of licensed prehospital provider agencies in the State/Territory?
2. What is the total number of hospitals with an ED in the State/Territory?
3. Does the State/Territory have intermediate (ILS) or some type of licensed ambulances other than BLS or ALS?
   • Yes. If yes, how were these other types of licensed ambulances classified for baseline data collection?
     • Grouped with ALS ambulances for baseline data collection
     • Grouped with BLS ambulances for baseline data collection
     • Excluded from baseline data collection
     • Other (please explain)
   • No

Performance Measure 66b: Pediatric Equipment

4. How did data collection occur for EHB entry of pediatric equipment?
   • Survey
   • Ambulance/Agency Inspection Process
   • Exemption from data collection from the NRC
   • Did not collect

If grantees used a survey:

5. If a survey was used, did NEDARC approve the survey instrument?
   • YES
   • NO (please explain). If no, submit a copy of the survey to NEDARC for review.
   
   
6. Who was the survey sent to for completion?
   • Licensed pre-hospital provider agency managers/directors/administrators
   • Pre-hospital provider personnel within an agency
   • EMS agency medical officers/directors
   • Regional or county EMS liaison personnel
   • Other (please describe)
   
   
7. Describe the oversight role(s) that the individual(s) who responded to the survey plays for the EMS agency.
8. Was the survey sent to a representative of all of the State’s/Territory’s pre-hospital provider agencies?
   • Yes. If yes, what was the total number of individuals it was sent to?
   • No. If no, did NEDARC help to develop a representative sample?
     • Yes
     • No. If no, how were the agencies selected? How many agencies received the survey?
   
   
9. What is the total number of respondents that completed the survey?

If grantees used an agency/ambulance inspection process:

10. Do the inspectors check for all equipment items contained on the 1996 ACEP Guidelines in the performance measure manual for BLS ambulances?
    • Yes
    • No (please list each piece of equipment not on the inspection form and why)
    • Not applicable (i.e. no BLS services exist in the State/Territory)
    
    
11. Do the inspectors check for all sizes contained on the 1996 ACEP Guidelines list in the performance measure manual for BLS ambulances?
    • Yes
    • No (please list each size not on the inspection form and why)
    • Not applicable (i.e. no BLS services exist in the State/Territory)
    
    
12. Do the inspectors check for all equipment items contained on the 1996 ACEP Guidelines in the performance measure manual for ILS/ALS ambulances?
    • Yes
    • No (please list each piece of equipment not on the inspection form and why)
    • Not applicable (i.e. no ILS/ALS services exist in the State/Territory)
    
    
13. Do the inspectors check for all sizes contained on the 1996 ACEP Guidelines in the performance measure manual for BLS ambulances?
    • Yes
    • No (please list each size not on the inspection form and why)
    • Not applicable (i.e. no BLS services exist in the State/Territory)
    
    
14. Did the grantee (or other authorized personnel) personally review individual inspection reports from all pre-hospital provider agencies to obtain performance measure data?
    • Yes
    • No. If no, how did the grantee decide which agencies to review inspection reports from? How many were reviewed?
    
    
15. If individual inspection reports were not reviewed, did the grantee review some type of summarized results from all pre-hospital provider agencies of inspections to obtain performance measure data?
    • Yes. Please describe the source of the summarized results.
    • No. If no, how did the grantee decide which agencies to review inspection reports from? How many were reviewed?
    
    
16. Whether EMS agencies were surveyed or inspection reports reviewed (or some combination), what is the total number of patient care units for which data was collected: BLS? ILS/ALS?

Based on the above numbers, use the table below to indicate the percentage of patient care units that carry each piece/size of equipment:

LIST OF BLS/ALS ESSENTIAL EQUIPMENT

Strategic Planning

Using the 2006 data, the State/Territory should assess compliance with having pediatric equipment and supplies on BLS and ALS patient care units. Data should be presented to the EMSC Advisory Committee to develop a strategy for meeting the performance measure.

Some specific strategic planning activities grantees can undertake to effect system changes in their States/Territories, which are needed to meet this measure, include:

• Review baseline data for the measure, and discuss system gaps with your EMS director and medical director. Specifically, discuss agencies that are missing equipment and the items that are frequently missing.
• Use data from your survey responses to assess reasons why EMS agencies are missing equipment (e.g., cost of equipment, replacement errors due to low use, etc.).
• Engage regional/agency medical directors to better understand the barriers to ensuring the availability of pediatric equipment.
• Engage the EMSC family member representative and EMSC Advisory Committee to brainstorm mechanisms for obtaining funding for equipment (if cost is a barrier) and replacement pieces when used (e.g., replacement agreements with receiving hospitals).
• Contact the NRC to identify models employed by other States/Territories to achieve this measure.

Guidelines for annual targets for this measure are provided below:

[back to introduction]

Significance of Measure

This performance measure emphasizes the importance of the existence of a standardized statewide, territorial, or regional system that recognizes hospitals capable of stabilizing and/or managing pediatric medical emergencies and trauma. A standardized categorization and/or designation process is necessary to assist hospitals in determining their capacity and readiness to effectively deliver pediatric emergency and specialty care.

This measure will help ensure that mechanisms are in place so that pediatric patients receive emergency and trauma care only from those hospitals that have been appropriately categorized and/or designated as qualified to provide such care. A statewide recognition system has also been shown to increase the number of EDs that are capable of providing pediatric emergency care.

For additional information on the importance of this measure, refer to the web resources, guidelines and policy/position statements, and publications listed below. Appendix A includes an annotated bibliography for each reference.

Web Resources

• Availability of Pediatric Services and Equipment in Emergency Departments: United States, 2002-03. Visit http://www.cdc.gov/nchs, click on “More Publications” on the left, click on “Advance Date” under “Reports” on the right, and then select report #367.
• NRC Toolbox: Facility Categorization. Visit http://bolivia.hrsa.gov/emsc/, and then click on “Toolbox” on left menu.
• NRC Toolbox: Inter-facility Transfer. Visit http://bolivia.hrsa.gov/emsc/, and then click on “Toolbox” on left menu.
• U.S. Department of Health and Human Services, Model Trauma System Planning and Evaluation, 2006. Visit http://www.hrsa.gov/trauma/model.htm.

Guidelines and Policy/Position Statements

• Emergency Department Approved for Pediatrics (EDAP) Guidelines. Visit http://www.luhs.org/depts/emsc/, click on “Archives” at the bottom of the page, the scroll down to 2001, and then select the EDAP link under “June.”
• AAP/ACEP Policy Statement Care of Children in the Emergency Department: Performance Measures: An Implementation Manual for State Partnership Grantees, 2007 Edition 39 Guidelines for Preparedness. Visit http://aappolicy.aappublications.org/, click on “AAP Policy Statements”, and then select policy statement under “C.”
• Emergency Nurse Association, Position Statement on Care of Critically Ill or Injured Patients during Inter facility Transfer, 2005.

Publications

• Athey, Jean, Dean, M., Ball, J., Weibe, R., d-Hospital, I. Ability of Hospitals to Care for Pediatric Emergency Patients. Pediatric Emergency Care, 2001; 17: 170-174.
• Haller,J. Toward a Comprehensive Emergency Medicine System for Children. Pediatrics, 1990; 86: 120-172.
• Institute of Medicine Committee, Future of Emergency Care in the United States Health System, Report Brief. National Academy of Sciences, 2006.
• Junkins, Edqard, O-Connell K., and Mann C., Pediatric Trauma Systems in the United States: Do They Make a Difference? Clinical Pediatric Emergency Medicine, 2006; 7: 76-81.
• Krug, Steve, Emergency Care Crisis: A Nation Unprepared for Public Health Disasters. Testimony for Homeland Security Subcommittee on Emergency Preparedness, Science, and Technology, 2006.
• Morrison, Wayne, Wright J., and Paldas C. Pediatric Trauma Systems. Critical Care Medicine, 2002; 30, #1 supplement.
• Perno, Joseph, Schunk J., Hanse K., and Furnival R., Significant Reduction in Delayed Diagnosis of Injury with Implementation of a Pediatric Trauma Service. Pediatric Emergency Care, 2005; 21: 367-371.
• Resources for Optimal Care of the Injured Patient 2006,Committee on Trauma, American College of Surgeons, Chicago, Illinois, 2006.
• Sigrest, Todd, and AAP Committee on Hospital Care, Facilities and Equipment for Care of Pediatric Patients in Community Hospitals. Pediatrics, 2003; 3: 1120-1123
• Woodward, George, et. al., The State of Pediatric Interfacility Transport: Consensus of the Second National Pediatric and Neonatal Interfacility Transport Medicine Conference. Pediatric Emergency Care 2002; 18: 38-43.

Definitions

Emergencies: A serious situation or occurrence that happens unexpectedly and demands immediate action, including injury or illness. Examples of medical emergencies include seizures, severe asthma attacks, allergies, and other acute illnesses. Examples of trauma include injuries, motor vehicle crashes, and falls.

Standardized system: A system that recognizes the readiness and capability of a hospital and its staff to triage and provide care appropriately, based upon the severity of illness/injury of the child.² The system designates/verifies hospitals as providers of a certain level of emergency care within a specified geographic area (e.g., region). A facility recognition process usually involves a formal assessment of a hospital’s capacity to provide pediatric emergency and/or trauma care via site visits and/or a formal application process by a State/Territory or local government body, such as the State EMSC Program, State EMS Office, and/or local hospital/health care provider association.³

This measure addresses the development of both a pediatric medical and trauma recognition system. Recognition programs are based upon defined criteria that address the qualifications of staff and providers of pediatric care, the availability of pediatric equipment, and a formal pediatric quality improvement or monitoring program. It is not sufficient to have either a pediatric trauma facility recognition program or pediatric medical emergency facility recognition program. States/Territories must have both recognition programs.

In addition, Performance Measure #66c does not require that the designation process be mandated. Voluntary facility recognition is an accepted form. However, the preferred status is to have a system monitored by the State/Territory. Examples of guidelines/standardized systems for pediatric medical and trauma recognition/designation are described below.

Pediatric Medical Emergency Facility Recognition: Examples of pediatric medical emergency recognition systems/classifications include:

• Emergency department approved for pediatrics (EDAP) designation: Classification of a hospital emergency department where staff are specially trained to care for children, using appropriate pediatric equipment and following guidelines for age-appropriate medications.
• Stand-by emergency department approved for pediatrics (SEDP) designation: Classification of a hospital emergency department where at least one of the registered nurses on duty in the hospital is available for pediatric emergency services at all times, and a licensed physician is “on-call” to the emergency department at all times to handle/manage pediatric emergencies. Examples of EDAP/SEDP criteria can be found at: http://www.luhs.org/depts/emsc/edap_sedp_criteria.htm.
• Pediatric Critical Care Centers (PCCC): Classification of a facility that has pediatric intensive care units as well as an emergency department and can provide specialty inpatient services for pediatric patients. The American Academy of Pediatrics (AAP) developed guidelines for levels of care for pediatric intensive care units, which are available at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;114/4/1114?fulltext=Critical+Care&searchid=QID_NOT_SET.
• Care of Children in the Emergency Department: Guidelines for Preparedness: Guidelines developed by AAP/ACEP for pediatric medical emergency facility recognition, which are available at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3B107/4/777.

Pediatric Trauma Facility Recognition: As an example of trauma facility recognition guidelines, the American College of Surgeons (ACS) developed trauma verification criteria that can be used to recognize pediatric trauma centers in your State/Territory. The latest guidelines are available for purchase on-line at: https://web2.facs.org/timssnet464/acspub/frontpage.cfm?product_class=trauma.

² Committee on Pediatric Emergency Pediatric Medicine Pediatric Section and Task Force on Regionalization of Pediatric Critical Care. (2000). Consensus report for Regionalization of Services for Critically Ill or Injured Children. Pediatrics, 105(1): 152-155.

³ Ibid

Data Collection Methods

This performance measure does not require specific data collection as reporting is based on State/Territory information.

HRSA may request supporting documentation for this measure. It also should be available to support EHB entries. Supporting documentation for this measure must include the following:

• Facility recognition application packet;
• Criteria that facilities must meet in order to receive recognition as a facility able to stabilize and/or manage pediatric medical emergencies; and
• List of hospitals participating in the pediatric medical emergency facility recognition program and their corresponding designation/recognition level.

Data entry will require scoring of the progress made towards meeting the performance measure. See below for examples of supporting documentation that your State/Territory may submit to HRSA by each point on the scale.

Examples of Supporting Documentation by Point on Scale

Data Entry

A template of the form grantees will be required to complete in the HRSA Electronic Handbook is provided below

Online Worksheet Data Entry

Grantees do not need to complete an online worksheet for this performance measure as all information is captured in the EHB.

Strategic Planning

Using the 2006 data, the State/Territory should assess their compliance with Performance Measure #66c. Data should be presented to the EMSC Advisory Committee to develop a strategy for meeting the performance measure.

Some specific strategic planning activities grantees can undertake to effect system changes to meet this measure in their States/Territories, could include:

• Review baseline data for the measure and discuss pediatric medical emergency and trauma facility recognition system gaps with your EMS director and medical director.
• Work with hospitals to perform a needs assessment to determine the potential for success and challenges faced by each in becoming pediatric capable (i.e., able to stabilize and/or manage pediatric medical emergencies or trauma). Utilize assessment results, determine the overall feasibility of a State/Territory-wide facility recognition program for pediatric medical emergency and trauma patients.
• Contact your State hospital association to discuss challenges and potential strategies for implementing a proposed plan for a hospital facility recognition process in your State/Territory.
• Work with hospitals in developing a cost analysis to define any additional costs for hospitals to become pediatric capable for possible association and/or participation within a pediatric medical emergency or trauma facility recognition program.
• Offer recommendations for partnerships and collaborative agreements to provide assistance to hospitals with purchasing pediatric equipment necessary to become pediatric-capable and participate in a pediatric medical emergency and/or trauma facility recognition program.
• Offer additional mechanisms of financial incentives available to participate in the pediatric medical emergency and/or trauma facility recognition system (e.g., money to a newly recognized hospital, scholarship money to attend a workshop).

Guidelines for annual targets for this measure are provided on the next page:

[back to introduction]

Significance of Measure

For additional information on the importance of this measure, refer to the web resources, guidelines/policy statements, and publications listed below. Appendix A includes an annotated bibliography for each reference.

Information Regarding EMTALA:

The Emergency Medical Treatment and Active Labor Act (EMTALA) is a Federal statute that dictates when and how a patient may be (1) refused treatment or (2) transferred from one hospital to another when he or she is in an unstable medical condition. EMTALA applies only to “participating hospitals” (i.e., hospitals which have entered into “provider agreements” under which they will accept payment from the Department of Health and Human Services, Centers for Medicare and Medicaid Services under the Medicare program for services provided to beneficiaries of that program). EMTALA was meant as an “anti-dumping” statute to avoid having patients transferred due to the inability to pay.

According to EMTALA regulations 42 CFR 489.24(d)(2) once the patient is admitted and stabilized, the EMTALA obligations end so a new emergency medical condition while inpatient does not invoke EMTALA. Thus, once the patient is admitted and stabilized, the EMTALA obligations end (under the 2003 regulations). Therefore, compliance with EMTALA does not cover the issues of this performance measure.

Web Resources

• American Medical Association PowerPoint Presentation on Requirements of EMTALA. Visit http://www.amaassn.org/ama1/pub/upload/mm/384/emtalafinal.ppt#358,7,Requirements of EMTALA
• Availability of Pediatric Services and Equipment in Emergency Departments: United States, 2002-03. Visit http://www.cdc.gov/nchs, click on “More Publications” on the left, click on “Advance Date” under “Reports” on the right, and then select report #367
• Emergency Department Approved for Pediatrics (EDAP) Guidelines — Visit http://www.luhs.org/depts/emsc/, click on “Archives” at the bottom of the page, the scroll down to 2001 and select the EDAP link under June
• EMTALA An Overview. Visit http://www.acutecare.com/emtala.htm
• EMTALA Frequently Asked Questions - Visit http://www.emtala.com/faq.htm
• NRC Toolbox: Inter-facility Transfer — Visit http://bolivia.hrsa.gov/emsc/, click on “Toolbox” on left menu
• 20 Commandments of EMTALA — Visit http://www.medlaw.com/healthlaw/EMTALA/education/the-20-commandmentsof-em.shtml
• U.S. Department of Health and Human Services, Model Trauma System Planning and Evaluation, 2006. Visit http://www.hrsa.gov/trauma/model.htm

Guidelines/Policy Statements

• American Academy of Pediatrics, Committee on Pediatric Emergency Medicine and American College of Emergency Physicians, Pediatric Committee, Care of Children in Emergency Departments, Guidelines for Preparedness. Pediatrics, 2001; 107: 777-781.
• AAP/ACEP Policy Statement Care of Children in the Emergency Department: Guidelines for Preparedness. Visit http://aappolicy.aappublications.org/, click on “AAP Policy Statements”, and then select policy statement under “C.”
• Emergency Nurse Association, Position Statement on Care of Critically Ill or Injured Patients during Inter facility Transfer, 2005.

Publications

• American Academy of Pediatrics, Committee on Pediatric Emergency Care, Access to Pediatric Emergency Care. Pediatrics, 2000; 105:647-649.
• Resources for Optimal Care of the Injured Patient 2006,Committee on Trauma, American College of Surgeons, Chicago, Illinois, 2006.
• Should Parents Accompany Pediatric Inter-Facility Ground Ambulance Transports? Results of a National Survey of Pediatric Transport Team Manager by George Woodward, in Pediatric Emergency Care (2002)
• Woodward, George, et. al., The State of Pediatric Inter-facility Transport: Consensus of the Second National Pediatric and Neonatal Inter-facility Transport Medicine Conference. Pediatric Emergency Care 2002; 18: 38-43.

Definitions

Inter-facility transfer guidelines: Hospital-to-hospital, including out of State/Territory, guidelines that outline procedural and administrative policies for transferring critically ill pediatric patients to facilities that provide specialized pediatric care. Inter-facility guidelines do not have to specify transfers of pediatric patients only. A guideline that applies to all patients or patients of all ages would suffice. Guidelines should include pediatric patients. Grantees should consult their NRC representative if they have questions regarding guideline inclusion of pediatric patients. In addition, hospitals may have one document that comprises both the pediatric inter-facility transfer guideline and agreement. This is acceptable as long as the document meets the definitions for pediatric inter-facility transfer guidelines and agreements (i.e., the document contains all six pediatric components of transfer).

All hospitals in the State/Territory should have guidelines to transfer to a tertiary care center capable of taking care of children. Tertiary care centers capable of taking care of all pediatric needs do not need to have guidelines for transferring children. These tertiary care centers must be capable of providing all pediatric care (trauma and medical). If a facility cannot provide a particular type of care (e.g., burn care), then it also should have transfer guidelines in place. Consult the NRC to ensure that the tertiary care center is capable of definitive care for all pediatric needs. Also, note that being in compliance with EMTALA does not constitute having inter-facility transfer guidelines.

Referring facility: The hospital or center that refers a pediatric patient to another, more specialized pediatric center better able to handle pediatric patients.

Referral center: A center with specialized pediatric critical care or pediatric trauma services to which referring facilities refer patients.

Tertiary care center: A tertiary care center is a medical facility that receives referrals from both primary and secondary care levels and usually offers tests, treatments, and procedures that are not available elsewhere. Most tertiary care centers offer a mixture of primary, secondary, and tertiary care services so that it is the specific level of service rendered rather than the facility that determines the designation of care in a given study.

Data Collection Methods

The two acceptable data collection methods for acquiring information for EHB data entry include surveys and/or other State/Territory legal documentation of the measure with an enforcement or monitoring process in place. If a grantee has an alternate source for gathering data, he/she must contact NEDARC for approval of the data collection method. Note that the proposed data collection method must be as rigorous as the methods listed above.

Surveys: Grantees must use surveys either developed or approved by NEDARC. Acceptable survey methods for this measure include:

• Grantees will be required to survey all hospitals in the State/Territory. Appropriate staff to be surveyed may vary by hospital and/or State/Territory. Contact NEDARC to discuss the target population for your survey. Potential hospital staff to survey include:
  • Emergency department administrator or manager
  • Emergency department nursing director or nursing supervisor
  • Hospital nursing director
  • Hospital administrator
  • Hospital inter-facility transport team manager
  • Hospital referral center, admitting office, or transfer office
  • Hospital legal department

  Note that state hospital associations may be able to provide guidance and assistance with identifying individual hospital contacts.

• If the State/Territory has tertiary care center(s) that account for 100% of pediatric transfers in the State/Territory, grantees will be allowed to survey only the tertiary care center(s) in their State/Territory. Tertiary care center(s) should be asked to list with which hospitals they have guidelines. The answer should include all hospitals in the State/Territory. If not, grantees will be required to survey those hospitals that are not included on the list. States/Territories should contact NEDARC to discuss this method and obtain approval.

HRSA may request supporting documentation for this measure. Documentation should also be available to support EHB entries. Supporting documentation for this measure may include one of the following:

• Copies of the hospitals’ pediatric inter-facility transfer guidelines. If a hospital refuses to share guidelines due to the fact that they are legal documents, grantees should survey all of the hospitals, and use the survey results as supporting documentation.
• Copy of State/Territory transfer guidelines utilized by all hospitals in the State/Territory.
• Survey results/analysis from the NEDARC online survey tool (provided by NEDARC).
• Raw data and survey analysis if utilizing paper surveys or another (non-NEDARC) online tool.

Other State/Territory Data: Other State/Territory data sources include pediatric medical and/or trauma facility recognition programs and other licensure, accreditation, or certification processes requiring written pediatric inter-facility transfer guidelines. Contact NEDARC to discuss and obtain approval for using these or other State/Territory data sources.

Supporting documentation for this method should be discussed with NEDARC before utilizing the data source.

Exemption from Data Collection

Exemption from data collection for Performance Measure #66d will require that the State/Territory mandate meets both of the following criteria:

• A State/Territory mandate with requirements for pediatric inter-facility transfer guidelines exists, and all hospitals in the State/Territory are required to follow the mandate with an enforcement or monitoring process in place.
• The State/Territory mandate meets the required pediatric components