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.

Grantees should contact their NRC representative as soon as possible to discuss possible data collection exemption for this measure. A copy of the State/Territory mandate with an explanation of how the mandate is used should be submitted to your NRC representative to obtain written approval for an exemption from data collection. Written responses will be sent within two weeks of submission. If approved, grantees will not need to gain approval in subsequent years unless directed so by the NRC or unless the State/Territory mandate has an expiration date.

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

The following decision tree should help grantees determine eligibility for an exemption from data collection due to a 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 calculation in the form above are listed below:

Numerator

The number of hospitals with emergency departments in the State/Territory that have written pediatric inter-facility transfer guidelines that include the following pediatric components of transfer:

• Defined process for initiation of transfer, including the roles and responsibilities of the referring facility and referral center (including responsibilities for requesting transfer and communication).
• Process for selecting the appropriate care facility.
• Process for selecting the appropriately staffed transport service to match the patient’s acuity level (level of care required by patient, equipment needed in transport, etc.).
• Process for patient transfer (including obtaining informed consent).
• Plan for transfer of patient information (e.g. medical record, copy of signed transport consent), personal belongings of the patient, and provision of directions and referral center information to family.
• Process for return transfer of the pediatric patient to the referring facility as appropriate.

Denominator

The total number of hospitals with emergency departments in the 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 #66d, the data worksheet will ask grantees the following questions:

1. How did data collection occur for EHB entry for Inter-facility transfer guidelines? (check all that apply)
   • Survey
   • Gathered copies of written guidelines from individual hospitals
   • Use requirements from the State’s pediatric hospital licensure/accreditation/ certification program
   • Exemption from data collection from the NRC
   • Did not collect data
   • Other (please explain)
2. What hospitals are represented in the data collection?
   • All hospitals in the State/Territory
   • All hospitals in the State/Territory with an ED
   • All pediatric tertiary care centers in the State/Territory
   • Other (please describe)
3. What is the total number of hospitals in the State/Territory in the category marked on the above question?
4. What is the total number of hospitals in the State/Territory with an ED?
5. In total, from how many hospitals was data collected (either thru a survey, reviewing individual transfer guidelines, or from other sources)?

If grantees 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. How many hospitals were surveyed?
8. Please indicate who the survey was sent to (check all that apply):
   • ED administrator or manager
   • ED 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
9. How many hospitals responded to the survey?

If grantees reviewed copies from their State’s pediatric hospital licensure program

10. Is the State’s pediatric hospital licensure/accreditation/certification program a mandatory or voluntary program?
    • Mandatory
    • Voluntary
    • State has both mandatory and voluntary pediatric hospital licensure programs
    • Don’t know
11. What is the total number of hospitals that participate in the State/Territory’s pediatric hospital recognition/accreditation/certification program?
12. Are all six required EMSC Program transfer guidelines included in the State/Territory’s pediatric hospital recognition/accreditation/certification program?
    • YES
    • NO (please list which guidelines are not included)

If grantees gathered copies of transfer guidelines from their hospitals:

13. From how many hospitals were transfer guidelines gathered?
14. Did these agreements specifically mention pediatric patients?
    • YES
    • NO (please indicate how children are represented)
15. Were all six required EMSC Program transfer guidelines included in each transfer guideline that grantees reviewed?
    • YES
    • NO (please list which guidelines are not included)

Strategic Planning

Using the 2006 data, the State/Territory should assess their compliance with having pediatric inter-facility transfer guidelines. 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 include:

• Review baseline data and discuss gaps in the existence and use of inter-facility transfer guidelines for pediatric patients with your EMS director and medical director.
• Use data from your survey responses to assess reasons why hospitals do not have inter-facility transfer guidelines for pediatric patients.
• Sponsor a meeting of hospitals (in partnership with the state hospital association) to assess the existence and use of inter-facility transfer guidelines for pediatric patients among hospitals in the State/Territory. Include a discussion of the barriers/challenges to using inter-facility transfer guidelines for pediatric patients. Brainstorm solutions.

Guidelines for annual targets for this measure are provided below:

[back to introduction]

Significance of Measure

Timely access to pediatric specialty services in the acute stages of illness and/or injury is critical to reducing poor pediatric outcomes (e.g., morbidity and mortality). When a child’s needs are beyond those available at a receiving facility, inter-facility transfer agreements help to ensure timely transfer of children to facilities with the appropriate resources and competencies to effectively treat pediatric emergencies and to provide high-level and high-quality pediatric care.

Note that EMTALA does not cover the issues of this performance measure. Refer to page 48 for more information about EMTALA.

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

• 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.
• EMTALA An Overview. Visit http://www.acutecare.com/emtala.htm.
• EMTALA Frequently Asked Questions. Visit http://www.emtala.com/faq.htm.
• NRC Toolbox: Interfacility 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.
• See a model pediatric inter-facility transfer agreement developed by the California EMSC Program at: http://www.emsa.ca.gov/aboutemsa/emsa186.pdf.

Guidelines and Policy/Position Statements

• American Academy 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 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.”
• 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 Medicine, Pediatric Care Recommendations for Free Standing Urgent Care Facilities, 2007.
• National Highway Traffic Safety Administration, Guide for Inter Facility Patient Transfer. April 2006.
• Resources for Optimal Care of the Injured Patient 2006,Committee on Trauma, American College of Surgeons, Chicago, Illinois, 2006.
• Selvan, J.S., Fields W.W., Chin W., Petitti D.B. and Wolde-TsadikG., Critical Care Transport: Outcome Evaluating After Interfacility Transfer and Hospitalization. Annals of Emergency Medicine, 33; 1: 33-43.
• 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)
• Sigrest, Todd, and AAP Committee on Hospital Care, Facilities and Equipment for Care of Pediatric Patients in Community Hospitals. Pediatrics, 2003; 3: 1120-1123 The State of Pediatric Interfacility Transport: Consensus of the Second National Pediatric Neonatal Interfacility Transport Medicine Leadership Conference by George Woodward in Pediatric Emergency Care (2002)
• 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

Inter-facility agreements: Written contracts between a referring facility (e.g., community hospital) and a specialized pediatric center or facility with a higher level of care and the appropriate resources to provide needed care required by the child. The agreements must formalize arrangements for consultation and transport of a pediatric patient to the higher-level care facility. Inter-facility agreements do not have to specify transfers of pediatric patients only. An agreement that applies to all patients or patients of all ages would suffice. The agreements should include pediatric patients. Grantees should consult the NRC if they have questions regarding inclusion of pediatric patients in established agreements.

In addition, hospitals may have one document that comprises both the pediatric interfacility agreement and guideline. This is acceptable as long as the document meets the definitions for pediatric inter-facility agreements and guidelines (i.e., the document must contain all six pediatric components of transfer for the guideline).

All hospitals in the State/Territory should have at least one agreement to transfer to a tertiary care center capable of taking care of pediatric patients regardless of whether the care center is out of the State/Territory. Tertiary care centers capable of taking care of pediatric patients do not need to have agreements for transferring the patient out of their facility unless they do not have the specialty resources required to provide care for all diagnoses (e.g., burn care).

Note that being in compliance with EMTALA does not constitute having interfacility transfer agreements.

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 the gathering of other State/Territory mandates that document 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 and get approval for the data collection method. Note that the proposed data collection method must be as rigorous as the two 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. Keep in mind that appropriate staff to survey may vary by hospital and/or State/Territory. Contact NEDARC to discuss the target population for the 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 centers that account for 100% of pediatric transfers in the State/Territory, grantees will be allowed to survey only the tertiary care centers in their State/Territory. The tertiary care centers should be asked to list hospitals with whom they have agreements. The answer should include all hospitals in the State/Territory. If not, grantees will be required to survey those hospitals that are not included in the list. States/Territories should contact NEDARC to discuss and obtain approval for this method.

HRSA may request supporting documentation for this measure. Supporting 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 agreements. Grantees do not need to have the agreements for supporting documentation if a hospital refuses to share them due to the fact that they are legal documents. Instead, grantees can survey all of the hospitals and use the survey results as supporting documentation.
• 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 agreements. 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 #66e will require that the State/Territory meets one of the following criteria:

• A State/Territory mandate with requirements for pediatric inter-facility transfer agreements exists, and all hospitals in the State/Territory are required to follow the mandate with an enforcement or monitoring process in place to assure compliance.
• A hospital licensure and enforcement or monitoring system exists that licenses all hospitals and has as one of its requirements for licensure the existence of pediatric-specific transfer agreements. Note: pediatric specific can be referred to as “all ages” or “children” or “pediatric”.

To request an exemption from data collection, grantees should contact their NRC representative as soon as possible. Grantees should provide a copy of the State/Territory mandate or hospital licensure system requirements, and an explanation of how the mandate or requirements are being used, as well as descriptor of the enforcement or monitoring process in place. Written responses will be sent within two weeks of submission. If approved, grantees will not need to gain approval in subsequent years unless directed so by the NRC or unless the State/Territory mandate or hospital licensure system requirements have an expiration date.

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.

Decision Tree for Exemption from Data Collection

[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 calculation in the form above are listed below:

Numerator

The number of hospitals with emergency departments in the State/Territory that have written pediatric inter-facility transfer agreements.

Denominator

The total number of hospitals with emergency departments in the 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 #66e, the data worksheet will ask grantees the following questions:

1. How was data collected for the EHB entry for inter-facility transfer agreements? (check all that apply)
   • Survey
   • Gathered copies of written agreements from individual hospitals
   • Use requirements from the State’s pediatric hospital licensure/accreditation/certification program
   • Exemption from data collection from the NRC
   • Did not collect data
   • Other (please explain)
   
   
2. What hospitals are represented in the data collection?
   • All hospitals in the State/Territory
   • All hospitals in the State/Territory with an ED
   • All pediatric tertiary care centers in our State/Territory
   • Other (please describe)
   
   
3. What is the total number of all hospitals in the State/Territory in the category marked on the above question?
   
   
4. In total, from how many hospitals was data collected (either thru a survey, reviewing individual transfer guidelines, or from other sources)?

If grantees used a survey:

5. 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.
6. How many hospitals were surveyed?
7. Please indicate who the survey was sent to (check all that apply):
   • ED administrator or manager
   • ED 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
8. How many hospitals responded to the survey?

If grantees reviewed copies from the State’s hospital licensure program:

9. Is the State hospital licensure/accreditation/certification program a mandatory or voluntary program?
   • Mandatory
   • Voluntary
   • State has both mandatory and voluntary hospital licensure programs
   • Don’t know
   
   
10. What is the total number of hospitals that participate in the State/Territory’s hospital licensure/accreditation/certification program?
11. Does the State/Territory’s hospital licensure program ensure that transfer agreements are in place for pediatric patients?
    • YES
    • NO (please explain)

If grantees gathered copies of transfer agreements from the hospitals:

12. From how many hospitals were transfer agreements gathered?
13. Did these agreements specifically mention pediatric patients?
    • YES
    • NO (please indicate how children are represented)
14. What are the challenges to meeting PM 66d/e in the State?

Strategic Planning

Using the 2006 data, the State/Territory should assess their compliance with having pediatric inter-facility transfer agreements. 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 include:

• Review baseline data, and discuss gaps in the existence and use of inter-facility transfer agreements for pediatric patients with the EMS director and medical director.
• Use data from the survey responses to assess the reasons why hospitals do not have interfacility transfer agreements for pediatric patients (can include such wording as all age patients).
• Facilitate a meeting of hospitals (in partnership with the state hospital association) to assess the existence and use of inter-facility transfer agreements for pediatric patients among hospitals in the State/Territory. Include a discussion of the barriers/challenges to using inter-facility transfer agreements for pediatric patients and brainstorm solutions.

Guidelines for annual targets for this measure are provided below:

Significance of Measure

This performance measure highlights the value of developing and adopting minimum requirements for pediatric emergency education for the license/certification renewal of BLS and ALS providers. Most EMS providers rarely treat a sufficient number of pediatric patients to develop and maintain the skills necessary to treat pediatric emergencies in the field. Continuing education helps ensure that pre-hospital providers are ready to take care of a pediatric patient in the field. Continuing education also improves the quality and effectiveness of pediatric emergency care, and thereby, improves pediatric outcomes (e.g., reduced morbidity and mortality).

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

Websites

• Training and Certification of EMS Personnel (2007). Visit http://www.nasemsd.org/, select “Monographs” under the “Resources” tab at the top of the page.

Journal Articles

• Miller, David, Kalinowski E., and Wood D., Pediatric Continuing Education for EMTs. Pediatric Emergency Care, 2004; 20:269-272.
• Morehead J, Donaldson A, Marmen M, Schnyder M, Mann C, Stuemky J (2006). Pediatric Continuing Education of EMS Professionals in Oklahoma, Pediatric Emergency Care, National Association of EMS Physicians Medical Journal. Oct/Dec. Pgs 530-531.
• National Association of EMS Educators, NAEMSE Standards and Practice Committee, Position Statement: Value of Continuing Medical Education in the Pre-hospital Arena. Journal of Pre-hospital, 2003: 12:232.
• Peckinpaugh, Karen, Izsak, E., Lindstrom, D., Orlow, G., Contour, T., and Rice, M., The Advanced Pedi- Bag Program: A Hospital-EMS Partnership to Implement Pre-hospital Training, Equipment and Protocols. Pediatric Emergency Care, 2000; 16: 409-412.
• Stevens, Sandra and Alexander, J., The Impact of Training and Experience on EMS Emergencies in a Rural State. Pediatric Emergency Care, 2005; 21: 12-17.
• Su, Eustacia, Schmidt, Terri A., Mann, N. Clay, and Zechnich, Andrew D., A Randomized Controlled Trial to Assess Decay in Acquired Knowledge among Paramedics Completing a Pediatric Resuscitation Course. Academic Emergency Medicine, 2000 7: 779-786.
• Wood D., Kalinowski E., and Miller D., Pediatric Continuing Education for Emergency Medicine Technicians. Pediatric Emergency Care, 2004: 20: 261-268.

Guidelines

• Stoy, Walt, National Guidelines for EMT Continuing Education. U.S. Department of Transportation/NHTSA, 1999.

Definitions

Adoption: The requirements have been formally put into place in a mandate at either the State/Territory or County/Regional level (i.e., at every county/region in the State/Territory) and apply to all BLS and ALS providers in the State/Territory.

License/Certification Renewal: Refers to the process of re-registering and fulfilling requirements for certification or licensure to continue practicing as a BLS or ALS provider.

Requirements: Formal written recommendations and guidelines exist for pediatric emergency care education as part of the recertification of BLS and ALS providers. Recommended training curricula and/or courses for BLS and ALS providers may include, but are not limited to, Pediatric Education for Pre-hospital Professionals (PEPP), Advanced Pediatric Life Support (APLS), and Pediatric Advanced Life Support (PALS) courses. Recommended training courses exclude cardiopulmonary resuscitation (CPR) courses. Requirements that offer a choice of topics, including pediatrics, do not meet the measure. The requirements must be specific to pediatric education.

Recertification: Refers to the process of re-registering and fulfilling requirements for certification or licensure to continue practicing as a BLS or ALS provider.

Data Collection Methods

For Performance Measure #67, grantees are not required to collect data. The measure requires the existence of either a State/Territory or county/regional mandate for pediatric emergency medical education for the recertification of BLS and ALS providers in the State/Territory.

States who require that 100% of their EMS providers re-certify through the National Registry of EMTs (NREMT) may report those hours required through NREMT and answer “Yes” in EHB. In 2007, NREMT requires the completion of two hours for EMT-Basics and eight hours for EMT-Paramedics.

For more information on the total number of continuing education hours needing to be dedicated to pediatrics for each type of EMT provider, refer to the NREMT website: http://www.nremt.org/EMTServices/rereg_brochures.asp.

Note that if a State/Territory has some providers registered through NREMT, but also has a State/Territory system for re-certifying EMTs and paramedics, the State/Territory should report the minimum level of education required.

For example, if the State/Territory accepts NREMT certification or pediatric education through a State/Territory training program, and NREMT has eight hours of pediatric education and the State/Territory only requires two, the grantee would indicate two hours in EHB.

HRSA may request supporting documentation for the measure. Supporting documentation should also be available to support EHB entries. Supporting documentation for this measure includes a copy of the State/Territory or county/regional mandate describing the requirements for pediatric emergency medical education for the recertification of BLS and ALS providers in the State/Territory.

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 EHB.

Strategic Planning

Although this performance measure does not require a minimum number of hours for pediatric education, the following standards are recommended for license/certification renewal:

• BLS Providers: provide pediatric education with a focus on pediatric assessment and airway management.
• ALS Providers: provide pediatric education with a focus on pediatric assessment, airway management, and medication dosing.

Adoption for certification in national courses, such as PALS and PEPP, is another way to ensure quality pediatric education.

Using the 2006 data, the State/Territory should assess their compliance with Performance Measure #67. 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 include:

• Review baseline data, and discuss gaps in the pediatric continuing educational offerings for BLS and ALS providers with the EMS director and medical director.
• Assess reasons why the State/Territory has not adopted requirements for pediatric emergency education for the recertification of BLS and ALS providers.
• Engage the EMS and medical directors, as well as training coordinators and EMS educators, to discuss barriers/challenges to adopting requirements for pediatric emergency education for the recertification of BLS and ALS providers.
• Determine the feasibility of the State/Territory adopting requirements for pediatric emergency education for the recertification of BLS and ALS providers.
• Consider systematically evaluating pediatric patient outcomes, comparing such to the number of pediatric education hours received.
• Consult with the NRC to identify pediatric education models employed in other States and Territories that could possibly be adapted for use by others.

Guidelines for annual targets for this measure are provided below:

[back to introduction]

Significance of Measure

An EMSC Advisory Committee is important to assist EMSC grantees in meeting each of their performance measures. Throughout this Implementation Manual, the role of the Advisory Committee has been discussed. Members of the EMSC Advisory Committee can assist the grantee in strategic planning, obtaining buy-in from the State/Territory leadership to effect system change, and ensuring that family issues are not overlooked.

For additional information on the importance of this measure, refer to the presentations, policy resources, and websites listed below. Appendix A includes an annotated bibliography for each reference.

Presentation

• Advisory Committees — How to develop and utilize the best team for EMSC Initiatives (a 2006 PowerPoint presentation). Visit http://www.cademedia.com/archives/mchb/emsc2006/Grantee2006/ppt/E%201-3.ppt.

Policy Resources

• American Academy of Pediatrics, Committee on State Government Affairs, Government Affairs Handbook, 1992.
• Amidei, Nancy, So You Want to Make a Difference, 1997.
• State Legislative Leaders Foundation, State Legislative Leaders: Keys to Effective Legislation for Children and Families, 1995.

Publications (of professional organizations from which EMSC Advisory Committee core and/or recommended members could be recruited)

• American Academy of Pediatrics - http://www.aap.org/.
• American Hospital Association - http://www.aha.org/.
• Emergency Nurse Association - http://www.ena.org/.
• Family Voices - http://www.familyvoices.org/.
• National Association of EMS Directors - http://www.nasemsd.org/.
• National Association of EMTs - http://www.naemt.org/.
• National Association of School Nurses - http://www.nasn.org/.
• National Highway Traffic Safety Administration - http://www.nhtsa.dot.gov/.

Definitions

Establishment: “Establishment” is defined by the following two elements. Note that both of the elements below must be met in order to meet this measure.

1. The EMSC Advisory Committee is composed of the following eight core (required) members:
   • Nurse with emergency pediatric experience
   • Physician with pediatric training (e.g., pediatrician or pediatric surgeon)
   • Emergency physician (a physician who primarily practices in the emergency department; does not have to be a board-certified emergency physician)
   • Emergency medical technician (EMT)/Paramedic who is currently a practicing, ground level pre-hospital provider (i.e., must be currently licensed and riding in a patient care unit such as an ambulance or fire truck)
   • EMS State agency representative (e.g., EMS medical director, EMS administrator)
   • EMSC principal investigator
   • EMSC grant manager
   • Family representative

   Note that no single individual listed above may serve as the EMT/Paramedic, nurse, physician, and family representative. In other words, there must be at least one pre-hospital provider, one nurse, one physician, and one family representative on the EMSC Advisory Committee. Each of these roles must be served by a distinct individual. However, for the other core member roles, a single individual can play dual or multiple roles as long as all eight roles are represented. For example, the EMSC principal investigator can be the same person as the EMSC grant manager.

   The EMSC Program also has identified a list of recommended committee members that should be selected based on the unique needs of each individual State/Territory. The following 16 members are strongly encouraged (but not required) to play a role on the Advisory Committee:

   • Hospital association representative
   • State trauma manager
   • EMS training manager
   • Tribal EMS representative
   • Data manager
   • School nurse
   • Ambulance association representative
   • Child death review representative
   • Fire-based EMS representative
   • Police representative
   • Bioterrorism representative
   • Disaster preparedness representative
   • Parent teacher association representative
   • Recipient of MCH block grant for CSHCN
   • Highway representative
   • Legislator
2. The EMSC Advisory Committee must meet either face-to-face or by conference call at least four times during each grant year (March – February grant cycle). If one of the core EMSC Advisory Committee members is unable to attend a meeting, an alternate substitute can be designated to attend on his/her behalf.

EMSC Advisory Committee: A group of either appointed or elected individuals who are responsible for guiding the EMSC Program, prioritizing EMSC issues, working on special projects, ensuring that pediatric emergency issues are addressed within the EMS system, and providing policy recommendations pertaining to the improvement of emergency medical services for children.

The EMSC Advisory Committee can be outside State/Territory government control (i.e., the Committee does not have to be State/Territory mandated). To ensure program sustainability though it is strongly recommended that the committee be State/Territory mandated. The EMSC Advisory Committee can be part of the State/Territory EMS Committee or Subcommittee (e.g., Pediatric Subcommittee of the EMS Board) as long as the eight core members are on the EMS Committee or Subcommittee as voting members (i.e., members exercising full membership rights). If the State/Territory government controls or limits the number of EMSC Advisory Committee members, the grantee is still required to have the eight core members on the committee in order to meet the measure.

Data Collection Methods

This measure does not require data collection. To meet this measure, the eight required members must meet four times during each grant year. This information will be used to calculate whether the measure has been met.

HRSA may request supporting documentation for this measure. Supporting documentation should also be available to support EHB entries. Supporting documentation for this measure must include the sign-in sheet, agenda, and meeting notes/minutes from each meeting held.

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

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 #68a, the data worksheet will ask grantees the following questions:

Question 2: Is the Advisory Committee State mandated? Yes/No

Question 3: Does any person serve more than a single core role? Yes/No

Strategic Planning

The EMSC Advisory Committee plays a pivotal role in ensuring that the State/Territory meets all the required performance measures.

EMSC managers can maximize the support they receive from their Advisory Committee members by:

• Educating committee members about how their contributions impact the EMSC grant initiatives (see section below on committee membership).
• Clarifying how each committee member contributes to improving EMS systems for pediatric patients.
• Reinforcing that achieving the EMSC performance measures is in the best interest of all participating organizations and agencies.
• Effectively utilizing and engaging members during meetings (see section below on running an effective meeting).

Purpose of the Advisory Committee Membership

Member Engagement and Utilization

How to assure a successful EMSC Advisory Committee

To effectively utilize, engage, and lead an EMSC Advisory Committee, it important to:

• Understand the value that each member brings to the committee.
• Educate yourself about each member’s scope of work in his/her organization.
• Meet regularly and address program planning and implementation.

By considering each member’s interests and priorities, it is possible to create a cohesive committee that is beneficial to the program and each committee member. By helping committee members address the mission of their organizations, grantees will secure continued committee member involvement in EMSC activities. Additional hints to improve EMSC Advisory Committee meetings include:

Before the meeting:

• Committee members are busy individuals. To get on their calendars, plan the meetings months in advance.
• Set a schedule for quarterly meetings three to six months in advance.
• Meet with the advisory committee chair and/or the principal investigator and prepare an agenda six weeks prior to the meeting (see Appendix 2.2 for a sample agenda)
• When developing the agenda, think of ways to engage each committee member. For example, schedule dedicated time for “organizational reports” that allows each member two to three minutes to highlight their organization’s major activities.
• Identify a time frame for each agenda item and make sure priority topics are covered first. Build in time for breaks and discussion.
• Arrange for meeting space and, if necessary, hotel rooms.
• Distribute the agenda electronically to members and other interested partners three to four weeks before the meeting.
• Include information on the EMSC performance measures and any other topics that will be discussed at the meeting.
• Provide instructions for making travel arrangements.
• Ask for additional agenda items. It is important that committee members have input on the agenda.
• Ask for a RSVP.
• Invite NRC and NEDARC representatives to periodically join the meetings by phone. Including the NRC and NEDARC representatives will demonstrate connection to the national EMSC Program.

During the meeting:

• Start the meeting on-time. If there is a history of starting meetings late, individuals will tend to show up late.
• Distribute an EMSC calendar that includes future advisory committee meetings and other Federal EMSC meetings and events.
• As new members or attendees join the group, ask them to share their organization’s mission. It may be advisable to have organizational updates provided in writing before the meeting.
• Have copies of the grant application and the EMSC Performance Measures Implementation Guide readily available as resources at all meetings.
• Assign tasks to members and ask them to provide monthly written progress reports and an update at the next meeting. This will keep the committee members engaged inbetween meetings.
• Create sub-committees on specific initiatives, such as medical protocols, inter-facility transport, EMT education, pediatric equipment, etc.
• Report on EMSC-related activities and progress made toward completing action items from the previous meeting.
• Schedule and allow ample time to hear sub-committee reports.

After the meeting:

• Meet with the principal investigator and/or the advisory committee chair to discuss action items from the meeting.
• Send an email to all committee members within three days of the meeting thanking them for attending. Provide a list of action items and identify members responsible for followup on each item.
• Create a listserv for all advisory committee members and a separate listserv for each subcommittee created.
• Draft meeting minutes quickly after each meeting. Meeting notes should be detailed enough to capture the discussions but not verbatim. (If needed, the NRC can review the minutes before they are distributed.)
• Bulleted points generally work well to remind people what was discussed. Key content for notes include:
  • Date and time of meeting
  • Participants
  • Agenda
  • What was discussed for each agenda item
  • Next meeting date
  • Action items and assignments (action items should be emailed separately to draw attention to them)
• Communicate via mail, email, telephone, and/or in-person between quarterly meetings to maintain relationships with members and to continue work on action items
• Forward EMSC QuickNews and other State/Federal EMSC updates to keep committee members involved.
• Distribute drafts or template protocols, agreements, and/or guidelines for review and approval at least 30 days prior to the quarterly meeting.
• Conduct quarterly meetings by conference call or in-person. It is strongly recommended that grantees conduct at least two face-to-face meetings and two conference call meetings each year to fulfill the advisory board meeting requirement.
• Have members evaluate all meetings to gain feedback for possible improvements. (A sample meeting evaluation form is available in Appendix 2.3.)

Common Challenges of Advisory Committees

Non-participatory Committee Members. Sometimes committee members are not able to participate in meetings consistently due to other work-related priorities or because they serve on multiple advisory committees/councils. For this reason, some members may demonstrate less interest in the EMSC Advisory Committee and attend meetings less frequently. Other members may view sporadic attendance as a distraction from the tasks at hand. It is difficult to weigh the benefits of their position as a committee member and the need to seek a replacement representative. This may not be an easy task for the EMSC manager. If non-attendance is negatively influencing the engagement of other committee members and/or delaying progress on grant initiatives, changes in representatives may be needed.

Hints to maintain active attendance:

• Ensure meetings start and end on time. Should there be a need to continue discussions with individual members on specific tasks, continue these discussions outside of the meeting.
• Allow those unable to attend meetings in person to join by telephone.
• Communicate frequently via any of the previously stated or other mechanisms available.
• Report on progress being made by sending monthly updates to members on the status of program initiatives.
• Regularly seek reports from each member who accepted a task assignment.
• If a member is not able to attend, ask them to send a replacement from their office.
• Publicly acknowledge membership participation through State newsletters or in other venues to thank those who participate.

Disruptive Committee Members. Disruptive committee members are a challenge; they can interject their personal agendas into meetings and do not focus on the task at hand. Disruptive members are those who focus on a problem, vent frustrations about the system, or do not want to discuss solutions.

Hints to manage such members:

• Stay focused and ask that off-the-topic discussions be taken off-line after the meeting.
• Make progress toward meeting the performance measures and improving pediatric emergency care the focus of each EMSC Advisory Committee meeting.
• Always steer conversations towards solutions. Progress will stall once a grantee has entertained a members’ constant focus on the negative instead of the positive. Ask any particularly negative person for a recommendation on how to solve the problem.
• One recommendation to inspire an unproductive/disruptive member is to offer your help to overcome obstacles. Occasionally, other advisory members will volunteer to help as well. As a result, you will gain control of the situation and set a standard and expectation of all members. This may create a competitive environment and entice the challenged member to overcome any barriers encountered.

Building Member Consensus

During EMSC Advisory Committee meetings, seek feedback from all members. Giving a voice to all members validates how valuable their membership is and will ensure open communication and collaboration among the members. Provide ample time for members to discuss issues and recommendations. Before moving on to the next item on the agenda, summarize the discussion so that all members are clear on conclusions, action steps, and assignments.

Significance of Measure

The EMS Board in a State/Territory is the decision-making body for EMS rules, regulations, and procedures. By incorporating pediatric representation on the State/Territory EMS Board, pediatric issues will more likely be addressed in EMS agendas, goals, practices, and policies.

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

Policy Resources

• American Academy of Pediatrics, Committee on State Government Affairs, Government Affairs Handbook, 1992.
• Amidei, Nancy, So You Want to Make a Difference, 1997.
• State Legislative Leaders Foundation, State Legislative Leaders: Keys to Effective Legislation for Children and Families, 1995.

Websites (of professional organizations from which pediatric representatives could be recruited)

• American Academy of Pediatrics - http://www.aap.org/.
• American Hospital Association - http://www.aha.org/.
• Emergency Nurse Association - http://www.ena.org/.
• Family Voices - http://www.familyvoices.org/.
• National Association of EMS Directors - http://www.nasemsd.org/.
• National Association of EMTs - http://www.naemt.org/.
• National Association of School Nurses - http://www.nasn.org/.
• National Highway Traffic Safety Administration - http://www.nhtsa.dot.gov/.

Definitions

Incorporation: “Incorporation” of pediatric representation means the existence of a formal, designated voting position for a pediatric representative on the EMS Board. In addition, a State/Territory mandate must exist to have a pediatric representative on the EMS Board. Without an official Board member, there is no guarantee that pediatric considerations will be taken into account when being incorporated into an EMS rule, regulation, or issue even if the issue is presented by the EMSC Advisory Committee.

Pediatric representation: Pediatric representation will be defined by each State/Territory. Examples of pediatric representatives include, but are not limited to:

• Practicing pediatricians
• Pediatric critical care physicians
• Board-certified pediatric emergency physicians
• Neonatologists
• Pediatric rehabilitation physicians
• Registered nurses with pediatric interests (e.g. PICU, Peds ED, CSHCN, APLS/PALS/PCEP instructors, or other pediatric experience not named)
• EMTs/Paramedics with pediatric interests (e.g. PICU, Peds ED, CSHCN, APLS/PALS/PEPP/PPC instructors, or other pediatric experience not named)
• Pediatric surgeons
• Parent/family representative

EMS Board: The EMS Board within the State/Territory refers to the State/Territory governing entity or body that provides oversight for emergency medical services and that has the primary responsibility and authority of advising on EMS issues in the State/Territory, which ultimately affects the decision-making process. The EMS Board may have different names in different States/Territories. The structure of EMS oversight (i.e., Board vs. Advisory Committee) is up to each State/Territory. In some States/Territories, the EMSC Advisory Committee may serve as the EMS Board. However, the EMSC Advisory Committee should be organized to address your EMSC grant initiatives and not the overall oversight of EMS within the State/Territory. If the State/Territory does not have an EMS Board, please consult the NRC.

Data Collection Methods

This measure does not require data collection from the grantee. To meet this measure, there has to be a pediatric representative on the EMS Board, and there also has to be a State/Territory mandate to have pediatric presentation on the EMS board. This information will be used to calculate whether the measure has been met.

Note that the requirement for this performance measure is a State/Territory mandate for the pediatric representative on the EMS board. State/Territories that currently have a pediatric person on the Board, but do not have the position mandated, will not meet the measure.

HRSA may request supporting documentation for this measure. Supporting documentation should also be available to support EHB entries. Supporting documentation for this measure will be a copy of the State/Territory mandate describing requirements for a formal, designated voting pediatric representative on the State/Territory EMS Board.

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 EHB.

Strategic Planning

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

• Assess the reasons why the State/Territory has not incorporated pediatric representation on the State/Territory EMS Board.
• Engage the EMSC Advisory Committee, and other stakeholders to discuss barriers/challenges to incorporating pediatric representation on the State/Territory EMS Board. Brainstorm solutions with these individuals.
• Engage the EMS Board in a discussion regarding the addition of a pediatric position.
• Engage pediatric champions in the State/Territory (such as State/Territory level pediatric leaders or pediatric friendly individuals) to assist in making a case for the pediatric representative.
• Determine the feasibility of the State/Territory incorporating pediatric representation on the State/Territory EMS Board.

[back to introduction]

Significance of Measure

This performance measure emphasizes the establishment of one full-time equivalent (FTE) EMSC manager that is dedicated solely to the EMSC Program. The State EMSC manager is an integral staff member of the EMSC Program. She/he is responsible for managing and coordinating the activities of the program. One FTE manager that is dedicated solely to the EMSC Program is an indication that the program is achieving permanence in the State/Territory EMS system.

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

Policy Resources

• American Academy of Pediatrics, Committee on State Government Affairs, Government Affairs Handbook, 1992.
• Amidei, Nancy, So You Want to Make a Difference, 1997.
• State Legislative Leaders Foundation, State Legislative Leaders: Keys to Effective Legislation for Children and Families, 1995.

Definitions

State/Territory, Federal, and/or other-funded: Although it is strongly recommended that the FTE EMSC manager is 100% State/Territory funded, Federal (e.g., EMSC Program), and/or other (e.g., private) funding for this position is acceptable. State/Territory-funded refers to any funds provided by State/Territorial government organizations or the State/Territory legislature (e.g., line item in the State/Territory budget) to support the EMSC manager position. State/Territory-funded excludes contracted EMSC manager positions (not an actual State/Territory funded position). Federal funding refers to any funding received from a Federal governmental agency. Other funding refers to any funding received from other sources, such as professional, private, and/or philanthropic groups (e.g., foundations, non-profits).

Solely: The EMSC manager must dedicate 100% of his/her effort (1.0 FTE) to the EMSC Program, EMSC activities, or other EMSC-related projects, regardless of the amount of time other personnel dedicate to EMSC. The EMSC manager could have other responsibilities from the performance measures, but they should be EMSC-related priorities. In addition, the measure is not met if the grantee has several individuals that work on EMSC and between all of them, they equal to one FTE. Grantees need one individual that is designated as the FTE for EMSC and responsible for the program. If the position is split between multiple individuals, it is easy for EMSC activities to be prioritized lower than other activities. Having one dedicated individual ensures that he/she is always considering the needs of children.

Data Collection Methods

This measure does not require data collection from the grantee. To meet this measure, there has to be a State/Territory, Federal, and/or other-funded FTE for an EMSC manager that is dedicated solely to the EMSC Program. Grantees will need to complete the EHB form for this measure.

HRSA may request supporting documentation for this measure. It also should be available to support EHB entries. Supporting documentation for this measure will be the name and job description for the full-time EMSC manager.

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 EHB.

Strategic Planning

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

• Assess the reasons why the State/Territory has not established a State/Territory, Federal, and/or other-funded FTE for an EMSC manager.
• Engage the EMSC Advisory Committee, EMS director, EMS medical director, and other stakeholders to discuss barriers/challenges to establishing a State/Territory, Federal, and/or other-funded FTE for an EMSC manager that is dedicated solely to the EMSC Program. Brainstorm solutions with these individuals.
• Determine the feasibility of the State/Territory establishing a State/Territory, Federal, and/or other-funded FTE for an EMSC manager.

Significance of Measure

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

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

Policy Resources

• American Academy of Pediatrics, Committee on State Government Affairs, Government Affairs Handbook, 1992.
• Amidei, Nancy, So You Want to Make a Difference, 1997.
• State Legislative Leaders Foundation, State Legislative Leaders: Keys to Effective Legislation for Children and Families, 1995.

Definitions

Priorities: The priorities of the EMSC Program include the following six areas:

1. Pre-hospital provider agencies in the State/Territory have on-line and off-line pediatric medical direction at the scene of an emergency for BLS and ALS providers.
2. BLS and ALS patient care units in the State/Territory have the essential pediatric equipment and supplies, as outlined in the 1996 ACEP recognized and endorsed guidelines.
3. The existence of a statewide, territorial, or regional standardized system that recognizes hospitals that is able to stabilize and/or manage pediatric medical emergencies and trauma.
4. Hospitals in the State/Territory have written pediatric inter-facility transfer guidelines that include the following pediatric components of transfer:
   • Defined process for initiation of transfer, including the roles and responsibilities of the referring facility and referral center (including responsibilities for requesting transfer and communication)
   • Process for selecting the appropriate care facility
   • Process for selecting the appropriately staffed transport service to match the patient’s acuity level (level of care required by patient, equipment needed in transport, etc.)
   • Process for patient transfer (including obtaining informed consent)
   • Plan for transfer of patient information (e.g. medical record, copy of signed transport consent), personal belongings of the patient, and provision of directions and referral institution information to family
   • Process for return transfer of the pediatric patient to the referring facility as appropriate
5. Hospitals in the State/Territory have written pediatric inter-facility transfer agreements.
6. The adoption of requirements by the State/Territory for pediatric emergency education for the license/certification renewal of BLS and ALS providers.

Data Collection Methods

For Performance Measure #68d, if a grantee has integrated all six EMSC priorities into existing mandates, no data collection is necessary.

HRSA may request supporting documentation for this measure. It also should be available to support EHB entries. Supporting documentation for this measure includes a copy of the mandates stating requirements related to each of the six EMSC priorities.

If grantees have not integrated the six EMSC priorities into existing mandates, supporting documentation will be required to demonstrate progress made towards integrating the EMSC priorities into mandates. The type of supporting documentation to submit to the NRC will depend on where the State/Territory falls on the scale in Exhibit A (see page 90).

Exhibit A provides examples of supporting documentation that the State/Territory may submit to the NRC by each point on the scale.

Exhibit A:
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 EHB.

Strategic Planning

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 existing State/Territory mandates, and discuss gaps in the integration of EMSC priorities with the EMSC Advisory Committee.
• Assess the reasons why the State/Territory has not integrated EMSC priorities into existing mandates.
• Engage family member representative to brainstorm ideas for effecting policy change.
• Engage child-friendly State legislators/officials and hospital representatives to discuss the barriers/challenges to integrating EMSC priorities into existing mandates. Brainstorm solutions with these individuals.
• Determine the feasibility of the State/Territory integrating EMSC priorities into existing mandates.

Guidelines for annual targets for this measure are provided below:

[back to introduction]

Appendix A: Annotated Bibliography

Appendix A includes an annotation for each reference listed in the “Significance of Measure” section for each performance measure.

Under Performance Measure #66a

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 then select the document from the list.

  ACEP has collected a series of board-approved statements describing its policies on the pre-hospital care and management of certain pediatric symptoms, illnesses, and injuries at the scene of medical emergencies.

• 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.

  The Georgia Division of Public Health has created various online educational resources designed to educate providers on the essential information needed when presented with a child with special needs. The resources include an Instructor Manual, a Provider Manual, and a standardized Emergency Information Form.

• NRC Toolbox — Medical Direction. Visit http://bolivia.hrsa.gov/emsc/ and click on “Previous Toolboxes,” and then click on “March 2007, Medical Direction.”

  The NRC has compiled information and resources pertaining to pediatric medical direction. This Toolbox includes website links to resources, example practices, database searches, as well as family and caregiver resources.

• 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.

  The National Association of Emergency Medical Services Physicians (NAEMSP) has created a guide that addresses the medical aspects of designing, implementing, and operating EMS systems. The guide contains recommendations for administering pre-hospital and medical oversight systems.

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.

  This webcast reviews the State Partnership Grantees’ performance measures and focuses in detail on Performance Measure #66a (having on-line and off-line pediatric medical direction). Definitions for on-line and off-line pediatric medical direction are provided, as well as model pediatric protocols, other resources, ways to assist State/Territory EMSC grant programs, and the benefits and challenges of having on-line and off-line pediatric medical direction.

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.

  The American Academy of Pediatrics’ Committee on Pediatric Emergency Medicine and the American College of Emergency Physicians’ Pediatric Committee have developed guidelines outlining the resources necessary to ensure that facilities (e.g., hospital emergency departments) and systems (e.g., local Emergency Medical Services system) provide quality emergency care to children. The statement also discusses the resources necessary for the timely transfer of pediatric patients to facilities with specialized pediatric services when appropriate.

• Committee on Pediatric Emergency Medicine, The Role of the Pediatrician in Rural EMSC, Policy Statement. Pediatrics, 2005, 116:1553-1556.

  The American Academy of Pediatrics' Committee on Pediatric Emergency Medicine examined the role of the pediatrician in rural communities in the development, implementation, and ongoing supervision of EMSC. The article states that rural access pediatricians are a vital resource for improving systemwide EMSC by providing education about clinical issues; technical assistance in protocol writing, hospital care, and data accumulation; and as advocates for community and state legislation to support the goals of EMSC.

• 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.

  This study examined the appropriateness of out-of-hospital interventions by EMS personnel to treat children with respiratory illnesses in an urban setting. Overall, 56% of the patients received appropriate interventions, 39% received one or two inappropriate interventions, and 5% received three or more inappropriate interventions. Increasing patient age, transport times, and illness severity tend to increase the use of certain interventions, while contact with online medical direction seems to improve appropriate use of interventions.

• 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.

  This position paper by the National Association of EMS Physicians (NAEMSP) states that the medical direction of an inter-facility transport is a shared responsibility. The paper includes statements that should serve as a guide to promote safe and effective transports of patients, including pediatric patients, between facilities.

• Thomas, Stephen, Williams, K., Claypool, D. Position Paper, National Association of EMS Physicians, Medical Director for Air Medical Transport Programs. Pre-hospital Emergency Care, 2002; 6:455-457.

  This position paper by the National Association of EMS Physicians (NAEMSP) provides guidelines for the education, experience, and licensure and administrative and operational duties of medical directors of air medical transport programs, which help to ensure safe, proficient, and cost-effective programs.

Under Performance Measure #66b

Web Resource

• NRC Toolbox — Pre-hospital Education. Visit http://bolivia.hrsa.gov/emsc/, click on “Toolbox” from the left menu, and then select “Pre-hospital Education.” The EMSC National Resource Center (NRC) has compiled information and resources pertaining to pre-hospital education. This Toolbox includes website links to resources, database searches, as well as family and caregiver resources.

Publications

• American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, Pediatric Care Recommendations for Free Standing Urgent Care Facilities, 2007.

  The American Academy of Pediatrics' Committee on Pediatric Emergency Medicine has updated and expanded its recommendations to freestanding urgent care facilities on stabilization procedures in pediatric emergency situations and on transfer protocols for pediatric patients. The policy statement notes that although an urgent care center is not an emergency department, it should have the capabilities to identify, stabilize, and coordinate care for pediatric patients.

• Institute of Medicine Committee, Future of Emergency Care in the United States Health System, Report Brief. National Academy of Sciences, 2006.

  The Institute of Medicine’s Committee on the Future of Emergency Care in the U.S. Health System issued three reports that identified key issues concerning the emergency medical system for both adults and children and made recommendations to improve the current system. The Committee reported that the majority of hospitals have insufficient specialty staff and medical equipment to address the specialized needs of children.

• Krug, Steven, Emergency Care Crisis: A Nation Unprepared for Public Health Disasters. Testimony for Homeland Security Subcommittee on Emergency Preparedness, Science, and Technology, 2006.

  On behalf of the American Academy of Pediatrics, Dr. Steven Krug testified before the Homeland Security Subcommittee on Emergency Preparedness, Science, and Technology at the following hearing: “Emergency Care Crisis: A Nation Unprepared for Public Health Disasters.” Dr. Krug discussed the limited emergency preparedness for pediatric patients, addressed the specific concerns related to pediatric emergency medical services, and provided policy recommendations for policymakers regarding children and emergency and disaster preparedness.

• Seidel J.S, et al. EMS and the Pediatric Patient: Are the Needs Being Met? Pediatrics, Volume 73, June, 1984.

  This study investigated the preparedness of emergency medical systems to treat the pediatric population. The study revealed that most U.S. hospitals are primarily prepared for myocardial infarction and trauma in adult patients, but fail to provide necessary care for critically ill children, who account for about 10% of all paramedic calls and emergency department visits. The study concluded that children’s needs in the pre-hospital and emergency department settings are not being met.

• 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.

  This study examined the training in pediatrics offered to paramedics and emergency medical technicians throughout the U.S. and the equipment carried by pre-hospital care provider agencies. The study revealed that half of pediatric emergency care training takes place at colleges and universities and the remainder at hospitals and emergency medical services agencies. Many programs have less than ten hours of didactic training in pediatrics and offer ten hours or less of clinical experience. Some programs offer no training in pediatric emergency medicine. The most common deficiencies in pediatric equipment included backboards, pediatric drugs, resuscitation masks, and small intravenous catheters. The study concluded that more attention to training and equipping pre-hospital personnel for pediatric emergencies may help to improve outcomes of out-ofhospital resuscitations of infants and children.

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.

  Refer to the annotation under “Journal Articles” for Performance Measure #66a.

• AAP/ACEP Joint Equipment Guidelines. Contact the NRC Library at 202-884-6847 for more information.

  The American Academy of Pediatrics and the American College of Emergency Physicians have developed guidelines for necessary equipment to address pediatric pre-hospital and emergency medical needs.

• 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.

  The Advanced Pedi-Bag Program, a partnership between a trauma center and county-wide EMS agency, developed a system to train all paramedics in the American Heart Association's Pediatric Advanced Life Support (PALS), to stock each patient care unit with a specific bag containing the equipment necessary to treat both basic and advanced pediatric emergencies, and to develop pediatric treatment protocols. A study of the Program found improved training of paramedics, patient care units that had an Advanced Pedi-Bag with specific equipment and supplies to manage pediatric emergencies, and pediatric protocols that support the use of this equipment.

Under Performance Measure #66c

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.

  The Centers for Disease Control and Prevention (CDC) reported on the availability and capacity of U.S. hospitals that admit pediatric patients. The CDC found that a significant number of children are treated at facilities lacking the recommended pediatric medical equipment and staff. Hospitals with a separate pediatric emergency unit were more likely to have board-certified pediatric emergency physicians and other properly trained staff.

• NRC Toolbox: Facility Categorization. Visit http://bolivia.hrsa.gov/emsc/, and then click on “Toolbox” on left menu.

  The EMSC National Resource Center (NRC) has compiled information and resources pertaining to facility categorization. This Toolbox includes website links to resources, example practices, database searches, as well as family and caregiver resources.

• NRC Toolbox: Inter-facility Transfer. Visit http://bolivia.hrsa.gov/emsc/, and then click on “Toolbox” on left menu.

  The EMSC National Resource Center (NRC) has compiled information and resources pertaining to inter-facility transfer for pediatric patients. This Toolbox includes website links to resources, information on why inter-facility transfer agreements are important, database searches, as well as family and caregiver resources.

• U.S. Department of Health and Human Services, Model Trauma System Planning and Evaluation, 2006. Visit http://www.hrsa.gov/trauma/model.htm.

  The Health Resources and Services Administration has created a guide for trauma system development, targeting trauma care professionals, public health officials, and policy experts. The guide attempts to evaluate trauma systems using a “public health approach” and ultimately aims to reduce mortality rates.

Guidelines and Policy/Position Statements

• Emergency Department Facility Recognition Criteria for EDAP and SEDP Levels. Visit http://www.luhs.org/depts/emsc/, click on “Archives” at the bottom of the page, scroll down to 2001, and then select the second link under “June.”

  The Illinois Emergency Medical Services for Children program has developed facility recognition criteria for both the Emergency Department Approved for Pediatrics (EDAP) and the Standby Emergency Department Approved for Pediatrics (SEDP).

• 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.”

  The American Academy of Pediatrics’ Committee on Pediatric Emergency Medicine and the American College of Emergency Physicians’ Pediatric Committee have developed guidelines for emergency medical systems and hospital administrators to ensure that children receive quality emergency care, and to facilitate, after stabilization, timely transfer to a facility with specialized pediatric services when appropriate. These guidelines are supported by 17 medical associations and organizations.

• Emergency Nurses Association, Position Statement on Care of Critically Ill or Injured Patients during Interfacility Transfer, 2005.

  The Emergency Nurses Association has developed a position statement on the challenges of the patient transport process from one medical facility to another. The statement reports that transport services require specific skills and protocols, which are currently lacking in many emergency medical service systems.

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.

  A study was conducted to analyze pediatric services in U.S. hospitals with emergency departments. The investigation showed that the majority of hospitals admitting pediatric patients did not have separate pediatric facilities. The study also found that appropriate medical equipment for children, especially for newborns, was missing at many hospitals.

• Haller,J. Toward a Comprehensive Emergency Medicine System for Children. Pediatrics, 1990; 86: 120-172.

  This study evaluated the effectiveness and impact of Maryland’s designated pediatric trauma center located in The Johns Hopkins Children’s Center. The level of compliance within Maryland’s regionalized pediatric trauma system was examined using hospital discharge abstract data from 58 acute care hospitals in the state. The proportion of patients with injuries and the proportion of inhospital deaths occurring at each level of care (i.e., statewide pediatric trauma care, regional trauma care, and community hospital) were analyzed.

• Institute of Medicine Committee, Future of Emergency Care in the United States Health System, Report Brief. National Academy of Sciences, 2006.

  Refer to the annotation under “Publications” for Performance Measure #66b.

• 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.

  This study investigated the effect of pediatric-specific emergency care within trauma systems on patient outcomes and mortality. The effects of acute management of children in a non-pediatric trauma center were investigated and compared to outcomes for children treated in the American College of Surgeons Committee on Trauma pediatric-verified trauma centers.

• Krug, Steve, Emergency Care Crisis: A Nation Unprepared for Public Health Disasters. Testimony for Homeland Security Subcommittee on Emergency Preparedness, Science, and Technology, 2006.

  Refer to the annotation under “Publications” for Performance Measure #66b.

• Morrison, Wayne, Wright J., and Paidas C. Pediatric Trauma Systems. Critical Care Medicine, 2002; 30, #1 supplement.

  This article examines the development of trauma centers and systems, for both adults and children. Studies of trauma system effectiveness suggest that the establishment of trauma systems may lead to improvements in mortality. The article states that continued system development, assessment, and educational efforts about how childhood injuries are different are essential to combat this leading killer of children.

• 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.

  This study examined the occurrence of delayed diagnosis of injury (DDI) in pediatric trauma patients. Results showed that the implementation of an effective pediatric trauma team and trauma service was associated with a significant reduction in DDI in children.

• Resources for Optimal Care of the Injured Patient 2006,Committee on Trauma, American College of Surgeons, Chicago, Illinois, 2006.

  As an aid to the process of American College of Surgeons’ Committee on Trauma verification and consultation for trauma centers, this book outlines the essential and desirable requirements for trauma centers pursuing consultation or seeking to gain or maintain verification. These guidelines are used by the ACS Verification/Consultation Program to evaluate trauma centers.

• Sigrest, Todd, and AAP Committee on Hospital Care, Facilities and Equipment for Care of Pediatric Patients in Community Hospitals. Pediatrics, 2003; 3: 1120-1123.

  This clinical report provides basic guidelines for furnishing and equipping a pediatric area in a community hospital. Guidelines for facility needs, essential medical equipment for pediatric care, support services, continuing education for all health care professionals, referral networks, and admission and transfer criteria are provided.

• Woodward, George, et. al., The State of Pediatric Interfacility Transport: Consensus of the Second National Pediatric and Neonatal Interfacility Transport Medicine Leadership Conference. Pediatric Emergency Care 2002; 18(1): 38-43.

  The American Academy of Pediatrics (AAP) and the AAP Section on Transport Medicine held the second National Pediatric and Neonatal Transport Leadership Conference in June 2000. Participants discussed and debated issues regarding pediatric transport medicine. This consensus statement reflects the insights and conclusions from this meeting.

Under Performance Measure #66d

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

  The Ethics Resource Center of the American Medical Association has developed a presentation to increase the understanding and application of the Emergency Medical Treatment and Active Labor Act (EMTALA) for emergency medical service systems, hospitals, and transfer centers. The presentation outlines the need, purpose, requirements, liabilities and fines, and implications of the Act.

• 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.

  Refer to the annotation under “Web Resources” for Performance Measure #66c.

• Emergency Department Approved for Pediatrics (EDAP) Guidelines. Visit http://www.luhs.org/depts/emsc/, click on “Archives” at the bottom of the page, scroll down to 2001, and then select the EDAP link under June.

  Refer to the annotation under “Guidelines and Policy/Position Statements” for Performance Measure #66c.

• EMTALA - An Overview. Visit http://www.acutecare.com/emtala.htm.

  This website provides an overview of the Emergency Medical Treatment and Active Labor Act (EMTALA), including EMTALA requirements for a medical screening examination, necessary stabilizing treatment, restricting transfers until stabilization, and appropriate transfers. The program available on the website is accredited for continuing medical education (CME) and continuing education hours (CEH).

• EMTALA Frequently Asked Questions. Visit http://www.emtala.com/faq.htm.

  This website provides a set of 24 frequently asked questions and 5 special situations for the Emergency Medical Treatment and Active Labor Act (EMTALA). Questions pertain to issues involving pre-hospital care, patient transport, patient rights, insurance issues, and legal obligations for transporting and receiving facilities.

• NRC Toolbox: Inter-facility Transfer. Visit http://bolivia.hrsa.gov/emsc/, and then click on “Toolbox” on left menu.

  Refer to the annotation under “Web Resources” for Performance Measure #66c.

• 20 Commandments of EMTALA. Visit http://www.medlaw.com/healthlaw/EMTALA/education/the-20-commandments-ofem. shtml.

  This website provides legal advice for healthcare professionals, hospitals, and their attorneys regarding EMTALA.

• U.S. Department of Health and Human Services, Model Trauma System Planning and Evaluation, 2006. Visit http://www.hrsa.gov/trauma/model.htm. Refer to the annotation under “Web Resources” for Performance Measure #66c.

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.

  Refer to the annotation under “Journal Articles” for Performance Measure #66a.

• 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.”

  Refer to the annotation under “Guidelines and Policy/Position Statements” for Performance Measure #66c.

• Emergency Nurses Association, Position Statement on Care of Critically Ill or Injured Patients during Interfacility Transfer, 2005.

  Refer to the annotation under “Guidelines and Policy/Position Statements” for Performance Measure #66c.

Publications

• American Academy of Pediatrics, Committee on Pediatric Emergency Care, Access to Pediatric Emergency Care. Pediatrics, 2000; 105:647-649.

  The American Academy of Pediatrics’ Committee on Pediatric Emergency Care has identified barriers limiting access to appropriate emergency care services for children. The Committee suggests increasing the education of emergency care providers on how to properly teat children, particularly those with special health care needs, and also recommends involving and incorporating the child’s medical home into emergency care.

• Resources for Optimal Care of the Injured Patient 2006,Committee on Trauma, American College of Surgeons, Chicago, Illinois, 2006.

  Refer to the annotation under “Publications” for Performance Measure #66c.

• 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).

  This study examined the effects of parents accompanying their children during emergency medical transport services. The study concluded that parents should interact with their children as much as possible during the transport and recommended parental involvement with the transport process.

• 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.

  Refer to the annotation under “Publications” for Performance Measure #66c.

Under Performance Measure #66e

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

  Refer to the annotation under “Web Resources” for Performance Measure #66d.

• 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.

  Refer to the annotation under “Web Resources” for Performance Measure #66c.

• EMTALA - An Overview. Visit http://www.acutecare.com/emtala.htm.

  Refer to the annotation under “Web Resources” for Performance Measure #66d.

• EMTALA Frequently Asked Questions. Visit http://www.emtala.com/faq.htm.

  Refer to the annotation under “Web Resources” for Performance Measure #66d.

• NRC Toolbox: Inter-facility Transfer. Visit http://bolivia.hrsa.gov/emsc/, and then click on “Toolbox” on left menu.

  Refer to the annotation under “Web Resources” for Performance Measure #66c.

• 20 Commandments of EMTALA. Visit http://www.medlaw.com/healthlaw/EMTALA/education/the-20-commandments-ofem. shtml.

  Refer to the annotation under “Web Resources” for Performance Measure #66d.

• U.S. Department of Health and Human Services, Model Trauma System Planning and Evaluation, 2006. Visit http://www.hrsa.gov/trauma/model.htm.

  Refer to the annotation under “Web Resources” for Performance Measure #66c.

Guidelines and Policy/Position 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.

  Refer to the annotation under “Journal Articles” for Performance Measure #66a.

• 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.”

  Refer to the annotation under “Guidelines and Policy/Position Statements” for Performance Measure #66c.

• Emergency Department Approved for Pediatrics (EDAP) Guidelines. Visit http://www.luhs.org/depts/emsc/, click on “Archives” at the bottom of the page, scroll down to 2001, and then select the EDAP link under “June.”

  Refer to the annotation under “Guidelines and Policy/Position Statements” for Performance Measure #66c.

• Emergency Nurses Association, Position Statement on Care of Critically Ill or Injured Patients during Inter facility Transfer, 2005.

  Refer to the annotation under “Guidelines and Policy/Position Statements” for Performance Measure #66c.

Publications

• American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, Pediatric Care Recommendations for Free Standing Urgent Care Facilities, 2007.

  Refer to the annotation under “Publications” for Performance Measure #66b.

• National Highway Traffic Safety Administration, Guide for Inter-facility Patient Transfer. April 2006.

  The National Highway Traffic Safety Administration organized an Emergency Medical Services Inter-facility Transfer Planning Group to analyze the current issues with inter-facility patient transfer. The Group reported that due to an increase in specialty care centers, there is a higher volume of patient transport. The Group used a consensus process to develop inter-facility patient transfer guidelines that emergency service systems can use to promote high-quality care for critically ill patients.

• Resources for Optimal Care of the Injured Patient 2006,Committee on Trauma, American College of Surgeons, Chicago, Illinois, 2006.

  Refer to the annotation under “Publications” for Performance Measure #66c.

• Selvan, J.S., Fields W.W., Chin W., Petitti D.B. and Wolde-TsadikG., Critical Care Transport: Outcome Evaluation After Interfacility Transfer and Hospitalization. Annals of Emergency Medicine, 33; 1: 33-43.

  This study investigated the effects of inter-facility transport on mortality rates. The investigators concluded that if there is appropriate pre-transfer patient stabilization, inter-facility transfer of critically ill patients has no adverse effects on clinical outcomes or increases in medical resource use.

• Should Parents Accompany Pediatric Interfacility Ground Ambulance Transports? Results of a National Survey of Pediatric Transport Team Manager by George Woodward, in Pediatric Emergency Care (2002).

  Refer to the annotation under “Publications” for Performance Measure #66d.

• Sigrest, Todd, and AAP Committee on Hospital Care, Facilities and Equipment for Care of Pediatric Patients in Community Hospitals. Pediatrics, 2003; 3: 1120-1123.

  Refer to the annotation under “Publications” for Performance Measure #66c.

• 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.

  Refer to the annotation under “Publications” for Performance Measure #66c.

Under Performance Measure #67:

Websites

• Training and Certification of EMS Personnel (2007). Visit http://www.nasemsd.org/, select “Monographs” under the “Resources” tab at the top of the page.

  The National Association of State EMS Officials has developed a monograph that outlines the training and certification requirements of emergency medical services personnel for all 56 states and territories in the U.S. The monograph addresses the variation in state and territory resources, jurisdiction, case law and governing experiences for training and certification of EMS providers.

Journal Articles

• Miller, David, Kalinowski E., and Wood D., Pediatric Continuing Education for EMTs. Pediatric Emergency Care, 2004; 20:269-272.

  The National Council of State Emergency Medical Services Training Coordinators has developed recommendations for pediatric emergency care training, including educational content, method, and frequency of training.

• National Association of EMS Educators (NAEMSE), NAEMSE Standards and Practice Committee, Position Statement: Value of Continuing Medical Education in the Pre-hospital. Journal of Prehospital, 2003: 12:232.

  The National Association of EMS Educators (NAEMSE) has developed a position paper outlining the importance of continuing medical education (CME). The NAEMSE reported a strong correlation between CME and the quality of care delivered by pre-hospital providers.

• 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.

  Refer to the annotation under “Guidelines/Protocols” for Performance Measure #66b.

• Stevens, Sandra and Alexander, J., The Impact of Training and Experience on EMS Emergencies in a Rural State. Pediatric Emergency Care, 2005; 21: 12-17.

  This study involved a survey of rural pediatric emergency medical services personnel in Maine. The report analyzed the effects of staff members’ comfort to treat critically ill children based on the amount of continuing medical education and pediatric calls per month. The investigators found that increased levels of continuing medical education and experience had positive impacts on the ability of staff to treat a pediatric emergency patient.

• Su, Eustacia, Schmidt, Terri A., Mann, N. Clay, and Zechnich, Andrew D., A Randomized Controlled Trial to Assess Decay in Acquired Knowledge among Paramedics Completing a Pediatric Resuscitation Course Academic Emergency Medicine, 2000 7: 779-786.

  This study analyzed the effectiveness of annual out-of-hospital pediatric education and the retention time of knowledge after the educational intervention. The study found that although there is significant knowledge enhancement at 6 months, trainees do not retain knowledge one year after receiving education. It concluded that additional education would be necessary to improve long-term knowledge retention for pediatric education.

• Wood, Don, Kalinowski E., and Miller D., Pediatric Continuing Education for Emergency Medicine Technicians. Pediatric Emergency Care, 2004: 20: 261-268.

  The National Council of State Emergency Medical Services Training Coordinators has developed recommendations for pediatric emergency medical education for EMTs, including content, method, and frequency of educational sessions.

Guidelines

• Stoy, Walt, National Guidelines for EMT Continuing Education. U.S. Department of Transportation/NHTSA, 1999.

  NHTSA has developed national guidelines for continuing medical education (CME) for emergency medical technicians. This document updates guidelines from 1985.

Under Performance Measure #68a

Presentation

• Advisory Committees — How to develop and utilize the best team for EMSC Initiatives (a 2006 PowerPoint presentation). Visit http://www.cademedia.com/archives/mchb/emsc2006/Grantee2006/ppt/E%201-3.ppt.

  This PowerPoint presentation includes strategies and action steps for developing and implementing EMSC Advisory Committee teams. The presentation also includes case studies of how some States have been successful in developing and utilizing their EMSC Advisory Committees.

Policy Resources

• American Academy of Pediatrics, Committee on State Government Affairs, Government Affairs Handbook, 1992.

  The American Academy of Pediatrics (AAP) has developed a handbook for AAP members and organizations interested in becoming involved with legislative and regulatory affairs. The handbook provides resources for pediatric advocacy at both the state and federal levels.

• Amidei, Nancy, So You Want to Make a Difference, 1997.

  This guide is for those who want to become more involved in policy-making, advocacy, and civic engagement. The guide outlines tools and resources for all citizens who want to become advocates.

• State Legislative Leaders Foundation, State Legislative Leaders: Keys to Effective Legislation for Children and Families, 1995.

  The State Legislative Leaders Foundation conducted a research project on the keys to effective legislation for children and families, which involved interviewing 177 of the most influential Republican and Democratic state legislature leaders from all 50 states and surveying 167 child and family organizations. The report outlines the key findings of the investigation, including the importance of child and family issues to legislative leaders; their knowledge of child and family issues; and the perception of child/family advocates.

Websites (of professional organizations from which EMSC Advisory Committee core and/or recommended members could be recruited)

• American Academy of Pediatrics - http://www.aap.org/.

  The American Academy of Pediatrics (AAP) is a group of over 60,000 pediatricians interested in improving the quality of care for children. The website includes information on the organization’s programs and activities, as well as publications and resources for AAP members.

• American Hospital Association - http://www.aha.org/.

  The American Hospital Association is an organization of about 5,000 hospitals, healthcare systems, and health communities, as well as over 37,000 individual members, whose aim is to increase advocacy efforts to increase quality of care for all institutions. The website provides news, publications, and resources for members and the general public.

• Emergency Nurses Association - http://www.ena.org/.

  The Emergency Nurses Association is an organization that aims to advance the practice of emergency medicine for the nursing profession. The website provides news, publications, links, and resources for emergency care nurses and administrators.

• Family Voices — http://www.familyvoices.org/.

  Family Voices is an organization that advocates for children with special needs and supports a partnership between healthcare professionals and families in the community. The website provides information, news, publications, links to other organizations, and state resources to increase the quality of care for children with special needs.

• National Association of State EMS Officials - http://www.nasemsd.org/.

  The National Association of State EMS Officials is a professional organization for state emergency medical services officials. The website provides publications and resources for EMS professionals regarding current initiatives and events to educate and increase the quality of emergency medical services and patient care.

• National Association of EMTs - http://www.naemt.org/.

  The National Association of Emergency Medical Technicians (EMTs) is a network that aims to represent paid and volunteer emergency medical technicians and paramedics. The website provides resources on EMS policy, as well as a list of educational and regional organizations that serve EMTs and paramedics.

• National Association of School Nurses — http://www.nasn.org/.

  The National Association of School Nurses is an organization that provides leadership to school nurses in order to advance the medical care and treatment of children. The website provides resources and publications for members regarding education, advocacy, and policy for school nursing.

• National Highway Traffic Safety Administration - http://www.nhtsa.dot.gov/.

  The National Highway Traffic Safety Administration is a government organization aimed at improving public safety. The website offers resources for citizens regarding traffic and automobile policies, publications, and news regarding traffic safety issues.

Under Performance Measure #68b

Policy Resources

• American Academy of Pediatrics, Committee on State Government Affairs, Government Affairs Handbook, 1992.

  Refer to the annotation under “Policy Resources” for Performance Measure #68a.

• Amidei, Nancy, So You Want to Make a Difference, 1997.

  Refer to the annotation under “Policy Resources” for Performance Measure #68a.

• State Legislative Leaders Foundation, State Legislative Leaders: Keys to Effective Legislation for Children and Families, 1995.

  Refer to the annotation under “Policy Resources” for Performance Measure #68a.

Websites (of professional organizations from which EMSC Advisory Committee core and/or recommended members could be recruited)

• All websites listed

  Refer to the annotation under “Websites” for Performance Measure #68a. Under Performance Measure #68c

Under Performance Measure #68c

Policy Resources

• American Academy of Pediatrics, Committee on State Government Affairs, Government Affairs Handbook, 1992.

  Refer to the annotation under “Policy Resources” for Performance Measure #68a.

• Amidei, Nancy, So You Want to Make a Difference, 1997.

  Refer to the annotation under “Policy Resources” for Performance Measure #68a.

• State Legislative Leaders Foundation, State Legislative Leaders: Keys to Effective Legislation for Children and Families, 1995.

  Refer to the annotation under “Policy Resources” for Performance Measure #68a.

Under Performance Measure #68d.

Policy Resources

• American Academy of Pediatrics, Committee on State Government Affairs, Government Affairs Handbook, 1992.

  Refer to the annotation under “Policy Resources” for Performance Measure #68a.

• Amidei, Nancy, So You Want to Make a Difference, 1997.

  Refer to the annotation under “Policy Resources” for Performance Measure #68a.

• State Legislative Leaders Foundation, State Legislative Leaders: Keys to Effective Legislation for Children and Families, 1995.

  Refer to the annotation under “Policy Resources” for Performance Measure #68a.

[back to introduction]

Appendix B: Case Studies

Appendix B includes case studies that highlight best practices, including lessons learned, for implementing Performance Measures #66c and #68d.

Performance Measure #66c:

Performance Measure #68d:

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

INSTITUTE OF MEDICINE’S FUTURE OF EMERGENCY CARE
EMERGENCY CARE FOR CHILDREN: GROWING PAINS REPORT
REPORT RECOMMENDATIONS COMPARED TO EMSC PERFORMANCE MEASURES AND OTHER EMSC PROGRAM ACTIVITIES

[back to introduction]

Implementation Manual Writing Team

This manual was produced by the EMSC National Resource Center. The EMSC National Resource Center is funded by the Emergency Medical Services for Children Program of Health Resources Services Administration (HRSA), Maternal and Child Health Bureau (MCHB) through contract number 240-03-011.

The manual was written by the following members with input from several grantees and national organization stakeholder members. Oversight was provided by the federal EMSC Program staff.

Tasmeen Singh, MPH, NREMTP Diana Fendya, RN, MSN Jim Morehead, MEd, BS, NREMTP Therese Morrison-Quinata Jocelyn Hulbert Karen Belli EMSC National Resource Center Child Health Advocacy Institute, Children’s National Medical Center 111 Michigan Ave NW, Washington DC, 20010 ****************************** Colleen Hirschkorn, MPA Jennifer Kuo, MHS Shalini Mehta, MPH Emma Goodrich, MPH, MBA Michael Marquardt Debbie Faulk The Lewin Group 3130 Fairview Park Drive, Suite 800, Falls Church, VA 22042 ****************************** Michael Ely, MHRM Patricia Schmuhl, BA Andrea Genovesi, MA National EMSC Data Analysis Resource Center 295 Chipeta Way, PO Box 581289, Salt Lake City, UT 84158-0289

[back to introduction]

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