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  • For many, George Clooney in ER which premiered in1994 was the introduction to Pediatric Emergency Medicine for many. It was exciting, romantic and occasionally realistic
  • The human suffering and financial loss from preventable accidental death constitute a public health problem second only to the ravages of ancient plagues or world wars. In one year alone vehicle accidents kill more than we lost in the Korean War, and in the past 60 years more Americans have died from accidents than from combat wounds in all of our Wars. Accidental Death and Disability: The Neglected Disease of Modern Society (1966) Institute of Medicine
  • Children possess unique anatomical, physiological, and developmental characteristics that create vitally important differences in the evaluation and management of many serious pediatric illnesses and injuries. Unique pediatric health care needs make it difficult for emergency care providers to provide optimal care in adultoriented EMS systems (eg, personnel training, facility design, equipment, medications).
  • Up to 10% EMS runs for children. Seidel 1984 Half of all trauma deaths in children may be preventable. Romenofsky 1984 Childrens outcomes given same ISSs as adults were worse. Seidel 1984,86. And that most Of these deaths occurred in areas lacking pediatric tertiary care centers.
  • Emergency Medical Services for Children provided a productive multidisciplinary setting where health department officials, EMS provider agencies, clinical leaders from professional societies, and key stakeholder groups came together with a shared mission to improve pediatric emergency care. Participants included members of organizations such as the American Academy of Pediatrics (AAP), American College of Emergency Physicians (ACEP), American College of Surgeons, Emergency Nurses Association, National Association of Children’s Hospitals and Related Institutions, National Association of EMS Physicians, National Association of State EMS Directors, and the National Association of Emergency Medical Technicians— just to name a few. Within communities and states, and at a national level, these groups collaborated effectively to narrow the pediatric emergency care gap.
  • Gausche-Hill, et al. Pediatric Preparedness of EDs : 2003 survey
  • PECARN is the Pediatric Emergency Care Applied Research Network, the first federally-funded multi-institutional network for research in pediatric emergency medicine.  What is PECARN's goal? The goal of this network is to conduct meaningful and rigorous multi-institutional research into the prevention and management of acute illnesses and injuries in children and youth across the continuum of emergency medicine health care. PECARN  will work with diverse demographic populations and across varied geographical regions to promote the health of children in all phases of care. To accomplish these tasks, PECARN provides the leadership and infrastructure needed to promote multi-center studies, support research collaboration among EMSC investigators, and encourage informational exchanges between EMSC investigators and providers.
  • Here is an example of a PECARN study that is currently being performed at UMD
  • Are we better off than 25 years ago when ER premiered
  • 2004
  • Rec 3.1 The DHHS and NHTSA in partnership with professional organizations should convene a panel of individuals with multidisciplinary expertise to develop an evidence-based categorization system for EMS, EDs and trauma centers based upon adult and pediatric service capabilities. Rec 3.3 – The DHHS should convene a panel of individuals with emergency and trauma care expertise to develop evidence-based indicators of emergency care performance, including performance of pediatric emergency care Rec 3.7 – Congress should appropriate 37.5 M each year for the next 5 years to the EMSC program Rec 4.1 – Every pediatric and emergency care-related health professional credentialing and certification body should define pediatric emergency care competencies and require practitioners to receive the appropriate level of initial and continuing education necessary to achieve and maintain those competencies Rec 4.3 – EMS agencies should appoint a pediatric emergency coordinator and hospitals should appoint two pediatric coordinators, one a physician, the other a nurse, to provide pediatric leadership for the organization
  • You know your child so know your child would be treated in an emergency

PowerPoint PowerPoint Presentation Transcript

  • Improving Outcomes for Children with Emergency Conditions Richard Lichenstein, MD Associate Professor Department of Pediatrics University of Maryland School of Medicine
  • What is Pediatric Emergency Medicine?
  • History of Emergency Medicine
    • 1966 - the National Academy of Sciences and National Research Council publish Accidental Death and Disability : The Neglected Disease of Modern Society
    • This was a watershed event in the development of EMS and EM in the US.
    • 1973 – EMS Act helped create the foundation for improvements in the care of patients with critical injury or illness.
  • Pediatric Emergency Medicine
    • Despite the improvements made with the EMS Act of 1973 significant gaps in the EM care for children existed.
    • These gaps were present because early efforts at improving EMS care did not appreciate that acutely ill and injured children could not be treated as small adults.
  •  
  • Timeline
    • 1970 - Bruce Janiak, MD, became the first Emergency Medicine resident at the University of Cincinnati
    • 1972 – AAP manual on pediatric emergency care. Disaster and Emergency Medical Services for Infants and Children published
    • 1979 - the American Board of Emergency Medicine was approved by the American Board of Medical Specialties
    • 1980 – First PEM Fellowship started
    • 1981 - Establishment of the AAP Section on Pediatric Emergency Medicine
  • Timeline
    • 1980s - Several Key studies on deficiencies in PEM care by both EMS and EDs published
    • 1984 - joint AAP/ACEP Task Force on Pediatric Emergency Medicine commenced operations
    • 1985 – First PEM Journal Published
  • A systems solution
    • 1985 - The recognition of a deficiency in pediatric emergency care ultimately prompted federal legislation and funding for the EMSC Program
  • EMSC
    • Emergency Medical Services for Children provided a productive multidisciplinary setting where health department officials, EMS provider agencies, clinical leaders from professional societies, and key stakeholder groups came together with a shared mission to improve pediatric emergency care.
  • EMSC Mission
    • To raise the bar for pediatric emergency care in every state
    • To foster collaboration both within and between states
    • It has established national norms for pediatric emergency care, and has made children’s issues in emergency medical care a national priority
  • So How Have We Done…?
  • 1993 IOM Report on EMSC
    • Report found that despite many advances there were still areas of needed improvement:
        • Education and Training
        • Appropriate Equipment and Supplies
        • Communication, Funding, and Planning
        • Evaluation and Research
  • Education and Training
    • 1988-1989 - first APLS course was implemented at the same time PALS was rolling out
    • 1992 – First PEM subspecialty exam given
    • 1994 EM/PEDS Combined Program Started at UMMS
    • 1999 – the Nation has about 1000 boarded PEM doctors
  • Appropriate Equipment and Supplies
    • Care of Children in the Emergency Department: Guidelines for Preparedness
    • Approved by ACEP Board of Directors September 2000 and the American Academy of Pediatrics Board of Directors December 2000
    • Written to ensure that every ED has proper equipment, supplies, drugs and the personnel with appropriate skills for pediatric emergency care.
    • Despite this resource a 2003 survey of US ED medical directors demonstrated that only 59% were aware that guidelines existed.
  • Is this the way to take care of our young?
    • A CDC study that looked at data from the 2002-2003 National Hospital Ambulatory Medical Care survey of EDs found that only 6% had all the pediatric supplies outlined in the guidelines
    • And only 50% of EDs had 85% of the supplies
  • Evaluation and Research
    • EMSC Has been key in funding and helping launch the Pediatric Emergency Care Applied Research Network (www. pecarn.org ) 2001
  • Pediatric Emergency Care Applied Research Network (PECARN)
    • PECARN is the first federally-funded national pediatric emergency medicine research network
    • Purpose: developing an infrastructure capable of overcoming barriers to pediatric EMSC research.
    • PECARN provides the leadership and infrastructure to conduct multi-center research studies, to support research collaboration among EMSC investigators, and to encourage informational EMSC exchanges
  • Barriers to EMSC Research : Why PECARN is Needed
    • Low incidence rates of pediatric emergency events require pooling of centers to conduct research
    • Large numbers of children are required to attain diverse and representative study samples
    • An infrastructure is needed to test the efficacy of treatments, as well as the transport and care that precede the arrival of children to hospital EDs
    • 4. A mechanism is needed to study the process of transferring research results to treatment settings
  • PECARN - Mission
    • To conduct high-priority,
    • multi-institutional research into the prevention and management of acute illnesses and injuries in children and youth of all ages
  • PECARN’S Hospital and Research Center Structure
    • PECARN consists of four research node centers (RNCs) located at diverse sites across the country
    • Each RNC hosts a regional network of hospital emergency department affiliates (HEDAs) for a total of 21 sites across the United States
  •  
  • PECARN Subcommittees PECARN Steering Committee Protocol Review & Development Subcommittee (PRADS) Safety & Regulatory Affairs Subcommittee (SRAS) Quality Assurance Subcommittee (QAS) Feasibility and Budget Subcommittee (FABS) Grant Writing and Publications Subcommittee (GAPS)
  • Role of the Steering Committee
    • Primary PECARN governing body
    • Equal membership from the 4 nodes / data center
    • Review and approve PECARN research proposals, formulate / monitor policies and procedures guiding the network
    • Establish scientific and administrative bylaws, policies, and procedures
    • Establish subcommittees to carry out specific tasks and activities
  • PECARN Strengths
    • Seven years experience as a network
    • 21 Hospital Emergency Department Affiliates
    • Serving ~800,000 acutely ill and injured children
    • Wide geographic and hospital representation
    • Senior-level EMSC researchers and clinicians
    • Outside investigators invited to participate
    • Have leveraged our strengths to successfully obtain extramural funding and accomplish important research
  • PECARN Research Successes Selected sample…
    • 5 completed, ~ 7 ongoing projects, many sub-studies
    • 10 federal grants
    • 10 published manuscripts and many under preparation
    • 40 abstracts presented
    • Pre-hospital research infrastructure established
  • Lorazepam for the Treatment of Pediatric Status Epilepticus Funded by NICHD for FDA’s Best Pharmaceuticals for Children Act (BPCA)
    • OBJECTIVES :
      • Lorazepam is widely used in children under 18 but has not been FDA approved for pediatric use
      • The first part of this study is a pharmacokinetic study of lorazepam in children with status epilepticus. 11 PECARN hospitals will be participating.
      • Study 1: pharmacokinetics of lorazepam in children 3 months to less than 18 years of age
      • Study 2: compare lorazepam with diazepam for the treatment of status epilepticus in children.
  • So Where Are We Now?
  • The Foundation of Our Nation’s Emergency Care System?
    • Existing public safety systems (EMS, fire, etc) are over-taxed by day-to-day demands
      • Especially in urban, high-risk areas
    • EMS and trauma systems are woefully under-funded
    • Hospital-based ED’s are dangerously overcrowded
    • Pediatric capabilities of our emergency and disaster care systems is uncertain
  • Emergency Care: At the Breaking Point
    • ED visits grew by 26% between 1993 and 2003 (90  114 million)
      • Number of ED’s declined by 425
    • Critical shortages of healthcare providers (MDs, RNs, etc)
    • Substantial ED overcrowding
    • Ambulances are frequently diverted from overcrowded EDs
      • ~ 500,000 diversions in 2003
    • In addition to ED access concerns, overcrowding is associated with poor care quality & medical error
    Institute of Medicine. Future of Emergency Care in the US Healthcare System, 2006.
  • Pediatric Readiness: “Growing Pains”
    • Although children make up at least 1/4 of all ED visits nationwide
      • Most general EDs and EMS agencies do not require specialized pediatric training for their clinical staff
      • Only 6% of all EDs have the full scope of pediatric equipment, medications, supplies
      • Paucity of research on best practices, clinical outcomes, & patient safety in pediatric emergency care
    “ If there is one word to describe the current state of pediatric emergency care in 2006, it is UNEVEN ” --- IOM Panel, 2006
  • Pediatric Emergency Experience Gap
    • Children account for 5 to 10% of all EMS patients
      • Limited training in pediatric care
      • Limited experience for EMT’s and paramedics with sick kids
    • Children make 25-30 million ED visits per year
      • Nearly 90% of children are cared for in general hospital ED’s
      • Many ED’s care for few children
        • 50% of ED’s see < 10 per day
      • Limited experience with sick kids for RNs and MDs in most US ED’s
    Gausche-Hill M, et al. Pediatrics 2007; 120:1229.
  • What Needs to Be Done?
  • Recommendation #1
    • Invest in the capacity of the emergency and acute care foundation of our nation’s healthcare system
      • EMS & trauma systems
      • Emergency departments
      • Hospitals
      • Emergency care providers
      • This same foundation will support disaster readiness
      • Heed recommendations from 2006 IOM report
  • Recommendation #2
    • Promote the presence of consistent day-to-day pediatric emergency readiness as this should assist pediatric disaster readiness
        • Facilities – categorization (3.1)
          • Medications, equipment, supplies, staffing
        • Training, training, training (4.1)
          • Define pediatric care competencies
        • Coordinators for pediatric care (4.3)
          • EMS, hospitals, disaster management
      • EMSC program needs to continue its leadership in this important area (3.7)
        • Develop pediatric performance measures (3.3)
    IOM - 2006 Pediatric Report Recommendations are in parentheses
  • Recommendation #3
    • Build upon existing systems/strengths in our nation’s acute care portfolio
      • Trauma centers/systems
      • Children’s hospitals/systems
      • Academic medical centers
        • Pediatric surge capacity
          • - Especially critical & sub-specialty care
        • Inter-hospital transport/evacuation
          • - Interstate mutual aid relationships
        • Specialized DMAT’s
        • Training resources
          • - PALS, PEPP, ENPC, PDLS, etc.
  • This Is The Reality
    • Training Positions for PEDS EM Specialists:
    • Total # Programs Grads/Yr
    • EM/PEDS 30 3 6
    • PEM(PED) 233 45 78
    • PEM (EM) 31 14 16
    • Tot PEM visits/year in US = 34,200,000
  • Know Your Hospital
    • Make sure the hospital where you take your child has the equipment and follows the ACEP/AAP position statement on Care of Children in the Emergency Department: Guidelines for Preparedness
    • Support EMSC/PECARN
  • We Need to Be Prepared
  • Children are not little adults…
  • …but they are our future.