An initial project of the Illinois Emergency Medical Services for Children (EMSC) program was conduction of a statewide needs assessment. Evaluating the pediatric component of the Illinois EMS system provided useful information related to the strengths and weaknesses of pediatric emergency care within our state. This needs assessment, which was conducted during 1994-1995, consisted of surveying all prehospital agencies, emergency departments, hospitals, hospital rehabilitation programs, EMS systems, poison control centers and rehabilitation centers within Illinois. Survey return compliance from each of these targeted areas ranged from 45% - 100% and was geographically representative of our state. Highlights from this needs assessment are contained in this report. Complete findings from this investigation are available through the Illinois EMSC office.
Findings from this evaluation indicated that educational issues appeared to strike a common chord among all levels of healthcare providers. In the prehospital arena, the majority of Illinois prehospital providers are licensed at the EMT-Basic level. The distribution of providers in rural Illinois is such that few rural patients receive advanced life support care and transport times are often prolonged in these areas of the state. With respect to primary prehospital education, at the time of this survey, initial EMT training required a minimum of 7 dedicated pediatric hours for the EMT-Basic level and only 6 hours for the EMT-Paramedic. In addition, only 50% of the EMS systems in our state noted the incorporation of a Pediatric Advanced Life Support (PALS) course or a PALS format into their paramedic training courses.
At the time of this survey, continuing education requirements for providers mandated only the number of required hours (not content), consequently pediatric specific material was not emphasized. Only 33% of EMS systems required pediatric specific continuing education hours at the paramedic level, while even fewer systems required pediatric focused continuing education at the EMT-I (19%) and EMT-B (7%) level. When comparing paramedic completion of an adult oriented resuscitation course (Advanced Cardiac Life Support - ACLS) versus a pediatric equivalent (Pediatric Advanced Life Support -PALS), a significant difference was noted. Although 60% of EMT-P's had received training in Advanced Cardiac Life Support, only 32% had successfully completed the Pediatric Advanced Life Support course. Approximately 9% of all Illinois ambulance runs are pediatric-related, suggesting the need for ongoing pediatric education in order to maintain pediatric cognitive and psychomotor skills. An overwhelming 97% of prehospital providers identified the need for additional training in pediatric emergency care. Access to educational opportunities was of particular concern in the rural sectors with 21% of rural providers identifying the lack of availability of educational programs.
In addition, in the prehospital arena, standardized pediatric training for dispatchers was not mandated. Dispatch is the initial point of EMS access and findings identified that although 40% of dispatchers received some type of formal EMS training, only 11% of that group received any pediatric specific education.
To further evaluate pediatric care and utilization of core skills, a retrospective review (utilizing system specific protocols and a peer review panel) was conducted of care provided to 300 pediatric patients from ten Illinois EMS systems. Findings indicated that 19% of the patients who required an intravenous line had no attempt made to establish an IV. In addition, in patients where intubation was required, over 50% of the intubation attempts were unsuccessful. Addressing crucial issues of airway management and intravenous access in the prehospital setting is essential.
On average, 21% of Illinois emergency department visits were identified through this survey as being pediatric related. The majority of pediatric emergency care was identified as being provided in "comprehensive" emergency departments and while 91% of emergency department physicians possessed ACLS training, only 63% had completed a formal pediatric resuscitation training (PALS or APLS). Survey findings identified that the mean number of pediatric arrests handled in emergency departments annually in our state is ten. This reinforces the need for ongoing education to ensure that practice is consistent with current standards. In addition, less than half of full-time non-board certified/prepared emergency physician or emergency pediatric physician staff identified the completion of a minimum of 4 hours of pediatric focused continuing medical education annually.
Although 90% of emergency department nursing staff identified attainment of ACLS certification, only 29% had completed a PALS course and 6% had completed the Emergency Nursing Pediatric Course (ENPC). A lack of instructors for these courses in the rural areas of the state was identified as hampering access to pediatric education. The Illinois Emergency Nurses Association (ENA) conducts an annual survey to ascertain nursing educational needs and found that a most frequently requested educational activity is a pediatric focused emergency nursing course.
Of those hospitals with a defined pediatric intensive care unit (PICU), all indicated that they have a pediatric intensivist and pediatric clinical specialist available, however, one-third of these facilities did not require prior pediatric experience for the nurses providing care in this area and only 51% of PICU nursing staff had completed a PALS course. National certification attainment was somewhat higher in the neonatal setting with 64% of the dedicated nursing staff having completed the Neonatal Resuscitation Program (NRP). Although there was evidence of continuing education for pediatric unit staff nurses (66%) within hospitals, only approximately 10% of the hospitals responding indicated ongoing conduction of pediatric morbidity/mortality or multidisciplinary pediatric trauma conferences.
A significant amount of public education is being conducted by healthcare provider organizations. It was noted that 60-70% of EMS agencies provide some type of public education related to CPR or First Aid yet only 15% conduct pediatric injury prevention programs. Eighty-seven percent of the responding hospitals indicated provision of some form of public education, however only 41% provided pediatric specific public education. At the time of this survey, Illinois' poison control centers noted the inability to develop an optimal level of public education. Educating the public as to the importance of poisoning prevention in the pediatric population is vital. Approximately 70% of all poison control calls are attributed to the pediatric population while 55% of these pediatric calls are related to the 0-6 year-old age group.
Pediatric emergency standards and policies tend to be local in origin. All EMS systems are required by the state to develop prehospital pediatric treatment protocols, however protocol development varies markedly between systems. Only one half of the surveyed EMS providers had policies/procedures that identified specific transport directives for children. In addition, there was little evidence that indicated the development of guidelines that ensure facilities have appropriate capabilities to treat the pediatric population.
The prehospital needs assessment survey identified minimal equipment issues, however certain concerns did surface. The study revealed that barely thirty-seven percent of providers carry infant/toddler car safety seats while only 30% of those providers have protocols regarding car seat use. Equipment concerns among the Advanced Life Support providers centered primarily on insufficient airway equipment, pediatric defibrillation equipment deficiencies and lack of a mechanism to effectively administer accurate medication dosages.
Quality assurance activities are conducted fairly routinely on the adult population, yet little was identified for pediatrics. One-half of the responding hospitals noted a policy for internal review and evaluation of pediatric emergency care while only 38% of EMS systems had an established mechanism for conducting pediatric prehospital quality assurance.
The rehabilitation community identified specific recommendations that were felt would lead to improved care. The need for enhanced rehabilitation health care provider education was emphasized. There is also a need for more effective discharge planning and enhanced awareness of rehabilitation services and the need for such services. Children who would benefit from rehabilitation services are not always appropriately referred to such services. In addition, monitoring activities implemented after the child re-enters the community could provide useful feedback regarding the effectiveness of rehabilitation programs.
A review to assess 9-1-1 access issues was conducted via a review of pediatric trauma patients admitted to Illinois trauma centers during 1993. This subset was chosen because the diagnoses are response time sensitive. Findings revealed that pediatric patients living in a non-9-1-1 county had a greater intensive care unit length of stay (5.49 days) than those patients who resided in a region with 9-1-1 availability (3.19 days). The mode of transport to the hospital for pediatric patients living in areas with 9-1-1 was accomplished most frequently by an ALS ambulance (44%) while their counterparts in areas without 9-1-1 access were transported half the time (49%) by private vehicle (p<.001).
The "School Health Activities in Illinois Survey", conducted annually by the Illinois Department of Public Health, identified injuries sustained at school as a major problem for Illinois children. A review of the Illinois Trauma Registry identified that during 1993, 400 children were injured to such a degree at school that they required hospitalization at a trauma center. "Falls" and "struck by person/object" were noted as the most frequent mechanism of injury. Of the 3% of cases in which injuries were classified as serious (ISS > 15), 33% of those seriously injured patients were transported by private vehicle to the emergency department. This emphasizes the need for education to train school health personnel in appropriate access of the EMS system and to better prepare them in effective assessment and initial management of health emergencies within schools.
Children are not "small adults". The ill and injured child has very special needs and does indeed require a different approach to care. Although progress has been made in recent years to improve emergency care for children, much work remains to be done. The information gathered during this needs assessment process was extremely assistive in identifying the extent to which pediatric care has been integrated within the Illinois Emergency Medical Services system. Defined obstacles to implementing an organized EMSC program include a lack of provider education, insufficient monitoring and research capabilities, widespread variations in standards addressing access, care and prevention issues, inadequate provider resources to effectively implement change and minimal EMSC legislative mandates. To address these challenges, the Illinois EMSC Advisory Board in 1995 identified the following as priority areas of focus.
Support of pediatric health care provider/instructor educational courses
Promotion of injury prevention programs/education
Collaboration with state database sources to establish a pediatric data surveillance system
Development of a voluntary emergency department recognition process
Promulgation of EMSC recommendations and guidelines
Pursuit of legislative/regulatory initiatives aimed at supporting ongoing EMSC activities
This comprehensive statewide needs assessment and evaluation of the pediatric capabilities within the Illinois EMS system has led to the development of a comprehensive plan which is aimed at addressing the well-being and health care needs of our children.