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EMSA #192
EMSC RECOMMENDATIONS FOR PEDIATRIC REHABILITATION
Prepared by:
The EMSC Project Rehabilitation Subcommittee
Maureen McNeil
EMSC Project Director
California EMS Authority
Ronald A. Dieckmann, M.D., M.P.H.
EMSC Project Medical Consultant
San Francisco General Hospital
Erni Crowder
EMSC Project Coordinator
California EMS Authority
Sandra Salaber
Support Staff
California EMS Authority
June 1994
EMSC PROJECT
REHABILITATION SUBCOMMITTEE
Robert Haining, M.D. Chairman, Pediatric Physiatrist
Department of Rehabilitation
Oakland Children's Hospital
Marian Dalsey, M.D.Chief, Program Standards and
Quality Assurance Section, Children's
Medical Services, California
Department of Health Service
Benjamin Mandac, M.D.,Director, Pediatric Rehabilitation
Santa Clara Valley Medical Center
Richard Quint, M.D., MPH Director, Pediatric Rehabilitation and Recovery
Mount Zion/UCSF Medical Center, Department of Pediatrics
Nadine Trainor, M.D. Medical Director, Pediatric
Rehabilitation Center, Valley Childrens Hospital
Judith Brill, M.D. Director PICU, Department of Pediatrics
UCLA Medical Center
Ron Dieckmann, M.D.,M.P.H. Medical Consultant, EMSC Project
San Francisco General Hospital
EMSC RECOMMENDATIONS FOR PEDIATRIC REHABILITATION
1. Pediatric rehabilitation is an essential component in the continuum of pediatric
emergency and critical care.
2. Pediatric rehabilitation should begin in the early phases of acute care.
3. Children should receive the most appropriate level of care to minimize their liability
and to assist families in dealing with the long term sequelae of injury or illness.
4. California Children Service (CCS) provided standards for pediatric rehabilitation. (See
Appendix A). The committee recommends that the Department of Health Services
(DHS) review and update these 1978 standards.
5. Children requiring in-patient rehabilitation services should leave such care provided by
a PRC that meets CCS standards (See Appendix B).
6. Pediatric emergency and critical care systems should facilitate early identification of
patients appropriate for PRC referral, using current CCS admission criteria (See
Appendix C). The committee recommends that the DHS review and update these
criteria.
7. A system QI mechanism should be established. The QI process should include data
collection, analyses and review to monitor system and facilities compliance with
community standards of care.
8. Specialized pediatric centers should obtain rehabilitation consultation as part of the
acute management plan.
9. Community facilities and pediatric specialized centers (Trauma center, PCCC, PTC)
should be linked to a geographically appropriate PRC.
10. An information management system in a pediatric emergency and critical care system
should include rehabilitation.
11. Every child cared for within a pediatric emergency and critical care system does not
need a specialized pediatric center, nor does every child discharged from an inpatient
facility need referral to a PRC. However, every child with a potential disability needs
a rehabilitation plan. Often this requires referral to either CCS and/or a Regional
Center (See Appendix D).
12. The ultimate functional outcome of the child after rehabilitation should be reviewed in
relation to the quality and appropriateness of care through every component of the
pediatric emergency and critical care continuum.
APPENDIX A
Department of Health Services California Children Services (CCS)
3.16 - 1
3.16 Standards for Rehabilitation Facilities
3.16.1 Facilities applying for CCS approval shall be licensed for supplemental services as a
rehabilitation center, as delineated in Title 22, California Administrative Code,
Division 5, Section 70595-70603.
3.16.2 Purpose
A. A rehabilitation facility participating in the CCS program shall provide
interdisciplinary services from relevant medical and allied health
professionals to physically handicapped persons under 21 years of age.
B. The facility shall serve individuals who have a CCS-eligible condition
that has resulted in a physical disability with a functional deficit.
Examples of such disability are: paralysis or weakness, ataxia, multiple
or major joint derangement, amputation, contractures.
C. The primary emphasis of services shall be on physical restoration.
3.16.3 Classification of Facility
A. A rehabilitation center shall be housed in a CCS approved tertiary care
("long term") hospital.
1. Any child on life support systems must receive rehabilitation
services in a tertiary level hospital.
B. A rehabilitation unit may be housed in a freestanding rehabilitation
facility, or in a CCS approved standard term hospital if:
1. The unit has rehabilitation personnel with pediatric training or
experience.
2. The unit has a sufficient pediatric population to maintain
expertise in pediatric rehabilitation.
3. The unit has a well defined, written agreement with a CCS
approved standard or long term hospital to provide emergency
medical service. The plan shall include a protocol for
transportation from one facility to the other.
Department of Health Services
California Children Services (CCS)
3.16 - 2
C. Rehabilitation centers and units must meet all requirements specified
below (Sections 3.16.4 - 3.16.8).
3.16.4 Administration and Organization
A. A Medical Advisory Committee shall serve as consultants to the
Medical Director. The following specialties shall be represented on the
Committee:
1. Physical Medicine
2. Pediatrics
3. Neurology
4. Orthopedics
5. Internal Medicine
6. Psychiatry
7. Other specialties as deemed necessary.
B. A basic health core team shall consist of the director of the unit,
qualified social worker (MSW), nurse specialist, occupational therapist,
and physical therapist. For professional qualifications of the core team
members, please refer to 3.16.6.
C. The facility shall have been in operation at least six months prior to
approval by CCS.
D. The facility shall accept CCS patients regardless of race, creed, length
of residence in California, and economic status of family.
3.16.5 Physical Facilities
A. In addition to complying with Title 22, a rehabilitation facility seeking
CCS approval shall have a physical plan which is adequate in size and
design to promote fulfillment of it's goals, and shall be equipped to
meet established standards for each professional service it provides:
Department of Health Services
California Children Services (CCS)
3.16 - 3
1. There shall be an area for the exclusive use of children under 14
years of age. This area shall be located within reasonable
proximity to the nurses station to provide adequate observation.
2. Facilities for infants shall be separate from those of older
children.
3. Proper isolation facilities shall be provided for children who
develop communicable diseases.
4. Therapeutic and play equipment shall be suitable for the age and
group served in each area.
5. There shall be a pediatric crash cart in the unit.
3.16.6. Personnel
A. There shall be a director who is board certified in physical medicine and
rehabilitation. For centers serving children below 14 years, the training
of the director shall include six months of FTE pediatric rehabilitation.
Comparable experience in pediatric rehabilitation will be considered in
lieu of the formal pediatric rehabilitation training.
B. Physical Therapist
1. The physical therapist shall be a graduate of an approved school
of physical therapy and shall be licensed by the California Board
of Medical Quality Assurance.
2. At least one physical therapist shall be designated by the facility
as the therapist responsible for pediatrics and that therapist shall
be on the CCS panel; he/she shall have at least one year of
experience, under supervision, in providing physical therapy
services to children with physical disabilities or sufficient
documented education and training to be judged appropriate by
the review team.
C. Occupation Therapist
1. The occupational therapist shall be a graduate of an approved
school of occupation therapy and shall be registered by the
National Registry of the American Occupational Therapy
Association.
Department of Health Services
California Children Services (CCS)
3.16 - 4
2. At least one occupational therapist shall be designated by the
facility as the therapist responsible for pediatrics and that
therapist shall be on the CCS panel listing. His/her registration
number shall be filed with CCS; he/she shall have one year of
experience, under supervision, in providing occupational therapy
services to children with physical handicaps or sufficient
documented education and training to be judged appropriate by
the review team.
D. Social Worker
1. The social worker shall have a master's degree in social work
from a school of social work accredited by the Council on Social
Work Education. In addition, the social worker shall have had a
minimum of two years experience in casework services under a
qualified social work supervisor in a pediatric or family health
setting. If such experience is lacking, supervision by an MSW
with such experience shall be provided.
2. The social worker shall be a CCS panel member.
E. Registered Nurse Specialist
1. A registered nurse with training and at least one year of
experience in rehabilitation nursing shall be responsible for
nursing care and nursing management of rehabilitation services.
2. Sufficient registered nurses experienced in rehabilitation nursing
shall be employed to meet the needs of the service.
3. A nurse with pediatric training and experience shall be
responsible for nursing care and nursing management of children
under 14 years of age who are on the rehabilitation unit.
3.16.7 Services
A. The services shall be multidisciplinary and coordinated to meet the
needs of the individual patient and family.
B. The following services shall be provided by the professional staff:
1. The patient shall be seen by a rehabilitation specialist within 12
hours of admission.
Department of Health Services
California Children Services (CCS)
3.16 - 5
2. All patients under age 14 years shall be seen by a pediatrician
within 24 hours of admission and subsequently, as needed, until
discharge.
3. All patients 14 years and older shall be seen by an internist
within 24 hours of admission and subsequently, as needed, until
discharge.
4. An evaluation by the core team members shall be completed
within 48 hours of admission.
5. Services by the core team members shall be provided in
accordance with the treatment plan.
6. The following services shall also be provided, as needed, by
facility staff or by formal affiliation or consultation:
a. Psychological services
b. Educational services
c. Speech and hearing services
d. Nutrition and dietary services
e. Orthotic and prosthetic services
f. Vocational rehabilitation services
7. Laboratory, x-ray, and pharmacy services shall be readily
available.
C. In addition to professional staff responsibilities and written policies for
intake procedures, evaluation and program planning procedures, case
conference, etc., there shall also be written policies for:
1. Discharge procedures which shall involve participation of local
resource personnel who will provide continuity of care and
follow-up services. State and county CCS personnel should be
included.
D. A planned recreational or activity program directed by a recreation
therapist or other qualified professional shall be provided.
E. Follow-up outpatient care must be readily available at the facility when
no community follow up is available.
Department of Health Services
California Children Services (CCS)
3.16 - 6
F. Flexible visiting hours for parents and significant others shall be
arranged.
G. There shall be specific procedures for parent involvement and teaching.
3.16.8 Records and Reports
A. Individual case records shall be maintained for each patient admitted to
the facility. The completed case record shall include:
1. Reports from referring sources.
2. Medical history, diagnosis, rehabilitation goals, treatment plan
and progress.
3. Designation of a program coordinator for each patient.
4. Evaluation and treatment report from each service involved.
5. Report of case conference.
6. Reports from outside consultants.
7. Discharge report including summary of care, disposition for
follow-up and referral.
B. Comprehensive, multidisciplinary reports shall be sent to the referring
CCS agency as follows:
1. At the time of the first evaluation at the facility and shall include
an early discharge plan.
2. Monthly progress reports.
3. Discharge plan and summary sent in time for arrangements for
local follow-up; generally about two weeks before discharge.
4. Reports shall include input from all core team members.
APPENDIX B
State Department of Health Services
California Children Services (CCS)
REHABILITATION CENTERS
Cass Colina Hospital for Rehab Medicine, Pomona
Children's Hospital and Health Center, San Diego
Children's Hospital at Stanford, Palo Alto
Children's Hospital of Los Angeles, Los Angeles
Children's Hospital Oakland (provisional)
Donald N. Sharp Rehabilitation Center, San Diego
Fresno Community Hospital, Fresno
Glendale Adventist Medical Center, Glendale
Grossmont Hospital, La Mesa
John Muir Med Center, Walnut Creek
Kaiser Foundation Rehabilitation Center, Vallejo
Loma Linda University Medical Center, Loma Linda
Mt. Zion, San Francisco (provisional)
Northridge Hospital Foundation, Northridge
Providence Hospital, Medford, Oregon
Ralph K. Davies Medical Center, San Francisco
Rancho Los Amigos Hospital, Downey
St. John's Regional Medical Center, Oxnard
St. Jude's Hospital, Fullerton
St. Mary's Hospital, San Francisco
San Bernardino Community Hospital, San Bernardino
(Ballard Center for Rehabilitation)
San Joaquin General Hospital, Stockton
Santa Barbara General Hospital, Santa Barbara
Santa Clara Valley Medical Center, San Jose
Tustin Rehab Hospital, Tustin
University of California, Davis Medical Center, Sacramento
University of California, Irvine Medical Center, Orange
University of California, San Diego Medical Center, San Diego
Valley Children's Hospital, Fresno
White Memorial Medical Center, Los Angeles
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