State of California

SYSTEM PLANNING, IMPLEMENTATION AND MANAGEMENT MODEL FOR THE INTEGRATION OF EMSC INTO LOCAL EMS SYSTEMS
EMSA #195

Prepared by: Systems Management and Medical Direction 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

Richard E. Watson Interim Director California EMS Authority

Sandra Smoley Secretary Health and Welfare Agency

Pete Wilson Governor

Systems Planning, Implementation and Management Subcommittee

Ronald Dieckmann M.D., M.P.H Co-Chair, Medical Consultant, EMSC Project; Director of Pediatric Emergency Medicine San Francisco General Hospital

Brenda Bruns, M.D. Co-Chair Former EMS Medical Director Alameda County

Ann Pettigrew, M.D. Pediatric Intensive Care Network of Northern and Central California

Richard Narad, Ph.D. California State University, Chico

Patricia Murrin, R.N., M.P.H. EMS Administrator, San Diego County EMS, EMS Administrators Association of California

Beverly Ness, R.N. Children's Hospital Emergency Department, San Diego

Introduction

All infants, children and adolescents should have access to high quality emergency and critical care. Care delivery should occur within an organized community system that includes illness and injury prevention activities, prehospital care, acute hospital care (including emergency and pediatric in-patient services), pediatric critical care and rehabilitation. This system, along with the numerous emergency and critical care service providers, should be linked and coordinated within a community EMS for Children (EMSC) plan formulated by the local or regional EMS agency or another designated lead agency. The community EMSC Plan should be developed by a mutidisciplinary EMSC Task Force that involves appropriate experts in pediatrics, emergency medicine, pediatric critical care, trauma surgery, nursing, and prehospital care, as well as other interested parties in the community.

The following document is a planning, implementation and management model for local or regional EMS systems to integrate EMSC. The model is not intended to be all inclusive. It presents the core components for EMSC, but does not address many additional essential services for children that should also be incorporated into any individual EMSC Plan (e.g., child protective services, mutual aid between counties or states). The paradigm presented here must be adapted to each EMS system, based on local needs and resources. This outline therefore is a template that requires further adaptation to individual EMS systems and elaboration with future progress and experience with EMSC.

SYSTEM PLANNING, IMPLEMENTATION AND MANAGEMENT MODEL FOR THE INTEGRATION OF EMERGENCY MEDICAL SERVICES FOR CHILDREN INTO LOCAL EMS SYSTEMS

I. BACKGROUND TASKS FOR PLANNING AND PRELIMINARY REVIEW

A. Commitment by local EMS agency to develop Emergency Medical Services for Children (EMSC)
1. Justification and authority for establishing EMSC
a. State EMS Systems Standards and Guidelines relevant to pediatrics (see Appendix A)
b. Review relevant literature
c. Review EMSC Guidelines and Recommendations (see Appendix B)
d. Acquisition of information from other EMS systems with EMS components
e. Consultation with experts
f. Recognition of local needs
g. Problem identification through review of system data or case studies
2. Estimate of feasibility and impact of EMSC planning and implementation
a. Fiscal
(1) EMS agency and EMS providers
(a) Education
(b) Personnel
(c) Equipment
(d) Case and payor mix
(e) Quality improvement
(f) Information management
(2) System providers
(a) Prehospital providers
(1) Non-transporting providers
(2) Transporting providers
(3) Base hospitals
(b) Hospital providers
(1) Receiving hospitals (especially emergency departments)
(2) Specialized centers (e.g., Pediatric Critical Care Centers
(PCCCs), Pediatric Trauma Centers, (PTCs), General Trauma Centers ((GTCs))
(c) Other providers
(1) Managed Care Organizations (e.g.,HMO's, PPO's)changes in patient flow and financial impact
(2) Poison centers
(3) Interfacility transport service providers
b. Additional considerations
(1) Political
(2) Geographic
(3) Technical
(4) Special populations
B. Evaluation of local EMS agency administrative organization and budget
1. Cost analysis, fees for facility selection, including identification of potential funding sources (e.g., EMS fund, EMS district, block grants,local funds,foundations)
2. Personnel and resource commitment
C. Impact on other EMS system operations and projects

II. PROMOTION OF SUPPORT AND INVOLVEMENT FROM THE COMMUNITY

A. Identification of representatives from appropriate groups for EMSC Task Force
1. Consumer groups
2. EMS agency (staff and appropriate committees)
3 Emergency Medical Care Committee (EMCC)
4. Health Department
5. Hospital council or association
6. Illness and injury prevention programs
7. Interfacility transport providers
8. Key professional groups and providers including:
a. Pediatricians and other primary care providers.
b. Emergency physicians and nurses representing key hospitals, base hospitals, and rural hospitals.
c. EMTs
9. Local medical society
10. Managed care organizations
11. Prehospital providers
12. Rehabilitation facilities
13. Specialized pediatric centers and referral centers (PCCCs, PTCs, GTCs) including physician and nursing specialists in pediatric intensive care, pediatric emergency care, and pediatric trauma care.
B. Discussion of purpose and intent of EMSC
1. Review of relevant statutes, regulations, guidelines and recommendations
2. Review of national, state and local EMSC experiences
3. Needs and feasibility assessment
4. Integration of EMSC into overall EMS system
5. Development of EMSC Task Force

III. FORMATION OF EMSC TASK FORCE (see Section II A for suggested membership)
A. Identification of lead organization (usually this is the local EMS agency)
B. Orientation of EMSC Task Force
1. EMSC background information (National & California)
2. EMS agency role, authority and responsibility
3. EMS agency's plans for EMSC
C. Formulation of Task Force goals and objectives
D. Explanation of process for developing and adopting recommendations
E. Delineation of short and long term commitment and responsibilities of members
F. Schedule of meetings and time lines
G. Selection of chair or co-chairs
H. Explanation of role of sub-committees (as needed) to address individual system components

IV. DEVELOPMENT OF DRAFT EMSC PLAN BY EMSC TASK FORCE

A. Interpret local EMS agency's authority to develop EMSC
B. Define terms
C. Describe EMSC catchment area
1. Define EMS catchment area (including areas in other regions to be included)
2. Describe geographic characteristics
3. Describe demographic characteristics
D. Indicate how current EMS system addresses EMSC components
1. Number and role of prehospital system providers (non-transporting and transporting)
2. Facilities, specialized services and resources for children (e.g., EDs, PCCCs, PTCs, GTCs)
3. Participation of hospitals and other providers inside and outside catchment area
4. Policies, procedures, protocols that are specific to children
E. Describe and prioritize problems and issues to be addressed by plan
F. Describe specific plans and recommendations for each component of EMSC based on state EMS System Guidelines and EMSC Guidelines and EMSC Recommendations (See appendices A and B)
G. Identify additional information needed to develop and implement EMSC
H. Formulate time line for implementation
I. Formulate how EMSC plan will be integrated into overall EMS system and local health and safety systems (e.g., law enforcement,children's protective services)
J. Outline method of monitoring/revision of EMSC plan

V. PUBLIC COMMENT PHASE

A. Presentation and/or distribution of draft plan to appropriate groups
B. Review of comments by task force and EMS staff
C. Revision of draft in response to comments and formulation of final draft

VI. ADOPTION OF EMSC PLAN BY LOCAL GOVERNING BOARD

VII. IMPLEMENTATION OF EMSC PLAN RECOMMENDATIONS

A. Definition of process and timeline for implementation
1. Identification of components requiring development or revisions of EMS agency policies, protocols, standards, or guidelines
2. Prioritization of components
3. Designation of responsible parties or subcommittees for development of each component
4. Development of recommendations for individual components, after appropriate review of relevant materials, based on local needs and resources
5. Review of recommendations for individual components by EMSC Task Force
6. Distribution of recommendation for review, in accordance with local EMS policy
7. Revision of component recommendations
8. Adoption of recommendations by appropriate authority
9. Selection of methods for implementation; (different methods may be required for different components)
10. Development of specific time lines and budget projections for implementation of each component
B. Facility Assessment and Identification
1. Facility assessment
a. Process for determining facility eligibility (e.g., Emergency departments, PCCCs, PTCs, GTCs)
b. Application procedures
c. Site visits for consultation, verification of compliance
2. Facility identification process (e.g., approval designation, confirmation)
3. Contracts or agreements with facilities
4. Periodic re-evaluation

VIII. EVALUATION

A. Establishment of ongoing EMSC Advisory Committee
1. Advisory to EMS agency on the operation of the pediatric sub-system
2. Assist EMS agency in evaluation processes
B. Development of pediatric information system
C. Identification of areas for on-going evaluation
1. Compliance by system participants with established policies, procedures, standards and contracts
2. Quality of patient care by each participant group
3. Integration and coordination of all EMSC components
4. Review of interface of pediatric system with other community health and safety services, including poison center, law enforcement, trauma system
5. Performance of EMS-EMSC system as a whole
6. Review of care of special need groups
D. Integration of pediatric data collection into quality improvement processes

APPENDIX A

Pediatric Excerpts from the "Emergency Medical Services Authority EMS Systems Standards And Guidelines" Publication #EMSA-101

1. CLINICAL TARGETS
Neonatal and Pediatric Emergencies--The EMS system should:
a. Provide training for EMS personnel in the special aspects of neonatal and pediatric emergency care.
b. Provide Basic and/or Advanced Life Support in the prehospital setting.
c. Set standards for Emergency Department pediatric capabilities and identify facilities meeting these standards.
d. Provide primary transport to the most appropriate emergency medical care facility.
e. Ensure the availability of secondary transport of selected patients to special care facilities.
2. PLANNING ACTIVITIES
a. Each local EMS Agency shall identify population groups served by the EMS system which require specialized services (e.g., elderly, handicapped, children, non-English speakers).
b. Each local EMS Agency should develop services, as appropriate, for special population groups served by the EMS system which require specialized services (e.g., elderly, handicapped, children, non-English speakers).
3. FACILITIES (ENHANCED LEVEL)
a. Local EMS agencies that develop pediatric critical care systems shall determine the optimal system, including:
(1) The number and role of system participants, particularly of emergency departments.
(2) The design of catchment areas (including areas in other counties, as appropriate), with consideration of workload and patient mix.
(3) Identification of patients who should be primarily triaged or secondarily transferred to a designated center, including consideration of patients who should be triaged to other critical care centers.
(4) Identification of providers who are qualified to transport such patients to a designated facility.
(5) The role of non-pediatric critical care hospitals including those which are outside of the primary triage area.
(6) A plan for monitoring and evaluation of the system.
b. Local EMS agencies shall identify minimum standards for pediatric capability of emergency departments, including:
(1) Staffing
(2) Training
(3) Equipment
(4) Identification of patients for whom consultation with a pediatric critical care center is appropriate
(5) Quality assurance
(6) Data reporting to the local EMS agency
c. Local EMS agencies should develop methods of identifying emergency departments which meet standards for pediatric care and for pediatric critical care centers and pediatric trauma centers. (Desirable)

APPENDIX B

1991-1993 California Emergency Medical Service for Children Project Final Report 1994 EMS Authority Publication #196 EMSC Guidelines and Recommendations

1. EMSC Project Guidelines
a. Paramedic Education Guidelines
b. Prehospital Pediatric Equipment for BLS/ALS Support Units
c. Pediatric Prehospital Treatment Protocols
d. Administration, Personnel and Policy Guidelines for the Care of Pediatric Patients in the Emergency Department
e. Interfacility Pediatric Trauma and Critical Care Consultation and/or Transfer Guidelines
f. Model Pediatric Interfacility Transfer Agreement
g. Guidelines for Pediatric Interfacility Transport programs
h. Guidelines for Pediatric Critical Care Centers
i. Guidelines for Pediatric Trauma Centers
2. EMSC Project Recommendations
a. System planning and management model for the development of a pediatric emergency and critical care system
b. Recommendations for prevention activities within EMSC
c. Recommendations for information management within EMSC
d. Recommendations for care of pediatric patients within the general trauma center
e. Recommendations for integration of pediatric rehabilitation within pediatric emergency and critical care systems
f. Recommendations for evaluation and referral of adolescents with HIV risk factors within the Emergency Medical Services