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 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 – 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 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 the American Board of Emergency Medicine was approved by the American Board of Medical Specialties 1980 – First PEM Fellowship started 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 joint AAP/ACEP Task Force on Pediatric Emergency Medicine commenced operations 1985 – First PEM Journal Published

A systems solution 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 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 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 1.Low incidence rates of pediatric emergency events require pooling of centers to conduct research 2.Large numbers of children are required to attain diverse and representative study samples 3.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” 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 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 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 # ProgramsGrads/Yr EM/PEDS PEM(PED) PEM (EM) 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.