PEDIATRICS Vol. 105 No. 3 March 2000, pp. 647-649

AMERICAN ACADEMY OF PEDIATRICS:
Access to Pediatric Emergency Medical Care

Committee on Pediatric Emergency Medicine

	ABSTRACT

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Hundreds of thousands of pediatric patients require some level of emergency care annually, and significant barriers limit access to appropriate services for large numbers of children. The American Academy of Pediatrics has a strong commitment to identify barriers to access to emergency care, work to surmount these obstacles, and encourage through education increased levels of emergency care available to all children. It is also crucial to involve and incorporate the child's medical home into emergency care, both during acute presentation when the medical home is identified and by assisting in locating a medical home for follow-up when none previously exists.

	ARTICLE

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Thousands of infants, children, adolescents, and young adults seek emergency care each day in the United States. Many of these individuals do not seek care in a timely fashion because of a variety of obstacles. Appropriate access to pediatric emergency medical care is especially important for children because substantial morbidity may occur if care is delayed.

The problems restricting access to pediatric emergency medical care exist in a rapidly changing climate of health care delivery. Long-standing issues include:

• lack of universal understanding and application of a definition of "emergency";
• lack of third-party payment for care for large numbers of children;
• lack of third-party use of prudent layperson standard for definition of emergency;
• retroactive denial of third-party payment when diagnostic signs and/or symptoms suggest an emergent condition, but final diagnosis (often after treatment) is "nonemergent";
• lack of reasonable access to alternative sources of health care until the emergency department (ED) is left as the only place that will see everyone;
• lack of universal access to enhanced or basic 911 service, with reliance in some areas on local 10-digit emergency telephone numbers;
• the misconception that freestanding urgent care centers provide comprehensive emergency services;
• variability in pediatric training and experience among physicians staffing EDsin the past (and fortunately decreasingly) ED staff were trained in internal medicine or family medicine, or were moonlighting residents from other nonpediatric specialties;
• lack of pediatric training and experience for prehospital transport personnel;
• lack of access to pediatric emergency medical care in rural regions of the country;
• failure to identify the medical home initially or to return child to medical home on ED discharge; and
• lack of a government body empowered to solve these issues.

Obstacles arising more recently include:

• managed care protocols that bypass regional emergency services for children;
• managed care protocols designed to reduce use of emergency facilities without providing appropriate alternative care;
• denial of payment for service to insured patients because of preexisting or chronic conditions;
• increasing legislation and managed care initiatives related to emergency access for children that often require complex and time-consuming phone calls and documentation;
• ill or injured children in families who fear retribution because of immigration issues, child custody issues, fear of social service agency intervention, and legal or financial concerns; and
• language and education barriers to understanding appropriate utilization of less emergent sources of care.

Since publication of the first policy on access to emergency medical care¹ by the American Academy of Pediatrics (AAP), substantial advances have occurred:

• significant increase in emergency medicine residency programs that include specific training and experience in pediatric emergencies;
• improvements in pediatric training and experience for ED residents, as more programs become affiliated with tertiary and quaternary level pediatric centers for the pediatric patient;
• substantial and ongoing increase in presence of Board-certified emergency medicine physicians in EDs throughout the country, although many more are needed;
• increasing dissemination of pediatric emergency courses, such as Pediatric Basic Life Support,² Pediatric Advanced Life Support,³ Advanced Pediatric Life Support,⁴ and the Neonatal Resuscitation Program⁵; also requirements by some hospitals that certain of these courses (or similar material) be studied to practice in the ED;
• improvements in pediatric education for emergency medical technicians^6-8; and a new emergency medical technician basic curriculum;
• publication of the Institute of Medicine report on pediatric emergency care⁷;
• development of models and educational materials on access to pediatric emergency medical care through the Emergency Medical Services for Children (EMSC) program of the Maternal and Child Health Bureau (MCHB)/National Highway Traffic Safety Administration (NHTSA), see http://www.ems-c.org;
• publication of new manuals and texts providing education and information about access to pediatric emergency care^8,9;
• publication of statements and guidelines for pediatric facility categorization, emergency centers, office preparedness, urgent care centers, and prehospital and interfacility transport^10-12;
• development of model legislation for emergency care for children; and
• increased availability of physicians with specific training and certification in pediatric emergency care. Despite progress in access to emergency care, more advances are necessary.

The AAP recommends that every child in need have access to quality pediatric emergency medical care. Efforts must be made at local, state, and federal levels to:

• guarantee prompt and appropriate access to pediatric emergency medical care for all children regardless of socioeconomic status, ethnic origin, type of insurance, geographic location, or health status;
• increase public, professional, and governmental awareness about the magnitude of the problem of access to pediatric emergency medical care for children;
• fund, support, and promote the further development and improvement of emergency medical services for children;
• improve awareness, dissemination, and use of the large body of resources available through the MCHB/NHTSA EMSC program;
• ensure optimal emergency care for children in every aspect of the EMSC continuum from injury prevention to tertiary level pediatric emergency and critical care through rehabilitation, and ultimately coordinated through the medical home;
• encourage the implementation of enhanced (emergency access) 911 systems;
• vigorous efforts to identify a medical home for every child before emergency care is needed; if not available before ED care, strong encouragement of ED to locate a medical home for follow-up and ongoing care after discharge;
• encourage managed care organizations to accept the prudent layperson definition of an emergency;
• recognizing that not every ED can be staffed by a full-time pediatrician; encourage 1) a schedule of pediatricians on call to every ED; 2) pediatrician input into training, equipping, and otherwise preparing the ED for care of children; and 3) increased education of primary care pediatricians in management of emergency medicine practice (especially multiple trauma). Refresher courses such as Advanced Pediatric Life Support would be strongly encouraged;
• encourage all EDs to establish transfer agreements with facilities with higher levels of pediatric care to ensure timely access to pediatric emergency medical care for critically ill and injured children.

Adoption of the AAP Model EMSC Legislation by each state would remedy many of the problems encountered in access to pediatric emergency care.¹³ The AAP membership and leadership, as advocates for children, can and should make a strong commitment to assist pediatricians and families to make decisions about seeking timely and appropriate emergency care.

COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE, 1999-2000
Robert A. Wiebe, MD, Chairperson
Barbara A. Barlow, MD
Ronald A. Furnival, MD
Barry W. Heath, MD
Steven E. Krug, MD
Karin A. McCloskey, MD
Lee A. Pyles, MD
Deborah Mulligan-Smith, MD
Timothy S. Yeh, MD

LIAISONS
Marianne Gausche-Hill, MD
 American College of Emergency Physicians
Dennis W. Vane, MD
 American College of Surgeons
David Markenson, MD
 National Association of EMS Physicians

SECTION LIAISONS
Joseph P. Cravero, MD
 Section on Anesthesiology
M. Douglas Baker, MD
 Section on Emergency Medicine
Michele Moss, MD
 Section on Critical Care
Dennis W. Vane, MD
 Section on Surgery

	FOOTNOTES

The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

	ABBREVIATIONS

ED, emergency department; AAP, American Academy of Pediatrics; EMSC, Emergency Medical Services for Children; MCHB, Maternal and Child Health Bureau; NHTSA, National Highway Traffic Safety Administration.

	REFERENCES

Top Abstract Article References

1. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine Access to emergency medical care. Pediatrics. 1992; 90:648 [Abstract/Free Full Text]
2. American Academy of Pediatrics and American Heart Association Subcommittee on Pediatric Resuscitation. Chameides L, Hazinski MF, eds. Pediatric Advanced Life Support. Dallas, TX: American Heart Association; 1997
3. American Heart Association. Pediatric Basic Life Support. Dallas, TX: American Heart Association; 1997
4. Strange GR, ed. APLS: The Pediatric Emergency Medicine Course. Elk Grove Village, IL/Dallas, TX: American Academy of Pediatrics/American College of Emergency Physicians; 1998
5. Bloom RS, Cropley C. Textbook of Neonatal Resuscitation. Elk Grove Village, IL: American Academy of Pediatrics/American Heart Association; 1994
6. US Department of Transportation, National Highway Traffic Safety Administration. Module 6, Lesson 6.1. In: Paramedic: National Standard Curriculum. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration; 1997
7. Foltin G, Tunik M, Cooper A, et al. Teaching Resources for Instructors of Prehospital Pediatrics. New York, NY: Center for Pediatric Emergency Medicine; 1998
8. Dieckmann R, Brownstein D, Gausche M. Pediatric Education for Paramedics. San Francisco, CA: National PEP Task Force; 1997
9. Institute of Medicine, Committee on Pediatric Emergency Medical Services. Durch JS, Lohr KN, eds. Institute of Medicine. Emergency Medical Services for Children. Washington, DC: National Academy Press; 1993
10. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine Guidelines for pediatric emergency care facilities. Pediatrics. 1995; 96:526-537 [Abstract/Free Full Text]
11. American Academy of Pediatrics, Task Force on Interhospital Transport. Guidelines for Air and Ground Transport of Neonatal and Pediatric Patients. Elk Grove Village, IL: American Academy of Pediatrics; 1999
12. American Academy of Pediatrics, Committee on Pediatric Medicine. Childhood Emergencies in the Office, Hospital, and Community: Organizing Systems of Care. Elk Grove Village, IL: American Academy of Pediatrics; 1992
13. American Academy of Pediatrics. Pediatric Emergency Medical Services Act [Model Legislation]. Elk Grove Village, IL: American Academy of Pediatrics; 1994