Consensus Report for Regionalization of Services for Critically Ill or Injured Children

RATIONALE FOR REGIONALIZATION

Emergency medical systems have historically been oriented toward adult care. The assessment and management of critical illness and injury in pediatric patients requires specialized training and experience.^{8 ,9} In areas where specialized pediatric emergency and critical care are not available, the outcome of pediatric critical illness and injury is adversely affected.^{10 ,11}

The death rate for trauma in children is higher than that of adults with similar injuries, and the discrepancy is greatest in areas without pediatric centers.⁹ Many deaths can be prevented with optimal specialized pediatric care.¹⁰ Mortality of pediatric patients with respiratory failure or head injury is lower in hospitals that provide tertiary-level pediatric intensive care than in those that do not.¹¹ The difference in mortality increases as the severity of illness or injury increases.¹¹Furthermore, the presence of a pediatric critical care specialist supervising care leads to lower severity-adjusted mortality for illness and injury in pediatric intensive care units (PICUs).^{12 ,13} Similar benefits have been shown when regionalized systems have been developed to deal with groups of patients for whom specialized knowledge and skills are needed such as perinatal care,^{14 ,15} or specific problems such as trauma.¹⁶

In its report on Emergency Medical Services for Children,the Institute of Medicine emphasized¹⁷:“A fundamental position is that society has a special obligation to address the needs of children because they must depend on others for the protection of their health and safety and have no political voice of their own. EMSC must be recognized as a public responsibility; the “market' cannot be relied on to produce the kind of planning and cooperation required to make services available to all who need them.”

Additionally, the special resources for optimal care of critically ill or severely injured children are expensive and limited in availability. Regionalization promotes more efficient use and greater availability of such resources.¹⁸

THE EMSC SYSTEM

EMSC embodies a system that provides a continuum of care for the pediatric patient. The full spectrum of care includes programs for illness and injury prevention, initial problem identification, access to the system, prehospital care, hospital-based emergency care, inpatient and specialized pediatric critical care, and rehabilitative services appropriate for children. Individual patients may require one or many or all of these components.⁸Although individual features may vary as a function of local circumstances, the central theme of these guidelines is that asystem of care be developed for each region to ensure that all children receive the care they need. Such a system provides a degree of planning and coordination that transcends the scope of any single component. To achieve this effectively and efficiently, critical linkages must be formed between the separate components of EMSC to the larger EMS system and to the broader elements of child health care, including illness and injury prevention programs.¹⁷ Such linkages can only be ensured and maintained within a system designed for this purpose.

Important definitions pertaining to a system of care and its components of the critically ill or injured child include:

Categorization, the process of delineating the readiness and capability of a health care facility and its staff to provide care.

Accreditation, which requires that a health care facility apply for and receive approval from a certifying group to qualify as a provider of specified services. The process requirescommitment on the part of an accredited facility to maintain its capability for service.

Designation, a process in which facilities are identified as providers of a certain level of care within a specified geographic area. The process usually involves formal evaluation by state or local governmental bodies.

Regionalization, a process of organizing resources within a geographic region to ensure access to medical care of a level appropriate to a patient's needs, while maintaining efficient use of the available resources. Regionalization incorporates the following:

1. Categorization to delineate the resources available in the region;

2. Accreditation to verify the commitment to provide the needed services; and

3. Designation to ensure that the necessary range of services will be available without inefficient duplication of resources.

Because of the variable availability of and access to essential services in different locales, regionalization is anintegral feature of an EMSC system.

ELEMENTS OF A REGIONALIZED EMSC SYSTEM

The specific organization of a regionalized EMSC system will vary, but certain elements are essential. These include:

1. Coordination at the state and regional level to ensure that the responsibilities of the EMSC system are met;

2. Training, equipping, and supervising prehospital care providers; and

3. Participation of emergency care facilities, interhospital transport systems, and pediatric critical care referral facilities.

IMPLEMENTATION

Implementation of any regionalized system involves a complex medical environment that includes a variety of traditional and managed care systems. Implementation can be achieved through voluntary association of those involved, including prehospital care providers, hospitals, physician and nursing professional organizations, insurance companies, and health care professional organizations. EMSC should have broad public and professional support throughout the community. Fundamental to a regionalized EMSC system, however, is the principle that specialized pediatric emergency and critical care be available toall children in need, without regard to financial resources or insurance plans. This suggests that state governmental involvement is essential to ensure representation of the public interest, adequacy of resources, and compliance with the EMSC plan. Currently 8 states (California, Colorado, Hawaii, Louisiana, New Jersey, Oklahoma, Texas, and Virginia) have enacted legislation establishing comprehensive EMSC systems including regionalization in some form. Three other states have legislated specific aspects of EMSC (Florida, Ohio, and Utah). Similar legislation is under consideration in 4 additional states (Illinois, Oregon, Rhode Island, and South Carolina). It seems evident that local circumstances will dictate a variety of approaches, but that a legislative and/or administrative initiative is needed to facilitate regionalization of EMSC. It is the responsibility of those who care for children to take the initiative, mobilize public and professional support, and provide leadership in promoting the development of this regionalized system.

Pediatric Section, Society of Critical Care Medicine, American College of Critical Care Medicine

• William H. Perloff, MD, Co-chairperson

• Judith Brill, MD, Co-chairperson

• Alice Ackerman, MD

• Frank Briglia, MD

• Robert Dimand, MD

• Ricardo Flores, MD

• Bruce Friedman, MD

• Brahm Goldstein, MD

• David Hardy, MD

• Mark Huelitt, MD

• Lynn Lloyd, MD

• Robert Lloyd, MD

• Robert Lynch, MD

• Thomas Mays, MD

• John Mickell, MD

• Olga Mohan, MD

• Michelle Moss, MD

• Daniel Notterman, MD

• Kevin Ragosta, MD

• Charles Schleien, MD

• Kathryn Weise, MD

• Jean Wright, MD

• Timothy Yeh, MD

• Howard Zucker, MD

• 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

• David Heppel, MD

•  Maternal and Child Health Bureau

• 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

• 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