Staff Training and Continuing Education

It is a reasonable expectation that all office staff, including receptionists and medical assistants, be trained in cardiopulmonary resuscitation (CPR) and that their certification be maintained on an annual basis. Nurses and physicians should also have training in a systematic approach to pediatric resuscitation. Core knowledge may be obtained through standardized courses in advanced life support (ALS) offered by national medical associations and professional organizations. Frequent recertification is important for knowledge retention and skill maintenance. Examples are the Pediatric Advanced Life Support (PALS) and Pediatric Emergency Assessment, Recognition and Stabilization (PEARS) courses sponsored by the American Heart Association, the Advanced Pediatric Life Support (APLS) course sponsored by the American Academy of Pediatrics (AAP) and the American College of Emergency Physicians (ACEP), and the Emergency Nurses Pediatric Course (ENPC) sponsored by the Emergency Nurses Association (ENA).

Pediatric Prehospital Care

Prehospital care refers to emergency assistance rendered by trained emergency medical personnel before a child reaches a treating medical facility. The goals of prehospital care are to further minimize systemic insult or injury through a series of well-defined and appropriate interventions and to embrace principles that ensure patient safety. Most communities in the USA have a formalized EMS system; the organizational structure and nature of emergency medical response depend greatly on local demographics and population base. EMS may be provided by volunteers or career professionals working in a fire-based or independent “third service” response system. Key points to recognize in negotiation of the juncture between the community physician and the local EMS system include access to the system, provider capability, and destination determination.

Destination Determination

The destination to which a pediatric patient is transported may be defined by parental preference, provider preference, or jurisdictional protocol, which is typically predicated on field assessment of anatomic and physiologic criteria and, in the case of trauma, mechanism of injury. In communities served by an organized trauma or regionalized EMS system that incorporates pediatric designation based on objectively verified hospital capabilities, seriously ill or injured children may be triaged by protocol to the highest-level center reachable within a reasonable amount of time. The mantra is to deliver the child to the “right care in the right time,” even if it requires bypassing closer hospitals. An exception is the child in full arrest, for whom expeditious transport to the nearest facility is always warranted. Regionalization in the context of EMS is defined as a geographically organized system of services that ensures access to care at a level appropriate to patient needs while maintaining efficient use of available resources. This system concept is especially germane in the care of children, given the relative scarcity of facilities capable of managing the full range and scope of pediatric conditions (Fig. 61-2). Regionalized systems of care coordinated with emergency medical dispatch, field triage, and EMS transport have demonstrated efficacy in improving outcomes for pediatric trauma patients, especially for younger children and children with isolated head injury. Emerging evidence also suggests a similar benefit conferred to children in shock identified in the field who are preferentially transported to hospital EDs with documented pediatric ALS capability. The existence of statewide or regional standardized systems that formally recognize hospitals able to stabilize and/or manage pediatric medical emergencies is another federal EMSC performance measure against which operational capacity to provide optimal pediatric emergency care in this country is currently being judged.

Figure 61-2 Transport options within a coordinated, regionalized emergency medical services system model. The objective is to ensure access to definitive care at a level appropriate to meet patient needs. Solid arrows, primary transport; dotted arrows, interfacility transport.

(Adapted from Institute of Medicine, Committee on the Future of Emergency Care in the US Health System: Hospital-based emergency care: at the breaking point, Washington, DC, 2006, National Academies Press.)

In communities that do not have a hospital with the equipment and personnel resources to provide definitive pediatric inpatient care, interfacility transport of a child to a regional center should be undertaken after initial stabilization (Chapter 61.1). When interfacility transport is to be undertaken, indications for transfer, parental consent for transfer, and acceptance of the patient by the receiving physician must all be clearly documented in the medical record.

The Emergency Department

The ability of hospital EDs to respond to the emergency care of children varies and depends on a number of factors in addition to availability of equipment and supplies. Training, awareness, and experience of the staff as well as access to pediatricians and medical and surgical subspecialists also play a key role. The majority of children who require emergency care are evaluated in community hospitals by physicians, nurses, and other health care providers with variable degrees of pediatric training and experience. Although children account for 25-30% of all ED visits, only a fraction of these encounters represent true emergencies. Because the volume of critical pediatric cases is low, emergency physicians and nurses working in community hospitals often have limited opportunity to reinforce their knowledge and skills in the assessment of ill or injured children and in pediatric resuscitation. General pediatricians from the community may be consulted when a seriously ill or injured child presents to the ED, and they should have a structured approach to the initial evaluation and treatment of an unstable child of any age, regardless of the underlying diagnosis. Early recognition of life-threatening abnormalities in oxygenation, ventilation, perfusion, and central nervous system function and rapid intervention to correct those abnormalities are key to successful resuscitation and stabilization of the pediatric patient.

In its 2006 report The Future of Emergency Care in the U.S. Health System, the IOM strongly recommended that hospitals and EMS systems appoint qualified coordinators for pediatric emergency care, a recommendation consistent with pediatric emergency readiness guidelines advocated by the AAP and ACEP. Only 18% of EDs in the USA currently appoint a physician coordinator, and 12% appoint a nursing coordinator for pediatric emergency care. EDs that do appoint these positions tend to be more prepared as measured by compliance with nationally published guidelines on the care of children in the ED.

Minimum standards must be met by community EDs to ensure that children receive the best emergency care possible. Updated guidelines for the care of children in the ED have been published and are endorsed by the AAP, the ACEP, and the ENA. These guidelines provide current information on policies, procedures, protocols, quality assurance methods, and equipment and supplies considered essential for managing pediatric emergencies. Specific recommendations on equipment, supplies, and medications for the ED are listed and updates are available on the AAP website. Sample policies, procedures, and protocols specifically addressing the needs of children in the ED are listed in Table 61-2.

The way in which the family supports the child during a crisis and, consequently, how the family is supported in the ED when caring for the child are critical to patient recovery, family satisfaction, and the mitigation of post-traumatic stress. Commitment to patient and family–centered care in the ED ensures that the patient and family experience guides the practice of culturally sensitive care and promotes patient dignity, comfort, and autonomy. In the ED setting, particular issues such as family presence deserve specific attention. Surveys of parents have indicated that most want to be with their child during invasive procedures and even during resuscitation. Allowing their presence has been shown to reduce parental and patient anxiety and does not interfere with procedure performance. Patient and family–centered care is also associated with improved care quality and patient safety.

Emerging Issues in EMSC

Of the pediatric-specific recommendations promulgated by the IOM in its widely publicized 2006 report on the future of emergency care, 3 have emerged as especially important moving forward for EMSC. The first has to do directly with increased federal funding for the EMSC program, which supports more than 70 grantees with an established presence in all 50 states, 5 U.S. territories, and the District of Columbia. The grant awards cover 4 distinct categories ranging from basic science and clinical investigation to public sector capacity-building programs to national technical assistance centers to multicenter trials conducted within a large research network. Through the diversity of activity generated within the program, and in collaboration with stakeholders, the EMSC program affords synergistic opportunity to further the progress realized in the program’s first 25 years. Congressional reauthorization in 2009 of the EMSC authorizing legislation, the Wakefield Act, ensures program stability in the near term.

In addition to EMSC resource support, the IOM also recommended that (1) federal agencies in partnership with state and regional planning bodies and emergency care provider organizations convene a panel with multidisciplinary expertise to develop strategies for addressing pediatric needs in the event of a disaster and (2) the U.S. Department of Health and Human Services conduct a study to examine the gaps and opportunities in emergency care research, including pediatric emergency care, and recommend a strategy for the optimal organization and funding of the research effort. Both of these recommendations have generated activity of significant import to the emergency care community, EMSC specifically, and warrant mention.

Advocacy for EMSC

By definition the scope of EMSC has both breadth and depth. EMSC encompasses service delivery along a continuum that links distinct clinical settings, involves professionals from multiple disciplines, and cares for children from preterm infancy to young adulthood. EMSC also embraces the fundamental tenants of pediatric medicine, including an emphasis on prevention, attention to the phenomenon of growth and development, and the incorporation of the principles of patient and family–centered care at every encounter. Yet, in order to be effective and valued, programmatically, EMSC must focus on the generation of quantifiable indicators and performance against benchmarked, population-based measures. Accommodating such broad accountability involves attention to process, collaboration, and the need for advocacy. Advocacy in support of core EMSC issues can take on many forms; for example, legislative advocacy with elected officials for continued budgetary support of the federal program, regulatory advocacy with policy-makers on the role of EMSC in at state and local levels, community advocacy with end users such as children, families, and PCPs, and institutional advocacy to encourage hospitals to incorporate the elements that make a difference in the care of children.

Communications and Dispatch Center

Communications are one of the most vital components of a regional transport system. Treating a critically ill or injured child is an uncommon event for most community physicians. Therefore, they need to know whom, how, and when to call for assistance in the stabilization and transfer of a pediatric patient. The communications and dispatch center provides a single telephone number for such calls.

The communications and dispatch center coordinates communications among the outlying facility, receiving unit, medical control physician, transport team, and others. This center may be part of a hospital unit (e.g., ED, PICU), self-contained in a single institution (e.g., Emergency Communications and Information Center), or based off-site as a freestanding center coordinating communications and dispatch for multiple transport programs.

Staffing varies depending on the type of center. On-duty nurses or physicians may receive calls at unit-based models with low volumes. In contrast, dedicated communications specialists usually staff self-contained or freestanding centers, which tend to be busier. The communications specialist has numerous responsibilities, including answering the referring physician’s call promptly; documenting essential patient demographic information; arranging for immediate consultation with the medical control physician; dispatching the transport team to the referring facility expeditiously; updating the referring facility with any changes in the arrival time; and coordinating medical control and other necessary transport-related calls. The transport team must be equipped with a cellular telephone or radio for immediate contact with the receiving and referring facilities.

Medical Control Physician

The MCP is involved in the clinical care and safe transport of the patient from the time of referral through arrival at the receiving hospital unit. The MCP’s oversight increases once the transport team arrives at the referring facility. The MCP should have expertise in pediatric critical care or pediatric emergency medicine (or sometimes neonatology). Besides having the knowledge required to stabilize a critically ill or injured child, the MCP must be familiar with the transport environment; the transport team members’ capabilities; the program’s policies and procedures; and the region’s geography, medical resources, and regulations regarding interhospital transport. The MCP must possess good interpersonal and communication skills and must be able to maintain collegiality with the referring hospital’s staff during a potentially difficult and stressful situation.

Once a transport call is received, the MCP must be immediately available to confer with the referring physician. Although the MCP may have other responsibilities, these transport responsibilities take priority in order to avoid undue delays when transferring a critically ill child. Often the MCP recommends further testing or therapeutic interventions that can be delivered by the referring hospital before the transport team arrives. The MCP may seek additional guidance from other specialists, as necessary. Because the child’s condition may change rapidly, the MCP must remain ready to give additional advice. All conversations and recommendations regarding the care of the patient should be documented. Some centers record these conversations.

After discussion with the referring physician—and, when warranted, with the transport staff—the MCP determines the best team composition and vehicle for transport. The MCP usually does not accompany the team but remains available, by phone or radio, to supervise care.

It is worth noting that the MCP assumes significant responsibility for a patient whom the MCP has never personally evaluated. Telemedicine may obviate this shortcoming and may even change transport medicine as telecommunications systems evolve.

Transport Team

Transport team composition varies among programs—and sometimes within an individual program. The team’s composition is based on a variety of factors, including the severity of the child’s illness or injury; the distance to the referring facility; the team members’ advanced practice abilities; the referrer’s (reasonable or unreasonable) insistence that a physician be present; the program’s historical professional makeup; and the region’s staffing regulations. The team should be composed of physicians, nurses, respiratory therapists, and/or paramedics who have experience in pediatric critical care or pediatric emergency medicine (or neonatology in some cases) as well as advanced education and training in those cognitive and procedural areas important for pediatric critical care transport. There is a lower incidence of transport-related morbidity for critically ill and injured children transported by pediatric specialty teams than for those transported by generalist teams.

Various scoring systems have been developed to predict the need for a physician during transport. It seems that a team member’s training, experience, and skill in treating critically ill patients are more important considerations than that team member’s professional degree. Team members must understand basic pediatric pathophysiology and collectively must be able to assess and monitor a critically ill or injured child; manage the airway and provide respiratory support; obtain vascular access; and administer those medications commonly used in pediatric critical care transport. They must be familiar with the physiologic alterations as well as practical difficulties of the transport environment and, importantly, must be comfortable working in an out-of-hospital setting. Physicians are less often deployed on transport teams in part because of the advanced training that other health care professionals on the transport team receive.

The transport team should have a designated team leader who, in addition to the team leader’s many other responsibilities, interacts with the MCP during the transport. Once the team arrives at the referring facility, the team should reassess the child’s condition, review all of the pertinent diagnostic studies and therapies, and discuss the situation with the referring staff and parents. If the patient’s condition has changed significantly, the team leader may need to contact the MCP for additional advice. Otherwise, the team leader should notify the MCP before starting to bring the child to the receiving facility. Any care delivered by the team during transport should be documented, and copies of all medical records—including laboratory data, radiographs, and scans—should accompany the child to the pediatric center. The receiving unit must be updated prior to arrival so it can finalize preparations for the patient.

Ground versus Air Ambulance

Transport options include ground, rotorcraft, and fixed-wing ambulances. Vehicle selection depends on the child’s emergency needs; transport team’s capabilities; any out-of-ordinary staffing or equipment requirements (e.g., for extracorporeal membrane oxygenation, inhaled nitric oxide or helium); referring facility’s abilities; distance; terrain; traffic patterns; ground or air ambulance availability; helicopter landing pad or airport access; weather conditions; and expense.

The transport vehicle must be equipped with electrical power, oxygen, and suction and must have sufficient space for the equipment and supplies that the team brings along—stretcher or isolette, monitor, ventilator, oxygen tank(s), medication pack(s), infusion pumps, and more. Compared with helicopters, ambulances are more spacious and able to carry more weight, so they can accommodate larger teams and more equipment. Another advantage of ground ambulance transport is the ability to stop en route if the patient’s condition deteriorates; this feature greatly facilitates the performance of certain interventions, such as intubation.

An airplane may be able to fly to an area when distance (>150 miles), altitude, or weather precludes helicopter use. The use of an airplane necessitates several ambulance transfers.

Transport Physiology

When possible, the transport team tries to provide the same care during transport as the patient would receive in the specialty center. This can be difficult, though, because of limitations in personnel, equipment, and space as well as other environmental challenges.

The team and child are subjected to variable intensities of background noise and vibration while traveling in the vehicle cabin. Noise can impair the team’s ability to auscultate breath sounds, heart sounds, and blood pressure, another reason for monitoring vital signs mechanically and relying on other assessment modalities, such as the level of mentation, skin color, and capillary refill. To mitigate noise, the helicopter crew and patient should wear helmets or headphones (or another wearable noise attenuator such as MiniMuffs [Natus Medical Incorporated, San Carlos, CA]. Motion and vibration can lead to increased metabolic rate, shortness of breath, and fatigue in the patient, as well as motion sickness in the patient and staff.

On fixed- or certain rotary-wing transports, the patient may suffer adverse physiologic effects from altitude. With increasing altitude, the barometric (atmospheric) pressure decreases and gases expand. As the barometric pressure drops and gas expands, the partial pressures of ambient oxygen (PO₂) and, consequently, arterial oxygen (PAO₂) decrease. For example, at 8,000 feet—an elevation at which unpressurized airplanes may fly, as well as the effective cabin altitude for many pressurized airplanes flying at 35,000 to 40,000 feet—the barometric pressure, PO₂, PAO₂, and arterial oxygen saturation fall to 565 mm Hg, 118 mm Hg, 61 mm Hg, and 93%, respectively. (In comparison, the barometric pressure, PO₂, PAO₂, and arterial oxygen saturation are 760 mm Hg, 159 mm Hg, 95 mm Hg, and 100% at sea level.) Although healthy individuals usually tolerate these changes well, patients with respiratory insufficiency, significant blood loss, or shock may decompensate and should receive supplemental oxygen.

Gases expand 10-15% at the few thousand feet at which helicopters typically fly, and approximately 30% at 8,000 feet. Gases within the body itself also expand as the altitude increases. Gas expansion must be appreciated during transport via air of a patient with a pneumocephalus, pneumothorax, bowel obstruction, or another condition involving entrapped gas. Prior to transport, a pneumothorax should be decompressed, and a nasogastric tube inserted for ileus.

Safety

Safety is of paramount importance and mandates constant vigilance by everyone involved. Accident rates for pediatric air and ground transport are estimated at approximately 1/1,000 transports. The team should routinely attend pilot briefs, as well as perform safety inspections of the vehicles and equipment, aided by checklists. When in doubt, the MCP should solicit input from the staff about whether to transport via air or ground ambulance or to employ lights and sirens, decisions that cannot be taken lightly. The pilot’s or driver’s judgment as to the safety of proceeding during inclement weather or with a mechanical problem must not be overruled.

Organizations, such as the FAA and the National Transportation Safety Board, play a role in ensuring safe interfacility transport. The Commission on Accreditation of Medical Transport Systems (CAMTS) is an independent, peer review organization established in 1990 in response to the number of air medical accidents in the 1980s. CAMTS, through voluntary participation, audits and accredits fixed-wing, rotary-wing, and ground interfacility medical transport services.

Family-Centered Care

Family-centered care represents a philosophy that respects the important role that family members play in a child’s care. It recognizes family members and health care providers as partners in caring for the child. Family presence during transport is beneficial because it provides support to children in stressful situations and assists health care providers in delivering care to patients with complex and/or chronic medical problems.

As care is transitioned from the referring hospital, it is the transport team’s responsibility to maintain family-centered care. The team meets with family members to explain the transport process, obtain consent, and discuss anticipated management. When possible, the transport team should attempt to accommodate a family member’s presence on-board. However, the family member and child may need to be separated when the child is critically ill and rapid transport is essential, or if there are space or weight limitations in the air or ground ambulance. In these situations, it is important that family members have a clear understanding of how the child will be cared for during the separation.

Referring Hospital Responsibilities

Transfer of a patient to another facility requires written documentation by the referring physician of the need and reasons for transfer, including a statement that the risks and benefits as well as any alternatives have been discussed with the parents. The parent’s informed consent to the transfer should be obtained.

Federal law under the Emergency Medical Treatment and Active Labor Act (EMTALA), part of the Consolidated Omnibus Budget Reconciliation Act (COBRA), imposes specific requirements that a patient presenting to an ED be given a medical screening examination without regard to ability to pay. If upon examination an emergency medical condition is found, the hospital is required to stabilize the patient or to transfer the patient to another facility if unable to stabilize the patient or if requested by the patient. The primary requirement is that the referring physician must certify that the medical risks of transfer are outweighed by its potential benefits. The receiving hospital must agree to accept the patient and have the space and staff to provide the necessary treatment. The transferring hospital is responsible for arranging for the transfer and ensuring that it is performed by qualified medical personnel with appropriate equipment. It must send copies of the patient’s medical records and test results, even those that become available after the transfer is complete.

Some referring hospitals have entered into transfer agreements with specialty centers in the interests of facilitating the smooth and safe transfer of the pediatric patient. Having prepared forms for all of the above purposes also aids in the transfer process.

Educational Outreach

Besides safe and rapid transport, regional pediatric transport programs (and their specialty centers) have an obligation to provide educational opportunities to community health care providers so that these providers can acquire the necessary skills to evaluate and stabilize a critically ill or injured child until the transport team arrives. These learning activities may include transport case reviews; lectures on pediatric acute care topics; resuscitation programs such as the PALS course, APLS course, and S.T.A.B.L.E. (sugar and safe care, temperature, airway, blood pressure, lab work, emotional support) program; and rotations through the specialty center’s pediatric ED and PICU. These activities also help cement relationships with the referring facility’s staff.

Outcome Measures in Emergency Medical Services for Children

Improving the quality of pediatric emergency care requires measurement. Emergency Care for Children: Growing Pains, one report of the 2007 IOM series on the future of emergency care, recommends that pediatric emergency medical systems specifically support the development of national standards for emergency care performance measurement. The Donabedian structure-process-outcome model has set the framework for most contemporary quality measurement and improvement activities. Structural elements provide indirect quality-of-care measures related to a physical setting and resources. Process indicators provide a measure of the quality of care and services by evaluating the method or process by which care is delivered, including both technical and interpersonal components. Outcome elements describe valued results related to lengthening life, relieving pain, reducing disabilities, and satisfying the consumer.

Defining relevant outcomes for pediatric emergency care is difficult. Process measures are abundant and typically focus on a particular condition or chief complaint. Yet defining outcomes pertinent to all pediatric emergency patients is critical to improve and transform emergency care delivery to children. A true “outcome based” approach describes observable measures such as mortality, risk of organ system failure, and disability. Although extremely important, such outcomes are quite rare, and it is often difficult to extricate the contribution of a brief ED encounter from what has taken place in the overall health care system in measuring these outcomes. An alternative approach is a “resource based” outcome measure definition related to the level of care required. Children who are more ill, in general, require more resources. Thus, resource use across groups of patients reflects relative severity of illness in the groups. Given the episodic and brief nature of emergency care, as well as the continuing trends of increasing ED volumes and overcrowding that make it increasingly important to provide each and every ED patient with timely and necessary resources, adopting a “resource based” approach to outcome measures in EMSC is sensible. Examples of resource based outcomes include need for hospital admission (ED disposition), ED length of stay, costs, and diagnostic and therapeutic interventions performed in the ED.

Risk Adjustment

Measuring outcomes offers opportunities for EDs and other components of the health care system to make effective improvements over time, benchmark, and compare their end results with those of other institutions. Meaningful comparisons between EDs or within an ED over time generally require risk adjustment, which accounts for patient-related attributes such as age, or for pre-existing conditions associated with the outcome of interest. Risk-adjustment “levels the playing field,” so that comparison of outcomes is as fair and meaningful as possible. Because children present to EDs with illnesses of varying acuity, ranging from rashes and colds to cardiac arrest, there is an inextricable linkage of severity to outcomes. Severity typifies the concept of “risk”—the higher the severity, the higher the risk of a given outcome. Without risk adjustment, EDs with sicker patients may appear to have worse outcomes.

A large number of instruments have been developed to adjust for severity or risk in clinical research and quality improvement activities. Two severity indices were developed for patients in intensive care units: the APACHE (Acute Physiology And Chronic Health Evaluation) system for adults and the PRISM (Pediatric Risk of Mortality) score for pediatric patients. These indices are not well-suited for EMSC, given the extremely low rate of mortality. Several disease-specific acuity scoring systems are available for use in EMSC. The majority of these are intended for use in trauma patients, including the Injury Severity Score, Trauma Score, and Pediatric Trauma Score. Others are available for asthma, croup, and febrile young children. These measures cannot be applied broadly to all pediatric emergency patients.

Risk Adjustment Tools in EMSC

The choice of a risk-adjustment tool depends on several factors, including the population under study, the setting, and the outcomes of interest. Two risk-adjustment tools have been developed specifically for pediatric emergency medicine, the second-generation Pediatric Risk of Admission (PRISA II) score and the Revised Pediatric Emergency Assessment Tool (RePEAT).

EMSC and the Continuum of Care Model

Emergency Medical Services for Children is a U.S. federal initiative designed to reduce child and youth disability and death due to severe illness or injury. The EMSC program has developed an operational framework for conceptualizing a systems approach to emergency care for children, known as the continuum of care model. The model specifically refers to the seamless care of ill and injured children from the community and medical home through to definitive care and return to the community. It has the following 5 principal components:

This framework can also be applied to discussion of emergency care for children on an international level. With medical infrastructures that may not be consistent or well organized, or that have been weakened by civil strife, natural disasters, and economic loss, the focus of child health in the developing world has been on prevention and acute care.

Applying the Continuum of Care Model to the Developing World

Humanitarian Disasters

Children are a vulnerable population who experience disproportionate suffering during humanitarian emergencies, either natural (earthquakes, tsunamis, hurricanes, floods, and droughts) or manmade (armed conflicts, terrorist attacks). The under–5 yr population is especially susceptible to infectious diseases, malnutrition, and trauma following disasters. The Rainbow Center for Global Child Health at the Case Western Reserve University School of Medicine offers a training course, Management of Humanitarian Emergencies: Focus on Children and Families, that concentrates on the needs of children in disasters. The intent of the Center is to educate and train health professionals, relief workers, and policymakers to recognize and address the unique needs of children affected by manmade and natural disasters worldwide. The AAP also maintains a CHILDisaster Network, which acts as an electronic database of child health professionals with education and experience in humanitarian emergencies. Nongovernmental organizations can access the database to solicit practitioners to aid in disaster response.

The WHO’s Manual for the Health Care of Children in Humanitarian Emergencies is based on IMCI guidelines and addresses the emergency care of children in disaster situations in which hospital facilities and resources are not immediately available. It goes beyond the IMCI guidelines by discussing initial assessment and management of trauma, burns, and poisonings. Pre-existing IMCI guidelines assumed a functioning health system that facilitated the referral of children, which may not be available in all emergency situations. This manual also includes the initial management of severe conditions, such as injuries, burns, neonatal illness, and psychosocial problems, which are considered high priority in acute care settings.

Improvement in Quality of Care

In many locations, low-resource interventions are the easiest to provide and can often make large differences in the quality of care offered by any given practitioner or health care center. A long-term goal should be the establishment of ongoing quality assessment and critical incident monitoring. International PEM development should incorporate all stakeholders in the delivery of emergency care in a given catchment area. This effort may include consumers, public health and government officials, and health care officers and practitioners. One may also make use of relationships with local and foreign universities, professional organizations (see Table 61-5), and governmental and nongovernmental organizations.