Organization Online resource Air Medical Physician Association American Academy of Pediatrics http://www.ampa.org American College of Emergency Physicians American Heart Association American Trauma Society Association of Air Medical Services Commission on Accreditation of Medical Transport Systems EMSC Federal Interagency Committee on EMS http://www.acep.org Language Line National Association of Emergency Medical Physicians National Association of Emergency Medical Technicians National Association of State EMS Officials National EMS Advisory Council National Highway http://www.languageline.com http://www.naemsp.org http://www.aap.org http://www.heart.org/HEARTORG/ http://www.amtrauma.org http://www.aams.org http://www.camts.org http://www.emscnrc.org/ http://www.ems.gov/FICEMS.html http://www.naemt.org http://www.nasemso.org http://www.ems.gov/nemsac.html http://www.nhtsa.gov Traffic Safety Administration National Registry http://www.nremt.org of Emergency Medical Technicians Pediatric http://www.heart.org/HEARTORG/CPRAndECC/HealthcareProviders/Pediatrics/PediatricAdvanced Life Advanced-Life-Support-PALS_UCM_303705_Article.jsp Support (PALS) Pediatric Trauma http://www.pediatrictraumasociety.org Society The reports stated that the federal government should support the development of national standards for emergency care performance measurement, the categorization of all emergency care facilities, and protocols for the treatment, triage, and transport of prehospital patients, with emphasis on using evidence-based practices NHTSA has supported the development of evidence-based guidelines (EBGs) for prehospital care, discussed further in a later section of this chapter A gap analysis of EMS-related research was completed after the recommendation of the IOM reports The EMSC program supported pediatric regionalization by providing grants to six states to fund regionalization demonstration programs in 2012 To address standardization in EMT competency, the report recommended that all states adopt a common scope of practice for EMS personnel The EMS Scope of Practice Model and Education Standards maintained by the DOT were discussed in detail earlier in this chapter Medical direction standardization has been addressed by the recognition of an EMS physician subspecialty Specifically addressing pediatric emergency care, the report stated “If there is one word to describe pediatric emergency care in 2006, it is uneven ” More details of the recommendations specific to pediatrics are listed here: The emergency care workforce should receive pediatric knowledge and skills training Pediatric competencies should be defined; EMS providers should be required to maintain those competencies Each EMS provider organization should have a pediatric emergency care coordinator Pediatric priorities in emergency preparedness should be enhanced The evidence base for pediatric emergency care should be supported Family-centered care should be fostered An evidence-based approach should be used to improve pediatric patient safety While many of the 2006 IOM recommendations have not been realized, significant strides have been made The EMS Agenda 2050, developed in 2018, and available at http://emsagenda2050.org , continues to strive toward the vision of a people-centered EMS system that is equitable, efficient, and evidence based EMS RESEARCH It is challenging to perform quality clinical research in the EMS system There are few large-scale, randomized clinical studies that have been undertaken in the pediatric EMS population The uncontrolled environment and the urgency of injury and illness treatment often make quality data collection and informed consent more complicated than in the ED setting Additional barriers include monitoring adherence to study protocols, providing ethical research training to EMS personnel, randomizing patients to treatment groups, and measuring patient outcome data that occur once patient care has been transitioned to a hospital In addition, a significant amount of funding, which has been lacking, is required to overcome these barriers Even with well-designed research, it may be difficult to generalize the findings outside the study population and locale due to the high level of variability within EMS systems across the United States No two systems are designed to operate in exactly the same way with regard to staffing, protocols, oversight, demographics, or training This further emphasizes the large amount of funding required to complete multicentered research that will be required to obtain sufficient sample sizes and make results generalizable TABLE 134.7 PECARN PRIORITIES FOR PEDIATRIC PREHOSPITAL RESEARCH Clinical topics System topics Rank Topic Rank Topic Airway management Respiratory distress Trauma Asthma Head trauma Effectiveness of out-of-hospital interventions Knowledge and skill deterioration Patient outcomes Evaluation of the impact of overall EMS system changes on children 10 11 Shock Pain Seizures Respiratory arrest C-spine immobilization Cardiac arrest Training effectiveness 12 13 Injury prevention Children with special healthcare needs Poisoning Abuse and neglect 14 15 Successful EMS researchers have noted the large investment in relationship building that is necessary between the research team and administrators at EMS agencies and receiving facilities Other recommendations include soliciting prehospital provider input during the planning phase, demonstrating to agencies and providers the benefits of participating in the study, and providing education regarding research and human studies to the agencies Providing results of data collected in the field back to the EMS providers and media recognition of the EMS agency’s research participation are also means for building strong research relationships with EMS systems The paucity of scientific scrutiny of EMS highlights the need for future research focusing on both EMS and EMSC The establishments of the federal EMSC program under the U.S Department of Health and Human Services, as well as the federally funded EMS for Children Innovation and Improvement Center, were important steps to assist EMS academicians in defining a research agenda around EMSC The PECARN has established a research node made entirely of EMS agency research sites, as well as added EMS affiliates to each of the other six research nodes These efforts assist in performing needed research, as well as providing avenues for funding these projects As the discipline evolves, EMS leaders should resist the temptation to quickly add or require new technologies, procedures, and protocols to prehospital care without ensuring that these modalities have proven efficacy There is a real concern that in an effort to aid one patient, others will suffer from unnecessary intervention or inappropriate allocation or utilization of resources Research agendas have been proposed and priorities have been addressed by consensus groups, including the IOM reports, the National EMS Research Agenda, the EMS Outcomes Project, Knowledge Translation in the EMS, the EMS Subcommittee of the Society of Academic Emergency Medicine, and a priority list from PECARN ( Table 134.7 ) A recent gap analysis prepared for FICEMS noted that the literature in the prehospital setting is less rigorous than in other medical disciplines and that many prehospital interventions lack scientific evidence, having been extrapolated from the adult hospital emergency care environment Authors of this analysis also reported that the majority of research agendas have been unmet, with specific deficiencies noted in pediatrics, trauma, patient safety and quality, and education and competency assessment The analysis serves to inform decisions regarding policy and funding priorities, while also guiding the EMS researcher toward topics in need of attention EVIDENCE-BASED GUIDELINES NHTSA responded to the IOM report recommendation to “convene a panel … to develop evidence-based model prehospital care protocols for the treatment, triage, and transport of patients, including children.” In 2008, the first National EMS EBGs conference was attended by EMS stakeholders and experts in EMS, research, and EBGs With funding from NHTSA and EMSC, a model process for the development, implementation, and evaluation of EMS EBGs was drafted and subsequently implemented Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process, a rigorous, validated appraisal tool to assess quality of evidence, multidisciplinary teams embarked on creating several prehospital EBGs In 2014, a description of the process and three EBGs were published in Prehospital Emergency Care: prehospital seizure management, prehospital analgesia in trauma, and air medical transportation of prehospital trauma patients NHTSA and EMSC have offered further funding to the NASEMSO as well as a targeted issue grant to evaluate EMS system utilization of EBGs Due to the labor-intensive nature of the process and the relative paucity of strong evidence for many prehospital practices, EBGs for all conditions treated by prehospital providers may not be available for some time Additional efforts to promote uniformity and quality of prehospital care include the development of Model EMS Clinical Guidelines, made public in 2014 (https://nasemso.org/projects/model-emsclinical-guidelines/ ) While these guidelines not use the same rigorous GRADE methodology, they were developed by multidisciplinary teams of EMS experts and reviewed by multiple EMS stakeholders They are based on the most current standards of practice and evidence They are available to EMS systems for adoption and customization to address specific needs SUMMARY U.S EMS systems were initially developed to primarily treat adults with cardiovascular disease and injuries from motor vehicle crashes; however, many advances have been made, and the prehospital needs of children are being recognized and addressed through the leadership of the EMSC program and its strong relationship with NHTSA EMS systems are variable without a federal lead agency for prehospital care, but the FICEMS aims to coordinate funding and regulations across three federal agencies National education and scope of practice standards exist for four levels of EMS provider EMS systems function well with strong medical direction, and the appointment of a pediatric coordinator within each system will ensure the best care for children in the prehospital setting EBGs represent a significant step toward improving quality of prehospital care through standardization and are a tangible response to the IOM reports on emergency care in the United States Suggested Readings and Key References EMS Epidemiology Carlson JN, Gannon E, Mann NC, et al Pediatric out-of-hospital critical procedures in the United States Pediatr Crit Care Med 2015;16(8):e260–e267 Federal Interagency Committee on EMS 2011 National EMS Assessment (Report No DOT HS 811 723) Washington, DC: National Highway Traffic Safety Administration; 2012 Available online at http://www.ems.gov/mwg-internal/de5fs23hu73ds/progress? id=vpdL22iKszd4DxK9BgzOzv1k_I_3XclTyLOFol Accessed August 10, 2015 Hansen M, Lambert W, Guise JM, et al Out-of-hospital pediatric airway management in the United States Resuscitation 2015;90:104–110 Shah MN, Cushman JT, Davis CO, et al The epidemiology of emergency medical services use by children: an analysis of the National Hospital Ambulatory Medical Care Survey Prehosp Emerg Care 2008;12(3):269–276 Suruda A, Vernon DD, Reading J Pre-hospital emergency medical services: a population based study of pediatric utilization Inj Prev 1999;5(4):294–297 EMS Providers National Association of State EMS Officials National EMS Scope of Practice Model 2019 (Report No DOT HS 812-666) Washington, DC: National Highway Traffic Safety Administration Available online at https://www.ems.gov/pdf/National_EMS_Scope_of_Practice_Model_2019.pdf Accessed March, 2020 ... provider organization should have a pediatric emergency care coordinator Pediatric priorities in emergency preparedness should be enhanced The evidence base for pediatric emergency care should be supported... addressing pediatric emergency care, the report stated “If there is one word to describe pediatric emergency care in 2006, it is uneven ” More details of the recommendations specific to pediatrics... National Registry http://www.nremt.org of Emergency Medical Technicians Pediatric http://www.heart.org/HEARTORG/CPRAndECC/HealthcareProviders/Pediatrics/PediatricAdvanced Life Advanced-Life-Support-PALS_UCM_303705_Article.jsp