MCHB Conference Webcasts
2005 EMSC Annual Grantee Meeting
April 12-13, 2005
ART COOPER: Good afternoon, everyone. My name is Art Cooper. I'm the current chair of the American College of Surgeons Committee on Trauma Pediatric Surgery Specialty Group. I'd like to acknowledge two of our members who are present today; Mary Fallat, Trace Shere, both of whom play a very active role on the committee.
The committee is relatively new. It was formed really in 1998 or 1999 out of a recognition that the newly published Gold Book, the (inaudible) resource document, perhaps could have had stronger pediatric input. Fortunately, the current chair of the committee on trauma at that time, Dave Hoyt, recognized the need to form a pediatric surgery specialty group and that need has continued to be recognized by his successor, Wayne Meredith.
I'm pleased to report that the committee is extremely active. We have just finished working with the executive committee, Dr. Fallat is our representative on the executive committee. As chair of the Prehospital Emergency Services Subcommittee for the Committee on Trauma, we have recently revised the pediatric chapter in the Gold Book and that will be available with the entire revised Gold Book later this fall.
In collaboration with Norm McSwain and Jeff Salimone and the Prehospital Working Group, and, of course, an EMT, and Tommy Loyacono's folks, the PHTLS textbook chapter has been reviewed and revised.
Many of you are aware that the National Trauma Registry For Children Project had strong input from the college. I'll say more about that in a moment. There is a National Trauma Data Bank Pediatric Report about which I'll also say more in a moment. The Trauma Registry of the American College of Surgeons has a pediatric module that's awaiting finalization, as soon as the final report of the National Trauma Registry for Children data set becomes available. We're working on a comparison project between the current National Trauma Data Bank and the previous National Pediatric Trauma Registry, emphasizing the differences in those registries.
We're looking to combine the resources of the National Trauma Data Bank with the Verification Review Committee Database of the college. That's, of course, the committee that performs the American College of Surgeons Committee site evaluations of trauma centers and awards the designations as level one, two, three, or four centers.
We're working in collaboration with NAAMSP and several other organizations on determination of resuscitation paper. Again, Dr. Fallat is taking the lead on that. We're working together with the disaster committee, and Sue Breggs from Boston on a pediatric module for the new American College of Surgeons Committee on Trauma Disaster Program.
We have put together a paper on splenic injuries based upon the National Trauma Data Bank. We're developing linkages with many injury prevention programs. Pediatric trauma web page is being designed for the college. An acute care surgery proposal which will be surgery, sort of answer to emergency medicine. Surgeons are considering developing a subspecialty of acute care surgery. In effect, emergency surgeons who would work much like emergency physicians work on a regular rotation kind of basis. I know those wonderful hours where you don't get to see your family or so on.
But we have a proposal forwarded to them for their consideration and emphasizing the need for appropriate pediatric education. And as many of you may know we're actively exploring the possibilities for interorganizational communication between the college of surgeons Committee on Trauma, specifically pediatric surgery specialty group and the AAP and ACEP and other interested organizations.
We have petitioned the executive committee considering establishing a surgeon's award for service to injured children, and of course we're all aware of the reauthorization pending with respect to both the federal trauma program and the federal EMSC program, and I'm very pleased to be able to report, again thanks to the executive committee of the Committee on Trauma, that the college is four squares behind the EMSC program, as well as the trauma program reauthorization, as we know EMSC is also behind and together we will certainly all accomplish more than before.
Now, I think the thing that I'm really most excited to report to you about is the National Trauma Data Bank Pediatric Report. And Dan Cavanaugh, I want to publicly thank the EMSC program for its support over the years, of the National Pediatric Trauma Registry and of the National Trauma Registry for Children Planning Grants over the last couple of years.
Many of you may know that the National Trauma Registry For Children Planning Group, although the report has not yet been finalized, is going to recommend that there be really two phases to a National Trauma Registry for Children. The first being a thin population based injury, surveillance system, which allows us to make population inferences from a carefully selected statistical sample of national hospitals, and then to establish a case contribution component to the National Trauma Registry for children, which will be like the previous NPTR, National Pediatric Trauma Registry, in that it will be a voluntary submission, case contribution registry that allows large numbers of cases to be accumulated in fairly rich detail, so that we can decide what the best treatments are.
Well, Dan, I'm happy to be able to tell you that, in front of this august group, that the second of those two components is a reality. And that is the national trauma data bank pediatric component, it now constitutes the largest repository of pediatric trauma data anywhere. It's based on 179,203 records from 1999 through 2003. This is a sliding five‑year window of cases that every year as new cases are accrued we drop the earlier year and add the later year. It really provides a robust tool for pediatric trauma data analysis. Pediatric topics comprise eight of the 105 data requests to the NTTB in 2004, and that number is growing.
It's, of course, consistent with and represents at this point, de facto, the case contribution component of the NTRC. We really thank the pediatric surgery specialty group which worked on this, as well as John Files and Wayne Meredith for their leadership for the NTTP subcommittee for the college and the Committee on Trauma itself. Of course, to our staff, Henry Gunua and Melanie Neil, who put this whole thing together. Please anticipate a new and improved report in 2005. We are hoping that the EMSC program will consider this report important enough that it might consider funding it. I just want to give you a few highlights really of this report to really give you a flavor of what's been accomplished.
I don't need to tell anybody the incredible importance of the National Pediatric Trauma Registry. Almost 100 articles published from that registry, probably 15 to 20 of which have profoundly changed the way we care for injured children. Again, the result of an EMSC‑sponsored project.
This first slide I'm going to show you from the report, which, by the way, is available on the college website, and is also available on its own website, www.nttb.org. There you see the most recent sliding five‑year window. The blue representing cases in the previous reports and red representing new cases.
As you would not be surprised to learn, we see more injured children in the adolescent age ranges. Although it's a pretty steady number at the lower age ranges. Of course, boys outnumber girls by about two to one. The ED disposition, you can see, listed on this slide, a large number of cases do go directly to the operating room. A large number to the ICU and large number to general care units. That is not true that pediatric trauma is a nonoperative disease solely there's a large number of patients that go to the operating room. Motor vehicle crashes of course constitute the largest single category of injuries and are responsible for most of the deaths. Firearms second, of course, in terms of deaths, but relatively small component in terms of the overall numbers of cases.
Because adolescents involve themselves in the wonderful risk‑taking activities that all of us of parents of adolescents understand all too well, namely motor vehicle crashes and firearms, we see the highest death rate among those children. But, of course, we also recognize that child battering accounts for a substantial proportion of child deaths under the age of one.
Again, deaths by age and gender. We can see that boys outnumber girls at every step along the way. In terms of mechanisms, by age, the motor vehicle crashes once again the leading cause of childhood fatality, particular will I in the adolescent age ranges. This depicts death by mechanism NH, same finding. Total hospital length of stay by mechanism, again, motor vehicle crashes falls and firearms, the major problems. Total ICU days, same. Most pediatric injuries, fortunately, at least among those contributed to the registry, remember this is not population‑based.
But the more cases we get the closer we get to something approximating a population‑based registry. Most injuries are relatively minor. But a fully one‑third of pediatric injuries reported to the NTTB are in the ISS range above 10, which means there's a significant risk of death associated with these injuries. So the registry is actually a pretty full.
We have obviously, in terms of severe cases, obviously the patients with very severe injuries are the ones who have the highest mortality risk in terms of injury severity. As you would expect, once again, because of the high preponderance of motor vehicle crashes and firearm injuries in the adolescent ranges, they're the ones with the highest injury severity; and once again they're the ones most likely to die as a result of trauma.
Fortunately, most injuries in children are intentional. But we're all aware that 10 to 15% are intentional. And the categories you can see depicted there in the pie chart. But sadly, of course, among intentional deaths, you can see there's a much, much higher proportion of death in that injury category. Once again, really reflecting the firearm component of the registry.
So I think you can get a sense from this particular set of slides the incredible depth and richness of this data set which is now available to the public on the college's public websites. This represents an extraordinary step forward in our ability to deal with injured children. And, once again, none of this would have been possible without the active support of the EMSC program over the last many, many years.
And to that end, it is now my pleasure to spend a moment as perhaps one of the older people in the room to share with you a bit of a perspective on the success that we've had as an EMSC program over the last 20 years. And in thinking about this, our success, it seemed to me that preparing a report card for the parents of America might be an interesting way to think about EMSC as a program.
I think some of us who have been affiliated with the program for a number of years are fully aware of where things were; long ago, many years ago, when Mr. Jim Seidell published those famous papers quoted in yesterday's celebration by Dave Heppel. We were nowhere. And as the saying goes: We ain't where we want to be, but thank God we ain't where we were. Because that was nowhere. And now we're somewhere. We still have a ways to go. But we are somewhere. So in ‑‑ I thought by looking at the recommendations that the IOM made in '93 and seeing how our program did over the past several years, you know in comparison with those recommendations might give us a bit of a sense of that kind of progress.
And might help us in our, you know, in our efforts in terms of letting others in the nation know of the value of this particular program. The first recommendation focuses or first set of recommendations I should say focus on education and training. I'll provide copies of this handout for all of you, but prior to the end of the meeting. So don't feel you need to write all this down.
But I think the first two categories, first two recommendations really have to do with public education. We really haven't done so well as a nation. That's not to say EMSC hasn't done well. EMSC has done very well. It's really taken a lead. It's championed these, our efforts in this regard. But we still are not where we need to be in terms of education and training and safety and prevention, first aid and CPR and how and when to use the EMSC system appropriately for children. But, again, that's not unique to EMSC. That's every program in healthcare has recognized that it has not done the job that it needs to do in terms of education of the general public.
But this really needs to be a major focus, I think, for our next several years.
Now, in terms of states and localities developing and maintaining specific guidelines or criteria to ensure basic consistency and quality of educational programs across communities and populations reached, likewise, we have not done as good a job as we could have done. Obviously, if we're not doing a great job with public education, you know to begin with, you know it's unlikely that we're going to be doing a great job with consistency of public education. But there have been efforts in that regard. Certainly EMSC has helped sponsor the life support collaborative between the Heart Association and the AAP and ACEP to at least agree on commonality of terminology on the programs, so at least we've taken a few steps forward in that regard in terms of consistency. We've got a ways to go there.
Now the good news begins. What about accreditation organizations that accredit EMT and paramedic programs, as well as nursing and medical residency and fellowship programs? Ladies and gentlemen, we are doing great. Okay? The committee on accreditation has adopted or actually in its 1999 standards and guidelines after an extensive national vending progress fully adopted pediatric educational components but not just components, a system for measuring the actual meaning of these educational targets by the programs involved.
And the programs are regularly tracked on an annual basis in terms of their ability to ensure that students are getting proper pediatric educational exposure. The same is true not only at the basic level, but at the advanced level in terms of EMT and paramedic education. Certainly we have made major strides in terms of identifying which emergencies need to be referred to the EMS system and our nursing and medical organizations have all adopted specific curricula for program graduates that must be met in order for programs to be recognized as sound by the respective program and residency review committee. So we've really done a great job in the education and training area.
What about putting essential tools in place? Well, all state regulatory agencies with jurisdiction over hospitals and EMS systems, the IOM felt that hospital EDs and ambulances haven't maintained the proper equipment. Now, I think you can see from the work that Dr. Gausche and Dr. Middleton both presented to us a short time ago, that while we have not gotten as far as we want to get over the last 20 years, we're a hell of a lot closer to 100 percent than we are to zero, which is where we were back in those days.
So, really, I think we can give ourselves as an EMSC community a tremendous sense of accomplishment that we have accomplished all this in as short a span as 20 years.
I think we have a little bit further to go in terms of the categorization and designation of pediatric facilities. But it's not to say that we haven't made good strides. The college of surgeons, of course, has had pediatric trauma on the, as part of its system for quite some time in terms of trauma center verification. I'm pleased to be able to report that as a result of the collaboration that I mentioned earlier between the pediatric surgery specialty group and the executive committee of the Committee on Trauma, that I believe the new Gold Book will contain substantial improvements in terms of how we measure the quality of pediatric care in college‑verified facilities.
We do have some way to go in terms of emergency departments. But the work that Marianne and Kimberly have shared with you, I think, will move that along in a tremendous way.
Certainly in terms of communications, we've made major strides. We're now not just talking about 911 or even E‑911, we're talking about wireless 911. Sue Dawson, Sue McHenry at NHTSA have just been given an incredible opportunity that is very, very large amount of money available to ensure that wireless E‑911 programs are in place nationwide and that, of course, will greatly enhance our ability to care for injured children.
What about planning, evaluation and research? We have done really pretty well in making sure that E codes are adopted by most states in their discharge data abstract programs. We have done a little less well but still pretty well on our ability to collect analyze and report data on EMS . Certainly the any sis project will move this along in a quantum way over the next five to ten years.
Linkage of data remains a serious problem. There was about ‑‑ there was quite a bit of enthusiasm, I'd say, about ten years ago that probabilistic linkage techniques would help us solve all the problems of the world in terms of data linkage. We realize that's not true; it turns out to be a far thornier and knottier problem than anyone mentioned. But with the opportunities provided through HIPAA and there are some opportunities, not only difficulties, but some opportunities, protection of privacy, we stand a chance at being able to do a little bit better job of linkage in the future.
What about a national data set for children? NMSA clearly includes that, and we're well on our way to making sure that that becomes a nationwide data set. And the work of this program in establishing the PCARN network has nothing been short of extraordinary. Hats off to Nate and all who participated in that program.
Finally, what about federal and state agencies and funding? We do pretty well here as well. Now, while Congress did not explicitly direct that the Secretary of the Department of Health and Human Services establish a federal center or office to conduct, oversee and coordinate EMSC activities, certainly Dan Cavanaugh and his predecessor, Cindy Doyle, Jean Athey and Art Funky, have served in that role extraordinarily well, supported by both the Center in Washington, the EMS National Resource Center, as well as previously the National EMSC State Resource Alliance in southern CALIFORNIA and, of course, the National Data Center headed by Mike Dean in Utah.
All of these entities constitute really a pretty formidable group of resources to or grouping of resources to support EMSC programs. And in my judgment, even though there hasn't been a direct order from the Secretary saying thou shalt do this, those in positions of responsibility for these programs did it anyway, because they knew it was the right thing.
Certainly going along with that is the National Advisory Council, the EMSC National Resource Center has established a national stakeholder group. Many of you are part of that, have spent many happy hours meeting today and deciding on directions for the center to go. And at the state level, as Dave Heppel reported yesterday, 56 states and territories now receive EMSC funding and the requirement of that funding is to have a state EMSC advisory council. We've done a great job there as well.
So the last but not least, of course, has to do with the support for all of these programs. And the reason we have a B minus here instead of an A minus is the IOM said that $30 million would be needed to accomplish all the ambitious goals set out in the IOM report in 1993. But we've only been given about $20 million a year. Now, listen, that's heck of a lot more than the $3 million that the trauma program gets. And it's a hell of a lot less than the gazillions of dollars that the Homeland Security programs get, but, you know, we've gone a long way on those $20 million a year. Made an enormous amount of progress.
So in summary, I think we can look back over the twenty‑year history of our program and report on the program to the parents of America that the program really has gotten an A minus. Looking at education and training, you can see the grades through all the various subsections there. Putting essential tools into place, communications, planning, evaluation and research and federal and state agencies and funding.
You can see all the grades of all the initial, or I should say, separate or individual categories listed there. So I think we're really in pretty fine shape. To the extent that our letter to the parents and program managers and policy makers of the nation might read as follows: Congratulations. Your baby, EMSC, has just turned 21 years old, has graduated to maturity with an A minus average and did so even though you got a bargain on tuition, room and board, spending only two‑thirds on what the experts said would be needed.
Be proud of a job well done, but please keep up your contributions to your child's alma mater so other children will have the same opportunities that EMSC did.
There we are. Everybody, please give yourselves a tremendous round of applause for the work you have done.
(Applause)