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This issue gets at the concept of regionalization of care, which has been recommended for children in certain instances in 2 Institute of Medicine (IOM) reports in 1993 ("Emergency Medical Services for Children") and 2007 ("Emergency Care for Children: Growing Pains").  According to the IOM, the goal of regionalization is "to direct critically ill and injured patients to facilities within a community with the personnel and resources to deliver high-level emergency care."  There is model for this for adult cardiac and stroke care.  For adults and children, there is also a model for this for trauma care.  Many regions and/or states have systems in place to designate a facility's capabilities as a cardiac, stroke, or trauma center.  For pediatric emergency and critical care, only a handful of states have a policy in place to allow bypass to specialty care centers for pediatrics and/or have a statewide system to designate pediatric specialty care centers (see Figures 190D and 196D in the 2011 National EMS Assessment: http://ems.gov/pdf/2011/National_EMS_Assessment_Final_Draft_12202011.pdf).  Having state or region-wide designation systems for medical emergencies is one of the 10 National EMS for Children Performance Measures (see http://www.emscnrc.org/Grantee_Portal/Performance_Measures.aspx).

So to answer your question about whether it is best to divert critically ill medical patients to a hospital with a PICU, I would say "yes" if it is obvious that the child is going to need admission to a PICU and if it seems that the risk of stopping at a closer hospital to stabilize a patient that EMS is unable to stabilize on their own outweighs the risk of the additional time required to get to the facility with the PICU.  Developing regional triage and transport guidelines for cases like this, in coordination with the EMS services and hospitals in your region, seems like the best approach to ensure that children get timely care in a critical situation.


Manish I. Shah, MD
EMS Subcommittee Chair, American Academy of Pediatrics Section of Emergency Medicine
Program Director, EMS for Children State Partnership Texas

Assistant Professor
Department of Pediatrics, Section of Emergency Medicine
Baylor College of Medicine

Texas Children's Hospital
6621 Fannin Street, Suite A2210
Houston, Texas 77030

Office: 832.824.6703
Pager: 832.824.7243, #4566
FAX: 832.825.1182
________________________________________
From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] on behalf of Susan Frayer [[log in to unmask]]
Sent: Sunday, May 25, 2014 6:17 PM
To: [log in to unmask]
Subject: Is it OK for EMS to bypass EDs to go to hospitals with specialized services?

I work in a city with 5 hospitals.  2 of these hospitals are trauma centers and have pediatric intensive care units and pediatric subspecialists on staff.  The other 3 hospitals have general pediatricians and would like to continue to see children in their emergency departments and admit children to their general pediatric floors.  The question has recently been brought up by EMS directors as to whether it would be better for critical pediatric patients if ambulances bypassed closer hospitals that do not have pediatric ICUs to go to one of the other 2 hospitals that have this capability.  All 5 hospital's emergency departments are staffed by board certified EM physicians with the capability of stabilizing critically ill children.  However, these children then have to be transferred by ambulance to one of the 2 hospitals with a PICU if they are found to be to sick to be admitted where they are.  Pediatric trauma patients are already diverted
directly to one of the trauma centers.  Is it best to divert critically ill medical patients to a hospital with a PICU?  This would meet with a lot of resistance from the hospital administrations of the smaller hospitals.  However, I believe this might be in the patient's best interest.  Any thoughts?

Susan Frayer
Medical Director
Lutheran Children's Hospital Pediatric Emergency Department
Ft. Wayne, IN

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