Pediatric mental health emergencies in the emergency medical services system

Emergency departments are vital in the management of pediatric patients with mental health emergencies. Pediatric mental health emergencies are an increasing part of emergency medical practice because emergency departments have become the safety net for a fragmented mental health infrastructure that is experiencing critical shortages in services in all sectors. Emergency departments must safely, humanely, and in a culturally and developmentally appropriate manner manage pediatric patients with undiagnosed and known mental illnesses, including those with mental retardation, autistic spectrum disorders, and attention-deficit/hyperactivity disorder and those experiencing a behavioral crisis. Emergency departments also manage patients with suicidal ideation, depression, escalating aggression, substance abuse, posttraumatic stress disorder, and maltreatment and those exposed to violence and unexpected deaths. Emergency departments must address not only the physical but also the mental health needs of patients during and after mass-casualty incidents and disasters. The American Academy of Pediatrics and the American College of Emergency Physicians support advocacy for increased mental health resources, including improved pediatric mental health tools for the emergency department, increased mental health insurance coverage, and adequate reimbursement at all levels; acknowledgment of the importance of the child's medical home; and promotion of education and research for mental health emergencies.     

Pediatric and adolescent mental health emergencies in the emergency medical services system

Emergency department (ED) health care professionals often care for patients with previously diagnosed psychiatric illnesses who are ill, injured, or having a behavioral crisis. In addition, ED personnel encounter children with psychiatric illnesses who may not present to the ED with overt mental health symptoms. Staff education and training regarding identification and management of pediatric mental health illness can help EDs overcome the perceived limitations of the setting that influence timely and comprehensive evaluation. In addition, ED physicians can inform and advocate for policy changes at local, state, and national levels that are needed to ensure comprehensive care of children with mental health illnesses. This report addresses the roles that the ED and ED health care professionals play in emergency mental health care of children and adolescents in the United States, which includes the stabilization and management of patients in mental health crisis, the discovery of mental illnesses and suicidal ideation in ED patients, and approaches to advocating for improved recognition and treatment of mental illnesses in children. The report also addresses special issues related to mental illness in the ED, such as minority populations, children with special health care needs, and children's mental health during and after disasters and trauma.     

Pediatric deaths and emergency medical services (EMS) in urban and rural areas

A total of 1078 pediatric coroners' cases in 11 rural and urban California counties were reviewed as they relate to emergency medical services (EMS). Pediatric coroners' death rates per 100,000 population varied from an average of 2.17 in the rural region to 30.4 in the urban region. Vehicular accidents caused the majority (66%) of the accidental deaths, and firearms caused 61% of the violent deaths. Violent deaths (homicide and suicide) were significantly more common in the urban region (P less than 0.001), and vehicular deaths (excluding auto versus pedestrian) were more common in the rural region (P less than 0.001). EMS provider usage was greater in the urban areas (84 vs 66%, P less than 0.001), as was the number of cases receiving advanced life support (97 vs 66%, P less than 0.001). Urban and rural differences in place of death were significant for two places of death; street and highway, and inhospital deaths. A significantly greater number of children died on the street/highway in rural areas (P less than 0.05). Hospital deaths were more likely to occur on the ward in the rural region, versus the intensive care unit in the urban region (P less than 0.001). Proposed factors which may explain these findings include differences in medical resources and in local transfer policies. The study demonstrates that EMS providers are involved in the care of children who have had a fatal emergency. Further evaluation of rural and urban differences in prehospital care of the pediatric patient is indicated.     

Prehospital evaluation of non-transported pediatric patients by a large emergency medical services system.

OBJECTIVES: 1) To determine whether demographic characteristics of prehospital pediatric patients evaluated, but not transported, by emergency medical services (EMS) personnel were different than those of transported patients in a large metropolitan area, 2) to determine whether chart documentation for non-transported (NT) patients by EMS personnel varied among paramedic and ambulance units, and 3) to describe the most common complaints of pediatric non-transported patients. METHODS: We conducted a cross-sectional study of children 12 years of age and less who were evaluated, but not transported, by EMS personnel over a 1-year period. We incorporated a nested case control study, comparing the demographic and presenting characteristics of the NT and transported children (eg, age, gender, ethnicity, and time of day). Among NT patients, significant elements of chart documentation as completed by personnel on paramedic versus ambulance units were compared. Chief complaints of the NT children were described. RESULTS: During the study period, 3057 patients met inclusion criteria for cases, and 12,302 met the criteria for controls. Non-transport was less common in the first two years of life, among Hispanic patients, and during the hours of midnight to 6 am. Among NT patients, personnel of paramedic units had significantly better documentation of contact with on-line medical command (OLMC) (52% vs. 33%) than did personnel of ambulance units. Injuries (27.7%), motor vehicle accidents (20.4%), and choking episodes (10.2%) were the most common complaints among NT patients. CONCLUSIONS: In this large metropolitan population, non-transport was less common in children under 2 years of age and during the early morning hours. Hispanic children were more likely to be transported. Ambulance units were significantly less likely than paramedic units to document contact with OLMC. Injuries were the most common complaints of pediatric NT patients.     

Consent for emergency medical services for children and adolescents

Parental consent generally is required for the medical evaluation and treatment of minor children. However, children and adolescents might require evaluation of and treatment for emergency medical conditions in situations in which a parent or legal guardian is not available to provide consent or conditions under which an adolescent patient might possess the legal authority to provide consent. In general, a medical screening examination and any medical care necessary and likely to prevent imminent and significant harm to the pediatric patient with an emergency medical condition should not be withheld or delayed because of problems obtaining consent. The purpose of this policy statement is to provide guidance in those situations in which parental consent is not readily available, in which parental consent is not necessary, or in which parental refusal of consent places a child at risk of significant harm.     

Consent for emergency medical services for children and adolescents

Pediatric patients frequently seek medical treatment in the emergency department (ED) unaccompanied by a legal guardian. Current state and federal laws and medical ethics recommendations support the ED treatment of minors with an identified emergency medical condition, regardless of consent issues. Financial reimbursement should not limit the minor patient's access to emergency medical care or result in a breach of patient confidentiality. Every clinic, office practice, and ED should develop policies and guidelines regarding consent for the treatment of minors. The physician should document all discussions of consent and attempt to seek consent for treatment from the family or legal guardian and assent from the pediatric patient. Appropriate medical care for the pediatric patient with an urgent or emergent condition should never be withheld or delayed because of problems with obtaining consent. This statement has been endorsed by the American College of Surgeons, the Society of Pediatric Nurses, the Society of Critical Care Medicine, the American College of Emergency Physicians, the Emergency Nurses Association, and the National Association of EMS Physicians.     

Priorities for research in emergency medical services for children: results of a consensus conference

OBJECTIVE: To arrive at a consensus on the priorities for future research in emergency medical services for children. METHODS: A consensus group was convened using the Rand-UCLA Consensus Process. The group took part in a 3-phase process. Round I involved reviewing a compendium of relevant research articles and answering a mailed questionnaire. Panel members were asked to prioritize topics on the basis of the 1993 Institute of Medicine Report on Emergency Medical Services for Children. Participants were asked to rate each topic based on the significance of the research, and whether the topic would (1) improve general knowledge (2), change behavior (3), improve health (4), decrease the cost of care, or (5) change public policy. A 4-point Likert scale was used. Participants were also asked if the research would require a multicenter study and if the research were feasible. Round II of the study involved a meeting of the panel, where the results of Round I were discussed and the topics were reprioritized. The topics were given a rank order and a final ranking was done in Round III. RESULTS: The panel considered a list of 32 topics; these were combined and reworded to give them more precise meaning. Several new topics were also added. Fifteen topics were given a rank order and placed within the 7 broad categories of the Institute of Medicine report. Clinical aspects of emergency care, systems organization, configuration, and operation and injury prevention were given high priority rankings. The first 5 topics were very close in point-rank order. CONCLUSION: The panel was able to develop a list of important topics for future research in emergency medical services for children that can be used by foundations, governmental agencies, and others in setting research agenda for such services.     

Prehospital intraosseous infusion by emergency medical services personnel: a prospective study

Intraosseous infusion technique by paramedics in the prehospital setting was prospectively evaluated. Intraosseous access was successfully established in 16 of 17 pediatric patients with cardiopulmonary arrest. There were 13 successful first attempts with intraosseous access established within 1 minute. No significant complications occurred. In this study, the ease of establishing intraosseous access by paramedics in the field is documented.     

Pre-hospital emergency medical services: a population based study of pediatric utilization

OBJECTIVES: To examine emergency medical services (EMS) usage by children in one state. METHODS: Dispatch of an EMS vehicle in response to a call in the US is referred to as a "run". Runs for Utah for 1991-92 were linked to corresponding hospital records. Abbreviated injury severity scores (AISs) were assigned using ICDMAP-90 software. RESULTS: For the two year period there were at least 15 EMS runs per 100 children per year, with incomplete reporting from rural areas. EMS response and scene times were similar for all age groups, but interventions were less frequent for children under 5 years of age. When the principal AIS region of injury was the head, neck, or face, cervical immobilization was less frequent for children less than 5 years of age (54%) than for older children (76%) and immobilization was associated with improved outcome, using the crude measure of lower hospital charges. There was a similar association between splinting of upper extremity fractures and reduced hospital charges. Both associations did not appear to be due to differences in injury severity. CONCLUSIONS: The majority of EMS use by children is for trauma. Children less than 5 years of age are less likely to have an EMS intervention than older children. Whether the lower frequency of interventions is due to the lack of properly sized equipment on the vehicle, or to other factors, is undetermined.     

American Academy of Pediatrics: Guidelines for emergency medical care in school

Minor and major illnesses and injuries can occur in children during the school day. This statement provides recommendations for emergency health care for children in school, including information about procedures, staff and their education, documentation, and parental notification.     

The role of the pediatrician in rural emergency medical services for children

In rural America, pediatricians can play a key role in the development, implementation, and ongoing supervision of emergency medical services for children. Pediatricians may represent the only source of pediatric expertise for a large region and are a vital resource for rural physicians (eg, general and family medicine, emergency medicine), other rural health care professionals (physician assistants, nurse practitioners, emergency medical technicians), and local emergency medical services medical directors. They can provide education about management and prevention of pediatric illness and injury; appropriate equipment for the acutely ill or injured child; and acute, chronic, and rehabilitative care. In addition to providing clinical expertise, the pediatrician may be involved in quality assurance, clinical protocol development, and advocacy and may serve as a liaison between emergency medical services and other entities working with children (eg, school nurses, child care centers, athletic programs, and programs for children with special health care needs).     

Emergency medical services and the pediatric patient: are the needs being met? II. Training and equipping emergency medical services providers for pediatric emergencies

Emergency medical services have been organized to meet the needs of adult patients. A study was undertaken to determine the training in pediatrics offered to paramedics and emergency medical technicians throughout the United States and the equipment carried by prehospital care provider agencies. Most training (50%) takes place at colleges and universities and the remainder at hospitals and emergency medical services agencies. Many programs (40%) have less than ten hours of didactic training in pediatrics and 41% offer ten hours or less of clinical experience. Some programs offer no training in pediatric emergency medicine. The most common deficiencies in pediatric equipment included backboards, pediatric drugs, resuscitation masks, and small intravenous catheters. More attention to training and equipping prehospital personnel for pediatric emergencies may help to improve outcomes of out-of-hospital resuscitations of infants and children.     

Pediatric emergency room visits: a risk factor for acquiring measles

In recent years, measles outbreaks have occurred among unimmunized children in inner cities in the United States. From May 1988 through June 1989, 1214 measles cases were reported in Los Angeles, and from October 1988 through June 1989, 1730 cases were reported in Houston. More than half of cases were in children younger than 5 years of age, most of whom were unvaccinated. Of cases of measles in preschool-aged children, nearly one fourth in Los Angeles and more than one third in Houston were reported by one inner-city emergency room. To evaluate whether emergency room visits were a risk factor for acquiring measles, in Los Angeles, 35 measles patients and 109 control patients with illnesses other than measles, and in Houston, 49 measles patients and 128 control patients, who visited these emergency rooms, were enrolled in case-control studies. Control patients were matched to case patients for ethnicity, age, and week of visit. Records were reviewed to determine whether case patients had visited the emergency room during the period of potential measles exposure, which was defined as 10 to 18 days before rash onset, and whether control patients had visited 10 to 18 days before their enrollment visit. In Los Angeles, 23% of case patients and 5% of control patients (odds ratio = 5.2, 95% confidence interval = 1.7, 15.9; P less than .01), and in Houston, 41% of case patients and 6% of control patients (odds ratio = 8.4, 95% confidence interval = 3.3, 21.2; P less than .01), visited the emergency room during these periods.(ABSTRACT TRUNCATED AT 250 WORDS)