Should pediatric emergency care be decentralized?: an out-of-hospital destination model for critically ill children.
OBJECTIVE
A time-to-initial-stabilization model for out-of-hospital destinations of critically ill children (CICs) was developed. Application of this model to assess the impact of changes in different parameters of an emergency medical services for children (EMSC) system is described.


METHODS
A computer model created a 2,500-square-mile community containing ten community hospitals (CHs) and one pediatric critical care center (PCC). Community hospitals capable of providing initial immediate stabilization of CICs were defined as emergency departments accepting pediatrics (EDAPs). Critically ill children were randomly selected in proportion to population densities across the modeled community. Time to initial stabilization (TIS) was defined as the time to arrival at either an EDAP or a PCC or time to arrival at a non-EDAP CH + travel time for a team from the PCC to the non-EDAP CH + preparation/dispatch (P/D) time. The following parameters of the model were varied and their effect on TIS was evaluated: location of CHs, location of PCC, primary destinations for CICs, percent of CHs meeting EDAP standards, out-of-hospital compliance with designated hospitals for CICs, P/D time, and ambulance speed.


RESULTS
The computer model selected 1,000 CICs in accordance with the population densities of the community. The scenario with the shortest TIS was one in which every CH achieved EDAP designation (9.8 +/- 0.5 minutes). The scenario with the longest TIS involved a model in which every CIC was transported directly to the PCC (28.6 +/- 0.33 minutes). The number of EDAPs in a community and out-of-hospital compliance with use of EDAPs produced comparable effects on the TIS. Travel speeds had a direct effect on TIS but also exaggerated inefficiencies between scenarios. The P/D time had little effect on the TIS.


CONCLUSIONS
An out-of-hospital destination model has been developed with the ability to modify multiple EMSC system variables. Application of this model demonstrates the shortest times to stabilization of critically ill children occur in systems that maximize the number of hospitals that meet EDAP standards and decentralize pediatric emergency care.
Department of Emergency Medicine, Our Lady of Lourdes Medical Center, Camden, NJ 08103, USA. a.sacchetti@worldnet.att.net
A
A
Sacchetti
J
J
Brennan
N
N
Kelly-Goodstein
D
D
Graff
D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D003198:Computer Simulation; D016638:Critical Illness / Q000628:therapy*; D004632:Emergency Medical Services / Q000458:organization & administration*; D004636:Emergency Service, Hospital / Q000458:organization & administration; D004638:Emergency Treatment / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D010372:Pediatrics / Q000379:methods*; D011057:Politics; D012041:Regional Medical Programs; D012680:Sensitivity and Specificity; D016896:Treatment Outcome; D014481:United States