Should pediatric emergency care be decentralized?: An out-of-hospital destination model for critically ill children

Objectives: A time-to-initial-stabilization model for out-of-hospital desti nations of critically ill children (CICs) was developed. Application of thi s model to assess the impact of changes in different parameters of an emerg ency medical services for children (EMSC) system is described. Methods: A c omputer model created a 2,500-square-mile community containing ten communit y hospitals (CHs) and one pediatric critical care center (PCC). Community h ospitals capable of providing initial immediate stabilization of CICs were defined as emergency departments accepting pediatrics (EDAPs). Critically i ll children were randomly selected in proportion to population densities ac ross 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 + prep aration/dispatch (P/D) time. The following parameters of the model were var ied 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 a mbulance speed. Results: The computer model selected 1,000 CICs in accordan ce with the population densities of the community. The scenario with the sh ortest 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 ever y CIC was transported directly to the PCC (28.6 +/- 0.33 minutes). The numb er 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 m odel has been developed with the ability to modify multiple EMSC system var iables. Application of this model demonstrates the shortest times to stabil ization of critically ill children occur in systems that maximize the numbe r of hospitals that meet EDAP standards and decentralize pediatric emergenc y care.