A statewide evaluation of pediatric prehospital and hospital emergency services

Paediatric prehospital trauma care

Trauma is the major cause of avoidable death in children in the UK. For many injured children, their initial contact with medical care is with the ambulance service. The main focus of this article is paediatric prehospital trauma care in the UK. It identifies its strengths and highlights areas where improvements are needed. For comparison’s sake, mention is also made of the prehospital care for traumatized children in the USA, which is part of a system termed ‘Emergency Medical Services for Children’ (EMSC). Training and equipment issues, field triage and the ABC of advanced life support of injured children is examined.

Future directions for this important aspect of emergency care are discussed, as are issues relevant to research and audit in this area.

Prehospital care and transportation of pediatric trauma patients

BACKGROUND

Despite advances in prehospital emergency medical services (EMS), most advocate "scoop-and-run" over "stay-and-play." However, there are almost no studies in children. We hypothesize that the transportation of mortally injured children is delayed and that the performance of prehospital interventions (PHIs) themselves delay transportation and worsen outcomes in pediatric trauma patients.

MATERIALS AND METHODS

A total of 1884 admissions (≤17-y-old) transported via EMS to a level 1 trauma center from January 2000-December 2012 were reviewed. Propensity scores were assigned based on the need for a PHI (intubation and resuscitation). PHI and non-PHI cohorts were matched 1:1 to compare outcomes. Data are expressed as mean ± standard deviation or median (interquartile range).

RESULTS

The population was 11 ± 6 y, 70% male, 50% black, 76% blunt injury, injury severity score 13 ± 12, length of stay 3 (7) d, and mortality 3.6%. Incident to EMS arrival was 38 (20) min, EMS on-scene time was 14 (12) min, and overall time of arrival to hospital was 27 (15) min. Patients that were mortally wounded, despite having significantly higher rates of PHI, still had similar transportation times to those who survived. Mostly every measure of injury severity was worse in those who required PHI. When these factors were corrected, EMS on-scene time was 18 (13) versus 14 (13) min (P = 0.551), EMS arrival at the hospital was 31 (16) versus 28 (12) min (P = 0.292), length of stay was 5 (15) versus 4 (12) d (P = 0.368), and mortality was 31.7% versus 28.3% (P = 0.842) for PHI and non-PHI matched cohorts.

CONCLUSIONS

PHIs did not delay transportation times or worsen outcomes in pediatric trauma patients. Although mortally injured children more often required PHIs, this did not delay transportation to the trauma center.

Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest

This multiorganizational literature review was undertaken to provide an evidence base for determining whether or not recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care, because the evidence suggests that either death or a poor outcome is inevitable.

Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest

This multiorganizational literature review was undertaken to provide an evidence base for determining whether recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care because the evidence suggests that either death or a poor outcome is inevitable.

Assessment of factors associated with the delayed transfer of pediatric trauma patients: an emergency physician survey

OBJECTIVES

The purpose of this study was to identify, among emergency department (ED) physicians, the potential barriers impacting the appropriate and timely transfer of injured children to pediatric trauma centers.

METHODS

Surveys assessed pediatric trauma knowledge and experience, transfer and imaging decisions, and perceived barriers to patient transfer. Two scenarios were created; one with a child meeting the state trauma triage criteria and one who did not. In April 2010, 936 surveys were mailed to randomly selected ED physicians. Respondents could answer by mail or online until June 30, 2010.

RESULTS

A total of 486 surveys were returned, and 109 were excluded, leaving 377 included in the study. A majority reported limited experience in the care of the critically ill child, with 93%, 99%, 99%, and 100% respectively, having performed less than 5 intubations, intraosseous line, central line, or chest tube placements in the last year. In the scenario in which the child met criteria to be transferred, 74% appropriately transferred the patient, whereas in the other scenario, 34% transferred the patient. As much as 56% of the respondents reported they would perform a head computed tomography before transfer, mainly to avoid missed injuries and medicolegal concerns. Among those who would not transfer either patient, 27% reported not having an on-call surgeon at all times.

CONCLUSIONS

Innovative measures should be developed so that ED physicians gain a greater understanding of the proper identification of pediatric patients requiring a timely transfer to a pediatric trauma center.

Pediatric educational needs assessment for urban and rural emergency medical technicians

OBJECTIVE

The objective of the study was to identify past experiences, present needs, barriers, and desired methods of training for urban and rural emergency medical technicians.

METHODS

This 62-question pilot-tested written survey was administered at the 2008 Oregon EMS and 2009 EMS for Children conferences. Respondents were compared with registration lists and the state emergency medical services (EMS) database to assess for nonresponder bias. Agencies more than 10 miles from a population of 40,000 were defined as rural.

RESULTS

Two hundred nineteen (70%) of 313 EMS personnel returned the surveys. Respondents were 3% first responders, 27% emergency medical technician basics, 20% intermediates, and 47% paramedics. Sixty-eight percent were rural, and 32% were urban. Sixty-eight percent reported fewer than 10% pediatric transports. Overall, respondents rated their comfort caring for pediatric patients as 3.1 on a 5-point Likert scale (95% confidence interval, 3.1-3.2). Seventy-two percent reported a mean rating of less than "comfortable" (4 on the scale) across 17 topics in pediatric care, which did not differ by certification level. Seven percent reported no pediatric training in the last 2 years, and 76% desired more. The "quality of available trainings" was ranked as the most important barrier to training; 26% of rural versus 7% of urban EMS personnel ranked distance as the most significant barrier (P < 0.01). Fifty-one percent identified highly realistic simulations as the method that helped them learn best. In the past 2 years, 19% had trained on a highly realistic pediatric simulator. One to 3 hours was the preferred duration for trainings.

CONCLUSIONS

Except for distance as a barrier, there were no significant differences between urban and rural responses. Both urban and rural providers desire resources, in particular, highly realistic simulation, to address the infrequency of pediatric transports and limited training.

Paramedic initiated non-transport of pediatric patients

INTRODUCTION

In a time of emergency department overcrowding and increased utilization of emergency medical services, a highly functional prehospital system will balance the needs of the individual patient with the global needs of the community. Our community addressed these issues through the development of a multitiered prehospital care system that incorporated EMS initiated non-transport of pediatric patients.

OBJECTIVE

To describe the outcome of pediatric patients accessing a progressive prehospital system that employed EMS initiated non-transport.

METHODS

A prospective observational case series was performed on pediatric patients (< 21 years old) designated EMS initiated non-transport. Patients were designated non-transport after an initial EMS protocol driven, complaint-specific clinical assessment in conjunction with medical oversight affirmation. Telephone follow-up was completed on all consecutively enrolled non-transport patients to collect information about outcome (safety) as well as overall satisfaction with the system. A five-point Likert scale was utilized to rate satisfaction.

RESULTS

There were 5,336 EMS requests during the study period. Seven hundred and four were designated non-transport, of which 74.8% completed phone follow-up. Categories of EMS request included minor; medical illness 43.4%, trauma 55.9%, and other 1.1%. There were 13 admissions (2.4%) to the hospital after EMS initiated non-transport designation. Admissions after non-transport had trends toward younger age (p = 0.002) and medical etiology (p = 0.006). There were no PICU admissions or deaths.

CONCLUSION

Our EMS system provides an alternative to traditional protocols, allowing EMS initiated non-transport of pediatric patients, resulting in effective resource utilization with a high level of patient safety and family satisfaction.

The National EMS Research strategic plan

One of the eight major recommendations put forth by the National EMS Research Agenda Implementation Project in 2002 was the development of an emergency medical services (EMS) research strategic plan. Using a modified Delphi technique along with a consensus conference approach, a strategic plan for EMS research was created. The plan includes recommendations for concentrating efforts by EMS researchers, policy makers, and funding resources with the ultimate goal of improving clinical outcomes. Clinical issues targeted for additional research efforts include evaluation and treatment of patients with asthma, acute cardiac ischemia, circulatory shock, major injury, pain, acute stroke, and traumatic brain injury. The plan calls for developing, evaluating, and validating improved measurement tools and techniques. Additional research to improve the education of EMS personnel as well as system design and operation is also suggested. Implementation of the EMS research strategic plan will improve both the delivery of services and the care of individuals who access the emergency medical system.

The perspective of paramedics about on-scene termination of resuscitation efforts for pediatric patients

OBJECTIVES

The purpose of this study was to assess the attitude of paramedics to on-scene termination of cardiopulmonary resuscitation (T-CPR) efforts in children prior to developing a pediatric T-CPR policy.

METHODS

A 26-item anonymous survey was conducted of all of the active paramedics in a large urban EMS system where T-CPR had been practiced routinely for adults. Questions addressed paramedic demographics, training level, experience with adult and pediatric advanced cardiac life support (ACLS), experience with T-CPR in adults, T-CPR case scenarios, and T-CPR in children.

RESULTS

All 201 paramedics in the system (mean age=34.2 years; mean years as paramedic = 8.5 ) completed all relevant items of the survey (100% compliance). Two-thirds had provided ACLS for cardiac arrest to >50 adults (93% >10 adults) and more than one-third had performed ACLS on >20 children (72% >5 children). In addition, 90% had participated in T-CPR for adults. The majority of paramedics reported at least occasional (pre-defined) difficulty with adult T-CPR including family confrontation, 43%; personal discomfort, 13%; disagreement with physician decision to continue efforts, 11%; and fear of liability, 10%. Paramedic self ratings of comfort with terminating CPR on a scale from 1 to 10 (1: very comfortable; 10: uncomfortable) for adults and children were 1 and 9, respectively (P<0.001). In addition, the clear majority (72%) responded that children deserve more aggressive resuscitative efforts than adults.

CONCLUSIONS

Paramedics feel relatively uncomfortable with the concept of terminating resuscitation efforts in children in the pre-hospital setting.

Reconocimiento del niño con riesgo de parada cardiorrespiratoria

Cardiorespiratory arrest in children with severe disease does not usually present suddenly or unexpectedly but is often the result of a progressive deterioration of respiratory and/or circulatory function. Before failure of these functions occurs, there is a series of clinical signs that serve as a warning. Health professionals should not only evaluate clinical signs of respiratory and/or circulatory insufficiency but should also be able to identify these warning signs as early as possible, preferably in the compensation phase, given that the possibility that this process can be reversed by therapeutic measures decreases as the process progresses.

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.

Critical pediatric equipment availability in Canadian hospital emergency departments

STUDY OBJECTIVE

Of all child visits to emergency departments, 1% to 5% involve critically ill children who require cardiopulmonary resuscitation. Numerous versions of pediatric equipment lists for EDs have been published. Despite these efforts, many EDs remain unprepared for pediatric emergencies. The objectives of this study were to assess the availability of pediatric resuscitation equipment items in Canadian hospital EDs and to identify risk factors for the unavailability of these items.

METHODS

Using the updated database of the Canadian Association of Emergency Physicians (CAEP), a questionnaire survey was sent to 737 Canadian hospital EDs with a maximum of 3 mailings to nonresponders. On-site visits to a selected subset of hospital EDs were completed to validate the results obtained by the mailed questionnaire.

RESULTS

The response rate was 88.3% (650/737). Results showed the following overall equipment unavailability: intraosseous needle, 15.9%; pediatric drug dose guidelines, 6.6%; infant blood pressure cuff, 14.8%; pediatric defibrillator paddles, 10.5%; infant warming device, 59.4%; infant bag-valve-mask device, 3.5%; infant laryngoscope blade, 3.5%; 3-mm endotracheal tube, 2.5%; and pediatric pulse oximeter, 18.0%. Low percentage of pediatric visits, lack of an on-call pediatrician for the ED, and lack of a pediatric advanced life support-trained physician on staff were independently associated with equipment unavailability.

CONCLUSION

This study demonstrated that essential pediatric resuscitation equipment is unavailable in a disturbingly high number of EDs across Canada and has identified several determinants of this unavailability.

Paediatric prehospital care: postal survey of paramedic training managers

BACKGROUND

The process of prehospital care continues to develop in the UK.

AIMS

To evaluate the availability of important paediatric resuscitation equipment in emergency ambulances and the extent of paramedic training in paediatric emergency medicine.

METHODS

Postal survey of paramedic training managers.

RESULTS

Completed questionnaires were returned by 41 (93%) training managers. No trust provided all of the equipment listed. Facemasks and self inflating bags (of appropriate sizes for all children) are provided by 32% and 42% of trusts respectively. Less than one third carry paediatric oximeter probes. Of the respondents, 16 (39%) trusts provide less than eight hours training in paediatric emergency medicine and five (12%) offer no training at all. Ongoing education varies from none to regular yearly updates.

CONCLUSIONS

Paramedics seem ill prepared to deal with paediatric emergencies. Important deficiencies in the provision of equipment and training are noted. The results of this survey provide information against which improvements can be measured.

The advanced pedi-bag program: a hospital-EMS partnership to implement prehospital training, equipment, and protocols

OBJECTIVE

The Advanced Pedi-Bag Program is a partnership between a trauma center and a county-wide EMS agency (LCEMS) with three major goals: 1) train all LCEMS paramedics in the American Heart Association's Pediatric Advanced Life Support (PALS), 2) stock each Life Squad with a specific bag containing the equipment necessary to treat both basic and advanced pediatric emergencies, and 3) develop treatment protocols for pediatric patients.

DESIGN

Descriptive study.

SETTING

LCEMS serves a population of 450,000. Pediatric runs account for 800 to 1,200 LCEMS runs per year.

RESULTS

The LCEMS Medical Director established and facilitated mandatory PALS training of 180 paramedics. A committee of emergency/pediatric/trauma professionals developed and distributed 40 bags with a comprehensive inventory of basic and advanced pediatric supplies and equipment to all LCEMS Life Squads upon completion of PALS training. Protocols were developed that integrate the use of the bag's contents.

CONCLUSION

This partnership between a trauma center and an EMS agency resulted in improved training of county paramedics, Life Squads that have an Advanced Pedi-Bag with specific equipment and supplies to manage pediatric emergencies, and pediatric protocols that support the use of this equipment. Paramedics benefit from advanced training opportunities and patients benefit from improved prehospital care.

Part 9: pediatric basic life support. European Resuscitation Council

The epidemiology and outcome of pediatric cardiopulmonary arrest and the priorities, techniques, and sequence of pediatric resuscitation assessments and intervention differ from those of adults. Current guidelines have been updated after extensive multinational evidence-based review and discussion over several years. Areas of controversy in current guidelines and recommendations made by consensus are detailed. A large degree of uniformity exists in the current guidelines advocated by the AHA, Council on Latin American Resuscitation, Heart and Stroke Foundation of Canada, European Resuscitation Council, Australian Resuscitation Council, and Resuscitation Council of Southern Africa. Differences are currently based on local and regional preferences, training networks, and customs rather than scientific controversy. Unresolved issues with potential for future universal application are highlighted.

Survey of nationally registered emergency medical services providers: pediatric education

STUDY OBJECTIVE

To survey emergency medical services (EMS) providers on a national level to determine and describe their perspective regarding their initial and continuing education (CE) needs in pediatrics.

METHODS

A 10-question survey was developed, pilot-tested, and sent to EMS providers as a part of their National Registry of Emergency Medical Technicians reregistration materials.

RESULTS

Surveys were completed by 18,218 EMS providers, a response rate of 67%. During a typical month, 60% of emergency medical technician-paramedics (EMT-Ps), 84% of EMT-intermediates (EMT-Is), and 87% of basic EMTs (EMT-Bs) care for 0 to 3 pediatric patients. CE was identified by all provider levels as the main source of their pediatric knowledge and skills. A state or national mandate for required CE in pediatrics was supported by 76% of surveyed providers. More than 70% of all providers responded they were comfortable to some degree with their own ability and their EMS system's ability when confronted with a critical pediatric call. Cost, availability, and travel distance were identified by all levels as the primary barriers to obtaining pediatric CE. All levels identified infants as the age of greatest concern if the provider was called to manage a critical case.

CONCLUSION

Surveyed practicing nationally registered EMS providers have infrequent contact with pediatric patients and have acquired most of their pediatric knowledge and skills from CE. In general, these providers are comfortable with their personal and their system's ability to care for children, but clearly support the need for required pediatric CE and identify the birth to 3-year age range as the priority for an educational focus. Cost, travel distance, and availability of pediatric CE are barriers that should be considered if pediatric CE is to be required of EMS providers.

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 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.

Pediatric cardiopulmonary resuscitation: a collective review

Little information is available about the effects of CPR in children, although it is known that the outcomes are dismal. Examples of unanswered questions include which advanced life support (ALS) procedures should be performed out-of-hospital, whether high-dose epinephrine improves survival, and the true prevalence of ventricular fibrillation as a presenting rhythm. Children differ from adults as to the cause and pathophysiology of cardiopulmonary arrest, but prehospital EMS and hospital resuscitation teams were initially designed for the care of adults. Because pediatric cardiopulmonary arrest is rare, prospective data are difficult to gather, and there are few large published studies. The purpose of this collective review was to review the current body of knowledge regarding survival rates and outcomes in pediatric CPR and, based on this review, to outline a course for future research.

Prehospital interventions in children

OBJECTIVES

Frequently performing procedures assists in skill maintenance. This study was conducted to characterize frequency and types of basic and advanced prehospital interventions performed on children.

METHODS

A retrospective study was conducted over a three-month period from emergency medical services (EMS) units working in central Michigan. Data were collected for age, sex, at-scene time, total run time, basic procedures (e.g., spinal immobilization), and advanced procedures (e.g., venous access).

RESULTS

A total of 535 EMS runs were reviewed. Runs were excluded for transport refusal (105) and site-to-site transfer (6). Of the remaining 424 children, 287 received an intervention (group 1) and 137 did not (group 2). Group 1 (9.5 +/- 5.6 years) was older (p < 0.001) than group 2 (6.0 +/- 5.8 years). There was no gender predominance between group 1 and group 2 (p = 0.06). In group 1 there were 104 patients who received multiple procedures. Basic procedures (n = 382) included spinal immobilization (149), oxygen administration (123), splinting (27), wound care (24), use of military anti-shock trousers (4), and cardiopulmonary resuscitation (1). Advanced procedures (n = 112) included venous access (65), medications of all routes (26), and cardiacoximetry monitoring (21). No child had an intraosseous line started and no child was successfully intubated. Only 82 of the 424 children (19.3%) had an advanced procedure. Group 1 at-scene times (16.1 +/- 8.1 min) were longer (p < 0.001) than those of group 2 (11.1 +/- 6.6 min). Total run times for group 1 (35.7 +/- 15.5 min) were longer (p < 0.001) than those for group 2 (26.7 +/- 11.3 min).

CONCLUSIONS

Advanced EMS procedures were performed on only 19.3% of children. Opportunities to perform critical interventions (e.g., intubation) were rarely present. Children receiving procedures were older and had longer scene and run times.