Medically unnecessary emergency medical services (EMS) transports among children ages 0 to 17 years

Pediatric Primary Care Provider Perspectives on Including Children in Alternative Emergency Medical Services Disposition Programs

INTRODUCTION

Many emergency medical services (EMS) agencies have implemented alternative disposition programs for low-acuity complaints, including transportation to clinics. Our objectives were to describe pediatric primary care providers' views on alternative EMS disposition programs.

METHOD

We conducted virtual focus groups with pediatric primary care providers. A hybrid inductive and deductive analytical strategy was used. Codes were grouped into themes by consensus.

RESULTS

Participants identified the benefits of alternative dispositions, including continuity of care, higher quality care, and freeing up emergency resources. Participants' concerns included undertriage, difficulty managing patients not previously known to a clinic, and inequitable implementation. Commonly identified logistical barriers included inadequate equipment, scheduling capacity, and coordinating triage.

DISCUSSION

Participants agreed there could be significant benefits from including clinics in EMS disposition programs. Participants identified several logistical constraints and raised concerns about patient safety and equitable implementation. These perspectives should be considered when designing pediatric alternative EMS disposition programs.

Prevalence of Low-Acuity Pediatric Emergency Medical Services Transports to a Pediatric Emergency Department in an Urban Area

OBJECTIVES

Many patients transported by Emergency Medical Services (EMS) do not have emergent resource needs. Estimates for the proportion of pediatric EMS calls for low-acuity complaints, and thus potential candidates for alternative dispositions, vary widely and are often based on physician judgment. A more accurate reference standard should include patient assessments, interventions, and dispositions. The objective of this study was to describe the prevalence and characteristics of low-acuity pediatric EMS calls in an urban area.

METHODS

This is a prospective observational study of children transported by EMS to a tertiary care pediatric emergency department. Patient acuity was defined using a novel composite measure that included physiologic assessments, resources used, and disposition. Bivariable and multivariable logistic regression were conducted to assess for factors associated with low-acuity status.

RESULTS

A total of 996 patients were enrolled, of whom 32.9% (95% confidence interval, 30.0-36.0) were low acuity. Most of the sample was Black, non-Hispanic with a mean age of 7 years. When compared with adolescents, children younger than 1 year were more likely to be low acuity (adjusted odds ratio, 3.1 [1.9-5.1]). Patients in a motor vehicle crash were also more likely to be low acuity (adjusted odds ratio, 2.4 [1.2-4.6]). All other variables, including race, insurance status, chief complaint, and dispatch time, were not associated with low-acuity status.

CONCLUSIONS

One third of pediatric patients transported to the pediatric emergency department by EMS in this urban area are for low-acuity complaints. Further research is needed to determine low-acuity rates in other jurisdictions and whether EMS providers can accurately identify low-acuity patients to develop alternative EMS disposition programs for children.

Emergency medical service use at a pediatric center in Turkey, during the COVID-19 pandemic period

AIM

This study aimed to evaluate aspects of pediatric patients presenting to a hospital in Turkey via emergency ambulance services, including incidence of visits to the hospital, acuity of illness and most common diagnoses, during the one-year period before and after the onset of the coronavrrus dsease 2019 (COVID-19) pandemic.

METHODS

This was a retrospective and single center analysis of children, transported by Emergency Medical Services to the Emergency Department (ED) of a children's hospital in Turkey, between 10 March 2019 and 11 March 2021.

RESULTS

Percentage of high acuity group (68.1% vs.76.9%) during pandemic period was significantly lower than prepandemic period (p < 0.001). On the contrary, the percentage of patients using emergency ambulance service with a low level of acuity increased during the pandemic period compared to the prepandemic period (31.9% vs. 23.1%) (p < 0.001). A significant decrease was observed in the cases of lower respiratory tract infections, febrile status epilepticus and excessive alcohol use during the pandemic period. No significant differences were found hospitalizations requiring PICU and mortality in ED during the pandemic period.

CONCLUSION

During the COVID-19 pandemic; also, a decrease in admissions was observed for those with high-risk conditions. On the contrary, an increase was detected in patients with low acuity levels. Efforts should be made to ensure access to safe and quality emergency care during the pandemic.

Effects of Closure of the Paediatric Department of a District Hospital on Regional Care: Analysis of Patient Flows

BACKGROUND

The consequences of economization and staff shortage in the German health care system strongly affect paediatric care structures, especially in rural regions. It is not known how closures of paediatric departments influence patient flows of surrounding hospitals. Here, we investigate the quantitative effects of closure of the paediatric department of a district hospital and the subsequent opening of an alternative inpatient service on the utilisation of inpatient and outpatient care services of the two neighboring hospitals and the emergency services of the region.

METHODOLOGY

In the observation period from 2015 to 2019, patient-related data from the three hospitals in the study region as well as data from the rescue service were evaluated.

RESULTS

In the year after the paediatric department of the district hospital was closed in 2016, the total number of inpatient cases in the region decreased by 33% (2015: n=1,787; 2016: n=1,193) and then decreased by an additional 11% (2019: n=1,005). The number of outpatient cases decreased by further 8% (2015: n=6,250; 2019: n=5,770). In the last observation year, emergency services were used much more frequently than in the year before the closure (2015: n=398; 2019: n=572). This means an increase of 44%.

CONCLUSION

After the closure of the paediatric department, the total number of inpatient cases in the region fell sharply. However, actual gaps in care apparently did not arise. Before closing, the consequences for the surrounding hospitals should be assessed more precisely. Real gaps in care must be counteracted, e. g. through alternative outpatient services.

Caregiver Perspectives on Including Children in Alternative Emergency Medical Services Disposition Programs: A Qualitative Study

OBJECTIVES

Almost half of pediatric EMS calls may be for low-acuity problems. Many EMS agencies have implemented alternative disposition programs for low-acuity patients, including transportation to clinics, substituting taxis for ambulances, and treatment in place without transport to an emergency department. Including children in such programs poses specific challenges, with one concern being potential caregiver opposition. Limited published evidence addresses caregiver perspectives on including children in alternative disposition programs. Our objective was to describe caregiver perspectives of alternative EMS disposition systems for low-acuity pediatric patients.

METHODS

We conducted six virtual focus groups (one in Spanish) with caregivers. A PhD-trained facilitator moderated all groups using a semi-structured moderator guide. A hybrid inductive and deductive analytical strategy was used. Multiple investigators independently coded a deidentified sample transcript. One team member then completed axial coding of the remaining transcripts. Thematic saturation was achieved. Clusters of similar codes were grouped into themes by consensus.

RESULTS

We recruited 38 participants. Participants had diverse race-ethnicity (39% non-Hispanic white, 29% non-Hispanic Black, and 26% Hispanic) and insurance status (42% Medicaid and 58% private health insurance). There was agreement that caregivers often utilize 9-1-1 for low-acuity complaints. Caregivers were generally supportive of alternative disposition programs, with some important caveats. Potential advantages of alternative dispositions included freeing up resources for more emergent cases, quicker access to care, and more cost-effective and patient-centered care. Caregivers had multiple concerns regarding the effects of alternative disposition programs, including timeliness in receiving care, capabilities of receiving sites (including pediatric expertise), and challenges to care coordination. Additional logistical concerns with alternative disposition programs for children included the safety of taxi services, the loss of parental autonomy, and the potential for inequitable implementation.

CONCLUSIONS

Caregivers in our study generally supported alternative EMS dispositions for some children and identified multiple potential benefits of such programs for both children and the health care system. Caregivers were concerned about the safety and logistical details of how such programs would be implemented and wanted to retain final decision-making authority. Caregiver perspectives should be considered when designing and implementing alternative EMS disposition programs for children.

The Child Opportunity Index and Pediatric Emergency Medical Services Utilization

Background: The delivery of emergency medical services (EMS) is a resource-intensive process, and prior studies suggest that EMS utilization in children may vary by socioeconomic status. The Child Opportunity Index (COI) provides a multidimensional measure of neighborhood-level resources and conditions that affect the health of children. We evaluated EMS utilization and measures of acuity among children by COI.Methods: We performed a cross-sectional study using encounters for patients less than 18 years of age from 10,067 EMS agencies in 47 US states and territories contributing to the National Emergency Medical Services Information System 2019 dataset. We compared patient demographics, EMS encounter characteristics, and care provided to children stratified by ZIP code using the COI 2.0.Results: We included 1,293,038 EMS encounters (median age 10 years, IQR 3-15 years). The distributions of encounters in the five tiers of COI were 30.6%, 20.1%, 18.0%, 16.3% and 15.1%, (from Very Low to Very High, respectively). The distribution of diagnoses between groups was similar. Most measures of EMS acuity/resource use were similar between groups, including non-transport status, cardiac arrest, vital sign abnormalities, and EMS-administered procedures and medications. Among children with respiratory-related encounters, children in the Very Low group had a greater need for nebulized medications (26.4% vs 18.3% in Very High COI children). Among children with trauma, a lower proportion in the Very Low group were given analgesia (4.0% vs 7.4% in the Very High group), though pain scores were similar in all groups.Conclusion: Pediatric EMS encounters from lower COI neighborhoods occur more frequently relative to encounters from higher COI neighborhoods. Despite these differences, children from lower COI strata generally have similar encounter characteristics to those in other COI strata, suggestive of a greater number of true out-of-hospital emergencies among children from these areas. Notable differences in care included use of respiratory medication to children with respiratory diagnoses, and administration of pain medication to children with trauma.

Health Inequities in Pediatric Trauma

This review article highlights the disparities evident in pediatric trauma care in the United States. Social determinants of health play a significant role in key aspects of trauma care including access to care, gun violence, child abuse, head trauma, burn injuries, and orthopedic trauma. We review the recent literature as it relates to these topics. The findings from these recent studies emphasize the important principle that trauma care for children should be designed with a focus on equity for all children.

Emergency Medical Services Clinicians' Perspectives on Pediatric Non-Transport

OBJECTIVES

Emergency medical services clinicians do not transport one-third of all children assessed, even without official pediatric non-transport protocols. Little is known about how EMS clinicians and caregivers decide not to transport a child. Our objectives were to describe how EMS clinicians currently decide whether or not to transport a child and identify barriers to and enablers of successfully implementing an EMS clinician-initiated pediatric non-transport protocol.

METHODS

We conducted six virtual focus groups with EMS clinicians from the mid-Atlantic. A PhD trained facilitator moderated all groups using a semi-structured moderator guide. Multiple investigators independently coded a deidentified sample transcript. One team member then completed axial coding of the remaining transcripts. Thematic saturation was achieved. Clusters of similar codes were grouped into themes by consensus.

RESULTS

We recruited 50 participants, of whom 70% were paramedics and 28% emergency medical technicians. There was agreement that caregivers often use 9-1-1 for low acuity complaints. Participants stated that non-transport usually occurs after shared decision-making between EMS clinicians and caregivers; EMS clinicians advise whether transport is necessary, but caregivers are responsible for making the final decision and signing refusal documentation. Subthemes for how non-transport decisions were made included the presence of agency protocols, caregiver preferences, absence of a guardian on the scene, EMS clinician variability, and distance to the nearest ED. Participants identified the following features that would enable successful implementation of an EMS clinician-initiated non-transport process: a user-friendly interface, clear protocol endpoints, the inclusion of vital sign parameters, resources to leave with caregivers, and optional direct medical oversight.

CONCLUSIONS

EMS clinicians in our study agreed that non-transport is currently a caregiver decision, but noted a collaborative process of shared decision-making where EMS clinicians advise caregivers whether transport is indicated. Further research is needed to understand the safety of this practice. This study suggests there may be a need for EMS-initiated alternative disposition/non-transport protocols.

Strengthening Behavioral Health Services Through Partnerships and Data Integration

Background

There has been an increase in emergency medical service (EMS) use for behavioral health reasons. Detroit Wayne Integrated Health Network (DWIHN) and Detroit East Medical Control Authority (DEMCA) collaborated to study the rising number of behavioral health (mental disorders and substance use disorders) calls to EMS.

Methodology

To examine the trend, DWIHN and DEMCA partnered on a data-sharing project and identified that a high volume of EMS runs (responses by EMS as a result of an emergency call) involved individuals served by DWIHN.

Results

Over a period of 2.5 years, an average of one-third (33.73%) of EMS runs involved individuals who receive behavioral health services through DWIHN.

Conclusions

DWIHN used the data to create interventions and internal process improvements that can help coordinate medical and behavioral healthcare for individuals who have been using EMS increasingly. The findings were also used to develop prevention efforts to decrease the occurrence of such crises and to avoid unwarranted member involvement with the justice system. We suggest that other comparable organizations consider similar partnerships, especially given the increasingly high EMS and Emergency Department use for behavioral health reasons.

The Prevalence and Characteristics of Non-Transports in a Provincial Emergency Medical Services System: A Population-Based Study

BACKGROUND

Emergency Medical Services (EMS) provide patients with out-of-hospital care, but not all patients are transported to the hospital. Non-transport represents an often undefined yet potentially significant risk for poor clinical outcomes. Few North American studies have quantified this risk.

OBJECTIVE

The objectives of this study were to determine the prevalence of non-transport and 48-h adverse event (composite of relapse responses that resulted in transport or death) and to identify characteristics associated with either outcome.

METHODS

An analysis of pooled cross-sectional, population-based administrative data from the provincial EMS electronic charting system in 2014 was conducted. Determination of non-transport was based on recorded call outcome. The data were searched by patient identifiers to determine the 48-h adverse event rate. Paramedic-documented patient, operational, and environmental characteristics were included in the logistic regression models.

RESULTS

Of 74,293 emergency responses, 14,072 (18.9%) were non-transport and, of those, 798 (5.6%) resulted in a 48-h adverse event. The characteristics statistically significantly and independently associated with non-transport and 48-h adverse event were younger age (odds ratio [OR] 1.72; 99.9% confidence interval [CI] 1.46-2.02), nonspecific paramedic clinical impression (OR 5; 99.9% CI 4.48-5.57), more than 7 comorbidities (OR 0.47; 99.9% CI 0.42-0.53), and incident location (jail) (OR 2.88; 99.9% CI 2.22-3.74).

CONCLUSIONS

This study provides an estimate of prevalence of non-transports and 48-h adverse event in a provincial mixed rural-urban EMS system. The results of this study describe the scope of non-transport and present several characteristics associated with non-transport. Future study should examine the appropriateness of EMS responses and methods to mitigate risk of adverse event after non-transport.

Lack of Health Insurance Coverage and Emergency Medical Service Transport for Pediatric Trauma Patients

INTRODUCTION

Pediatric trauma patients who lack insurance coverage may have less access to transport other than emergency medical services (EMS) or face financial barriers that prevent utilization of these services. We analyzed the association between health insurance coverage and EMS transport while controlling for injury and patient characteristics.

MATERIALS AND METHODS

De-identified Trauma Quality Programs registry data were queried for pediatric trauma patients age <18 y. The primary outcome was arrival by EMS (excluding interfacility transfer) versus private transport or walk-in, and the primary exposure was insurance coverage (any versus none). After exact matching on injury and facility characteristics, propensity matching was used to balance demographic covariates and comorbidities between insured and uninsured patients.

RESULTS

Of the 130,246 patients analyzed, 9501 (7%) did not have insurance coverage. After matching 9494 uninsured cases to 9494 insured controls, fixed-effects logistic regression found that uninsured patients had 18% greater odds of using EMS transport, compared to insured patients (odds ratio: 1.18; 95% confidence interval: 1.11, 1.26; P < 0.001). Results were similar when comparing uninsured patients to privately insured or publicly insured patients only.

CONCLUSIONS

Uninsured pediatric trauma patients have a higher likelihood of using EMS transport compared to insured patients with similar demographic and clinical characteristics, including the exact same score of injury severity. Lack of access to private transport may drive higher EMS utilization in uninsured patients with minor injuries and contribute to higher costs of pediatric trauma care borne by institutions and families.

Emergency Medical Service Utilization and Response Following COVID-19 Emergency and Stay-at-Home Policies: An Interrupted Time-Series Analysis

Objective

Examine changing emergency medical services (EMS) utilization and response patterns associated with coronavirus disease 2019 (COVID-19) emergency declaration and stay-at-home orders during the first year of the COVID-19 pandemic.

Methods

We conducted an uncontrolled interrupted time series analysis of EMS calls (January 1, 2019 - March 1, 2021) in Marin County, California analyzing call volume (All calls, n=46,055); patient refusal of EMS care or transport and patient care resolved on scene (Calls with opportunity for transport; n=37,401); and call severity (Transported calls; n=27,887).

Results

Pre-COVID-19 (1/1/2019-3/2/2020), EMS transported patients were predominately female (50.6%), 80+ years old (31.6%), and Marin County residents (68.0%). During COVID-19 (3/3/2020-3/1/2021), EMS transported patients were predominately male (52.7%), 35-64 years old (29.8%), and Marin County residents (70.4%). After the first stay-at-home order on 3/17/2020, call volume immediately decreased by 48% (adjusted incidence rate ratio [aIRR]=0.52; 95% CI=0.35,0.79) for children (0-15 years) and 34% for adults 80+ years (aIRR=0.66;95% CI=0.46,0.95). The odds of a transported call being prioritized as severe doubled (adjusted odds ratio [aOR]=2.26; 95% CI=1.11,4.59). Though transport refusals increased by 69% for children after the first order (aOR, 1.69 [95% CI, 1.13-2.52]), immediately following the second order on 12/8/2020, transport refusals decreased by 30% for children but increased 38-40% for adults 35-79 years (aOR=1.40 [95% CI=1.04-1.89] for 35-64 years; 1.38 [95% CI=1.02-1.87] for 65-79 years). Calls resolved on scene by EMS increased after the first order among all ages and after the second order for adults 16-79 years. 

Conclusions

Call volume reduced for children and older adults after the first COVID-19 stay-at-home order. Changes in call severity, patient care refusals, and on-scene care provided by EMS indicated a changing role for EMS during the outbreak.

What factors are associated with ambulance use for non-emergency problems in children? A systematic mapping review and qualitative synthesis

OBJECTIVE

To explore what factors are associated with ambulance use for non-emergency problems in children.

METHODS

This study is a systematic mapping review and qualitative synthesis of published journal articles and grey literature. Searches were conducted on the following databases, for articles published between January 1980 and July 2020: MEDLINE, EMBASE, PsycINFO, CINAHL and AMED. A Google Scholar and a Web of Science search were undertaken to identify reports or proceedings not indexed in the above. Book chapters and theses were searched via the OpenSigle, EThOS and DART databases. A literature advisory group, including experts in the field, were contacted for relevant grey literature and unpublished reports. The inclusion criteria incorporated articles published in the English language reporting findings for the reasons behind why there are so many calls to the ambulance service for non-urgent problems in children. Data extraction was divided into two stages: extraction of data to generate a broad systematic literature 'map', and extraction of data from highly relevant papers using qualitative methods to undertake a focused qualitative synthesis. An initial table of themes associated with reasons for non-emergency calls to the ambulance for children formed the 'thematic map' element. The uniting feature running through all of the identified themes was the determination of 'inappropriateness' or 'appropriateness' of an ambulance call out, which was then adopted as the concept of focus for our qualitative synthesis.

RESULTS

There were 27 articles used in the systematic mapping review and 17 in the qualitative synthesis stage of the review. Four themes were developed in the systematic mapping stage: socioeconomic status/geographical location, practical reasons, fear of consequences and parental education. Three analytical themes were developed in the qualitative synthesis stage including practicalities and logistics of obtaining care, arbitrary scoring system and retrospection.

CONCLUSIONS

There is a lack of public and caregiver understanding about the use of ambulances for paediatrics. There are factors that appear specific to choosing ambulance care for children that are not so prominent in adults (fever, reassurance, fear of consequences). Future areas for attention to decrease ambulance activation for paediatric low-acuity reports were highlighted as: identifying strategies for helping caregivers to mitigate perceived risk, increasing availability of primary care, targeted education to particular geographical areas, education to first-time parents with infants and providing alternate means of transportation.

PROSPERO REGISTRATION NUMBER

CRD42019160395.

Association of Insurance With Use of Emergency Medical Services Among Children

OBJECTIVE

The use of emergency medical services (EMS) can be lifesaving for critically ill children and should be defined by the child's clinical need. Our objective was to determine whether nonclinical demographic factors and insurance status are associated with EMS use among children presenting to the emergency department (ED).

METHODS

In this cross-sectional study using the National Hospital Ambulatory Medical Care Survey, we included children presenting to EDs from 2009 to 2014. We evaluated the association between EMS use and patients' insurance status using multivariable logistic regressions, adjusting for demographic, socioeconomic, and clinical factors such as illness severity as measured by a modified and recalibrated version of the Revised Pediatric Emergency Assessment Tool (mRePEAT) and the presence of comorbidities or chronic conditions. A propensity score analysis was performed to validate our findings.

RESULTS

Of the estimated 191,299,454 children presenting to EDs, 11,178,576 (5.8%) arrived by EMS and 171,145,895 (89.5%) arrived by other means. Children arriving by EMS were more ill [mRePEAT score, 1.13; 95% confidence interval (CI), 1.12-1.14 vs mRePEAT score, 1.01; 95% CI: 1.01-1.02] and more likely to have a comorbidity or chronic condition (OR: 3.17, 95% CI: 2.80-3.59). In the adjusted analyses, the odds of EMS use were higher for uninsured children and lower for children with public insurance compared with children with private insurance [OR (95% CI): uninsured, 1.41 (1.12-1.78); public, 0.77 (0.65-0.90)]. The propensity score analysis showed similar results.

CONCLUSIONS

In contrast to adult patients, children with public insurance are less likely to use EMS than children with private insurance, even after adjustment for illness severity and other confounders.

Drivers of ‘clinically unnecessary’ use of emergency and urgent care: the DEUCE mixed-methods study

Background

There is widespread concern about the pressure on emergency and urgent services in the UK, particularly emergency ambulances, emergency departments and same-day general practitioner appointments. A mismatch between supply and demand has led to interest in what can be termed ‘clinically unnecessary’ use of services. This is defined by the research team in this study as ‘patients attending services with problems that are classified as suitable for treatment by a lower urgency service or self-care’. This is a challenging issue to consider because patients may face difficulties when deciding the best action to take, and different staff may make different judgements about what constitutes a legitimate reason for service use.

Objectives

To identify the drivers of ‘clinically unnecessary’ use of emergency ambulances, emergency departments and same-day general practitioner appointments from patient and population perspectives.

Design

This was a sequential mixed-methods study with three components: a realist review; qualitative interviews (n = 48) and focus groups (n = 3) with patients considered ‘clinically unnecessary’ users of these services, focusing on parents of young children, young adults and people in areas of social deprivation; and a population survey (n = 2906) to explore attitudes towards seeking care for unexpected, non-life-threatening health problems and to identify the characteristics of someone with a tendency for ‘clinically unnecessary’ help-seeking.

Results

From the results of the three study components, we found that multiple, interacting drivers influenced individuals’ decision-making. Drivers could be grouped into symptom related, patient related and health service related. Symptom-related drivers were anxiety or need for reassurance, which were caused by uncertainty about the meaning or seriousness of symptoms; concern about the impact of symptoms on daily activities/functioning; and a need for immediate relief of intolerable symptoms, particularly pain. Patient-related drivers were reduced coping capacity as a result of illness, stress or limited resources; fear of consequences when responsible for another person’s health, particularly a child; and the influence of social networks. Health service-related drivers were perceptions or previous experiences of services, particularly the attractions of emergency departments; a lack of timely access to an appropriate general practitioner appointment; and compliance with health service staff’s advice.

Limitations

Difficulty recruiting patients who had used the ambulance service to the interviews and focus groups meant that we were not able to add as much as we had anticipated to the limited evidence base regarding this service.

Conclusions

Patients use emergency ambulances, emergency departments and same-day general practitioner appointments when they may not need the level of clinical care provided by these services for a multitude of inter-related reasons that sometimes differ by population subgroup. Some of these reasons relate to health services, in terms of difficulty accessing general practice leading to use of emergency departments, and to population-learnt behaviour concerning the positive attributes of emergency departments, rather than to patient characteristics. Social circumstances, such as complex and stressful lives, influence help-seeking for all three services. Demand may be ‘clinically unnecessary’ but completely understandable when service accessibility and patients’ social circumstances are considered.

Future work

There is a need to evaluate interventions, including changing service configuration, strengthening general practice and addressing the stressors that have an impact on people’s coping capacity. Different subgroups may require different interventions.

Study registration

This study is registered as PROSPERO CRD42017056273.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 15. See the NIHR Journals Library website for further project information.

Emergency Medical Services Utilization by Children

OBJECTIVE

The aim of this study was to compare demographic and clinical features of children (0-14 years old) who arrived at general emergency departments (EDs) by emergency medical services (EMS) to those who arrived by private vehicles and other means in a rural, 3-county region of northern California.

METHODS

We reviewed 507 ED records of children who arrived at EDs by EMS and those who arrived by other means in 2013. We also analyzed prehospital procedures performed on all children transported to an area hospital by EMS.

RESULTS

Children arriving by EMS were older (9.0 vs 6.0 years; P < 0.001), more ill (mean Severity Classification Score, 2.9 vs 2.4; P < 0.001), and had longer lengths of stay (3.6 vs 2.1 hours; P < 0.001) compared with children who were transported to the EDs by other means. Children transported by EMS received more subspecialty consultations (18.7% vs 6.9%; P < 0.05) and had more diagnostic testing, including laboratory testing (22.9% vs 10.6%; P < 0.001), radiography (39.7% vs 20.8%; P < 0.001), and computed tomography scans (16.8% vs 2.9%; P < 0.001). Children arriving by EMS were transferred more frequently (8.8% vs 1.6%; P < 0.001) and had higher mean Severity Classification Scores compared with children arriving by other transportation even after adjusting for age and sex (β = 0.48; 95% confidence interval, 0.35-0.61; P < 0.001). Older children received more prehospital procedures compared with younger children, and these were of greater complexity and a wider spectrum.

CONCLUSIONS

Children transported to rural EDs via EMS are more ill and use more medical resources compared with those who arrive to the ED by other means of transportation.

Factors Associated With Pediatric Nontransport in a Large Emergency Medical Services System

BACKGROUND

Pediatric patients attended to by emergency medical services (EMS) but not transported to the hospital are an at-risk population. We aimed to evaluate risk factors associated with nontransport by EMS in pediatric patients.

METHODS

We reviewed medical records of 24 agencies in a regional EMS system in Southwestern Pennsylvania between January 1, 2014, and December 31, 2017. We abstracted demographics (age, sex, medical complaint, median household income by zip code, race, ethnicity), clinical characteristics (abnormal vital signs by age, procedures done), and transport characteristics. We excluded patients ≥ 18 years, interfacility transfers, scene assists, cardiac arrest, and those without a patient encounter. We used unadjusted and adjusted logistic regression to identify factors associated with nontransport, reporting adjusted odds ratios (aOR) with 95% confidence intervals (CIs).

RESULTS

We included 30,663 pediatric patients (52.9% male, mean ± SD age = 8.5 ± 6.2 years), of whom 5,002 (16.3%) were nontransports. In adjusted analysis (aOR, 95% CI), nontransports were associated with medical categories of trauma (4.32, 3.57-5.23), respiratory (4.03, 3.09-5.26), toxicologic (2.53, 1.66-3.86), and syncope (5.97, 3.78-9.41). Nontransports were less likely for psychiatric (0.52, 0.34-0.79) complaints; for black patients compared to white (0.31, 0.26-0.37); and in patients 6 to <12 years (0.76, 0.65-0.90), 2 to <6 years (0.77, 0.65-0.91), 1 to <2 years (0.53, 0.42-0.66), and 1 month to 1 year (0.52, 0.40-0.66) compared to patients ≥ 12 years of age. Nontransport was associated with longer scene time (1.03, 1.02-1.04) and with fall compared to winter (1.29, 1.08-1.54) and was less likely in those with abnormal mental status (0.45, 0.33-0.62), medication administration (0.16, 0.08-0.31), or monitor application (0.10, 0.06-0.15).

CONCLUSION

Pediatric nontransports are associated with traumatic, respiratory, and toxicologic complaints and older age. These findings can facilitate development of refusal protocols and research on outcomes of these at-risk patients.

Initial assessment, level of care and outcome among children who were seen by emergency medical services: a prospective observational study

Background

The assessment of children in the Emergency Medical Service (EMS) is infrequent representing 5.4% of the patients in an urban area in the western part of Sweden. In Sweden, patients are assessed on scene by an EMS nurse whom independently decides on interventions and level of care. To aid the EMS nurse in the assessment a triage instrument, Rapid Emergency Triage and Treatment System-paediatrics (RETTS-p) developed for Emergency Department (ED) purpose has been in use the last 5 years. The aim of this study was to evaluate the EMS nurse assessment, management, the utilisation of RETTS-p and patient outcome.

Methods

A prospective, observational study was performed on 651 children aged < 16 years from January to December 2016. Statistical tests used in the study were Mann-Whitney U test, Fisher’s exact test and Spearman’s rank statistics.

Results

The dispatch centre indexed life-threatening priority in 69% of the missions but, of all children, only 6.1% were given a life threatening RETTS-p red colour by the EMS nurse. A total of 69.7% of the children were transported to the ED and, of these, 31.7% were discharged without any interventions. Among the non-conveyed patients, 16 of 197 (8.1%) visited the ED within 72 h but only two were hospitalised. Full triage, including five out of five vital signs measurements and an emergency severity index, was conducted in 37.6% of all children. A triage colour was not present in 146 children (22.4%), of which the majority were non-conveyed. The overall 30-day mortality rate was 0.8% (n = 5) in children 0–15 years.

Conclusions

Despite the incomplete use of all vital signs according to the RETTS-p, the EMS nurse assessment of children appears to be adapted to the clinical situation in most cases and the patients appear to be assessed to the appropriate level of care but indicating an over triage. It seems that the RETTS-p with full triage is used selectively in the pre-hospital assessment of children with a risk of death during the first 30 days of less than 1%.

Ambulance dispatch versus general practitioner home visit for highly urgent out-of-hours primary care

BACKGROUND

Patients with life-threatening conditions who contact out-of-hours primary care either receive a home visit from a GP of a GP cooperative (GPC) or are handed over to the ambulance service.

OBJECTIVE

The objective of this study was to determine whether highly urgent visits, after a call to the GPC, are delivered by the most appropriate healthcare provider: GPC or ambulance service.

METHODS

We performed a cross-sectional study using patient record data from a GPC and ambulance service in an urban district in The Netherlands. During a 21-month period, all calls triaged as life-threatening (U1) to the GPCs were included. The decision to send an ambulance or not was made by the triage nurse following a protocolized triage process. Retrospectively, the most appropriate care was judged by the patient's own GP, using a questionnaire.

RESULTS

Patient and care characteristics from 1081 patients were gathered: 401 GPC visits, 570 ambulance responses and 110 with both ambulance and GPC deployment. In 598 of 1081 (55.3%) cases, questionnaires were returned by the patients' own GP. About 40% of all visits could have been carried out with a lower urgency in retrospect, and almost half of all visits should have received a different type of care or different provider. In case of ambulance response, 60.7% concerned chest pain.

CONCLUSION

Research should be done on the process of triage and allocation of care to optimize labelling complaints with the appropriate urgency and to deploy the appropriate healthcare provider, especially for patients with chest pain.

Emergency medical services (EMS) versus non-EMS transport among injured children in the United States

OBJECTIVES

This study aimed to assess the proportions of injured children transported to trauma centers by different transportation modes and evaluate the effect of transportation mode on inter-facility transfer rates using the US national trauma registry.

METHODS

We analyzed data from the 2007-2012 National Trauma Data Bank (NTDB) to study trends of EMS versus non-EMS transport. Multivariable logistic regression was used to evaluate the association between transport mode and inter-facility transfer.

RESULTS

There were 286,871 pediatric trauma patients in the 2007-2012 NTDB; 45.8% arrived by ground ambulance, 8.6% arrived by air ambulance, and 37.5% arrived by non-EMS. From 2007 to 2012, there was no significant change in transportation mode. Moderate to severely injured patients (ISS>15) comprised 13.3% of arrivals by ground ambulance, 26.7% of arrivals by air ambulance, and 8.3% of arrivals by non-EMS; those who used EMS were significantly less likely to be transferred to another facility than patients who used non-EMS transport. Moderate and severe pediatric patients arriving by non-EMS to adult trauma centers were more often transferred than those arriving at mixed trauma centers (45.8% and 6.8%, respectively).

CONCLUSIONS

Over one third of US pediatric trauma patients used non-EMS transport to arrive at trauma centers. Moderate to severely injured children benefit from EMS transport and professional field triage to reach the appropriate trauma facility. Our study suggests that national efforts are needed to increase awareness among parents and the general public of the benefits of EMS transportation and care.

Pediatric Use of Emergency Medical Services: The Role of Chronic Illnesses and Behavioral Health Problems

OBJECTIVE

The increasing use of prehospital emergency medical services (EMS) and its contribution to rising emergency department use and healthcare costs point to the need for better understanding factors associated with EMS use to inform preventive interventions. Understanding patient factors associated with pediatric use of EMS will inform pediatric-specific intervention. We examined pediatric patient demographic and health factors associated with one-time and repeat use of EMS.

METHODS

We reviewed data from Baltimore City Fire Department EMS patient records over a 23-month period (2008-10) for patients under 21 years of age (n = 24,760). Repeat use was defined as involvement in more than one EMS incident during the observation period. Analyses compared demographics of EMS users to the city population and demographics and health problems of repeat and one-time EMS users. Health comparisons were conducted at the patient and incident levels of analysis.

RESULTS

Repeat users (n = 1,931) accounted for 9.0% of pediatric users and 20.8% of pediatric incidents, and were over-represented among the 18-20 year age group and among females. While trauma accounted for approximately one-quarter of incidents, repeat versus one-time users had a lower proportion of trauma-related incidents (7.2% vs. 26.7%) and higher proportion of medical-related incidents (92.6% vs. 71.4%), including higher proportions of incidents related to asthma, seizures, and obstetric/gynecologic issues. In patient-level analysis, based on provider or patient reports, greater proportions of repeat compared to one-time users had asthma, behavioral health problems (mental, conduct and substance use problems), seizures, and diabetes.

CONCLUSIONS

Chronic somatic conditions and behavioral health problems appear to contribute to a large proportion of the repeat pediatric use of this EMS system. Interventions may be needed to engage repeat users in primary care and behavioral health services, to train EMS providers on the recognition and management of behavioral health emergencies, and to improve family care and self-management of pediatric asthma and other chronic conditions.

Why do patients with 'primary care sensitive' problems access ambulance services? A systematic mapping review of the literature

OBJECTIVE

Emergency ambulance use for problems that could be managed in primary care continues to rise owing to complex reasons that are poorly understood. The objective of this systematic review is to draw together published evidence across a variety of study methodologies and settings to gain a better understanding of why patients seek help from ambulance services for these problems.

DESIGN

Systematic searches were undertaken across the MEDLINE, EMBASE, PsychINFO, CINAHL, Health Management Information Consortium and Health Management Information Service publication databases. Google Scholar, Web of Science, OpenSigle, EThOS and DART databases were also systematically searched for reports, proceedings, book chapters and theses, along with hand-searching of grey literature sources. Studies were included if they reported on findings examining patient, carer, health professional or service management interactions with ambulance services for primary care problems. All study methodologies and perspectives were of interest. Data were extracted, quality assessed and systematically mapped according to key findings through generation of an iterative framework.

RESULTS

A total of 31 studies met inclusion criteria. Findings were summarised across 5 broad categories: factors associated with individual patients; actions of care-givers and bystanders; population-level factors; health infrastructure factors; challenges faced by health professionals. A number of subcategories were developed to explore these factors in more detail.

CONCLUSIONS

This review reports important factors that may impact on ambulance use for primary care problems across a global setting, including demographic measures associated with deprivation, minority status and individual social circumstances. Categorising ambulance calls for primary care problems as 'inappropriate' is context dependant and may be unhelpful. Potential implications for triage and risk management strategies are discussed.

Emergency medical services system utilization over the last 10 years: what predicts transport of children?

OBJECTIVE

The aim of this study was to determine the predictors of pediatric ambulance transport and evaluate changes in utilization over a 10-year period.

METHODS

The National Health Ambulatory Medical Care Survey emergency department (ED) data for visits by children aged younger than 19 years from 2000 to 2009 were analyzed using logistic regression. Age, ethnicity, race, sex, triage level, time of arrival, injury/poisoning, insurance, disposition, critical patient status, metropolitan statistical area (MSA), region, and hospital type were used to predict the mode of arrival (ambulance or nonambulance). Significant variables were evaluated for trends over time.

RESULTS

Representing 209 million ED visits, 60,761 records were analyzed. Ambulance transport was more likely among children who were aged 12 to 18 years (P < 0.05), black (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.06-1.38), evaluated for an injury/poisoning (OR, 3.03; 95% CI, 2.75-3.34), publicly insured (OR, 1.16; 95% CI, 1.03-1.31), living in an MSA (OR, 1.73; 95% CI, 1.34-2.23), living in the northeast (P < 0.05), and overnight arrivals (OR, 1.47; 95% CI, 1.26-1.7). They were more likely to have an urgency of less than 15 minutes (OR, 4.46; 95% CI, 3.56-5.59), require admission (OR, 2.82; 95% CI, 2.33-3.41), and considered critical (OR, 5.15; 95% CI, 3.43-7.73). There was no significant change in ambulance utilization in children; however, about half of critical patients and over 80% of those with a high triage level did not arrive by ambulance.

CONCLUSIONS

Ambulance transport to the ED is used more often by teens, blacks, publicly insured, overnight arrivals, and those living in an MSA or the northeast. It is concerning that many children triaged with a high urgency or requiring critical care did not arrive by ambulance.

How well do General EMS 911 dispatch protocols predict ED resource utilization for pediatric patients?

INTRODUCTION

The use of Emergency Medical Services (EMS) for low-acuity pediatric problems is well documented. Attempts have been made to curb potentially unnecessary transports, including using EMS dispatch protocols, shown to predict acuity and needs of adults. However, there are limited data about this in children. The primary objective of this study is to determine the pediatric emergency department (PED) resource utilization (surrogate of acuity level) for pediatric patients categorized as "low-acuity" by initial EMS protocols.

METHODS

Records of all pediatric patients classified as "low acuity" and transported to a PED in winter and summer of 2010 were reviewed. Details of the PED visit were recorded. Patients were categorized and compared based on chief complaint group. Resource utilization was defined as requiring any prescription medications, labs, procedures, consults, admission or transfer. "Under-triage" was defined as a "low-acuity" EMS transport subsequently requiring emergent interventions.

RESULTS

Of the 876 eligible cases, 801 were included; 392/801 had no resource utilization while 409 of 801 had resource utilization. Most (737/801) were discharged to home; however, 64/801 were admitted, including 1 of 801 requiring emergent intervention (under-triage rate 0.12%). Gastroenterology and trauma groups had a significant increase in resource utilization, while infectious disease and ear-nose-throat groups had decreased resource utilization.

DISCUSSION

While this EMS system did not well predict overall resource utilization, it safely identified most low-acuity patients, with a low under-triage rate. This study identifies subgroups of patients that could be managed without emergent transport and can be used to further refine current protocols or establish secondary triage systems.

Technical report--racial and ethnic disparities in the health and health care of children

OBJECTIVE

This technical report reviews and synthesizes the published literature on racial/ethnic disparities in children's health and health care.

METHODS

A systematic review of the literature was conducted for articles published between 1950 and March 2007. Inclusion criteria were peer-reviewed, original research articles in English on racial/ethnic disparities in the health and health care of US children. Search terms used included "child," "disparities," and the Index Medicus terms for each racial/ethnic minority group.

RESULTS

Of 781 articles initially reviewed, 111 met inclusion criteria and constituted the final database. Review of the literature revealed that racial/ethnic disparities in children's health and health care are quite extensive, pervasive, and persistent. Disparities were noted across the spectrum of health and health care, including in mortality rates, access to care and use of services, prevention and population health, health status, adolescent health, chronic diseases, special health care needs, quality of care, and organ transplantation. Mortality-rate disparities were noted for children in all 4 major US racial/ethnic minority groups, including substantially greater risks than white children of all-cause mortality; death from drowning, from acute lymphoblastic leukemia, and after congenital heart defect surgery; and an earlier median age at death for those with Down syndrome and congenital heart defects. Certain methodologic flaws were commonly observed among excluded studies, including failure to evaluate children separately from adults (22%), combining all nonwhite children into 1 group (9%), and failure to provide a white comparison group (8%). Among studies in the final database, 22% did not perform multivariable or stratified analyses to ensure that disparities persisted after adjustment for potential confounders.

CONCLUSIONS

Racial/ethnic disparities in children's health and health care are extensive, pervasive, and persistent, and occur across the spectrum of health and health care. Methodologic flaws were identified in how such disparities are sometimes documented and analyzed. Optimal health and health care for all children will require recognition of disparities as pervasive problems, methodologically sound disparities studies, and rigorous evaluation of disparities interventions.

Do all pediatric patients who have a febrile seizure require transport by advanced life support?

OBJECTIVE

In the state of New Jersey, all pediatric patients who are transported to the hospital by emergency medical services for seizures are evaluated by both advanced life support (ALS) and basic life support (BLS) units. The state triage protocol mandates that a paramedic unit be dispatched. The purpose of this study is establish that the subset of those patients who experience simple febrile seizures could be safely transported by BLS, subsequently freeing much needed ALS resources.

METHODS

This study was performed using a retrospective chart review. Seventy-one consecutive patients who experienced febrile seizures and were transported to the Bristol-Meyers-Squib Children's Hospital/Robert Wood Johnson University Hospital via ALS were included. These patients were risk stratified into groups which were analyzed for interventions, including inpatient admission, medication delivery, intubation, or respiratory support.

RESULTS

From this analysis, we are identified factors in the history and physical examination of patients in the field that would help to classify the patient as having a "simple febrile seizure" and thus significantly lowering the risk of any potential negative outcome.

CONCLUSIONS

Simple febrile seizure patients are suitable for transport via BLS. Further studies should be done to confirm this conclusion.

Factors associated with ambulance requests for febrile seizures

The objective of this study was to determine factors associated with ambulance requests for febrile seizures. This study retrospectively investigated medical records of patients who visited the Emergency Care Unit at Tokyo Metropolitan Toshima Hospital in the 5-year period after April 2001. Subjects' basic characteristics (e.g., age and sex), medical history of febrile seizures, sibling and parental medical history of febrile seizures, and distance from hospital were investigated. In total, 310 subjects used ambulances, and 106 came to the hospital without requesting ambulances. The results of binomial logistic analysis indicated that factors associated with ambulance requests included patient's and parents' medical history of febrile seizures. Increasing awareness of febrile seizures and provision of a general public educational campaign are possible strategies to help decrease unnecessary ambulance requests. However, a medical history of febrile seizures among siblings revealed no association, indicating the need to conduct repeated early-stage interventions.