Survey of nationally registered emergency medical services providers: pediatric education

Establishing outcome-driven vital signs ranges for children in the prehospital setting

BACKGROUND

Vital signs are frequently used in pediatric prehospital assessments and guide protocol utilization. Common pediatric vital sign classification criteria identify >80% of children in the prehospital setting as having abnormal vital signs, though few receive lifesaving interventions (LSIs). We sought to identify data-driven thresholds for abnormal vital signs by evaluating their association with prehospital LSIs.

METHODS

We evaluated prehospital care records for children (<18 years) transported to the hospital during 2022 from a large, national repository of emergency medical services (EMS) patient encounters. Predictors of interest were heart rate (HR), respiratory rate (RR), systolic blood pressure (SBP), and pulse oximetry. HR, RR, and SBP were converted to Z-scores using age-based distributional models. Our outcome was potential LSIs, defined as performance of selected respiratory procedures, resuscitative interventions, or medication administrations. Using cut point analysis, we identified higher specificity (maximal specificity with a minimum of 25% sensitivity) and higher sensitivity (maximal sensitivity with a minimum of 25% specificity) ranges for each vital sign and evaluated measures of diagnostic accuracy.

RESULTS

We included 987,515 children (median age 10 years, IQR 2-15 years). An LSI occurred in 4.3% (2.1% with respiratory procedures, 1.2% with resuscitative interventions, and 2.0% with medication administration). HR, RR, and SBP demonstrated a U-shaped association with LSIs. Specificities ranged from 84.1% to 93.7% for higher specificity criteria, with RR demonstrating the best performance (sensitivity 84.6%, specificity 27.0%). Sensitivities ranged from 62.3% to 84.4% for higher sensitivity criteria.

CONCLUSIONS

Cut points for pediatric vital signs were associated with LSIs. Specific age-adjusted ranges can identify children at higher and lower risk for receipt of LSI. These ranges may be combined with other objective measures to improve the assessment of children in the prehospital setting, assist in optimizing protocol utilization, improve transport decision making, and guide destination selection.

An Analysis of Prehospital Pediatric Medication Dosing Errors after Implementation of a State-Wide EMS Pediatric Drug Dosing Reference

BACKGROUND

Medication dosing errors are common in prehospital pediatric patients. Prior work has shown the overall medication error rate by emergency medical services (EMS) in Michigan was 34.7%. To reduce these errors, the state of Michigan implemented a pediatric dosing reference in 2014 listing medication doses and volume to be administered.

OBJECTIVE

To examine changes in pediatric dosing errors by EMS in Michigan after implementation of the pediatric dosing reference.

METHODS

We conducted a retrospective review of the Michigan Emergency Medical Services Information System of children ≤ 12 years of age from June 2016-May 2017 treated by 16 EMS agencies. Agencies were a mix of public, private, third-service, and fire-based. A dosing error was defined as >20% deviation from the weight-appropriate dose listed on the pediatric dosing reference. Descriptive statistics with confidence intervals and standard deviations are reported.

RESULTS

During the study period, there were 9,247 pediatric encounters, of whom 727 (7.9%) received medications and are included in the study. There were 1078 medication administrations, with 380 dosing errors (35.2% [95% CI 25.3-48.4]). The highest error rates were for dextrose 50% (3/4 or 75% [95% CI 32.57-100.0]) and glucagon (3/4 or 75% [95% CI 32.57-100.0]). The next highest proportions of incorrect doses were opioids: intranasal fentanyl (11/16 or 68.8% [95% CI 46.04-91.46]) and intravenous fentanyl (89/130 or 68.5% [95% CI 60.47-76.45]). Morphine had a much lower error rate (24/51 or 47.1% [95% CI 33.36-60.76]). Midazolam had the third highest error rate, for intravenous (27/50 or 54.0% [95% CI (40.19-67.81]) and intramuscular (25/68 or 36.8% [95% CI 40.19-67.81]) routes. Epinephrine 1 mg/10 ml had an incorrect dosage rate of 35/119 (29.4% [95% CI 20.64-36.99]). Asthma medications had the lowest rate of incorrect dosing (albuterol sulfate 9/247 or 3.6% [95% CI 1.31-5.98]).

CONCLUSIONS

Medications administered to prehospital pediatric patients continue to demonstrate dosing errors despite pediatric dosing reference implementation. Although there have been improvements in error rates in asthma medications, the overall error rate has increased. Continued work to build patient safety strategies to reduce pediatric medication dosing errors by EMS is needed.

A Statewide Collaboration to Deliver and Evaluate a Pediatric Critical Care Simulation Curriculum for Emergency Medical Services

OBJECTIVE

Care of the critically ill child is a rare but stressful event for emergency medical services (EMS) providers. Simulation training can improve resuscitation care and prehospital outcomes but limited access to experts, simulation equipment, and cost have limited adoption by EMS systems. Our objective was to form a statewide collaboration to develop, deliver, and evaluate a pediatric critical care simulation curriculum for EMS providers.

METHODS

We describe a statewide collaboration between five academic centers to develop a simulation curriculum and deliver it to EMS providers. Cases were developed by the collaborating PEM faculty, reviewed by EMS regional directors, and based on previously published EMS curricula, a statewide needs assessment, and updated state EMS protocols. The simulation curriculum was comprised of 3 scenarios requiring recognition and acute management of critically ill infants and children. The curriculum was implemented through 5 separate education sessions, led by a faculty lead at each site, over a 6 month time period. We evaluated curriculum effectiveness with a prospective, interventional, single-arm educational study using pre-post assessment design to assess the impact on EMS provider knowledge and confidence. To assess the intervention effect on knowledge scores while accounting for nested data, we estimated a mixed effects generalized regression model with random effects for region and participant. We assessed for knowledge retention and self-reported practice change at 6 months post-curriculum. Qualitative analysis of participants' written responses immediately following the curriculum and at 6 month follow-up was performed using the framework method.

RESULTS

Overall, 78 emergency medical technicians (EMTs) and 109 paramedics participated in the curriculum over five separate sessions. Most participants were male (69%) and paramedics (58%). One third had over 15 years of clinical experience. In the regression analysis, mean pediatric knowledge scores increased by 9.8% (95% CI: 7.2%, 12.4%). Most (93% [95% CI: 87.2%, 96.5%]) participants reported improved confidence caring for pediatric patients. Though follow-up responses were limited, participants who completed follow up surveys reported they had used skills acquired during the curriculum in clinical practice.

CONCLUSION

Through statewide collaboration, we delivered a pediatric critical care simulation curriculum for EMS providers that impacted participant knowledge and confidence caring for pediatric patients. Follow-up data suggest that knowledge and skills obtained as part of the curriculum was translated into practice. This strategy could be used in future efforts to integrate simulation into EMS practice.

Emergency Medical Services Clinicians' Pediatric Destination Decision-Making: A Qualitative Study

Objective This study sought to identify factors that influence emergency medical services (EMS) clinicians' destination decision-making for pediatric patients. We also sought EMS clinicians' opinions on potential systems improvements, such as protocol changes and the use of evidence-based transport guidelines. Methods Thirty-six in-depth phone interviews were conducted using a semi-structured format. We utilized a modified Grounded Theory approach to understand the complicated decision-making processes of EMS personnel. Memo writing was used throughout the data collection and analysis processes in order to identify emerging themes. The research team utilized hierarchical coding of interview transcripts to organize data into sub-categories for final analysis.  Results EMS clinicians cited the perceived need for specialty care, the presence of a medical home, a desire for improved continuity of care, and the availability of aeromedical transport as factors that promoted transport to a pediatric specialty center. They voiced that children with emergent stabilization needs should be transported to the closest facility, however, they did not identify any specific medical conditions suitable for transport to non-specialty centers. EMS clinicians recommended improvements in pediatric-specific education, improved clarity of hospitals' pediatric capabilities, and the creation of a pediatric-specific destination decision-making tool. Conclusion This study describes specific factors that influence EMS clinicians' transport destination decision-making for pediatric patients. It also describes potential systems and educational improvements that may increase pediatric transport directly to definitive care. EMS clinicians are in support of specific designations for hospitals' pediatric capabilities and were in favor of the creation of a formal destination decision-making tool.

Effect of Repetitive Simulation Training on Emergency Medical Services Team Performance in Simulated Pediatric Medical Emergencies

OBJECTIVE

Emergency medical services (EMS) professionals infrequently transport children leading to difficulty in recognition and management of pediatric critical illness. Simulation provides an opportunity to train EMS professionals on pediatric emergencies. The objective of this study was to examine the effect of serial simulation training over 6 months on EMS psychomotor and cognitive performance during team-based care.

METHODS

This was a longitudinal prospective study of a simulation curriculum enrolling EMS professionals over a 6-month period during which they performed three high-fidelity simulations at 3-month intervals. The simulation scenarios included a 15-month-old seizure (T₀), 1-month-old with hypoglycemia (T₁), and 4-year-old clonidine ingestion (T₂). All scenarios were standardized and required recognition and management of respiratory failure and decompensated shock. Scenarios were videotaped and two investigators scored EMS team interventions during simulations using a standardized scoring tool. Inter-rater reliability was assessed on 30% of videos using kappa analysis. Volumes of administered intravenous fluid (IVF) and medications were measured to assess for errors in administration. The primary outcome was the change in scenario score from T₀ to T₂.

RESULTS

A total of 135 team-based simulations were conducted over the study period (48, 40, and 47 at T₀, T₁, and T₂, respectively). Inter-rater reliability between reviewers was very good (κ = 0.7). Median simulation score improved from T₀ to T₂ (24 vs 31, p < 0.001, maximum score possible = 42). The proportion of completed tasks increased across multiple categories including improved recognition of respiratory decompensation (19% vs. 56%), management of the pediatric airway (44% vs. 88%), and timeliness of vascular access (10% vs. 38%). Correct IVF administration varied by scenario (25% vs. 52% vs. 30%, p = 0.02).

CONCLUSION

Serial simulation improved EMS team-based care in both recognition and management of pediatric emergencies. A standardized pediatric simulation curriculum can be used to train EMS professionals on pediatric emergencies and improve performance.

Ready for Children Part II: Increasing Pediatric Care Coordination and Psychomotor Skills Evaluation in the Prehospital Setting

OBJECTIVES

Treating pediatric patients often invokes discomfort and anxiety among emergency medical service (EMS) personnel. As part of the process to improve pediatric care in the prehospital system, the Health Resources and Services Administration (HRSA) Emergency Services for Children (EMSC) Program implemented two prehospital performance measures -access to a designated pediatric care coordinator (PECC) and skill evaluation using pediatric equipment-along with a multi-year plan to aid states in achieving the measures. Baseline data from a survey conducted in 2017 showed that less than 25% of EMS agencies had access to PECC and 47% performed skills evaluation using pediatric equipment at least twice a year. To evaluate change over time, the survey was again conducted in 2020, and agencies that participated in both years are compared.

METHODS

A web-based survey was sent to EMS agency administrators in 58 states and territories from January to March 2020. Descriptive statistics, odds ratios, and 95% confidence intervals were conducted.

RESULTS

The response rate was 56%. A total of 5,221 agencies participated in both survey periods representing over 250,000 providers. The percentage of agencies reporting the presence of a PECC increased from 24% to 34% (p= <0.001). However, some agencies reported that they no longer had a PECC, while others reported having a PECC for the first time. Fifty percent (50%) of agencies conduct pediatric psychomotor skills evaluation at least twice/year, a 2% increase over time (p = 0.041); however, a third (34%) evaluate skills using pediatric equipment less than once a year. The presence of a PECC continues to be the variable associated with the highest odds (AOR 2.15, 95% CI 1.91-2.43) of conducting at least semi-annual skills evaluation.

CONCLUSIONS

There is an increase in the presence of pediatric care coordination and the frequency of pediatric psychomotor skills evaluation among national EMS agencies over time. Continued efforts to increase and sustain PECC presence should be an ongoing focus to improve pediatric readiness in the prehospital system.

Comparison of Four Methods of Paramedic Continuing Education in the Management of Pediatric Emergencies

Introduction: Finite resources limit the amount of time EMS agencies can dedicate to continuing education in pediatric emergencies. EMS instructors need effective, efficient, and affordable educational strategies for these high-risk, low frequency events.Objective: To compare the effectiveness of four training methods in management of pediatric emergencies for paramedics.Methods: A validated, performance-based, simulated clinical assessment module was used to provide a baseline measurement of paramedics' resuscitation skills during three simulated pediatric emergencies. Educational modules were developed that targeted deficiencies identified by the baseline assessment, including advanced pediatric life support skills, airway management, use of the Broselow-Luten Tape®, pediatric drug dose calculations and drug delivery, seizure management, and trauma assessment. Paramedics from five EMS agencies in Michigan were randomized to four education intervention groups. The control group used an existing, online, continuing education course. Three experimental groups were exposed to the same content during five, one-hour sessions conducted over 2.5 years. Instruction was delivered using high-fidelity, simulated case-based training, low-fidelity simulation training, or lecture with procedural skills lab, based on group assignment. After the training, all groups were tested within 4-6 months using methods identical to baseline testing.Results: One hundred forty-seven subjects completed the study. There were no differences in baseline skill levels among the four groups. Only the low fidelity simulation training group demonstrated improvement of combined scenario scores (p = 0.0008). Scores for targeted skills improved in one scenario in the high-fidelity group, two in the low-fidelity group, one in the lecture/lab group, and none in the control group.Conclusions: Although improvements in those skills included in the training were found in three groups, two hours of training in pediatric emergencies per year was insufficient to produce a substantial improvement overall. Expensive, high-fidelity simulators were not necessary for teaching pediatric resuscitation skills to paramedics; instructive scenarios using low-fidelity manikins and debriefings appear to be adequate. The content delivered by an online refresher course did not provide any improvement in performance as measured by simulated, case-based assessments.

Priorities for Prehospital Evidence-Based Guideline Development: A Modified Delphi Analysis

Objective: Few areas of prehospital care are supported by evidence-based guidelines (EBGs). We aimed to identify gaps in clinical and operational prehospital EBGs to prioritize future EBG development and research funding. Methods: Using modified Delphi methodology, we sought consensus among experts in prehospital care and EBG development. Five rounds of surveys were administered between October 2019 and February 2020. Round 1 asked participants to list the top three gaps in prehospital clinical guidelines and top three gaps in operational guidelines that should be prioritized for guideline development and research funding. Based on responses, 3 reviewers performed thematic analysis to develop a list of prehospital EBG gaps, with participant feedback in Round 2. In Round 3, participants rated each gap's importance using a 5-point Likert scale, and participants' responses were averaged. In Round 4, participants rank-ordered 10 gaps with the highest mean scores identified in Round 3. In Round 5, participants indicated their agreement with sets of the highest ranked gaps. Results: Of 23 invited participants, 14 completed all 5 rounds. In Rounds 1 and 2, participants submitted 65 clinical and 58 operational gaps, and thematic analysis identified 23 unique clinical gaps and 28 unique operational gaps. The final prioritized list of clinical EBG gaps was: 1) airway management in adult and pediatric patients, 2) care of the pediatric patient, and 3) management of prehospital behavioral health emergencies, with 79% of participants agreeing. The final prioritized list of operational EBG gaps was: 1) define and measure the impact of EMS care on patient outcomes, 2) practitioner wellness, and 3) practitioner safety in the out-of-hospital environment, with 86% of participants agreeing. Conclusions: This modified Delphi study identifies gaps in prehospital EBGs that, if prioritized for development and research funding, would be expected to have the greatest impact on prehospital clinical care and operations.

Level of Comfort With Pediatric Trauma Transports: Survey of Prehospital Providers

BACKGROUND

Unintentional injury is the leading cause of death in pediatric patients. Despite a heavy burden of pediatric trauma, prehospital transport and triage of pediatric trauma patients are not standardized. Prehospital providers report anxiety and a lack of confidence in transport, triage, and care of pediatric trauma patients.

MATERIALS AND METHODS

Prehospital transport providers with 3 organizations across southeast Georgia and northeast Florida were contacted via email (n = 146) and asked to complete 2 Web-based surveys to evaluate their comfort level with performing tasks in the transport of pediatric and adult trauma patients. Bivariate statistics and qualitative thematic analyses were performed to assess comfort with pediatric trauma transports.

RESULTS

Survey 1 (N = 35) showed that mean comfort levels of prehospital providers were significantly lower for pediatric patients than adult trauma patients in 7 out of 9 tasks queried, including airway management and interpreting children's physiology. The following themes emerged from survey 2 (N = 14) responses: additional clinical knowledge resources would be beneficial when caring for pediatric trauma patients, pediatric medication administration is a source of uncertainty, prehospital transport teams would benefit from additional pediatric trauma training, infrequent transport of pediatric trauma patients affects provider comfort level, and pediatric trauma generates higher levels of anxiety among providers.

DISCUSSION

Prehospital transport of pediatric trauma patients is infrequent and a source of anxiety for prehospital providers. Rigs should be equipped with a reference tool addressing crucial tasks and deficiencies in training.

Multicenter Evaluation of Prehospital Seizure Management in Children

BACKGROUND

Seizures are a common reason why emergency medical services (EMS) transports children by ambulance. Timely seizure cessation prevents neurologic morbidity, respiratory compromise, and mortality. Implementing recommendations from an evidence-based pediatric prehospital guideline may enhance timeliness of seizure cessation and optimize medication dosing.

OBJECTIVE

We compared management of pediatric prehospital seizures across several EMS systems after protocol revision consistent with an evidence-based guideline.

METHODS

Using a retrospective, cross-sectional approach, we evaluated actively seizing patients (0-17 years old) EMS transported to a hospital before and after modifying local protocols to include evidence-based recommendations for seizure management in three EMS agencies. We electronically queried and manually abstracted both EMS and hospital data at each site to obtain information about patient demographics, medications given, seizure cessation and recurrence, airway interventions, access obtained, and timeliness of care. The primary outcome of the study was the appropriate administration of midazolam based on route and dose. We analyzed these secondary outcomes: frequency of seizure activity upon emergency department (ED) arrival, frequency of respiratory failure, and timeliness of care.

RESULTS

We analyzed data for 533 actively seizing patients. Paramedics were more likely to administer at least one dose of midazolam after the protocol updates [127/208 (61%) vs. 232/325 (71%), p = 0.01, OR = 1.60 (95% CI: 1.10-2.30)]. Paramedics were also more likely to administer the first midazolam dose via the preferred intranasal (IN) or intramuscular (IM) routes after the protocol change [(63/208 (49%) vs. 179/325 (77%), p < 0.001, OR = 3.24 (2.01-5.21)]. Overall, paramedics administered midazolam approximately 14 min after their arrival, gave an incorrect weight-based dose to 130/359 (36%) patients, and gave a lower than recommended dose to 94/130 (72%) patients. Upon ED arrival, 152/533 (29%) patients had a recurrent or persistent seizure. Respiratory failure during EMS care or subsequently in the ED occurred in 90/533 (17%) patients.

CONCLUSIONS

Implementation of an evidence-based seizure protocol for EMS increased midazolam administration. Patients frequently received an incorrect weight-based dose. Future research should focus on optimizing administration of the correct dose of midazolam to improve seizure cessation.

Assessing the effectiveness of pediatric emergency medicine education in emergency medicine residency training: A national survey

Background:

Evaluating the effectiveness of pediatric emergency medicine training is essential to ensure that emergency physicians and emergency medicine residents have sufficient knowledge, skill, and confidence in optimizing care for acute pediatric visits. Although the field of pediatric emergency medicine has experienced phenomenal growth in past decades, it still faces challenges in how to best implement the curriculums in emergency medicine residency training programs.

Objectives:

Exploring emergency physicians’ and emergency residents’ perspectives on pediatric emergency medicine training in emergency residency training programs in Taiwan through a nationwide survey.

Methods:

The survey was distributed to 1281 emergency physicians and emergency medicine residents in 43 teaching hospitals. The survey inquired about demographic data, hospital type, rank of proctored trainers and assessors, and the setting of pediatric emergency medicine training. Participants’ confidence in managing acute pediatric visits and their satisfaction and reflections of their pediatric emergency medicine training were explored.

Results:

In all, 258 responses were received from 117 residents and 141 emergency physicians. Seventy-seven percent reported working in medical centers. Clinical supervision was primarily performed by pediatric attending physicians and emergency physicians. Fifty-eight percent of participants felt satisfied with their pediatric emergency medicine training. However, only 52.3% felt confident managing acute pediatric visits, which was attributed to inadequate exposure to pediatric patients. Residents noted lack of confidence in managing newborns, infants, and clinical procedures. Therefore, simulation training and point-of-care ultrasound learning were considered advantageous.

Conclusion:

The pediatric emergency medicine training in emergency medicine residency programs is diverse in intensive care training, supervisors, and assessors. Surveys demonstrate that learning experience in pediatric wards and emergency department rotations is associated with overall satisfaction with pediatric emergency medicine training; inadequate exposure to pediatric patients contributed to learners having less confidence. Emergency medicine residency program reform might focus on adequate hands-on pediatric patient care.

Success of Pediatric Intubations Performed by a Critical Care Transport Service

Background: Prehospital pediatric endotracheal intubation (ETI) is rarely performed. Previous research has suggested that pediatric prehospital ETI, when performed by ground advanced life support crews, is associated with poor outcomes. In this study, we aim to evaluate the first-attempt success rate, overall success rate and complications of pediatric prehospital ETI performed by critical care transport (CCT) personnel.Methods: We conducted a retrospective observational study in a multi-state CCT service performing rotor wing, ground, and fixed wing missions. We included pediatric patients (<18 years) for whom ETI was performed by CCT personnel (flight nurse or flight paramedic).Our primary outcome of interest was rate of first-attempt ETI. Secondary outcomes were overall rates of successful ETI, complications encountered, and outcomes of patients with unsuccessful intubation.Results: 993 patients were included (63.2% male, median age 12 years, IQR 4-16 years). 807/993 (81.3%) patients were intubated on the first attempt. Lower rates of successful first-attempt intubation were seen in younger ages (42.9% in infants ≤30 days of age). In multivariable logistic regression, lower odds (adjusted odds ratio, 95% confidence interval) of successful first-attempt ETI were associated with ages >30 days to <1 year (0.33, 0.18-0.61) and 2 to <6 years (0.60, 0.39-0.94) compared to patients 12 to <18 years. Patients given an induction agent and neuromuscular blockade (NMB) had a higher odds of first-attempt ETI success (1.53, 1.06-2.15). 13 (1.3%) had immediately recognized esophageal intubation and 33 (3.3%) had vomiting. No episodes of pneumothorax were reported. 962/993 (96.9%) patients were successfully intubated after all attempts. In patients without successful ETI (n = 31), supraglottic airways were used in 24, bag-valve mask ventilation in 5, and surgical cricothyroidotomy in 2, with an overall advanced airway success rate of 988/993 (99.5%).Conclusion: Critical care flight nurses and paramedics performed successful intubations in pediatric patients at a high rate of success. Younger age was associated with lower success rates. Improved ETI training for younger patients and use of an induction agent and NMB may improve airway management in critically ill children.

Pediatric Readiness in Emergency Medical Services Systems

This is a joint policy statement from the American Academy of Pediatrics, American College of Emergency Physicians, Emergency Nurses Association, National Association of Emergency Medical Services Physicians, and National Association of Emergency Medical Technicians on pediatric readiness in emergency medical services systems.

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.

Paramedic-Identified Enablers of and Barriers to Pediatric Seizure Management: A Multicenter, Qualitative Study

Background: Seizures have the potential to cause significant morbidity and mortality, and are a common reason emergency medical services (EMS) are requested for a child. An evidence-based guideline (EBG) for pediatric prehospital seizures was published and has been implemented as protocol in multiple EMS systems. Knowledge translation and protocol adherence in medicine can be incomplete. In EMS, systems-based factors and providers' attitudes and beliefs may contribute to incomplete knowledge translation and protocol implementation. Objective: The purpose of this study was to identify paramedic attitudes and beliefs regarding pediatric seizure management and regarding potential barriers to and enablers of adherence to evidence-based pediatric seizure protocols in multiple EMS systems. Methods: This was a qualitative study utilizing semi-structured interviews of paramedics who recently transported actively seizing 0-17 year-old patients in 3 different urban EMS systems. Interviewers explored the providers' decision-making during their recent case and regarding seizures in general. Interview questions explored barriers to and enablers of protocol adherence. Two investigators used the grounded theory approach and constant comparison to independently analyze transcribed interview recordings until thematic saturation was reached. Findings were validated with follow-up member-checking interviews. Results: Several themes emerged from the 66 interviewed paramedics. Enablers of protocol adherence included point-of-care references, the availability of different routes for midazolam and availability of online medical control. Systems-level barriers included equipment availability, controlled substance management, infrequent pediatric training, and protocol ambiguity. Provider-level barriers included concerns about respiratory depression, provider fatigue, preferences for specific routes, febrile seizure perceptions, and inaccurate methods of weight estimation. Paramedics suggested system improvements to address dose standardization, protocol clarity, simplified controlled substance logistics, and equipment availability. Conclusions: Paramedics identified enablers of and barriers to adherence to evidence-based pediatric seizure protocols. The identified barriers existed at both the provider and systems levels. Paramedics identified multiple potential solutions to overcome several barriers to protocol adherence. Future research should focus on using the findings of this study to revise seizure protocols and to deploy measures to improve protocol implementation. Future research should also analyze process and outcome measures before and after the implementation of revised seizure protocols informed by the findings of this study.

Emergency Medical Responders and Adolescents With Autism Spectrum Disorder

OBJECTIVES

Because of the high prevalence of Autism Spectrum Disorder (ASD) and wandering behavior, emergency medical responders (EMRs) will likely encounter children and adolescents with ASD. The objectives were to describe interactions between EMRs and children and adolescents with ASD, to evaluate EMRs' ability to recognize ASD in a simulated trauma setting, and to determine if EMRs' demographic characteristics affected their interactions with ASD youth.

METHODS

A study of 75 videos of a simulated school bus crash was performed. The simulation included an adolescent with ASD portrayed by an actor. Videos were coded based on 5 domains: (1) reassurance attempts by the EMR, (2) quality of the EMR's interactions, (3) EMR's elicitation of information, (4) EMR's interactions with others, and (5) EMR's recognition of a disability. Two clinicians coded the videos independently, and consensus was reached for any areas of disagreement.

RESULTS

Of 75 interactions, 27% provided reassurance to the adolescent with ASD, 1% elicited information, 11% asked bystanders for information or assistance, and 35% suggested a disability with 13% considering ASD. No differences across domains were found based on the EMR's sex. Emergency medical responders with greater than or equal to 5 years of experience were significantly more likely to elicit information than those with less than 5 years of experience, and paramedics had significantly higher total performance scores than paramedic students or those with EMT-Basic.

CONCLUSIONS

Few EMRs in this study optimally interacted with adolescents with ASD or recognized a disability. These findings suggest a strong need for targeted educational interventions.

Emergency Medical Services Provider Perspectives on Pediatric Calls: A Qualitative Study

Objective: Previous research indicates that 9-1-1 response to incidents involving children is particularly distressing for emergency medical services (EMS) clinicians. This qualitative study was conducted to increase understanding about the difficulties of responding to pediatric calls and to obtain information about how organizations can better support EMS providers in managing potentially difficult calls. Methods: Paramedics and emergency medical technicians from a single U.S. ambulance service were invited to participate in focus groups about responding to 9-1-1 calls involving pediatric patients. A total of 17 providers from both rural and metro service regions participated in six focus groups held in community meeting spaces. A semi-structured focus group guide was used to explore (1) elements that make pediatric calls difficult, (2) pre-arrival preparation practices, (3) experiences with coping after difficult pediatric calls, and (4) perspectives about offered and desired resources or support. Focus groups were audio recorded and transcripts were analyzed using standard coding, memoing, and content analysis methods in qualitative analysis software (NVivo). Results: Responses about elements that make pediatric calls difficult were organized into the following themes: (1) special social value of children, (2) clinical difficulties with pediatric patients, (3) added acuity to already challenging calls, (4) caregivers as secondary patient, and (5) identifying with patient or patient's family. Pre-arrival preparation methods included mental or verbal review of hypothetical scenarios and refocusing nerves or emotions back to the technical aspect of the job. Participants described using available resources that largely took the form of social support. Suggestions for additional resources included: increased opportunities for external feedback; more frequent pediatric clinical training; institutionalization of recovery time after difficult calls; and improved storage and labeling of pediatric equipment. Conclusions: This study provides qualitative data about the difficulties of responding to pediatric calls and resources needed to support clinicians. Findings from this study can be used to guide EMS leaders in designing and implementing institutional initiatives to enhance training and support for prehospital clinicians providing care to children.

A needs assessment for simulation-based training of emergency medical providers in Nebraska, USA

Background

Training emergency medical services (EMS) workforce is challenging in rural and remote settings. Moreover, critical access hospitals (CAHs) struggle to ensure continuing medical education for their emergency department (ED) staff. This project collected information from EMS and ED providers across Nebraska to identify gaps in their skills, knowledge, and abilities and thus inform curriculum development for the mobile simulation-based training program.

Methods

The needs assessment used a three-step process: (1) four facilitated focus group sessions were conducted in distinct geographical locations across Nebraska to identify participants’ perceived training gaps; (2) based on the findings from the focus group, a needs assessment survey was constructed and sent to all EMS and ED staff in Nebraska; and (3) 1395 surveys were completed and analyzed.

Results

Thematic areas of training gaps included cardiopulmonary conditions, diabetes management, mass casualty incidents (MCI), maternal health and child delivery, patient assessment, pediatric care (PC), and respiratory emergency care. Gaps in non-clinical skills were related to crisis management such as maintaining effective teamwork. Participants frequently identified cardiopulmonary care, PC, and MCI as highly needed trainings. Other needs included life support-related retaining courses, sessions informing protocol updates, the availability of retraining tailored for rural areas, substance use-related emergencies, and farming-related injuries.

Conclusion

EMS and ED staff identified several skill gaps and training needs in the provision of emergency services in rural communities. These results allow for the development of customized training curricula and, with the help of an on-site simulation-based program, can identify gaps in health professionals’ skills, knowledge, and abilities and thus help them respond to acute healthcare needs of rural communities.

Differences in Prehospital Patient Assessments for Pediatric Versus Adult Patients

OBJECTIVE

To evaluate whether completion of vital signs assessments in pediatric transports by emergency medical services (EMS) differs by patient age.

STUDY DESIGN

We reviewed records by 20 agencies in a regional EMS system in Southwestern Pennsylvania between April 1, 2013 and December 31, 2016. We abstracted demographics, vital signs (systolic blood pressure, heart rate, respiratory rate), clinical, and transport characteristics. We categorized age as neonates (≤30 days), infants (1 month to <1 year), toddler (1 to <2 years), early childhood (2 to <6 years), middle childhood (6 to <12 years), adolescent (12 to <18 years), and adult (≥18 years). We used unadjusted and adjusted logistic regression to test if age group was associated with vital signs documentation, reporting of Glasgow Coma Scale and pain scale after trauma, and recording of oxygen saturation and breath sounds in respiratory complaints, using adults as the reference group.

RESULTS

In total, 371 746 cases (21 883 pediatric, 5.9%) were included. In adjusted analysis, most pediatric categories had reduced odds of complete vitals documentation (percent, OR, 95% CI): neonates (49.6%, 0.02, 0.02-0.03), infants (68.2%, 0.04, 0.03-0.04), toddlers (78.1%, 0.07, 0.06-0.07), early childhood (87.4%, 0.13, 0.12-0.15), and middle childhood (95.3%, 0.54, 0.46-0.63). Pain score documentation was lower in children after trauma (OR 0.80, 95%CI 0.76-0.85), and oxygen saturation documentation was lower in children with respiratory complaints (OR 0.20, 95%CI 0.18-0.25).

CONCLUSIONS

Pediatric patients were at increased risk of lacking vital signs documentation during prehospital care. This represents a critical area for education and quality improvement.

60 Seconds to Survival: A Multisite Study of a Screen-based Simulation to Improve Prehospital Providers Disaster Triage Skills

OBJECTIVES

Paramedics and emergency medical technicians (EMTs) perform triage at disaster sites. There is a need for disaster triage training. Live simulation training is costly and difficult to deliver. Screen-based simulations may overcome these training barriers. We hypothesized that a screen-based simulation, 60 Seconds to Survival (60S), would be associated with in-game improvements in triage accuracy.

METHODS

This was a prospective cohort study of a screen-based simulation intervention, 60S. Participants included emergency medical services (EMS) personnel from 21 EMS agencies across 12 states. Participants performed assessments (e.g., check for pulse) and actions (e.g., reposition the airway) for 12 patients in each scenario and assigned color-coded triage levels (red, yellow, green, or black) to each patient. Participants received on-screen feedback about triage performance immediately after each scenario. A scoring system was designed to encourage accurate and timely triage decisions. Participants who played 60S included practicing EMTs, paramedics, and nurses as well as students studying to assume these roles. Participants played the game at least three times over 13 weeks.

RESULTS

In total, 2,234 participants began game play and 739 completed the study and were included in the analysis. Overall, the median number of plays of the game was just above the threshold inclusion criteria (three or more plays) with a median of four plays during the study period (interquartile range [IQR] = 3-7). There was a significant difference in triage accuracy from the first play of the game to the last play of the game. Median baseline triage accuracy in the game was 89.7% (IQR = 82.1%-94.9%), which then increased to a median of 100% at the last game play (IQR = 87.5%-100.0%; p < 0.001). There was some variability in median triage accuracy on fourth through 11th game plays, ranging from 95% to 100%, and on the 12th to 16th plays, the median accuracy was sustained at 100%. There was a significant decrease in the rate of undertriage: from 10.3% (IQR = 5.1%-18.0%) to 0 (IQR = 0%-12.5%; p < 0.001).

CONCLUSION

60 Seconds to Survival is associated with improved in-game triage accuracy. Further study of the correlation between in-game triage accuracy and improvements in live simulation or real-world triage decisions is warranted.

Parental and Pediatricians' Perception of Need for Subspecialty Training in Pediatric Emergency Medicine for Delivering Emergency Care to Pediatric Patients

The quality of pediatric emergency care may depend on the competence of the emergency department physicians. It is important to know whether parents and general pediatricians associate the quality of pediatric emergency care with the pediatric emergency medicine (PEM) training of the emergency department physicians. We designed the study to determine parental and pediatricians’ opinion and expectation in regard to this question. Most of the surveyed parents’ and pediatricians’ recognize the importance of PEM training and believed that physicians trained in PEM can provide better emergency care for children. However, 53.8% of parents, especially Spanish speaking and with Medicaid/no insurance coverage, believe that the emergency care provided for their children by general pediatricians and PEM physicians is equivalent. The results of our study could be utilized by accredited PEM planners in the creation of strategies to ensure the quality of emergency care for children population.

Impact of an Offline Pain Management Protocol on Prehospital Provider Self-Efficacy: A Randomized Trial

BACKGROUND

Pain in children is inadequately treated in the prehospital setting despite the reported recognition by prehospital providers (PHPs) of pain treatment as an important part of patient care. The impact of pediatric pain management protocol (PPP) implementation on PHP self-efficacy (SE), a measure congruent with performance, is unknown.

OBJECTIVE

The aim of this study was to evaluate the impact of PPP implementation and pain management education on PHP SE.

METHODS

This was a prospective study evaluating the change in PHP SE after a PPP was implemented. Prehospital providers were randomized to 3 groups: protocol introduction alone, protocol introduction with education, and protocol introduction with education and a 3-month interim review. Prehospital provider SE was assessed for pain management given 3 age-based scenarios. Self-efficacy was measured with a tool that uses a ranked ordinal scale ranging from "certain I cannot do it" (0) to "completely certain I can do it" (100) for 10 pain management actions: pain assessment (3), medication administration (4), dosing (1), and reassessment (2). An averaged composite score (0-100) was calculated for each of the 3 age groups (adult, child, toddler). Paired-sample t tests compared post-PPP and 13-month scores to pre-PPP scores.

RESULTS

Of 264 PHPs who completed initial surveys, 142 PHPs completed 13-month surveys. Ninety-three (65%) received education with protocol review, and 49 (35%) had protocol review only. Self-efficacy scores increased over the study period, most notably for pain assessment. This increase persisted at 13 months for child (6.6 [95% confidence interval {CI}, 1.4-11.8]) and toddler pain assessment (22.3 [95% CI, 16.4-28.3]). Composite SE scores increased immediately for all age groups (adult, 3.1 [95% CI, 1.3-4.9]; child, 6.1 [95% CI, 3.8-8.5]; toddler, 12.0 [95% CI, 9.5-14.5]) and persisted at 13 months for the toddler group alone (7.0 [95% CI, 4.3-9.7]). There was no difference between groups who received protocol review alone compared with those with education or education plus a 3-month interim review.

CONCLUSIONS

After a pain management protocol was introduced, SE scores among PHPs increased immediately and remained elevated for some individual actions involved in pain management, most notably pain assessment. Prehospital provider pain assessment SE scores declined 13 months after protocol introduction for adults, but remained elevated compared with baseline for the pediatric age groups.

Improving Pediatric Education for Emergency Medical Services Providers: A Qualitative Study

OBJECTIVES

Previous studies have illustrated pediatric knowledge deficits among Emergency Medical Services (EMS) providers. The purpose of this study was to identify perspectives of a diverse group of EMS providers regarding pediatric prehospital care educational deficits and proposed methods of training improvements.

METHODS

Purposive sampling was used to recruit EMS providers in diverse settings for study participation. Two separate focus groups of EMS providers (administrative and non-administrative personnel) were held in three locations (urban, suburban, and rural). A professional moderator facilitated focus group discussion using a guide developed by the study team. A grounded theory approach was used to analyze data.

RESULTS

Forty-two participants provided data. Four major themes were identified: (1) suboptimal previous pediatric training and training gaps in continuing pediatric education; (2) opportunities for improved interactions with emergency department (ED) staff, including case-based feedback on patient care; (3) barriers to optimal pediatric prehospital care; and (4) proposed pediatric training improvements.

CONCLUSION

Focus groups identified four themes surrounding preparation of EMS personnel for providing care to pediatric patients. These themes can guide future educational interventions for EMS to improve pediatric prehospital care. Brown SA , Hayden TC , Randell KA , Rappaport L , Stevenson MD , Kim IK . Improving pediatric education for Emergency Medical Services providers: a qualitative study. Prehosp Disaster Med. 2017;32(1):20-26.

The Demographics and Education of Emergency Medical Services (EMS) Professionals: A National Longitudinal Investigation

Objectives

The objectives of this study were to assess longitudinal and cross-sectional changes in Emergency Medical Technician (EMT)-Basics and Paramedics: (1) demographics, (2) employment characteristics, and (3) initial Emergency Medical Services (EMS) education.

Methods

These data were collected between 1999 and 2008 employing survey techniques aimed at collecting valid data. A random, stratified sample was utilized to allow results to be generalizable to the nationally certified EMS population. Survey weights that were adjusted for each stratum’s response were estimated. Weighted percentages, averages for continuous variables, and 95% confidence intervals (CIs) were calculated. Significant changes over time were noted when the CIs did not overlap.

Results

In all 10 years of data collection, the proportion of EMT-Paramedics who were male was greater than the proportion of EMT-Basics who were male. A substantial proportion of respondents performed EMS services for more than one agency: between 39.8% and 43.5% of EMT-Paramedics and 18.4% and 22.4% of EMT-Basic respondents reported this. The most common type of employer for both EMT-Basics and EMT-Paramedics was fire-based organizations. About one-third of EMT-Basics (32.3%-40.1%) and almost one-half of EMT-Paramedics (43.1%-45.3%) reported that these organizations were their main EMS employer. Rural areas (<25,000 residents) were the most common practice settings for EMT-Basics (52.1%-63.7%), while more EMT-Paramedics worked in urban settings (65.2%-77.7%).

Conclusions

This analysis serves as a useful baseline to measure future changes in the EMS profession. This study described the demographic and work-life characteristics of a cohort of nationally certified EMT-Basics and Paramedics over a 10-year period. This analysis also summarized initial EMS education changes over time.

BentleyMA, ShobenA, LevineR. The demographics and education of Emergency Medical Services (EMS) professionals: a national longitudinal investigation. Prehosp Disaster Med. 2016;31(Suppl. 1):s18–s29.

Comparison of Errors Using Two Length-Based Tape Systems for Prehospital Care in Children

BACKGROUND

The use of a length/weight-based tape (LBT) for equipment size and drug dosing for pediatric patients is recommended in a joint statement by multiple national organizations. A new system, known as Handtevy™, allows for rapid determination of critical drug doses without performing calculations.

OBJECTIVE

To compare two LBT systems for dosing errors and time to medication administration in simulated prehospital scenarios.

METHODS

This was a prospective randomized trial comparing the Broselow Pediatric Emergency Tape™ (Broselow) and Handtevy LBT™ (Handtevy). Paramedics performed 2 pediatric simulations: cardiac arrest with epinephrine administration and hypoglycemia mandating dextrose. Each scenario was repeated utilizing both systems with a 1-year-old and 5-year-old size manikin. Facilitators recorded identified errors and time points of critical actions including time to medication.

RESULTS

We enrolled 80 paramedics, performing 320 simulations. For Dextrose, there were significantly more errors with Broselow (63.8%) compared to Handtevy (13.8%) and time to administration was longer with the Broselow system (220 seconds vs. 173 seconds). For epinephrine, the LBTs were similar in overall error rate (Broselow 21.3% vs. Handtevy 16.3%) and time to administration (89 vs. 91 seconds). Cognitive errors were more frequent when using the Broselow compared to Handtevy, particularly with dextrose administration. The frequency of procedural errors was similar between the two LBT systems.

CONCLUSION

In simulated prehospital scenarios, use of the Handtevy LBT system resulted in fewer errors for dextrose administration compared to the Broselow LBT, with similar time to administration and accuracy of epinephrine administration.

Impact of High-Fidelity Pediatric Simulation on Paramedic Seizure Management

BACKGROUND

A simulation-based course, Pediatric Simulation Training for Emergency Prehospital Providers (PediSTEPPs), was developed to optimize pediatric prehospital care. Seizures are common in Emergency Medical Services (EMS), and no studies have evaluated pediatric outcomes after EMS simulation training.

OBJECTIVES

The primary objective was to determine if PediSTEPPs enhances seizure protocol adherence in blood glucose measurement and midazolam administration for seizing children. The secondary objective was to describe management of seizing patients by EMS and Emergency Departments (EDs).

METHODS

This is a two-year retrospective cohort study of paramedics who transported 0-18 year old seizing patients to ten urban EDs. Management was compared between EMS crews with at least one paramedic who attended PediSTEPPs and crews that had none. Blood glucose measurement, medications administered, intravenous (IV) access, seizure recurrence, and respiratory failure data were collected from databases and run reports. Data were compared using Pearson's χ(2) test and odds ratios with 95% confidence intervals (categorical) and the Mann-Whitney test (continuous).

RESULTS

Of 2200 pediatric transports with a complaint of seizure, 250 (11%) were actively seizing at the time of transport. Of these, 65 (26%) were treated by a PediSTEPPs-trained paramedic. Blood glucose was slightly more likely to be checked by trained than untrained paramedics (OR = 1.35, 95% CI 0.72-2.51). Overall, 58% received an indicated dose of midazolam, and this was slightly more likely in the trained than untrained paramedics (OR = 1.39, 95% CI 0.77-2.49). There were no differences in secondary outcomes between groups. The prevalence of hypoglycemia was low (2%). Peripheral IVs were attempted in 80%, and midazolam was predominantly given by IV (68%) and rectal (12%) routes, with 51% receiving a correct dose. Seizures recurred in 22%, with 34% seizing on ED arrival. Respiratory failure occurred in the prehospital setting in 25 (10%) patients in the study.

CONCLUSION

Simulation-based training on pediatric seizure management may have utility. Data support the need to optimize the route and dose of midazolam for seizing children. Blood glucose measurement in seizure protocols may warrant reprioritization due to low hypoglycemia prevalence.

KEY WORDS

seizure; emergency medical services; simulation; pediatrics.

Outcome and risk factors in children after traumatic cardiac arrest and successful resuscitation

INTRODUCTION

Prospective collected data of the TraumaRegister DGU(®) were analyzed to derive survival rates and predictors for non-survival in the children who had suffered traumatic cardiorespiratory arrest. Different time points of resuscitation efforts (only preclinical, in the emergency room (ER) or preclinical+ER) were analyzed in terms of mortality and neurological outcome.

METHODS

The database of the TraumaRegister DGU(®) comprising 122,742 patients from 1993 to 2013 was analyzed. The main focus of this survey was on the paediatric group defined by an age ≤ 14 years who could be compared to adults. Different statistical analysis (univariate and multivariate analysis, logistic regression) were performed with mortality as the target variable. Differences between the paedatric group and adults were analysed by Fisher's exact test.

RESULTS

Data after preclinical and/or ER resuscitation from 152 children and 1690 adults were analyzed. A good or moderate outcome (GOS 5+4) was found in 19.4% of the children's group compared to 12.4% of the adults (p=0.02). Analysis of the GOS 5+4 subgroups after preclinical resuscitation only revealed that these outcomes were achieved by 19.4% of the paediatric group and 13.2% of the adults (p=0.24), after ER-only resuscitation by 37.0% of the children and 19.6% of the adults (p=0.046), and after preclinical and ER resuscitation by only 10.9% of the children compared to 2.5% of the adults (p=0.006). Taking only survivors into account, 84.8% of the children and 62% of the adults had a GOS 4+5. The highest risk for mortality in the logistic regression model was associated with preclinical intubation, followed by GCS 3, blood transfusion and severe head injury with AIS ≥3 and ISS.

CONCLUSIONS

CPR in children after severe trauma seems to yield a better outcome than in adults, and appears to be more justified than the current guidelines would imply. Resuscitation in the ER is associated with better neurological outcomes compared with resuscitation in a preclinical context or in both the preclinical phase and the ER. Our children's outcomes seem to be better than those in most of the earlier studies, and the data presented might support algorithms in the future especially for paediatric resuscitation.

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.

Paramedics accurately apply the pediatric assessment triangle to drive management

OBJECTIVE

To provide an evaluation of the Pediatric Assessment Triangle (PAT) as an assessment tool for use by paramedic providers in the prehospital care of pediatric patients.

METHODS

Paramedics from Los Angeles Fire Department (LAFD) received training in the Pediatric Education for Prehospital Professionals (PEPP) course, PAT study procedures, and completed training in applying the PAT to assess children 0-14 years of age. A convenience sample of LAFD paramedic assessments of the pediatric patients transported to 29 participating institutions, over an 18-month period ending July 2010, were eligible for inclusion. Patients who were not transported were excluded from the study, as were the assessments of children with special health-care needs (CSHCN). PAT Study Forms, emergency medical services (EMS) report forms, and emergency department (ED) and hospital charts were entered into a secure database. Two study investigators, blinded to paramedic PAT assessment, reviewed hospital charts and determined the category of illness or injury.

RESULTS

A total of 1,552 PAT Study Forms were collected. Overall, 1,168 of the patient (75%) assessments met inclusion criteria, were transported, and had all three data points (PAT Study Form, paramedic EMS report form, and ED/hospital chart) available for analysis. When paramedics used the PAT to identify abnormalities in the three arms of the triangle (PAT Paramedic Pattern) and applied that pattern to form a general impression (PAT Paramedic Impression), the agreement resulted in a κ coefficient of 0.93 [95% CI: 0.91-0.95]. The PAT paramedic impression was congruent with field management, as the majority of patients received consistent interventions with local EMS protocols. The PAT Paramedic Impression for instability demonstrated a sensitivity of 77.4% [95% CI: 72.6-81.5%], a specificity of 90.0% [95% CI: 87.1-91.5%] with a positive likelihood ratio (LR+) of 7.7 [95% CI: 5.9-9.1] and a negative likelihood ratio (LR-) of 0.3 [95% CI: 0.2-0.3].

CONCLUSION

The PAT is a rapid assessment tool that can be readily and reliably used by paramedics in the prehospital setting. The PAT should be used in conjunction with other assessments but can safely drive initial field management.

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.

Understanding safety in prehospital emergency medical services for children

OBJECTIVE

For over a decade, the field of medicine has recognized the importance of studying and designing strategies to prevent safety issues in hospitals and clinics. However, there has been less focus on understanding safety in prehospital emergency medical services (EMS), particularly in regard to children. Roughly 27.7 million (or 27%) of the annual emergency department visits are by children under the age of 19, and about 2 million of these children reach the hospital via EMS. This paper adds to our qualitative understanding of the nature and contributors to safety events in the prehospital emergency care of children.

METHODS

We conducted four 8- to 12-person focus groups among paid and volunteer EMS providers to understand 1) patient safety issues that occur in the prehospital care of children, and 2) factors that contribute to these safety issues (e.g., patient, family, systems, environmental, or individual provider factors). Focus groups were conducted in rural and urban settings. Interview transcripts were coded for overarching themes.

RESULTS

Key factors and themes identified in the analysis were grouped into categories using an ecological approach that distinguishes between systems, team, child and family, and individual provider level contributors. At the systems level, focus group participants cited challenges such as lack of appropriately sized equipment or standardized pediatric medication dosages, insufficient human resources, limited pediatric training and experience, and aspects of emergency medical services culture. EMS team level factors centered on communication with other EMS providers (both prehospital and hospital). Family and child factors included communication barriers and challenging clinical situations or scene characteristics. Finally, focus group participants highlighted a range of provider level factors, including heightened levels of anxiety, insufficient experience and training with children, and errors in assessment and decision making.

CONCLUSIONS

The findings of our study suggest that, just as in hospital medicine, factors at the systems, team, child/family, and individual provider level system contribute to errors in prehospital emergency care. These factors may be modifiable through interventions and systems improvements. Future studies are needed to ascertain the generalizability of these findings and further refine the underlying mechanisms.

Ethical Challenges in Emergency Medical Services: Controversies and Recommendations

Emergency Medical Services (EMS) providers face many ethical issues while providing prehospital care to children and adults. Although provider judgment plays a large role in the resolution of conflicts at the scene, it is important to establish protocols and policies, when possible, to address these high-risk and complex situations. This article describes some of the common situations with ethical underpinnings encountered by EMS personnel and managers including denying or delaying transport of patients with non-emergency conditions, use of lights and sirens for patient transport, determination of medical futility in the field, termination of resuscitation, restriction of EMS provider duty hours to prevent fatigue, substance abuse by EMS providers, disaster triage and difficulty in switching from individual care to mass-casualty care, and the challenges of child maltreatment recognition and reporting. A series of ethical questions are proposed, followed by a review of the literature and, when possible, recommendations for management.

BeckerTK, Gausche-HillM, AsweganAL, BakerEF, BookmanKJ, BradleyRN, De LorenzoRA, SchoenwetterDJ for the American College of Emergency Physicians’ EMS Committee. Ethical challenges in Emergency Medical Services: controversies and recommendations. Prehosp Disaster Med. 2013;28(5):1-10.

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.

Medication dosing errors in pediatric patients treated by emergency medical services

BACKGROUND

Medication dosing errors occur in up to 17.8% of hospitalized children. There are limited data to describe pediatric medication errors by emergency medical services (EMS) paramedics. It has been shown that paramedics have infrequent encounters with pediatric patients.

OBJECTIVE

To characterize medication dosing errors in children treated by EMS.

METHODS

We studied patients aged ≤11 years who were treated by paramedics from eight Michigan EMS agencies from January 2004 through March 2006. We defined a medication dosing error as ≥20% deviation from the weight-appropriate dose, as determined by the patient's reported weight in the prehospital medical record or by use of the Broselow-Luten tape (BLT). We studied errors in administering six EMS medications commonly given to children: albuterol, atropine, dextrose, diphenhydramine, epinephrine, and naloxone.

RESULTS

There were 5,547 children aged ≤11 years who were treated during the study period, of whom 230 (4.1%) received drugs and had a documented weight. These patients received a total of 360 medication administrations. Multiple drug administrations occurred in 73 cases. Medication dosing errors occurred in 125 of the 360 drug administrations (34.7%; 95% confidence interval [CI] 30.0, 39.8). Relative drug dosage errors (with 95% CI) were as follows: albuterol 23.3% (18.4, 29.1), atropine 48.8% (34.3, 63.5), diphenhydramine 53.8% (29.1, 76.8), and epinephrine 60.9% (49.9, 73.9). The mean error (± standard deviation) for intravenous/intraosseous 1:1000 epinephrine overdoses was 808% ± 428%. The mean error (± standard deviation) for intravenous/intraosseous 1:1000 epinephrine underdoses was 35.5% ± 27.4%.

CONCLUSIONS

Medications delivered in the prehospital care of children were frequently administered outside of the proper dose range when compared with patient weights recorded in the prehospital medical record. EMS systems should develop strategies to reduce pediatric medication dosing errors.

Universally poor outcomes of pediatric traumatic arrest: a prospective case series and review of the literature

OBJECTIVE

Few data are available on traumatic cardiopulmonary arrest in children. Efforts at resuscitation typically result in heavy utilization of finite resources with little understanding of which characteristics, if any, may be associated with success. The objectives of this study were to describe the outcome of children in traumatic cardiac arrest and to identify patients for whom aggressive resuscitation may or may not be warranted.

METHODS

Data were analyzed from a previous study of prehospital pediatric airway management in Los Angeles and Orange Counties, Calif, over a 33-month period. Patients included in this secondary analysis were younger than 13 years and found pulseless and apneic after having had an injury. Data sources included prospective, phone interviews with paramedics after transfer of care to the receiving facility, and chart review to determine outcome. Two main outcomes were assessed: survival and neurological function as measured by the Pediatric Cerebral Performance Category.

RESULTS

The emergency medical services responded to 118 traumatic arrests during the study period. Of these victims, only 6 (5%) survived. Median Injury Severity Score was 25 with an interquartile range of 16 to 75. The survivors all were neurologically impaired with a median Pediatric Cerebral Performance Category of 5 (interquartile range, 4-5).

CONCLUSIONS

Children who had trauma resulting in cardiac arrest have universally poor outcomes, and survivors have severe neurological compromise. We are unable to identify a subset of patients for whom aggressive resuscitation is indicated. This is the largest prospective study of pediatric traumatic arrest to date.

First responder performance in pediatric trauma: a comparison with an adult cohort

INTRODUCTION

Is the prehospital care of injured children comparable with adult standards? This question has been asked repeatedly by many clinicians, yet there are no definite answers.

OBJECTIVE

To evaluate the prehospital care provided by first responders to pediatric patients (<12 yrs of age) with head injury compared with the adult group (>12 yrs of age) to determine whether the emergency medical services providers are able to adequately assess the children and provide emergency services comparable with adult standards.

PATIENTS AND METHODS

A retrospective 4-yr review of pediatric (n = 102) and adult (n = 99) patients with head injury and Glasgow coma scale score <15 who were treated at a level 1 trauma center. Emergency medical service interventions such as intravenous access, endotracheal intubation, and fluid resuscitation were reviewed. Patients who required further intervention on arrival at the trauma center either from nonperformance of a required procedure or complications arising from such procedures were documented.

MAIN RESULTS

There were 102 pediatric and 99 adult patients included in the final analysis. Injury severity based on Glasgow coma scale score was not different between the groups. A total of 91 patients, 52 adults (52.5%) and 39 children (38.2%), needed endotracheal intubation at the scene. Significantly more pediatric patients had problems with intubation, 27 children (69.2%) vs. 11 adults (21.2%), p < .001.Intravenous access was successfully established in 85.9% of adults compared to 65.7% in children at the scene (p = .001). Consequently, on arrival at the trauma center, more children required intravenous access, 80.4% compared with 63.6% for adults (p = .011). As a result, more children (25.5%) required initial or additional fluid bolus at the trauma center compared with adults (9.1%, p = .003).

CONCLUSIONS

Prehospital care of children is suboptimal compared with adults in areas of endotracheal intubation, establishment of peripheral intravenous access, and fluid resuscitation.

Ambulance personnel perceptions of near misses and adverse events in pediatric patients

OBJECTIVE

To identify emergency medical services (EMS) provider perceptions of factors that may affect the occurrence, identification, reporting, and reduction of near misses and adverse events in the pediatric EMS patient.

METHODS

This was a subgroup analysis of a qualitative study examining the nature of near misses and adverse events in EMS as it relates to pediatric prehospital care. Complementary qualitative methods of focus groups, interviews, and anonymous event reporting were used to collect results and emerging themes were identified and assigned to specific analytic domains.

RESULTS

Eleven anonymous event reports, 17 semistructured interviews, and two focus groups identified 61 total events, of which 12 were child-related. Eight of those were characterized by participants as having resulted in no injury, two resulted in potential injury, and two involved an ultimate fatality. Three analytic domains were identified, which included the following five themes: reporting is uncommon, blaming errors on others, provider stress/discomfort, errors of omission, and limited training. Among perceived causes of events, participants noted factors relating to management problems specific to pediatrics, problems with procedural skill performance, medication problems/calculation errors, improper equipment size, parental interference, and omission of treatment related to providers' discomfort with the patient's age. Few participants spoke about errors they had committed themselves; most discussions centered on errors participants had observed being made by others.

CONCLUSIONS

It appears that adverse events and near misses in the pediatric EMS environment may go unreported in a large proportion of cases. Participants attributed the occurrence of errors to the stress and anxiety produced by a lack of familiarity with pediatric patients and to a reluctance to cause pain or potential harm, as well as to inadequate practical training and experience in caring for the pediatric population. Errors of omission, rather than those of commission, were perceived to predominate. This study provides a foundation on which to base additional studies of both a qualitative and quantitative nature that will shed further light on the factors contributing to the occurrence, reporting, and mitigation of adverse events and near misses in the pediatric EMS setting.

Disaster Training for Prehospital Providers

OBJECTIVE

To survey prehospital providers to determine 1) the quantity and format of training recalled over the past year in chemical, biological, radiological/nuclear (CBRN), and other mass casualty events (MCEs); 2) preferred educational formats; 3) self-assessed preparedness for various CBRN/MCEs; and 4) perceived likelihood of occurrence for CBRN/MCEs.

METHODS

A survey, consisting of 11 questions, was distributed to 1,010 prehospital providers in a system where no formal CBRN/mass casualty training was given.

RESULTS

Surveys were completed by 640 (63%) prehospital providers. Twenty-two percent (22%) of prehospital providers recalled no training within the past year for CBRN or other MCEs, 19% reported 1-5 hours, 15% reported 6-10 hours, 24% reported 11-39 hours, and 7% reported receiving greater than 40 hours. Lectures and drills were the most common formats for prior education. On a five-point scale (1: "Never Helpful" through 5: "Always Helpful") regarding the helpfulness of training methods, median scores were the following: drills-5, lectures-4, self-study packets-3, Web-based learning-3, and other-4. On another five-point scale (1: "Totally Unprepared" through 5: "Strongly Prepared"), prehospital providers felt most prepared for MCEs-4, followed by chemical-4, biological-3, and radiation/nuclear-3. Over half (61%) felt MCEs were "Somewhat Likely" or "Very Likely" to occur, whereas chemical (42%), biological (38%), or radiation/nuclear (33%) rated lower.

CONCLUSION

The amount of training in the past year reported for CBRN events varied greatly, with almost a quarter recalling no education. Drills and lectures were the most used and preferred formats for disaster training. Prehospital providers felt least prepared for a radiological;/nuclear event. Future studies should focus on the consistency and quality of education provided.

Emergency medical service attitudes toward geriatric prehospital care and continuing medical education in geriatrics

OBJECTIVES

To understand the opinions of emergency medical service (EMS) providers regarding their ability to care for older adults, the domains of geriatric medicine in which they need more training, and the modality through which continuing education could be best delivered.

DESIGN

Qualitative study using key informant interviews.

SETTING

Prehospital EMS system in Rochester, New York.

PARTICIPANTS

EMS providers, EMS instructors and administrators, emergency physicians, and geriatricians.

MEASUREMENTS

Semistructured interviews were conducted using an interview guide that addressed knowledge and skill deficiencies, recommendations for improvement of geriatrics continuing education, and delivery methods of education.

RESULTS

Participant responses were generally congruous despite the diverse backgrounds, and redundancy was achieved rapidly. All participants perceived a deficit in EMS education on the care of older adults, particularly related to communications with patients and skilled nursing facility staff. All desired more geriatric continuing education for EMS providers, especially in communications and psychosocial issues. Education was desired in various modalities.

CONCLUSION

Further geriatric continuing education for EMS providers is needed. Some specific topics relate to medical issues, but a large proportion involve communications and psychosocial issues. Education should be delivered in a variety of modalities to meet the needs of the EMS community. Emerging on-line video technologies may bridge the gap between learners preferring classroom-based modailities and those preferring self-study modules.