Multimedia Evaluation of EMT-Paramedic Assessment and Management of Pediatric Respiratory Distress

Development of a Computable Phenotype for Prehospital Pediatric Asthma Encounters

INTRODUCTION

Asthma exacerbations are a common cause of pediatric Emergency Medical Services (EMS) encounters. Accordingly, prehospital management of pediatric asthma exacerbations has been designated an EMS research priority. However, accurate identification of pediatric asthma exacerbations from the prehospital record is nuanced and difficult due to the heterogeneity of asthma symptoms, especially in children. Therefore, this study's objective was to develop a prehospital-specific pediatric asthma computable phenotype (CP) that could accurately identify prehospital encounters for pediatric asthma exacerbations.

METHODS

This is a retrospective observational study of patient encounters for ages 2-18 years from the ESO Data Collaborative between 2018 and 2021. We modified two existing rule-based pediatric asthma CPs and created three new CPs (one rule-based and two machine learning-based). Two pediatric emergency medicine physicians independently reviewed encounters to assign labels of asthma exacerbation or not. Taking that labeled encounter data, a 50/50 train/test split was used to create training and test sets from the labeled data. A 90/10 split was used to create a small validation set from the training set. We used specificity, sensitivity, positive predictive value (PPV), negative predictive value (NPV) and macro F1 to compare performance across all CP models.

RESULTS

After applying the inclusion and exclusion criteria, 24,283 patient encounters remained. The machine-learning models exhibited the best performance for the identification of pediatric asthma exacerbations. A multi-layer perceptron-based model had the best performance in all metrics, with an F1 score of 0.95, specificity of 1.00, sensitivity of 0.91, negative predictive value of 0.98, and positive predictive value of 1.00.

CONCLUSION

We modified existing and developed new pediatric asthma CPs to retrospectively identify prehospital pediatric asthma exacerbation encounters. We found that machine learning-based models greatly outperformed rule-based models. Given the high performance of the machine-learning models, the development and application of machine learning-based CPs for other conditions and diseases could help accelerate EMS research and ultimately enhance clinical care by accurately identifying patients with conditions of interest.

Evaluation of the implementation of evidence-based pediatric asthma exacerbation treatments in a regional consortium of emergency medical Services Agencies

OBJECTIVE

Asthma exacerbations are a frequent reason for pediatric emergency medical services (EMS) encounters. The objective of this study was to examine the implementation of evidence-based treatments for pediatric asthma in a regional consortium of EMS agencies.

METHODS

This retrospective study applied the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) implementation framework to data from an EMS agency consortium in the Cincinnati, Ohio region. The study analyzed one year before an oral systemic corticosteroid (OCS) option was added to the agencies' protocol, and five years after the protocol change. We constructed logistic regression models for the primary outcome of Reach, defined as the proportion of pediatric asthma patients who received a systemic corticosteroid. We modeled Maintenance (Reach measured monthly over time) using time series models.

RESULTS

A total of 713 patients were included, 133 pre- and 580 post-protocol change. In terms of Reach, 3% (n = 4) of eligible patients received a systemic corticosteroid pre-OCS versus 20% (n = 116) post-OCS. Multivariable modeling of Reach revealed the study period, EMS transport time, months since implementation of OCS, and number of bronchodilators administered by EMS as significant covariates for the administration of a systemic corticosteroid. For Maintenance, it took approximately two years to reach maximal administration of systemic corticosteroids.

CONCLUSIONS

Indicators of asthma severity and time since the protocol change were significantly associated with EMS administration of systemic corticosteroids to pediatric asthma patients. The two-year time for maximal Reach suggests further work is required to understand how to best implement evidence-based pediatric asthma treatments in EMS.

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.

Prehospital Emergency Provider's Knowledge of and Comfort With Pediatric and Special Needs Cases: A Cross-Sectional Study in Los Angeles County

The current study assesses the relationship between continuing education (CE) with a focus on pediatrics and children with special heath care needs and how CE influences the knowledge and comfort levels of prehospital providers who treat these cases. Data are survey responses provided by paramedic and emergency medical technician (EMT) level providers (N = 575) in Los Angeles County. Regression models assessed the relationship between pediatric-focused continuing education and EMTs' knowledge of and comfort with pediatric cases, adjusting for relevant covariates. EMTs' participation in continuing education focusing on pediatrics and special health care needs was significantly associated with an increase in perceived comfort and knowledge. Among EMTs who did not receive continuing education focused on either pediatrics or special health care needs, the most frequently reported barrier to education was a perceived lack of availability. The impact of continuing education on perceived comfort and knowledge was more pronounced than the effect of prior experience, especially considering the limited prevalence of provider exposure to pediatric and childhood special health care needs cases compared to adult cases. Expanding educational opportunities is a promising approach to increasing the comfort and knowledge of EMTs who transport and care for pediatric cases.