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Gyedu A, Issaka A, Appiah AB, Donkor P, Mock C. Care of Injured Children Compared to Adults at District and Regional Hospitals in Ghana and the Impact of a Trauma Intake Form: A Stepped-Wedge Cluster Randomized Trial. J Pediatr Surg 2024; 59:1210-1218. [PMID: 38154994 PMCID: PMC11105994 DOI: 10.1016/j.jpedsurg.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/16/2023] [Accepted: 12/03/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND This study aimed to determine the effectiveness of a standardized trauma intake form (TIF) to improve achievement of key performance indicators (KPIs) of initial trauma care among injured children, compared to adults, at non-tertiary hospitals in Ghana. METHODS A stepped-wedge cluster randomized trial was performed with research assistants directly observing the management of injured patients before and after introducing the TIF at emergency units of 8 non-tertiary hospitals for 17.5 months. Differences in outcomes between children and adults in periods before and after TIF introduction were determined with multivariable logistic regression. Differences in outcomes among children after TIF introduction were determined using generalized linear mixed regression. RESULTS Management of 3889 injured patients was observed; 757 (19%) were children <18 years. Trauma care KPIs at baseline were lower for children compared to adults. Improvements in primary survey KPIs were observed among children after TIF introduction. Examples include airway assessment [279 (71%) to 359 (98%); adjusted odds ratio (AOR): 74.42, p = 0.005)] and chest examination [225 (58%) to 349 (95%); AOR 53.80, p = 0.002)]. However, despite these improvements, achievement of KPIs was still lower compared to adults. Examples are pelvic fracture evaluation [children: 295 (80%) vs adults: 1416 (88%), AOR: 0.56, p = 0.001] and respiratory rate assessment (children: 310 (84%) vs adults: 1458 (91%), AOR: 058, p = 0.030). CONCLUSIONS While the TIF was effective in improving most KPIs of pediatric trauma care, more targeted education is needed to bridge the gap in quality between pediatric and adult trauma care at non-tertiary hospitals in Ghana and other low- and middle-income countries. TYPE OF STUDY Stepped-wedged cluster randomized controlled trial. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Adam Gyedu
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Adamu Issaka
- Department of Surgery, School of Medicine, University for Development Studies, Tamale, Ghana
| | - Anthony Baffour Appiah
- Ghana Field Epidemiology and Laboratory Training Program, School of Public Health, University of Ghana, Legon, Accra, Ghana
| | - Peter Donkor
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Charles Mock
- Department of Surgery, University of Washington, Seattle, WA, USA; Harborview Injury Prevention and Research Center, Seattle, WA, USA
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Ward CE, Adelgais KM, Holsti M, Jacobsen KK, Simon HK, Morris CR, Gonzalez VM, Lerner G, Ghaffari K, VanBuren JM, Lerner EB, Shah MI. Public support for and concerns regarding pediatric dose optimization for seizures in emergency medical services: An exception from informed consent (EFIC) trial. Acad Emerg Med 2024. [PMID: 38450918 DOI: 10.1111/acem.14884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 01/20/2024] [Accepted: 01/28/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Federal regulations allow exception from informed consent (EFIC) to study emergent conditions when obtaining prospective consent is not feasible. Little is known about public views on including children in EFIC studies. The Pediatric Dose Optimization for Seizures in EMS (PediDOSE) trial implements age-based, standardized midazolam dosing for pediatric seizures. The primary objective of this study was to determine public support for and concerns about the PediDOSE EFIC trial. The secondary objective was to assess how support for PediDOSE varied by demographics. METHODS We conducted a mixed-methods study in 20 U.S. communities. Participants reviewed information about PediDOSE before completing an online survey. Descriptive data were generated. Univariable and multivariable logistic regression analysis identified factors associated with support for PediDOSE. Reviewers identified themes from free-text response data regarding participant concerns. RESULTS Of 2450 respondents, 79% were parents/guardians, and 20% had a child with previous seizures. A total of 96% of respondents supported PediDOSE being conducted, and 70% approved of children being enrolled without prior consent. Non-Hispanic Black respondents were less likely than non-Hispanic White respondents to support PediDOSE with an adjusted odds ratio (aOR) of 0.57 (95% CI 0.42-0.75). Health care providers were more likely to support PediDOSE, with strongest support among prehospital emergency medicine clinicians (aOR 5.82, 95% CI 3.19-10.62). Age, gender, parental status, and level of education were not associated with support of PediDOSE. Common concerns about PediDOSE included adverse effects, legal and ethical concerns about enrolling without consent, and potential racial bias. CONCLUSIONS In communities where this study will occur, most respondents supported PediDOSE being conducted with EFIC and most approved of children being enrolled without prior consent. Support was lowest among non-Hispanic Black respondents and highest among health care providers. Further research is needed to determine optimal ways to address the concerns of specific racial and ethnic groups when conducting EFIC trials.
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Affiliation(s)
- Caleb E Ward
- George Washington University School of Medicine and Health Sciences, Children's National Hospital, Washington, DC, USA
| | - Kathleen M Adelgais
- University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Maija Holsti
- University of Utah, Primary Children's Medical Center, Salt Lake City, Utah, USA
| | | | - Harold K Simon
- Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Claudia R Morris
- Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Victor M Gonzalez
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Gonzalo Lerner
- University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | | | | | - E Brooke Lerner
- University of Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Manish I Shah
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
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Fishe JN, Garvan G, Bertrand A, Burcham S, Hendry P, Shah M, Kothari K, Ashby DW, Ostermeyer D, Riney L, Semenova O, Abo B, Abes B, Shimko N, Myers E, Frank M, Turner T, Kemp M, Landry K, Roland G, Blake KV. Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial (EASI-AS-ODT). Acad Emerg Med 2024; 31:49-60. [PMID: 37786991 PMCID: PMC10842452 DOI: 10.1111/acem.14813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/20/2023] [Accepted: 09/27/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND In the emergency department (ED), prompt administration of systemic corticosteroids for pediatric asthma exacerbations decreases hospital admission rates. However, there is sparse evidence for whether earlier administration of systemic corticosteroids by emergency medical services (EMS) clinicians, prior to ED arrival, further improves pediatric asthma outcomes. METHODS Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial is a multicenter, observational, nonrandomized stepped-wedge design study with seven participating EMS agencies who adopted an oral systemic corticosteroid (OCS) into their protocols for pediatric asthma treatment. Using univariate analyses and multivariable mixed-effects models, we compared hospital admission rates for pediatric asthma patients ages 2-18 years before and after the introduction of a prehospital OCS and for those who did and did not receive a systemic corticosteroid from EMS. RESULTS A total of 834 patients were included, 21% of whom received a systemic corticosteroid from EMS. EMS administration of systemic corticosteroids increased after the introduction of an OCS from 14.7% to 28.1% (p < 0.001). However, there was no significant difference between hospital admission rates and ED length of stay before and after the introduction of OCS or between patients who did and did not receive a systemic corticosteroid from EMS. Mixed-effects models revealed that age 14-18 years (coefficient -0.83, p = 0.002), EMS administration of magnesium (coefficient 1.22, p = 0.04), and initial EMS respiratory severity score (coefficient 0.40, p < 0.001) were significantly associated with hospital admission. CONCLUSIONS In this multicenter study, the addition of an OCS into EMS agency protocols for pediatric asthma exacerbations significantly increased systemic corticosteroid administration but did not significantly decrease hospital admission rates. As overall EMS systemic corticosteroid administration rates were low, further work is required to understand optimal implementation of EMS protocol changes to better assess potential benefits to patients.
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Affiliation(s)
- Jennifer N Fishe
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
- Center for Data Solutions, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Gerard Garvan
- Center for Data Solutions, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Andrew Bertrand
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Shannon Burcham
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Phyllis Hendry
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Manish Shah
- Baylor College of Medicine, Houston, Texas, USA
| | | | | | - Daniel Ostermeyer
- McGovern Medical School, University of Texas Health, Houston, Texas, USA
| | - Lauren Riney
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Olga Semenova
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Benjamin Abo
- Lee County Emergency Medical Services, Fort Myers, Florida, USA
- Florida State University College of Medicine, Tallahassee, Florida, USA
| | - Benjamin Abes
- Lee County Emergency Medical Services, Fort Myers, Florida, USA
| | - Nichole Shimko
- Golisano Children's Hospital of Southwest Florida, Fort Myers, Florida, USA
| | - Emily Myers
- Sarasota County Fire Department, Sarasota, Florida, USA
| | - Marshall Frank
- Florida State University College of Medicine, Tallahassee, Florida, USA
- Sarasota County Fire Department, Sarasota, Florida, USA
| | - Tim Turner
- Walton County Fire Rescue, Defuniak Springs, Florida, USA
| | - Mac Kemp
- Leon County EMS, Tallahassee, Florida, USA
| | - Kim Landry
- Leon County EMS, Tallahassee, Florida, USA
| | - Greg Roland
- Nassau County Fire Rescue Department, Yulee, Florida, USA
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Heyming TW, Knudsen-Robbins C, Shelton SK, Pham PK, Brukman S, Wickens M, Valdez B, Bacon K, Thorpe J, Kwon KT, Schultz C. 9-1-1 Activations from Ambulatory Care Centers: A Sicker Pediatric Population. Prehosp Disaster Med 2023; 38:749-756. [PMID: 37877361 PMCID: PMC10694466 DOI: 10.1017/s1049023x23006544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/29/2023] [Accepted: 09/04/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Pediatric patients transferred by Emergency Medical Services (EMS) from urgent care (UC) and office-based physician practices to the emergency department (ED) following activation of the 9-1-1 EMS system are an under-studied population with scarce literature regarding outcomes for these children. The objectives of this study were to describe this population, explore EMS level-of-care transport decisions, and examine ED outcomes. METHODS This was a retrospective review of patients zero to <15 years of age transported by EMS from UC and office-based physician practices to the ED of two pediatric receiving centers from January 2017 through December 2019. Variables included reason for transfer, level of transport, EMS interventions and medications, ED medications/labs/imaging ordered in the first hour, ED procedures, ED disposition, and demographics. Data were analyzed with descriptive statistics, X test, point biserial correlation, two-sample z test, Mann-Whitney U test, and 2-way ANOVA. RESULTS A total of 450 EMS transports were included in this study: 382 Advanced Life Support (ALS) runs and 68 Basic Life Support (BLS) runs. The median patient age was 2.66 years, 60.9% were male, and 60.7% had private insurance. Overall, 48.9% of patients were transported from an office-based physician practice and 25.1% were transported from UC. Almost one-half (48.7%) of ALS patients received an EMS intervention or medication, as did 4.41% of BLS patients. Respiratory distress was the most common reason for transport (46.9%). Supplemental oxygen was the most common EMS intervention and albuterol was the most administered EMS medication. There was no significant association between level of transport and ED disposition (P = .23). The in-patient admission rate for transported patients was significantly higher than the general ED admission rate (P <.001). CONCLUSION This study demonstrates that pediatric patients transferred via EMS after activation of the 9-1-1 system from UC and medical offices are more acutely ill than the general pediatric ED population and are likely sicker than the general pediatric EMS population. Paramedics appear to be making appropriate level-of-care transport decisions.
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Affiliation(s)
- Theodore W. Heyming
- Children’s Hospital of Orange County (CHOC Children’s), Orange, CaliforniaUSA
- Department of Emergency Medicine, University of California at Irvine School of Medicine, Irvine, CaliforniaUSA
| | - Chloe Knudsen-Robbins
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OhioUSA
| | - Shelby K. Shelton
- Children’s Hospital of Orange County (CHOC Children’s), Orange, CaliforniaUSA
| | - Phung K. Pham
- Children’s Hospital of Orange County (CHOC Children’s), Orange, CaliforniaUSA
| | - Shelley Brukman
- Children’s Hospital of Orange County (CHOC Children’s), Orange, CaliforniaUSA
| | - Maxwell Wickens
- Children’s Hospital of Orange County (CHOC Children’s), Orange, CaliforniaUSA
| | - Brooke Valdez
- Children’s Hospital of Orange County (CHOC Children’s), Orange, CaliforniaUSA
| | - Kellie Bacon
- Children’s Hospital of Orange County (CHOC Children’s), Orange, CaliforniaUSA
| | - Jonathan Thorpe
- Department of Pediatrics, University of California at Irvine School of Medicine, Irvine, CaliforniaUSA
| | - Kenneth T. Kwon
- CHOC Children’s at Mission Hospital, Mission Viejo, CaliforniaUSA
| | - Carl Schultz
- Orange County Health Care Agency, Santa Ana, CaliforniaUSA
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Mockler S, Metelmann C, Metelmann B, Thies KC. Prevalence and severity of pediatric emergencies in a German helicopter emergency service: implications for training and service configuration. Eur J Pediatr 2023; 182:5057-5065. [PMID: 37656240 PMCID: PMC10640406 DOI: 10.1007/s00431-023-05178-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/15/2023] [Accepted: 08/23/2023] [Indexed: 09/02/2023]
Abstract
This study primarily aims to determine the frequency of life-threatening conditions among pediatric patients served by the DRF, a German helicopter emergency service (HEMS) provider. It also seeks to explore the necessity of invasive procedures in this population, discussing the implications for HEMS crew training and service configuration based on current literature. We analyzed the mission registry from 31 DRF helicopter bases in Germany, focusing on 7954 children aged 10 or younger over a 5-year period (2014-2018). Out of 7954 identified children (6.2% of all primary missions), 2081 (26.2%) had critical conditions. Endotracheal intubation was needed in 6.5% of cases, while alternative airway management methods were rare (n = 14). Half of the children required intravenous access, and 3.6% needed intraosseous access. Thoracostomy thoracentesis and sonography were only performed in isolated cases. Conclusions: Critically ill or injured children are infrequent in German HEMS operations. Our findings suggest that the likelihood of HEMS teams encountering such cases is remarkably low. Besides endotracheal intubation, life-saving invasive procedures are seldom necessary. Consequently, we conclude that on-the-job training and mission experience alone are insufficient for acquiring and maintaining the competencies needed to care for critically ill or injured children. What is Known: • Pediatric emergencies are relatively rare in the prehospital setting, but their incidence is higher in helicopter emergency medical services (HEMS) compared to ground-based emergency services. What is New: • On average, HEMS doctors in Germany encounter a critically ill or injured child approximately every 1.5 years in their practice, establish an IV or IO access in infants or toddlers every 2 years, and intubate an infant every 46 years. • This low frequency highlights the insufficiency of on-the-job training alone to develop and maintain pediatric skills among HEMS crews. Specific interdisciplinary training for HEMS crews is needed to ensure effective care for critically unwell pediatric patients.
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Affiliation(s)
- Stefan Mockler
- Department of Anesthesiology, University Hospital Greifswald, Sauerbruchstr, 17475, Greifswald, Germany.
| | - Camilla Metelmann
- Department of Anesthesiology, University Hospital Greifswald, Sauerbruchstr, 17475, Greifswald, Germany
| | - Bibiana Metelmann
- Department of Anesthesiology, University Hospital Greifswald, Sauerbruchstr, 17475, Greifswald, Germany
| | - Karl Christian Thies
- Department of Anaesthesiology and Critical Care, EvKB, OWL University Medical Center, Campus Bielefeld Bethel, Burgsteig 13, 33617, Bielefeld, Germany
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Cimino J, Braun C. Clinical Research in Prehospital Care: Current and Future Challenges. Clin Pract 2023; 13:1266-1285. [PMID: 37887090 PMCID: PMC10605888 DOI: 10.3390/clinpract13050114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/08/2023] [Accepted: 10/19/2023] [Indexed: 10/28/2023] Open
Abstract
Prehospital care plays a critical role in improving patient outcomes, particularly in cases of time-sensitive emergencies such as trauma, cardiac failure, stroke, bleeding, breathing difficulties, systemic infections, etc. In recent years, there has been a growing interest in clinical research in prehospital care, and several challenges and opportunities have emerged. There is an urgent need to adapt clinical research methodology to a context of prehospital care. At the same time, there are many barriers in prehospital research due to the complex context, posing unique challenges for research, development, and evaluation. Among these, this review allows the highlighting of limited resources and infrastructure, ethical and regulatory considerations, time constraints, privacy, safety concerns, data collection and analysis, selection of a homogeneous study group, etc. The analysis of the literature also highlights solutions such as strong collaboration between emergency medical services (EMS) and hospital care, use of (mobile) health technologies and artificial intelligence, use of standardized protocols and guidelines, etc. Overall, the purpose of this narrative review is to examine the current state of clinical research in prehospital care and identify gaps in knowledge, including the challenges and opportunities for future research.
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Affiliation(s)
- Jonathan Cimino
- Clinical Research Unit, Fondation Hôpitaux Robert Schuman, 44 Rue d’Anvers, 1130 Luxembourg, Luxembourg
- Hôpitaux Robert Schuman, 9 Rue Edward Steichen, 2540 Luxembourg, Luxembourg
| | - Claude Braun
- Clinical Research Unit, Fondation Hôpitaux Robert Schuman, 44 Rue d’Anvers, 1130 Luxembourg, Luxembourg
- Hôpitaux Robert Schuman, 9 Rue Edward Steichen, 2540 Luxembourg, Luxembourg
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Kadish CB, Lloyd JK, Adelgais KM, Ward CE, Lo CB, Truelove A, Leonard JC. Prehospital Recognition and Management of Pediatric Sepsis: A Qualitative Assessment. PREHOSP EMERG CARE 2023; 27:775-785. [PMID: 37141419 DOI: 10.1080/10903127.2023.2210217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/10/2023] [Accepted: 04/28/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND AND PURPOSE Sepsis is a life-threatening disease in children and is a leading cause of morbidity and mortality. Early prehospital recognition and management of children with sepsis may have significant effects on the timely resuscitation of this high-risk clinical condition. However, the care of acutely ill and injured children in the prehospital setting can be challenging. This study aims to understand barriers, facilitators, and attitudes regarding recognition and management of pediatric sepsis in the prehospital setting. METHODS This was a qualitative study of EMS professionals participating in focus groups using a grounded theory-based design to gather information on recognition and management of septic children in the prehospital setting. Focus groups were held for EMS administrators and medical directors. Separate focus groups were held for field clinicians. Focus groups were conducted via video conference until saturation of ideas was reached. Using consensus methodology, transcripts were coded in an iterative process. Data were then organized into positive and negative factors based on the validated PRECEDE-PROCEED model for behavioral change. RESULTS Thirty-eight participants in six focus groups identified nine environmental factors, 21 negative factors, and 14 positive factors pertaining to recognition and management of pediatric sepsis. These findings were organized into the PRECEDE-PROCEED planning model. Pediatric sepsis guidelines were identified as positive factors when they did exist and negative factors when they were complicated or did not exist. Six interventions were identified by participants. These include raising awareness of pediatric sepsis, increasing pediatric education, receiving feedback on prehospital encounters, increasing pediatric exposure and skills training, and improving dispatch information. CONCLUSION This study fills a gap by examining barriers and facilitators to prehospital diagnosis and management of pediatric sepsis. Using the PRECEDE-PROCEED model, nine environmental factors, 21 negative factors, and 14 positive factors were identified. Participants identified six interventions that could create the foundation to improve prehospital pediatric sepsis care. Policy changes were suggested by the research team based on the results of this study. These interventions and policy changes provide a roadmap for improving care in this population and lay the groundwork for future research.
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Affiliation(s)
- Chelsea B Kadish
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, Ohio
| | - Julia K Lloyd
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, Ohio
| | - Kathleen M Adelgais
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Caleb E Ward
- Children's National Hospital, George Washington University, Washington, District of Columbia
| | - Charmaine B Lo
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Annie Truelove
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Julie C Leonard
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, Ohio
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
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Cercone A, Ramgopal S, Martin-Gill C. Completeness of Pediatric Versus Adult Patient Assessment Documentation in the National Emergency Medical Services Information System. PREHOSP EMERG CARE 2023; 28:243-252. [PMID: 36758201 DOI: 10.1080/10903127.2023.2178563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/23/2023] [Accepted: 01/31/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Pediatric prehospital encounters are proportionally low-frequency events. National pediatric readiness initiatives have targeted gaps in prehospital pediatric assessment and management. Regional studies suggest that pediatric vital signs are inconsistently obtained and documented. We aimed to assess national emergency medical services (EMS) data to evaluate completeness of assessment documentation for pediatric versus adult patients and to identify the documentation of condition-specific assessments. METHODS We performed a retrospective cross-sectional analysis of EMS encounters from the National Emergency Medical Services Information System for 2019, including all 9-1-1 encounters resulting in transport. Our primary outcome was the proportion of encounters with complete vital signs (heart rate, respiratory rate, and systolic blood pressure) documented by pediatric age category relative to adult encounters. Pediatric patients were considered as those less than 18 years old. Our secondary outcome was condition-specific assessments for encounters with respiratory emergencies, cardiac complaints, and trauma. We performed multivariable logistic regression to calculate odds ratios (OR) and 95% confidence intervals (95% CI) for vital signs documentation by age after adjusting for sex, injury status, transport type (advanced vs basic life support), census region, urbanicity, organization nonprofit status, and organization type. RESULTS Of 18,918,914 EMS encounters, 6.4% involved pediatric patients. Documentation of complete vital signs was lowest in those <1 month old (30.8%) and rose with increasing age (highest in adults; 91.8%). Relative to adults, the adjusted odds of documented complete vital signs in patients <1 month old was 0.03 (95% CI 0.03-0.03) and increased with age to 0.76 (95% CI 0.75-0.77) in those 12-17 years old. Among those patients with respiratory, cardiac, and traumatic complaints, children had lower proportions of documented pulse oximetry, monitor use, and pain scores, respectively, compared to adults. CONCLUSION Documentation of complete vital signs and condition-specific assessments occurs less frequently in children, especially in younger age groups, as compared to adults, which is a finding that exists across urbanicity, region, and level of response. These findings provide a benchmark for clinical care, quality improvement, and research in the prehospital setting.
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Affiliation(s)
- Angelica Cercone
- Division of Emergency Medicine, UPMC Children's Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Sullivan TM, Milestone ZP, Colson CD, Tempel PE, Gestrich-Thompson WV, Burd RS. Evaluation of Missing Prehospital Physiological Values in Injured Children and Adolescents. J Surg Res 2023; 283:305-312. [PMID: 36423480 PMCID: PMC9990680 DOI: 10.1016/j.jss.2022.10.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/11/2022] [Accepted: 10/16/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Prehospital vital signs and the Glasgow Coma Scale score are often missing in clinical practice and not recorded in trauma databases. Our study aimed to identify factors associated with missing prehospital physiological values, including systolic blood pressure, heart rate, respiratory rate, peripheral oxygen saturation, and Glasgow Coma Scale. METHODS We used our hospital trauma registry to obtain patient, injury, resuscitation, and transportation characteristics for injured children and adolescents (age <15 y). We evaluated the association of missing documentation of prehospital values with other patient, injury, transportation, and resuscitation characteristics using multivariable regression. We standardized vital sign values using age-adjusted z-scores. RESULTS The odds of a missing physiological value decreased with age (odds ratio [OR] = 0.9, 95% confidence interval [CI] = 0.9, 0.9) and were higher when prehospital cardiopulmonary resuscitation was required (OR = 3.3, 95% CI = 1.9, 5.7). Among the physiological values considered, we observed the highest odds of missingness of systolic blood pressure, respiratory rate, and oxygen saturation. The odds of observing normal emergency department physiological values were lower when prehospital physiological values were missing (OR = 0.9, 95% CI = 0.9, 1.0; P = 0.04). CONCLUSIONS Missing prehospital physiological values were associated with younger age and cardiopulmonary resuscitation among the injured children treated at our hospital. Measurement and documentation of physiological variables of patients with these characteristics should be targeted.
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Affiliation(s)
- Travis M Sullivan
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia
| | - Zachary P Milestone
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia
| | - Cindy D Colson
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia
| | - Peyton E Tempel
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia
| | | | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia.
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Lee MC, Tseng WC, Hsu LM, Shin SD, Jamaluddin SF, Tanaka H, Son DN, Hong KJ, Riyapan S, Haedar A, Lin HY, Huang EPC, Hsieh MJ, Ma MHM, Sun JT, Chiang WC. Epidemiology and Prehospital Care of Pediatric Unintentional Injuries Among Countries with Different Economic Status in Asia: A Cross-National, Multi-Center Observational Study. PREHOSP EMERG CARE 2023; 27:227-237. [PMID: 35380921 DOI: 10.1080/10903127.2022.2062804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Injury is a major cause of morbidity and mortality in children. However, the epidemiology and prehospital care for pediatric unintentional injuries in Asia are still unclear. METHODS A total of 9,737 pediatric patients aged <18 years with unintentional injuries cared for at participating centers of the Pan-Asian Trauma Outcome Study (PATOS) from October 2015 to December 2020 were reviewed retrospectively. Patients were divided into two groups: those <8 and those ≥8 years of age. Variables such as patient demographics, injury epidemiology, Injury Severity Score (ISS), and prehospital care were collected. Injury severity and administered prehospital care stratified by gross national income were also analyzed. RESULTS Pediatric unintentional injuries accounted for 9.4% of EMS-transported trauma cases in the participating Asian centers, and the mortality rate was 0.88%. The leading cause of injury was traffic injuries in older children aged ≥8 years (56.5%), while falls at home were common among young children aged <8 years (43.9%). Compared with younger children, older children with similar ISS tended to receive more prehospital interventions. Uneven disease severity was found in that older children in lower-middle and upper-middle-income countries had higher ISS compared with those in high-income countries. The performance of prehospital interventions also differed among countries with different gross national incomes. Immobilizations were the most performed prehospital intervention followed by oxygen administration, airway management, and pain control; only one patient received prehospital thoracentesis. Procedures were performed more frequently in high-income countries than in upper-middle-income and lower-middle-income countries. CONCLUSIONS The major cause of injury was road traffic injuries in older children, while falls at home were common among young children. Prehospital care in pediatric unintentional injuries in Asian countries was not standardized and might be insufficient, and the economic status of countries may affect the implementation of prehospital care.
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Affiliation(s)
- Meng-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Chieh Tseng
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Min Hsu
- Department of Traumatology and Critical Care, National Taiwan University Hospital, Taipei City, Taiwan
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | | | - Hideharu Tanaka
- Graduate School of Emergency Medical Service System, Kokushikan University, Tokyo, Japan
| | - Do Ngoc Son
- Center for Critical Care Medicine, Bach Mai Hospital, Hanoi, Vietnam.,Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam.,Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | - Ki Jeong Hong
- Department of Emergency Medicine, Seoul National University College of Medicine and Hospital, Seoul, South Korea
| | - Sattha Riyapan
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand
| | - Ali Haedar
- Department of Emergency Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
| | - Hao-Yang Lin
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Edward Pei-Chuan Huang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, National Taiwan University Hospital, Hsin-Chu city, Taiwan
| | - Ming-Ju Hsieh
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Matthew Huei-Ming Ma
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, National Taiwan University Hospital, Douliu City, Taiwan
| | - Jen-Tang Sun
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Wen-Chu Chiang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, National Taiwan University Hospital, Douliu City, Taiwan
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11
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Nielsen VML, Søvsø MB, Kløjgård TA, Skals RG, Corfield AR, Bender L, Lossius HM, Mikkelsen S, Christensen EF. Prehospital vital sign monitoring in paediatric patients: an interregional study of educational interventions. Scand J Trauma Resusc Emerg Med 2023; 31:4. [PMID: 36639802 PMCID: PMC9839956 DOI: 10.1186/s13049-023-01067-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 01/04/2023] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Prehospital vital sign documentation in paediatric patients is incomplete, especially in patients ≤ 2 years. The aim of the study was to increase vital sign registration in paediatric patients through specific educational initiatives. METHODS Prospective quasi-experimental study with interrupted time-series design in the North Denmark and South Denmark regions. The study consecutively included all children aged < 18 years attended by the emergency medical service (EMS) from 1 July 2019 to 31 December 2021. Specific educational initiatives were conducted only in the North Denmark EMS and included video learning and classroom training based on the European Paediatric Advanced Life Support principles. The primary outcome was the proportion of patients who had their respiratory rate, peripheral capillary oxygen saturation, heart rate and level of consciousness recorded at least twice. We used a binomial regression model stratified by age groups to compare proportions of the primary outcome in the pre- and post-intervention periods in each region. RESULTS In North Denmark, 7551 patients were included, while 15,585 patients from South Denmark were used as a reference. Virtually all of the North Denmark EMS providers completed the video learning (98.7%). The total study population involved patients aged ≤ 2 months (5.5%), 3-11 months (7.4%), 1-2 years (18.8%), 3-7 years (16.2%) and ≥ 8 years (52.1%). In the intervention region, the primary outcome increased from the pre- to the post-intervention period from 35.3% to 40.5% [95% CI for difference 3.0;7.4]. There were large variations in between age groups with increases from 18.8% to 27.4% [95% CI for difference 5.3;12.0] among patients aged ≤ 2 years, from 33.5% to 43.7% [95% CI for difference 4.9;15.5] among patients aged 3-7 years and an insignificant increase among patients aged ≥ 8 years (from 46.4% to 47.9% [95% CI for difference - 1.7;4.7]). In the region without the specific educational interventions, proportions were steady for all age groups throughout the entire study period. CONCLUSIONS Mandatory educational initiatives for EMS providers were associated with an increase in the extent of vital sign registration in paediatric patients ≤ 7 years. Incomplete vital registration was associated with, but not limited to non-urgent cases.
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Affiliation(s)
- Vibe Maria Laden Nielsen
- grid.5117.20000 0001 0742 471XCentre for Prehospital and Emergency Research, Department of Clinical Medicine, Aalborg University Hospital, Aalborg University, Aalborg, Denmark
| | - Morten Breinholt Søvsø
- grid.5117.20000 0001 0742 471XCentre for Prehospital and Emergency Research, Department of Clinical Medicine, Aalborg University Hospital, Aalborg University, Aalborg, Denmark ,grid.425870.cPrehospital Emergency Services, Aalborg, North Denmark Region Denmark
| | - Torben Anders Kløjgård
- grid.5117.20000 0001 0742 471XCentre for Prehospital and Emergency Research, Department of Clinical Medicine, Aalborg University Hospital, Aalborg University, Aalborg, Denmark
| | - Regitze Gyldenholm Skals
- grid.27530.330000 0004 0646 7349Unit of Clinical Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Alasdair Ross Corfield
- grid.8756.c0000 0001 2193 314XNational Health Service Greater Glasgow and Clyde, University of Glasgow, Glasgow, UK
| | - Lars Bender
- grid.27530.330000 0004 0646 7349Paediatric Department, Aalborg University Hospital, Aalborg, Denmark
| | - Hans Morten Lossius
- grid.18883.3a0000 0001 2299 9255Norwegian Air Ambulance Foundation, University of Stavanger, Stavanger, Norway
| | - Søren Mikkelsen
- grid.7143.10000 0004 0512 5013The Prehospital Research Unit, Odense University Hospital, Odense, Region of Southern Denmark Denmark
| | - Erika Frischknecht Christensen
- grid.5117.20000 0001 0742 471XCentre for Prehospital and Emergency Research, Department of Clinical Medicine, Aalborg University Hospital, Aalborg University, Aalborg, Denmark ,grid.425870.cPrehospital Emergency Services, Aalborg, North Denmark Region Denmark
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12
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Sullivan TM, Gestrich-Thompson WV, Milestone ZP, Burd RS. Time is tissue: Barriers to timely transfusion after pediatric injury. J Trauma Acute Care Surg 2023; 94:S22-S28. [PMID: 35916621 PMCID: PMC9805480 DOI: 10.1097/ta.0000000000003752] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT Strategies to improve outcomes among children and adolescents in hemorrhagic shock have primarily focused on component resuscitation, pharmaceutical coagulation adjuncts, and hemorrhage control techniques. Many of these strategies have been associated with better outcomes in children, but the barriers to their use and the impact of timely use on morbidity and mortality have received little attention. Because transfusion is uncommon in injured children, few studies have identified and described barriers to the processes of using these interventions in bleeding patients, processes that move from the decision to transfuse, to obtaining the necessary blood products and adjuncts, and to delivering them to the patient. In this review, we identify and describe the steps needed to ensure timely blood transfusion and propose practices to minimize barriers in this process. Given the potential impact of time on hemorrhage associated outcomes, ensuring timely intervention may have a similar or greater impact than the interventions themselves.
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Affiliation(s)
- Travis M. Sullivan
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | | | - Zachary P. Milestone
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
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13
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Scott J, Khanom A, Straw J, Strickland A, Porter A, Snooks H. Paediatric frequent use of emergency medical services: a systematic review. Emerg Med J 2022; 40:emermed-2021-211701. [PMID: 36600465 DOI: 10.1136/emermed-2021-211701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 10/27/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Frequent use of emergency medical services (EMS) is recognised to be a global phenomenon, although paediatric frequent use is poorly understood. This systematic review aimed to understand how paediatric frequent use of EMS is currently defined, identify factors associated with paediatric frequent use of EMS and determine effectiveness of interventions for paediatric patients who frequently use EMS. METHODS Four electronic databases (Medline, CINAHL, Web of Science and PsycINFO) were searched to September 2022 for primary, peer-reviewed research studies published in English from January 2000. Studies were included that examined frequent use (>1 contact during study period) of EMS or other services with arrival via EMS. Paediatric patients were defined as <18 years of age or otherwise defined by study authors as paediatric/adolescent/children. Data were extracted using a structured proforma, and quality was assessed using the Standard Quality Assessment Criteria for Quantitative Studies but did not influence inclusion decisions. Data were presented using narrative synthesis. RESULTS The search resulted in 4172 unique references, with 12 papers included in the review from 7 countries. Four were EMS studies, and eight Emergency Department with arrival via EMS. All studies used retrospective designs, with no interventional studies identified. Paediatric frequent EMS users were more likely to use services for medical reasons rather than trauma, including respiratory complaints, mental health and seizures, but data on gender and ethnicity were inconclusive and silent on socioeconomic status. There was no consistency in definitions of either a paediatric patient or of frequent use. CONCLUSION The broad range of reasons for frequent use suggests that a single intervention is unlikely to be effective at addressing the causes of frequent use. There is a need for further research to better identify the underlying reasons for frequent EMS use among paediatric patients and to develop interventions in this population.
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Affiliation(s)
- Jason Scott
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | | | - Joanne Straw
- Emergency Operations Centre, Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | - Annette Strickland
- Emergency Operations Centre, Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | - Alison Porter
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Helen Snooks
- Swansea University Medical School, Swansea University, Swansea, UK
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14
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Fishe JN, Heintz H, Owusu-Ansah S, Schmucker K, Riney LC, Semenova O, Garvan G, Browne LR. Prehospital Pediatric Asthma Care during COVID-19: Changes to EMS Treatment Protocols and Downstream Clinical Effects. PREHOSP EMERG CARE 2022; 27:893-899. [PMID: 36260781 PMCID: PMC10164835 DOI: 10.1080/10903127.2022.2137864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/05/2022] [Accepted: 10/10/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION During the COVID-19 pandemic, many emergency medical services (EMS) agencies modified treatment guidelines for clinical care and standard operating procedures. For the prehospital care of pediatric asthma exacerbations, modifications included changes to bronchodilator administration, systemic corticosteroid administration, and introduction of alternative medications. Since timely administration of bronchodilators and systemic corticosteroids has been shown to improve pediatric asthma clinical outcomes, we investigated the association of COVID-19 protocol modifications in the prehospital management of pediatric asthma on hospital admission rates and emergency department (ED) length-of-stay. METHODS This is a multicenter, retrospective, observational cohort study comparing prehospital pediatric asthma patients treated by EMS clinicians from four EMS systems before and after implementation of COVID-19 interim EMS protocol modifications. We included children ages 2-18 years who were treated and transported by ground EMS for respiratory-related prehospital primary complaints, and who also had asthma-related ED discharge diagnoses. Patient data and outcomes were compared from 12 months prior to and 12 months after the implementation of interim COVID-19 prehospital protocol modifications using univariate and multivariable statistics. RESULTS A total of 430 patients met inclusion criteria with a median age of 8 years. There was a slight male predominance (57.9%) and the majority of patients were African American (78.4%). There were twice as many patients treated prior to the COVID-19 protocol modifications (N = 287) compared to after (N = 143). There was a significant decrease in EMS bronchodilator administration from 76% to 59.4% of patients after COVID-19 protocol guidelines were implemented (p < 0.0001). Mixed effects models for hospital admission (to both pediatric inpatient units and pediatric intensive care units) as well as ED length-of-stay did not show any significant effect after the COVID-19 protocol change period (p = 0.18 and p = 0.55, respectively). CONCLUSIONS Despite a decrease in prehospital bronchodilator administration after COVID-19 changes to prehospital pediatric asthma management protocols, hospital admission rates and ED length-of-stay did not significantly increase. However, this finding is tempered by the marked decrease in study patients treated after COVID-19 prehospital protocol modifications. Given the potential for future waves of COVID-19 variants, further studies with larger patient populations are warranted.
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Affiliation(s)
- Jennifer N Fishe
- Center for Data Solutions, University of Florida College of Medicine, Jacksonville, Florida
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Hanna Heintz
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sylvia Owusu-Ansah
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kyle Schmucker
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Texas Southwestern, Dallas, Texas
| | - Lauren C Riney
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Olga Semenova
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Gerard Garvan
- Center for Data Solutions, University of Florida College of Medicine, Jacksonville, Florida
| | - Lorin R Browne
- Departments of Pediatrics and Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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15
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Tsao HS, Alter R, Kane E, Gross T, Browne LR, Auerbach M, Leonard JC, Ludwig L, Adelgais KM. Pediatric Emergency Care Coordination in EMS Agencies: Findings of a Multistate Learning Collaborative. PREHOSP EMERG CARE 2022; 27:1004-1015. [PMID: 36125189 DOI: 10.1080/10903127.2022.2126040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/14/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND In 2017, the Health Resources and Services Administration's Maternal Child and Health Bureau's Emergency Medical Services for Children program implemented a performance measure for State Partnership grants to increase the percentage of EMS agencies within each state that have designated individuals who coordinate pediatric emergency care, also called a pediatric emergency care coordinator (PECC). The PECC Learning Collaborative (PECCLC) was established to identify best practices to achieve this goal. This study's objective is to report on the structure and outcomes of the PECCLC conducted among nine states. METHODS This study used quantitative and qualitative methods to evaluate outcomes from the PECCLC. Participating state representatives engaged in a 6-month collaborative that included monthly learning sessions with subject matter experts and support staff and concluded with a two-day in-person meeting. Outcomes included reporting the number of PECCs recruited, identifying barriers and enablers to PECC recruitment, characterizing best practices to support PECCs, and identifying barriers and enablers to enhance and sustain the PECC role. Outcomes were captured by self-report from participating state representatives and longitudinal qualitative interviews conducted with representative PECCs at 6 and 18 months after conclusion of the PECCLC. RESULTS During the 6-month collaborative, states recruited 341 PECCs (92% of goal). Follow up at 5 months post-collaborative revealed an additional recruitment of 184 for a total of 525 PECCs (142% of the goal). Feedback from state representatives and PECCs revealed the following barriers: competition from other EMS responsibilities, budgetary constraints, lack of incentive for agencies to create the position, and lack of requirement for establishing the role. Enablers identified included having an EMS agency recognition program that includes the PECC role, train-the-trainer programs, and inclusion of the PECC role in agency licensure requirements. Longitudinal interviews with PECCs identified that the most common activity associated with their role was pediatric-specific education and the most important need for PECC success was agency-level support. CONCLUSION Over the 6-month Learning Collaborative, nine states were successful in recruiting a substantial number of PECCs. Financial and time constraints were significant barriers to statewide PECC recruitment, yet these can be potentially addressed by EMS agency recognition programs.
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Affiliation(s)
- Hoi See Tsao
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
- Emergency Medical Services for Children Innovation & Improvement Center, The University of Texas Austin, Austin, Texas
| | - Rachael Alter
- Emergency Medical Services for Children Innovation & Improvement Center, The University of Texas Austin, Austin, Texas
| | - Erica Kane
- EMS for Children, Emergency Medical Services for Children at Children's Health Alliance of Wisconsin, Milwaukee, Wisconsin
| | - Toni Gross
- Department of Emergency Medicine, Children's Hospital of New Orleans, New Orleans, Louisiana
| | - Lorin R Browne
- Department of Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, Wisconsin
| | - Marc Auerbach
- Yale University School of Medicine, New Haven, Connecticut
| | - Julie C Leonard
- Division of Emergency Medicine, Department of Pediatrics, The Ohio State University College of Medicine and the Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Lorah Ludwig
- Emergency Medical Services for Children Program, Maternal and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services, Rockville, Maryland
| | - Kathleen M Adelgais
- Emergency Medical Services for Children Innovation & Improvement Center, The University of Texas Austin, Austin, Texas
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
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16
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Shinohara M, Muguruma T, Toida C, Gakumazawa M, Abe T, Takeuchi I. The association between age and vital signs documentation of trauma patients in prehospital settings: analysis of a nationwide database in Japan. BMC Emerg Med 2022; 22:165. [PMID: 36195850 PMCID: PMC9531500 DOI: 10.1186/s12873-022-00725-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 09/26/2022] [Indexed: 11/27/2022] Open
Abstract
Background Emergency medical service (EMS) providers are the first medical professionals to make contact with patients in an emergency. However, the frequency of care by EMS providers for severely injured children is limited. Vital signs are important factors in assessing critically ill or injured patients in the prehospital setting. However, it has been reported that documentation of pediatric vital signs is sometimes omitted, and little is known regarding the performance rate of vital sign documentation by EMS providers in Japan. Using a nationwide data base in Japan, this study aimed to evaluate the relationship between patients’ age and the documentation of vital signs in prehospital settings. Methods This study was a secondary data analysis of the Japan Trauma Data Bank. The inclusion criterion was patients with severe trauma, as defined by an Injury Severity Score ≥ 16. Our primary outcome was the rate of recording all four basic vital signs, namely blood pressure, heart rate, respiratory rate, and level of consciousness in the prehospital setting among different age groups. We also compared the prehospital vital sign completion rate, that is, the rate at which all four vital signs were recorded in a prehospital setting based on age groups. Multivariate analysis was performed to evaluate factors associated with the prehospital vital sign completion rate. Results We analyzed 75,777 severely injured patients. Adults accounted for 94% (71400) of these severely injured patients, whereas only 6% of patients were children. The rate of prehospital recording of vital signs was lower in children ≤5 years than in adult patients for all four vital signs. When the adult group was used as a reference, the adjusted odds ratios of vital sign completion rate in infants (0 years), younger children (1–5 years), older children (6–11 years), and teenagers (12–17 years) were 0.09, 0.30, 0.78, and 0.87, respectively. Conclusions Analysis of the nationwide trauma registry showed that younger children tended to have a lower rate of vital sign documentation in prehospital settings.
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Affiliation(s)
- Mafumi Shinohara
- Advanced Critical Care and Emergency Center,
- Yokohama City University Medical Center, 4-57 Urafunecho. Minamiku, Yokohama City, Kanagawa, 232-0024, Japan.
| | - Takashi Muguruma
- Advanced Critical Care and Emergency Center,
- Yokohama City University Medical Center, 4-57 Urafunecho. Minamiku, Yokohama City, Kanagawa, 232-0024, Japan
| | - Chiaki Toida
- Advanced Critical Care and Emergency Center,
- Yokohama City University Medical Center, 4-57 Urafunecho. Minamiku, Yokohama City, Kanagawa, 232-0024, Japan
| | - Masayasu Gakumazawa
- Advanced Critical Care and Emergency Center,
- Yokohama City University Medical Center, 4-57 Urafunecho. Minamiku, Yokohama City, Kanagawa, 232-0024, Japan
| | - Takeru Abe
- Advanced Critical Care and Emergency Center,
- Yokohama City University Medical Center, 4-57 Urafunecho. Minamiku, Yokohama City, Kanagawa, 232-0024, Japan
| | - Ichiro Takeuchi
- Advanced Critical Care and Emergency Center,
- Yokohama City University Medical Center, 4-57 Urafunecho. Minamiku, Yokohama City, Kanagawa, 232-0024, Japan
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17
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Hirschhorn RM, Kerr ZY, Mensch JM, Huggins RA, Dompier TP, Rudisill C, Yeargin SW. Epidemiology of Emergency Medical Services Activations for Sport-Related Injuries in the United States. Cureus 2022; 14:e27403. [PMID: 36046296 PMCID: PMC9419755 DOI: 10.7759/cureus.27403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2022] [Indexed: 11/29/2022] Open
Abstract
Background Literature examining emergency medical services (EMS) activations for sport-related injuries is limited to the pediatric, high school, and collegiate student-athlete populations, excluding older individuals and recreational athletes. The purpose of this study was to examine EMS activations for sport-related injuries using the National EMS Information System Database from 2017-2018. Methods Data were obtained using the National EMS Information System Database from 2017-2018. EMS activations were limited to 9-1-1 responses for individuals aged 3-99 who sustained a sports-related injury. Independent variables included patient age group: pediatric (<18 years old) vs. adult (≥18 years old). Dependent variables were patient age, gender, and chief complaint anatomic location. Frequencies and proportions were calculated for each variable. Injury proportion ratios (IPRs) with 95% confidence intervals were calculated to compare chief complaint anatomic location by age group. Results There were 71,322 sport-related injuries. Patients were 36.6±22.9 years and most (58.1%, n=41,132) were male. Adults had higher proportions of injuries affecting the abdomen (IPR: 2.05, 95%CI: 1.83, 2.31), chest (IPR: 1.90, 95%CI: 1.75, 2.05), general/global (IPR: 1.54, 95%CI: 1.50, 1.58), and genitalia (IPR: 2.40, 95%CI: 1.39, 4.15), and lower proportions of injuries affecting the back (IPR: 0.55, 95%CI: 0.50, 0.60), lower extremity (IPR: 0.63, 95%CI: 0.60, 0.65), upper extremity (IPR: 0.50, 95%CI: 0.47, 0.53), head (IPR: 0.73, 95%CI: 0.70, 0.77), and neck (IPR: 0.18, 95%CI: 0.16, 0.20) compared to pediatric patients. Conclusion Injuries sustained differed between adult and pediatric patients, indicating sport-related emergencies may change across the lifespan. General/global chief complaints likely indicate sport-related injuries affecting multiple anatomic locations and organ systems. Stakeholders planning large or high-risk athletic events should consider arranging standby or dedicated advanced life support units for their events.
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18
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Vetschera A, Beliveau V, Esswein K, Linzmeier K, Gozzi R, Hohlrieder M, Simma B. Preclinical Pediatric Care by Emergency Physicians: A Comparison of Trauma and Nontrauma Patients in a Population-Based Study in Austria. Pediatr Emerg Care 2022; 38:e1384-e1390. [PMID: 35696293 DOI: 10.1097/pec.0000000000002759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Fewer than 10% of emergency medical system (EMS) calls concern children and adolescents younger than 18 years. Studies have shown that the preclinical care of children differs from that of adults regarding assessment, interventions, and monitoring. The aims of this study were to describe the preclinical care and emergency transport of pediatric patients in Vorarlberg, Austria and to compare trauma and nontrauma cases. METHODS This is a population-based study, analyzing medical records of EMS calls to children and adolescents. We received all patient records of EMS calls to children and adolescents younger than 18 years (n = 4390 in total) from the 2 local EMS providers, the Red Cross Vorarlberg and the Austrian Mountain Rescue Service (Christophorus 8 and Gallus 1) covering a study period of 7 years, from 2013 to 2019. The record data were extracted by automation with an in-house program and subsequently anonymized. Statistical analyses were performed with SPSS Statistics. RESULTS During the study period, 7.9% of all EMS calls concerned children and adolescents younger than 18 years. For our study, 3761 records were analyzed and 1270 trauma cases (33.8%) were identified. The most common injuries were injuries of the extremities and traumatic brain injury. The frequency of National Advisory Committee of Aeronautics Scores of 4 or higher was 17.7%, similar for all age groups and for trauma as well as nontrauma patients. Mean Glasgow Coma Scale scores were higher in the trauma group than in the nontrauma group (14.2 vs 11.2). In 62.9% of all patients, 1 or more vital parameters were documented. A majority of these values was in the pathologic range for the respective age group. The rate of pulsoxymetry monitoring during transport was low (42.1% in trauma and 30.3% in nontrauma patients) and decreased significantly with patient age. Moreover, while the placing of intravenous lines and monitoring during transport were significantly more frequent in trauma patients, the administration of medication or oxygen was significantly more frequent in nontrauma patients. CONCLUSIONS The pediatric population lacks assessments and monitoring in preclinical care, especially the youngest children and nontrauma patients, although emergency severity scores are similar.
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Affiliation(s)
- Anna Vetschera
- From the Department of Pediatrics, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch
| | - Vincent Beliveau
- Department of Neurology, Medical University of Innsbruck, Innsbruck
| | | | | | | | - Matthias Hohlrieder
- Department of Anesthesiology and Intensive Care Medicine, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - Burkhard Simma
- From the Department of Pediatrics, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch
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Nezu M, Shiima Y, Kurosawa H, Miyakoshi C. Outcomes of Pediatric Patients in Secondary Transport to Tertiary Hospital: A Retrospective Observational Study. Pediatr Emerg Care 2022; 38:283-289. [PMID: 35436767 DOI: 10.1097/pec.0000000000002711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Emergency medical service (EMS) providers play an important role in determining which hospital to choose. To date, there is no evidence-based guideline to support their decisions, except for major trauma cases. Secondary transport is considered when a patient needs further investigation or treatment after primary transport, but this can delay treatment and put patients at unnecessary risk. The objective of this study was to investigate the outcomes of pediatric secondary transport patients to tertiary hospitals. METHODS This was a citywide population-based observational study conducted in Kobe, Japan. We reviewed the EMS registry to identify secondary transport patients younger than 19 years and investigated their clinical characteristics. We excluded cases of unknown hospital destinations, nontransported cases, and major trauma patients who followed a different protocol for a hospital destination. The primary endpoint was the hospital outcome 12 hours after transport. Because there was no link between the EMS patient transport data and the hospital medical records, a probabilistic linkage was performed to obtain the hospital outcomes. Patients who required secondary transport were compared with patients transported directly to tertiary hospitals. RESULTS A total of 13,720 pediatric patients were transported from the field by Kobe EMS between January 2013 and December 2015. Among them, 81 pediatric patients (0.6%) required secondary transport to tertiary hospitals within 24 hours of the primary transport, whereas a total of 3673 patients (27%) were transported directly to tertiary hospitals. Despite no apparent difference in prehospital severity, secondary transport patients were associated with higher hospitalization rates and a need for critical care compared with those who had direct transport. Seizure was the most common reason for the use of secondary transport, and 89% of the seizure patients were hospitalized after undergoing secondary transport; minor trauma was the second most common reason for the use of secondary transport, and 53% of the patients were hospitalized. CONCLUSIONS In this study, the characteristics of the secondary transport patients and hospital outcomes revealed a heterogeneity in pediatric prehospital transport. It is recommended that the development of pediatric EMS destination guidelines cover children's diverse conditions. Further studies are required, and linkages between prehospital and hospital data will help promote a better understanding of appropriate hospital destinations.
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Affiliation(s)
- Mari Nezu
- From the Department of Pediatrics, Kobe City Medical Center General Hospital
| | - Yuko Shiima
- Division of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital
| | - Hiroshi Kurosawa
- Division of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital
| | - Chisato Miyakoshi
- Department of Research Support, Center for Clinical Research and Innovation, Kobe City Medical Center General Hospital, Hyogo, Japan
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20
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Mandt M, Harris M, Lyng J, Moore B, Gross T, Gausche-Hill M, Donofrio-Odmann JJ. Quality Management of Prehospital Pediatric Respiratory Distress and Airway Programs: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:111-117. [PMID: 35001832 DOI: 10.1080/10903127.2021.1986184] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The unique challenges of pediatric respiratory and airway emergencies require the development and maintenance of a prehospital quality management program that includes pediatric-focused medical oversight and clinical care expertise, data collection, operational considerations, focused education, and clinician competency evaluation.NAEMSP recommends:Medical director oversight must include a focus on pediatric airway and respiratory management and integrate pediatric-specific elements in guideline development, competency assessment, and skills maintenance efforts.EMS agencies are encouraged to collaborate with medical professionals who have expertise in pediatric emergency care to provide support for quality management initiatives in pediatric respiratory distress and airway management.EMS agencies should define quality indicators for pediatric-specific elements in respiratory distress and airway management and benchmark performance based on regional and national standards.EMS agencies should implement both quantitative (objective) and qualitative (subjective) measures of performance to assess competency in pediatric respiratory distress and airway management.EMS agencies choosing to incorporate pediatric endotracheal intubation or supraglottic airway insertion must use pediatric-specific quality management benchmarks and perform focused review of advanced airway management.
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21
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Farrell C, Dorney K, Mathews B, Boyle T, Kitchen A, Doyle J, Monuteaux MC, Li J, Walsh B, Nagler J, Chung S. A Statewide Collaboration to Deliver and Evaluate a Pediatric Critical Care Simulation Curriculum for Emergency Medical Services. Front Pediatr 2022; 10:903950. [PMID: 35774102 PMCID: PMC9237480 DOI: 10.3389/fped.2022.903950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/18/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Caitlin Farrell
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Kate Dorney
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Bonnie Mathews
- Division of Emergency Medicine, Department of Pediatrics, UMass Medical School, Worcester, MA, United States
| | - Tehnaz Boyle
- Division of Emergency Medicine, Department of Pediatrics, Boston University School of Medicine, Boston, MA, United States
| | - Anthony Kitchen
- Department of Emergency Medicine, Baystate Medical Center, Springfield, MA, United States
| | - Jeff Doyle
- Department of Public Health, Emergency Medical Services for Children, Boston, MA, United States
| | - Michael C Monuteaux
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Joyce Li
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Barbara Walsh
- Division of Emergency Medicine, Department of Pediatrics, Boston University School of Medicine, Boston, MA, United States
| | - Joshua Nagler
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Sarita Chung
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Boston, MA, United States
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Schneck E, Janßen G, Vaillant V, Voelker T, Dechert O, Trocan L, Schmitz L, Rohde M, Sander M, Hauch H. Cardiopulmonary resuscitation in pediatric patients under palliative home care - A multicenter retrospective study. Front Pediatr 2022; 10:1105609. [PMID: 36704133 PMCID: PMC9872029 DOI: 10.3389/fped.2022.1105609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 12/21/2022] [Indexed: 01/11/2023] Open
Abstract
Introduction: Patients under palliative home care have special needs for their end-of-life support, which in general does not automatically include cardiopulmonary resuscitation. However, emergency medical services (EMS) respond to emergencies in children under palliative care that lead to cardiopulmonary resuscitation. To understand the underlying steps of decision-making, this retrospective, cross-sectional, multicenter study aimed to analyze pediatric patients under palliative home care who had been resuscitated. Methods: This study included patients from three spezialized pediatric palliative home care (SHPC) teams. The primary study parameters were the prevalence of cardiopulmonary resuscitation and the decision-making for carrying out pediatric advanced life support (PALS). Further analyses included the causes of cardiac arrest, the type of CPR (basic life support, advanced life support), the patient´s outcome, and involvement of the SHPC in the resuscitation. Descriptive statistical analysis was performed. Results: In total, 880 pediatric patients under palliative home care were included over 8.5 years, of which 17 patients were resuscitated once and two patients twice (overall, 19 events with CPR, 21.6 per 1,000 cases). In 10 of the 19 incidents (52.6%), cardiac arrest occurred suddenly without being predictable. The causes of cardiac arrest varied widely. PALS was performed in 78.9% of the cases by EMS teams. In 12 of 19 events (63.2%) resuscitation was performed on explicit wish of the parents. However, from a medical point of view, only four resuscitation attempts were reasonable. In total 7 of 17 (41.2%) patients survived cardiac arrest with a comparable quality of life. Discussion: Overall, resuscitation attempts were rare events in children under home palliative therapy, but if they occur, EMS are often the primary caregivers. Most resuscitation attempts occurred on explicit wish of the parents independently of the meaningfulness of the medical procedure. Despite the presence of a life-limiting disease, survival with a similar quality was achieved in one third of all resuscitated patients. This study indicates that EMS should be trained for advanced life support in children under home palliative therapy and SHPC should address the scenario of cardiac arrest also in early stages of palliative treatment. These results underline that advance care planning for these children is urgently needed.
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Affiliation(s)
- Emmanuel Schneck
- Department for Anaesthesiology, Intensive Care Medicine and Pain Therapy, Justus Liebig University, Giessen, Hesse, Germany
| | - Gisela Janßen
- Palliative Care Team for Children, Heinrich-Heine-University, Duesseldorf, North Rhine-Westphalia, Germany
| | - Vera Vaillant
- Palliative Care Team for Children, Justus Liebig University, Giessen, Hesse, Germany
| | - Thomas Voelker
- Palliative Care Team for Children, Kleine Riesen Kassel, Kassel, Hesse, Germany
| | - Oliver Dechert
- Palliative Care Team for Children, Heinrich-Heine-University, Duesseldorf, North Rhine-Westphalia, Germany
| | - Laura Trocan
- Palliative Care Team for Children, Heinrich-Heine-University, Duesseldorf, North Rhine-Westphalia, Germany
| | - Lioba Schmitz
- Palliative Care Team for Children, Heinrich-Heine-University, Duesseldorf, North Rhine-Westphalia, Germany
| | - Marius Rohde
- Department for Pediatric Oncology and Hematology, Justus Liebig University, Giessen, Hesse, Germany
| | - Michael Sander
- Department for Anaesthesiology, Intensive Care Medicine and Pain Therapy, Justus Liebig University, Giessen, Hesse, Germany
| | - Holger Hauch
- Palliative Care Team for Children, Justus Liebig University, Giessen, Hesse, Germany
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23
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Kothari K, Zuger C, Desai N, Leonard J, Alletag M, Balakas A, Binney M, Caffrey S, Kotas J, Mahar P, Roswell K, Adelgais KM. Effect of Repetitive Simulation Training on Emergency Medical Services Team Performance in Simulated Pediatric Medical Emergencies. AEM EDUCATION AND TRAINING 2021; 5:e10537. [PMID: 34099990 PMCID: PMC8166302 DOI: 10.1002/aet2.10537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 05/22/2023]
Abstract
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.
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Affiliation(s)
- Kathryn Kothari
- From theDepartment of PediatricsSection of Pediatric Emergency MedicineUniversity of Colorado School of MedicineAuroraCOUSA
- theDenver Health and Hospital AuthorityDenverCOUSA
| | - Chelsea Zuger
- From theDepartment of PediatricsSection of Pediatric Emergency MedicineUniversity of Colorado School of MedicineAuroraCOUSA
| | - Neil Desai
- theEmergency DepartmentBritish Columbia Children’s HospitalVancouverBritish ColumbiaCanada
| | - Jan Leonard
- From theDepartment of PediatricsSection of Pediatric Emergency MedicineUniversity of Colorado School of MedicineAuroraCOUSA
| | - Michelle Alletag
- From theDepartment of PediatricsSection of Pediatric Emergency MedicineUniversity of Colorado School of MedicineAuroraCOUSA
| | - Ashley Balakas
- theEmergency Medical Services Education and Outreach ProgramChildren’s Hospital ColoradoAuroraCOUSA
| | - Mike Binney
- theWest Metro Fire Protection DistrictLakewoodCOUSA
| | - Sean Caffrey
- and theEMS DivisionCrested Butte Fire Protection AuthorityCrested ButteCOUSA
| | - Jason Kotas
- theEmergency Medical Services Education and Outreach ProgramChildren’s Hospital ColoradoAuroraCOUSA
| | - Patrick Mahar
- From theDepartment of PediatricsSection of Pediatric Emergency MedicineUniversity of Colorado School of MedicineAuroraCOUSA
| | - Kelley Roswell
- From theDepartment of PediatricsSection of Pediatric Emergency MedicineUniversity of Colorado School of MedicineAuroraCOUSA
| | - Kathleen M. Adelgais
- From theDepartment of PediatricsSection of Pediatric Emergency MedicineUniversity of Colorado School of MedicineAuroraCOUSA
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24
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Hewes HA, Genovesi AL, Codden R, Ely M, Ludwig L, Macias CG, Schmuhl P, Olson LM. Ready for Children Part II: Increasing Pediatric Care Coordination and Psychomotor Skills Evaluation in the Prehospital Setting. PREHOSP EMERG CARE 2021; 26:503-510. [PMID: 34142919 DOI: 10.1080/10903127.2021.1942340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Hilary A Hewes
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Utah, School of Medicine, Salt Lake City, UT.,Department of Pediatrics, University of Utah, Data Coordinating Center, Salt Lake City, UT
| | - Andrea L Genovesi
- Department of Pediatrics, University of Utah, Data Coordinating Center, Salt Lake City, UT
| | - Rachel Codden
- Department of Pediatrics, University of Utah, Data Coordinating Center, Salt Lake City, UT
| | - Michael Ely
- Department of Pediatrics, University of Utah, Data Coordinating Center, Salt Lake City, UT
| | - Lorah Ludwig
- Emergency Medical Services for Children Program, Maternal and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services
| | - Charles G Macias
- Department of Pediatrics, University Hospitals Rainbow Babies and Children's/Case Western Reserve University, Cleveland, OH
| | - Patricia Schmuhl
- Department of Pediatrics, University of Utah, Data Coordinating Center, Salt Lake City, UT
| | - Lenora M Olson
- Department of Pediatrics, University of Utah, Data Coordinating Center, Salt Lake City, UT
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25
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Improving Administration of Prehospital Corticosteroids for Pediatric Asthma. Pediatr Qual Saf 2021; 6:e410. [PMID: 34046539 PMCID: PMC8143736 DOI: 10.1097/pq9.0000000000000410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 11/24/2020] [Indexed: 11/26/2022] Open
Abstract
Early administration of systemic corticosteroids for asthma exacerbations in children is associated with improved outcomes. Implementation of a new emergency medical services (EMS) protocol guiding the administration of systemic corticosteroids for pediatric patients with asthma exacerbations went into effect in January 2016 in Southwest Ohio. Our SMART aim was to increase the proportion of children receiving systemic prehospital corticosteroids for asthma exacerbations from 0% to 70% over 2 years.
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26
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Browne LR, Ahmad FA, Schwartz H, Wallendorf M, Kuppermann N, Lerner EB, Leonard JC. Prehospital Factors Associated With Cervical Spine Injury in Pediatric Blunt Trauma Patients. Acad Emerg Med 2021; 28:553-561. [PMID: 33217762 DOI: 10.1111/acem.14176] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 11/12/2020] [Accepted: 11/18/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND The risk for cervical spine injury (CSI) must be assessed in children who sustain blunt trauma. The Pediatric Emergency Care Applied Research Network (PECARN) retrospectively derived CSI model identifies CSI risk in children based on emergency department (ED) provider observations. The objective of this pilot study was to determine the univariate association of emergency medical services (EMS) provider-observed historical, mechanistic, and physical examination factors with CSI in injured children. Secondarily, we assessed the performance of the previously identified eight PECARN CSI risk factors (PECARN model) based exclusively on EMS provider observation. METHODS We conducted a four-center, prospective observational study of children 0 to 17 years old who were transported by EMS after blunt trauma and underwent spinal motion restriction or trauma team activation in the ED. In the ED, EMS providers recorded their observations for a priori determined CSI risk factors. CSIs were classified by reviewing imaging, consultations, and/or telephone follow-up. We calculated bivariable relative risks and test characteristics for the PECARN model based solely on EMS provider observations. RESULTS Of 1,372 enrolled children, 25 (1.8%) had CSIs. Of the a priori determined CSI risk factors, seven factors had bivariable associations with CSIs: axial load, altered mental status, signs of basilar skull fracture, substantial torso injury, substantial thoracic injury, respiratory distress, and decreased oxygen saturation. The PECARN model (high-risk motor vehicle collision, diving mechanism, predisposing condition, neck pain, decreased neck mobility, altered mental status, neurologic deficits, and/or substantial torso injury) exhibited the following test characteristics when based on EMS provider observations: sensitivity = 96.0% (95% confidence interval [CI] = 88.3% to 100.0%); negative predictive value = 99.8% (95% CI = 99.4% to 100.0%); specificity = 38.5% (95% CI = 35.9% to 41.1%); and positive predictive value = 2.8% (95% CI = 1.7% to 3.9%). CONCLUSION EMS providers can identify risk factors associated with CSI in injured children who experience blunt trauma. These risk factors may be considered for inclusion in a pediatric CSI decision rule specific to the prehospital setting.
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Affiliation(s)
- Lorin R. Browne
- From the Department of Pediatrics and Emergency Medicine Medical College of Wisconsin Milwaukee WIUSA
| | - Fahd A. Ahmad
- the Department of Pediatrics Washington University School of Medicine in St. Louis St. Louis MOUSA
| | - Hamilton Schwartz
- Department of Pediatrics Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine Cincinnati OHUSA
| | - Michael Wallendorf
- Department of Biostatistics Washington University School of Medicine in St. Louis St. Louis MOUSA
| | - Nathan Kuppermann
- the Department of Emergency Medicine and Pediatrics University of California Davis School of Medicine Sacramento CAUSA
| | - E. Brooke Lerner
- Department of Emergency Medicine University at Buffalo Buffalo NYUSA
| | - Julie C. Leonard
- Department of Pediatrics Nationwide Children’s Hospital and The Ohio State University College of Medicine Columbus OHUSA
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Cheetham AL, Navanandan N, Leonard J, Spaur K, Markowitz G, Adelgais KM. Impact of prehospital pediatric asthma management protocol adherence on clinical outcomes. J Asthma 2021; 59:937-945. [PMID: 33504232 DOI: 10.1080/02770903.2021.1881969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the frequency of EMS protocol non-adherence during pediatric asthma encounters and its association with emergency department (ED) length of stay (LOS) and hospital admission. METHODS This is a retrospective review of asthma encounters aged 2-17 years transported by EMS to a pediatric ED from 2012 to 2017. Our primary outcome was hospital admission based on prehospital protocol adherence defined as: (1) bronchodilator administration, (2) treatment of hypoxia with oxygen, or (3) administration of intramuscular (IM) epinephrine in encounters with high severity of distress. Multivariable logistic regression estimated the association between protocol non-adherence and hospital admission. RESULTS During the study period, 290 EMS encounters met inclusion criteria. Median age was 9 years (IQR 5-12), 63% were male, 40% had moderate to severe exacerbations, and 24% were admitted. Protocol non-adherence occurred in 32% of encounters with failure to administer bronchodilators in 27% and failure to administer IM epinephrine when indicated in 83%. Prehospital steroids were administered in 8% of encounters. After adjusting for covariates, protocol non-adherence was not statistically associated with likelihood of inpatient admission (OR 1.3; 95% CI: 0.6-2.6). CONCLUSIONS Among prehospital pediatric asthma encounters, EMS protocol non-adherence is common but not associated with a higher frequency of hospital admission. Hospital admission was associated with acute exacerbation severity suggesting further research is needed to develop a valid prehospital asthma severity assessment scoring tool. Supplemental data for this article can be accessed at publisher's website.
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Affiliation(s)
- Alexandra L Cheetham
- Pediatric Residency Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nidhya Navanandan
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jan Leonard
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kelsey Spaur
- University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Kathleen M Adelgais
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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Oude Alink MB, Moors XRJ, Karrar S, Houmes RJ, Hartog DD, Stolker RJ. Characteristics, management and outcome of prehospital pediatric emergencies by a Dutch HEMS. Eur J Trauma Emerg Surg 2021; 48:989-998. [PMID: 33543366 PMCID: PMC9001565 DOI: 10.1007/s00068-020-01579-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 12/16/2020] [Indexed: 11/28/2022]
Abstract
Background In prehospital care, the Helicopter Emergency Medical Service (HEMS) can be dispatched for critically injured or ill children. However, little detail is known about dispatches for children, in terms of the incidence of prehospital interventions and overall mortality. The primary objective of this study is to provide an overview of pediatric patient characteristics and incidence of interventions. Methods A retrospective chart review of all patients ≤ 17 years who received medical care by Rotterdam HEMS from 2012 until 2017 was carried out. Results During the study period, 1905 pediatric patients were included. 59.1% of patients were male and mean age was 6.1 years with 53.2% of patients aged ≤ 3 years. 53.6% were traumatic patients and 49.7% were non-traumatic patients. 18.8% of patients were intubated. Surgical procedures were performed in 0.9%. Medication was administered in 58.1% of patients. Cardiopulmonary resuscitation (CPR) was necessary in 12.9% of patients, 19.9% were admitted to the intensive care unit and 14.0% needed mechanical ventilation. Overall mortality was 9.5%. Mortality in trauma patients was 5.5% and in non-trauma group 15.3%. 3.9% of patients died at the scene. Conclusions Patients attended by HEMS are at high risk of prehospital interventions like CPR or intubation. EMS has little exposure to critically ill or injured children. Hence, HEMS expertise is required to perform critical procedures. Trauma patients had higher survival rates than non-traumatic patients. This may be explained by underlying illnesses in non-traumatic patients and CPR as reason for dispatch. Further research is needed to identify options for improving prehospital care in the non trauma pediatric patients.
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Affiliation(s)
- Michelle Berdien Oude Alink
- Department of Anesthesiology, Erasmus University Medical Center-Sophia Children's Hospital Rotterdam, Rotterdam, The Netherlands. .,Department of Pediatric Anesthesiology, Erasmus University Medical Center Rotterdam-Sophia Children's Hospital, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Xavier Roland Johnny Moors
- Department of Anesthesiology, Erasmus University Medical Center-Sophia Children's Hospital Rotterdam, Rotterdam, The Netherlands.,HEMS, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Senned Karrar
- Department of Anesthesiology, Erasmus University Medical Center-Sophia Children's Hospital Rotterdam, Rotterdam, The Netherlands
| | - Robert Jan Houmes
- HEMS, Erasmus University Medical Center, Rotterdam, The Netherlands.,Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Dennis Den Hartog
- Department of Surgery-Traumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Robert Jan Stolker
- Department of Anesthesiology, Erasmus University Medical Center-Sophia Children's Hospital Rotterdam, Rotterdam, The Netherlands
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Hauch H, El Mohaui N, Wolff JEA, Vaillant V, Brill S, Schneck E, Ströter N, Sibelius U, Kriwy P, Berthold D. Out-of-Hospital Emergencies in Children Under Palliative Home Care. Front Pediatr 2021; 9:734181. [PMID: 35004533 PMCID: PMC8727697 DOI: 10.3389/fped.2021.734181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 11/30/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction: Specialized palliative home care (SPHC) enables children and adolescents with life-limiting illnesses and complex needs to receive care at home. In addition to controlling symptoms and stabilizing the psychosocial situation, crisis anticipation is a component of SPHC. Since the establishment of the reporting SPHC team, parents have called for additional help from emergency medical services (EMS) in emergency situations with unexpected frequency. Children with life limiting diseases could undergo invasive procedures and unhelpful treatments with uncertain consequences. The questions arose as to which factors led to the involvement of the EMS in a palliative situation, what therapy was performed and what outcome could be reached. Methods: Records of the pediatric SPHC patients and EMS call-outs in these children of the reporting SPHC-team in the central region of Hesse, Germany (population: 1.1 million) were retrospectively analyzed from 01.11.2014 to 01.05.2021. The causes of the call-outs, the existence of an emergency agreement, the National Advisory Committee for Aeronautics (NACA) score, EMS therapy and outcome were examined. Patient data included age, palliative-justifying diagnosis, duration and intensity of care, place of death and median overall survival (MOS) and palliative SHPC treatment. Results: In total, 172 patients were analyzed during the study period. There were 27 EMS calls for a total of 20 patients/families (= EMS group). Palliative illness or a complication was the most frequent cause of call-outs. The patients in the EMS group were significantly less likely to have a DNR order, required more home visits and telephone calls and were under SPHC care for longer. There was a significantly higher proportion of crisis interventions at home visits. The children in the EMS group died less often from the underlying disease. Of the remaining 152 patients (= non-EMS group), a significantly higher proportion had a European home country. Conclusions: Despite the introduction of the SPHC, parents still call the EMS. Good cooperation and joint training should be sought to prepare all those involved for future call-outs.
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Affiliation(s)
- Holger Hauch
- Palliative Care Team for Children, University Children's Hospital Giessen, Giessen, Germany
| | - Naual El Mohaui
- Palliative Care Team for Children, University Children's Hospital Giessen, Giessen, Germany
| | | | - Vera Vaillant
- Palliative Care Team for Children, University Children's Hospital Giessen, Giessen, Germany
| | - Sabine Brill
- Palliative Care Team for Children, University Children's Hospital Giessen, Giessen, Germany
| | - Emmanuel Schneck
- Anesthesiology and Intensive Medicine, University Hospital Giessen, Giessen, Germany
| | - Natascha Ströter
- Pediatric Oncology, University Children's Hospital Giessen, Giessen, Germany
| | - Ulf Sibelius
- Palliative Care Team for Adults, University Hospital Giessen, Giessen, Germany
| | - Peter Kriwy
- Institute of Sociology, Chemnitz University of Technology, Chemnitz, Germany
| | - Daniel Berthold
- Palliative Care Team for Adults, University Hospital Giessen, Giessen, Germany
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Nielsen VML, Kløjgård T, Bruun H, Søvsø MB, Christensen EF. Progression of vital signs during ambulance transport categorised by a paediatric triage model: a population-based historical cohort study. BMJ Open 2020; 10:e042401. [PMID: 33257494 PMCID: PMC7705491 DOI: 10.1136/bmjopen-2020-042401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To examine the severity and progression of acute illness or injury in children using vital signs obtained during ambulance transport and categorised according to a paediatric triage model. DESIGN A population-based historical cohort study using data from prehospital patient medical records linked to a national civil registration database. SETTING Emergency medical services providing ground-level transport in a mixed urban-rural region with three hospitals in Denmark. PARTICIPANTS 25 039 events with patients aged <18 years attended by emergency medical services dispatched after a 1-1-2 emergency call during the years 2006-2018. PRIMARY AND SECONDARY OUTCOME MEASURES Distribution of the first observed vital signs according to a paediatric triage model: heart rate, Glasgow Coma Score, respiratory rate, oxygen saturation and oxygen treatment, and proportion of patients progressing to a triage score with a lower level of urgency during ambulance transport. RESULTS The proportion of patients with the first observed vital signs outside the normal age-specific range was as follows: 33.6% for heart rate, 15.3% for Glasgow Coma Score, 17.4% for respiratory rate and 37.4% for oxygen saturation regardless of oxygen treatment. The proportion of patients progressing to a triage score with a lower level of urgency during transport varied with age: 146/354 (41.2%) for age 0-2 months, 440/986 (44.6%) for age 3-11 months, 1278/3212 (39.8%) for age 1-2 years, 967/2814 (34.4%) for age 3-7 years and 4029/13 864 (29.1%) for age 8-17 years (p<0.001). One-day mortality was 3.05 deaths per 1000 patient-days (95% CI 2.43 to 3.83). CONCLUSIONS One third of the patients' condition progressed to a triage score with a lower level of urgency during ambulance transport. Vital sign documentation in paediatric patients was incomplete, and educational initiatives should be taken to increase documentation of vital signs, especially in patients aged ≤2 years.
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Affiliation(s)
- Vibe Maria Laden Nielsen
- Centre for Prehospital and Emergency Research, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Torben Kløjgård
- Centre for Prehospital and Emergency Research, Aalborg University Hospital, Aalborg, Denmark
| | - Henrik Bruun
- Centre for Prehospital and Emergency Research, Aalborg University Hospital, Aalborg, Denmark
| | - Morten Breinholt Søvsø
- Centre for Prehospital and Emergency Research, Aalborg University Hospital, Aalborg, Denmark
- Prehospital Emergency Medical Services, North Denmark Region, Denmark
| | - Erika Frischknecht Christensen
- Centre for Prehospital and Emergency Research, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Emergency Department and Trauma Centre, Aalborg University Hospital, Aalborg, Denmark
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Abramson TM, Rose E, Crow E, Lane CJ, Kearl Y, Loza-Gomez A. Paramedic Identification of Pediatric Seizures: A Prospective Cohort Study. PREHOSP EMERG CARE 2020; 25:682-688. [PMID: 33026283 DOI: 10.1080/10903127.2020.1831667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Pediatric seizures commonly trigger emergency medical services (EMS) activation and account for approximately 5-15% of all pediatric 911-EMS calls. More than 50% of children with active seizure activity do not receive prehospital antiepileptic drugs, potentially because they are not recognized by EMS. The purpose of this study is to evaluate specificity and sensitivity of paramedic identification of pediatric seizures and to describe the characteristics of unrecognized seizures. METHODS This is an 18-month prospective cohort study at a single, pediatric emergency department (ED). EMS patients ≤15 years old with a prehospital provider impression of seizure were included. Upon ED arrival, a data collection form, which included the EMS verbal report and patient's clinical status, was completed by the attending emergency physician. The primary outcome was sensitivity and specificity of paramedic identification of active seizure. Secondary outcomes included characteristics of missed seizures, ED interventions, and disposition. Descriptive statistics, sensitivity, and specificity were computed. Patient characteristics and clinical outcomes were compared. RESULTS Surveys were completed for 349 patients (Median 3, IQR = 3.4). Fifty-two of the patients (15%) were actively seizing upon arrival at the ED. Sensitivity was 54% and specificity was 96% for paramedic identification of active seizure. Common features of missed cases were abnormal vital signs (75%), gaze deviation (50%) and clenched jaw (33%). Of these, 37% required intubation and 53% were admitted to the intensive care unit. CONCLUSION Paramedics were highly specific, but not sensitive in identifying active seizures on ED arrival. Patients with unrecognized seizures presented most commonly with abnormal vital signs and gaze deviation.
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Schroter S, Thomas D, Nimmer M, Visotcky A, Fraser R, Colella MR, Browne LR. Multimedia Evaluation of EMT-Paramedic Assessment and Management of Pediatric Respiratory Distress. PREHOSP EMERG CARE 2020; 25:664-674. [PMID: 32870748 DOI: 10.1080/10903127.2020.1817211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The prehospital care of asthma, bronchiolitis and croup is directed by evidence-based Emergency Medical Services (EMS) protocols. Determining the appropriate intervention for these conditions requires Emergency Medical Technicians-Paramedics (EMT-Ps) to correctly differentiate asthma/bronchospasm, bronchiolitis, and croup. The diagnostic accuracy of EMT-Ps for these pediatric respiratory distress conditions is unknown. OBJECTIVE We hypothesized increasing provider age, years of provider experience, higher volume of pediatric cases, self-reported comfort with pediatric patients, and having children of one's own would be associated with increased accuracy in diagnosis on a validated multimedia questionnaire. METHODS This is a cross-sectional study of paramedics from a single EMS agency who completed a validated, case-based questionnaire between July and September 2018. The multimedia questionnaire consisted of four cases, each of which included patient videos and lung sound recordings. Paramedics were asked to assess the severity of distress and ascribe the correct diagnosis and prehospital intervention for each case. Each paramedic completed the questionnaire independently. We defined high questionnaire performance a priori as correctly identifying the diagnosis for ≥75% of cases and used multivariate regression to assess factors associated with high questionnaire performance. Provider age and EMS experience were reported in years and analyzed as continuous variables. Volume of pediatric cases was dichotomized to <1 and ≥1 case per shift and having children was dichotomized to either having children or not having children. RESULTS Of 514 paramedics, 420 (82%) completed the questionnaire. Overall, paramedics correctly assessed the severity of respiratory distress 92% of the time. However, they only ascribed the correct diagnosis 50% and selected the correct intervention(s) 38% of the time. Increasing age, years of experience, higher volume of pediatric cases, self-reported comfort with pediatric patients, and having children of their own were not associated with questionnaire performance. CONCLUSION Paramedics accurately assessed severity of distress in multimedia cases of asthma/bronchospasm, bronchiolitis and croup in children, but showed significant room for improvement in correctly identifying the diagnosis and in selecting appropriate intervention(s). Age, years of EMS experience, higher volume of clinical pediatric cases, self-reported comfort with pediatric patients, and having children of their own were not associated with questionnaire performance.
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Affiliation(s)
- Stephanie Schroter
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (SS, DT, MN, LRB); Department of Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin (AV, RF, MRC); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (MRC, LRB)
| | - Danny Thomas
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (SS, DT, MN, LRB); Department of Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin (AV, RF, MRC); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (MRC, LRB)
| | - Mark Nimmer
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (SS, DT, MN, LRB); Department of Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin (AV, RF, MRC); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (MRC, LRB)
| | - Alexis Visotcky
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (SS, DT, MN, LRB); Department of Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin (AV, RF, MRC); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (MRC, LRB)
| | - Raphael Fraser
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (SS, DT, MN, LRB); Department of Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin (AV, RF, MRC); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (MRC, LRB)
| | - M Riccardo Colella
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (SS, DT, MN, LRB); Department of Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin (AV, RF, MRC); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (MRC, LRB)
| | - Lorin R Browne
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (SS, DT, MN, LRB); Department of Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin (AV, RF, MRC); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (MRC, LRB)
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Heschl S, Bernard S, Andrew E, Smith K. Characteristics of paediatric patients with altered conscious state attended by road ambulances in a metropolitan area — An 8 year observational study. Australas Emerg Care 2020; 23:142-146. [DOI: 10.1016/j.auec.2020.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 02/25/2020] [Accepted: 02/25/2020] [Indexed: 11/15/2022]
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Abstract
OBJECTIVES Pediatric patients represent a small proportion of emergency medical services (EMS) calls, challenging providers in maintaining skills in treating children. Having structural capacity to appropriately diagnose and treat pediatric patients is critical. Our study measured the availability of off-line and on-line medical direction and recommended pediatric equipment at EMS agencies. METHODS A Web-based survey was sent to EMS agencies in 2010 and 2013, and results were analyzed to determine availability of medical direction and equipment. RESULTS Approximately 5000 agencies in 32 states responded, representing over 80% response. Availability of off-line medical direction increased between years (78% in 2010 to 85% in 2013), was lower for basic life support (BLS) (63% and 72%) than advanced life support (ALS) agencies (90% and 93%), and was generally higher in urban than rural or frontier locations. On-line medical direction was consistently available (90% both years) with slight increases for BLS agencies (87% to 90%) and slightly greater availability for urban and rural compared with frontier agencies. The majority of agencies carried most recommended equipment; however, less than one third of agencies reported carrying all equipment. Agencies with off-line medical direction, on-line medical direction, and with both off-line and on-line medical direction were respectively 1.69, 1.31, and 2.21 times more likely to report carrying all recommended equipment. CONCLUSIONS Basic structural capacity exists in EMS for treating children, with improvements seen over time. However, gaps remain, particularly for BLS and nonurban agencies. Continuous attention to infrastructure is necessary, and the recent development of national performance measures should further promote quality emergency care for all children.
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Ramgopal S, Mazzarini A, Martin-Gill C, Owusu-Ansah S. Prehospital management of pediatric asthma patients in a large emergency medical services system. Pediatr Pulmonol 2020; 55:83-89. [PMID: 31626398 DOI: 10.1002/ppul.24542] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 09/23/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Asthma is a common pediatric diagnosis for emergency medical services (EMS) transports, however there is a paucity of data on prehospital asthma management. The purpose of this study was to describe prehospital management of pediatric patients with suspected asthma exacerbation. METHODS We conducted a retrospective review of electronic medical records from 24 ground EMS agencies in Southwestern Pennsylvania between 1 January 2014 to 31 December 2017. We identified patients 2 to 17 years with documented wheezing, excluding those with suspected anaphylaxis. Patients with documented respiratory distress were classified as severe asthma. We report descriptive statistics of demographics, vital signs, and management including administration of medications and performance of procedures. RESULTS Of 19 246 pediatric transports, 1078 (5.6%) patients had wheezing. Of these, 532 (49%) met criteria for severe asthma. Patients with severe asthma were more likely to be adolescents compared to those with nonsevere asthma (49.6% vs 6%; P < .001). While rates of intravenous methylprednisolone administration were higher in patients with severe asthma (68/532, 12.8%) compared to those with nonsevere asthma (13/546, 2.4%; P < .001), overall use of steroids was low (7.5%). Other therapies provided included albuterol (n = 699, 64.8%), ipratropium bromide (n = 271, 25.1%), and oxygen (n = 280, 26.0%). One hundred eighty patients (16.7%) received a peripheral IV line. Two patients (0.4%) were given continuous positive airway pressure. CONCLUSION Approximately 6% of pediatric EMS transports are for asthma. Steroid usage was low in even those with severe asthma, representing an area of process improvement. These data provide a baseline to future research to identify interventions that may improve outcomes.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Chicago, Illinois
| | - Angelica Mazzarini
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sylvia Owusu-Ansah
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Eriksson CO, Ovregaard N, Hansen M, Meckler G, Skarica B, Guise JM. Reliability and Usability of a 7-Minute Chart Review Tool to Identify Pediatric Prehospital Adverse Safety Events. Hosp Pediatr 2019; 8:494-498. [PMID: 30061112 DOI: 10.1542/hpeds.2017-0155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Although medical errors in the hospital are a recognized source of morbidity and mortality, less is known about safety events in the prehospital care of children. As part of a multiphase study, we developed and evaluated the reliability and usability of the pediatric prehospital safety event detection system (PEDS), a tool used to identify safety events in prehospital care. METHODS The tool was based on hospital chart review tools, literature review, and results from focus groups and a national Delphi survey. After reviewer training, preliminary testing, and initial use, we refined the tool on the basis of data analysis and reviewer feedback. Thirty charts were randomly selected from our study population of pediatric transports with lights and sirens in Multnomah County, Oregon, and independently reviewed by 2 pediatric emergency physicians with experience in prehospital care to evaluate interrater reliability and time to completion of the final tool. RESULTS The PEDS tool contains 36 items, takes reviewers a median of 7 minutes to complete (interquartile range: 4-12), and exists in both paper and electronic formats. When comparing the presence or absence of severe safety events between 2 expert arbiters, we found 87% agreement (κ = 0.68), indicating good agreement. CONCLUSIONS The PEDS tool is the first chart review tool designed to identify safety events for children receiving prehospital care, and it displayed good usability and reliability in this study. With this tool, we provide a novel mechanism for researchers, clinicians, and prehospital care leaders to identify opportunities to improve care for children.
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Affiliation(s)
- Carl O Eriksson
- Division of Pediatric Critical Care, Department of Pediatrics,
| | - Nicole Ovregaard
- School of Public Health, Oregon Health and Science University and Portland State University, Portland, Oregon; and
| | - Matthew Hansen
- Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon.,Departments of Emergency Medicine, and
| | - Garth Meckler
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada.,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology
| | - Barbara Skarica
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology
| | - Jeanne-Marie Guise
- School of Public Health, Oregon Health and Science University and Portland State University, Portland, Oregon; and.,Departments of Emergency Medicine, and.,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology.,Medical Informatics and Clinical Epidemiology, and
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Hewes HA, Ely M, Richards R, Shah MI, Busch S, Pilkey D, Hert KD, Olson LM. Ready for Children: Assessing Pediatric Care Coordination and Psychomotor Skills Evaluation in the Prehospital Setting. PREHOSP EMERG CARE 2018; 23:510-518. [DOI: 10.1080/10903127.2018.1542472] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Adelgais KM, Hansen M, Lerner EB, Donofrio JJ, Yadav K, Brown K, Liu YT, Denslow P, Denninghoff K, Ishimine P, Olson LM. Establishing the Key Outcomes for Pediatric Emergency Medical Services Research. Acad Emerg Med 2018; 25:1345-1354. [PMID: 30312993 DOI: 10.1111/acem.13637] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 10/01/2018] [Accepted: 10/06/2018] [Indexed: 11/28/2022]
Abstract
The evidence supporting best practices when treating children in the prehospital setting or even the effect emergency medical services (EMS) has on patient outcomes is limited. Standardizing the critical outcomes for EMS research will allow for focused and comparable effort among the small but growing group of pediatric EMS investigators on specific topics. Standardized outcomes will also provide the opportunity to collectively advance the science of EMS for children and demonstrate the effect of EMS on patient outcomes. This article describes a consensus process among stakeholders in the pediatric emergency medicine and EMS community that identified the critical outcomes for EMS care in five clinical areas (traumatic brain injury, general injury, respiratory disease/failure, sepsis, and seizures). These areas were selected based on both their known public health importance and their commonality in EMS encounters. Key research outcomes identified by participating stakeholders using a modified nominal group technique for consensus building, which included small group brainstorming and independent voting for ranking outcomes that were feasible and/or important for the field.
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Affiliation(s)
| | - Kathleen M. Adelgais
- Department of Pediatrics Section of Pediatric Emergency Medicine University of Colorado School of Medicine Aurora CO
| | - Matthew Hansen
- Department of Emergency Medicine Oregon Health Sciences University PortlandOR
| | - E. Brooke Lerner
- Departments of Emergency Medicine and Pediatrics Medical College of Wisconsin Milwaukee WI
| | - J. Joelle Donofrio
- Departments of Emergency Medicine and Pediatrics University of California San Diego Rady Children's Hospital San Diego CA
| | - Kabir Yadav
- Department of Emergency Medicine Harbor‐UCLA Medical Center Torrance CA
| | - Kathleen Brown
- Department of Emergency Medicine The George Washington University School of Medicine and Children's National Medical Center Washington DC
| | - Yiju T. Liu
- Department of Emergency Medicine Harbor‐UCLA Medical Center Torrance CA
| | | | - Kurt Denninghoff
- Department of Emergency Medicine University of Arizona School of Medicine Tucson AZ
| | - Paul Ishimine
- Departments of Emergency Medicine and Pediatrics University of California San Diego Rady Children's Hospital San Diego CA
| | - Lenora M. Olson
- Division of Pediatric Critical Care Department of Pediatrics University of Utah School of Medicine Salt Lake City UT
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Oliveira J E Silva L, Anderson JL, Bellolio MF, Campbell RL, Myers LA, Luke A, Jeffery MM. Pediatric emergency medical services in privately insured patients: A 10-year national claims analysis. Am J Emerg Med 2018; 37:1409-1415. [PMID: 30361150 DOI: 10.1016/j.ajem.2018.10.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 10/05/2018] [Accepted: 10/17/2018] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE To characterize pediatric Emergency Medicine Service (EMS) transports to the Emergency Department (ED) using a national claims database. METHODS We included children, 18 years and younger, transported by EMS to an ED, from 2007 to 2016 in the OptumLabs Data Warehouse. ICD-9 and ICD-10 diagnosis codes were used to categorize disease system involvement. Interventions performed were extracted using procedure codes. ED visit severity was measured by the Minnesota Algorithm. RESULTS Over a 10-year period, 239,243 children were transported. Trauma was the most frequent diagnosis category for transport for children ≥5 years of age, 35.1% (age 6-13) and 32.7% (age 14-18). The most common diagnosis category in children <6 years of age was neurologic (29.3%), followed by respiratory (23.1%). Over 10 years, transports for mental disorders represented 15.3% in children age 14 to 18, and had the greatest absolute increase (rate difference + 10.4 per 10,000) across all diagnoses categories. Neurologic transports also significantly increased in children age 14 to 18 (rate difference + 6.9 per 10,000). Trauma rates decreased across all age groups and had its greatest reduction among children age 14 to 18 (rate difference - 6.8 per 10,000). Across all age groups, an intervention was performed in 15.6%. Most children (83.3%) were deemed to have ED care needed type of visit, and 15.8% of the transports resulted in a hospital admission. CONCLUSION Trauma is the most frequent diagnosis for transport in children older than 5 years of age. Mental health and neurologic transports have markedly increased, while trauma transports have decreased. Most children arriving by ambulance were classified as requiring ED level of care. These changes might have significant implication for EMS personnel and policy makers.
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Affiliation(s)
- Lucas Oliveira J E Silva
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States of America; Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Brazil
| | - Jana L Anderson
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - M Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States of America; Department of Health Sciences Research, Mayo Clinic, Rochester, MN, United States of America
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Lucas A Myers
- Mayo Clinic Medical Transport, Mayo Clinic, Rochester, MN, United States of America
| | - Anuradha Luke
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Molly M Jeffery
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States of America; Department of Health Sciences Research, Mayo Clinic, Rochester, MN, United States of America; OptumLabs, Cambridge, MA, United States of America
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Adelgais KM, Sholl JM, Alter R, Gurley KL, Broadwater-Hollifield C, Taillac P. Challenges in Statewide Implementation of a Prehospital Evidence-Based Guideline: An Assessment of Barriers and Enablers in Five States. PREHOSP EMERG CARE 2018; 23:167-178. [PMID: 30118367 DOI: 10.1080/10903127.2018.1495284] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Individual states, regions, and local emergency medical service (EMS) agencies are responsible for the development and implementation of prehospital patient care protocols. Many states lack model prehospital guidelines for managing common conditions. Recently developed national evidence-based guidelines (EBGs) may address this gap. Barriers to statewide dissemination and implementation of model guidelines have not been studied. The objective of this study was to examine barriers and enablers to dissemination and implementation of an evidence-based guideline for traumatic pain management across 5 states. METHODS This study used mixed methods to evaluate the statewide dissemination and implementation of a prehospital EBG. The guideline provided pain assessment tools, recommended opiate medication dosing, and indications and contraindications for analgesia. Participating states were provided an implementation toolkit, standardized training materials, and a state-specific implementation plan. Outcomes were assessed via an electronic self-assessment tool in which states reported barriers and enablers to dissemination and implementation and information about changes in pain management practices in their states after implementation of the EBG. RESULTS Of the 5 participating states, 3 reported dissemination of the guideline, one through a state model guideline process and 2 through regional EMS systems. Two states did not disseminate or implement the guideline. Of these, one state chose to utilize a locally developed guideline, and the other state did not perform guideline dissemination at the state level. Barriers to state implementation were the lack of authority at the state level to mandate protocols, technical challenges with learning management systems, and inability to track and monitor training and implementation at the agency level. Enablers included having a state/regional EMS office champion and the availability of an implementation toolkit. No participating states demonstrated an increase in opioid delivery to patients during the study period. CONCLUSION Statewide dissemination and implementation of an EBG is complex with many challenges. Future efforts should consider the advantages of having statewide model or mandatory guidelines and the value of local champions and be aware of the challenges of a statewide learning management system and of tracking the success of implementation efforts.
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Differences in Prehospital Patient Assessments for Pediatric Versus Adult Patients. J Pediatr 2018; 199:200-205.e6. [PMID: 29759850 PMCID: PMC7073459 DOI: 10.1016/j.jpeds.2018.03.069] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 02/27/2018] [Accepted: 03/27/2018] [Indexed: 11/22/2022]
Abstract
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.
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Improving Prehospital Management of Children With Respiratory Distress. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Nassif A, Ostermayer DG, Hoang KB, Claiborne MK, Camp EA, Shah MI. Implementation of a Prehospital Protocol Change For Asthmatic Children. PREHOSP EMERG CARE 2018; 22:457-465. [PMID: 29351496 DOI: 10.1080/10903127.2017.1408727] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Respiratory distress due to asthma is a common reason for pediatric emergency medical services (EMS) transports. Timely initiation of asthma treatment, including glucocorticoids, improves hospital outcomes. The impact of EMS-administered glucocorticoids on hospital-based outcomes for pediatric asthma patients is unknown. OBJECTIVE The objective of this study was to evaluate the effect of an evidence-based pediatric EMS asthma protocol update, inclusive of oral glucocorticoid administration, on time to hospital discharge. METHODS This was a retrospective cohort study of children (2-18 years) with an acute asthma exacerbation transported by an urban EMS system to 10 emergency departments over 2 years. The investigators implemented an EMS protocol update one year into the study period requiring glucocorticoid administration for all patients, with the major change being inclusion of oral dexamethasone (0.6 mg/kg, max. dose = 10 mg). Protocol implementation included mandatory paramedic training. Data was abstracted from linked prehospital and hospital records. Continuous data were compared before and after the protocol change with the Mann-Whitney test, and categorical data were compared with the Pearson χ2 test. RESULTS During the study period, 482 asthmatic children met inclusion criteria. After the protocol change, patients were more likely to receive a prehospital glucocorticoid (11% vs. 18%, p = 0.02). Median total hospital time after the protocol change decreased from 6.1 hours (95% CI: 5.4-6.8) to 4.5 hours (95% CI: 4.2-4.8), p < 0.001. Total care time, defined as time from ambulance arrival to hospital discharge, also decreased [6.6 hours (95% CI: 5.8-7.3) vs. 5.2 hours (95% CI: 4.8-5.6), p = 0.01]. Overall, patients were less likely to be admitted to the hospital (30% vs. 21%, p = 0.02) after the change. Those with more severe exacerbations were less likely to be admitted to a critical care unit (82% vs. 44%, p = 0.02) after the change, rather than an acute care floor. CONCLUSIONS Prehospital protocol change for asthmatic children is associated with shorter total hospital and total care times. This protocol change was also associated with decreased hospitalization rates and less need for critical care in those hospitalized. Further study is necessary to determine if other factors also contributed.
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Browne LR, Schwartz H, Ahmad FA, Wallendorf M, Kuppermann N, Lerner EB, Leonard JC. Interobserver Agreement in Pediatric Cervical Spine Injury Assessment Between Prehospital and Emergency Department Providers. Acad Emerg Med 2017; 24:1501-1510. [PMID: 28921731 DOI: 10.1111/acem.13312] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 08/25/2017] [Accepted: 09/11/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND Investigators have derived cervical spine injury (CSI) decision support tools from physician observations. There is a need to demonstrate that prehospital emergency medical services (EMS) providers can use these tools to appropriately determine the need for spinal motion restrictions and make field disposition decisions. OBJECTIVES The objective was to determine the interobserver agreement between EMS and emergency department (ED) providers for CSI risk assessment variables and overall gestalt for CSI in children after blunt trauma. METHODS This was a planned, substudy of a four-site, prospective cohort of children < 18 years transported by EMS to pediatric EDs for evaluation of CSI after blunt trauma. Inclusion criteria were trauma team activation and/or EMS-initiated spinal motion restriction. Exclusion criteria were penetrating trauma, transfer to another facility for definitive care, state custody, or substantial language barrier. For each eligible child, the transporting EMS provider and treating ED provider independently recorded their clinical assessment for CSI. This included mechanism of injury and patient history and physical examination findings. We assessed each paired variable for interobserver agreement between EMS and ED provider using kappa (κ) analysis. We considered variables with κ lower confidence interval values ≥0.4 to have moderate or better agreement. RESULTS We obtained 1,372 paired observations for 29 variables. After finding prevalence and observer bias were adjusted for, all variables achieved moderate to better agreement including eight variables previously shown to be independently associated with CSI in children: diving mechanism, high-risk motor vehicle collision, altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, and predisposing medical condition. EMS and ED providers, however, showed less than moderate agreement for their overall gestalt for CSI in children. Of note, both EMS and ED providers did not assess for neck pain, inability to move the neck, and/or cervical spine tenderness in more than 10% of study patients. CONCLUSIONS Emergency medical services and ED providers achieved at least moderate agreement in the assessment of CSI risk factors in children after blunt trauma. However, EMS and ED providers did not achieve moderate agreement on gestalt for CSI and some risk factors went unassessed by providers. These findings support the development of a pediatric CSI risk assessment tool for EMS and ED providers to reduce interventions for those children at very low risk for CSIs while still identifying all children with injury.
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Affiliation(s)
- Lorin R. Browne
- Department of Pediatrics and Emergency Medicine; Medical College of Wisconsin (LRB, EBL); Madison WI
| | - Hamilton Schwartz
- Department of Pediatrics; University of Cincinnati College of Medicine (HS); Cincinnati OH
| | - Fahd A. Ahmad
- Department Pediatrics; Washington University School of Medicine in St. Louis; St. Louis MO
| | - Michael Wallendorf
- Department of Biostatistics; Washington University School of Medicine in St. Louis; St. Louis MO
| | - Nathan Kuppermann
- Department of Emergency Medicine and Pediatrics; University of California Davis School of Medicine; Sacramento CA
| | - E. Brooke Lerner
- Department of Pediatrics and Emergency Medicine; Medical College of Wisconsin (LRB, EBL); Madison WI
| | - Julie C. Leonard
- Nationwide Children's Hospital and The Ohio State University College of Medicine; Columbus OH
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VanderKooy T, Spaur K, Brou L, Caffrey S, Adelgais KM. Utilization of Intravenous Catheters by Prehospital Providers during Pediatric Transports. PREHOSP EMERG CARE 2017; 22:50-57. [PMID: 28792258 DOI: 10.1080/10903127.2017.1347225] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Prehospital intravenous (IV) access in children may be difficult and time-consuming. Emergency Medical Service (EMS) protocols often dictate IV placement; however, some IV catheters may not be needed. The scene and transport time associated with attempting IV access in children is unknown. The objective of this study is to examine differences in scene and transport times associated with prehospital IV catheter attempt and utilization patterns of these catheters during pediatric prehospital encounters. METHODS Three non-blinded investigators abstracted EMS and hospital records of children 0-18 years of age transported by EMS to a pediatric emergency department (ED). We compared patients in which prehospital IV access was attempted to those with no documented attempt. Our primary outcome was scene time. Secondary outcomes include utilization of the IV catheter in the prehospital and ED settings and a determination of whether the catheter was indicated based on a priori established criteria (prehospital IV medication administration, hypotension, GCS < 13, and ICU admission). RESULTS We reviewed 1,138 records, 545 meeting inclusion criteria. IV catheter placement was attempted in 27% (n = 149) with success in 77% (n = 111). There was no difference in the presence of hypotension or median GCS between groups. Mean scene time (12.5 vs. 11.8 minutes) and transport time (16.9 vs. 14.6 minutes) were similar. Prehospital IV medications were given in 38.7% (43/111). One patient received a prehospital IV medication with no alternative route of administration. Among patients with a prehospital IV attempt, 31% (46/149) received IV medications in the ED and 23% (34/396) received IV fluids in the ED. Mean time to use of the IV in the ED was 70 minutes after arrival. Patients with prehospital IV attempt were more likely to receive IV medication within 30 minutes of ED arrival (39.1% vs. 19.0%, p = 0.04). Overall, 34.2% of IV attempts were indicated. CONCLUSIONS Prehospital IV catheter placement in children is not associated with an increase in scene or transport time. Prehospital IV catheters were used in approximately one-third of patients. Further study is needed to determine which children may benefit most from IV access in the prehospital setting.
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Bölenius K, Vestin C, Saveman BI, Gyllencreutz L. Validating a questionnaire - prehospital preparedness for pediatric trauma patients. Int Emerg Nurs 2017; 34:2-6. [PMID: 28545931 DOI: 10.1016/j.ienj.2017.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 05/05/2017] [Indexed: 11/20/2022]
Abstract
In recent decades, prehospital emergency care has undergone extensive development. Today, prehospital emergency nurses (PENs) are well trained and provide advanced care to patients of all ages. Caring for pediatric trauma patients is considered to be particularly demanding. However, in Sweden and internationally, there is a lack of research regarding PENs' preparedness for caring for pediatric trauma patients. OBJECTIVE The development and testing of a questionnaire on self-reported preparedness among PENs caring for pediatric trauma patients in a prehospital emergency setting. METHODS Questionnaire development included face and content validity tests resulting in 38 questions. Eighteen of these questions were analyzed by test-retest. The content of the questionnaire was statistically analyzed. RESULTS Fifteen questions were considered valid after reliability and validity tests. Three questions did not fulfill the stability criteria. The content analyses show a low degree of experience with pediatric trauma patients and half of the participants reported stress symptoms when responding to such alarms. CONCLUSION The questionnaire assessing PENs preparedness caring for pediatric trauma patients in Sweden is considered to be suitable for research and clinical practice to improve the care of pediatric trauma patients and the health of PENs, although further testing of the questionnaire is required.
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Abstract
Children and young adults tend to have reduced mortality and disability after acquired brain injuries such as trauma or stroke and across other disease processes seen in critical care medicine. However, after out-of-hospital cardiac arrest (OHCA), outcomes are remarkably similar across age groups. The consistent lack of witnessed arrests and a high incidence of asphyxial or respiratory etiology arrests among pediatric and young adult patients with OHCA account for a substantial portion of the difference in outcomes. Additionally, in younger children, differences in pre-hospital response and the activation of developmental apoptosis may explain more severe outcomes after OHCA. These require us to consider whether present practices are in line with the science. The present recommendations for compression-only cardiopulmonary resuscitation in young adults, normothermia as opposed to hypothermia (33°C) after asphyxial arrests, and paramedic training are considered within this review in light of existing evidence. Modifications in present standards of care may help restore the benefits of youth after brain injury to the young survivor of OHCA.
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Affiliation(s)
- Brian Griffith
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Patrick Kochanek
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Cameron Dezfulian
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Clinical and Translational Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Chang CD, Crowe RP, Bentley MA, Janezic AR, Leonard JC. EMS Providers' Beliefs Regarding Spinal Precautions for Pediatric Trauma Transport. PREHOSP EMERG CARE 2016; 21:344-353. [DOI: 10.1080/10903127.2016.1254696] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Lerner EB, Drendel AL, Cushman JT, Badawy M, Shah MN, Guse CE, Cooper A. Ability of the Physiologic Criteria of the Field Triage Guidelines to Identify Children Who Need the Resources of a Trauma Center. PREHOSP EMERG CARE 2016; 21:180-184. [DOI: 10.1080/10903127.2016.1233311] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Calhoun A, Keller M, Shi J, Brancato C, Donovan K, Kraus D, Leonard JC. Do Pediatric Teams Affect Outcomes of Injured Children Requiring Inter-hospital Transport? PREHOSP EMERG CARE 2016; 21:192-200. [DOI: 10.1080/10903127.2016.1218983] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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