Determinants of Pediatric EMS Utilization in Children with High-Acuity Conditions.

BACKGROUND: Underutilization of emergency medical services (EMS) for children with high-acuity conditions is poorly understood. Our objective was to identify differences in demographic factors and describe caregivers' knowledge, beliefs, and attitudes regarding EMS utilization for children with high-acuity conditions. DESIGN/METHODS: This was a mixed-methods study of children with high acuity conditions, defined as requiring immediate medical or surgical intervention and intensive care admission, over a one year period. Demographic data were collected through a retrospective chart review. Qualitative analysis of semi-structured interviews from a purposive sample of caregivers was conducted until thematic saturation was achieved. RESULTS: Three hundred seventy-four charts were reviewed; 19 caregivers were interviewed (17 in-person, 2 via telephone). The 232 (62%) children not arriving by EMS tended to be younger (1.58 years vs. 2.31 years, p = 0.02), privately insured (30% vs. 19%, p = 0.04), and lived further from the hospital (16.80 miles vs. 12.45 miles, p = 0.001). Patient gender, ethnicity, comorbidities and caregiver language were not associated with EMS underutilization. Immediate invasive medical interventions were more often required for EMS utilizers (85% vs. 60%, p < 0.001). EMS utilizers were more likely to require intubation (78% vs. 47%, p < 0.001) and cardiopulmonary resuscitation (CPR) (26% vs. 2%, p < 0.001), and had shorter hospital stays (4.70 vs. 8.16 days; p-value < 0.001). Three principal themes determined EMS utilization: expectations, knowledge, and perceived barriers. Three principal themes determined EMS utilization: expectations, knowledge, and perceived barriers. Caretakers expected EMS would provide timely, safe transportation that expedited medical care and emotional support. Medical knowledge and prior experience with EMS influenced decision-making about arrival mode. Timeliness, cost, socioeconomic and demographic characteristics, loss of autonomy, and the logistics of EMS activation and transport were the most commonly reported barriers. CONCLUSIONS: Young age, private insurance status, and greater distance from the hospital were associated with EMS underutilization. Understanding caregiver expectations, knowledge, and perceived barriers may have important implications for the use of EMS for children. These findings reveal opportunities for improved public education on EMS systems to enhance appropriate EMS utilization for children with high acuity conditions.

Improving Prehospital Protocol Adherence Using Bundled Educational Interventions.

BACKGROUND: Seizures and anaphylaxis are life-threatening conditions that require immediate treatment in the prehospital setting. There is variation in treatment of pediatric prehospital patients for both anaphylaxis and seizures. This educational study was done to improve compliance with pediatric prehospital protocols, educate prehospital providers and decrease variation in care. OBJECTIVE: To improve the quality of care for children with seizures and anaphylaxis in the prehospital setting using a bundled, multifaceted educational intervention. METHODS: Evidence-based pediatric prehospital guidelines for seizures and anaphylaxis were used to create a curriculum for the paramedics in the EMS system. The curriculum included in-person training, videos, distribution of decision support tools, and a targeted social media campaign to reinforce the evidence-based guidelines. Prehospital charts were reviewed for pediatric patients with a chief complaint of anaphylaxis or seizures who were transported by paramedics to one of ten hospitals, including three children's hospitals, for 8 months prior to the intervention and eight months following the intervention. The primary outcome for seizures was whether midazolam was given via the preferred intranasal (IN) or intramuscular (IM) routes. The primary outcome for anaphylaxis was whether IM epinephrine was given. RESULTS: A total of 1,402 pediatric patients were transported for seizures by paramedics to during the study period. A total of 88 patients were actively seizing pre-intervention and 93 post-intervention. Of the actively seizing patients, 52 were given midazolam pre-intervention and 62 were given midazolam post-intervention. Pre-intervention, 29% (15/52) of the seizing patients received midazolam via the preferred IM or IN routes, compared to 74% (46/62) of the seizing patients post-intervention. A total of 45 patients with anaphylaxis were transported by paramedics, 30 pre-intervention and 15 post-intervention. Paramedics administered epinephrine to 17% (5/30) patients pre-intervention and 67% (10/15) patients post-intervention. CONCLUSION: The use of a bundled, multifaceted educational intervention including in-person training, decision support tools, and social media improved adherence to updated evidence-based pediatric prehospital protocols.

Impact of High-Fidelity Pediatric Simulation on Paramedic Seizure Management.

BACKGROUND: A simulation-based course, Pediatric Simulation Training for Emergency Prehospital Providers (PediSTEPPs), was developed to optimize pediatric prehospital care. Seizures are common in Emergency Medical Services (EMS), and no studies have evaluated pediatric outcomes after EMS simulation training. OBJECTIVES: The primary objective was to determine if PediSTEPPs enhances seizure protocol adherence in blood glucose measurement and midazolam administration for seizing children. The secondary objective was to describe management of seizing patients by EMS and Emergency Departments (EDs). METHODS: This is a two-year retrospective cohort study of paramedics who transported 0-18 year old seizing patients to ten urban EDs. Management was compared between EMS crews with at least one paramedic who attended PediSTEPPs and crews that had none. Blood glucose measurement, medications administered, intravenous (IV) access, seizure recurrence, and respiratory failure data were collected from databases and run reports. Data were compared using Pearson's χ(2) test and odds ratios with 95% confidence intervals (categorical) and the Mann-Whitney test (continuous). RESULTS: Of 2200 pediatric transports with a complaint of seizure, 250 (11%) were actively seizing at the time of transport. Of these, 65 (26%) were treated by a PediSTEPPs-trained paramedic. Blood glucose was slightly more likely to be checked by trained than untrained paramedics (OR = 1.35, 95% CI 0.72-2.51). Overall, 58% received an indicated dose of midazolam, and this was slightly more likely in the trained than untrained paramedics (OR = 1.39, 95% CI 0.77-2.49). There were no differences in secondary outcomes between groups. The prevalence of hypoglycemia was low (2%). Peripheral IVs were attempted in 80%, and midazolam was predominantly given by IV (68%) and rectal (12%) routes, with 51% receiving a correct dose. Seizures recurred in 22%, with 34% seizing on ED arrival. Respiratory failure occurred in the prehospital setting in 25 (10%) patients in the study. CONCLUSION: Simulation-based training on pediatric seizure management may have utility. Data support the need to optimize the route and dose of midazolam for seizing children. Blood glucose measurement in seizure protocols may warrant reprioritization due to low hypoglycemia prevalence. KEY WORDS: seizure; emergency medical services; simulation; pediatrics.