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

OBJECTIVES: Almost half of pediatric EMS calls may be for low-acuity problems. Many EMS agencies have implemented alternative disposition programs for low-acuity patients, including transportation to clinics, substituting taxis for ambulances, and treatment in place without transport to an emergency department. Including children in such programs poses specific challenges, with one concern being potential caregiver opposition. Limited published evidence addresses caregiver perspectives on including children in alternative disposition programs. Our objective was to describe caregiver perspectives of alternative EMS disposition systems for low-acuity pediatric patients. METHODS: We conducted six virtual focus groups (one in Spanish) with caregivers. A PhD-trained facilitator moderated all groups using a semi-structured moderator guide. A hybrid inductive and deductive analytical strategy was used. Multiple investigators independently coded a deidentified sample transcript. One team member then completed axial coding of the remaining transcripts. Thematic saturation was achieved. Clusters of similar codes were grouped into themes by consensus. RESULTS: We recruited 38 participants. Participants had diverse race-ethnicity (39% non-Hispanic white, 29% non-Hispanic Black, and 26% Hispanic) and insurance status (42% Medicaid and 58% private health insurance). There was agreement that caregivers often utilize 9-1-1 for low-acuity complaints. Caregivers were generally supportive of alternative disposition programs, with some important caveats. Potential advantages of alternative dispositions included freeing up resources for more emergent cases, quicker access to care, and more cost-effective and patient-centered care. Caregivers had multiple concerns regarding the effects of alternative disposition programs, including timeliness in receiving care, capabilities of receiving sites (including pediatric expertise), and challenges to care coordination. Additional logistical concerns with alternative disposition programs for children included the safety of taxi services, the loss of parental autonomy, and the potential for inequitable implementation. CONCLUSIONS: Caregivers in our study generally supported alternative EMS dispositions for some children and identified multiple potential benefits of such programs for both children and the health care system. Caregivers were concerned about the safety and logistical details of how such programs would be implemented and wanted to retain final decision-making authority. Caregiver perspectives should be considered when designing and implementing alternative EMS disposition programs for children.

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

OBJECTIVES: Many patients transported by Emergency Medical Services (EMS) do not have emergent resource needs. Estimates for the proportion of pediatric EMS calls for low-acuity complaints, and thus potential candidates for alternative dispositions, vary widely and are often based on physician judgment. A more accurate reference standard should include patient assessments, interventions, and dispositions. The objective of this study was to describe the prevalence and characteristics of low-acuity pediatric EMS calls in an urban area. METHODS: This is a prospective observational study of children transported by EMS to a tertiary care pediatric emergency department. Patient acuity was defined using a novel composite measure that included physiologic assessments, resources used, and disposition. Bivariable and multivariable logistic regression were conducted to assess for factors associated with low-acuity status. RESULTS: A total of 996 patients were enrolled, of whom 32.9% (95% confidence interval, 30.0-36.0) were low acuity. Most of the sample was Black, non-Hispanic with a mean age of 7 years. When compared with adolescents, children younger than 1 year were more likely to be low acuity (adjusted odds ratio, 3.1 [1.9-5.1]). Patients in a motor vehicle crash were also more likely to be low acuity (adjusted odds ratio, 2.4 [1.2-4.6]). All other variables, including race, insurance status, chief complaint, and dispatch time, were not associated with low-acuity status. CONCLUSIONS: One third of pediatric patients transported to the pediatric emergency department by EMS in this urban area are for low-acuity complaints. Further research is needed to determine low-acuity rates in other jurisdictions and whether EMS providers can accurately identify low-acuity patients to develop alternative EMS disposition programs for children.

Clinician and Caregiver Determinations of Acuity for Children Transported by Emergency Medical Services: A Prospective Observational Study.

STUDY OBJECTIVE: Many Emergency Medical Services (EMS) agencies have developed alternative disposition processes for patients with nonemergency problems, but there is a lack of evidence demonstrating EMS clinicians can accurately determine acuity in pediatric patients. Our study objective was to determine EMS and other stakeholders' ability to identify low acuity pediatric EMS patients. METHODS: We conducted a prospective, observational study of children transported to a pediatric emergency department (ED) by EMS. Acuity was defined using a composite measure that included data from the patient's vital signs and examination, resources used (laboratory results, radiographs, etc), and disposition. For each patient, an EMS clinician, patient caregiver, ED nurse, and ED provider completed a survey as soon as possible after the patient's arrival at the ED. The survey asked respondents 2 questions: to state their level of agreement that a patient was low acuity and could the patient have been managed by various alternative dispositions. For each respondent group, we calculated the sensitivity, specificity, and positive and negative predictive values for low acuity versus the composite measure. RESULTS: From August 2020 through September 2021, we approached 1,015 caregivers, of whom 996 (99.8%) agreed to participate and completed the survey. Survey completion varied between 78.7% and 84.1% for EMS and ED nurses and providers. The mean patient age was 7 years, 62.6% were non-Hispanic Black, and 60% were enrolled in public insurance programs. Of the 996 patient encounters, 33% were determined to be low acuity by the composite measure. The positive predictive value for EMS clinicians when identifying low acuity children was 0.60 (95% confidence intervals [CI], 0.58 to 0.67). The positive predictive value for ED nurses and providers was 0.67 (95% CI, 0.61 to 0.72) and 0.68 (95% CI, 0.63 to 0.74) respectively. The negative predictive value for EMS clinicians when identifying not low acuity children was 0.62 (95% CI, 0.58 to 0.67). The negative predictive value for ED nurses and providers was 0.72 (95% CI, 0.68 to 0.76) and 0.73 (95% CI, 0.70 to 0.77) respectively. Caregivers had the lowest positive predictive value 0.34 (95% CI, 0.30 to 0.40) but the highest negative predictive value 0.82 (95% CI, 0.79 to 0.85). The EMS clinicians, ED nurses and providers were more likely than caregivers to think that a child with a low acuity complaint could have been safely managed by alternative disposition. CONCLUSION: All 4 groups studied had a limited ability to identify which children transported by EMS would have no emergency resource needs, and support for alternative disposition was limited. For children to be included in alternative disposition processes, novel triage tools, training, and oversight will be required to prevent undertriage.

The Effect of Documenting Patient Weight in Kilograms on Pediatric Medication Dosing Errors in Emergency Medical Services.

Objectives: Up to 40% of children who receive a medication from emergency medical services (EMS) are subject to a dosing error. One of the reasons for this is difficulties adjusting dosages for weight. Converting weights from pounds to kilograms complicates this further. This is the rationale for the National EMS Quality Alliance measure Pediatrics-03b, which measures the proportion of children with a weight documented in kilograms. However, there is little evidence that this practice is associated with lower rates of dosing errors. Therefore, our objective was to determine whether EMS documentation of weight in kilograms was associated with a lower rate of pediatric medication dosing errors.Methods: We conducted a retrospective cross-sectional study of children 0-14 y/o in the 2016-17 electronic Maryland Emergency Medical Services Data System that received a weight-based medication. Using validated age-based formulas, we assigned a weight to patients without one documented. Doses were classified as errors and severe errors if they deviated from the state protocol by >20% or >50%, respectively. We compared the dosage errors in the two groups and completed secondary analyses for specific medications and age groups.Results: We identified 3,618 cases of medication administration, 53% of which had a documented weight. Patients with a documented weight had a significantly lower overall dose error rate than those without (22 vs. 26%, p<.05). A sensitivity analysis in which we assigned a weight to those patients with a weight recorded did not significantly change this result. Sub-analyses by individual medication showed that only epinephrine (34 vs. 56%, p<.05) and fentanyl (10 vs. 31%, p <.05) had significantly lower dosing error rates for patients with a documented weight. Infants were the only age group where documenting a weight was associated with a lower dosing error rate (33 vs. 53% p<.05).Conclusion: Our findings suggest that documenting a weight in kilograms is associated with a small but significantly lower rate of pediatric dosing errors by EMS. Documenting a weight in kilograms appears particularly important for specific medications and patient age groups. Additional strategies (including age-based standardized dosing) may be needed to further reduce pediatric dosing errors by EMS.

Emergency Medical Services Clinicians' Perspectives on Pediatric Non-Transport.

OBJECTIVES: Emergency medical services clinicians do not transport one-third of all children assessed, even without official pediatric non-transport protocols. Little is known about how EMS clinicians and caregivers decide not to transport a child. Our objectives were to describe how EMS clinicians currently decide whether or not to transport a child and identify barriers to and enablers of successfully implementing an EMS clinician-initiated pediatric non-transport protocol. METHODS: We conducted six virtual focus groups with EMS clinicians from the mid-Atlantic. A PhD trained facilitator moderated all groups using a semi-structured moderator guide. Multiple investigators independently coded a deidentified sample transcript. One team member then completed axial coding of the remaining transcripts. Thematic saturation was achieved. Clusters of similar codes were grouped into themes by consensus. RESULTS: We recruited 50 participants, of whom 70% were paramedics and 28% emergency medical technicians. There was agreement that caregivers often use 9-1-1 for low acuity complaints. Participants stated that non-transport usually occurs after shared decision-making between EMS clinicians and caregivers; EMS clinicians advise whether transport is necessary, but caregivers are responsible for making the final decision and signing refusal documentation. Subthemes for how non-transport decisions were made included the presence of agency protocols, caregiver preferences, absence of a guardian on the scene, EMS clinician variability, and distance to the nearest ED. Participants identified the following features that would enable successful implementation of an EMS clinician-initiated non-transport process: a user-friendly interface, clear protocol endpoints, the inclusion of vital sign parameters, resources to leave with caregivers, and optional direct medical oversight. CONCLUSIONS: EMS clinicians in our study agreed that non-transport is currently a caregiver decision, but noted a collaborative process of shared decision-making where EMS clinicians advise caregivers whether transport is indicated. Further research is needed to understand the safety of this practice. This study suggests there may be a need for EMS-initiated alternative disposition/non-transport protocols.

Prehospital Recognition and Management of Pediatric Sepsis: A Qualitative Assessment.

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.

Evaluation of a Selective Prehospital Pediatric Spinal Protection Protocol.

Background: Recent studies demonstrate an association between spinal immobilization and neck pain, increased use of radiographs, and increased admission rates for pediatric trauma patients. There is an increasing trend toward spinal protection protocols that limit the use of backboards in trauma patients. However, many of these protocols do not address the youngest patients. Objectives: The objective was to analyze whether implementation of a selective prehospital pediatric spinal protection protocol was associated with a reduction in spinal imaging, hospital admission rates, and Emergency Department (ED) length of stay (LOS). Methods: We conducted a single center retrospective chart review to assess the effect of implementing a new selective pediatric spinal immobilization protocol in an EMS system. Patients transported to the same center from a neighboring EMS jurisdiction without a protocol change were analyzed for comparison. We extracted data for all pediatric patients with trauma-related discharge diagnoses transported by EMS to a pediatric trauma center for one year before and after the implementation of the protocol. Results: There were 878 eligible trauma patients transported under the new protocol, compared to 782 transported prior to implementation. We did not find a significant difference in the percentage of trauma patients who received spinal imaging pre- and post-protocol change (20% vs. 18%, OR 0.84 [95% CI 0.66, 1.07]), but did observe a significant reduction in the proportion of trauma patients who were admitted to the hospital (25% vs. 18%, OR 0.66 [95% CI 0.52, 0.83]). This reduced admission rate was not observed in the neighboring jurisdiction. Conclusions: Implementation of a selective spinal immobilization protocol was associated with reduced admission rates, but did not significantly reduce rates of plain radiographs.

Chikungunya in Children: A Clinical Review.

Chikungunya (CHIKV) is an emerging arboviral infection with recent spikes in transmission in the Americas. Chikungunya is most commonly transmitted by mosquitos, specifically Aedes aegypti and Aedes albopictus. These mosquitoes are found throughout many parts of the United States. The classic tetrad of symptoms for CHIKV is fever, symmetric polyarthralgia, maculopapular rash, and nonpurulent conjunctivitis. Although the majority (3 of 4) of infected people will be symptomatic, the viral illness generally runs a benign course. Nevertheless, when compared with infected adults, children more commonly have neurological and dermatological symptoms and are less likely to have arthralgia. The key differential diagnosis to consider is dengue, which has greater immediate morbidity and which can cause coinfection. Local health departments facilitate diagnostic testing, using either RNA polymerase chain reaction or antibody screening based on the timing of presentation. Management is supportive. The purpose of this review article is to provide readers basic knowledge regarding the microbiology, epidemiology, risk factors for transmission, and typical clinical presentation of CHIKV. A practical approach to diagnosis and management of infected children is provided.

Public support for and concerns regarding pediatric dose optimization for seizures in emergency medical services: An exception from informed consent (EFIC) trial.

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.

PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study.

BACKGROUND: Cervical spine injuries in children are uncommon but potentially devastating; however, indiscriminate neck imaging after trauma unnecessarily exposes children to ionising radiation. The aim of this study was to derive and validate a paediatric clinical prediction rule that can be incorporated into an algorithm to guide radiographic screening for cervical spine injury among children in the emergency department. METHODS: In this prospective observational cohort study, we screened children aged 0-17 years presenting with known or suspected blunt trauma at 18 specialised children's emergency departments in hospitals in the USA affiliated with the Pediatric Emergency Care Applied Research Network (PECARN). Injured children were eligible for enrolment into derivation or validation cohorts by fulfilling one of the following criteria: transported from the scene of injury to the emergency department by emergency medical services; evaluated by a trauma team; and undergone neck imaging for concern for cervical spine injury either at or before arriving at the PECARN-affiliated emergency department. Children presenting with solely penetrating trauma were excluded. Before viewing an enrolled child's neck imaging results, the attending emergency department clinician completed a clinical examination and prospectively documented cervical spine injury risk factors in an electronic questionnaire. Cervical spine injuries were determined by imaging reports and telephone follow-up with guardians within 21-28 days of the emergency room encounter, and cervical spine injury was confirmed by a paediatric neurosurgeon. Factors associated with a high risk of cervical spine injury (>10%) were identified by bivariable Poisson regression with robust error estimates, and factors associated with non-negligible risk were identified by classification and regression tree (CART) analysis. Variables were combined in the cervical spine injury prediction rule. The primary outcome of interest was cervical spine injury within 28 days of initial trauma warranting inpatient observation or surgical intervention. Rule performance measures were calculated for both derivation and validation cohorts. A clinical care algorithm for determining which risk factors warrant radiographic screening for cervical spine injury after blunt trauma was applied to the study population to estimate the potential effect on reducing CT and x-ray use in the paediatric emergency department. This study is registered with ClinicalTrials.gov, NCT05049330. FINDINGS: Nine emergency departments participated in the derivation cohort, and nine participated in the validation cohort. In total, 22 430 children presenting with known or suspected blunt trauma were enrolled (11 857 children in the derivation cohort; 10 573 in the validation cohort). 433 (1·9%) of the total population had confirmed cervical spine injuries. The following factors were associated with a high risk of cervical spine injury: altered mental status (Glasgow Coma Scale [GCS] score of 3-8 or unresponsive on the Alert, Verbal, Pain, Unresponsive scale [AVPU] of consciousness); abnormal airway, breathing, or circulation findings; and focal neurological deficits including paresthesia, numbness, or weakness. Of 928 in the derivation cohort presenting with at least one of these risk factors, 118 (12·7%) had cervical spine injury (risk ratio 8·9 [95% CI 7·1-11·2]). The following factors were associated with non-negligible risk of cervical spine injury by CART analysis: neck pain; altered mental status (GCS score of 9-14; verbal or pain on the AVPU; or other signs of altered mental status); substantial head injury; substantial torso injury; and midline neck tenderness. The high-risk and CART-derived factors combined and applied to the validation cohort performed with 94·3% (95% CI 90·7-97·9) sensitivity, 60·4% (59·4-61·3) specificity, and 99·9% (99·8-100·0) negative predictive value. Had the algorithm been applied to all participants to guide the use of imaging, we estimated the number of children having CT might have decreased from 3856 (17·2%) to 1549 (6·9%) of 22 430 children without increasing the number of children getting plain x-rays. INTERPRETATION: Incorporated into a clinical algorithm, the cervical spine injury prediction rule showed strong potential for aiding clinicians in determining which children arriving in the emergency department after blunt trauma should undergo radiographic neck imaging for potential cervical spine injury. Implementation of the clinical algorithm could decrease use of unnecessary radiographic testing in the emergency department and eliminate high-risk radiation exposure. Future work should validate the prediction rule and care algorithm in more general settings such as community emergency departments. FUNDING: The Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Health Resources and Services Administration of the US Department of Health and Human Services in the Maternal and Child Health Bureau under the Emergency Medical Services for Children programme.

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

INTRODUCTION: Many emergency medical services (EMS) agencies have implemented alternative disposition programs for low-acuity complaints, including transportation to clinics. Our objectives were to describe pediatric primary care providers' views on alternative EMS disposition programs. METHOD: We conducted virtual focus groups with pediatric primary care providers. A hybrid inductive and deductive analytical strategy was used. Codes were grouped into themes by consensus. RESULTS: Participants identified the benefits of alternative dispositions, including continuity of care, higher quality care, and freeing up emergency resources. Participants' concerns included undertriage, difficulty managing patients not previously known to a clinic, and inequitable implementation. Commonly identified logistical barriers included inadequate equipment, scheduling capacity, and coordinating triage. DISCUSSION: Participants agreed there could be significant benefits from including clinics in EMS disposition programs. Participants identified several logistical constraints and raised concerns about patient safety and equitable implementation. These perspectives should be considered when designing pediatric alternative EMS disposition programs.

Caregiver Perceptions Regarding Alternative Emergency Medical Services Dispositions for Children: A Cross-Sectional Survey Analysis.

INTRODUCTION: Emergency medical services (EMS) systems have developed alternative disposition processes for patients (including leaving the patient at the scene, using taxis, and transporting to clinics) vs taking patients directly to an emergency department (ED). Studies show that patients favorably support these alternative options but have not included the perspectives of caregivers of children. Our objective was to describe caregivers' views about these alternative disposition processes and analyze whether caregiver support is associated with sociodemographic factors. METHODS: We surveyed a convenience sample of caregivers in a pediatric ED. We asked caregivers 15 questions based on a previously validated survey. We then conducted logistic regressions to determine whether sociodemographic factors were associated with levels of support. RESULTS: We enrolled 241 caregivers. The median age of their children was five years. The majority of respondents were non-Hispanic Black (57%) and had public insurance (65%). We found that a majority of respondents supported all alternative EMS disposition options. The overall level of agreement for survey questions ranged from 51-93%. We grouped questions by theme: non-transport; alternative destinations; communication with EMS physician; communication with primary care physician and sharing records; restricted EMS role; and shared decision-making. Regression analyses for each theme found that race/ethnicity, public insurance, and patient age were not significantly associated with the level of support. CONCLUSION: Most caregivers were supportive of alternative EMS disposition options for children with low-acuity complaints. Support did not vary significantly by respondent race/ethnicity, public insurance status, or patient age.

Premature adrenarche.

Premature adrenarche refers to the presence of secondary sexual hair in girls younger than 8 years old and boys younger than 9 years old. It is a relatively common presentation to paediatricians and is more frequent in girls than boys. It is a benign diagnosis, but other causes of androgen excess such as congenital adrenal hyperplasia or adrenal tumours should be excluded first. In conjunction with history and clinical examination, first line investigations should include determination of serum androgen concentrations, along with bone age, proceeding to synacthen stimulation test (for 17OHP levels) and adrenal ultrasound if indicated. The phenotype of premature adrenarche varies considerably between populations but may be associated with low birth weight, insulin resistance, adverse cardio-metabolic risk and progression to polycystic ovarian syndrome in some populations. In the majority of cases, no specific treatment is recommended, but where there is a history of low birth weight, with associated insulin resistance, intervention with the insulin sensitising agent metformin may be considered on a case by case basis.