Assessing Infrastructure to Care for Pediatric Patients in the Prehospital Setting.

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.

Transitions of Care: The Presence of Written Interfacility Transfer Guidelines and Agreements for Pediatric Patients.

OBJECTIVE: Every year, emergency medical services agencies transport approximately 150,000 pediatric patients between hospitals. During these transitions of care, patient safety may be affected and contribute to adverse events when important clinical information is missing, incomplete, or inaccurate. Written interfacility transfer policies are one way to standardize procedures and facilitate communication between the hospitals leading to improved patient safety and satisfaction for children and families. METHODS: We assessed the presence and components of written interfacility transfer guidelines and agreements for pediatric patients via a survey sent to US hospital emergency department (ED) nurse managers during 2010 and 2013. RESULTS: Although there was an increase in the presence of written interfacility transfer guidelines and agreements, a third of hospitals did not have either by 2013, and only 50% had guidelines with all recommended pediatric components. Hospitals with medium and low ED pediatric patient volumes were less likely to have written guidelines or agreements compared with hospitals with high volume. Hospitals with advanced pediatric resources, such as a pediatric emergency care coordinator or EDs designated approved for pediatrics, were more likely to have guidelines or agreements than less resourced hospitals. CONCLUSIONS: Although there was improvement over time, opportunities exist for increasing the presence of written interfacility transfer guidelines as well as agreements for pediatric patients. Further studies are needed to demonstrate whether improved delivery of patient care is associated with the presence of written interfacility transfer guidelines and agreements and to identify other elements in the process to ensure optimal pediatric patient care.

Access to High Pediatric-Readiness Emergency Care in the United States.

OBJECTIVE: To determine the geographic accessibility of emergency departments (EDs) with high pediatric readiness by assessing the percentage of US children living within a 30-minute drive time of an ED with high pediatric readiness, as defined by collaboratively developed published guidelines. STUDY DESIGN: In this cross-sectional analysis, we examined geographic access to an ED with high pediatric readiness among US children. Pediatric readiness was assessed using the weighted pediatric readiness score (WPRS) of US hospitals based on the 2013 National Pediatric Readiness Project (NPRP) survey. A WPRS of 100 indicates that the ED meets the essential guidelines for pediatric readiness. Using estimated drive time from ZIP code centroids, we determined the proportions of US children living within a 30-minute drive time of an ED with a WPRS of 100 (maximum), 94.3 (90th percentile), and 83.6 (75th percentile). RESULTS: Although 93.7% of children could travel to any ED within 30 minutes, only 33.7% of children could travel to an ED with a WPRS of 100, 55.3% could travel to an ED with a WPRS at or above the 90th percentile, and 70.2% could travel to an ED with a WPRS at or above the 75th percentile. Among children within a 30-minute drive of an ED with the maximum WPRS, 90.9% lived closer to at least 1 alternative ED with a WPRS below the maximum. Access varied across census divisions, ranging from 14.9% of children in the East South Center to 56.2% in the Mid-Atlantic for EDs scoring a maximum WPRS. CONCLUSION: A significant proportion of US children do not have timely access to EDs with high pediatric readiness.

Pediatric Readiness in Indian Health Service and Tribal Emergency Departments: Results from the National Pediatric Readiness Project.

INTRODUCTION: In 2014, 45 Indian Health Service (IHS)/Tribal emergency departments serving American Indian and Alaskan Native communities treated approximately 650,000 patients of which, 185,000 (28%) were children and youth younger than 19 years. This study presents the results of the National Pediatric Readiness Project (NPRP) assessment of the 45 IHS/Tribal emergency departments. METHODS: Data were obtained from the 2013 NPRP national assessment, which is a 55-question Web-based questionnaire based on previously published 2009 national consensus guidelines. The main measure of readiness is the weighted pediatric readiness score (WPRS), with the highest score being 100. RESULTS: The overall mean WPRS for all emergency departments is 60.9. Of the IHS/Tribal emergency departments that had pediatric emergency care coordinators, scores across all domains were higher than those of emergency departments without pediatric emergency care coordinators. All 45 emergency departments have readily available a pediatric medication dosing chart, length-based tape, medical software, or other system to ensure proper sizing of resuscitation equipment and proper dosing of medication. Of the 45 IHS/Tribal 37% report having 100% of the equipment items, and 78% report having at least 80% of these items. DISCUSSION: This article reports the results of the NPRP assessment in IHS/Tribal emergency departments that, despite serving a historically vulnerable population, scored favorably when compared with national data. The survey identified areas for improvement, including implementation of QI processes, stocking of pediatric specific equipment, implementation of policies and procedures on interfacility transport, and maintaining staff pediatric competencies.

Research in Prehospital Care: Overcoming the Barriers to Success.

OBJECTIVE: The objective of this project was to determine how investigators conduct clinical trials in the prehospital setting and to suggest how emergency medical services (EMS) systems can develop the capacity to conduct prehospital clinical research. METHODS: A representative sample of U.S.-based study sites was selected from all studies registered on clinicaltrials.gov since the year 2000, where prehospital care providers conducted study-related activities in the prehospital setting. The site principal investigator and the research coordinator or EMS liaison were invited to participate in a structured discussion. A single interviewer conducted each discussion following a structured guide that generically asked for barriers and enablers to the sites' research success and then reviewed commonly identified prehospital research barriers. Notes were taken during each discussion and reviewed for common themes. Themes were reviewed by the project team and sent for comment to all participants. RESULTS: Discussions were held with 25 principal investigators, 9 coordinators, and 7 EMS liaisons. A total of 27 communities were represented in the discussions from 22 different states. The communities had a range of research experience from one prehospital trial to multiple trials. Key barriers were funding, ethics approval, data collection, protocol training and compliance, randomizing and blinding interventions, obtaining patient outcomes, adequate study staffing, and partnering with EMS agencies. CONCLUSION: This project identified many challenges to EMS research, but they were not insurmountable. Not every community can conduct every prehospital study. Communities should engage in studies that align with their values and resources. Investigators need to develop honest relationships where issues can be openly discussed and the community can collaborate on prehospital research. Learning from those who have overcome challenges may be a key to expanding the quality and quantity of EMS research.

A tale of two populations: addressing pediatric needs in the continuum of emergency care.

Nearly 27% of all annual emergency department (ED) visits are pediatric related, a relatively small percentage in comparison to the number of visits from the adult population. The majority of the 31 million children and adolescents access care in nonpediatric facilities and have different clinical presentations and needs than adults. Administered by the Health Resources and Services Administration within the Department of Health and Human Services, the Emergency Medical Services for Children (EMSC) program is a federal entity that aims to ensure that pediatric care is well integrated into the entire emergency medical services system so that no matter where a child lives or travels, he or she can receive appropriate and timely care. The objective of this article is to describe the role of the EMSC program in the development of the pediatric emergency care system. The program is striving to improve pediatric emergency care in a number of ways: EMSC State Partnership grant performance measures address the ability of the out-of-hospital and hospital settings to care for children; the National Pediatric Readiness project works with EDs to ensure that essential resources are present to care for children; regionalization grants focus on the challenges of geographic isolation, access to specialty care, and limited resources; and the targeted issue grants focus on the care of the child in the out-of-hospital setting in which there is a paucity of evidence-based knowledge.

Pediatric Readiness in Critical Access Hospital Emergency Departments.

PURPOSE: Critical Access Hospitals (CAHs), often the first point of access for emergency care, see few children and are challenged to remain proficient in caring for pediatric patients. Our analysis provides guidance to facilitate increasing CAHs staffs' ability to provide effective pediatric emergency care. METHODS: The National Pediatric Readiness Project (NPRP) assessment of 4,146 emergency departments (EDs) was linked with the CAHs list from Centers for Medicare and Medicaid Services. Pediatric readiness was assessed using the weighted pediatric readiness score (WPRS). A WPRS of 100 indicates that the ED meets essential guidelines for pediatric readiness. Using descriptive statistics, we also compared low (fewer than 5 children a day) and medium patient volume (5-14 children a day) EDs in 6 core areas of readiness. FINDINGS: Eighty-six percent (1,140) of CAHs were linked to the NPRP. In the study, 80% were low and 20% medium volume. The median WPRS was 59.0 for low and 67.3 for medium volume. While some differences were found by patient volume, overall 63% of CAHs had a pediatric emergency care coordinator, 34% had a pediatric patient care review process, 62% had interfacility transfer guidelines, and 45% weighed children only in kilograms. CAHs participating in a facility recognition program had significantly higher median WPRS scores (84.3) compared to those not participating (59.5). CONCLUSION: CAHs have challenges in being ready to care for children in the areas of pediatric emergency care coordinators, policies, procedures, and patient safety. Minimal cost interventions are available to increase the readiness of CAHs to care for children.

Pediatric emergency department readiness among US trauma hospitals.

BACKGROUND: Pediatric readiness among US emergency departments is not universal. Trauma hospitals adhere to standards that may support day-to-day readiness for children. METHODS: In 2013 4,146 emergency departments participated in the NPRP to assess compliance with the 2009 Guidelines to Care for Children in the Emergency Department. Probabilistic linkage (90%) to the 2009 American Hospital Association survey found 1,247 self-identified trauma hospitals (levels 1, 2, 3, 4). Relationship between trauma hospital level and weighted pediatric readiness score (WPRS) on a 100-point scale was performed; significance was assessed using a Kruskal-Wallis test and pediatric readiness elements using χ. Adjusted relative risks were calculated using modified Poisson regression, controlling for pediatric volume, hospital configuration, and geography. RESULTS: The overall WPRS among all trauma hospitals (1,247) was 71.8. Among those not self-identified as a children's hospital or emergency department approved for pediatrics (EDAP) (1088), Level 1 and 2 trauma hospitals had higher WPRS than level 3 and 4 trauma hospitals, 83.5 and 71.8, respectively versus 64.9 and 62.6. Yet, compared with EDAP trauma hospitals (median 90.5), level 1 general trauma hospitals were less likely to have critical pediatric-specific elements. Common gaps among general trauma hospitals included presence of interfacility transfer agreements for children, measurement of pediatric weights solely in kilograms, quality improvement processes with pediatric-specific metrics, and disaster plans that include pediatric-specific needs. CONCLUSION: Self-identified trauma hospital level may not translate to pediatric readiness in emergency departments. Across all levels of general non-EDAP, nonchildren's trauma hospitals, gaps in pediatric readiness exist. Nonchildren's hospital EDs (i.e., EDAPs) can be prepared to meet the emergency needs of all children and trauma hospital designation should incorporate these core elements of pediatric readiness. LEVEL OF EVIDENCE: Care management, level III.

Counseling about proper use of motor vehicle occupant restraints and avoidance of alcohol use while driving: a systematic evidence review for the U.S. Preventive Services Task Force.

BACKGROUND: Motor vehicle-related injuries are the leading cause of death among children, adolescents, and young adults. PURPOSE: To systematically review evidence of the effectiveness of counseling people of any age in primary care settings about occupant restraints or alcohol-related driving to prevent injuries. DATA SOURCES: MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, CINAHL, and Traffic Research Information Service; published systematic evidence reviews; experts; and bibliographies of selected trials. STUDY SELECTION: Randomized, controlled trials (RCTs); controlled clinical trials (CCTs); or comparative observational research studies that evaluated behavioral counseling interventions feasible to conduct in primary care or referral from primary care. DATA EXTRACTION: Investigators abstracted data on study design, setting, patients, interventions, outcomes, and quality-related study details. DATA SYNTHESIS: Trials report that counseling to increase the use of child safety seats leads to increased short-term restraint use (7 CCTs, 6 RCTs). Interventions that included a demonstration of correct use or distribution of a free or reduced-cost child safety seat reported larger effects. Few trials described the effect of counseling children 4 to 8 years of age to use booster seats (1 RCT); counseling older children, adolescents, or adults to use seat belts (1 CCT, 2 RCTs); or counseling unselected primary care patients to reduce alcohol-related driving behaviors (no trials). LIMITATIONS: Most of the relevant trials were published before the widespread enactment of child safety seat legislation and had methodological flaws. CONCLUSIONS: The incremental effect of primary care counseling to increase the correct use of child safety seats in the current regulatory environment is not established. The effectiveness of primary care counseling to reduce alcohol-related driving has not been tested. Studies are needed.

Integrating evidence-based clinical and community strategies to improve health.

Multiple and diverse preventive strategies in clinical and community settings are necessary to improve health. This paper (1) introduces evidence-based recommendations from the U.S. Preventive Services Task Force sponsored by the Agency for Healthcare Research and Quality and the Community Task Force sponsored by the Centers for Disease Control and Prevention, (2) examines, using a social-ecologic model, the evidence-based strategies for use in clinical and community settings to address preventable health-related problems such as tobacco use and obesity, and (3) advocates for prioritization and integration of clinical and community preventive strategies in the planning of programs and policy development, calling for additional research to develop the strategies and systems needed to integrate them.

A national assessment of pediatric readiness of emergency departments.

IMPORTANCE: Previous assessments of readiness of emergency departments (EDs) have not been comprehensive and have shown relatively poor pediatric readiness, with a reported weighted pediatric readiness score (WPRS) of 55. OBJECTIVES: To assess US EDs for pediatric readiness based on compliance with the 2009 guidelines for care of children in EDs; to evaluate the effect of physician/nurse pediatric emergency care coordinators (PECCs) on pediatric readiness; and to identify gaps for future quality initiatives by a national coalition. DESIGN, SETTING, AND PARTICIPANTS: Web-based assessment of US EDs (excluding specialty hospitals and hospitals without an ED open 24 hours per day, 7 days per week) for pediatric readiness. All 5017 ED nurse managers were sent a 55-question web-based assessment. Assessments were administered from January 1 through August 23, 2013. Data were analyzed from September 12, 2013, through January 11, 2015. MAIN OUTCOMES AND MEASURES: A modified Delphi process generated a WPRS. An adjusted WPRS was calculated excluding the points received for the presence of physician and nurse PECCs. RESULTS: Of the 5017 EDs contacted, 4149 (82.7%) responded, representing 24 million annual pediatric ED visits. Among the EDs entered in the analysis, 69.4% had low or medium pediatric volume and treated less than 14 children per day. The median WPRS was 68.9 (interquartile range [IQR] 56.1-83.6). The median WPRS increased by pediatric patient volume, from 61.4 (IQR, 49.5-73.6) for low-pediatric-volume EDs compared with 89.8 (IQR, 74.7-97.2) for high-pediatric-volume EDs (P < .001). The median percentage of recommended pediatric equipment available was 91% (IQR, 81%-98%). The presence of physician and nurse PECCs was associated with a higher adjusted median WPRS (82.2 [IQR, 69.7-92.5]) compared with no PECC (66.5 [IQR, 56.0-76.9]) across all pediatric volume categories (P < .001). The presence of PECCs increased the likelihood of having all the recommended components, including a pediatric quality improvement process (adjusted relative risk, 4.11 [95% CI, 3.37-5.02]). Barriers to guideline implementation were reported by 80.8% of responding EDs. CONCLUSIONS AND RELEVANCE: These data demonstrate improvement in pediatric readiness of EDs compared with previous reports. The physician and nurse PECCs play an important role in pediatric readiness of EDs, and their presence is associated with improved compliance with published guidelines. Barriers to implementation of guidelines may be targeted for future initiatives by a national coalition whose goal is to ensure day-to-day pediatric readiness of our nation's EDs.

Predictors of seat-belt use among school-aged children in two low-income Hispanic communities.

OBJECTIVES: To examine the prevalence of seat belt use among school-aged children in low-income Hispanic communities. METHODS: We conducted unobtrusive observations of school-aged children (aged 5 to 12 years) traveling to and from nine elementary schools in two communities. We documented vehicle type, and belted status and seating position of children, driver, and other passengers. Results are presented as percentages with 95% confidence intervals (CIs). RESULTS: We observed 3651 children, of which restraint use could be determined for 2741. Overall, 29% of children were using seat belts. By seating location, 58% were in the front seat with 40% belted, and 42% were in the back seat with 14% belted. Children were most likely to be restrained when traveling in the front seat (40.0%, CI=37.6-42.5); traveling with a belted driver (42.4%, CI=40.0-44.8); or traveling without additional passengers (40.3%, CI=37.0-43.7) CONCLUSIONS: Seat belt use among children from this study population was below the national average and was alarmingly low among children in the back seat. While traveling, being belted in the back seat provides the most protection in a collision. Prevention efforts need to be based on an understanding of the barriers to restraint use for children traveling in the back seat.

Not all child safety seats are created equal: the potential dangers of shield booster seats.

OBJECTIVE: Children are safest when traveling in a child safety seat appropriate for their age and size. Previous research indicates that children are often transitioned to shield booster seats (SBSs) before reaching the 40-lb weight limit for their forward-facing child safety seat (FFCSS). These children could have otherwise been restrained in a FFCSS as is currently recommended by the American Academy of Pediatrics and the National Highway Traffic Safety Administration. The objective of this study was to compare the injury patterns among children who were restrained in SBSs and FFCSSs. Children in FFCSSs were chosen as a comparison group because SBS are predominantly used to restrain children who are <40 lb and could have been restrained in an FFCSS, and SBSs are no longer certified for use in children who are >40 lb. METHODS: This is a cohort study involving restrained crash victims who were admitted to a level 1 pediatric trauma center between 1991 and 2003. Patients were older than 1 year, weighed between 20 and 40 lb, and were restrained in an SBS (N = 16) or an FFCSS (N = 30). Injury Severity Score, Abbreviated Injury Scale, Glasgow coma score, intensive care admission, length of stay, and acute care charges served as outcomes of interest. RESULTS: No significant differences regarding crash and occupant characteristics were found (mean Delta V, crash type, passenger compartment intrusion, driver restraint use). Odds of severe injury were greater for children in SBSs compared with children in FFCSSs as measured by Injury Severity Score >15 (odds ratio [OR]: 8.3; 95% confidence interval [CI]: 2.1-33.6), intensive care admission (OR: 5.5; 95% CI: 1.5-20.5), length of stay >2 days (OR: 6.3; 95% CI: 1.6-24.6), and Abbreviated Injury Scale > or = 3 (OR: 4.4; 95% CI: 1.2-16.1). Furthermore, SBS cases had greater odds of head (OR: 4.5; 95% CI: 1.2-17.3), chest (OR: 29.0; 95% CI: 3.1-267.3), and abdominal/pelvic injury (25% vs 0%). CONCLUSION: This study provides information about the increased risk of injury associated with shield boosters when compared with FFCSSs. The challenge for pediatricians is not only to promote the use of child restraints but also to ensure that parents use the most appropriate restraint for their child's age and weight.

Patterns of injury to restrained children in side impact motor vehicle crashes: the side impact syndrome.

BACKGROUND: Injury patterns among children in frontal collisions have been well documented, but little information exists regarding injuries to children in side impact collisions. METHODS: Restrained children 14-years-old or younger admitted to the hospital for crash injuries were analyzed. Data concerning injuries, medical treatment, and outcome were correlated with crash data. Case reviews achieved consensus regarding injury contact points. Side impacts were compared with frontal impacts. These results were then compared with data from the National Automotive Sampling System. RESULTS: There were no differences between the groups with respect to age, sex, restraint type, or seat position. Compared with frontal crashes, children in side impacts were more likely to have an Injury Severity Score > 15 (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.7-5.8) and were more likely to have Abbreviated Injury Scale score 2+ injuries to the head (OR, 2.5; 95% CI, 1.4-4.4), chest (OR, 4.0; 95% CI, 2.0-8.0), and cervical spine (OR, 3.7; 95% CI, 1.2-11.3). When compared with National Automotive Sampling System data, similar trends were seen regarding Abbreviated Injury Scale score 2+ injuries to the head, chest, and extremities. CONCLUSION: In this study population, side impacts resulted in more injuries to the head, cervical spine, and chest. Knowledge of this pattern-the side impact syndrome-can help guide diagnosis, treatment, and prevention strategy.