Emergency Medical Services (EMS) 2050: A Vision for the Future of Pediatric Prehospital Care.

The National Highway Traffic Safety Administration (NHTSA) released EMS Agenda 2050 in 2019. It places into context the problems of prehospital care of children today and projects where we want to be in 2050. It does not provide a list of solutions but provides a vision for EMS as a people-centered EMS system that meets the goals of the six guiding principles. This vision for EMS in 2050 can be applied by leaders in pediatrics, emergency medicine, emergency medical services (EMS), and local, state and federal governments, and proposed actions help to frame how the emergency medicine and EMS communities can optimize the care of children in future EMS systems.

Characteristics Associated With Presence of Pediatric Mental Health Care Policies in Emergency Departments.

OBJECTIVES: The majority of US children do not have access to an emergency department (ED) with a pediatric mental health care policy in place. Our objective was to understand factors associated with whether US EDs have a pediatric mental health care policy. METHODS: We analyzed data from the National Pediatric Readiness Project, a nationally representative cross-sectional survey of US EDs. Nurse managers reported whether their hospitals had a policy to care for children with social/mental health concerns (n = 3612). We calculated prevalence estimates, prevalence ratios (PRs), and confidence intervals (CIs) for regional and ED characteristics (eg, rurality and types of personnel) by whether EDs had a pediatric mental health care policy. RESULTS: Overall, 46.2% (n = 1668/3612) of EDs had a pediatric mental health care policy. Emergency departments located in remote areas were 60% less likely to have such a policy compared with EDs in urban areas (PR, 0.4; CI, 0.3-0.5). Emergency department characteristics associated with having a pediatric mental health care policy included having a policy to transfer children with social/mental health concerns (PR, 5.4; CI, 4.7-6.2), having a policy to address maltreatment (PR, 3.4; CI, 2.6-4.4), and having nurse and physician pediatric emergency care coordinators (PR, 1.6; CI, 1.5-1.8). CONCLUSIONS: Lower prevalence of pediatric mental health policies in rural EDs is concerning considering EDs are often the first point of contact for pediatric patients. This work highlights the importance of pediatric emergency care coordinators in fostering ED capacity to meet children's mental health needs.

Impact of Personal Protective Equipment on the Performance of Emergency Pediatric Tasks.

OBJECTIVES: Personal protective equipment (PPE) is worn by health care providers (HCPs) to protect against hazardous exposures. Studies of HCPs performing critical resuscitation tasks in PPE have yielded mixed results and have not evaluated performance in care of children. We evaluated the impacts of PPE on timeliness or success of emergency procedures performed by pediatric HCPs. METHODS: This prospective study was conducted at 2 tertiary children's hospitals. For session 1, HCPs (medical doctors and registered nurses) wore normal attire; for session 2, they wore full-shroud PPE garb with 2 glove types: Ebola level or chemical. During each session, they performed clinical tasks on a patient simulator: intubation, bag-valve mask ventilation, venous catheter (IV) placement, push-pull fluid bolus, and defibrillation. Differences in completion time per task were compared. RESULTS: There were no significant differences in medical doctor completion time across sessions. For registered nurses, there was a significant difference between baseline and PPE sessions for both defibrillation and IV placement tasks. Registered nurses were faster to defibrillate in Ebola PPE and slower when wearing chemical PPE (median difference, -3.5 vs 2 seconds, respectively; P < 0.01). Registered nurse IV placement took longer in Ebola and chemical PPE (5.5 vs 42 seconds, respectively; P < 0.01). After the PPE session, participants were significantly less likely to indicate that full-body PPE interfered with procedures, was claustrophobic, or slowed them down. CONCLUSIONS: Personal protective equipment did not affect procedure timeliness or success on a simulated child, with the exception of IV placement. Further study is needed to investigate PPE's impact on procedures performed in a clinical care context.

Impact of Personal Protective Equipment on Pediatric Cardiopulmonary Resuscitation Performance: A Controlled Trial.

OBJECTIVES: This study aimed to determine whether personal protective equipment (PPE) results in deterioration in chest compression (CC) quality and greater fatigue for administering health care providers (HCPs). METHODS: In this multicenter study, HCPs completed 2 sessions. In session 1 (baseline), HCPs wore normal attire; in session 2, HCPs donned full PPE. During each session, they performed 5 minutes of uninterrupted CCs on a child manikin. Chest compression rate, depth, and release velocity were reported in ten 30-second epochs. Change in CC parameters and self-reported fatigue were measured between the start and 2- and 5-minute epochs. RESULTS: We enrolled 108 HCPs (prehospital and in-hospital providers). The median CC rate did not change significantly between epochs 1 and 10 during baseline sessions. Median CC depth and release velocity decreased for 5 minutes with PPE. There were no significant differences in CC parameters between baseline and PPE sessions in any provider group. Median fatigue scores during baseline sessions were 2 (at start), 4 (at 2 minutes), and 6 (at 5 minutes). There was a significantly higher median fatigue score between 0 and 5 minutes in both study sessions and in all groups. Fatigue scores were significantly higher for providers wearing PPE compared with baseline specifically among prehospital providers. CONCLUSIONS: During a clinically appropriate 2-minute period, neither CC quality nor self-reported fatigue worsened to a significant degree in providers wearing PPE. Our data suggest that Pediatric Basic Life Support recommendations for CC providers to switch every 2 minutes need not be altered with PPE use.

"Patients who can't get an appointment go to the ER": access to specialty care for publicly insured children.

STUDY OBJECTIVE: Emergency departments (EDs) frequently refer patients for needed outpatient specialty care, but little is known about the dynamics of these referrals when patients are publicly insured. Hence, we explored factors, including the role of ED referrals, associated with specialists' willingness to accept patients covered by Medicaid and the Children's Health Insurance Program (CHIP). METHODS: We conducted semistructured qualitative interviews with a purposive sample of 26 specialists and 14 primary care physicians in Cook County, Illinois, from April to September 2009, until theme saturation was reached. Transcripts and notes were entered into ATLAS.ti and analyzed using an iterative coding process to identify patterns of responses, ensure reliability, examine discrepancies, and achieve consensus through content analysis. RESULTS: Themes that emerged indicate that primary care physicians face considerable barriers getting publicly insured patients into outpatient specialty care and use the ED to facilitate this process. Specialty physicians reported that decisions to refuse or limit the number of patients with Medicaid/CHIP are due to economic strain or direct pressure from their institutions. Factors associated with specialist acceptance of patients with Medicaid/CHIP included high acuity or complexity, personal request from or an informal economic relationship with the primary care physician, geography, and patient hardship. Referral through the ED was a common and expected mechanism for publicly insured patients to access specialty care. CONCLUSION: These exploratory findings suggest that specialists are willing to see children with Medicaid/CHIP if they are referred from an ED. As health systems restructure, EDs have the potential to play a role in improving care coordination and access to outpatient specialty care.

Going viral: adapting to pediatric surge during the H1N1 pandemic.

OBJECTIVES: The objective of this study was to assess hospital and emergency department (ED) pediatric surge strategies utilized during the 2009 H1N1 influenza pandemic as well as compliance with national guidelines. METHODS: Electronic survey was sent to a convenience sample of emergency physicians and nurses from US EDs with a pediatric volume of more than 10,000 annually. Survey questions assessed the participant's hospital baseline pandemic and surge preparedness, as well as strategies for ED surge and compliance with Centers for Disease Control and Prevention (CDC) guidelines for health care personal protection, patient testing, and treatment. RESULTS: The response rate was 54% (53/99). Preexisting pandemic influenza plans were absent in 44% of hospitals; however, 91% developed an influenza plan as a result of the pandemic. Twenty-four percent reported having a preexisting ED pandemic staffing model, and 36% had a preexisting alternate care site plan. Creation and/or modifications of existing plans for ED pandemic staffing (82%) and alternate care site plan (68%) were reported. Seventy-nine percent of institutions initially followed CDC guidelines for personal protection (use of N95 masks), of which 82% later revised their practices. Complete compliance with CDC guidelines was 60% for patient testing and 68% for patient treatment. CONCLUSIONS: Before the H1N1 pandemic, greater than 40% of the hospitals in our study did not have an influenza pandemic preparedness plan. Many had to modify their existing plans during the surge. Not all institutions fully complied with CDC guidelines. Data from this multicenter survey should assist clinical leaders to create more robust surge plans for children.

Access to Critical Health Information for Children During Emergencies: Emergency Information Forms and Beyond.

ABSTRACT: Children with chronic medical conditions rely on complex management plans for problems that cause them to be at increased risk for suboptimal outcomes in emergency situations. The emergency information form (EIF) is a medical summary that provides rapid access to critical information to physicians and other members of the health care team so that optimal emergency medical care can be provided. This statement describes an updated approach to EIFs and the information they contain. Essential common data elements are reviewed, integration with electronic health records is discussed, and broadening the rapid availability and use of health data for all children and youth is proposed. A broader approach to data accessibility and use could extend the benefits of rapid access to critical information for all children receiving emergency care as well as further facilitating emergency preparedness during disaster management.

Impact of Personal Protective Equipment on the Performance of Emergency Pediatric Procedures by Prehospital Providers.

BACKGROUND: Personal protective equipment (PPE) is worn by prehospital providers (PHPs) for protection from hazardous exposures. Evidence regarding the ability of PHPs to perform resuscitation procedures has been described in adult but not pediatric models. This study examined the effects of PPE on the ability of PHPs to perform resuscitation procedures on pediatric patients. METHODS: This prospective study was conducted at a US simulation center. Paramedics wore normal attire at the baseline session and donned full Level B PPE for the second session. During each session, they performed timed sets of psychomotor tasks simulating clinical care of a critically ill pediatric patient. The difference in time to completion between baseline and PPE sessions per task was examined using Wilcoxon signed-rank tests. RESULTS: A total of 50 paramedics completed both sessions. Median times for task completion at the PPE sessions increased significantly from baseline for several procedures: tracheal intubation (+4.5 s; P = 0.01), automated external defibrillator (AED) placement (+9.5 s; P = 0.01), intraosseous line insertion (+7 s; P < 0.0001), tourniquet (+8.5 s; P < 0.0001), intramuscular injection (+21-23 s, P < 0.0001), and pulse oximetry (+4 s; P < 0.0001). There was no significant increase in completion time for bag-mask ventilation or autoinjector use. CONCLUSIONS: PPE did not have a significant impact on PHPs performing critical tasks while caring for a pediatric patient with a highly infectious or chemical exposure. This information may guide PHPs faced with the situation of resuscitating children while wearing Level B PPE.

Neonatal and pediatric regionalized systems in pediatric emergency mass critical care.

INTRODUCTION: Improved health outcomes are associated with neonatal and pediatric critical care in well-organized, cohesive, regionalized systems that are prepared to support and rehabilitate critically ill victims of a mass casualty event. However, present systems lack adequate surge capacity for neonatal and pediatric mass critical care. In this document, we outline the present reality and suggest alternative approaches. METHODS: In May 2008, the Task Force for Mass Critical Care published guidance on provision of mass critical care to adults. Acknowledging that the critical care needs of children during disasters were unaddressed by this effort, a 17-member Steering Committee, assembled by the Oak Ridge Institute for Science and Education with guidance from members of the American Academy of Pediatrics, convened in April 2009 to determine priority topic areas for pediatric emergency mass critical care recommendations.Steering Committee members established subcommittees by topic area and performed literature reviews of MEDLINE and Ovid databases. The Steering Committee produced draft outlines through consensus-based study of the literature and convened October 6-7, 2009, in New York, NY, to review and revise each outline. Eight draft documents were subsequently developed from the revised outlines as well as through searches of MEDLINE updated through March 2010.The Pediatric Emergency Mass Critical Care Task Force, composed of 36 experts from diverse public health, medical, and disaster response fields, convened in Atlanta, GA, on March 29-30, 2010. Feedback on each manuscript was compiled and the Steering Committee revised each document to reflect expert input in addition to the most current medical literature. TASK FORCE RECOMMENDATIONS: States and regions (facilitated by federal partners) should review current emergency operations and devise appropriate plans to address the population-based needs of infants and children in large-scale disasters. Action at the state, regional, and federal levels should address legal, operational, and information systems to provide effective pediatric mass critical care through: 1) predisaster/mass casualty planning, management, and assessment with input from child health professionals; 2) close cooperation, agreements, public-private partnerships, and unique delivery systems; and 3) use of existing public health data to assess pediatric populations at risk and to model graded response plans based on increasing patient volume and acuity.

Emergency Medical Services for Children: Office Emergency and Disaster Readiness.

Pediatricians are resources for families to provide ongoing care, education, and guidance during emergencies. They must be prepared to handle both office emergencies and local disasters. In office emergencies, readiness should focus on stabilizing life-threats until patients can be transported to an emergency department. Preparedness must also focus on providing aid in the setting of large-scale disasters in conjunction with local public health officials, hospitals, health care coalitions, emergency medical services systems, and local emergency officials, and plans should address hazards local to the area. [Pediatr Ann. 2021;50(4):e160-e164.].

Extending the Reach of Pediatric Emergency Preparedness: A Virtual Tabletop Exercise Targeting Children's Needs.

OBJECTIVES: Virtual tabletop exercises (VTTXs) simulate disaster scenarios to help participants improve their emergency-planning capacity. The objectives of our study were to (1) evaluate the effectiveness of a VTTX in improving preparedness capabilities specific to children's needs among pediatricians and public health practitioners, (2) document follow-up actions, and (3) identify exercise strengths and weaknesses. METHODS: In February 2017, we conducted and evaluated a VTTX facilitated via videoconferencing among 26 pediatricians and public health practitioners from 4 states. Using a mixed-methods design, we assessed participants' knowledge and confidence to fulfill targeted federal preparedness capabilities immediately before and after the exercise. We also evaluated the degree to which participants made progress on actions through surveys 1 month (n = 14) and 6 months (n = 14) after the exercise. RESULTS: Participants reported a greater ability to identify their state's pediatric emergency preparedness strengths and weaknesses after the exercise (16 of 18) compared with before the exercise (10 of 18). We also observed increases in (1) knowledge of and confidence in performing most pediatric emergency preparedness capabilities and (2) most dimensions of interprofessional collaboration. From 1 month to 6 months after the exercise, participants (n = 14) self-reported making progress in increasing awareness for potential preparedness partners and in conducting similar pediatric exercises (from 4-7 for both). CONCLUSIONS: Participants viewed the VTTX positively and indicated increased pediatric emergency preparedness knowledge and confidence. Addressing barriers to improving local pediatric emergency preparedness-particularly long term-is an important target for future tabletop exercises.

Electronic medical record-based tools aid in timely triage of disc-shaped foreign body ingestions.

OBJECTIVES/HYPOTHESIS: Children presenting to the emergency department with coin-shaped foreign body (FB) ingestion must be evaluated urgently to rule out a button battery. As many of these ingestions are well-appearing on presentation, delays in triage put patients at risk for further injury. STUDY DESIGN: Quality initiative. METHODS: A quality initiative, utilizing electronic medical record (EMR)-based tools, was implemented at our academic children's hospital. A chief complaint pertaining to coin-shaped FB ingestion was created and was linked to a best practice advisory, instructing assignment of acuity level 2 and the order of a Stat x-ray. A link to the hospital's relevant algorithm was provided. A review was conducted comparing children who underwent FB removal preinitiative (January 1, 2016-January 28, 2017) and postinitiative (January 31, 2017-August 30, 2017). Primary outcomes were frequency of assignment of acuity level 2 and time from patient arrival to x-ray order placement and x-ray completion. RESULTS: Thirty-six patients in the baseline group and 30 in the postintervention group underwent FB removal. The rate of appropriate acuity assignment increased from 63.8% (23/36) pre implementation to 100% (30/30) postimplementation (P = .0003). Median time from arrival to imaging ordered and completed decreased from 36.5 to 4 minutes (95% confidence interval [CI]: -44 to -17) and 59 to 41 minutes (95% CI: -39 to -1), respectively. CONCLUSIONS: Utilization of EMR-based tools was associated with improved timeliness in initiation of care in metallic FB ingestion patients. Further initiatives will be aimed at downstream events in the diagnosis and treatment of these patients. LEVEL OF EVIDENCE: NA Laryngoscope, 128:2697-2701, 2018.

Emergency department overcrowding and children.

Emergency department (ED) overcrowding has been a serious issue on the national agenda for the past 2 decades and is rapidly becoming an increasingly significant problem for children. The goal of this report is to focus on the issues of overcrowding that directly impact children. Our findings reveal that although overcrowding seems to affect children in ways similar to those of adults, there are several important ways in which they differ. Recent reports document that more than 90% of academic emergency medicine EDs are overcrowded. Although inner-city, urban, and university hospitals have historically been the first to feel the brunt of overcrowding, community and suburban EDs are now also being affected. The overwhelming majority of children (92%) are seen in general community EDs, with only a minority (less than 10%) treated in dedicated pediatric EDs. With the exception of patients older than 65 years, children have higher visit rates than any other age group. Children may be at particularly increased risk for medical errors because of their inherent variability in size and the need for age-specific and weight-based dosing. We strongly recommend that pediatric issues be actively included in all future aspects of research and policy planning issues related to ED overcrowding. These include the development of triage protocols, clinical guidelines, research proposals, and computerized data monitoring systems.

Disaster Preparedness in Neonatal Intensive Care Units.

Disasters disproportionally affect vulnerable, technology-dependent people, including preterm and critically ill newborn infants. It is important for health care providers to be aware of and prepared for the potential consequences of disasters for the NICU. Neonatal intensive care personnel can provide specialized expertise for their hospital, community, and regional emergency preparedness plans and can help develop institutional surge capacity for mass critical care, including equipment, medications, personnel, and facility resources.

Establishing a Hospital Response Network Among Children's Hospitals.

A timely and effective response to public health threats requires a broad-reaching infrastructure. Children's hospitals are focused on evaluating and managing some of the most vulnerable patients and thus have unique preparedness and response planning needs. A virtual forum was established specifically for children's hospitals during the 2014-15 Ebola outbreak, and it demonstrated the importance and utility of connecting these specialty hospitals to discuss their shared concerns. Developing a successful children's hospital response network could build the national infrastructure for addressing children's needs in preparedness and response and for enhancing preparedness and response to high-consequence pathogens. Using the Laboratory Response Network and tiered-hospital network as models, a network of children's hospitals could work together, and with government and nongovernment partners, to establish and refine best practices for treating children with pathogens of public health concern. This network could more evenly distribute hospital readiness and tertiary pediatric patient care capabilities for highly infectious diseases across the country, thus reducing the need to transport pediatric patients across the country and increasing the national capacity to care for children infected with high-consequence pathogens.

The use of high-dose epinephrine for patients with out-of-hospital cardiopulmonary arrest refractory to prehospital interventions.

OBJECTIVE: To determine if high-dose epinephrine (HDE) used during out-of-hospital cardiopulmonary arrest refractory to prehospital interventions improves return of spontaneous circulation, 24-hour survival, discharge survival, and neurological outcomes. METHODS: A multicenter randomized controlled trial was conducted between May 1991 and October 1996 to compare the effectiveness of HDE versus standard-dose epinephrine (SDE) in patients having out-of-hospital cardiopulmonary arrest refractory to prehospital resuscitation efforts. Cardiopulmonary arrest was classified as "medical" or "traumatic." Two hundred thirty patients were enrolled in 7 pediatric emergency departments. Ages ranged from newborn to 22 years. Seventeen patients met exclusion criteria. Patients were assigned to receive HDE (0.1 mg/kg for the initial dose and 0.2 mg/kg for subsequent doses) or SDE (0.01 mg/kg). The main end points evaluated were return of spontaneous circulation, 24-hour survival, discharge survival, and neurological outcome. RESULTS: One hundred twenty-seven patients received HDE (32 trauma patients), and 86 patients received SDE (27 trauma patients). Among medical patients, 24 (25%) of 95 experienced return of spontaneous circulation in the HDE group as compared with 9 (15%) of 59 in the SDE group (P = 0.14, chi2 = 2.17, relative risk = 1.66 [0.83-3.31]). Sixteen (17%) of 95 HDE patients and 5 (8%) of 59 SDE patients survived at least 24 hours (P = 0.14, chi2 = 2.16, relative risk = 1.99 [0.77-5.14]). Nine survivors to discharge received HDE, and 2 received SDE (P = 0.21, Fisher exact test, relative risk = 2.75 [0.61-12.28]). There were no long-term survivors among the trauma patients. Eight of 11 long-term survivors had severe neurological outcomes defined by the Glasgow Outcome Scale (2/2 SDE, 6/9 HDE; P = 0.51, Fisher exact test). CONCLUSION: HDE does not improve or diminish return of spontaneous circulation, 24-hour survival, long-term survival, or neurological outcome compared with SDE in out-of-hospital cardiopulmonary arrest.

Teaching Spanish to pediatric emergency physicians: effects on patient satisfaction.

BACKGROUND: Language barriers are known to negatively affect patient satisfaction. OBJECTIVE: To determine whether a course of instruction in medical Spanish for pediatric emergency department (ED) physicians is associated with an increase in satisfaction for Spanish-speaking-only families. DESIGN, SETTING, PARTICIPANTS, AND INTERVENTION: Nine pediatric ED physicians completed a 10-week medical Spanish course. Mock clinical scenarios and testing were used to establish an improvement in each physician's ability to communicate with Spanish-speaking-only families. Before (preintervention period) and after (postintervention period) the course, Spanish-speaking-only families cared for by these physicians completed satisfaction questionnaires. Professional interpreters were equally available during both the preintervention and postintervention periods. MAIN OUTCOME MEASURES: Responses to patient family satisfaction questionnaires. RESULTS: A total of 143 Spanish-speaking-only families completed satisfaction questionnaires. Preintervention (n = 85) and postintervention (n = 58) cohorts did not differ significantly in age, vital signs, length of ED visit, discharge diagnosis, or self-reported English proficiency. Physicians used a professional interpreter less often in the postintervention period (odds ratio [OR], 0.34; 95% confidence interval [CI], 0.16-0.71). Postintervention families were significantly more likely to strongly agree that "the physician was concerned about my child" (OR, 2.1; 95% CI, 1.0-4.2), "made me feel comfortable" (OR, 2.6; 95% CI, 1.1-4.4), "was respectful" (OR, 3.0; 95% CI, 1.4-6.5), and "listened to what I said" (OR, 2.9; 95% CI, 1.4-5.9). CONCLUSIONS: A 10-week medical Spanish course for pediatric ED physicians was associated with decreased interpreter use and increased family satisfaction.