Evidence-Based Guideline for Prehospital Airway Management.

Airway management is a cornerstone of emergency medical care. This project aimed to create evidence-based guidelines based on the systematic review recently conducted by the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel was assembled to review the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The panel made specific recommendations on the different PICO (population, intervention, comparison, outcome) questions reviewed in the AHRQ review and created good practice statements that summarize and operationalize these recommendations. The recommendations address the use of ventilation with bag-valve mask ventilation alone vs. supraglottic airways vs. endotracheal intubation for adults and children with cardiac arrest, medical emergencies, and trauma. Additional recommendations address the use of video laryngoscopy and drug-assisted airway management. These recommendations, and the associated good practice statements, offer EMS agencies and clinicians an opportunity to review the available evidence and incorporate it into their airway management strategies.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies.

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

Prehospital and emergency department pediatric readiness for injured children: A statement from the American College of Surgeons Committee on Trauma Emergency Medical Services Committee.

ABSTRACT: Injury is the leading cause of death in children older than 1 year, and children make up 22% of the population. Pediatric readiness (PR) of the nation's emergency departments and state trauma and emergency medical services (EMS) systems is conceptually important and vital to mitigate mortality and morbidity in this population. The extension of PR to the trauma community has become a focused area for training, staffing, education, and equipment at all levels of trauma center designation, and there is evidence that a higher level of emergency department PR is independently associated with long-term survival among injured children. Although less well studied, there is an associated need for EMS PR, which is relevant to the injured child who needs assessment, treatment, triage, and transport to a trauma center. We outline a blueprint along with recommendations for incorporating PR into trauma system development in this opinion from the EMS Committee of the American College of Surgeons Committee on Trauma. These recommendations are particularly pertinent in the rural and underserved areas of the United States but are directed toward all levels of professionals who care for an injured child along the trauma continuum of care.

Crowding in the Emergency Department: Challenges and Recommendations for the Care of Children.

Emergency department (ED) crowding results when available resources cannot meet the demand for emergency services. ED crowding has negative impacts on patients, health care workers, and the community. Primary considerations for reducing ED crowding include improving the quality of care, patient safety, patient experience, and the health of populations, as well as reducing the per capita cost of health care. Evaluating causes, effects, and seeking solutions to ED crowding can be done within a conceptual framework addressing input, throughput, and output factors. ED leaders must coordinate with hospital leadership, health system planners and policy decision makers, and those who provide pediatric care to address ED crowding. Proposed solutions in this policy statement promote the medical home and timely access to emergency care for children.

Crowding in the Emergency Department: Challenges and Best Practices for the Care of Children.

Emergency department (ED) crowding has been and continues to be a national concern. ED crowding is defined as a situation in which the identified need for emergency services outstrips available resources in the ED. Crowding is associated with higher morbidity and mortality, delayed pain control, delayed time to administration of antibiotics, increased medical errors, and less-than-optimal health care. ED crowding impedes a hospital's ability to achieve national quality and patient safety goals, diminishes the effectiveness of the health care safety net, and limits the capacity of hospitals to respond to a disaster and/or sudden surge in disease. Both children and adults seeking care in emergency settings are placed at risk. Crowding negatively influences the experience for patients, families, and providers, and can impact employee turnover and well-being. No single factor is implicated in creating the issue of crowding, but elements that influence crowding can be divided into those that affect input (prehospital and outpatient care), throughput (ED), and output (hospital and outpatient care). The degree of ED crowding is difficult to quantify but has been linked to markers such as hours on ambulance diversion, hours of inpatient boarding in the emergency setting, increasing wait times, and patients who leave without being seen. A number of organizations, including the American College of Emergency Physicians, the Emergency Nurses Association, and the National Quality Forum, have convened to better define emergency metrics and definitions that help provide data for benchmarks for patient throughput performance. The Joint Commission has acknowledged that patient safety is tied to patient throughput and has developed guidance for hospitals to ensure that hospital leadership engages in the process of safe egress of the patient out of the ED and, most recently, to address efficient disposition of patients with mental health emergencies. It is important that the American Academy of Pediatrics acknowledges the potential impact on access to optimal emergency care for children in the face of ED crowding and helps guide health policy decision-makers toward effective solutions that promote the medical home and timely access to emergency care.

Pediatric Emergency Care Coordination in EMS Agencies: Findings of a Multistate Learning Collaborative.

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.

Individual Medical Emergencies Occurring at School.

Children and adults may face emergency medical situations because of injuries, complications of chronic health conditions, or unexpected major illnesses that occur in schools. The American Academy of Pediatrics published a policy statement in 2001 titled "Guidelines for Emergency Medical Care in Schools," and in 2008, published its revision, "Medical Emergencies Occurring at School." Those statements focused on the preparedness of schools to address individual student emergencies. The increase in the number of children with special health care needs and chronic medical conditions attending schools, together with the added challenges faced by school districts to ensure that schools have access to on-site, licensed health care professionals on an ongoing basis, have contributed to added risks that medical and nonmedical personnel face in dealing with medical emergencies in schools. This newly revised policy statement serves as an update of the statement published in 2008 and reaffirmed in 2017, and intends to increase pediatricians' awareness of schools' roles in preparing for individual student emergencies and provide recommendations for the medical home and school physicians on how to assist and support school personnel. This statement does not address schoolwide or communitywide emergencies that might occur as a result of natural or man-made disasters.

Prehospital Pediatric Respiratory Distress and Airway Management Training and Education: An NAEMSP Position Statement and Resource Document.

Although pediatric airway and respiratory emergencies represent high-acuity situations, the ability of EMS clinicians to effectively manage these patients is hampered by infrequent clinical exposure and shortcomings in pediatric-specific education. Cognitive gaps in EMS clinicians' understanding of the differences between pediatric and adult airway anatomy and respiratory physiology and pathology, variability in the training provided to EMS clinicians, and decay of the psychomotor skills necessary to safely and effectively manage pediatric patients experiencing respiratory emergencies collectively pose significant threats to the quality and safety of care delivered to pediatric patients. NAEMSP recommends:Pediatric airway education should include discussion of the factors that make pediatric airway management challenging.EMS agencies should provide pediatric-specific education that addresses recognition and treatment of pediatric respiratory distress based upon pathophysiology affecting upper airways, lower airways, cardiovascular systems, or extrinsic causes of disordered breathing. Pediatric airway training should also differentiate between hypoxic and hypercapnic respiratory failure. Education should emphasize that the cognitive and psychomotor skills requisite in management of pediatric respiratory emergencies will differ across patient age groups.EMS clinicians should be provided education and training in technology-dependent children and children and youth with special health care needs.EMS clinicians should receive initial and ongoing education and training in pediatric airway and respiratory conditions that emphasizes the principle of using the least invasive most effective strategies to achieve oxygenation and ventilation.Initial and continuing pediatric-focused education should be structured to maintain EMS clinician competency in the assessment and management of pediatric airway and respiratory emergencies and should be provided on a recurring basis to mitigate the decay of EMS clinicians' knowledge and skills that occurs due to infrequent field-based clinical exposure.Integration of clinician education programs with quality management programs is essential for the development and delivery of initial and continuing education intended to help EMS clinicians attain and maintain proficiency in pediatric airway and respiratory management.

Prehospital Pediatric Respiratory Distress and Airway Management Interventions: An NAEMSP Position Statement and Resource Document.

Devices and techniques such as bag-valve-mask ventilation, endotracheal intubation, supraglottic airway devices, and noninvasive ventilation offer important tools for airway management in critically ill EMS patients. Over the past decade the tools, technology, and strategies used to assess and manage pediatric respiratory and airway emergencies have evolved, and evidence regarding their use continues to grow.NAEMSP recommends:Methods and tools used to properly size pediatric equipment for ages ranging from newborns to adolescents should be available to all EMS clinicians. All pediatric equipment should be routinely checked and clearly identifiable in EMS equipment supply bags and vehicles.EMS agencies should train and equip their clinicians with age-appropriate pulse oximetry and capnography equipment to aid in the assessment and management of pediatric respiratory distress and airway emergencies.EMS agencies should emphasize noninvasive positive pressure ventilation and effective bag-valve-mask ventilation strategies in children.Supraglottic airways can be used as primary or secondary airway management interventions for pediatric respiratory failure and cardiac arrest in the EMS setting.Pediatric endotracheal intubation has unclear benefit in the EMS setting. Advanced approaches to pediatric ETI including drug-assisted airway management, apneic oxygenation, and use of direct and video laryngoscopy require further research to more clearly define their risks and benefits prior to widespread implementation.If considering the use of pediatric endotracheal intubation, the EMS medical director must ensure the program provides pediatric-specific initial training and ongoing competency and quality management activities to ensure that EMS clinicians attain and maintain mastery of the intervention.Paramedic use of direct laryngoscopy paired with Magill forceps to facilitate foreign body removal in the pediatric patient should be maintained even when pediatric endotracheal intubation is not approved as a local clinical intervention.

Quality Management of Prehospital Pediatric Respiratory Distress and Airway Programs: An NAEMSP Position Statement and Resource Document.

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.

Recommended Essential Equipment for Basic Life Support and Advanced Life Support Ground Ambulances 2020: A Joint Position Statement.

In continued support of establishing and maintaining a foundation for standards of care, our organizations remain committed to periodic review and revision of this position statement. This latest revision was created based on a structured review of the National Model EMS Clinical Guidelines Version 2.2 in order to identify the equipment items necessary to deliver the care defined by those guidelines. In addition, in order to ensure congruity with national definitions of provider scope of practice, the list is differentiated into BLS and ALS levels of service utilizing the National Scope of Practice-defined levels of Emergency Medical Responder (EMR) and Emergency Medical Technician (EMT) as BLS, and Advanced EMT (AEMT) and Paramedic as ALS. Equipment items listed within each category were cross-checked against recommended scopes of practice for each level in order to ensure they were appropriately dichotomized to BLS or ALS levels of care. Some items may be considered optional at the local level as determined by agency-defined scope of practice and applicable clinical guidelines. In addition to the items included in this position statement our organizations agree that all EMS service programs should carry equipment and supplies in quantities as determined by the medical director and appropriate to the agency's level of care and available certified EMS personnel and as established in the agency's approved protocols.

Point-of-Care Ultrasound for Confirmation of Nasogastric and Orogastric Tube Placement in Pediatric Patients.

OBJECTIVES: The aim of the study was to investigate the role of point-of-care ultrasound (POCUS) as an alternative imaging modality to confirm proper placement for nasogastric tubes (NGTs) and orogastric tubes (OGTs) in pediatric patients. METHODS: This was a prospective descriptive study performed at a tertiary care free-standing children's hospital. Patients 21 years and younger requiring radiographic confirmation of NGT or OGT placement were eligible for enrollment. Bedside ultrasonography examination of the epigastric area was performed by a blinded pediatric emergency medicine physician. An abdominal radiograph was obtained to confirm NGT or OGT placement in all patients. RESULTS: A total of 26 patients with a mean age of 2.6 years (standard deviation, 3.9 years) were enrolled. All 26 patients had x-ray confirmation of NGT and OGTs correctly placed in the stomach. Confirmation of NGT or OGT placement by ultrasound was obtained in 23 patients. For these 23 patients, POCUS agreed with radiographic findings. For 3 patients, the NGT and OGT was unable to be identified by ultrasound. The sensitivity of ultrasound for detecting a properly placed tube was 88% (95% confidence interval, 70.0%-97.6%). CONCLUSIONS: This pilot study described ultrasound confirmation of NGT or OGT placement. If confirmed in larger studies, POCUS can be used as an objective tool for the confirmation of NGT or OGT placement in pediatric patients and limit the need for routine x-ray confirmation.

Comparison of Prehospital Calculated Age-Adjusted Pediatric Shock Index (SIPA) to Those Calculated in the ED for Identifying Trauma Patients That Needed the Highest-Level Activation Based on Consensus Criteria.

Background: The shock index (SI) is defined as the ratio of the heart rate to systolic blood pressure and a pediatric age-adjusted SI (SIPA) is more specific than the standard adult cutoff of 0.9 in identifying the sickest children presenting to a trauma center.Goal: To utilize prehospital vital signs to calculate the SIPA score and compare them to the SIPA calculated in the trauma bay to determine if they have the same validity in identifying critically ill children as determined by the consensus based standard criteria for trauma activation.Methods: Retrospective study using a cohort of patients transferred by EMS to a free standing, urban, level one, pediatric trauma center aged 1 to 16 years inclusive, and seen between January 1, 2016 and December 31, 2017. Vital signs collected during the patch call from the EMS agency were used to calculate the EMS SIPA. The first set of vital signs collected in the trauma bay was used to calculate the ED SIPA. Patients were dichotomized to an elevated or non-elevated ED SIPA and an elevated or non-elevated EMS SIPA.Results: Our cohort consisted of 2651 patients. 546 (20.6%) patients had an elevated EMS SIPA and 438 (16.5%) had an elevated ED SIPA. When compared to their non-elevated counterparts, EMS and ED SIPA were both able to identify patients who met consensus criteria in all areas except the need for IR intervention, and unstable spinal fracture/spinal cord injury. For these criteria, the ED SIPA was better than the EMS SIPA. Sensitivity and specificity analysis reveal poor sensitivity for both measures but a high specificity for ED and EMS SIPA. Both SI and SIPA have a poor PPV but high NPV.Conclusions: This study utilized prehospital vital signs to calculate the SIPA score and compare them to the SIPA calculated in the trauma bay. Both scores had similar test metrics when based on the consensus based standard trauma criteria and could be utilized in the triage traumatic injuries.

Predictive value of the shock index (SI) compared to the age-adjusted pediatric shock index (SIPA) for identifying children that needed the highest-level trauma activation based on the presence of consensus criteria.

OBJECTIVES: In previous studies, SIPA was shown to be better than the SI in identifying children who have an elevated ISS, required transfusion, or were at a high risk of death. No comparison has been made to the consensus-based criteria that identify patients requiring the highest-level trauma activation. The objective of this study was to determine if the SIPA was more accurate than the SI in identifying children with increased need for trauma team activation as defined by the criterion standard definition, and secondly the sensitivity and specificity of the SI and SIPA. METHODS: Retrospective review of prospectively collected trauma based data. Children aged 1-17 years admitted to a pediatric level 1 trauma center between 1/1/16 and 12/31/17 and met the prehospital criteria for level 1 or 2 trauma activation were included. We evaluated the ability of SI > 0.9 at ED presentation and elevated SIPA to predict need for trauma activation based on consensus criteria. SIPA cutoffs were > 1.22 (age 4-6), >1.0 (age 7-12), and > 0.9 (age 13-17). RESULTS: Among 3378 children, 1486 (44%) had an elevated SI and 590 (18%) had an elevated SIPA. There were 160 (5%) patients who met at least one consensus criterion. Broadly, sensitivity and specificity analyses reveal poor sensitivity for both SI and SIPA (59.4% versus 43.1% respectively) measures but a moderate specificity for SIPA (83.8%). Both SI and SIPA have a poor PPV (6.4% versus 11.7%) but high NPV (96.6% versus 96.7%). Overall, SIPA has higher accuracy than SI in predicting consensus criteria 82% versus 57%). CONCLUSION: SIPA is more accurate than the SI in identifying children who meet a consensus criterion defining the need for highest-level trauma activation. The low PPV and sensitivity suggest that SIPA alone, while somewhat less likely to lead to overtriage than SI is not ideal for ruling in the need for level one resources as defined by the consensus criteria. Prognosis study, retrospective. LEVEL OF EVIDENCE: Level II.

Pediatric Readiness in Emergency Medical Services Systems.

Ill and injured children have unique needs that can be magnified when the child's ailment is serious or life-threatening. This is especially true in the out-of-hospital environment. Providing high-quality out-of-hospital care to children requires an emergency medical services (EMS) system infrastructure designed to support the care of pediatric patients. As in the emergency department setting, it is important that all EMS agencies have the appropriate resources, including physician oversight, trained and competent staff, education, policies, medications, equipment, and supplies, to provide effective emergency care for children. Resource availability across EMS agencies is variable, making it essential that EMS medical directors, administrators, and personnel collaborate with outpatient and hospital-based pediatric experts, especially those in emergency departments, to optimize prehospital emergency care for children. The principles in the policy statement "Pediatric Readiness in Emergency Medical Services Systems" and this accompanying technical report establish a foundation on which to build optimal pediatric care within EMS systems and serve as a resource for clinical and administrative EMS leaders.

Pediatric Readiness in Emergency Medical Services Systems.

This is a joint policy statement from the American Academy of Pediatrics, American College of Emergency Physicians, Emergency Nurses Association, National Association of Emergency Medical Services Physicians, and National Association of Emergency Medical Technicians on pediatric readiness in emergency medical services systems.

Pediatric Readiness in Emergency Medical Services Systems.

This is a joint policy statement from the American Academy of Pediatrics, American College of Emergency Physicians, Emergency Nurses Association, National Association of Emergency Medical Services Physicians, and National Association of Emergency Medical Technicians on pediatric readiness in emergency medical services systems.

Pediatric Pain Management.

Nearly 20 years ago, standards were established for hospitals to assess and treat pain in all patients. Research continues to demonstrate evolving trends in the measurement and effective treatment of pain in children. Behavioral research demonstrating long-lasting effects of inadequate pain control during childhood supports the concepts of early and adequate pain control for children suffering from painful conditions in the acute care setting. The authors discuss pain concepts, highlighting factors specific to the emergency department, and include a review of evidence for pharmacologic and nonpharmacologic treatments.