Pediatric mental health emergency department visits from 2017 to 2022: A multicenter study.

BACKGROUND: The COVID-19 pandemic adversely affected children's mental health (MH) and changed patterns of MH emergency department (ED) utilization. Our objective was to assess how pediatric MH ED visits during the COVID-19 pandemic differed from expected prepandemic trends. METHODS: We retrospectively studied MH ED visits by children 5 to <18 years old at nine U.S. hospitals participating in the Pediatric Emergency Care Applied Research Network Registry from 2017 to 2022. We described visit length by time period: prepandemic (January 2017-February 2020), early pandemic (March 2020-December 2020), midpandemic (2021), and late pandemic (2022). We estimated expected visit rates from prepandemic data using multivariable Poisson regression models. We calculated rate ratios (RRs) of observed to expected visits per 30 days during each pandemic time period, overall and by sociodemographic and clinical characteristics. RESULTS: We identified 175,979 pediatric MH ED visits. Visit length exceeded 12 h for 7.3% prepandemic, 8.4% early pandemic, 15.0% midpandemic, and 19.2% late pandemic visits. During the early pandemic, observed visits per 30 days decreased relative to expected rates (RR 0.80, 95% confidence interval [CI] 0.78-0.84), were similar to expected rates during the midpandemic (RR 1.01, 95% CI 0.96-1.07), and then decreased below expected rates during the late pandemic (RR 0.92, 95% CI 0.86-0.98). During the late pandemic, visit rates were higher than expected for females (RR 1.10, 95% CI 1.02-1.20) and for bipolar disorders (RR 1.83, 95% CI 1.38-2.75), schizophrenia spectrum disorders (RR 1.55, 95% CI 1.10-2.59), and substance-related and addictive disorders (RR 1.50, 95% CI 1.18-2.05). CONCLUSIONS: During the late pandemic, pediatric MH ED visits decreased below expected rates; however, visits by females and for specific conditions remained elevated, indicating a need for increased attention to these groups. Prolonged ED visit lengths may reflect inadequate availability of MH services.

Physical restraint use in children with mental and behavioral health emergencies in the prehospital setting.

Objective: Emergency medical services (EMS) transport for mental and behavioral health (MBH) emergencies occurs frequently in children, yet little is understood regarding prehospital physical restraint use despite the potential for serious adverse events. We aim to describe restraint use prevalence and primary impressions among children with MBH emergencies. Methods: This is a retrospective cross-sectional study of children with MBH emergencies evaluated by Alameda County (ALCO), California EMS from January 1, 2012 to December 31, 2018. Patient demographics and clinical variables were collected from the EMS records including sex, age at time of encounter, year of encounter, transport destination, medication use, and primary impression(s). The primary outcome was the use of physical restraints. Descriptive statistics were used to characterize the primary outcome and associated demographic and diagnostic features, as well as temporal use patterns. Sex and age were compared between restrained and non-restrained youth using chi-square analysis. Results: Over the 7-year study period, ALCO EMS transported 9775 children with MBH emergencies. Of these transports, 1205 (12.3%) were physically restrained. Most children restrained had the primary impression of "behavioral/psychiatric crisis" (51.1%), "psychiatric crisis" (27.4%), and "behavioral-other" (12.4%) and the remaining children (9.1%) had a non-psychiatric/behavioral health primary impression. Over time, there was no statistically significant change in either number of children with MBH emergencies transported or physical restraint rate. Conclusions: More than 1 in 8 children with MBH emergencies are being physically restrained during EMS transport. Restraint rate did not substantially change over time. Further studies to understand existing restraint rates and EMS resources available to address acute agitation in children are needed to inform quality and care enhancing initiatives.

Safety of a prehospital emergency medical services protocol for an alternative destination for pediatric behavioral emergencies in Alameda County.

Background: Pediatric patients with behavioral health emergencies (BHEs) are often transported to an emergency department (ED) by emergency medical services (EMS), despite having no physical medical complaints, to await psychiatric evaluation and treatment. This process leads to significant delays in their care. We examined the safety of directly transporting pediatric patients with BHEs from the field to an alternative destination of a psychiatric emergency service (PES) facility using an EMS protocol. Methods: A retrospective review from November 1, 2011, to November 1, 2016, was conducted for pediatric EMS encounters using EMS data from Alameda County, California. Our primary outcome was the safety of a prehospital alternative destination protocol. We identified the proportion of patients who required retransport to an ED within 24 h after arriving at PES (defined as a failed diversion). We also describe the mortality of all patients being transported for a BHE. Results: There were 38,241 total pediatric encounters, with 20.1% for BHEs. A total of 3122 (41%) BHE encounters met protocol criteria and were transported directly to the PES. Only 16 (0.5%) patients had a secondary transport (failed diversion) to an ED within 24 h of arrival. No patients with a BHE transported to the PES died within 30 days of the EMS encounter. Conclusion: Death and adverse clinical outcomes are extremely rare in pediatric patients using a prehospital alternative destination protocol. This information could significantly improve the care of children with BHEs.

Paramedic use of the Physician Order for Life-Sustaining Treatment (POLST) for medical intervention and transportation decisions.

BACKGROUND: Physician Order for Life-Sustaining Treatment forms (POLST) exist in some format in all 50 states. The objective of this study is to determine paramedic interpretation and application of the California POLST for medical intervention and transportation decisions. METHODS: This study used a prospective, convenience sample of California Bay Area paramedics who reviewed six fictional scenarios of patients and accompanying mock POLST forms. Based on the clinical case and POLST, paramedics identified medical interventions that were appropriate (i.e. non-invasive positive pressure airway) as well as transportation decisions (i.e. non-transport to the hospital against medical advice). EMS provider confidence in their POLST interpretation was also assessed. RESULTS: There were 118 paramedic participants with a mean of 13.3 years of EMS experience that completed the survey. Paramedics routinely identified the selected medical intervention on a patients POLST correctly as either comfort focused, selective or full treatment (113-118;96%-100%). For many clinical scenarios, particularly when a patient's POLST indicated comfort focused treatment, paramedics chose to use online medical oversight through base physician contact (68-73;58%-62%). In one case, a POLST indicated "transport to hospital only if comfort needs cannot be met in current location", 13 (14%) paramedics elected to transport the patient anyway and 51 (43%) chose "Non-transport, Against Medical Advice". The majority of paramedics agreed or strongly agreed that they knew how to use a POLST to decide which medical interventions to provide (106;90%) and how to transport a patient (74;67%). However, after completing the cases, similar proportions of paramedics agreed (42;36%), disagreed (43;36%) or were neutral (30;25%) when asked if they find the POLST confusing. CONCLUSION: The POLST is a powerful tool for paramedics when caring patients with serious illness. Although paramedics are confident in their ability to use a POLST to decide appropriate medical interventions, many still find the POLST confusing particularly when making transportation decisions. Some paramedics rely on online medical oversight to provide guidance in challenging situations. Authors recommend further research of EMS POLST utilization and goal concordant care, dedicated paramedic POLST education, specific EMS hospice and palliative care protocols and better nomenclature for non-transport in order to improve care for patients with serious illness.

Emergency medical service interpretation of Physician Orders for Life-Sustaining Treatment (POLST) in cardiopulmonary arrest.

Objective: Physician Orders for Life-Sustaining Treatment (POLST) forms exist in some form in all 50 states. This study evaluates emergency medical service (EMS) practitioners interpretation of the POLST in cardiopulmonary arrest. Methods: This study used a prospective convenience sample of California Bay Area EMS practitioners who reviewed 6 fictional scenarios of patients in cardiopulmonary arrest and accompanying California POLST forms. Based on the cases and POLST, EMS practitioners identified patient preference for "attempt resuscitation," "do not attempt resuscitation/DNR," or "unsure" and subsequently selected medical interventions (ie, chest compressions, defibrillation, and so on). They also rated their confidence in POLST use and interpretation. Results: In scenarios of cardiopulmonary arrest and POLST that indicated do not resuscitate (DNR)/do not attempt resuscitation (DNAR) and full treatment, only 45%-65% of EMS practitioners correctly identified the patient as DNR/DNAR. EMS practitioners were more likely to interpret the POLST correctly in scenarios where patients were DNR/DNAR but indicated selective treatment (86%; 168/196) or comfort-focused treatment (86%; 169/196). In cardiopulmonary arrest scenarios where the patient was correctly identified as DNR/DNAR, EMS practitioners frequently selected defibrillation, advanced airway, or epinephrine as appropriate treatment. For all 6 scenarios, there was no statistical difference in response selection with level of training (emergency medical technician/paramedics) or type of EMS personnel (fire based/private). Conclusion: The POLST is a powerful tool to convey medical treatment preferences; however, there is significant variation in the interpretation and application by EMS practitioners. To improve the POLST effectiveness, the authors suggest more EMS input into POLST development, concise language that defines resuscitation, and more EMS education about clinical application.

EMS Experience Caring and Communicating with Patients and Families with a Life-Limiting-Illness.

Introduction: The emergency medical services (EMS) system was designed to reduce death and disability and EMS training focuses on saving lives through resuscitation, aggressive treatment and transportation to the emergency department. EMS providers commonly care for patients who have life-limiting illnesses. The objective was to explore EMS provider challenges, self-perceived roles and training experiences caring for patients and families with life-limiting illness. Methods: Qualitative content analysis of semi-structured interviews with EMS providers (n = 15) in Alameda County, CA. Purposive sampling was used to ensure a variety of perspectives including provider age, years of EMS experience, emergency medical technicians and paramedics, fire-based versus private, transport versus non-transporting. Recorded and transcribed interviews were analyzed using a thematic approach. Results: In their work with patients with life-limiting illness, participating EMS providers were interviewed and reported challenges for which their formal training had not prepared them: responding to grief and emotion expressed by families during traumatic events or death notification, and performing in the moment decision-making to determine the course of action after acute, unexpected, and traumatic events. Many participants reported becoming comfortable with grief counseling and death notification after acquiring some clinical experience. In the moment decision-making was eased when patients and families had had advance care planning discussions, however many patients, especially those from vulnerable and underserved populations, lacked advance care planning. In the face of situations where the course of action was not immediately clear, EMS providers voiced two frames for their role in caring for patients with life-limiting illness: transportation only ("transport people") versus a more "holistic" view, where EMS providers provided counseling and information about available resources. Conclusions: EMS providers interface with patients who have life-limiting illness and their families in the setting of traumatic events where the course of action is often unclear. There is an opportunity to provide formal training to EMS providers around grief counseling as well as how they can assist patients and families in in the moment decision-making to support previously identified goals and align care with patient goals and preferences.

Qualitative needs assessment for paediatric emergency care in Kampala, Uganda.

INTRODUCTION: Acute childhood illnesses, such as malaria, pneumonia, and diarrhoea, represent the leading causes of under-five mortality in Uganda. Given that most early child deaths are treatable with timely interventions, emergency units dedicated to paediatric populations have been established in the country. In light of recent developments, the department of paediatrics at Makerere University requested a needs assessment in the paediatric acute care unit (PACU) at Mulago National Referral Hospital, which could guide the development of a new training curriculum for medical providers. METHODS: We administered a survey for medical providers working in the PACU at Mulago Hospital, which assessed their self-rated comfort levels with paediatric assessment, treatment, and teamwork skills. We also conducted focus groups with a smaller subset of medical providers to understand barriers and facilitators to paediatric emergency and critical care. RESULTS: Of 35 paediatric assessment, treatment, and teamwork skills, 29 (83%) questions had the median comfort rating of 6 or 7 on a 7-point Likert scale. The remaining 6 (17%) skills had a median comfort rating of 5 or lower. Focus groups identified a number of major barriers to caring for critically ill children, including limited resources and staffing, training gaps, and challenges with interprofessional teamwork. In terms of training development, focus group participants suggested continuous training for all medical providers working in the PACU led by local leaders. DISCUSSION: This study identified the need and desirability of continuous trainings in the PACU. Key components include objective skills assessment, simulation-based scenarios, and interprofessional teamwork. Training development should be augmented by increases in resources, staffing, and training opportunities in collaboration with the Uganda Ministry of Health.

Pediatric Simulation-Based Prehospital Training Course in Botswana.

Audience: This simulation-based training focuses on the most common and high risk pediatric prehospital scenarios in low- and middle-income countries (LMIC). The curriculum was developed based on a needs assessment to train Ministry of Health and Wellness (MOHW) prehospital providers in Botswana specifically for pediatric resuscitation and could be used for emergency medical services (EMS) providers in other LMIC. After participating in this curriculum, providers should enhance their assessment and interventions in acutely ill pediatric prehospital patients. Length of Curriculum: The entire course was designed to be presented over two days with 6-8 hours of instruction each day. Introduction: In recent years, prehospital medicine has shown continued growth in LMICs, specifically in Sub-Saharan Africa. As these programs develop focused training for the pediatric population, equipping the workforce with pediatric resuscitation skills is essential. A few years after its inception, the Botswana MOHW identified deficiencies in their current training program and sought external expertise and educational training. We partnered with the MOHW to create and implement a novel, prehospital simulation curriculum to teach pediatric resuscitation to prehospital providers. Our aim was to create a curriculum based on the needs of the community that could also be implemented in other similar resource-limited settings. This course included didactic sessions, five simulation scenarios using low fidelity mannequins and three pediatric-focused skill sessions. This program was found to be effective based on statistically significant improvement in written and simulation post-test scores. Educational Goals: The objective of this educational project was to design, implement, and evaluate a curriculum relevant to an EMS system based in a LMIC, so that it could be a basis for curricula for use in similar contexts. The educational goal is to improve prehospital providers performance in common pediatric resuscitations. Educational Methods: The educational methods used in this curriculum included simulation using rapid cycle deliberate practice (RCDP), didactic lectures, and hands on skills training for common pediatric scenarios. Outcomes were measured by comparing performance on written and simulation-based pre-and post-tests. Research Methods: Participants completed written and simulation-based pre- and post-tests covering the concepts taught in the curriculum. Continuous variables (written and simulation test scores) were compared between two dependent groups (pre- and post-trainings) using paired t-tests. Results: Mean written test scores increased by 11%, from 75% to 86% (p<0.0001), while mean simulated test scores increased by 22% (from 56% to 78 % (p<0.0001). Discussion: The curriculum we developed focused on high-yield pediatric skills based on the needs of the Botswana MOHW EMS program. We believe simulation training was an excellent and effective method for this type of training. We specifically designed RCDP scenarios for the training, due to the limited experience of the prehospital providers at that time. RCDP offers ample opportunities for feedback with immediate practice and improvement. Trainees demonstrated retention of knowledge and improved performance in simulation-based testing. The overall satisfaction level of the trainees was high and suggests additional training would be beneficial and desired. Additionally, as the results of our needs assessment mirrored common chief complaints in other LMIC countries in Sub-Saharan Africa1,2 we feel that this curriculum can be utilized and adopted with minor modifications in other LMIC settings, particularly where EMS programs are developing and in circumstances where few EMS providers have had extensive field experience. Topics: Respiratory distress, asthma, dehydration, hypovolemic shock, hypoglycemia, seizure, toxic ingestion, newborn resuscitation, precipitous delivery, traumatic injury, EMS, Botswana, global health, collaboration, rapid cycle deliberate practice (RCDP), medical simulation.

Educational impact of a pilot paediatric simulation-based training course in Botswana.

Background: As emergency medical services (EMS) systems develop globally in resource-limited settings, equipping providers with paediatric training is essential. Low-fidelity simulation-based training is an effective modality for training healthcare workers, though limited data exist on the impact of such training programmes. The objective of this study was to evaluate the paediatric portion of a simulation-based curriculum for prehospital providers in Botswana. Methods: This was a prospective cohort study of EMS providers from more populated regions of Botswana, who attended a 2-day training that included didactic lectures, hands-on skills stations and low-fidelity simulation training. We collected data on participant self-efficacy with paediatric knowledge and skills and performance on both written and simulation-based tests. Self-efficacy and test data were analysed, and qualitative course feedback was summarised. Results: Thirty-one EMS providers participated in the training. Median self-efficacy levels increased for 13/15 (87%) variables queried. The most notable improvements were observed in airway management, newborn resuscitation and weight estimation. Mean written test scores increased by 10.6%, while mean simulation test scores increased by 21.5% (p<0.0001). One hundred per cent of the participants rated the course as extremely useful or very useful. Discussion/Conclusion: We have demonstrated that a low-fidelity simulation-based training course based on a rigorous needs assessment may enhance short-term paediatric knowledge and skills for providers in a developing EMS system in a limited-resource setting. Future studies should focus on studying larger groups of learners in similar settings, especially with respect to the impact of educational programmes like these on real-world patient outcomes.

Evaluating a Novel Simulation Course for Prehospital Provider Resuscitation Training in Botswana.

INTRODUCTION: In 2012, Botswana embarked on an organized public approach to prehospital medicine. One goal of the Ministry of Health (MOH) was to improve provider education regarding patient stabilization and resuscitation. Simulation-based instruction is an effective educational strategy particularly for high-risk, low-frequency events. In collaboration with partners in the United States, the team created a short, simulation-based course to teach and update prehospital providers on common field responses in this resource-limited setting. The objective of this study was to evaluate an educational program for Botswanan prehospital providers via written and simulation-based examinations. METHODS: We developed a two-day course based on a formal needs assessment and MOH leadership input. The subject matter of the simulation scenarios represented common calls to the prehospital system in Botswana. Didactic lectures and facilitated skills training were conducted by U.S. practitioners who also served as instructors for a rapid-cycle, deliberate practice simulation education model and simulation-based testing scenarios. Three courses, held in three cities in Botswana, were offered to off-duty MOH prehospital providers, and the participants were evaluated using written multiple-choice tests, videotaped traditional simulation scenarios, and self-efficacy surveys. RESULTS: Collectively, 31 prehospital providers participated in the three courses. The mean scores on the written pretest were 67% (standard deviation [SD], 10) and 85% (SD, 7) on the post-test (p < 0.001). The mean scores for the simulation were 42% (SD, 14.2) on the pretest and 75% (SD, 11.3) on the post-test (p < 0.001). Moreover, the intraclass correlation coefficient scores between reviewers were highly correlated at 0.64 for single measures and 0.78 for average measures (p < 0.001 for both). Twenty-one participants (68%) considered the course "extremely useful." CONCLUSION: Botswanan prehospital providers who participated in this course significantly improved in both written and simulation-based performance testing. General feedback from the participants indicated that the simulation scenarios were the most useful and enjoyable aspects of the course. These results suggest that this curriculum can be a useful educational tool for teaching and reinforcing prehospital care concepts in Botswana and may be adapted for use in other resource-limited settings.

Needs Assessment for Simulation Training for Prehospital Providers in Botswana.

BACKGROUND: In June 2012, the Botswana Ministry of Health and Wellness (MOHW; Gaborone, Botswana) initiated a national Emergency Medical Services (EMS) system in response to significant morbidity and mortality associated with prehospital emergencies. The MOHW requested external expertise to train its developing workforce. Simulation-based training was planned to equip these health care providers with clinical knowledge, procedural skills, and communication techniques. OBJECTIVE: The objective of this study was to assess the educational needs of the pioneer Botswana MOHW EMS providers based on retrospective EMS logbook review and EMS provider feedback to guide development of a novel educational curriculum. METHODS: Data were abstracted from a representative sample of the Gaborone, Botswana MOHW EMS response log from 2013-2014 and were quantified into the five most common call types for both adults and children. Informal focus groups with health professionals and EMS staff, as well as surveys, were used to rank common response call types and self-perceived educational needs. RESULTS: Based on 1,506 calls, the most common adult response calls were for obstetric emergencies, altered mental status, gastrointestinal/abdominal pain, trauma, gynecological emergencies, and cardiovascular and respiratory distress-related emergencies. The most common pediatric response calls were for respiratory distress, gastrointestinal complaints/dehydration, trauma and musculoskeletal injuries, newborn delivery, seizures, and toxic ingestion/exposure. The EMS providers identified these same chief complaints as priorities for training using the qualitative approach. A locally relevant, simulation-based curriculum for the Botswana MOHW EMS system was developed and implemented based on these data. CONCLUSIONS: Trauma, respiratory distress, gastrointestinal complaints, and puerperal/perinatal emergencies were common conditions for all age groups. Other age-specific conditions were also identified as educational needs based on epidemiologic data and provider feedback. This needs assessment may be useful when designing locally relevant EMS curricula in other low-income and middle-income countries. GlombNW, KosokoAA, DoughtyCB, RusMC, ShahMI, CoxM, GalapiC, ParkesPS, KumarS, LabaB. Needs assessment for simulation training for prehospital providers in Botswana. Prehosp Disaster Med. 2018;33(6):621-626.

Prioritising minimum standards of emergency care for children in resource-limited settings.

BACKGROUND: There is global variation in the ability of hospital-based emergency centres to provide paediatric emergency medicine (PEM) services. Although minimum standards have been proposed, they may not be applicable in resource-limited settings. OBJECTIVE: The goal was to identify reasonable minimum standards to provide safe and effective care for acutely ill children in resource-limited settings. METHODS: Using previously proposed standards from the International Federation of Emergency Medicine (IFEM), a modified Delphi approach was used to reach agreement regarding minimum standards for PEM in resource-limited settings. Three rounds of surveys were electronically distributed to physicians working in resource-limited settings. Those standards with >67% agreement advanced to the subsequent round. RESULTS: The categories of the surviving criteria included integrated service design, child and family-friendly care, initial assessment of the ill child, stabilising and treating an ill child, staff training and competence, equipment, supplies and medications, quality and safety, child protection, and advanced training and academic research. CONCLUSIONS: Experts with experience in acute care of children in resource-limited settings have prioritised standards for paediatric emergency care. They identified 26 variables in nine domains from the original IFEM list of standards and two additional free text standards for the care of acutely ill children. This list may serve as a helpful guide for emergency centres to provide medical treatment for acutely ill children in resource-limited settings.