Epidemiology of out-of-hospital pediatric airway management in the 2019 national emergency medical services information system data set.

OBJECTIVE: Airway management is an important priority in the care of critically ill children. We sought to provide updated estimates of the epidemiology of pediatric out-of-hospital airway management and ventilation interventions in the United States. METHODS: We used data from the 2019 National Emergency Medical Services Information System (NEMSIS) data set. We performed a descriptive analysis of all patients < 18 years receiving one or more of the following: bag-valve-mask ventilation (BVM), tracheal intubation (TI), supraglottic airway (SGA) insertion, continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP) and surgical airway placement. We determined success and complication rates for each airway procedure. RESULTS: Among 1,148,943 pediatric patient care encounters, airway and ventilation interventions occurred in 22,637 (1,970 per 100,000 pediatric Emergency Medical Services (EMS) activations), including 64% <11 years old, 56.1% male, 16.9% cardiac arrest, 16.6% injured, and 83.9% in urban areas. Airway interventions included: BVM 3,997 (17.7% of pediatric airway encounters), TI 3,165 (14.0%), SGA 582 (2.6%), CPAP/BiPAP 331 (1.5%) and surgical airway 29 (0.1%). TI success was 75.2% (95% CI 73.7-76.7%) and lowest for the 0-1 month age group (56.8%; 49.2-64.2%). SGA success was 88.0% (95% CI 85.1-90.6%). Vomiting was the most common airway complication (n = 223, 1%). CONCLUSIONS: BVM and advanced airway management occur in 1 of every 51 pediatric EMS encounters. BVM is the most commonly prehospital pediatric airway management technique, followed by TI and SGA insertion. These data provide contemporary perspectives of pediatric prehospital airway management.

Critical Factors in Planning a Pediatric Prehospital Airway Trial.

Objective: The objective of this study was to assess factors influencing the design of a pediatric prehospital airway management trial, including minimum clinically significant differences for three clinical subgroups. Methods: We conducted a virtual consensus-conference among U.S. emergency medical services (EMS) agency medical directors and researchers in the Fall of 2020. This included (1) a preconference survey, (2) an interactive live videoconference, and (3) a postconference survey. Participants were identified through co-investigator relationships and by surveying "The Eagles," a consortium of medical directors from large urban EMS systems and, subsequently, through follow up email contact based on survey responses. Results: Twenty-seven of the 34 (80%) EMS agencies we invited responded to the prewebinar survey. Of the 27 agencies, 27 (100%) use BMV, 19 (70%) use endotracheal intubation (ETI), 21 (78%) use supraglottic airways (SGA). SGA use included 14 (52%) who use the iGel, 8 (30%) who use the King laryngeal tube (LT), and 2 (7%) who use a laryngeal mask airway (LMA). Three agencies use more than one of the available SGAs. Twenty (74%) of the EMS agencies indicated they had access to an SGA suitable for pediatric patients, and 9 (33%) agencies have access to pediatric video laryngoscopy. The majority of agencies indicated that the minimum clinically significant difference for survival to change practice was 1% for cardiac arrest patients with a baseline survival assumption of 7%, 4% for respiratory failure with a baseline survival assumption of 73%, and 3% for trauma with a baseline survival assumption of 42%. Overall, these agencies responded that BVM vs. SGA is the most important comparison that would change their practice. Conclusions: This virtual consensus conference provided a new perspective on current airway management practice and identified specific factors likely to drive change in pediatric prehospital airway management. This information will be leveraged in future trial design to ensure impactful clinical trials.

The Effects of Leadership Curricula With and Without Implicit Bias Training on Graduate Medical Education: A Multicenter Randomized Trial.

PURPOSE: To determine whether a brief leadership curriculum including high-fidelity simulation can improve leadership skills among resident physicians. METHOD: This was a double-blind, randomized controlled trial among obstetrics-gynecology and emergency medicine (EM) residents across 5 academic medical centers from different geographic areas of the United States, 2015-2017. Participants were assigned to 1 of 3 study arms: the Leadership Education Advanced During Simulation (LEADS) curriculum, a shortened Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) curriculum, or as active controls (no leadership curriculum). Active controls were recruited from a separate site and not randomized to limit any unintentional introduction of materials from leadership curricula. The LEADS curriculum was developed in partnership with the Council on Resident Education in Obstetrics and Gynecology and Council of Residency Directors in Emergency Medicine as a novel way to provide a leadership toolkit. Both LEADS and the abbreviated TeamSTEPPS were designed as six 10-minute interactive web-based modules.The primary outcome of interest was the leadership performance score from the validated Clinical Teamwork Scale instrument measured during standardized high-fidelity simulation scenarios. Secondary outcomes were 9 key components of leadership from the detailed leadership evaluation measured on 5-point Likert scales. Both outcomes were rated by a blinded clinical video reviewer. RESULTS: One hundred ten obstetrics-gynecology and EM residents participated in this 2-year trial. Participants in both LEADS and TeamSTEPPS had statistically significant improvement in leadership scores from "average" to "good" ranges both immediately and at the 6-month follow-up, while controls remained unchanged in the "average" category throughout the study. There were no differences between LEADS and TeamSTEPPS curricula with respect to the primary outcome. CONCLUSIONS: Residents who participated in a brief structured leadership training intervention had improved leadership skills that were maintained at 6-month follow-up.

An international survey of healthcare workers use of personal protective equipment during the early stages of the COVID-19 pandemic.

OBJECTIVE: Little is known regarding the specific ways personal protective equipment (PPE) has been used and reused during the coronavirus disease 2019 (COVID-19) pandemic. The objective of this study was to evaluate the patterns of PPE use and the impact of PPE availability on the attitudes and well-being of an international population of healthcare workers. METHODS: This was an online, cross-sectional survey of healthcare workers. The survey was disseminated internationally using social media, specialty society list-serves, and email augmented by snowball sampling to healthcare workers who provided direct care to patients with suspected or confirmed COVID-19. The survey was conducted between April 13 and May 1, 2020. The primary outcome was self-reported PPE use during aerosol-generating medical procedures. Other outcomes included PPE use during care for respiratory patients in general, PPE reuse, PPE decontamination, and healthcare worker impressions related to their work and the pandemic. RESULTS: A total of 2227 healthcare workers from 23 countries completed the survey. The N95 was the most common respirator among the 1451 respondents who performed aerosol-generating procedures (n = 1050, 72.3%). Overall, 1783 (80.1%) of providers reported general reuse of PPE, which was similar across US regions but less common in Canada, Italy, and Spain. The most commonly reused item of PPE was the N95 respirator, with the majority of respondents who reused PPE reporting N95 reuse (n = 1157, 64.9%). Of the 1050 individuals who wore an N95 mask while performing an aerosol-generating medical procedure, 756 (72%) reported re-using an N95, and 344 (45.5%) reported reuse for >3 days. Qualitative results identified several common themes, including (1) lack of availability of PPE, (2) fear and anxiety as a result of inadequate PPE, (3) potential exposure to family members, and (4) concerns regarding workload and pay. CONCLUSIONS: This international survey of healthcare workers found that N95 respirators were commonly used to care for patients with respiratory symptoms with and without aerosol-generating medical procedures. Healthcare workers reported an unprecedented need to reuse PPE that was designed for single-use, specifically the N95 respirator. The reuse of PPE increased the perceived risk for COVID-19 infection and harmed mental health.

Factors associated with parents' willingness to enroll their children in trials for COVID-19 vaccination.

The coronavirus disease 2019 (COVID-19) pandemic has taken an unprecedented global toll and vaccination is needed to restore healthy living. Timely inclusion of children in vaccination trials is critical. We surveyed caregivers of children seeking care in 17 Emergency Departments (ED) across 6 countries during the peak of the pandemic to identify factors associated with intent to participate in COVID-19 vaccine trials. Questions about child and parent characteristics, COVID-19 expressed concerns and parental attitudes toward participation in a trial were asked.Of 2768 completed surveys, 18.4% parents stated they would enroll their child in a clinical trial for a COVID-19 vaccine and 14.4% would agree to a randomized placebo-controlled study. Factors associated with willingness to participate were parents agreeing to enroll in a COVID-19 vaccine trial themselves (Odds Ratio (OR) 32.9, 95% Confidence Interval (CI) (21.9-51.2)) having an older child (OR 1.0 (1.0-1.01)), having children who received all vaccinations based on their country schedule (OR 2.67 (1.35-5.71)) and parents with high school education or lower (OR 1.79 (1.18-2.74)). Mothers were less likely to enroll their child in a trial (OR 0.68 (0.47-0.97)). Only one fifth of families surveyed will consider enrolling their child in a vaccine trial. Parental interest in participation, history of vaccinating their child, and the child being older all are associated with parents allowing their child to participate in a COVID vaccine trial. This information may help decision-makers and researchers shape their strategies for trial design and participation engagement in upcoming COVID19 vaccination trials.

Retrospective chart review and survey to identify adverse safety events in the emergency medical services care of children with out-of-hospital cardiac arrest in the USA: a study protocol.

INTRODUCTION: Efforts to improve the quality of emergency medical services (EMS) care for adults with out-of-hospital cardiac arrest (OHCA) have led to improved survival over time. Similar improvements have not been observed for children with OHCA, who may be at increased risk for preventable adverse safety events during prehospital care. The purpose of this study is to identify patient and organisational factors that are associated with adverse safety events during the EMS care of paediatric OHCA. METHODS AND ANALYSIS: This is a large multisite EMS study in the USA consisting of chart reviews and agency surveys to measure, characterise and evaluate predictors of our primary outcome severe adverse safety events in paediatric OHCA. Using the previously validated Paediatric prehospital adverse Event Detection System tool, we will review EMS charts for 1500 children with OHCA from 2013 to 2019 to collect details of each case and identify severe adverse safety events (ASEs). Cases will be drawn from over 40 EMS agencies in at least five states in geographically diverse areas of the USA. EMS agencies providing charts will also be invited to complete an agency survey to capture organisational characteristics. We will describe the frequency and proportion of severe ASEs in paediatric OHCA across geographic regions and clinical domains, and identify patient and EMS organisational characteristics associated with severe ASEs using logistic regression. ETHICS AND DISSEMINATION: This study has been approved by the Oregon Health & Science University Institutional Review Board (IRB Approval# 00018748). Study results will be disseminated through scientific publications and presentations, and to EMS leaders and staff through local EMS medical directors, quality and training officers and community engagement activities.

Caregiver willingness to vaccinate their children against COVID-19: Cross sectional survey.

BACKGROUND: More than 100 COVID-19 vaccine candidates are in development since the SARS-CoV-2 genetic sequence was published in January 2020. The uptake of a COVID-19 vaccine among children will be instrumental in limiting the spread of the disease as herd immunity may require vaccine coverage of up to 80% of the population. Prior history of pandemic vaccine coverage was as low as 40% among children in the United States during the 2009 H1N1 influenza pandemic. PURPOSE: To investigate predictors associated with global caregivers' intent to vaccinate their children against COVID-19, when the vaccine becomes available. METHOD: An international cross sectional survey of 1541 caregivers arriving with their children to 16 pediatric Emergency Departments (ED) across six countries from March 26 to May 31, 2020. RESULTS: 65% (n = 1005) of caregivers reported that they intend to vaccinate their child against COVID-19, once a vaccine is available. A univariate and subsequent multivariate analysis found that increased intended uptake was associated with children that were older, children with no chronic illness, when fathers completed the survey, children up-to-date on their vaccination schedule, recent history of vaccination against influenza, and caregivers concerned their child had COVID-19 at the time of survey completion in the ED. The most common reason reported by caregivers intending to vaccinate was to protect their child (62%), and the most common reason reported by caregivers refusing vaccination was the vaccine's novelty (52%). CONCLUSIONS: The majority of caregivers intend to vaccinate their children against COVID-19, though uptake will likely be associated with specific factors such as child and caregiver demographics and vaccination history. Public health strategies need to address barriers to uptake by providing evidence about an upcoming COVID-19 vaccine's safety and efficacy, highlighting the risks and consequences of infection in children, and educating caregivers on the role of vaccination.

Prospective evaluation of airway management in pediatric out-of-hospital cardiac arrest.

OBJECTIVE: The objective of the study was to identify the association between airway management modality and time to the initial dose of epinephrine in pediatric out-of-hospital cardiac arrest (OHCA). METHODS: This was a prospective observational study conducted between April 2016 to April 2018. Ten Emergency Medical Services (EMS) agencies in 2 US metropolitan areas, which were part of the Resuscitation Outcomes Consortium research network, participated in the study. We included all EMS-treated OHCA patients less than 18 years of age during the study period. Study outcomes included time to the initial dose of epinephrine, airway management success rates, rescue techniques, and complications (e.g. pneumothorax, pneumonia). RESULTS: The study included a total of 155 patients, 67% were male, and 55% were less than age one. The airway management modality (TI, SGA, BMV) was not associated with the time to the intial dose of epinephrine in the adjusted analysis. Tracheal intubation (TI) was the most common airway management modality (47.1%) followed by bag-mask-ventilation (BMV) (40.7%), and supraglottic airways (SGA) (12.3%). Success was 65.7% for TI and 94.7% for SGA. We found a significant difference in the proportion of initial survivors diagnosed with pneumonia on chest X-ray between those with BMV (1/19) versus TI (13/21) p < 0.001. CONCLUSIONS: In this prospective study, the airway management modality was not associated with the time to the initial dose of epinephrine. Unexpectedly, pneumonia was significantly more common among children treated with TI compared to BMV. SGAs had high first-attempt success rates, while intubation success rates were low.

Racial disparities in out-of-hospital cardiac arrest interventions and survival in the Pragmatic Airway Resuscitation Trial.

BACKGROUND: Prior studies have reported racial disparities in survival from out-of-hospital cardiac arrest (OHCA). However, these studies did not evaluate the association of race with OHCA course of care and outcomes. The purpose of this study was to evaluate racial disparities in OHCA airway placement success and patient outcomes in the multicenter Pragmatic Airway Resuscitation Trial (PART). METHOD: We conducted a secondary analysis of adult OHCA patients enrolled in PART. The parent trial randomized subjects to initial advanced airway management with laryngeal tube or endotracheal intubation. For this analysis, the primary independent variable was patient race categorized by emergency medical services (EMS) as white, black, Hispanic, other, and unknown. We used general estimating equations to examine the association of race with airway attempt success, 72-h survival, and survival to hospital discharge, adjusting for sex, age, witness status, bystander cardiopulmonary resuscitation (CPR), initial rhythm, arrest location, and PART randomization cluster. RESULTS: Of 3002 patients, EMS-assessed race as 1537 white, 860 black, 163 Hispanic, 90 other, and 352 unknown. Initial shockable rhythms (13.8% vs. 21.5%, p < 0.001), bystander CPR (35.6% vs. 51.4%, p < 0.001), and survival to hospital discharge (7.6% vs. 10.8%, p = 0.011) were lower for black compared to white patients. After adjustment for confounders, no difference was seen in airway success, 72-h survival, and survival to hospital discharge by race. CONCLUSIONS: In one of the largest studies evaluating differences in prehospital airway interventions and outcomes by EMS-assessed race for OHCA patients, we found no significant adjusted differences between airway success or survival outcomes.

Outcomes With the Use of Bag-Valve-Mask Ventilation During Out-of-hospital Cardiac Arrest in the Pragmatic Airway Resuscitation Trial.

BACKGROUND: While emergency medical services (EMS) often use endotracheal intubation (ETI) or supraglottic airways (SGA), some patients receive only bag-valve-mask (BVM) ventilation during out-of-hospital cardiac arrests (OHCA). Our objective was to compare patient characteristics and outcomes for BVM ventilation to advanced airway management (AAM) in adults with OHCA. METHODS: Using data from the Pragmatic Airway Resuscitation Trial, we identified patients receiving AAM (ETI or a SGA), BVM ventilation only (BVM-only), and BVM ventilation as a rescue after at least one failed attempt at advanced airway placement (BVM-rescue). The outcomes were return of spontaneous circulation (ROSC), 72-hour survival, survival to hospital discharge, neurologically intact survival (Modified Rankin Scale ≤ 3), and the presence of aspiration on a chest radiograph. Comparisons were made using generalized mixed-effects models while adjusting for age, sex, initial rhythm, EMS-witnessed status, bystander cardiopulmonary resuscitation, response time, study cluster, and advanced life support first on scene. RESULTS: Of 3,004 patients enrolled, there were 282 BVM-only, 2,129 AAM, and 156 BVM-rescue patients with complete covariates. Shockable initial rhythms (34% vs. 18.6%) and EMS-witnessed arrests (21.6% vs. 11.3%) were more likely in BVM-only than AAM but similar between BVM-rescue and AAM. Compared to AAM, BVM-only patients had similar ROSC (odds ratio [OR] = 1.29, 95% confidence interval [CI] = 0.96 to 1.73), but higher 72-hour survival (OR = 1.96, 95% CI = 1.42 to 2.69), survival to discharge (OR = 4.47, 95% CI = 3.03 to 6.59), and neurologically intact survival (OR = 7.05, 95% CI = 4.40 to 11.3). Compared to AAM, BVM-rescue patients had similar ROSC (OR = 0.73, 95% CI = 0.47 to 1.12) and 72-hour survival (OR = 1.08, 95% CI = 0.66 to 1.77) but higher survival to discharge (OR = 2.15, 95% CI = 1.17 to 3.95) and neurologically intact survival (OR = 2.64, 95% CI = 1.20 to 5.81). Aspiration incidence was similar. CONCLUSIONS: Bag-valve-mask-only ventilation is associated with improved OHCA outcomes. Despite similar rates of ROSC and 72-hour survival, BVM-rescue ventilation was associated with improved survival to discharge and neurologically intact survival compared to successful AAM.

Vital sign monitoring during out-of-hospital pediatric advanced airway management.

OBJECTIVE: To evaluate physiologic monitoring in pediatric patients undergoing out-of-hospital advanced airway management. METHODS: Retrospective case series of pediatric patients (<18 years) with advanced airways placed in the out-of-hospital setting. Patients given cardiopulmonary resuscitation (CPR) or defibrillation before the first advanced airway attempt were excluded. Reviewers abstracted physiologic data from the patient monitor files and patient care reports. The primary outcome was the proportion of time pulse oximetry was in place during airway management. Other outcomes included the proportion of time ECG monitoring and waveform end-tidal capnography were in place as well as the incidence of oxygen desaturation events. RESULTS: We evaluated 23 pediatric patients with a mean age of 10.7 years (SD 6.5). Eleven of 18 (61%) children with medication-facilitated intubation had pulse oximetry in place when the first medication was documented as given. Eight of 18 (44%) had ECG monitoring, 12 of 18 (66%) had waveform capnography, and 5 of 18 (28%) had a blood pressure check within the 3 minutes before receiving the first medication. In the 3-minute preoxygenation phase, pulse oximetry was in place for an average of 1.4 minutes (47%, SD 0.37) and a visible photoplethysmogram (PPG) waveform obtained from the pulse oximeter was present for 0.6 minutes (20%, SD 0.34). During airway device placement, pulse oximetry was in place 73% (SD 0.39) of the time and 30% (SD 0.41) of the time there was a visible PPG waveform. CONCLUSIONS: Pediatric patients had critical deficits in physiologic monitoring during advanced airway management.

Association between measured teamwork and medical errors: an observational study of prehospital care in the USA.

OBJECTIVES: The goal of this study was to examine the relationship between measured teamwork and adverse safety events in the prehospital emergency care of children using high-fidelity simulation. We posit that non-technical skills such as leadership, teamwork, situation awareness and decision-making are associated with the clinical success of teams. DESIGN: Observational study. SETTING: Emergency medical services (EMS) responders were recruited from public fire and private transport agencies in Oregon State to participate in four simulations of paediatric emergencies using high-fidelity patient simulators, scene design, and professional actors playing parents and bystanders. PARTICIPANTS: Forty-four fire/transport teams consisting of 259 EMS professionals consented to participate and completed simulations. PRIMARY AND SECONDARY OUTCOME MEASURES: Teams were assessed using the Clinical Teamwork Scale (CTS), a validated instrument that measures overall teamwork and 15 specific elements in five overarching domains: communication, decision-making, role responsibility (leadership and followership), situational awareness/resource management and patient-friendliness. We used generalised estimating equations to estimate the odds of error with increasing overall CTS teamwork score while adjusting for clinical scenario and potential clustering by team. RESULTS: Across 176 simulations, the mean overall score on the CTS was 6.04 (SD 2.10; range 1=poor to 10=perfect) and was normally distributed. The distribution of scores was similar across the four clinical scenarios. At least one error was observed in 82% of the simulations. In simulations with at least one observed error, the mean CTS score was 5.76 (SD 2.04) compared with 7.16 (SD 1.95) in scenarios with no observed error. Logistic regression analysis accounting for clustering at the team level revealed that the odds of an error decreased 28% with each unit increase in CTS (OR 0.72, 95% CI 0.59 to 0.88). CONCLUSIONS: This study found that overall teamwork among care delivery teams was strongly associated with the risk of serious adverse events in simulated scenarios of caring for critically ill and injured children.

Implicit gender bias among US resident physicians.

BACKGROUND: The purpose of this study was to characterize implicit gender bias among residents in US Emergency Medicine and OB/GYN residencies. METHODS: We conducted a survey of all allopathic Emergency Medicine and OB/GYN residency programs including questions about leadership as well as an implicit association test (IAT) for unconscious gender bias. We used descriptive statistics to analyze the Likert-type survey responses and used standard IAT analysis methods. We conducted univariate and multivariate analyses to identify factors that were associated with implicit bias. We conducted a subgroup analysis of study sites involved in a multi-site intervention study to determine if responses were different in this group. RESULTS: Overall, 74% of the programs had at least one respondent. Out of 14,234 eligible, 1634 respondents completed the survey (11.5%). Of the five sites enrolled in the intervention study, 244 of 359 eligible residents completed the survey (68%). Male residents had a mean IAT score of 0.31 (SD 0.23) and females 0.14 (SD 0.24), both favoring males in leadership roles and the difference was statistically significant (p < 0.01). IAT scores did not differ by postgraduate year (PGY). Multivariable analysis of IAT score and participant demographics confirmed a significant association between female gender and lower IAT score. Explicit bias favoring males in leadership roles was associated with increased implicit bias favoring males in leadership roles (r = 0.1 p < 0.001). CONCLUSIONS: We found that gender bias is present among US residents favoring men in leadership positions, this bias differs between male and female residents, and is associated with discipline. Implicit bias did not differ across training years, and is associated with explicit bias.

Global humid tropics forest structural condition and forest structural integrity maps.

Remotely sensed maps of global forest extent are widely used for conservation assessment and planning. Yet, there is increasing recognition that these efforts must now include elements of forest quality for biodiversity and ecosystem services. Such data are not yet available globally. Here we introduce two data products, the Forest Structural Condition Index (SCI) and the Forest Structural Integrity Index (FSII), to meet this need for the humid tropics. The SCI integrates canopy height, tree cover, and time since disturbance to distinguish short, open-canopy, or recently deforested stands from tall, closed-canopy, older stands typical of primary forest. The SCI was validated against estimates of foliage height diversity derived from airborne lidar. The FSII overlays a global index of human pressure on SCI to identify structurally complex forests with low human pressure, likely the most valuable for maintaining biodiversity and ecosystem services. These products represent an important step in maturation from conservation focus on forest extent to forest stands that should be considered "best of the last" in international policy settings.

Effect of initial airway strategy on time to epinephrine administration in patients with out-of-hospital cardiac arrest.

INTRODUCTION: Epinephrine and advanced airway management are commonly used during treatment of out-of-hospital cardiac arrest (OHCA). Recent studies suggest that early but not late administration of epinephrine is associated with improved survival. The purpose of this study was to evaluate the effect of initial airway strategy on timing to the first epinephrine dose in OHCA. METHODS: This is a secondary analysis of patients enrolled in the Pragmatic Airway Resuscitation Trial who had an advanced airway attempted. We examined differences in time to epinephrine administration by randomly assigned airway strategy, laryngeal tube (LT) or endotracheal tube (ETI); by the duration of airway attempt; and by number of attempts. We used survival methods to account for interval censoring due to unknown administration time. We also examined the association of epinephrine administration timing with survival to hospital discharge. RESULTS: Among 2652 subjects (1299 ETI and 1353 LT), 2579 received epinephrine.There were no significant differences between ETI and LT in median time to initial epinephrine administration (min) (ETI - 9.0 vs. LT - 8.6, p = 0.55). There was no significant association between the duration of airway attempt or number of attempts and time to initial epinephrine administration (p = 0.12 and 0.66, respectively). Early administration of epinephrine (<10 min from EMS arrival) was significantly associated with survival compared to administration ≥10 min (OR 1.36, 95% CI: 1.05, 1.77). CONCLUSIONS: There was no significant association between airway strategy and time to initial epinephrine administration. Earlier administration of epinephrine (< 10 min from EMS arrival) was associated with improved survival.

Emergency Medical Services Provider Pediatric Adverse Event Rate Varies by Call Origin.

OBJECTIVE: Emergency medical services providers may be called to a variety of sites to transport pediatric patients, whether it be a scene call for initial evaluation and care, a clinic for transportation of a patient who has been assessed by medical providers, or a hospital where assessment and stabilization have already begun. We hypothesize that there may be a direct relationship between adverse event rates and adverse event severity in transports from less medically stabilizing origins. METHODS: Emergency medical services records of all critical pediatric transports in an urban Oregon county in 2011 were reviewed and abstracted using a standardized tool. From this, UNSEMs (unintended injury, near miss, suboptimal action, error, management complication) were determined, and the potential severity of the issue was assessed. Then, UNSEMs were compared with the origin of transport using logistic regression. RESULTS: Four hundred ninety records were abstracted: 59 hospital transports, 48 clinic transports, and 384 scene transports. Furthermore, UNSEMs were noted in 24 hospital transports (40.7%), 33 clinic transports (68.8%), and 263 scene transports (68.5%). Severe UNSEMs were reported on 0 hospital transports (0.0%), 12 clinic transports (25.0%), and 65 scene transports (16.9%). The odds ratio of UNSEM occurrence from a hospital compared with nonmedical scenes was 0.35 (95% confidence interval, 0.20-0.60), and the odds ratio of a severe UNSEM from a hospital compared with nonmedical scenes was 0.09 (95% confidence interval, 0.01-0.63). CONCLUSIONS: In conclusion, UNSEMs involving the emergency medical services care of children are more likely to occur when transport originates from a clinic or scene compared with a hospital.

Safety events in pediatric out-of-hospital cardiac arrest.

OBJECTIVE: The objective of this study was to explore the types of patient safety events that take place during pediatric out-of-hospital cardiac arrest resuscitation. METHODS: Retrospective medical record review from a single large urban EMS system of EMS-treated pediatric (<18years of age) out-of-hospital cardiac arrests (OHCA) occurring between 2008 and 2011. A chart review tool was developed for this project and each chart was reviewed by a multidisciplinary review panel. Safety events were identified in the following clinical domains: resuscitation; assessment, impression/diagnosis, and clinical decision making; airway/breathing; fluids and medications; procedures; equipment; environment; and system. RESULTS: From a total of 497 critical transports during the study period, we identified 35 OHCA cases (7%). A total of 87% of OHCA cases had a safety event identified. Epinephrine overdoses were identified in 31% of the OHCA cases, most of which were 10-fold overdoses. Other medication errors included failure to administer epinephrine when indicated and administration of atropine when not indicated. In 20% of OHCA cases, 3 or more intubation attempts took place or intubation attempts were ultimately not successful. Lack of end-tidal C02 use for tube confirmation was also common. The most common arrest algorithm errors were placing an advanced airway too early (before administration of epinephrine) and giving a medication not included in the algorithm, primarily atropine, both occurring in almost 1/3 of cases. CONCLUSIONS: Safety events were common during pediatric OHCA resuscitation especially in the domains of medications, airway/breathing, and arrest algorithms.

Safety Events in High Risk Prehospital Neonatal Calls.

OBJECTIVE: The objective of this study was to quantify and characterize patient safety events during high-risk neonatal transports in the prehospital setting. METHOD: We conducted a retrospective chart review of all "lights and sirens" ambulance transports of neonates ≤30 days old over a four-year period in a metropolitan area. Each case was independently reviewed for potential patient safety events that may have occurred in clinical assessment and decision making, resuscitation, airway management, fluid or medication administration, procedures performed, and/or equipment used. RESULTS: Twenty-six patients ≤30 days old were transported by ambulance using lights and sirens during the four-year study period. Overall, safety events occurred in 19 patients and severe safety events (potentially causing permanent injury or harm, including death) occurred in ten. The incidence of safety events related to medication administrations was 90% (70% severe), resuscitation 64.7% (47.1% severe), procedures 64.7% (35.3% severe), fluid administration 50% (25% severe), clinical assessment and decision making 50% (30.8% severe), airway management 47.6% (28.6% severe), equipment use 25.5% (10.0% severe), and systems processes 19.2% (7.7% severe). CONCLUSIONS: High-risk neonatal calls are infrequent and prone to a high incidence of serious patient safety events.

An Ecoregion-Based Approach to Protecting Half the Terrestrial Realm.

We assess progress toward the protection of 50% of the terrestrial biosphere to address the species-extinction crisis and conserve a global ecological heritage for future generations. Using a map of Earth's 846 terrestrial ecoregions, we show that 98 ecoregions (12%) exceed Half Protected; 313 ecoregions (37%) fall short of Half Protected but have sufficient unaltered habitat remaining to reach the target; and 207 ecoregions (24%) are in peril, where an average of only 4% of natural habitat remains. We propose a Global Deal for Nature-a companion to the Paris Climate Deal-to promote increased habitat protection and restoration, national- and ecoregion-scale conservation strategies, and the empowerment of indigenous peoples to protect their sovereign lands. The goal of such an accord would be to protect half the terrestrial realm by 2050 to halt the extinction crisis while sustaining human livelihoods.