Emergency department pediatric mental and behavioral health patients transported by EMS and police: Trends and interventions.

OBJECTIVE: We aimed to understand transport utilization trends, demographics, Emergency Department (ED) interventions, and outcomes of pediatric mental and behavioral health (MBH) patients transported by emergency medical services (EMS), police, or self-transported. METHODS: This retrospective cohort study utilized electronic health record data from patients aged 5-18 years presenting with acute MBH conditions at two affiliated pediatric EDs from January 2012 to December 2020. Data included demographics, ED interventions for aggression/agitation, Brief Rating of Aggression by Children and Adolescents (BRACHA) scores, and ED dispositions. Descriptive statistics and comparative analyses were conducted using Chi-square, Wilcoxon rank sum tests, and multivariable logistic regression. Linear regression analyzed trends. RESULTS: Of 440,302 ED encounters, 70,557 (16%) were for acute MBH concerns, with 14.6% transported by EMS and 5.9% by police. The proportion of MBH visits increased from 9.9% in 2012 to 19.8% in 2020 (95% CI [0.7, 1.7], p = 0.0009), with a concurrent 0.4% annual increase in those transported by EMS (95% CI [0.2, 0.6], p = 0.006). MBH patients transported by EMS and police had significantly higher odds of requiring restraint in the ED and were more likely to have higher BRACHA scores, and to be admitted compared to self-transported patients (all comparisons p < 0.001). CONCLUSIONS: Pediatric MBH ED visits and EMS utilization are increasing. MBH patients transported by EMS and police may represent a more aggressive ED population. Given the rising encounters within this high-risk population, our EDs, EMS, and police need support and resources for safe pediatric MBH patient management. WHAT'S NEW: With higher numbers of pediatric mental and behavioral health (MBH) patients transported by EMS or police requiring ED interventions for agitation/aggression, this study reveals insights into their high-acuity. Notably unique, it includes pediatric MBH patients transported by police.

A Dedicated Outpatient Pharmacy Improves Access to Discharge Medications in a Pediatric Emergency Department: A Quality Improvement Study.

STUDY OBJECTIVE: Following discharge from a pediatric emergency department (ED) or urgent care, many families do not pick up their prescribed medications. The aim of this quality improvement study was to increase the percentage of patients discharged home with medications in-hand from 6% to 30% within 6 months. METHODS: Due to the planned construction of a new ED, urgent care, and dedicated pharmacy, a multidisciplinary team was formed to increase access to discharge medications. We performed a pilot study in the urgent care to improve the discharge prescription process and expanded its scope to the ED. We evaluated the effect of our interventions on the percentage of patients discharged with medications in-hand through statistical process control charts. Process measures included the percentage of prescriptions electronically prescribed and directed to an on-site pharmacy. RESULTS: Between June 21, 2021 and March 27, 2022, 7,678 patients were discharged with at least 1 medication in-hand. The percentage of patients discharged with medications in-hand increased from 6.2% to 60.6%. The percentage of prescriptions e-prescribed and directed to an on-site pharmacy increased to 94.6% and 65.6% respectively. CONCLUSIONS: In this study, the availability of a 24-hour on-site pharmacy appears to be the most impactful intervention increasing access to discharge medications for families. Other interventions, such as a pilot study in the urgent care and implementing default electronic prescribing, may have potentiated the effect of the new pharmacy.

Impact of Race and Ethnicity on Emergency Medical Services Administration of Opioid Pain Medications for Injured Children.

BACKGROUND: Treatment with analgesics for injured children is often not provided or delayed during prehospital transport. OBJECTIVE: Our aim was to evaluate racial and ethnic disparities with the use of opioids during transport of injured children. METHODS: We conducted a prospective study of injured children transported to 1 of 10 emergency departments from July 2019 to April 2020. Emergency medical services (EMS) providers were surveyed about prehospital pain interventions during transport. Our primary outcome was the use of opioids. We performed multivariate regression analyses to evaluate the association of patient demographic characteristics (race, ethnicity, age, and gender), presence of a fracture, EMS provider type (Advanced Life Support [ALS] or non-ALS) and experience (years), and study site with the use of opioids. RESULTS: We enrolled 465 patients; 19% received opioids during transport. The adjusted odds ratios (AORs) for Black race and Hispanic ethnicity were 0.5 (95% CI 0.2-1.2) and 0.4 (95% CI 0.2-1.3), respectively. The presence of a fracture (AOR 17.0), ALS provider (AOR 5.6), older patient age (AOR 1.1 for each year), EMS provider experience (AOR 1.1 for each year), and site were associated with receiving opioids. CONCLUSIONS: There were no statistically significant associations between race or ethnicity and use of opioids for injured children. The presence of a fracture, ALS provider, older patient age, EMS provider experience, and site were associated with receiving opioids.

Improving Administration of Prehospital Corticosteroids for Pediatric Asthma.

Early administration of systemic corticosteroids for asthma exacerbations in children is associated with improved outcomes. Implementation of a new emergency medical services (EMS) protocol guiding the administration of systemic corticosteroids for pediatric patients with asthma exacerbations went into effect in January 2016 in Southwest Ohio. Our SMART aim was to increase the proportion of children receiving systemic prehospital corticosteroids for asthma exacerbations from 0% to 70% over 2 years. METHODS: Key drivers were derived and tested using multiple plan-do-study-act cycles. Interventions included community EMS outreach and education, improved clarity in the prehospital protocol language, distribution of pocket-sized educational cards, and ongoing individualized EMS agency feedback on protocol adherence. Eligible patients included children age 3-16 years, who were transported by EMS to the pediatric emergency department with diagnoses consistent with asthma exacerbation. Manual chart review assessed eligibility to receive prehospital corticosteroids. Statistical process control charts tracked adherence to corticosteroid recommendations. RESULTS: A total of 256 encounters met the criteria for receiving prehospital corticosteroids for pediatric asthma exacerbations between January 1, 2016, and April 30, 2019. Special cause variation was demonstrated following education at high-volume EMS stations, and the centerline shifted to 34%. This shift has been sustained for 28 months. CONCLUSION: Improvement methodology increased prehospital corticosteroid administration for pediatric asthma exacerbations, although we failed to achieve our aim of increasing use to 70%. Many barriers exist in pediatric prehospital protocol implementation, many of which can be improved with quality improvement tools.

Prehospital Factors Associated With Cervical Spine Injury in Pediatric Blunt Trauma Patients.

BACKGROUND: The risk for cervical spine injury (CSI) must be assessed in children who sustain blunt trauma. The Pediatric Emergency Care Applied Research Network (PECARN) retrospectively derived CSI model identifies CSI risk in children based on emergency department (ED) provider observations. The objective of this pilot study was to determine the univariate association of emergency medical services (EMS) provider-observed historical, mechanistic, and physical examination factors with CSI in injured children. Secondarily, we assessed the performance of the previously identified eight PECARN CSI risk factors (PECARN model) based exclusively on EMS provider observation. METHODS: We conducted a four-center, prospective observational study of children 0 to 17 years old who were transported by EMS after blunt trauma and underwent spinal motion restriction or trauma team activation in the ED. In the ED, EMS providers recorded their observations for a priori determined CSI risk factors. CSIs were classified by reviewing imaging, consultations, and/or telephone follow-up. We calculated bivariable relative risks and test characteristics for the PECARN model based solely on EMS provider observations. RESULTS: Of 1,372 enrolled children, 25 (1.8%) had CSIs. Of the a priori determined CSI risk factors, seven factors had bivariable associations with CSIs: axial load, altered mental status, signs of basilar skull fracture, substantial torso injury, substantial thoracic injury, respiratory distress, and decreased oxygen saturation. The PECARN model (high-risk motor vehicle collision, diving mechanism, predisposing condition, neck pain, decreased neck mobility, altered mental status, neurologic deficits, and/or substantial torso injury) exhibited the following test characteristics when based on EMS provider observations: sensitivity = 96.0% (95% confidence interval [CI] = 88.3% to 100.0%); negative predictive value = 99.8% (95% CI = 99.4% to 100.0%); specificity = 38.5% (95% CI = 35.9% to 41.1%); and positive predictive value = 2.8% (95% CI = 1.7% to 3.9%). CONCLUSION: EMS providers can identify risk factors associated with CSI in injured children who experience blunt trauma. These risk factors may be considered for inclusion in a pediatric CSI decision rule specific to the prehospital setting.

The impact of public health interventions on critical illness in the pediatric emergency department during the SARS-CoV-2 pandemic.

Study objective: The impact of public health interventions during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic on critical illness in children has not been studied. We seek to determine the impact of SARS-CoV-2 related public health interventions on emergency healthcare utilization and frequency of critical illness in children. Methods: This was an interrupted time series analysis conducted at a single tertiary pediatric emergency department (PED). All patients evaluated by a provider from December 31 through May 14 of 6 consecutive years (2015-2020) were included. Total patient visits (ED and urgent care), shock trauma suite (STS) volume, and measures of critical illness were compared between the SARS-CoV-2 period (December 31, 2019 to May 14, 2020) and the same period for the previous 5 years combined. A segmented regression model was used to explore differences in the 3 outcomes between the study and control period. Results: Total visits, STS volume, and volume of critical illness were all significantly lower during the SARS-CoV-2 period. During the height of public health interventions, per day there were 151 fewer total visits and 7 fewer patients evaluated in the STS. The odds of having a 24-hour period without a single critical patient were >5 times higher. Trends appeared to start before the statewide shelter-in-place order and lasted for at least 8 weeks. Conclusions: In a metropolitan area without significant SARS-CoV-2 seeding, the pandemic was associated with a marked reduction in PED visits for critical pediatric illness.

Cervical Spine Injury Risk Factors in Children With Blunt Trauma.

BACKGROUND: Adult prediction rules for cervical spine injury (CSI) exist; however, pediatric rules do not. Our objectives were to determine test accuracies of retrospectively identified CSI risk factors in a prospective pediatric cohort and compare them to a de novo risk model. METHODS: We conducted a 4-center, prospective observational study of children 0 to 17 years old who experienced blunt trauma and underwent emergency medical services scene response, trauma evaluation, and/or cervical imaging. Emergency department providers recorded CSI risk factors. CSIs were classified by reviewing imaging, consultations, and/or telephone follow-up. We calculated bivariable relative risks, multivariable odds ratios, and test characteristics for the retrospective risk model and a de novo model. RESULTS: Of 4091 enrolled children, 74 (1.8%) had CSIs. Fourteen factors had bivariable associations with CSIs: diving, axial load, clotheslining, loss of consciousness, neck pain, inability to move neck, altered mental status, signs of basilar skull fracture, torso injury, thoracic injury, intubation, respiratory distress, decreased oxygen saturation, and neurologic deficits. The retrospective model (high-risk motor vehicle crash, diving, predisposing condition, neck pain, decreased neck mobility (report or exam), altered mental status, neurologic deficits, or torso injury) was 90.5% (95% confidence interval: 83.9%-97.2%) sensitive and 45.6% (44.0%-47.1%) specific for CSIs. The de novo model (diving, axial load, neck pain, inability to move neck, altered mental status, intubation, or respiratory distress) was 92.0% (85.7%-98.1%) sensitive and 50.3% (48.7%-51.8%) specific. CONCLUSIONS: Our findings support previously identified pediatric CSI risk factors and prospective pediatric CSI prediction rule development.

Emergency Medical Services Utilization Is Associated With Community Deprivation in Children.

BACKGROUND: Pediatric emergency medical services (EMS) utilization is costly and resource intensive; significant variation exists across large-scale geographies. Less is known about variation at smaller geographic levels where factors including lack of transportation, low health literacy, and decreased access to medical homes may be more relevant. Our objective was to determine whether pediatric EMS utilization varied across Hamilton County, Ohio, census tracts and whether such utilization was associated with socioeconomic deprivation. METHODS: This was a retrospective analysis of children living in Hamilton County, Ohio, transported by EMS to the Cincinnati Children's emergency department between July 1, 2014, and July 31, 2016. Participants' addresses were assigned to census tracts and an EMS utilization rate and deprivation index were calculated for each. Pearson's correlation coefficients evaluated relationships between tract-level EMS utilization and deprivation. Tract-level deprivation was used as a predictor in patient-level evaluations of acuity. RESULTS: During the study period, there were 4,877 pediatric EMS transports from 219 of the 222 county census tracts. The county EMS utilization rate during the study period was 2.4 transports per 100 children (range 0.2-11). EMS utilization rates were positively correlated with increasing deprivation (r = 0.72, 95% confidence interval [CI], 0.65-0.77). Deprivation was associated with lower illness severity at triage, fewer transports resulting in resuscitation suite use, and fewer transports resulting in hospitalizations (all p < 0.05). CONCLUSIONS: EMS utilization varied substantially across census tracts in Hamilton County, Ohio. A deeper understanding into why certain socioeconomically deprived areas contribute to disproportionately high rates of EMS utilization could support development of targeted interventions to improve use.

From the street to the ICU: a review of pediatric emergency medical services and critical care transport.

Emergency medical services and critical care transport teams are relatively new parts of the American healthcare delivery system. Although most healthcare providers regularly interact with these groups and rely upon their almost ubiquitous availability, few know how these services developed or what sort of infrastructure currently exists to maintain them. This article provides a focused overview of the history and present practices of both emergency medical services and critical care transport teams, with a concentrated look at the implementation of these services in the pediatric population. Within this context, we also consider current challenges and future opportunities for both groups and conclude with ways to become involved in the improvement of out-of-hospital pediatric critical care.

Setting the Benchmark for the Ground and Air Medical Quality in Transport International Quality Improvement Collaborative.

OBJECTIVE: Critical care transport (CCT) supports regionalization of medical care. Focus on the quality of CCT care prompted the development of the Ground and Air Medical qUality in Transport (GAMUT) Quality Improvement collaborative database which tracks consensus quality metrics. The Institute of Medicine recommends benchmarking of comparative data to accelerate improvement. Herein, we report the strategies and rationale for GAMUT QI Collaborative benchmarking. METHODS: The GAMUT database includes >350 programs internationally with >200,000 annual patient contacts. Evidence-based literature review performed in May 2016 and October 2017 identified benchmarking strategies were evaluated and summarized, specific to the GAMUT metrics. Statistical analyses include simple statistics and weighted expectation calculations for benchmark examples (Pearson chi-square with Bonferroni adjusted post-hoc z tests). RESULTS: Evidence-based literature search yielded 70 articles, and 31 were selected for inclusion in our evidence table. 5 evidence-based benchmark strategies were considered: average (mean), average (median), adjusted benchmark (based on expected outcome), Achievable Benchmark of Care (ABC), and Delphi. ABC threshold establishes a higher target (90th percentile) forcing more programs to achieve higher performance. CONCLUSION: Benchmarking is not well-suited for a single strategy and requires customized consideration based on each metric, though adjusted benchmark and ABC generally set higher performance benchmarks.

Intubation Success in Critical Care Transport: A Multicenter Study.

INTRODUCTION: Tracheal intubation (TI) is a lifesaving critical care skill. Failed TI attempts, however, can harm patients. Critical care transport (CCT) teams function as the first point of critical care contact for patients being transported to tertiary medical centers for specialized surgical, medical, and trauma care. The Ground and Air Medical qUality in Transport (GAMUT) Quality Improvement Collaborative uses a quality metric database to track CCT quality metric performance, including TI. We sought to describe TI among GAMUT participants with the hypothesis that CCT would perform better than other prehospital TI reports and similarly to hospital TI success. METHODS: The GAMUT Database is a global, voluntary database for tracking consensus quality metric performance among CCT programs performing neonatal, pediatric, and adult transports. The TI-specific quality metrics are "first attempt TI success" and "definitive airway sans hypoxia/hypotension on first attempt (DASH-1A)." The 2015 GAMUT Database was queried and analysis included patient age, program type, and intubation success rate. Analysis included simple statistics and Pearson chi-square with Bonferroni-adjusted post hoc z tests (significance = p < 0.05 via two-sided testing). RESULTS: Overall, 85,704 patient contacts (neonatal n [%] = 12,664 [14.8%], pediatric n [%] = 28,992 [33.8%], adult n [%] = 44,048 [51.4%]) were included, with 4,036 (4.7%) TI attempts. First attempt TI success was lowest in neonates (59.3%, 617 attempts), better in pediatrics (81.7%, 519 attempts), and best in adults (87%, 2900 attempts), p < 0.001. Adult-focused CCT teams had higher overall first attempt TI success versus pediatric- and neonatal-focused teams (86.9% vs. 63.5%, p < 0.001) and also in pediatric first attempt TI success (86.5% vs. 75.3%, p < 0.001). DASH-1A rates were lower across all patient types (neonatal = 51.9%, pediatric = 74.3%, adult = 79.8%). CONCLUSIONS: CCT TI is not uncommon, and rates of TI and DASH-1A success are higher in adult patients and adult-focused CCT teams. TI success rates are higher in CCT than other prehospital settings, but lower than in-hospital success TI rates. Identifying factors influencing TI success among high performers should influence best practice strategies for TI.

Interobserver Agreement in Pediatric Cervical Spine Injury Assessment Between Prehospital and Emergency Department Providers.

BACKGROUND: Investigators have derived cervical spine injury (CSI) decision support tools from physician observations. There is a need to demonstrate that prehospital emergency medical services (EMS) providers can use these tools to appropriately determine the need for spinal motion restrictions and make field disposition decisions. OBJECTIVES: The objective was to determine the interobserver agreement between EMS and emergency department (ED) providers for CSI risk assessment variables and overall gestalt for CSI in children after blunt trauma. METHODS: This was a planned, substudy of a four-site, prospective cohort of children < 18 years transported by EMS to pediatric EDs for evaluation of CSI after blunt trauma. Inclusion criteria were trauma team activation and/or EMS-initiated spinal motion restriction. Exclusion criteria were penetrating trauma, transfer to another facility for definitive care, state custody, or substantial language barrier. For each eligible child, the transporting EMS provider and treating ED provider independently recorded their clinical assessment for CSI. This included mechanism of injury and patient history and physical examination findings. We assessed each paired variable for interobserver agreement between EMS and ED provider using kappa (κ) analysis. We considered variables with κ lower confidence interval values ≥0.4 to have moderate or better agreement. RESULTS: We obtained 1,372 paired observations for 29 variables. After finding prevalence and observer bias were adjusted for, all variables achieved moderate to better agreement including eight variables previously shown to be independently associated with CSI in children: diving mechanism, high-risk motor vehicle collision, altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, and predisposing medical condition. EMS and ED providers, however, showed less than moderate agreement for their overall gestalt for CSI in children. Of note, both EMS and ED providers did not assess for neck pain, inability to move the neck, and/or cervical spine tenderness in more than 10% of study patients. CONCLUSIONS: Emergency medical services and ED providers achieved at least moderate agreement in the assessment of CSI risk factors in children after blunt trauma. However, EMS and ED providers did not achieve moderate agreement on gestalt for CSI and some risk factors went unassessed by providers. These findings support the development of a pediatric CSI risk assessment tool for EMS and ED providers to reduce interventions for those children at very low risk for CSIs while still identifying all children with injury.

Methods for Collecting Paired Observations From Emergency Medical Services and Emergency Department Providers for Pediatric Cervical Spine Injury Risk Factors.

OBJECTIVES: Cervical spine injuries (CSIs) after blunt trauma in children are rare, but cause substantial morbidity and mortality. Emergency medical services (EMS) and emergency department (ED) providers routinely use spinal precautions and cervical spine imaging, respectively, during the management of children experiencing blunt trauma. These practices lack evidence, and there is concern that they may be harmful. A pediatric CSI risk assessment tool is needed to inform EMS and ED provider decision making. Creating this tool requires prospective data collection from EMS and ED providers at the time of patient evaluation. The purpose of this article is to describe the methods used to prospectively capture paired EMS and ED provider observations of children cared for after blunt trauma. Given the rarity of prospective observational research with EMS, the novel use of Research Electronic Data Capture (REDCap) in this study, and the potential to inform future studies, we are publishing our methodology in advance of outcome data related to the risk assessment tool. METHODS: The study was conducted at four tertiary children's hospitals as a prerequisite for a planned larger study to derive a CSI risk assessment tool. We created a web-based, branch-logic questionnaire using the REDCap data collection system. The survey was administered via tablet computer to ED providers evaluating children with blunt trauma and, if applicable, to EMS providers who provided patient care at the scene. We collected information regarding factors determined a priori to be plausibly associated with CSI in children. Eligible children presenting to the ED after blunt trauma with at least one of the following one of the following were included: prehospital EMS spinal precautions, ED trauma team evaluation, or cervical spine imaging in the ED. Exclusions included penetrating trauma, language barrier, or state's custody. Enrollment occurred when research coordinators (RCs) were available, generally 12-16 hours/day. RCs approached EMS providers prior to departing the ED and ED providers after they completed their patient assessments. An ED provider survey was required for enrollment. Enrolled children were followed for 28 days to determine the presence of CSI (primary outcome) by subsequent imaging or by patient/family telephone follow-up for those without imaging. RESULTS: Over 18 months, we prospectively enrolled 4,144 of 5,764 (71.9%) eligible children, including 74 of 110 (67.3%) children diagnosed with CSI. Enrollment during RC hours was 85.9%. Fifty-three enrolled children were withdrawn from the study. Of those in the final study cohort, 36.5% arrived by EMS scene response in spinal precautions. The remaining 63.5% arrived by EMS scene response without spinal precautions or by private vehicle or interfacility transfer. EMS scene response providers completed surveys for 60.2% of enrolled children arriving in spinal precautions. RCs missed the EMS providers for 37.1% of children; however, EMS declined participation for only 2.6%. CONCLUSIONS: Our method of data collection demonstrates the ability to prospectively capture paired observations from EMS and ED personnel for children undergoing evaluation after blunt trauma. While this methodology will be used to implement and evaluate a CSI tool in future studies, it may also be adapted to studies requiring prospective data collection from EMS and ED personnel.

Benchmarking Pain Assessment Rate in Critical Care Transport.

The purpose of this study is to determine the rate of pain assessment in pediatric neonatal critical care transport (PNCCT). The GAMUT database was interrogated for an 18-month period and excluded programs with less than 10% pediatric or neonatal patient contacts and less than 3 months of any metric data reporting during the study period. We hypothesized pain assessment during PNCCT is superior to prehospital pain assessment rates, although inferior to in-hospital rates. Sixty-two programs representing 104,445 patient contacts were analyzed. A total of 21,693 (20.8%) patients were reported to have a documented pain assessment. Subanalysis identified 17 of the 62 programs consistently reporting pain assessments. This group accounted for 24,599 patients and included 7,273 (29.6%) neonatal, 12,655 (51.5%) pediatric, and 4,664 (19.0%) adult patients. Among these programs, the benchmark rate of pain assessment was 90.0%. Our analysis shows a rate below emergency medical services and consistent with published hospital rates of pain assessment. Poor rates of tracking of this metric among participating programs was noted, suggesting an opportunity to investigate the barriers to documentation and reporting of pain assessments in PNCCT and a potential quality improvement initiative.

Quality Metrics in Neonatal and Pediatric Critical Care Transport: A National Delphi Project.

OBJECTIVES: The transport of neonatal and pediatric patients to tertiary care facilities for specialized care demands monitoring the quality of care delivered during transport and its impact on patient outcomes. In 2011, pediatric transport teams in Ohio met to identify quality indicators permitting comparisons among programs. However, no set of national consensus quality metrics exists for benchmarking transport teams. The aim of this project was to achieve national consensus on appropriate neonatal and pediatric transport quality metrics. DESIGN: Modified Delphi technique. SETTING: The first round of consensus determination was via electronic mail survey, followed by rounds of consensus determination in-person at the American Academy of Pediatrics Section on Transport Medicine's 2012 Quality Metrics Summit. SUBJECTS: All attendees of the American Academy of Pediatrics Section on Transport Medicine Quality Metrics Summit, conducted on October 21-23, 2012, in New Orleans, LA, were eligible to participate. MEASUREMENTS AND MAIN RESULTS: Candidate quality metrics were identified through literature review and those metrics currently tracked by participating programs. Participants were asked in a series of rounds to identify "very important" quality metrics for transport. It was determined a priori that consensus on a metric's importance was achieved when at least 70% of respondents were in agreement. This is consistent with other Delphi studies. Eighty-two candidate metrics were considered initially. Ultimately, 12 metrics achieved consensus as "very important" to transport. These include metrics related to airway management, team mobilization time, patient and crew injuries, and adverse patient care events. Definitions were assigned to the 12 metrics to facilitate uniform data tracking among programs. CONCLUSIONS: The authors succeeded in achieving consensus among a diverse group of national transport experts on 12 core neonatal and pediatric transport quality metrics. We propose that transport teams across the country use these metrics to benchmark and guide their quality improvement activities.

Intubation in Pediatric/Neonatal Critical Care Transport: National Performance.

BACKGROUND: There are nearly 200,000 US infants/children transported annually for specialty care and there are no published best practices in transport intubation. OBJECTIVE: Respiratory interventions are a priority in pediatric and neonatal critical care transport (PNCCT). A recent Delphi study identified intubation performance as an important PNCCT quality metric, though data are insufficient. The objective of the study is to determine multi-center rates of first attempt intubation success in pediatric/neonatal transport and identify practice processes associated with higher performing centers. METHODS: Retrospective chart review where data was collected from the 9 participating centers over a 6-month period from January-June 2013. Data describing intubation training and practices were gathered using SurveyMonkey® (Palo Alto, CA). Data were tabulated in Microsoft Excel (Redmond, WA) and analyzed using descriptive statistics. Through the determination of 1(st) intubation success rate across multiple pediatric/neonatal critical care transport programs, we hypothesized that the features of higher and lower performing centers can be identified to inform practice. RESULTS: 9 of 14 invited institutions participated. The median (IQR) 6-month transport volume for neonates(neo) was 289(35-646) and pediatric (ped) 510(122-831). On average, 7%(+/-3.0) of neo and 1.6%(+/-0.7) of ped transport patients required intubation. Individual centers had their initial success rate calculated and a 95% confidence interval was determined for those centers satisfying the np > 5 and n(1-p) > 5 sample size requirement for normality assumption of proportions. Since the overall success rate was 64%, it was determined that n = 14 initial intubation attempts would be the minimum number needed per center in order to fulfill the sample size requirement for normality assumption. Centers whose 95% confidence interval did not contain the initial overall success rate were identified. CONCLUSION: This represents the first multi-center neo/ped intubation dataset in PNCCT. First attempt intubation success lags behind reported anesthesia intubation rates but parallels pediatric emergency department intubation success rates. Training and operational processes are variable in PNCCT, though top performing teams require live-patient intubation success to achieve initial intubation competency.

Risk Factors for Failed Tracheal Intubation in Pediatric and Neonatal Critical Care Specialty Transport.

Abstract Objective. Nearly 200,000 pediatric and neonatal transports occur in the United States each year with some patients requiring tracheal intubation. First-pass intubation rates in both pediatric and adult transport literature are variable as are the factors that influence intubation success. This study sought to determine risk factors for failed tracheal intubation in neonatal and pediatric transport. Methods. A retrospective chart review was performed over a 2.5-year period. Data were collected from a hospital-based neonatal/pediatric critical care transport team that transports 2,500 patients annually, serving 12,000 square miles. Patients were eligible if they were transported and tracheally intubated by the critical care transport team. Patients were categorized into two groups for data analysis: (1) no failed intubation attempts and (2) at least one failed intubation attempt. Data were tabulated using Epi Info Version 3.5.1 and analyzed using SPSSv17.0. Results. A total of 167 patients were eligible for enrollment and were cohorted by age (48% pediatric versus 52% neonatal). Neonates were more likely to require multiple attempts at intubation when compared to the pediatric population (69.6% versus 30.4%, p = 0.001). Use of benzodiazepines and neuromuscular blockade was associated with increased successful first attempt intubation rates (p = 0.001 and 0.008, respectively). Use of opiate premedication was not associated with first-attempt intubation success. The presence of comorbid condition(s) was associated with at least one failed intubation attempt (p = 0.006). Factors identified with increasing odds of at least one intubation failure included, neonatal patients (OR 3.01), tracheal tube size ≤ 2.5 mm (OR 3.78), use of an uncuffed tracheal tube (OR 6.85), and the presence of a comorbid conditions (OR 2.64). Conclusions. There were higher rates of tracheal intubation failure in transported neonates when compared to pediatric patients. This risk may be related to the lack of benzodiazepine and neuromuscular blocking agents used to facilitate intubation. The presence of a comorbid condition is associated with a higher risk of tracheal intubation failure.

Specialty pediatric transport in primary care or urgent care settings.

OBJECTIVE: We sought to describe a single center's experience with specialized critical care transport from non-hospital settings, including primary care offices and urgent care centers. We hypothesized that the majority of patients will require procedures outside the scope of practice of most EMS providers and will be better served by specialized pediatric critical care transport (SPCCT) teams. METHODS: This study sought to retrospectively evaluate instances where children (0-18 years old) were transported by our SPCCT team from nonhospital settings, including primary care offices and urgent care centers, in 2009 and 2010. Data were extracted from a customized database and appropriate statistical tests were applied, including Fisher's exact test for categorical comparisons and Mann-Whitney U test for non-parametric data comparisons. RESULTS: Fifty-two patients were included. Most of the children were transported for respiratory distress (78%), and many were treated with albuterol (42%) and steroids (42%) prior to the SPCCT team arrival. The most common interventions performed by the SPCCT team were obtaining IV access and administering IV fluid boluses; 4 (7.7%) patients required advanced critical care treatments unique to SPCCT. Most patients (n = 34; 65%) were directly admitted to the general care floor, but a high number of patients (n = 12; 23%; PICU = 11, NICU = 1) required pediatric or neonatal intensive care unit admission. Only 3 patients (5.7%) were discharged home without hospital admission. For the 11 patients admitted to the PICU, the median length of stay (LOS) was 2.5 days (IQR 0.14-13.2). All patients survived to hospital discharge with an additional hospital LOS of 1.3 days (IQR 0.2-6.7). Patients were billed for these critical care transports an average of $2,660.14 ± $940. CONCLUSION: Our small cohort demonstrates infrequent application of advanced critical care interventions beyond those provided by the referring primary care office or urgent care centers. This supports the practice of SPCCT teams providing transport services for select critically ill children at primary care offices and urgent care centers, but not as a standard practice for most pediatric patients in these settings.

Characteristics of the pediatric patients treated by the Pediatric Emergency Care Applied Research Network's affiliated EMS agencies.

OBJECTIVE: To describe pediatric patients transported by the Pediatric Emergency Care Applied Research Network's (PECARN's) affiliated emergency medical service (EMS) agencies and the process of submitting and aggregating data from diverse agencies. METHODS: We conducted a retrospective analysis of electronic patient care data from PECARN's partner EMS agencies. Data were collected on all EMS runs for patients less than 19 years old treated between 2004 and 2006. We conducted analyses only for variables with usable data submitted by a majority of participating agencies. The investigators aggregated data between study sites by recoding it into categories and then summarized it using descriptive statistics. RESULTS: Sixteen EMS agencies agreed to participate. Fourteen agencies (88%) across 11 states were able to submit patient data. Two of these agencies were helicopter agencies (HEMS). Mean time to data submission was 378 days (SD 175). For the 12 ground EMS agencies that submitted data, there were 514,880 transports, with a mean patient age of 9.6 years (SD 6.4); 53% were male, and 48% were treated by advanced life support (ALS) providers. Twenty-two variables were aggregated and analyzed, but not all agencies were able to submit all analyzed variables and for most variables there were missing data. Based on the available data, median response time was 6 minutes (IQR: 4-9), scene time 15 minutes (IQR: 11-21), and transport time 9 minutes (IQR: 6-13). The most common chief complaints were traumatic injury (28%), general illness (10%), and respiratory distress (9%). Vascular access was obtained for 14% of patients, 3% received asthma medication, <1% pain medication, <1% assisted ventilation, <1% seizure medication, <1% an advanced airway, and <1% CPR. Respiratory rate, pulse, systolic blood pressure, and GCS were categorized by age and the majority of children were in the normal range except for systolic blood pressure in those under one year old. CONCLUSIONS: Despite advances in data definitions and increased use of electronic databases nationally, data aggregation across EMS agencies was challenging, in part due to variable data collection methods and missing data. In our sample, only a small proportion of pediatric EMS patients required prehospital medications or interventions.

Evaluation of regional hospitals' use of children in disaster drills.

OBJECTIVE: Describe the prevalence of pediatric casualties in disaster drills by community hospitals and determine if there is an association between the use of pediatric casualties in disaster drills and the proximity of a community hospital to a tertiary children's hospital. DESIGN: Survey, descriptive study. SETTING: Tertiary children's hospital and surrounding community hospitals. PARTICIPANTS: Hospital emergency management personnel for 30 general community hospitals in the greater Cincinnati, Ohio region. INTERVENTIONS: None MAIN OUTCOME MEASURE(S): The utilization of pediatric casualties in community hospital disaster drills and its relationship to the distance of those hospitals from a tertiary children's hospital. RESULTS: Sixteen hospitals reported a total of 57 disaster drills representing 1,309 casualties. The overwhelming majority (82 percent [1,077/1,309]) of simulated patients from all locations were 16 years of age or older. Those hospitals closest to the children's hospital reported the lowest percentage of pediatric patients (10 percent [35/357]) used in their drills. The hospitals furthest from the children's hospital reported the highest percentage of pediatric patients (32 percent [71/219]) used during disaster drills. CONCLUSIONS: The majority of community hospitals do not incorporate children into their disaster drills, and the closer a community hospital is to a tertiary children's hospital, the less likely it is to include children in its drills. Focused effort and additional resources should be directed toward preparing community hospitals to care for children in the event of a disaster.