Measures of Patient Acuity Among Children Encountered by Emergency Medical Services by the Child Opportunity Index.

Background: Children have differing utilization of emergency medical services (EMS) by socioeconomic status. We evaluated differences in prehospital care among children by the Child Opportunity Index (COI), the agreement between a child's COI at the scene and at home, and in-hospital outcomes for children by COI. Methods: We performed a retrospective study of pediatric (<18 years) scene encounters from approximately 2,000 United States EMS agencies from the 2021-2022 ESO Data Collaborative. We evaluated socioeconomic status using the multi-dimensional COI v2.0 at the scene. We described EMS interventions and in-hospital outcomes by COI categories using ordinal regression. We evaluated the agreement between the home and scene COI. Results: Data were available for 99.8% of pediatric scene runs, with 936,940 included EMS responses. Children from lower COI areas more frequently had a response occurring at home (62.9% in Very Low COI areas; 47.1% in Very High COI areas). Children from higher COI areas were more frequently not transported to the hospital (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.86-0.87). Children in lower COI areas had lower use of physical (OR 1.23, 95% CI 1.13-1.33) and chemical (OR 1.41, 95% CI 1.29-1.55) restraints for behavioral health problems. Among injured children with elevated pain scores (≥7), analgesia was provided more frequently to children in higher COI areas (OR 1.73, 95% CI 1.65-1.81). The proportion of children in cardiac arrest was lowest from higher COI areas. Among 107,114 encounters with in-hospital data, the odds of hospitalization was higher among children from higher COI areas (OR 1.14, 95% CI 1.11-1.18) and was lower for in-hospital mortality (OR 0.75, 95% CI 0.65-0.85). Home and scene COI had a strong agreement (Kendall's W = 0.81). Conclusion: Patterns of EMS utilization among children with prehospital emergencies differ by COI. Some measures, such as for in-hospital mortality, occurred more frequently among children transported from Very Low COI areas, whereas others, such as admission, occurred more frequently among children from Very High COI areas. These findings have implications in EMS planning and in alternative out-of-hospital care models, including in regional placement of ambulance stations.

TeleEMS: An EMS Telemedicine Pilot Program Barriers to Implementation.

INTRODUCTION: In response to the COVID-19 pandemic, emergency medical services (EMS) and hospitals recognized the need for innovative programs addressing 9-1-1 utilization and ambulance transport to provide patient-centered, safe, cost-effective care. The ET3 (Emergency Triage, Treatment, and Transport) model provides flexibility and new payments to ambulance care teams for Medicare beneficiaries for alternate strategies of care. This includes providing treatment in place through telehealth after a 9-1-1 call and ambulance response. Our objective is to evaluate the implementation barriers of a telemedicine service to 9-1-1 responding ambulances providing treatment in place for low-acuity conditions. METHODS: The TeleEMS program was piloted in a large, urban fire-based EMS system with eight ambulances geographically surrounding one hospital. Paramedics received training on the telemedicine software and screening criteria, which were age 1-70 and vital sign parameters. Pregnant, combative, and patients with no clear need for emergency department transport were excluded. Three emergency physicians with additional training in EMS provided the TeleEMS service from 8am to 6 pm on Monday - Friday. The telemedicine software was application-based and provided HIPAA-compliant two-way, real-time audio and video communication through the 4G network on a tablet. The TeleEMS physicians had access to a database of clinics and hospitals that coordinate health care. The TeleEMS physician contacted the patient within 24-72 hours after the encounter for follow-up. RESULTS: The TeleEMS pilot program ran for 12 weeks from April - June 2021. During this time, there were seven completed consults with treatment in place, one completed consult with transport to an emergency department, and five consult attempts that failed due to technological issues with resultant transport. Each of the consults (13/13) met the TeleEMS screening criteria. Post-pilot focus group sessions were held to determine paramedic feedback. Barriers to an EMS telemedicine program include paramedic buy-in, patient expectations for emergency care, technology limitations, and qualified physician resources. CONCLUSIONS: An EMS telemedicine program can be successfully implemented in urban fire-based EMS systems for 9-1-1 responding ambulances. Barriers to implementation should be addressed at the paramedic, patient, technology, and program levels to improve success.

The Child Opportunity Index and Pediatric Emergency Medical Services Utilization.

Background: The delivery of emergency medical services (EMS) is a resource-intensive process, and prior studies suggest that EMS utilization in children may vary by socioeconomic status. The Child Opportunity Index (COI) provides a multidimensional measure of neighborhood-level resources and conditions that affect the health of children. We evaluated EMS utilization and measures of acuity among children by COI.Methods: We performed a cross-sectional study using encounters for patients less than 18 years of age from 10,067 EMS agencies in 47 US states and territories contributing to the National Emergency Medical Services Information System 2019 dataset. We compared patient demographics, EMS encounter characteristics, and care provided to children stratified by ZIP code using the COI 2.0.Results: We included 1,293,038 EMS encounters (median age 10 years, IQR 3-15 years). The distributions of encounters in the five tiers of COI were 30.6%, 20.1%, 18.0%, 16.3% and 15.1%, (from Very Low to Very High, respectively). The distribution of diagnoses between groups was similar. Most measures of EMS acuity/resource use were similar between groups, including non-transport status, cardiac arrest, vital sign abnormalities, and EMS-administered procedures and medications. Among children with respiratory-related encounters, children in the Very Low group had a greater need for nebulized medications (26.4% vs 18.3% in Very High COI children). Among children with trauma, a lower proportion in the Very Low group were given analgesia (4.0% vs 7.4% in the Very High group), though pain scores were similar in all groups.Conclusion: Pediatric EMS encounters from lower COI neighborhoods occur more frequently relative to encounters from higher COI neighborhoods. Despite these differences, children from lower COI strata generally have similar encounter characteristics to those in other COI strata, suggestive of a greater number of true out-of-hospital emergencies among children from these areas. Notable differences in care included use of respiratory medication to children with respiratory diagnoses, and administration of pain medication to children with trauma.