Pediatric Conditions Requiring Interfacility Transport From Emergency Departments: A Statewide Study of Regionalization.

OBJECTIVES: Pediatric care is increasingly regionalized, increasing rates of interfacility transport (IFT). However, it is unknown what conditions most frequently require IFT. This study's objective was to identify high-frequency pediatric conditions requiring IFT. METHODS: This is a statewide retrospective observational study from 2010 to 2012 of pediatric patients (<18 years of age) who underwent IFT in Maryland. Patients were identified from the Health Care Utilization Project's database using probabilistic linkage. This study identified the 20 most common pediatric IFT conditions, and the conditions with the highest IFT rates. RESULTS: Probabilistic linkage was successful for 2254 records. The largest age category was 0 to 4 years (43%). The top 3 IFT conditions were asthma (13.5%), epilepsy (8.5%), and diabetes mellitus (6.6%). Diabetes mellitus had the highest IFT rate (24%), followed by appendicitis (15.5%) and internal obstruction (14.4%). CONCLUSIONS: Specific pediatric conditions commonly require IFT and had high IFT rates in this statewide study. In addition, the largest age group undergoing IFT was young children (0 to 4 years of age). This study provides specific detail regarding conditions and ages impacted by IFT, and emergency medical services should consider incorporating these findings into transport destination algorithms. In addition, public health stakeholders should address implications of the concentration of care for these common pediatric conditions and younger age groups.

Diagnostic Discordance in Pediatric Critical Care Transport: A Single-Center Experience.

OBJECTIVES: The aims of the study were to describe diagnostic discordance rates at our pediatric tertiary care center between the reason for transfer of critically ill/injured children (determined by the referring institution) and the inpatient admission diagnosis (determined by our accepting institution), to identify potential factors associated with discordance, and to determine its impact on patient outcomes. METHODS: We conducted a retrospective chart review of all critically ill/injured children transferred to the Johns Hopkins Children's Center between July 1, 2017, and June 30, 2018. All patients whose initial inpatient disposition was the pediatric intensive care unit were included. RESULTS: Six hundred forty-three children (median age, 51 months) from 57 institutions (median pediatric capability level: 3) met inclusion criteria: 46.8% were transported during nighttime, 86.5% by ground, and 21.2% accompanied by a physician. Nearly half (43.4%) had respiratory admission diagnoses. The rest included surgical/neurosurgical (14.2%), neurologic (11.2%), cardiovascular/shock (8.7%), endocrine (8.2%), infectious disease (6.8%), poisoning (3.1%), hematology-oncology (2.2%), gastrointestinal/metabolic (1.9%), and renal (0.3%). Forty-six (7.2%) had referral-to-admission diagnostic discordance: 25 of 46 had discordance across different diagnostic groups and 21 of 46 had clinically significant discordance within the same diagnostic group. The discordant group had higher need for respiratory support titration in transport (43.9% vs 27.9%, p = 0.02); more invasive procedures and vasopressor needs during the day of admission (26.1% vs 11.6%, P = 0.008; 19.6% vs 7%, P = 0.006); and longer intensive care unit (ICU) and hospital stays (5 vs 2 days; 11 vs 3 days, P < 0.001). When compared with respiratory admission diagnoses, patients with cardiovascular/shock and neurologic diagnoses were more likely to have discordant diagnoses (odds ratio [95% confidence interval], 13.24 [5.41-35.05]; 6.47 [2.48-17.75], P < 0.001). CONCLUSIONS: Seven percent of our critically ill/injured pediatric cohort had clinically significant referral-to-admission diagnostic discordance. Patients with cardiovascular/shock and neurologic diagnoses were particularly at risk. Those with discordant diagnoses had more in-transit events; a higher need for ICU interventions postadmission; and significantly longer ICU stays and hospitalizations, deserving further investigation.

A Statewide Analysis of EMS' Pediatric Transport Destination Decisions.

Introduction: Deciding where to transport a patient is a key decision made by emergency medical services (EMS), particularly for children because pediatric hospital resources are regionalized. Since evidence-based guidelines for pediatric transport destinations are being developed, the purpose of this study was to use a large statewide EMS database to describe current patterns of EMS providers' transport destination decisions for pediatric patients.Methods: This is a retrospective study of pediatric transports from 2011-2016 in EMS Tracking and Reporting System (EMSTARS), Florida's statewide EMS database. We included patients greater than 1 day and less than or equal to 18 years who were primary EMS scene transports. Our primary outcome variable was 'reason for choosing destination.' We performed descriptive and comparative analysis between closest facility and all other 'reason for choosing destination' choices. We used geospatial analysis to examine destination choice in urban and rural counties.Results: Our final study sample was 446,274, and 48.2% of patients had closest facility as their 'reason for choosing destination.' The next largest category was patient/family choice (154,035 patients, 35.7%). Closest facility patients were older (median age 12 versus 10 years, p < 0.0001) and had shorter median EMS transport times (11.3 versus 15 minutes, p < 0.0001) compared to all other destination decisions. Notably, 60% of respiratory distress patients' and 44% of seizure patients' reason for choosing destination was something other than closest facility. Geospatial analysis revealed that fewer rural patients were documented as closest facility compared to urban (43.9% versus 47%, p < 0.0001). Correspondingly, more rural patients' destination decision was patient/family choice than urban patients (36.3% versus 34.3%, p < 0.0001).Conclusions: This large, statewide study describes EMS' reason for choosing destination for pediatric patients. We found that just under half of patients were documented as closest facility, and over one-third as patient/family choice. Significant differences in destination reasons were noted for rural versus urban counties. This study can help those currently developing pediatric EMS destination guidelines by revealing a high proportion of patient/family choice and identifying conditions with high proportions of destination reasons other than closest facility.

Emergency Medical Services Bypass of the Closest Facility for Pediatric Patients.

Objectives: Pediatric specialty care is increasingly regionalized. It is unknown how regionalization affects emergency medical services (EMS) providers' destination decisions for non-trauma pediatric patients. We sought to characterize the rates of bypass of the closest facility, and destination facilities' levels of pediatric care in three diverse EMS agencies. Methods: This is a one-year retrospective study of non-trauma pediatric patients less than 18 years of age transported by three EMS agencies (Baltimore City, Prince George's County, and Queen Anne's County) in 2016. A priori, a bypass was defined as transport to a facility more than 2 km farther than the distance to the closest facility. We calculated rates of bypass and categorized destination and closest facilities by their pediatric service availability using publicly available information. EMS transport distance and time were also compared for bypass and closest facility patients. Results: The three EMS agencies in 2016 transported a total of 12,258 non-trauma pediatric patients, of whom 11,945 (97%) were successfully geocoded. Overall 43% (n = 5,087) of patients bypassed the nearest facility, of which 87% (n = 4,439) were transported to a facility with higher-level pediatric care than the closest facility. Both bypass rates and destination facility pediatric levels differed between agencies. Bypasses had significantly longer transport times and distances as compared to closest facility transports (p < 0.001). For non-trauma pediatric bypasses alone, an additional 41,494 kilometers traveled, and 979 hours of EMS transport time was attributable to bypassing the closest facility. Conclusions: This study reveals a high rate of pediatric bypass for non-trauma patients in three diverse EMS agencies. Bypass results in increased EMS resource utilization through longer transport time and distance. For non-trauma pediatric patients for whom there is little destination guidance, further work is required to determine bypass' effects on patient outcomes.

Retrospective Evaluation of Risk Factors for Pediatric Secondary Transport.

OBJECTIVE: Emergency medical services (EMS) typically transports patients to the nearest emergency department (ED). After initial presentation, children who require specialized care must undergo secondary transport, exposing them to additional risks and delaying definitive treatment. EMS direct transport protocols exist for major trauma and certain adult medical conditions, however the same cannot be said for pediatric medical conditions or injuries that do not meet trauma center criteria ('minor trauma'). To explore the utility of such future protocols, we sought to first describe the pediatric secondary transport population and examine prehospital risk factors for secondary transport. METHODS: Pediatric secondary transport patients aged 0-18 years were identified. Patients meeting state EMS trauma protocol criteria or who were clinically unstable were excluded. Data were abstracted by chart review of EMS, community hospital ED, and specialty hospital records. Patients were compared to control patients with similar conditions who did not require secondary transport. RESULTS: This study identified 211 medical or minor trauma pediatric secondary transport patients between 2013 and 2014. The three most prevalent conditions were seizure (n = 52), isolated orthopedic injury (n = 49), and asthma/respiratory distress (n = 27). Increased odds of secondary transport for seizure patients were associated with administration of supplemental oxygen, glucose measurement, and online medical direction; for isolated orthopedic injuries, online medical direction; and for asthma/respiratory distress, administration of supplemental oxygen, and online medical direction. Decreased odds of secondary transport for seizure patients were associated with a higher GCS; for isolated orthopedic injuries, increased age and oxygen saturation; and for asthma/respiratory distress, administration of albuterol only. CONCLUSIONS: Children with seizures, isolated orthopedic injuries, and asthma/respiratory distress comprised the majority of the medical or minor trauma pediatric secondary transport population. Each of those conditions had specific risk factors for secondary transport. This study's results provide information to guide future prospective studies and the development of direct transport protocols for those populations.

Cyclical Abdominal Pain in an Adolescent Female: A Case Report of Agenesis of the Lower Vagina.

Congenital agenesis of the lower vagina is a rare disorder characterized by separation between the unaffected proximal vagina and the distal vagina by a band of fibrous tissue. The typical presentation is an early adolescent female with chronic, cyclic abdominal pain and primary amenorrhea. In this case report, we describe an adolescent who presented to the pediatric emergency department on 2 occasions with a chief complaint of lower abdominal pain.

Defining Pediatric Trauma Center Resource Utilization: Multidisciplinary Consensus-Based Criteria from the Pediatric Trauma Society.

BACKGROUND: Pediatric trauma triage and transfer decisions should incorporate the likelihood that an injured child will require pediatric trauma center (PTC) resources. Resource utilization may be a better basis than mortality risk when evaluating pediatric injury severity. However, there is currently no consensus definition of PTC resource utilization that encompasses the full scope of PTC services. METHODS: Consensus criteria were developed in collaboration with the Pediatric Trauma Society (PTS) Research Committee using a modified Delphi approach. An expert panel was recruited representing the following pediatric disciplines: prehospital care, emergency medicine, nursing, general surgery, neurosurgery, orthopedics, anesthesia, radiology, critical care, child abuse, and rehabilitation medicine. Resource utilization criteria were drafted from a comprehensive literature review, seeking to complete the following sentence: "Pediatric patients with traumatic injuries have used PTC resources if they..." Criteria were then refined and underwent three rounds of voting to achieve consensus. Consensus was defined as agreement of 75% or more panelists. Between the second and third voting rounds, broad feedback from attendees of the PTS annual meeting was obtained. RESULTS: The Delphi panel consisted of 18 members from 15 institutions. Twenty initial draft criteria were developed based on literature review. These criteria dealt with airway interventions, vascular access, initial stabilization procedures, fluid resuscitation, blood product transfusion, abdominal trauma/solid organ injury management, intensive care monitoring, anesthesia/sedation, advanced imaging, radiologic interpretation, child abuse evaluation, and rehabilitative services. After refinement and panel voting, 14 criteria achieved the >75% consensus threshold. The final consensus criteria were reviewed and endorsed by the PTS Guidelines Committee. CONCLUSIONS: This study defines multidisciplinary consensus-based criteria for PTC resource utilization. These criteria are an important step toward developing a gold standard, resource-based, pediatric injury severity metric. Such metrics can help optimize system-level pediatric trauma triage based on likelihood of requiring PTC resources. LEVEL OF EVIDENCE/STUDY TYPE: Level II, diagnostic test/criteria.

Emergency Medical Services Clinicians' Pediatric Destination Decision-Making: A Qualitative Study.

Objective This study sought to identify factors that influence emergency medical services (EMS) clinicians' destination decision-making for pediatric patients. We also sought EMS clinicians' opinions on potential systems improvements, such as protocol changes and the use of evidence-based transport guidelines. Methods Thirty-six in-depth phone interviews were conducted using a semi-structured format. We utilized a modified Grounded Theory approach to understand the complicated decision-making processes of EMS personnel. Memo writing was used throughout the data collection and analysis processes in order to identify emerging themes. The research team utilized hierarchical coding of interview transcripts to organize data into sub-categories for final analysis.  Results EMS clinicians cited the perceived need for specialty care, the presence of a medical home, a desire for improved continuity of care, and the availability of aeromedical transport as factors that promoted transport to a pediatric specialty center. They voiced that children with emergent stabilization needs should be transported to the closest facility, however, they did not identify any specific medical conditions suitable for transport to non-specialty centers. EMS clinicians recommended improvements in pediatric-specific education, improved clarity of hospitals' pediatric capabilities, and the creation of a pediatric-specific destination decision-making tool. Conclusion This study describes specific factors that influence EMS clinicians' transport destination decision-making for pediatric patients. It also describes potential systems and educational improvements that may increase pediatric transport directly to definitive care. EMS clinicians are in support of specific designations for hospitals' pediatric capabilities and were in favor of the creation of a formal destination decision-making tool.

Creating a Pediatric Prehospital Destination Decision Tool Using a Modified Delphi Method.

Decisions for patient transport by emergency medical services (EMS) are individualized; while established guidelines help direct adult patients to specialty hospitals, no such pediatric equivalents are in wide use. When children are transported to a hospital that cannot provide definitive care, care is delayed and may cause adverse events. Therefore, we created a novel evidence-based decision tool to support EMS destination choice. A multidisciplinary expert panel (EP) of stakeholders reviewed published literature. Four facility capability levels for pediatric care were defined. Using a modified Delphi method, the EP matched specific conditions to a facility pediatric-capability level in a draft tool. The literature review and EP recommendations identified seventeen pediatric medical conditions at risk for secondary transport. In the first voting round, two were rejected, nine met consensus for a specific facility capability level, and six did not reach consensus on the destination facility level. A second round reached consensus on a facility level for the six conditions as well as revision of one previously rejected condition. In the third round, the panel selected a visual display format. Finally, the panel unanimously approved the PDTree. Using a modified Delphi technique, we developed the PDTree EMS destination decision tool by incorporating existing evidence and the expertise of a multidisciplinary panel.

Introduction of a New EMS Protocol Using the Communities of Practice Educational Model.

Emergency Medical Services (EMS) protocol implementation can be a challenging endeavor given the large and diverse provider workforce. These efforts can be even more challenging given training restrictions, career and volunteer combination EMS agencies, and inconsistent work schedules. In an effort to educate as many providers as possible in a relatively short time, the community of practice educational model was used during a new evidence-based EMS protocol implementation. This model identifies providers who are enthusiastic during initial training as advocates. These advocates then continue to educate their peers going forward. This allows for the initial educational effort to continue to propagate during pilot testing and beyond. During this protocol implementation, a total of 17 educational visits were made to EMS stations and 43 providers were identified as advocates.FrattaKA, FisheJN, AndersJF, SmithTG. Introduction of a new EMS protocol using the communities of practice educational model. Prehosp Disaster Med. 2019;34(1):108-109.

Urgency of evaluation and outcome of acute ovarian torsion in pediatric patients.

OBJECTIVE: To describe the symptoms, diagnostic studies, and rate of ovarian salvage among children and adolescents with ovarian torsion. METHODS: We reviewed the medical records of all children with acute ovarian torsion treated at a university-affiliated pediatric hospital from 1987 to 2002; prenatal cases were excluded. For each child we recorded the time from onset of symptoms to initial examination and the time from initial examination to operation. We reviewed diagnostic tests used, operative reports, and pathology reports. RESULTS: We identified 22 cases; the mean age was 10.2 years (range, 3-15 years). In 6 cases (27%), the ovary was salvaged. Prolonged duration of symptoms prior to initial examination was not significantly associated with ovarian necrosis. Mean time of symptoms prior to care was 76 hours for both salvaged and nonsalvaged ovaries (range, 7-159 hours). The mean time from initial examination to operation, 11 hours for salvaged ovaries (range, 1-23 hours) and 21 hours for nonsalvaged ovaries (range, 2-71 hours), was not significantly different between groups. Twenty-one patients underwent imaging; 19 of 20 ultrasounds and 4 of 5 computed tomographic scans suggested the diagnosis. Less than half (10 of 22) of the torsed ovaries contained cysts, teratomas, or other masses. CONCLUSIONS: These data suggest pediatric ovarian torsion is a more salvageable condition than previously reported. Prolonged time of symptoms prior to initial examination does not preclude ovarian salvage. Ovarian tumor accounts for less than half of cases. Urgent imaging and surgical management may lead to improved outcomes.

Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury.

BACKGROUND: Pediatric cervical spine injury is rare. As a result, evidence-based guidance for prehospital triage of children with suspected cervical spine injuries is limited. The effects of transport time and secondary transfer for specialty care have not previously been examined in the subset of children with cervical spine injuries. OBJECTIVES: The primary objective was to determine if prehospital destination choice affects outcomes for children with cervical spine injuries. The secondary objectives were to describe prehospital and local hospital interventions for children ultimately transferred to pediatric trauma centers for definitive care of cervical spine injuries. METHODS: The authors searched the Pediatric Emergency Care Applied Research Network (PECARN) cervical spine injury data set for children transported by emergency medical services (EMS) from scene of injury. Neurologic outcomes in children with cervical spine injuries transported directly to pediatric trauma centers were compared with those transported to local hospitals and later transferred to pediatric trauma centers, adjusting for injury severity, indicated by altered mental status, focal neurologic deficits, and substantial comorbid injuries. In addition, transport times and interventions provided in the prehospital, local hospital, and pediatric trauma center settings were compared. Multiple imputation was used to handle missing data. RESULTS: The PECARN cervical spine injury cohort contains 364 patients transported from scene of injury by EMS. A total of 321 met our inclusion criteria. Of these, 180 were transported directly to pediatric trauma centers, and 141 were transported to local hospitals and later transferred. After adjustments for injury severity, odds of a normal outcome versus death or persistent neurologic deficit were higher for patients transported directly to pediatric trauma centers (odds ratio [OR] = 1.89, 95% confidence interval [CI] = 1.03 to 3.47). EMS transport times to first hospital did not differ and did not affect outcomes. Prehospital analgesia was very infrequent. CONCLUSIONS: Initial destination from scene (pediatric trauma center vs. local hospital) appears to be associated with neurologic outcome of children with cervical spine injuries. Markers of injury severity (altered mental status and focal neurologic findings) are important predictors of poor outcome in children with cervical spine injuries and should remain the primary guide for prehospital triage to designated trauma centers.