Priorities for research in Emergency Medical Services for Children: results of a consensus conference. EMSC Research Agenda Consensus Committee, National EMSC Resource Alliance

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.

Disparities rank high in prioritized research, systems and service delivery needs in Missouri

OBJECTIVES

An essential function of public health is to conduct research and in Missouri, a research agenda was initiated to promote the health and well being of women and children. In 2005, a survey was emailed to 180 maternal and child health (MCH) researchers throughout the state, with 130 responding for a 72.2% response rate. These individuals were asked to select research priorities out of a list of 130 research agenda items, identify personal areas of expertise, and to recommend new research topics.

RESULTS

Results focused on identifying research priorities and research experts. The first, of the five leading research priorities, was researching disparities in terms of age, race, ethnicity, and gender, regarding sexually transmitted diseases, chronic disease, birth outcomes, prenatal care, access to care, childhood exposure to lead, immunizations and vaccinations, mental health, substance abuse, and oral health. The four remaining, of the top five specific research priorities, in order of priority, included (2) reducing barriers to health care access, (3) constructing research ecologically, (4) increasing access to oral health care for children, and (5) reducing the prevalence of children who are at-risk for being overweight. Of the 130 respondents, 83.1% reported at least one area of expertise, with a mean of 7.4 areas of expertise per respondent (range 0-41). Forty percent of the respondents reported health care access as an area of expertise, followed by school health, community development, family support, and pre/post natal care (38.5%, 36.2%, 30.0%, 28.5%, and 26.9%) respectively. Interestingly, only 17.7% of the respondents reported disparities as their area of expertise.

CONCLUSIONS

The goal of moving innovations towards changes in practice can only happen when resources are available to assess innovations and communities are ready to implement those innovations. The prioritization of this MCH research agenda, prioritized by a community of MCH researchers with expertise in conducting MCH related research, is the first step towards changes in practice, ultimately leading to improvements in the health of women and children in Missouri.

Development of measures of the quality of emergency department care for children using a structured panel process

BACKGROUND

Performance measures are essential components of public reporting and quality improvement. To date, few such measures exist to provide a comprehensive assessment of the quality of emergency department services for children.

OBJECTIVES

Our goal was to use a systematic process to develop measures of emergency department care for children (0-19 years) that are (1) based on research evidence and expert opinion, (2) representative of a range of conditions treated in most emergency departments, (3) related to links between processes and outcomes, and (4) feasible to measure.

METHODS

We presented a panel of providers and managers data from emergency department use to identify common conditions across levels of patient acuity, which could be targets for quality improvement. We used a structured panel process informed by a literature review to (1) identify condition-specific links between processes of care and defined outcomes and (2) select indicators to assess these process-outcome links. We determined the feasibility of calculating these indicators using an administrative data set of emergency department visits for Ontario, Canada.

RESULTS

The panel identified 18 clinical conditions for indicator development and 61 condition-specific links between processes of care and outcomes. After 2 rounds of ratings, the panel defined 68 specific clinical indicators for the following conditions: adolescent mental health problems, ankle injury, asthma, bronchiolitis, croup, diabetes, fever, gastroenteritis, minor head injury, neonatal jaundice, seizures, and urinary tract infections. Visits for these conditions account for 23% of all pediatric emergency department use. Using an administrative data set, we were able to calculate 19 indicators, covering 9 conditions, representing 20% of all emergency department visits by children.

CONCLUSIONS

Using a structured panel process, data on emergency department use, and literature review, it was possible to define indicators of emergency department care for children. The feasibility of these indicators will depend on the availability of high-quality data.

Report of the National Consensus Conference on Family Presence During Pediatric Cardiopulmonary Resuscitation and Procedures

Representatives from 18 national organizations were convened for a conference to develop recommendations regarding family presence (FP) during pediatric procedures and cardiopulmonary resuscitation. Before the conference, invitees were given a questionnaire and provided with current literature regarding FP. A modified Delphi process was used to develop consensus, including use of multiple questionnaires and breakouts for discussion of specific issues. Participants were encouraged to develop consensus recommendations based on the literature and discussions. Changes in attitude were tracked with repeat questionnaires. Results of the conference were circulated to participants for review and revision. Consensus recommendations include (1) consider FP as an option for families during pediatric procedures and cardiopulmonary resuscitation, (2) offer FP as an option after assessing factors that could adversely affect the interaction, (3) if family is not offered the option for FP, document the reasons why, (4) always consider the safety of the health care team, (5) develop in-hospital transport and transfer policies and procedures for FP, such as family member definition, preparation of the family, handling disagreements, and providing support for the staff, (6) obtain legal review of policies, (7) include education in FP in all core curricula and orientation for health care providers, (8) promote research into best methods for education; effects of FP on patients, family, and staff; best practices for FP; and legal issues regarding FP, among others. These recommendations were approved in concept by the American Academy of Pediatrics and the Ambulatory Pediatrics Association.

Report of the National Consensus Conference on Family Presence During Pediatric Cardiopulmonary Resuscitation and Procedures

Representatives from 18 national organizations were convened for a conference to develop recommendations regarding family presence (FP) during pediatric procedures and cardiopulmonary resuscitation. Before the conference, invitees were given a questionnaire and provided with current literature regarding FP. A modified Delphi process was used to develop consensus, including use of multiple questionnaires and breakouts for discussion of specific issues. Participants were encouraged to develop consensus recommendations based on the literature and discussions. Changes in attitude were tracked with repeat questionnaires. Results of the conference were circulated to participants for review and revision. Consensus recommendations include (1) consider FP as an option for families during pediatric procedures and cardiopulmonary resuscitation, (2) offer FP as an option after assessing factors that could adversely affect the interaction, (3) if family is not offered the option for FP, document the reasons why, (4) always consider the safety of the health care team, (5) develop in-hospital transport and transfer policies and procedures for FP, such as family member definition, preparation of the family, handling disagreements, and providing support for the staff, (6) obtain legal review of policies, (7) include education in FP in all core curricula and orientation for health care providers, (8) promote research into best methods for education; effects of FP on patients, family, and staff; best practices for FP; and legal issues regarding FP, among others. These recommendations were approved in concept by the American Academy of Pediatrics and the Ambulatory Pediatrics Association.

The role of the emergency physician in emergency medical services for children

Emergency physicians have a duty to advance the care of pediatric patients in the emergency medical services (EMS) system. This policy resource and education paper, designed to support the American College of Emergency Physicians policy paper "The Role of the Emergency Physician in Emergency Medical Services for Children," describes the development of the federal EMS for Children Program, the importance of the integration of EMS for children into EMS systems, and the role of the emergency physician in EMS for children.

The research potential of practice nurses

Little is known about the research aspirations and experiences of practice nurses. The study discussed in the present paper had three main aims: (1) to assess the level of research interest among practice nurses working in Essex and East London, UK; (2) to identify practice nurses' research priorities; and (3) to explore factors which facilitate and impede the development of practice nursing research. All practice nurses (n = 1,054) in the above areas were sent a questionnaire, and a total of 40% (n = 426) responded after two follow-up letters. Fifty-five respondents who volunteered for further participation were interviewed, either individually or in focus groups. About half (n = 207) of the survey respondents expressed an interest in undertaking research. One-third (n = 145) reported previous participation in research, and 20% (n = 85) had initiated their own research. Logistic regression showed that practice nurses educated to graduate level, and those working in practices with nurse training or participation in external research, were most likely to want to undertake research. Working in a medical training practice was found to be a negative predictor of research interest. Respondents prioritised research into long-term health problems with a high prevalence in the local population; for example, diabetes. Their reasons for wishing to engage in research included improving the service, career development, making work more interesting and reducing isolation. The main barriers identified were lack of time, lack of support from some general practitioners and poor access to higher education resources outside formal courses. The development of practice nurse research would provide a distinctive perspective on health need and service provision. It would contribute to the achievement of the national strategic objective of improving the quality of primary care, enhance the status of the profession, utilise the enthusiasm of individuals, increase job satisfaction and staff retention, and answer real questions.

The importance of outcomes research in pediatric emergency medicine

Applying the methods and tools of outcomes research, "evaluation of the impact of health care on the health outcomes or 'end results' of patients and populations," to the clinical domain of emergency services for children offers an important strategic opportunity for addressing the questions that confront all health care services: What works? For which patients? At what cost? From whose perspective? Although the important questions to address are extensive, much of the intersection between emergency services and outcomes research remains unexplored. Important challenges for researchers intrigued by the opportunities at this intersection of fields include: 1) clear definition of the scope of emergency services; 2) consideration of the appropriate end-point of emergency services-the entire episode of illness and/or services provided within the emergency setting; 3) selection and development of measures that incorporate children's and families' perspectives; and 4) a clear focus on linking research findings with strategies for improving outcomes and informed decision making. This essay will provide an overview of accomplishments and challenges from the field of outcomes research, suggest important opportunities for applying existing methods to emergency medical services for children, and identify potential career paths for current and future investigators.