Priorities for research in emergency medical services for children: results of a consensus conference

Youth Victims of Violence Report Worse Quality of Life Than Youth With Chronic Diseases

OBJECTIVES

Measuring health-related quality of life (HRQOL) provides the patient's perspective of his/her well-being and offers a unique outcome measure to demonstrate the impact of violence on the victim. To date, no study has described HRQOL in youth victims of violence in the United States. The purpose of this study was to describe HRQOL in youth victims of violence as compared with healthy youth and youth with chronic disease.

METHODS

We conducted an exploratory cross-sectional study of the HRQOL of victims of violence aged 8 to 18 years. Descriptive statistics were reported for participant and injury demographics. One sample t tests were used to compare the sample population's HRQOL to known HRQOL of healthy populations and specific disease populations.

RESULTS

Fifty-eight victims of violence participated in the study. Youth victims of violence had significantly worse mean HRQOL scores (mean, 71.4) compared with healthy youth in overall functioning (mean, 83.9), P < 0.001. Youth victims of violence reported worse psychosocial (mean, 67.6), emotional (mean, 62.9), and school (mean, 63.8) functioning than youth with obesity (mean, 72.1, 68.6, 75.0, respectively) and cancer (mean, 72.1, 72.2, 68.3, respectively). Mean Patient-Reported Outcomes Measurement Information System T scores for youth victims of violence were significantly worse in anxiety (T = 51.9) and depression (T = 52.4) compared with youth with obesity (T = 48.3, 49.2), cancer (T = 47.7, 47.6), and sickle cell disease (T = 43, 44).

CONCLUSIONS

Youth victims of violence suffer significant impairment in HRQOL compared with healthy populations and youth with specific disease burdens. Future studies into violence prevention effectiveness should use HRQOL as a comparative outcome measure to better tailor post injury management and interventions.

Variation in Pediatric Care Between Academic and Nonacademic US Emergency Departments, 1995-2010

OBJECTIVES

The aim of this study was to describe the resource utilization for children with common pediatric conditions treated in academic and nonacademic emergency departments (EDs).

METHODS

We performed a retrospective, cross-sectional descriptive study using the National Hospital Ambulatory Medical Care Survey Data from 1995 to 2010 including children less than 18 years old with a diagnosis of asthma, bronchiolitis, croup, gastroenteritis, fever, febrile seizure, or afebrile seizure. Academic EDs (A-ED) were those with greater than 25% of patients seen by a trainee. For each condition, we reported the proportion of testing, medications, and disposition between A-ED and nonacademic EDs (NA-ED).

RESULTS

From 1995 to 2010, approximately 450,000,000 estimated pediatric visits are represented by the survey based on 122,811 actual visits. For most common conditions, testing and disposition were comparable; however, some variation was noted. Among patients with bronchiolitis, a higher proportion of patients was admitted and had radiographs in NA-EDs (18% vs 10% and 56% vs 45%, respectively). For children with croup, radiographs were performed more often at NA-EDs (27% vs 6%). Among those with febrile seizures, more lumbar punctures were performed in NA-EDs (14% vs 0%). In children with afebrile seizures, more head computed tomography scans were obtained at NA-EDs (34% vs 21%).

CONCLUSION

Among pediatric patients with croup, bronchiolitis, and febrile and afebrile seizure, higher resource utilization and admissions were observed in NA-EDs. These preliminary findings from a national survey require a more detailed investigation into the variation in care between A-ED and NA-ED settings.

Isolated LOC in head trauma associated with significant injury on brain CT scan

Background

A report of loss of consciousness (LOC) is frequently considered reason enough to obtain a computed tomography (CT) scan in the evaluation of head trauma. We conducted this study to reduce exposure to radiation from CT, while still not overlooking clinically significant injuries.

Objective

The objective of the study is to determine the correlation between LOC status and brain CT scan results in patients with blunt head trauma and to determine whether there is a subset of patients for whom CT scan need not be performed, without missing clinically significant intracranial injuries.

Methods

This is a retrospective study conducted in the emergency department of an inner-city hospital. The patient population included patients ranging between 13 and 35 years of age, with blunt head trauma, who presented to the emergency department (ED) between January 2010 and December 2013. Patients were divided into two groups: “LOC” group and “no LOC” group. The results of brain CT scans from each group were compared with LOC status. For study purposes, “clinically significant” were those that required interventions or ICU hospitalization of at least 24 h or extended hospitalization. The results were analyzed using chi-square calculations.

Results

During the study period, 494 patients were identified as having suffered head trauma. Of these, 185 (37.5%) reported LOC and 309 (62.5%) did not lose consciousness. In the LOC group, 15 (8.1%) had significant CT findings compared to 1.3% (4/309) of those without LOC (p < .001). Of the 4 who had no LOC and had significant brain CT findings, all 4 patients had positive physical findings of head, neck, or facial trauma. In the LOC group, only 1/15 (6.7%) had significant CT findings with a normal GCS of 15 and no physical signs of the head, neck, or facial trauma.

Conclusions

A small proportion of patients with LOC had CT finding requiring intervention. Head trauma patients with no physical injuries to the head, neck, or face and a normal GCS had no significant brain CT findings. This raises the question of whether a routine brain CT scan should be obtained in patients with LOC, no physical findings, and a normal GCS after blunt head trauma.

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.

2015 Pediatric Research Priorities in Prehospital Care

BACKGROUND

Pediatric prehospital research has been limited, but work in this area is starting to increase particularly with the growth of pediatric-specific research endeavors. Given the increased interest in pediatric prehospital research, there is a need to identify specific research priorities that incorporate the perspective of prehospital providers and other emergency medical services (EMS) stakeholders.

OBJECTIVES

To develop a list of specific research priorities that is relevant, specific, and important to the practice of pediatric prehospital care.

METHODS

Three independent committees of EMS providers and researchers were recruited. Each committee developed a list of research topics. These topics were collated and used to initiate a modified Delphi process for developing consensus on a list of research priorities. Participants were the committee members. Topics approved by 80% were retained as research priorities. Topics that were rejected by more than 50% were eliminated. The remaining topics were modified and included on subsequent surveys. Each survey allowed respondents to add additional topics. The surveys were continued until all topics were either successfully retained or rejected and no new topics were suggested.

RESULTS

Fifty topics were identified by the three independent committees. These topics were included on the initial electronic survey. There were 5 subsequent surveys. At the completion of the final survey a total of 29 research priorities were identified. These research priorities covered the following study areas: airway management, asthma, cardiac arrest, pain, patient-family interaction, resource utilization, seizure, sepsis, spinal immobilization, toxicology, trauma, training and competency, and vascular access. The research priorities were very specific. For example, under airway the priorities were: "identify the optimal device for effectively managing the airway in the prehospital setting" and "identify the optimal airway management device for specific disease processes."

CONCLUSION

This project developed a list of relevant, specific, and important research priorities for pediatric prehospital care. Some similarities exist between this project and prior research agendas but this list represents a current, more specific research agenda and reflects the opinions of working EMS providers, researchers, and leaders.

KEY WORDS

emergency medical technician; research; emergency medical services; priorities.

Evidence-Based Criteria for the Choice and the Clinical use of the Most Appropriate Lock Solutions for Central Venous Catheters (Excluding Dialysis Catheters): A GAVeCeLT Consensus

Background

The most appropriate lock solution for central venous access devices is still to be defined. GAVeCeLT – the Italian group for venous access devices – has developed a consensus on the evidence-based criteria for the choice and the clinical use of the most appropriate lock solution for central venous catheters (excluding dialysis catheters).

Method

After the constitution of a panel of experts, a systematic collection and review of the literature has been performed, focusing on clinical studies dealing with lock solutions used for prevention of occlusion (heparin, citrate, urokinase, recombinant tissue plasminogen activator [r-TPA], normal saline) or for prevention of infection (citrate, ethanol, taurolidine, ethylene-diamine-tetra-acetic acid [EDTA], vancomycin, linezolid and other antibiotics), in both adults and in pediatric patients. Studies on central lines used for dialysis or pheresis, on peripheral venous lines and on arterial lines were excluded from this analysis. Studies on lock solutions used for treatment of obstruction or infection were not considered. The consensus has been carried out according to the Delphi method.

Results

The panel has concluded that: (a) there is no evidence supporting the heparin lock; (b) the prevention of occlusion is based on the proper flushing and locking technique with normal saline; (c) the most appropriate lock solution for infection prevention should include citrate and/or taurolidine, which have both anti-bacterial and anti-biofilm activity, with negligible undesired effects if compared to antibiotics; (d) the patient populations most likely to benefit from citrate/taurolidine lock are yet to be defined.

Conclusions

The actual value of heparinization for non-dialysis catheters should be reconsidered. Also, the use of lock with substances with anti-bacterial and anti-biofilm activity (such as citrate or taurolidine) should be taken into consideration in selected populations of patients.

Epidemiology of Pediatric Prehospital Basic Life Support Care in the United States

Children have unique medical needs compared to adults. Emergency medical services personnel need proper equipment and training to care for children. The purpose of this study is to characterize emergency medical services pediatric basic life support to help better understand the needs of children transported by ambulance. Pediatric basic life support patients were identified in this retrospective descriptive study. Descriptive statistics were used to examine incident location, possible injury, cardiac arrest, resuscitation attempted, chief complaint, primary symptom, provider's primary impression, cause of injury, and procedures performed during pediatric basic life support calls using the largest aggregate of emergency medical services data available, the 2013 National Emergency Medical Services Information System (NEMSIS) Public Release Research Data Set. Pediatric calls represented 7.4% of emergency medical services activations. Most pediatric patients were male (49.8%), White (40.0%), and of non-Hispanic origin (56.5%). Most incidents occurred in the home. Injury, cardiac arrest, and resuscitation attempts were highest in the 15 to 19 year old age group. Global complaints (37.1%) predominated by anatomic location and musculoskeletal complaints (26.9%) by organ system. The most common primary symptom was pain (30.3%) followed by mental/psychiatric (13.4%). Provider's top primary impression was traumatic injury (35.7%). The most common cause of injury was motor vehicle accident (32.3%). The most common procedure performed was patient assessment (27.4%). Median EMS system response time was 7 minutes (IQR: 5-12). Median EMS scene time was 12 minutes (IQR: 8-19). Median transport time was 14 minutes (IQR: 8-24). Median EMS total call time was 51 minutes (IQR: 33-77). The epidemiology of pediatric basic life support can help to guide efforts in both emergency medical services operations and training.

Research in Prehospital Care: Overcoming the Barriers to Success

OBJECTIVE

The objective of this project was to determine how investigators conduct clinical trials in the prehospital setting and to suggest how emergency medical services (EMS) systems can develop the capacity to conduct prehospital clinical research.

METHODS

A representative sample of U.S.-based study sites was selected from all studies registered on clinicaltrials.gov since the year 2000, where prehospital care providers conducted study-related activities in the prehospital setting. The site principal investigator and the research coordinator or EMS liaison were invited to participate in a structured discussion. A single interviewer conducted each discussion following a structured guide that generically asked for barriers and enablers to the sites' research success and then reviewed commonly identified prehospital research barriers. Notes were taken during each discussion and reviewed for common themes. Themes were reviewed by the project team and sent for comment to all participants.

RESULTS

Discussions were held with 25 principal investigators, 9 coordinators, and 7 EMS liaisons. A total of 27 communities were represented in the discussions from 22 different states. The communities had a range of research experience from one prehospital trial to multiple trials. Key barriers were funding, ethics approval, data collection, protocol training and compliance, randomizing and blinding interventions, obtaining patient outcomes, adequate study staffing, and partnering with EMS agencies.

CONCLUSION

This project identified many challenges to EMS research, but they were not insurmountable. Not every community can conduct every prehospital study. Communities should engage in studies that align with their values and resources. Investigators need to develop honest relationships where issues can be openly discussed and the community can collaborate on prehospital research. Learning from those who have overcome challenges may be a key to expanding the quality and quantity of EMS research.

A tale of two populations: addressing pediatric needs in the continuum of emergency care

Nearly 27% of all annual emergency department (ED) visits are pediatric related, a relatively small percentage in comparison to the number of visits from the adult population. The majority of the 31 million children and adolescents access care in nonpediatric facilities and have different clinical presentations and needs than adults. Administered by the Health Resources and Services Administration within the Department of Health and Human Services, the Emergency Medical Services for Children (EMSC) program is a federal entity that aims to ensure that pediatric care is well integrated into the entire emergency medical services system so that no matter where a child lives or travels, he or she can receive appropriate and timely care. The objective of this article is to describe the role of the EMSC program in the development of the pediatric emergency care system. The program is striving to improve pediatric emergency care in a number of ways: EMSC State Partnership grant performance measures address the ability of the out-of-hospital and hospital settings to care for children; the National Pediatric Readiness project works with EDs to ensure that essential resources are present to care for children; regionalization grants focus on the challenges of geographic isolation, access to specialty care, and limited resources; and the targeted issue grants focus on the care of the child in the out-of-hospital setting in which there is a paucity of evidence-based knowledge.

Interfacility transfers of noncritically ill children to academic pediatric emergency departments

OBJECTIVES

We aimed to characterize the demographics, diagnoses, and management of transferred patients who were directly discharged from the emergency department (ED) or admitted less than 24 hours.

METHODS

We conducted a retrospective, cross-sectional study of patients classified as interfacility ED transfers over a 12-month period in the Pediatric Health Information System database, an administrative database of 42 tertiary care pediatric US hospitals. The primary study outcomes were ED resource utilization at the receiving facility with a focus on children who were discharged directly from the ED or admitted less than 24 hours.

RESULTS

Overall, 24,905 interfacility transfers were identified, accounting for 1.3% of the ED volume of these academic pediatric centers. Of these, 24.7% were discharged directly from the ED and 17.0% were admitted for less than 24 hours. Among those directly discharged from the ED, the 3 most common complaints were orthopedic problems, nonsurgical abdominal pain, and viral gastroenteritis; 20.7% received no medical or procedural intervention. Among those admitted for less than 24 hours, the 3 most common complaints were orthopedic problems, traumatic head injury, and gastrointestinal conditions.

CONCLUSIONS

A significant proportion of interfacility transfers to academic pediatric EDs is discharged directly from the ED or is admitted for less than a day. These patients and their clinical outcomes provide insight into the educational needs and medical capabilities of referring hospitals and clinicians.

Health-related quality of life in pediatric minor injury: reliability, validity, and responsiveness of the Pediatric Quality of Life Inventory in the emergency department

OBJECTIVE

To evaluate the feasibility, reliability, validity, and responsiveness of the Pediatric Quality of Life Inventory 4.0 Generic Core Scales (PedsQL) in the first 2 weeks after pediatric emergency department care of minor injury.

DESIGN

Prospective cohort study.

SETTING

Pediatric hospital emergency department.

PARTICIPANTS

Children and adolescents with minor injury (n = 334).

MAIN OUTCOME MEASURES

Child- and parent-reported clinical outcomes and PedsQL scale scores.

RESULTS

The PedsQL had good to excellent internal consistency reliability (α range, 0.73-0.93). For each day that the clinical symptoms persisted, there were consistent decreases in mean health-related quality of life (HRQOL) scores (validity testing). There were significantly greater negative changes in mean HRQOL scores for fractures vs soft-tissue injuries and for lower vs upper extremity injuries. Clinical outcomes categorized as poor had large negative changes in HRQOL not seen in good outcome groups. Distribution-based indicators of change supported good responsiveness (effect sizes for the physical summary score, 0.01-2.44; group differences at follow-up exceeded estimates of the minimal importance difference).

CONCLUSIONS

The PedsQL is feasible, reliable, and demonstrates good construct and discriminant validity and responsiveness in measuring short-term outcome after minor injury care in the pediatric emergency department. Assessing short-term outcome from the patient perspective with HRQOL measures may greatly enhance our ability to evaluate the effectiveness of emergency department care.

A qualitative assessment of factors that influence emergency medical services partnerships in prehospital research

OBJECTIVES

  Recent efforts to increase emergency medical services (EMS) prehospital research productivity by focusing on reducing systems-related barriers to research participation have had limited effect. The objective of this study was to explore the barriers and motivators to participating in research at the agency and provider levels and to solicit suggestions for improving the success of prehospital research projects.

METHODS

  The authors conducted a qualitative exploratory study of EMS personnel using focus group and focused interview methodology. EMS personnel affiliated with the Pediatric Emergency Care Applied Research Network (PECARN) hospitals were selected for participation using a purposive sampling plan. Exploratory questioning identified identified factors that influence participation in research and suggestions for ensuring successful research partnerships. Through iterative coding and analysis, the factors and suggestions that emerged from the data were organized into a behavioral change planning model.

RESULTS

  Fourteen focus groups were conducted, involving 88 EMS prehospital providers from 11 agencies. Thirty-five in-depth interviews with EMS administrators and researchers were also conducted. This sample was representative of prehospital personnel servicing the PECARN catchment area and was sufficient for analytical saturation. From the transcripts, the authors identified 17 barriers and 12 motivators to EMS personnel participation in research. Central to these data were patient safety, clarity of research purpose, benefits, liability, professionalism, research training, communication with the research team, reputation, administrators' support, and organizational culture. Interviewees also made 29 suggestions for increasing EMS personnel participation in research. During data analysis, the PRECEDE/PROCEED planning model was chosen for behavioral change to organize the data. Important to this model, factors and suggestions were mapped into those that predispose (knowledge, attitudes, and beliefs), reinforce (social support and norms), and/or enable (organizational) the participation in prehospital research.

CONCLUSIONS

  This study identified factors that influence the participation of EMS personnel in research and gathered suggestions for improvement. These findings were organized into the PRECEDE/PROCEED planning model that may help researchers successfully plan, implement, and complete prehospital research projects. The authors provide guidance to improve the research process including directly involving EMS providers throughout, a strong theme that emerged from the data. Future work is needed to determine the validity of this model and to assess if these findings are generalizable across prehospital settings other than those affiliated with PECARN.

Mild traumatic brain injury and postconcussive symptoms in children and adolescents

The vast majority of traumatic brain injuries (TBI) in children are of mild severity. Even if only a small proportion of children with mild TBI suffer negative outcomes, then mild TBI is a serious public health problem. This review summarizes the literature regarding the neurobehavioral outcomes associated with mild TBI in children and adolescents, focusing on the longstanding debate regarding postconcussive symptoms and attendant conceptual and methodological issues. The review also discusses future research directions, the long-term goal of which is to develop a comprehensive and integrated biopsychosocial model of outcomes that helps guide clinical management.

Improving pretransport care of pediatric emergency patients: an assessment of referring hospital care

OBJECTIVES

Before effective educational interventions can be implemented to improve health care, a needs assessment is essential to determine areas best targeted for improvement. The purpose of this study was to assess the educational needs of referring community hospitals with regard to the pretransport care of pediatric patients.

METHODS

We performed a prospective survey of physicians accepting referrals from community hospitals in the emergency department of a large, urban, academic, pediatric hospital. Based on the routine pretransport telephone consultation, we asked the accepting physician to document the appropriateness of the referring hospital's management of the patient before the request for transport. We reviewed the corresponding transport records of all children for whom pretransport care was categorized as suboptimal. We report frequencies and relative frequencies for suboptimal care, reasons for suboptimal care, and the pretransport diagnoses of these patients.

RESULTS

There were 817 pediatric patients transported from 54 different hospitals during the 3-month study period, for which we received 477 surveys (58% response rate). The accepting physician rated the pretransport care as suboptimal for 105 (22%) of 477 patients. The most common diagnoses of referrals were respiratory distress, asthma, and seizures. Care was more likely to be reported suboptimal for patients with fever (P = 0.001) and asthma (P = 0.04).

CONCLUSIONS

Using a simple survey, we identified opportunities for improvement in the management of pediatric emergency patients by referring hospitals in 22% of cases.

A new diagnosis grouping system for child emergency department visits

OBJECTIVES

A clinically sensible system of grouping diseases is needed for describing pediatric emergency diagnoses for research and reporting. This project aimed to create an International Classification of Diseases (ICD)-based diagnosis grouping system (DGS) for child emergency department (ED) visits that is 1) clinically sensible with regard to how diagnoses are grouped and 2) comprehensive in accounting for nearly all diagnoses (>95%). The second objective was to assess the construct validity of the DGS by examining variation in the frequency of targeted groups of diagnoses within the concepts of season, age, sex, and hospital type.

METHODS

A panel of general and pediatric emergency physicians used the nominal group technique and Delphi surveys to create the DGS. The primary data source used to develop the DGS was the Pediatric Emergency Care Applied Research Network (PECARN) Core Data Project (PCDP).

RESULTS

A total of 3,041 ICD-9 codes, accounting for 98.9% of all diagnoses in the PCDP, served as the basis for creation of the DGS. The expert panel developed a DGS framework representing a clinical approach to the diagnosis and treatment of pediatric emergency patients. The resulting DGS has 21 major groups and 77 subgroups and accounts for 96.5% to 99% of diagnoses when applied to three external data sets. Variations in the frequency of targeted groups of diagnoses related to seasonality, age, sex, and site of care confirm construct validity.

CONCLUSIONS

The DGS offers a clinically sensible method for describing pediatric ED visits by grouping ICD-9 codes in a consensus-derived classification scheme. This system may be used for research, reporting, needs assessment, and resource planning.

Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study

BACKGROUND

CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary.

METHODS

We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission >or=2 nights).

FINDINGS

We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35.3%); ciTBIs occurred in 376 (0.9%), and 60 (0.1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100.0%, 95% CI 99.7-100 0) and sensitivity of 25/25 (100%, 86.3-100.0). 167 (24.1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99.95%, 99.81-99.99) and sensitivity of 61/63 (96.8%, 89.0-99.6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations.

INTERPRETATION

These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated.

FUNDING

The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.

Health-related quality of life for pediatric emergency department febrile illnesses: an evaluation of the Pediatric Quality of Life Inventory 4.0 Generic Core Scales

OBJECTIVE

We sought to assess the validity and short-term responsiveness of the Pediatric Quality of Life Inventory 4.0 Generic Core Scales (PedsQL) for febrile illnesses evaluated in the pediatric emergency department (ED).

DESIGN

Prospective cohort study of children 2-18 years discharged after ED evaluation for fever (>or= 38 degrees C). Self-administered, parent-report of health-related quality of life (HRQOL) was assessed using the PedsQL Acute Version, a validated HRQOL instrument. HRQOL was measured on ED presentation and at 7-10 day follow-up. At follow-up, duration of fever, child functional impairment, missed daycare/school, and disrupted family unit functioning, were assessed.

RESULTS

Of 160 subjects enrolled, 97 (61%) completed the study; mean follow-up was 8.7 days. Mean total HRQOL score on ED presentation was 76.4; mean follow-up score was 86.3. Compared to subjects that returned to baseline, statistically significant differences in HRQOL were noted for those with prolonged fever, child functional impairment, and relapse. Significant correlation was observed between HRQOL at follow-up and days of daycare/school missed (r = -0.35, p = .003) and days of family disruption (r = -0.43, p < .001). Mean change in HRQOL within subjects, from ED visit to follow-up, was +9.8 (95% CI: 5.6-14.6). Effect size was 0.53, indicating moderate responsiveness.

CONCLUSION

The PedsQL appears to be a valid and responsive indicator of HRQOL for short-term febrile illnesses evaluated in the ED.

The epidemiology of emergency medical services use by children: an analysis of the National Hospital Ambulatory Medical Care Survey

OBJECTIVE

There is an absence of nationally representative data describing pediatric patients who use emergency medical services (EMS) and the factors associated with EMS use by children. This study characterizes pediatric emergency department (ED) visits for which the patient arrived by EMS and identifies factors associated with those visits using a nationally representative database.

METHODS

A secondary analysis of the ED component of the 1997-2000 National Hospital Ambulatory Medical Care Survey was performed. The dependent variable was the mode of arrival to the ED (EMS vs. not EMS), and independent variables were grouped into four domains: demographic, clinical, system, and service characteristics. Bivariate analyses and multivariate logistic regression analyses were conducted.

RESULTS

There were 110.9 million ED visits by children aged<19 years between 1997 and 2000. Pediatric patients constituted 27.3% of all ED visits during this time, and 7.9 million (7.1%) of these patients arrived via EMS. Pediatric patients represented 13% of all EMS transports. The annual EMS utilization rate by children was 26 per 1,000, compared with 66 per 1,000 in the adult population (p<0.001). Sixteen percent of children transported by EMS were admitted to the hospital. Sixty-two percent of pediatric patients arriving at the ED by EMS were transported as a result of injury or poisoning. Characteristics significantly associated with arrival by EMS in the final multivariate model included demographic (age, African American race, urban residence), clinical (need for greater immediacy of care, illnesses associated with certain diagnoses), and service (greater number of diagnostic services) variables.

CONCLUSIONS

Pediatric patients transported by EMS are more likely to have injuries and poisoning, and have higher-acuity illness than those arriving at the ED by other means. The epidemiology of pediatric EMS use may have important operational, training, and public health implications and requires further study.

Revisiting the emergency medicine services for children research agenda: priorities for multicenter research in pediatric emergency care

OBJECTIVES

To describe the creation of an Emergency Medical Services for Children (EMSC) research agenda specific to multicenter research. Given the need for multicenter research in EMSC and the unique opportunity afforded by the creation of the Pediatric Emergency Care Applied Research Network (PECARN), the authors revisited existing EMSC research agendas to develop a PECARN-specific research agenda. They sought to prioritize PECARN research efforts, to guide investigators planning to conduct research in PECARN, and to describe the creation of a prioritized EMSC research agenda specific for multicenter research.

METHODS

The authors used the Nominal Group Process and Hanlon Process of Prioritization (HPP), which are recognized research prioritization methods incorporating both quantitative and qualitative data collection in group settings. The formula used to generate the final priority list heavily weighted practicality of conduct in a multicenter research network. By using size, seriousness, and practicality measures of each health priority, PECARN was able to identify factors that could be scored individually and were weighted relative to each other.

RESULTS

The prioritization processes resulted in a ranked list of 16 multicenter EMSC research topics. Top among these priorities were 1) respiratory illnesses/asthma, 2) prediction rules for high-stakes/low-likelihood diseases, 3) medication error reduction, 4) injury prevention, and 5) urgency and acuity scaling.

CONCLUSIONS

The PECARN prioritization process identified high-priority EMSC research topics specific to multicenter research. PECARN has the capacity to answer long-standing, important clinical controversies in EMSC, largely due to its ability to conduct randomized controlled trials and observational studies on a large scale.

Short-term outcomes of pediatric emergency department febrile illnesses

OBJECTIVE

To describe short-term outcomes relevant to children and their caregivers after evaluation in the emergency department (ED) for febrile illnesses.

METHODS

This was a prospective cohort study of children aged 28 days to 18 years presenting with fever (> or =38 degrees C), or chief complaint of fever, who were evaluated and discharged to home from tertiary care pediatric ED. Enrollment occurred on randomly selected study days over 1 year. Caregivers were then contacted via telephone after 7 to 10 days to assess outcomes, including days of fever, child and family activity impairments, as well as return to health care.

RESULTS

Follow-up was complete for 322 (72%) of 451 enrolled subjects. Mean age of subjects was 31.5 months. The most common discharge diagnosis was undifferentiated febrile illness (20.5%). Mean total duration of fever was 4.41 days (95% confidence interval [CI], 4.14-4.81); 38.9% remained febrile for 5 days or longer. For children, impairments in each outcome (activity, oral intake, sleep, behavior) persisted longer than 2.5 days; over 14% of them remained impaired at follow-up in each outcome. Children missed a mean of 2.63 days of day care or school (95% CI, 2.21-3.06); 37.4% missed 3 days or longer. Primary caregivers missed 1.47 days of work or school (95% CI, 1.19-1.75); 10.5% missed 5 days or longer. After ED evaluation, 23.7% made a nonscheduled revisit to the primary medical doctor or ED.

CONCLUSIONS

Children, and their caregivers, experience prolonged fever and impairments in activities, and frequently relapse to health care as a result of febrile illnesses. Often considered minor in nature, febrile illnesses have considerable effects on the child, caregivers, and families after ED evaluation.

Epidemiology of a pediatric emergency medicine research network: the PECARN Core Data Project

OBJECTIVE

To examine the epidemiology of pediatric patient visits to emergency departments (ED).

METHODS

We conducted a cross-sectional study of pediatric ED visits at the participating Pediatric Emergency Care Applied Research Network (PECARN) hospitals in 2002. We provide descriptive characteristics of pediatric ED visits and a comparison of the study database to the National Hospital Ambulatory Medical Care Survey (NHAMCS). Bivariate analyses were calculated to assess characteristics associated with hospital admission, death in the ED, and length of ED visit. We also performed multivariate regression to model the likelihood of admission to the hospital.

RESULTS

Mean patient age was 6.2 years; 53.5% were boys; 47.5% black; and 43.2% had Medicaid insurance. The most common ED diagnoses were fever, upper respiratory infection, asthma, otitis media, and viral syndromes. The inpatient admission rate was 11.6%. The most common diagnoses requiring hospitalization were asthma, dehydration, fever, bronchiolitis, and pneumonia. In multivariate analysis, patients who were black or Hispanic, had Medicaid insurance or were uninsured, or were older than 1 year were less likely to be hospitalized. Demographics of the PECARN population were similar to NHAMCS, with notable exceptions of a larger proportion of black patients and of admitted patients from the PECARN EDs.

CONCLUSION

We describe previously unavailable epidemiological information about childhood illnesses and injuries that can inform development of future studies on the effectiveness, outcomes, and quality of emergency medical services for children. Most pediatric ED patients in our study sought care for infectious causes or asthma and were discharged from the ED. Hospital admission rate differed according to age, payer type, race/ethnicity, and diagnosis.

Economic value of out-of-hospital emergency care: a structured literature review

STUDY OBJECTIVE

The evaluation of the impact of out-of-hospital emergency care is a relatively new research focus. As such, there is a compelling need to determine how finite health care resources should be used in this setting. The objective of this study is to conduct a structured review of published economic evaluations of out-of-hospital emergency care to assess its economic value.

METHODS

A structured literature search and structured review of articles pertaining to the economic value of out-of-hospital care was performed. The bibliographic database MEDLINE was searched for pertinent English-language articles published between 1966 and 2003. The search used the medical subject headings "emergency medical services" and "emergency medical technician" and was limited to the subheading "economics" and crossed with the medical subject heading "economics." The titles generated by this search were systematically reviewed and limited by topic. Abstracts from the identified titles were reviewed to select a final set of pertinent articles. These articles were further limited based on explicit inclusion and exclusion criteria. Authors used a previously published structured evaluation tool to review the final set of identified articles for quality and content.

RESULTS

The initial MEDLINE search identified 3,533 citations. From this set, 535 potentially relevant abstracts were reviewed. From the abstract review, 46 articles were identified, along with an additional 14 from searching the secondary references. Of these 60 articles, 32 met the review inclusion criteria and were subjected to a full structured review. These studies predominantly addressed the cost of cardiac arrest (n=13, 41%), major trauma (n=8, 25%), and emergency medical services treatment in general (n=8, 25%). Only 14 studies considered the costs and consequences of competing alternatives. Of these, 2 were cost-benefit and 12 were cost-effectiveness evaluations. Two of the 14 studies met all 10 criteria for high-quality economic evaluation, whereas 2 others met none.

CONCLUSION

There is a paucity of out-of-hospital care literature that addresses cost and economic value. The extant literature is limited in scope, poor in quality, and evaluates small subsets of out-of-hospital emergency care costs. Favorable cost-effectiveness has not been firmly established for most aspects of out-of-hospital emergency care.

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 National EMS Research strategic plan

One of the eight major recommendations put forth by the National EMS Research Agenda Implementation Project in 2002 was the development of an emergency medical services (EMS) research strategic plan. Using a modified Delphi technique along with a consensus conference approach, a strategic plan for EMS research was created. The plan includes recommendations for concentrating efforts by EMS researchers, policy makers, and funding resources with the ultimate goal of improving clinical outcomes. Clinical issues targeted for additional research efforts include evaluation and treatment of patients with asthma, acute cardiac ischemia, circulatory shock, major injury, pain, acute stroke, and traumatic brain injury. The plan calls for developing, evaluating, and validating improved measurement tools and techniques. Additional research to improve the education of EMS personnel as well as system design and operation is also suggested. Implementation of the EMS research strategic plan will improve both the delivery of services and the care of individuals who access the emergency medical system.

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.

Out-of-hospital pediatric cardiac arrest: an epidemiologic review and assessment of current knowledge

STUDY OBJECTIVE

We systematically summarize pediatric out-of-hospital cardiac arrest epidemiology and assess knowledge of effects of specific out-of-hospital interventions.

METHODS

We conducted a comprehensive review of published articles from 1966 to 2004, available through MEDLINE, Cumulative Index to Nursing and Allied Health Literature, EmBase, and the Cochrane Registry, describing outcomes of children younger than 18 years with an out-of-hospital cardiac arrest. Patient characteristics, process of care, and outcomes were compared using pediatric Utstein outcome report guidelines. Effects of out-of-hospital care processes on survival outcomes were summarized.

RESULTS

Forty-one studies met inclusion criteria; 8 complied with Utstein reporting guidelines. Included in the review were 5,363 patients: 12.1% survived to hospital discharge, and 4% survived neurologically intact. Trauma patients (n=2,299) had greater overall survival (21.9%, 6.8% intact); a separate examination of studies with more rigorous cardiac arrest definition showed poorer survival (1.1% overall, 0.3% neurologically intact). Submersion injury-associated arrests (n=442) had greater overall survival (22.7%, 6% intact). Pooled data analysis of bystander cardiopulmonary resuscitation and witnessed arrest status showed increased likelihood of survival (relative risk 1.99, 95% confidence interval 1.54 to 2.57) for witnessed arrests. The effect of bystander cardiopulmonary resuscitation is difficult to determine because of study heterogeneity.

CONCLUSION

Outcomes from out-of-hospital pediatric cardiac arrest are generally poor. Variability may exist in survival by patient subgroups, but differences are hard to accurately characterize. Conformity with Utstein guidelines for reporting and research design is incomplete. Witnessed arrest status remains associated with improved survival. The need for prospective controlled trials remains a high priority.

Does an isolated history of loss of consciousness or amnesia predict brain injuries in children after blunt head trauma?

BACKGROUND

A history of loss of consciousness (LOC) is frequently used as an indication for cranial computed tomography (CT) in the emergency department (ED) evaluation of children with blunt head trauma.

OBJECTIVE

We sought to determine whether an isolated LOC and/or amnesia is predictive of traumatic brain injury (TBI) in children with blunt head trauma.

METHODS

We prospectively enrolled children <18 years old presenting to a level I trauma center ED between July 1998 and September 2001 with blunt head trauma. We evaluated the association of LOC and/or amnesia with 1) TBI identified on CT and 2) TBI requiring acute intervention. We defined the latter by a neurosurgical procedure, antiepileptic medication for >1 week, persistent neurologic deficits, or hospitalization for > or =2 nights. We then investigated the association of LOC and/or amnesia with TBI in those patients without other symptoms or signs of TBI ("isolated" LOC and/or amnesia).

RESULTS

Of eligible children, 2043 (77%) were enrolled, 1271 (62%) of whom underwent CT; 1159 (91%) of these 1271 had their LOC and/or amnesia status known. A total of 801 (39%) of the 2043 enrolled children had a documented history of LOC and/or amnesia. Of the 745 with documented LOC and/or amnesia who underwent CT, 70 (9.4%; 95% confidence interval [CI]: 7.4%, 11.7%) had TBI identified on CT versus 11 of 414 (2.7%; 95% CI: 1.3%, 4.7%) without LOC and/or amnesia (difference: 6.7%; 95% CI: 4.1%, 9.3%). Of the 801 children known to have had LOC and/or amnesia (regardless of whether they underwent CT), 77 (9.6%; 95% CI: 7.7%, 11.9%) had TBI requiring acute intervention versus 11 of 1115 (1%; 95% CI: 0.5%, 1.8%) of those without LOC and/or amnesia (difference: 8.6%; 95% CI: 6.5%, 10.7%). For those with an isolated LOC and/or amnesia without other signs or symptoms of TBI, however, 0 of 142 (95% CI: 0%, 2.1%) had TBI identified on CT, and 0 of 164 (95% CI: 0%,1.8%) had TBI requiring acute intervention.

CONCLUSIONS

Isolated LOC and/or amnesia, defined by the absence of other clinical findings suggestive of TBI, are not predictive of either TBI on CT or TBI requiring acute intervention. Elimination of an isolated LOC and/or amnesia as an indication for CT may decrease unnecessary CT use in those patients without an appreciable risk of TBI.

A decision rule for identifying children at low risk for brain injuries after blunt head trauma

STUDY OBJECTIVE

Computed tomography (CT) is frequently used in evaluating children with blunt head trauma. Routine use of CT, however, has disadvantages. Therefore, we sought to derive a decision rule for identifying children at low risk for traumatic brain injuries.

METHODS

We enrolled children with blunt head trauma at a pediatric trauma center in an observational cohort study between July 1998 and September 2001. We evaluated clinical predictors of traumatic brain injury on CT scan and traumatic brain injury requiring acute intervention, defined by a neurosurgical procedure, antiepileptic medications for more than 1 week, persistent neurologic deficits, or hospitalization for at least 2 nights. We performed recursive partitioning to create clinical decision rules.

RESULTS

Two thousand forty-three children were enrolled, 1,271 (62%) underwent CT, 98 (7.7%; 95% confidence interval [CI] 6.3% to 9.3%) had traumatic brain injuries on CT scan, and 105 (5.1%; 95% CI 4.2% to 6.2%) had traumatic brain injuries requiring acute intervention. Abnormal mental status, clinical signs of skull fracture, history of vomiting, scalp hematoma (in children < or =2 years of age), or headache identified 97/98 (99%; 95% CI 94% to 100%) of those with traumatic brain injuries on CT scan and 105/105 (100%; 95% CI 97% to 100%) of those with traumatic brain injuries requiring acute intervention. Of the 304 (24%) children undergoing CT who had none of these predictors, only 1 (0.3%; 95% CI 0% to 1.8%) had traumatic brain injury on CT, and that patient was discharged from the ED without complications.

CONCLUSION

Important factors for identifying children at low risk for traumatic brain injuries after blunt head trauma included the absence of: abnormal mental status, clinical signs of skull fracture, a history of vomiting, scalp hematoma (in children < or =2 years of age), and headache.

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 Pediatric Emergency Care Applied Research Network (PECARN): rationale, development, and first steps

Since its formal recognition as a medical specialty, the field of pediatric emergency medicine has made substantial advances with respect to its scope and sophistication. These advances have occurred in clinical practice as well as in the research base to improve clinical practice. There remain, however, many areas in emergency medical services for children (EMSC) in the out-of-hospital, emergency department (ED), and hospital settings that suffer from a lack of data to guide practice. In an effort to expand the quality and quantity of research in pediatric emergency care, the Pediatric Emergency Care Applied Research Network (PECARN) was created in October of 2001. PECARN is the first federally funded national network for research in EMSC and is the result of cooperative agreement grants funded through the Health Resources and Services Administration with the purpose of developing an infrastructure capable of overcoming inherent barriers to EMSC research. Among these recognized barriers are low incidence rates of serious pediatric emergency events, the need for large numbers of children from varied backgrounds to achieve broadly representative study samples, lack of an infrastructure to test the efficacy of pediatric emergency care, and the need for a mechanism to translate study results into clinical practice. PECARN will serve as a national platform for collaborative research involving the continuum of care within the EMSC system, including out-of-hospital care, patient transport, ED and in-hospital care, and rehabilitation. This article describes the history of EMSC, the need for a national collaborative research network in EMSC, the organization and development of PECARN, and the work plan for the network.

Outcomes research and emergency medical services for children: domains, challenges, and opportunities

Outcomes research focuses on the end results of medical care. This paper describes the specific domains of outcomes research, namely, clinical effectiveness, quality of care, quality of life, patient satisfaction, cost-effectiveness, and organization of care, which are the primary domains of outcomes research. Specific examples of pediatric emergency medicine applications are provided for each domain. Outcomes research in the clinical specialties of pediatrics, emergency medicine, and emergency medical services is in an early stage of development relative to that of adult medicine. Thus, the intersection of these clinical specialties, pediatric emergency medicine, presents many challenges and opportunities.

Identifying research priorities on infections in older adults: proceedings of an interdisciplinary workshop

BACKGROUND

Infections pose a substantial burden to the health of older adults. In this report, we describe the proceedings of a workshop to formulate and prioritize research questions about infections in older adults using an interdisciplinary approach.

METHODS

Researchers from four sectors (basic science, clinical sciences, health services and epidemiology/determinants of health) and representatives from various Canadian local, provincial, and federal stakeholder groups were invited to a two-day workshop. Five multi-disciplinary groups and stakeholders from each of three healthcare settings (long term, acute care and community) discussed research priorities for each of the settings. Five to ten research questions were identified for each setting.

RESULTS

The research questions proposed ranged from risk factors and outcomes for different infections to the effect of nutrition on infection and the role of alternative and complementary medicine in treating infections. Health service issues included barriers to immunization, prolongation of hospital length of stay by infection, use of care paths for managing infections, and decision-making in determining the site of care for individuals with infections. Clinical questions included risk factor assessment for infection, the effectiveness of preventative strategies, and technology evaluation. Epidemiologic issues included the challenge of achieving a better understanding of respiratory infections in the community and determining the prevalence of colonization with multi-resistant bacteria.

CONCLUSIONS

The questions are of direct relevance to researchers in a wide variety of fields. Bringing together a multi-disciplinary group of researchers to frame and prioritize research questions about aging is feasible, participants valued the opinions of people working in other areas.

Probabilistic linkage of computerized ambulance and inpatient hospital discharge records: a potential tool for evaluation of emergency medical services

STUDY OBJECTIVES

Emergency medical services (EMS) is an important part of the health care system. The effect of EMS on morbidity, mortality, and costs of illness is difficult to evaluate because hospital information is not available in out-of-hospital databases. We used probabilistic linkage to create such a database from ambulance and inpatient data and demonstrate the potential for linkage to facilitate evaluation of EMS responses resulting in hospital admission.

METHODS

Statewide ambulance and inpatient hospital discharge records were available for 1994 through 1996. Ambulance records indicating admission to the emergency department or hospital (165,649 records) were linked to inpatient hospital records indicating emergency admission (146,292 records) by using probabilistic linkage. Out-of-hospital data (dispatch code, treatments rendered, and ages), linkage rates, and inpatient data (discharge status, charges, length of stay, and payer category) were analyzed.

RESULTS

We linked 24,299 (14.7%) ambulance events to inpatient hospital discharges. If we had used exact linkage methods, we would have only linked 14,621 record pairs, a loss of nearly 40%. Linkage rates were relatively constant between years (approximately 15%) but differed by ambulance dispatch codes. Out-of-hospital dispatch codes with high linkage rates included breathing problems (22.6%), chest pain (21.5%), diabetic problems (16.9%), drowning incidents (14.9%), falls (19.2%), strokes (32.8%), and unconsciousness or fainting episodes (16.1%). Linkage to the hospital record provided access to hospital outcome data. Inpatient mortality was 6.8%. Survivors were discharged home (60.7%), transferred to other acute-care facilities (3.6%) or intermediate-care facilities (23.3%), or discharged with home health care provision (4.9%). The median length of stay was 3 days, and median charges were $6,620; total inpatient charges were $286,737,067.

CONCLUSION

Probabilistic linkage enables ambulance and hospital discharge records to be linked together and potentially increases our ability to critically evaluate EMS by providing access to hospital-based outcomes. Such evaluation will be further improved by linking to ED, other outpatient, and other public health data sources.

Use of out-of-hospital interventions for the pediatric patient in an urban emergency medical services system

OBJECTIVE

To determine appropriateness of out-of-hospital interventions by emergency medical services (EMS) personnel on children with respiratory illnesses.

METHODS

A retrospective, cross-sectional study was performed on a random sample of 304 children transported by an urban EMS system during 1994. Data were abstracted from EMScan (a computerized database of all EMS dispatches) and the EMS narrative records. Appropriate utilization of interventions was determined by comparison with the standard EMS protocol for respiratory complaints in this system. An assessment of whether interventions were inappropriately underutilized or inappropriately overutilized was made. Effect of severity of illness, patient age, transport times, and use of medical command on the use of interventions was evaluated.

RESULTS

Two hundred three patients (67%) were classified as having respiratory distress. Overall, 56% of the patients received appropriate interventions, 39% received one or two inappropriate interventions, and 5% received three or more inappropriate interventions. Rates of inappropriate utilization with 95% CI for each intervention were: oxygen 16% (95% CI = 12 to 20), assisted ventilation 2% (95% CI = 0.5 to 4), medication use 9% (95% CI = 6 to 13), vascular access 11% (95% CI = 7 to 14), phlebotomy 9% (95% CI = 6 to 13), and cardiac monitoring 18% (95% CI = 14 to 22). Oxygen and medications were underutilized (p < 0.005), whereas vascular access, cardiac monitoring, and phlebotomy were overutilized (p < 0.005). Online medical command (used in 9% of transports) improved appropriate use of vascular access [OR 8.3 (95% CI = 3 to 25) (p < 0.001)] and cardiac monitoring [OR = 3 (95% CI = 1 to 8) (p < 0.05)].

CONCLUSIONS

Emergency medical services personnel underutilized oxygen and medications and overutilized vascular access, phlebotomy, and cardiac monitoring in children with respiratory illness in this urban setting. Increasing patient age, transport times, and illness severity tend to increase the use of certain interventions, while contact with online medical direction seems to improve appropriate use of interventions.