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Mould-Millman NK, Dixon J, Beaty BL, Suresh K, de Vries S, Bester B, Moreira F, Cunningham C, Moodley K, Cermak R, Schauer SG, Maddry JK, Bills CB, Havranek EP, Bebarta VS, Ginde AA. Improving prehospital traumatic shock care: implementation and clinical effectiveness of a pragmatic, quasi-experimental trial in a resource-constrained South African setting. BMJ Open 2023; 13:e060338. [PMID: 37185181 PMCID: PMC10151988 DOI: 10.1136/bmjopen-2021-060338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 04/13/2023] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVES This project seeks to improve providers' practices and patient outcomes from prehospital (ie, ambulance-based) trauma care in a middle-income country using a novel implementation strategy to introduce a bundled clinical intervention. DESIGN We conduct a two-arm, controlled, mixed-methods, hybrid type II study. SETTING This study was conducted in the Western Cape Government Emergency Medical Services (EMS) system of South Africa. INTERVENTIONS We pragmatically implemented a simplified prehospital bundle of trauma care (with five core elements) using a novel workplace-based, peer-to-peer, rapid training format. We assigned the intervention and control sites. OUTCOME MEASURES We assessed implementation effectiveness among EMS providers and stakeholders, using the RE-AIM framework. Clinical effectiveness was assessed at the patient level, using changes in Shock Index x Age (SIxAge). Indices and cut-offs were established a priori. We performed a difference-in-differences (D-I-D) analysis with a multivariable mixed effects model. RESULTS 198 of 240 (82.5%) EMS providers participated, 93 (47%) intervention and 105 (53%) control, with similar baseline characteristics. The overall implementation effectiveness was excellent (80.6%): reach was good (65%), effectiveness was excellent (87%), implementation fidelity was good (72%) and adoption was excellent (87%). Participants and stakeholders generally reported very high satisfaction with the implementation strategy citing that it was a strong operational fit and effective educational model for their organisation. A total of 770 patients were included: 329 (42.7%) interventions and 441 (57.3%) controls, with no baseline differences. Intervention arm patients had more improved SIxAge compared with control at 4 months, which was not statistically significant (-1.4 D-I-D; p=0.35). There was no significant difference in change of SIxAge over time between the groups for any of the other time intervals (p=0.99). CONCLUSIONS In this quasi-experimental trial of bundled care using the novel workplace rapid training approach, we found overall excellent implementation effectiveness but no overall statistically significant clinical effectiveness.
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Affiliation(s)
- Nee-Kofi Mould-Millman
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Julia Dixon
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Brenda L Beaty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Krithika Suresh
- Department of Biostatistics & Informatics, University of Colorado School of Public Health, Aurora, Colorado, USA
| | - Shaheem de Vries
- Emergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South Africa
| | - Beatrix Bester
- Emergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South Africa
| | - Fabio Moreira
- Emergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South Africa
| | - Charmaine Cunningham
- Division of Emergency Medicine, University of Cape Town Faculty of Health Sciences, Belville, South Africa
| | - Kubendhren Moodley
- Emergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South Africa
| | - Radomir Cermak
- Emergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South Africa
| | - Steven G Schauer
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, Texas, USA
| | - Joseph K Maddry
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, Texas, USA
| | - Corey B Bills
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Edward P Havranek
- Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA
| | - Vikhyat S Bebarta
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
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Hanna A, Crowe RP, Fishe JN. Pediatric Bradycardia Is Undertreated in the Prehospital Setting: A Retrospective Multi-Agency Analysis. PREHOSP EMERG CARE 2023; 27:101-106. [PMID: 34913820 DOI: 10.1080/10903127.2021.2018075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Bradycardia is the most common terminal cardiac electrical activity in children, and early recognition and treatment is necessary to avoid cardiac arrest. Interventions such as oxygen, chest compressions, epinephrine, and atropine recommended by American Heart Association (AHA) Pediatric Advanced Life support (PALS) guidelines have been shown to improve outcomes (including higher survival rates) for inpatient pediatric patients with bradycardia. However, little is known about the epidemiology of pediatric prehospital bradycardia. We sought to investigate the incidence and management of pediatric bradycardia in the prehospital setting by emergency medical services (EMS). METHODS This was a retrospective study of 911 scene response prehospital encounters for patients ages 0-18 years in 2019 from the United States ESO Research Data Collaborative. We defined age-based bradycardia per the 2015 AHA PALS guidelines. We performed general descriptive statistics and a univariate analysis examining any PALS-recommended interventions in the presence of altered mental status, hypotension for age, and a first heart rate less than 60. RESULTS Of 7,422,710 encounters in the 2019 ESO Data Collaborative, 1,209 patients met inclusion criteria. Most (58.5%) were male, and the median age was 2 years (interquartile range 0-13 years). One-quarter (24.7%) of patients received fluids, and bag-valve mask ventilation was the most common airway intervention (12.1% of patients). Receipt of any PALS-recommended interventions was associated with age-adjusted hypotension (odds ratio (OR) 4.0, 95% confidence interval (CI) 3.9-5.4) and altered mental status (OR 15.5, 95% CI 10.7-22.3), but not a first heart rate less than 60 bpm (OR 0.9, 95% CI 0.6-1.1). CONCLUSIONS To our knowledge, this study is the first to examine the incidence and management of prehospital pediatric bradycardia. Incidence was rare, but adherence to PALS guidelines was variable. Further research and education are needed to ensure proper prehospital treatment of pediatric bradycardia.
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Affiliation(s)
- Andrew Hanna
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | | | - Jennifer N Fishe
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
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Kjerulff J, Bach A, Væggemose U, Skaarup SH, Bøtker MT. Implementation and findings on a one-minute sit-stand test for prehospital triage in patients with suspected COVID-19-a pilot project. BMC Emerg Med 2022; 22:54. [PMID: 35361120 PMCID: PMC8968777 DOI: 10.1186/s12873-022-00605-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 03/11/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction During the initial Coronavirus Disease 2019 (COVID-19) pandemic wave, sparse personal protection equipment made telephone triage of suscpeted COVID-19 patients for ambulance transport necessary. To spare resources, stable patients were often treated and released on-scene, but reports from Italy suggested that some later detoriated. We implemented a prehospital sit-stand test to identify patients in risk for detoriation. Methods The test was implemented as part of a new guideline in stable suspected COVID-19 patients younger than 70 years with no risk factors for serious disease triaged by general practitioners to ambulance response in the Central Denmark Region. Data were collected from April 6th to July 6th 2020. The primary outcome for this study was the proportion of patients treated with oxygen within 7 days among patients decompensating vs patients not decompensating during the test. Results Data on 156 patients triaged to ambulance response by general practioners were analysed. In total 86/156 (55%) were tested with the sit-stand test. Due to off-guideline use of the test, 30/86 (34.8%) were either older than 70 or had risk factors for serious disease. 10/156 (6%) of patients had a positive COVID-19-test. In total, 17/86 (20%) decompensated during the test and of these, 9/17 (53%) were treated with oxygen compared to 2/69 (3%) in patients who did not decompensate (p < 0.001). Conclusion In a population suspected of COVID-19 but with a low COVD-19 prevalence, decompensation with the sit-stand test was observed in 20% of patients and was associated with oxygen treatment within 7 days. These findings are hypotheses-generating and suggest that physical exercise testing may be usefull for decision making in emergency settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-022-00605-9.
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Affiliation(s)
- Julie Kjerulff
- Prehospital Emergency Medical Services, Research and Development, Central Denmark Region, Olof Palmes Allé 34, 2.floor, 8200, Aarhus N, Denmark. .,Emergency Department, Regional Hospital Horsens, Sundvej 30, 8700, Horsens, Denmark.
| | - Allan Bach
- Prehospital Emergency Medical Services, Ambulances and Physician Critical Care Unit, Central Denmark Region, Olof Palmes Allé 34, 2.floor, 8200, Aarhus N, Denmark
| | - Ulla Væggemose
- Prehospital Emergency Medical Services, Research and Development, Central Denmark Region, Olof Palmes Allé 34, 2.floor, 8200, Aarhus N, Denmark
| | - Søren Helbo Skaarup
- Department of Respiratory Medicine and Allergy, Aarhus University Hospital, Central Denmark Region, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Morten Thingemann Bøtker
- Prehospital Emergency Medical Services, Research and Development, Central Denmark Region, Olof Palmes Allé 34, 2.floor, 8200, Aarhus N, Denmark.,Department of Anesthesiology and Intensive Care Medicine, Regional Hospital Randers, Skovlyvej 15, 8930, Randers, Denmark
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Mould-Millman NK, Dixon JM, van Ster B, Moreira F, Bester B, Cunningham C, de Vries S, Beaty B, Suresh K, Schauer SG, Maddry JK, Wallis LA, Bebarta VS, Ginde AA. Clinical impact of a prehospital trauma shock bundle of care in South Africa. Afr J Emerg Med 2022; 12:19-26. [PMID: 35004137 PMCID: PMC8718736 DOI: 10.1016/j.afjem.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/23/2021] [Accepted: 10/08/2021] [Indexed: 11/28/2022] Open
Abstract
Introduction Patients experiencing traumatic shock are at a higher risk for death and complications. We previously designed a bundle of emergency medical services traumatic shock care (“EMS-TruShoC”) for prehospital providers in resource-limited settings. We assess how EMS-TruShoC changes clinical outcomes of critically injured prehospital patients. Methods This is a quasi-experimental educational implementation of a simplified bundle of care using a pre-post design with a control group. The intervention was delivered to EMS providers in Western Cape, South Africa. Delta shock index (heart rate divided by systolic blood pressure, reported as change from the scene to facility arrival) from the 13 months preceding intervention were compared to the 13 months post-implementation. A difference-in-differences analysis examined the difference in mean shock index change between the groups. Results Data were collected from 198 providers who treated 770 severe trauma patients. The patient groups had similar demographic and clinical characteristics at baseline. Over all time-points, both groups had an increase in mean delta shock index (worsening shock), with the largest difference occurring 4-months post-implementation (0.047 change in control arm, 0.004 change in intervention arm; −0.043 difference-in-differences, P = 0.27). In pre-specified subgroup analyses, there was a statistically significant improvement in delta shock index in the intervention arm in patients with penetrating trauma cared for by basic providers immediately post-implementation (−0.372 difference-in-differences, P = 0.02). Discussion Overall, there was no significant difference in delta shock index between the EMS-TruShoC intervention versus control groups. However, significant improvement in shock index in one subgroup suggests the intervention may be more likely to benefit penetrating trauma patients and basic providers.
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Affiliation(s)
- Nee-Kofi Mould-Millman
- University of Colorado Denver, School of Medicine, Department of Emergency Medicine, Aurora, CO, USA
- Corresponding author.
| | - Julia M. Dixon
- University of Colorado Denver, School of Medicine, Department of Emergency Medicine, Aurora, CO, USA
| | - Bradley van Ster
- Western Cape Government, Department of Health, Emergency Medical Services, Cape Town, South Africa
| | - Fabio Moreira
- Western Cape Government, Department of Health, Emergency Medical Services, Cape Town, South Africa
| | - Beatrix Bester
- Western Cape Government, Department of Health, Emergency Medical Services, Cape Town, South Africa
| | - Charmaine Cunningham
- University of Cape Town, Department of Surgery, Division of Emergency Medicine, Cape Town, South Africa
| | - Shaheem de Vries
- Western Cape Government, Department of Health, Emergency Medical Services, Cape Town, South Africa
| | - Brenda Beaty
- University of Colorado Denver, Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, CO, USA
| | - Krithika Suresh
- University of Colorado Denver, Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, CO, USA
| | - Steven G. Schauer
- U.S. Army Institute of Surgical Research, Joint Base San Antonio-Ft Sam Houston, TX, USA
| | - Joseph K. Maddry
- U.S. Air Force En Route Care Research Center, Joint Base San Antonio-Lackland, TX, USA
| | - Lee A. Wallis
- University of Cape Town, Department of Surgery, Division of Emergency Medicine, Cape Town, South Africa
| | - Vikhyat S. Bebarta
- University of Colorado Denver, School of Medicine, Center for COMBAT Research, Aurora, CO, USA
| | - Adit A. Ginde
- University of Colorado Denver, School of Medicine, Department of Emergency Medicine, Aurora, CO, USA
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Braithwaite S, Stephens C, Remick K, Barrett W, Guyette FX, Levy M, Colwell C. Prehospital Trauma Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:64-71. [PMID: 35001817 DOI: 10.1080/10903127.2021.1994069] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Definitive management of trauma is not possible in the out-of-hospital environment. Rapid treatment and transport of trauma casualties to a trauma center are vital to improve survival and outcomes. Prioritization and management of airway, oxygenation, ventilation, protection from gross aspiration, and physiologic optimization must be balanced against timely patient delivery to definitive care. The optimal prehospital airway management strategy for trauma has not been clearly defined; the best choice should be patient-specific. NAEMSP recommends:The approach to airway management and the choice of airway interventions in a trauma patient requires an iterative, individualized assessment that considers patient, clinician, and environmental factors.Optimal trauma airway management should focus on meeting the goals of adequate oxygenation and ventilation rather than on specific interventions. Emergency medical services (EMS) clinicians should perform frequent reassessments to determine if there is a need to escalate from basic to advanced airway interventions.Management of immediately life-threatening injuries should take priority over advanced airway insertion.Drug-assisted airway management should be considered within a comprehensive algorithm incorporating failed airway options and balanced management of pain, agitation, and delirium.EMS medical directors must be highly engaged in assuring clinician competence in trauma airway assessment, management, and interventions.
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Farrell C, Dorney K, Mathews B, Boyle T, Kitchen A, Doyle J, Monuteaux MC, Li J, Walsh B, Nagler J, Chung S. A Statewide Collaboration to Deliver and Evaluate a Pediatric Critical Care Simulation Curriculum for Emergency Medical Services. Front Pediatr 2022; 10:903950. [PMID: 35774102 PMCID: PMC9237480 DOI: 10.3389/fped.2022.903950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/18/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Care of the critically ill child is a rare but stressful event for emergency medical services (EMS) providers. Simulation training can improve resuscitation care and prehospital outcomes but limited access to experts, simulation equipment, and cost have limited adoption by EMS systems. Our objective was to form a statewide collaboration to develop, deliver, and evaluate a pediatric critical care simulation curriculum for EMS providers. METHODS We describe a statewide collaboration between five academic centers to develop a simulation curriculum and deliver it to EMS providers. Cases were developed by the collaborating PEM faculty, reviewed by EMS regional directors, and based on previously published EMS curricula, a statewide needs assessment, and updated state EMS protocols. The simulation curriculum was comprised of 3 scenarios requiring recognition and acute management of critically ill infants and children. The curriculum was implemented through 5 separate education sessions, led by a faculty lead at each site, over a 6 month time period. We evaluated curriculum effectiveness with a prospective, interventional, single-arm educational study using pre-post assessment design to assess the impact on EMS provider knowledge and confidence. To assess the intervention effect on knowledge scores while accounting for nested data, we estimated a mixed effects generalized regression model with random effects for region and participant. We assessed for knowledge retention and self-reported practice change at 6 months post-curriculum. Qualitative analysis of participants' written responses immediately following the curriculum and at 6 month follow-up was performed using the framework method. RESULTS Overall, 78 emergency medical technicians (EMTs) and 109 paramedics participated in the curriculum over five separate sessions. Most participants were male (69%) and paramedics (58%). One third had over 15 years of clinical experience. In the regression analysis, mean pediatric knowledge scores increased by 9.8% (95% CI: 7.2%, 12.4%). Most (93% [95% CI: 87.2%, 96.5%]) participants reported improved confidence caring for pediatric patients. Though follow-up responses were limited, participants who completed follow up surveys reported they had used skills acquired during the curriculum in clinical practice. CONCLUSION Through statewide collaboration, we delivered a pediatric critical care simulation curriculum for EMS providers that impacted participant knowledge and confidence caring for pediatric patients. Follow-up data suggest that knowledge and skills obtained as part of the curriculum was translated into practice. This strategy could be used in future efforts to integrate simulation into EMS practice.
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Affiliation(s)
- Caitlin Farrell
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Kate Dorney
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Bonnie Mathews
- Division of Emergency Medicine, Department of Pediatrics, UMass Medical School, Worcester, MA, United States
| | - Tehnaz Boyle
- Division of Emergency Medicine, Department of Pediatrics, Boston University School of Medicine, Boston, MA, United States
| | - Anthony Kitchen
- Department of Emergency Medicine, Baystate Medical Center, Springfield, MA, United States
| | - Jeff Doyle
- Department of Public Health, Emergency Medical Services for Children, Boston, MA, United States
| | - Michael C Monuteaux
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Joyce Li
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Barbara Walsh
- Division of Emergency Medicine, Department of Pediatrics, Boston University School of Medicine, Boston, MA, United States
| | - Joshua Nagler
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Sarita Chung
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Boston, MA, United States
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Ramgopal S, McCans K, Martin-Gill C, Owusu-Ansah S. Variation in Prehospital Protocols for Pediatric Seizure Within the United States. Pediatr Emerg Care 2021; 37:e1331-e1338. [PMID: 32011553 DOI: 10.1097/pec.0000000000002029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective of this study was to compare statewide prehospital protocols for the management of pediatric seizures. METHODS We performed a descriptive analysis comparing statewide protocols for emergency medical services management of pediatric seizures within the United States, excluding states for which no statewide protocol/model was available. We compared antiepileptic drugs (AEDs), routes and doses of administration, and differences in febrile seizure management. RESULTS Of 50 states, 34 had either statewide protocols or models and were included. All had a protocol for the management of seizures and provided specific recommendations for the management of pediatric seizures. Twelve states (35%) preferentially recommended midazolam over other benzodiazepines. Thirty-two (94%) of 34 allowed for use of midazolam, with variable use of other AEDs. All allowed for use of intramuscular AED. Twenty-six (77%) allowed for intranasal AED. Nine (27%) allowed emergency medical services to administer a patient's own abortive AED, and 6 (18%) allowed for use of a patient's vagal nerve stimulator, when present. There was a wide variability with respect to dosing ranges for medications. Thirty-two (94%) of 34 included blood glucose measurement within the protocol. Twenty-one protocols (62%) provided recommendations for febrile seizures, including recommending active/passive cooling (8/34, 24%) and antipyretic administration (9/34, 26%). CONCLUSIONS All statewide protocols carried specific guidelines for the prehospital management of pediatric seizures; however, there was wide variability with respect to specific AEDs, routes of administration, and drug dosages. In addition to broader availability of statewide guidance, areas of potential protocol improvement and research include AED dose optimization, reprioritization of blood glucose, and greater emphasis on intranasal or intramuscular medication dosing.
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Affiliation(s)
- Sriram Ramgopal
- From the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Chicago, IL
| | - Kerry McCans
- UPMC Center for Emergency Medicine, School of Health and Rehabilitation Sciences
| | | | - Sylvia Owusu-Ansah
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Improving Administration of Prehospital Corticosteroids for Pediatric Asthma. Pediatr Qual Saf 2021; 6:e410. [PMID: 34046539 PMCID: PMC8143736 DOI: 10.1097/pq9.0000000000000410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 11/24/2020] [Indexed: 11/26/2022] Open
Abstract
Early administration of systemic corticosteroids for asthma exacerbations in children is associated with improved outcomes. Implementation of a new emergency medical services (EMS) protocol guiding the administration of systemic corticosteroids for pediatric patients with asthma exacerbations went into effect in January 2016 in Southwest Ohio. Our SMART aim was to increase the proportion of children receiving systemic prehospital corticosteroids for asthma exacerbations from 0% to 70% over 2 years.
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Abramson TM, Rose E, Crow E, Lane CJ, Kearl Y, Loza-Gomez A. Paramedic Identification of Pediatric Seizures: A Prospective Cohort Study. PREHOSP EMERG CARE 2020; 25:682-688. [PMID: 33026283 DOI: 10.1080/10903127.2020.1831667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Pediatric seizures commonly trigger emergency medical services (EMS) activation and account for approximately 5-15% of all pediatric 911-EMS calls. More than 50% of children with active seizure activity do not receive prehospital antiepileptic drugs, potentially because they are not recognized by EMS. The purpose of this study is to evaluate specificity and sensitivity of paramedic identification of pediatric seizures and to describe the characteristics of unrecognized seizures. METHODS This is an 18-month prospective cohort study at a single, pediatric emergency department (ED). EMS patients ≤15 years old with a prehospital provider impression of seizure were included. Upon ED arrival, a data collection form, which included the EMS verbal report and patient's clinical status, was completed by the attending emergency physician. The primary outcome was sensitivity and specificity of paramedic identification of active seizure. Secondary outcomes included characteristics of missed seizures, ED interventions, and disposition. Descriptive statistics, sensitivity, and specificity were computed. Patient characteristics and clinical outcomes were compared. RESULTS Surveys were completed for 349 patients (Median 3, IQR = 3.4). Fifty-two of the patients (15%) were actively seizing upon arrival at the ED. Sensitivity was 54% and specificity was 96% for paramedic identification of active seizure. Common features of missed cases were abnormal vital signs (75%), gaze deviation (50%) and clenched jaw (33%). Of these, 37% required intubation and 53% were admitted to the intensive care unit. CONCLUSION Paramedics were highly specific, but not sensitive in identifying active seizures on ED arrival. Patients with unrecognized seizures presented most commonly with abnormal vital signs and gaze deviation.
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Shah MI, Ostermayer DG, Browne LR, Studnek JR, Carey JM, Stanford C, Fumo N, Lerner EB. Multicenter Evaluation of Prehospital Seizure Management in Children. PREHOSP EMERG CARE 2020; 25:475-486. [PMID: 32589502 DOI: 10.1080/10903127.2020.1788194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Seizures are a common reason why emergency medical services (EMS) transports children by ambulance. Timely seizure cessation prevents neurologic morbidity, respiratory compromise, and mortality. Implementing recommendations from an evidence-based pediatric prehospital guideline may enhance timeliness of seizure cessation and optimize medication dosing. OBJECTIVE We compared management of pediatric prehospital seizures across several EMS systems after protocol revision consistent with an evidence-based guideline. METHODS Using a retrospective, cross-sectional approach, we evaluated actively seizing patients (0-17 years old) EMS transported to a hospital before and after modifying local protocols to include evidence-based recommendations for seizure management in three EMS agencies. We electronically queried and manually abstracted both EMS and hospital data at each site to obtain information about patient demographics, medications given, seizure cessation and recurrence, airway interventions, access obtained, and timeliness of care. The primary outcome of the study was the appropriate administration of midazolam based on route and dose. We analyzed these secondary outcomes: frequency of seizure activity upon emergency department (ED) arrival, frequency of respiratory failure, and timeliness of care. RESULTS We analyzed data for 533 actively seizing patients. Paramedics were more likely to administer at least one dose of midazolam after the protocol updates [127/208 (61%) vs. 232/325 (71%), p = 0.01, OR = 1.60 (95% CI: 1.10-2.30)]. Paramedics were also more likely to administer the first midazolam dose via the preferred intranasal (IN) or intramuscular (IM) routes after the protocol change [(63/208 (49%) vs. 179/325 (77%), p < 0.001, OR = 3.24 (2.01-5.21)]. Overall, paramedics administered midazolam approximately 14 min after their arrival, gave an incorrect weight-based dose to 130/359 (36%) patients, and gave a lower than recommended dose to 94/130 (72%) patients. Upon ED arrival, 152/533 (29%) patients had a recurrent or persistent seizure. Respiratory failure during EMS care or subsequently in the ED occurred in 90/533 (17%) patients. CONCLUSIONS Implementation of an evidence-based seizure protocol for EMS increased midazolam administration. Patients frequently received an incorrect weight-based dose. Future research should focus on optimizing administration of the correct dose of midazolam to improve seizure cessation.
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Ostermayer DG, Camp EA, Langabeer JR, Brown CA, Mondragon J, Persse DE, Shah MI. Impact of an Extraglottic Device on Pediatric Airway Management in an Urban Prehospital System. West J Emerg Med 2019; 20:962-969. [PMID: 31738725 PMCID: PMC6860396 DOI: 10.5811/westjem.2019.8.44464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 08/25/2019] [Indexed: 11/30/2022] Open
Abstract
Introduction Prehospital pediatric endotracheal intubation has lower first-pass success rates compared to adult intubations and in general may not offer a survival benefit. Increasingly, emergency medical services (EMS) systems are deploying prehospital extraglottic airways (EGA) for primary pediatric airway management, yet little is known about their efficacy. We evaluated the impact of a pediatric prehospital airway management protocol change, inclusive of EGAs, on airway management and patient outcomes in children in cardiac arrest or respiratory failure. Methods Using data from a large, metropolitan, fire-based EMS service, we performed an observational study of pediatric patients with respiratory failure or cardiac arrest who were transported by EMS before and after implementation of an evidence-based airway management protocol inclusive of the addition of the EGA. The primary outcome was change in frequency of intubation attempts when paired with an initial EGA. Secondary outcomes included EGA and intubation success rates and patient survival to hospitalization and discharge. Results We included 265 patients age <16 years old, with 142 pre- and 123 post-protocol change. Patient demographics and event characteristics were similar between groups. Intubation attempts declined from 79.6% pre- to 44.7% (p<0.01) post-protocol change. In patients with an intubation attempt, overall intubation success declined from 81.4% to 63.6% (p<0.01). Post-protocol change, an EGA was attempted in 52.8% of patients with 95.4% success. Conclusion Implementation of an evidenced-based airway management algorithm for pediatric patients, inclusive of an EGA device for all age groups, was associated with fewer prehospital intubations. Intubation success may be negatively impacted due to decreases in procedural frequency.
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Affiliation(s)
- Daniel G Ostermayer
- McGovern Medical School, University of Texas Health Sciences Center, Department of Emergency Medicine, Houston, Texas.,Houston Fire Department, Houston, Texas
| | - Elizabeth A Camp
- Baylor College of Medicine, Texas Children's Hospital, Department of Pediatrics, Section of Emergency Medicine, Houston, Texas
| | - James R Langabeer
- McGovern Medical School, University of Texas Health Sciences Center, Department of Emergency Medicine, Houston, Texas
| | - Charles A Brown
- University of Michigan Medical School, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Juan Mondragon
- Baylor College of Medicine, Texas Children's Hospital, Department of Pediatrics, Section of Emergency Medicine, Houston, Texas
| | | | - Manish I Shah
- Baylor College of Medicine, Texas Children's Hospital, Department of Pediatrics, Section of Emergency Medicine, Houston, Texas
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Seo B, Lee SH, Yang MS, Lee SH, Kim SH, Cho SH, Chang YS. 119 Rescue team's awareness of anaphylaxis and asthma exacerbation in Gyeonggi-do province of Korea: Before and after education. ALLERGY ASTHMA & RESPIRATORY DISEASE 2019. [DOI: 10.4168/aard.2019.7.4.199] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Bomi Seo
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Gyeonggi-do Atopy·Asthma Education Information Center, Seongnam, Korea
| | - So-Hee Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Min-Suk Yang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, Korea
| | - Seon Hwa Lee
- Gyeonggi-do Atopy·Asthma Education Information Center, Seongnam, Korea
| | - Sae-Hoon Kim
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Gyeonggi-do Atopy·Asthma Education Information Center, Seongnam, Korea
| | - Sang-Heon Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yoon-Seok Chang
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Gyeonggi-do Atopy·Asthma Education Information Center, Seongnam, Korea
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