"Inappropriate" pediatric emergency medical services utilization redefined

Utilization of Transport Data to Decrease Unnecessarily Repeated Laboratory Tests

OBJECTIVES

In pediatric patients being transported for management of diabetic ketoacidosis, laboratory tests will frequently be trended throughout transportation and subsequently immediately repeated upon arrival to a particular institution. These laboratory tests may not add value to a patient's care trajectory and therefore may be unnecessary. This study examines differences between pH, sodium, potassium, chloride, bicarbonate, and glucose levels drawn during transportation and those drawn at our home institution immediately upon arrival to determine if repeating those laboratory tests upon arrival to the emergency department serves any purpose in adding to patient care.

METHODS

This study compares pH, sodium, potassium, chloride, bicarbonate, and glucose levels drawn during transport and at our home institution. Box and whisker plots between transport and institution laboratory values were constructed. A Wilcoxon signed rank test was performed to determine differences between pH, sodium, potassium, bicarbonate, and glucose levels, as these value sets were not normally distributed. A paired t test was performed to determine differences between transport and institution chloride values given that these value sets were normally distributed. Savings were then calculated based on charges to the patient to determine overall cost savings by not immediately repeating these laboratory tests upon presentation.

RESULTS

Box and whisker plots showed marked similarity between laboratory tests drawn in transport and those immediately upon arrival to our ED. Paired t test did not demonstrate a statistical difference between transport and ED chloride levels ( P = 0.5699); therefore, we failed to reject the null hypothesis. Wilcoxon signed rank test did not demonstrate a statistical difference between transport and ED pH ( P = 0.1294) and potassium ( P = 0.4523) values; therefore, we failed to reject the null hypothesis. However, Wilcoxon signed rank test did demonstrate a statistically significant difference between uncorrected sodium ( P = 0.0006), corrected sodium ( P = 0.0075), bicarbonate ( P = <0.0001), and glucose levels ( P = 0.0086).

CONCLUSIONS

Although there were some statistically significant differences between the laboratory value sets, it is arguable whether there are any clinically significant differences between them.Based on our failure to show a clinically significant difference between laboratory values drawn during transportation and those drawn immediately upon presentation to the institution, repeating laboratory draws after transportation do not add value to a patient's care trajectory. We should therefore rely on the laboratory values that were drawn from our transportation teams as part of the continuum of patient care.

Health Inequities in Pediatric Trauma

This review article highlights the disparities evident in pediatric trauma care in the United States. Social determinants of health play a significant role in key aspects of trauma care including access to care, gun violence, child abuse, head trauma, burn injuries, and orthopedic trauma. We review the recent literature as it relates to these topics. The findings from these recent studies emphasize the important principle that trauma care for children should be designed with a focus on equity for all children.

Lack of Health Insurance Coverage and Emergency Medical Service Transport for Pediatric Trauma Patients

INTRODUCTION

Pediatric trauma patients who lack insurance coverage may have less access to transport other than emergency medical services (EMS) or face financial barriers that prevent utilization of these services. We analyzed the association between health insurance coverage and EMS transport while controlling for injury and patient characteristics.

MATERIALS AND METHODS

De-identified Trauma Quality Programs registry data were queried for pediatric trauma patients age <18 y. The primary outcome was arrival by EMS (excluding interfacility transfer) versus private transport or walk-in, and the primary exposure was insurance coverage (any versus none). After exact matching on injury and facility characteristics, propensity matching was used to balance demographic covariates and comorbidities between insured and uninsured patients.

RESULTS

Of the 130,246 patients analyzed, 9501 (7%) did not have insurance coverage. After matching 9494 uninsured cases to 9494 insured controls, fixed-effects logistic regression found that uninsured patients had 18% greater odds of using EMS transport, compared to insured patients (odds ratio: 1.18; 95% confidence interval: 1.11, 1.26; P < 0.001). Results were similar when comparing uninsured patients to privately insured or publicly insured patients only.

CONCLUSIONS

Uninsured pediatric trauma patients have a higher likelihood of using EMS transport compared to insured patients with similar demographic and clinical characteristics, including the exact same score of injury severity. Lack of access to private transport may drive higher EMS utilization in uninsured patients with minor injuries and contribute to higher costs of pediatric trauma care borne by institutions and families.

What factors are associated with ambulance use for non-emergency problems in children? A systematic mapping review and qualitative synthesis

OBJECTIVE

To explore what factors are associated with ambulance use for non-emergency problems in children.

METHODS

This study is a systematic mapping review and qualitative synthesis of published journal articles and grey literature. Searches were conducted on the following databases, for articles published between January 1980 and July 2020: MEDLINE, EMBASE, PsycINFO, CINAHL and AMED. A Google Scholar and a Web of Science search were undertaken to identify reports or proceedings not indexed in the above. Book chapters and theses were searched via the OpenSigle, EThOS and DART databases. A literature advisory group, including experts in the field, were contacted for relevant grey literature and unpublished reports. The inclusion criteria incorporated articles published in the English language reporting findings for the reasons behind why there are so many calls to the ambulance service for non-urgent problems in children. Data extraction was divided into two stages: extraction of data to generate a broad systematic literature 'map', and extraction of data from highly relevant papers using qualitative methods to undertake a focused qualitative synthesis. An initial table of themes associated with reasons for non-emergency calls to the ambulance for children formed the 'thematic map' element. The uniting feature running through all of the identified themes was the determination of 'inappropriateness' or 'appropriateness' of an ambulance call out, which was then adopted as the concept of focus for our qualitative synthesis.

RESULTS

There were 27 articles used in the systematic mapping review and 17 in the qualitative synthesis stage of the review. Four themes were developed in the systematic mapping stage: socioeconomic status/geographical location, practical reasons, fear of consequences and parental education. Three analytical themes were developed in the qualitative synthesis stage including practicalities and logistics of obtaining care, arbitrary scoring system and retrospection.

CONCLUSIONS

There is a lack of public and caregiver understanding about the use of ambulances for paediatrics. There are factors that appear specific to choosing ambulance care for children that are not so prominent in adults (fever, reassurance, fear of consequences). Future areas for attention to decrease ambulance activation for paediatric low-acuity reports were highlighted as: identifying strategies for helping caregivers to mitigate perceived risk, increasing availability of primary care, targeted education to particular geographical areas, education to first-time parents with infants and providing alternate means of transportation.

PROSPERO REGISTRATION NUMBER

CRD42019160395.

Trends in ambulance transports and costs among Medicare beneficiaries, 2007-2018

BACKGROUND

The primary purpose of this study was to evaluate trends in ambulance utilization and costs among Medicare beneficiaries from 2007 to 2018. Community characteristics associated with ambulance use and costs are also explored.

METHODS

Aggregated county-level fee-for-service (FFS) Medicare beneficiary claims data from 2007 to 2018 were used to assess ambulance transports per 1000 FFS Medicare beneficiaries and standardized inflation-adjusted ambulance costs. Multivariable linear mixed models were used to quantify trends in ambulance utilization and costs and to control for confounders.

RESULTS

A total of 37,675 county-years were included from 2007 to 2018. Ambulance transports per 1000 beneficiaries increased 15% from 299 (95% CI: 291.63, 307.30) to 345 (95% CI: 336.91, 353.10) from 2007 to 2018. Inflation-adjusted standardized per user costs exhibited an increasing (1.04, 95% CI: 1.04, 1.05), but non-linear relationship (0.996, 95% CI: 0.996, 0.996) over time with costs peaking in 2012. Indicators of lower socioeconomic status (SES) were associated with increases in both ambulance events and costs (p < .0001). A higher prevalence of Medicare beneficiaries utilizing Skilled Nursing Facilities was associated with increased levels of ambulance events per 1000 beneficiaries (95% CI: 8.06, 10.63). Rural location was associated with a 38% increase in ambulance costs (95% CI 1.30-1.47) compared to urban location.

CONCLUSIONS

Numerous policy solutions have been proposed to address growing ambulance costs in the Medicare program. While ambulance transports and costs continue to increase, a bend in the ambulance cost curve is detected suggesting that one or more policies altered Medicare ambulance costs, although utilization has continued to grow linearly. Ambulance use and costs vary significantly with community-level factors. As policy makers consider how to address growing ambulance use and costs, targeting identified community-level factors associated with greater costs and utilization, and their root causes, may offer a targeted approach to addressing current trends.

Cost-effectiveness of a video game versus live simulation for disaster training

Introduction

Disaster triage training for emergency medical service (EMS) providers is unstandardised. We hypothesised that disaster triage training with the paediatric disaster triage (PDT) video game ‘60 s to Survival’ would be a cost-effective alternative to live simulation-based PDT training.

Methods

We synthesised data for a cost-effectiveness analysis from two previous studies. The video game data were from the intervention arm of a randomised controlled trial that compared triage accuracy in a live simulation scenario of exposed vs unexposed groups to the video game. The live simulation and feedback data were from a prospective cohort study evaluating live simulation and feedback for improving disaster triage skills. Postintervention scores of triage accuracy were measured for participants via live simulations and compared between both groups. Cost-effectiveness between the live simulation and video game groups was assessed using (1) A net benefit regression model at various willingness-to-pay (WTP) values. (2) A cost-effectiveness acceptability curve (CEAC).

Results

The total cost for the live simulation and feedback training programme was $81 313.50 and the cost for the video game was $67 822. Incremental net benefit values at various WTP values revealed positive incremental net benefit values, indicating that the video game is more cost-effective compared with live simulation and feedback. Moreover, the CEAC revealed a high probability (>0.6) at various WTP values that the video game is more cost-effective.

Conclusions

A video game-based simulation disaster triage training programme was more cost-effective than a live simulation and feedback-based programme. Video game-based training could be a simple, scalable and sustainable solution to training EMS providers.

Emergency Medical Services Utilization by Children

OBJECTIVE

The aim of this study was to compare demographic and clinical features of children (0-14 years old) who arrived at general emergency departments (EDs) by emergency medical services (EMS) to those who arrived by private vehicles and other means in a rural, 3-county region of northern California.

METHODS

We reviewed 507 ED records of children who arrived at EDs by EMS and those who arrived by other means in 2013. We also analyzed prehospital procedures performed on all children transported to an area hospital by EMS.

RESULTS

Children arriving by EMS were older (9.0 vs 6.0 years; P < 0.001), more ill (mean Severity Classification Score, 2.9 vs 2.4; P < 0.001), and had longer lengths of stay (3.6 vs 2.1 hours; P < 0.001) compared with children who were transported to the EDs by other means. Children transported by EMS received more subspecialty consultations (18.7% vs 6.9%; P < 0.05) and had more diagnostic testing, including laboratory testing (22.9% vs 10.6%; P < 0.001), radiography (39.7% vs 20.8%; P < 0.001), and computed tomography scans (16.8% vs 2.9%; P < 0.001). Children arriving by EMS were transferred more frequently (8.8% vs 1.6%; P < 0.001) and had higher mean Severity Classification Scores compared with children arriving by other transportation even after adjusting for age and sex (β = 0.48; 95% confidence interval, 0.35-0.61; P < 0.001). Older children received more prehospital procedures compared with younger children, and these were of greater complexity and a wider spectrum.

CONCLUSIONS

Children transported to rural EDs via EMS are more ill and use more medical resources compared with those who arrive to the ED by other means of transportation.

Parental factors predicting unnecessary ambulance use for their child with acute illness: A cross-sectional study

AIMS

To examine characteristics of parents of children with acute, albeit mild, illnesses who used ambulance transport unnecessarily.

DESIGN

A cross-sectional study.

METHODS

From 2016 - 2017, we recruited parents who visited the emergency room of a Japanese paediatric hospital and whose children were discharged without hospitalization. Participants whose children arrived by ambulance were classified as using ambulance services unnecessarily. Participants answered a questionnaire consisting of parents' characteristics, including health literacy scales and the Parents' Uncertainty regarding their Children with Acute Illness Scale. We conducted a receiver operating characteristic analysis to convert the Parents' Uncertainty regarding their Children with Acute Illness Scale results to binary scores. We analysed questionnaire responses using logistic regression analysis.

RESULTS

Analysed data were from 171 participants. The cut-off score was 59 for the Parents' Uncertainty regarding their Children with Acute Illness Scale. Results of the logistic regression indicated that parents who did not use resources to obtain information regarding their child's illness, had low health literacy, were observing presenting symptoms for the first time in their child, or had high uncertainty, were significantly more likely to unnecessarily use ambulances.

CONCLUSION

Publicizing available resources regarding child health information, social healthcare activities to raise parents' health literacy and providing explanations in accordance with parents' uncertainty, especially when confronting new symptoms in their child, might reduce unnecessary ambulance use.

IMPACT

Of patients transported to hospitals by ambulance, the rate of paediatric parents with mild conditions has been found to be high. The study findings could contribute to the appropriateness of using ambulances and have implications for policymakers and healthcare providers, particularly in the Japanese paediatric emergency system. In particular, parental uncertainty, one of four significant characteristics, could be resolved in clinical settings. Generalization for global health services requires further research.

Emergency Medical Services Utilization Is Associated With Community Deprivation in Children

BACKGROUND

Pediatric emergency medical services (EMS) utilization is costly and resource intensive; significant variation exists across large-scale geographies. Less is known about variation at smaller geographic levels where factors including lack of transportation, low health literacy, and decreased access to medical homes may be more relevant. Our objective was to determine whether pediatric EMS utilization varied across Hamilton County, Ohio, census tracts and whether such utilization was associated with socioeconomic deprivation.

METHODS

This was a retrospective analysis of children living in Hamilton County, Ohio, transported by EMS to the Cincinnati Children's emergency department between July 1, 2014, and July 31, 2016. Participants' addresses were assigned to census tracts and an EMS utilization rate and deprivation index were calculated for each. Pearson's correlation coefficients evaluated relationships between tract-level EMS utilization and deprivation. Tract-level deprivation was used as a predictor in patient-level evaluations of acuity.

RESULTS

During the study period, there were 4,877 pediatric EMS transports from 219 of the 222 county census tracts. The county EMS utilization rate during the study period was 2.4 transports per 100 children (range 0.2-11). EMS utilization rates were positively correlated with increasing deprivation (r = 0.72, 95% confidence interval [CI], 0.65-0.77). Deprivation was associated with lower illness severity at triage, fewer transports resulting in resuscitation suite use, and fewer transports resulting in hospitalizations (all p < 0.05).

CONCLUSIONS

EMS utilization varied substantially across census tracts in Hamilton County, Ohio. A deeper understanding into why certain socioeconomically deprived areas contribute to disproportionately high rates of EMS utilization could support development of targeted interventions to improve use.

Determinants of Pediatric EMS Utilization in Children with High-Acuity Conditions

BACKGROUND

Underutilization of emergency medical services (EMS) for children with high-acuity conditions is poorly understood. Our objective was to identify differences in demographic factors and describe caregivers' knowledge, beliefs, and attitudes regarding EMS utilization for children with high-acuity conditions.

DESIGN/METHODS

This was a mixed-methods study of children with high acuity conditions, defined as requiring immediate medical or surgical intervention and intensive care admission, over a one year period. Demographic data were collected through a retrospective chart review. Qualitative analysis of semi-structured interviews from a purposive sample of caregivers was conducted until thematic saturation was achieved.

RESULTS

Three hundred seventy-four charts were reviewed; 19 caregivers were interviewed (17 in-person, 2 via telephone). The 232 (62%) children not arriving by EMS tended to be younger (1.58 years vs. 2.31 years, p = 0.02), privately insured (30% vs. 19%, p = 0.04), and lived further from the hospital (16.80 miles vs. 12.45 miles, p = 0.001). Patient gender, ethnicity, comorbidities and caregiver language were not associated with EMS underutilization. Immediate invasive medical interventions were more often required for EMS utilizers (85% vs. 60%, p < 0.001). EMS utilizers were more likely to require intubation (78% vs. 47%, p < 0.001) and cardiopulmonary resuscitation (CPR) (26% vs. 2%, p < 0.001), and had shorter hospital stays (4.70 vs. 8.16 days; p-value < 0.001). Three principal themes determined EMS utilization: expectations, knowledge, and perceived barriers. Three principal themes determined EMS utilization: expectations, knowledge, and perceived barriers. Caretakers expected EMS would provide timely, safe transportation that expedited medical care and emotional support. Medical knowledge and prior experience with EMS influenced decision-making about arrival mode. Timeliness, cost, socioeconomic and demographic characteristics, loss of autonomy, and the logistics of EMS activation and transport were the most commonly reported barriers.

CONCLUSIONS

Young age, private insurance status, and greater distance from the hospital were associated with EMS underutilization. Understanding caregiver expectations, knowledge, and perceived barriers may have important implications for the use of EMS for children. These findings reveal opportunities for improved public education on EMS systems to enhance appropriate EMS utilization for children with high acuity conditions.

Children Covered by Medicaid/State Children's Health Insurance Program More Likely to Use Emergency Departments for Food Allergies

BACKGROUND

Food allergies (FAs) occur in 4% to 8% of children in the United States, and emergency department (ED) visits account for up to 20% of their costs. In 2010, the National Institute of Allergy and Infectious Diseases established diagnostic criteria and management practices for FAs, and recognition and treatment of FAs for pediatric ED practitioners has been described.

OBJECTIVE

This study identified trends and factors related to ED visits for pediatric FAs in the United States from 2001 to 2010. It was hypothesized that FAs increased and that differences existed in ED utilization based on age, insurance status, and geography. Low concordance with treatment guidelines for FAs was expected.

METHODS

Multivariate logistic regression, using National Hospital Ambulatory Medical Care Survey data, estimated factors associated with ED visits and treatment of FAs and nonspecific allergic reactions. Trends and treatment patters used weighted frequencies to account for the complex 4-stage probability survey design.

RESULTS

An estimated 239,303 (95% confidence interval [CI], 180,322-298,284) children visited the ED for FAs, demonstrating a significant rate increase during the period (53.08, P < 0.001). Logistic regression showed that the odds of ED visits for FAs were significantly associated with Medicaid/State Children's Health Insurance Program insurance (OR, 1.65 [95% CI, 1.01-2.69], P = 0.04), adolescents (OR, 1.92 [95% CI, 1.10-3.35], P = 0.02), and boys (OR, 1.55 [95% CI, 1.03-2.35], P = 0.04). Treatment with epinephrine for anaphylaxis diagnoses occurred in 57.4% of visits (95% CI, 42.3%-66.8%).

CONCLUSIONS

Medicaid/State Children's Health Insurance Program-insured pediatric patients had higher odds of visiting ED for recognized FAs and nonspecific allergic reactions and higher odds of receiving epinephrine than privately insured children.

Prehospital Transport for Pediatric Trauma: A Comparison of Private Transport and Emergency Medical Services

OBJECTIVES

We describe the demographics of pediatric patients with trauma transferred using private transport (PT) versus emergency medical services (EMS) and evaluate the potential impact on their treatment and outcome.

METHODS

We accessed data from our national trauma registry, a prospectively collected database. Data were extracted on all patients with trauma admitted to our institution between January 2011 and June 2013, with injury severity score (ISS) higher than 8. We categorized unstable injuries as head injuries, spinal injuries, or proximal long bone fractures. Major trauma was defined as the presence of any of the following: ISS of 16 or higher, intensive care unit (ICU) admission or death.

RESULTS

Ninety children were studied, including 27 major trauma and 66 unstable injuries; 69 patients (77%) used PT. Most patients with major trauma (17/27, 63%) and unstable injuries (50/66, 76%) used PT. Compared with EMS patients, PT patients were younger, smaller, took longer for emergency department physician review and stayed longer in the emergency department. Rates of ICU admission were similar in both groups, but length of stay in ICU and total hospital stay were shorter in the PT group despite similar proportions of major trauma and unstable injuries as well as median ISS. Each group had 1 mortality.

CONCLUSIONS

Most children with major trauma and unstable injuries were brought by PT, risking deterioration en route. Nevertheless, this does not seem to translate to worse outcomes overall.

Challenges and Opportunities to Engaging Emergency Medical Service Providers in Substance Use Research: A Qualitative Study

Introduction Research suggests Emergency Medical Services (EMS) over-use in urban cities is partly due to substance users with limited access to medical/social services. Recent efforts to deliver brief, motivational messages to encourage these individuals to enter treatment have not considered EMS providers. Problem Little research has been done with EMS providers who serve substance-using patients. The EMS providers were interviewed about participating in a pilot program where they would be trained to screen their patients for substance abuse and encourage them to enter drug treatment.

METHODS

Qualitative interviews were conducted with Baltimore City Fire Department (BCFD; Baltimore, Maryland USA) EMS providers (N=22). Topics included EMS misuse, work demands, and views on participating in the pilot program. Interviews were transcribed and analyzed using grounded theory and constant-comparison.

RESULTS

Participants were mostly white (68.1%); male (68.2%); with Advanced Life Skills training (90.9%). Mean age was 37.5 years. Providers described the "frequent flyer problem" (eg, EMS over-use by a few repeat non-emergent cases). Providers expressed disappointment with local health delivery due to resource limitations and being excluded from decision making within their administration, leading to reduced team morale and burnout. Nonetheless, providers acknowledged they are well-positioned to intervene with substance-using patients because they are in direct contact and have built rapport with them. They noted patients might be most receptive to motivational messages immediately after overdose revival, which several called "hitting their bottom." Several stated that involvement with the proposed study would be facilitated by direct incorporation into EMS providers' current workflow. Many recommended that research team members accompany EMS providers while on-call to observe their day-to-day work. Barriers identified by the providers included time constraints to intervene, limited knowledge of substance abuse treatment modalities, and fearing negative repercussions from supervisors and/or patients. Despite reservations, several EMS providers expressed inclination to deliver brief motivational messages to encourage substance-using patients to consider treatment, given adequate training and skill-building.

CONCLUSIONS

Emergency Medical Service providers may have many demands, including difficult case time/resource limitations. Even so, participants recognized their unique position as first responders to deliver motivational, harm-reduction messages to substance-using patients during transport. With incentivized training, implementing this program could be life- and cost-saving, improving emergency and behavioral health services. Findings will inform future efforts to connect substance users with drug treatment, potentially reducing EMS over-use in Baltimore. Maragh-Bass AC , Fields JC , McWilliams J , Knowlton AR . Challenges and opportunities to engaging Emergency Medical Service providers in substance use research: a qualitative study. Prehosp Disaster Med. 2017;32(2):148-155.

Emergency medical services (EMS) versus non-EMS transport among injured children in the United States

OBJECTIVES

This study aimed to assess the proportions of injured children transported to trauma centers by different transportation modes and evaluate the effect of transportation mode on inter-facility transfer rates using the US national trauma registry.

METHODS

We analyzed data from the 2007-2012 National Trauma Data Bank (NTDB) to study trends of EMS versus non-EMS transport. Multivariable logistic regression was used to evaluate the association between transport mode and inter-facility transfer.

RESULTS

There were 286,871 pediatric trauma patients in the 2007-2012 NTDB; 45.8% arrived by ground ambulance, 8.6% arrived by air ambulance, and 37.5% arrived by non-EMS. From 2007 to 2012, there was no significant change in transportation mode. Moderate to severely injured patients (ISS>15) comprised 13.3% of arrivals by ground ambulance, 26.7% of arrivals by air ambulance, and 8.3% of arrivals by non-EMS; those who used EMS were significantly less likely to be transferred to another facility than patients who used non-EMS transport. Moderate and severe pediatric patients arriving by non-EMS to adult trauma centers were more often transferred than those arriving at mixed trauma centers (45.8% and 6.8%, respectively).

CONCLUSIONS

Over one third of US pediatric trauma patients used non-EMS transport to arrive at trauma centers. Moderate to severely injured children benefit from EMS transport and professional field triage to reach the appropriate trauma facility. Our study suggests that national efforts are needed to increase awareness among parents and the general public of the benefits of EMS transportation and care.

Pediatric Disaster Triage: Multiple Simulation Curriculum Improves Prehospital Care Providers' Assessment Skills

OBJECTIVE

Paramedics and emergency medical technicians (EMTs) triage pediatric disaster victims infrequently. The objective of this study was to measure the effect of a multiple-patient, multiple-simulation curriculum on accuracy of pediatric disaster triage (PDT).

METHODS

Paramedics, paramedic students, and EMTs from three sites were enrolled. Triage accuracy was measured three times (Time 0, Time 1 [two weeks later], and Time 2 [6 months later]) during a disaster simulation, in which high and low fidelity manikins and actors portrayed 10 victims. Accuracy was determined by participant triage decision concordance with predetermined expected triage level (RED [Immediate], YELLOW [Delayed], GREEN [Ambulatory], BLACK [Deceased]) for each victim. Between Time 0 and Time 1, participants completed an interactive online module, and after each simulation there was an individual debriefing. Associations between participant level of training, years of experience, and enrollment site were determined, as were instances of the most dangerous mistriage, when RED and YELLOW victims were triaged BLACK.

RESULTS

The study enrolled 331 participants, and the analysis included 261 (78.9%) participants who completed the study, 123 from the Connecticut site, 83 from Rhode Island, and 55 from Massachusetts. Triage accuracy improved significantly from Time 0 to Time 1, after the educational interventions (first simulation with debriefing, and an interactive online module), with a median 10% overall improvement (p < 0.001). Subgroup analyses showed between Time 0 and Time 1, paramedics and paramedic students improved more than EMTs (p = 0.002). Analysis of triage accuracy showed greatest improvement in overall accuracy for YELLOW triage patients (Time 0 50% accurate, Time1 100%), followed by RED patients (Time 0 80%, Time 1 100%). There was no significant difference in accuracy between Time 1 and Time 2 (p = 0.073).

CONCLUSION

This study shows that the multiple-victim, multiple-simulation curriculum yields a durable 10% improvement in simulated triage accuracy. Future iterations of the curriculum can target greater improvements in EMT triage accuracy.

Geospatial Analysis of Pediatric EMS Run Density and Endotracheal Intubation

Introduction

The association between geographic factors, including transport distance, and pediatric emergency medical services (EMS) run clustering on out-of-hospital pediatric endotracheal intubation is unclear. The objective of this study was to determine if endotracheal intubation procedures are more likely to occur at greater distances from the hospital and near clusters of pediatric calls.

Methods

This was a retrospective observational study including all EMS runs for patients less than 18 years of age from 2008 to 2014 in a geographically large and diverse Oregon county that includes densely populated urban areas near Portland and remote rural areas. We geocoded scene addresses using the automated address locator created in the cloud-based mapping platform ArcGIS, supplemented with manual address geocoding for remaining cases. We then use the Getis-Ord Gi spatial statistic feature in ArcGIS to map statistically significant spatial clusters (hot spots) of pediatric EMS runs throughout the county. We then superimposed all intubation procedures performed during the study period on maps of pediatric EMS-run hot spots, pediatric population density, fire stations, and hospitals. We also performed multivariable logistic regression to determine if distance traveled to the hospital was associated with intubation after controlling for several confounding variables.

Results

We identified a total of 7,797 pediatric EMS runs during the study period and 38 endotracheal intubations. In univariate analysis we found that patients who were intubated were similar to those who were not in gender and whether or not they were transported to a children’s hospital. Intubated patients tended to be transported shorter distances and were older than non-intubated patients. Increased distance from the hospital was associated with reduced odds of intubation after controlling for age, sex, scene location, and trauma system entry status in a multivariate logistic regression. The locations of intubations were superimposed on hot spots of all pediatric EMS runs. This map demonstrates that most of the intubations occurred within areas where pediatric EMS calls were highly clustered. By mapping the intubation procedures and pediatric population density, we found that intubation procedures were not clustered in a similar distribution to the pediatric population in the county.

Conclusion

In this geographically diverse county the location of intubation procedures was similar to the clustering of pediatric EMS calls, and increased distance from the hospital was associated with reduced odds of intubation after controlling for several potential confounding variables.

Emergency medical services system utilization over the last 10 years: what predicts transport of children?

OBJECTIVE

The aim of this study was to determine the predictors of pediatric ambulance transport and evaluate changes in utilization over a 10-year period.

METHODS

The National Health Ambulatory Medical Care Survey emergency department (ED) data for visits by children aged younger than 19 years from 2000 to 2009 were analyzed using logistic regression. Age, ethnicity, race, sex, triage level, time of arrival, injury/poisoning, insurance, disposition, critical patient status, metropolitan statistical area (MSA), region, and hospital type were used to predict the mode of arrival (ambulance or nonambulance). Significant variables were evaluated for trends over time.

RESULTS

Representing 209 million ED visits, 60,761 records were analyzed. Ambulance transport was more likely among children who were aged 12 to 18 years (P < 0.05), black (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.06-1.38), evaluated for an injury/poisoning (OR, 3.03; 95% CI, 2.75-3.34), publicly insured (OR, 1.16; 95% CI, 1.03-1.31), living in an MSA (OR, 1.73; 95% CI, 1.34-2.23), living in the northeast (P < 0.05), and overnight arrivals (OR, 1.47; 95% CI, 1.26-1.7). They were more likely to have an urgency of less than 15 minutes (OR, 4.46; 95% CI, 3.56-5.59), require admission (OR, 2.82; 95% CI, 2.33-3.41), and considered critical (OR, 5.15; 95% CI, 3.43-7.73). There was no significant change in ambulance utilization in children; however, about half of critical patients and over 80% of those with a high triage level did not arrive by ambulance.

CONCLUSIONS

Ambulance transport to the ED is used more often by teens, blacks, publicly insured, overnight arrivals, and those living in an MSA or the northeast. It is concerning that many children triaged with a high urgency or requiring critical care did not arrive by ambulance.

US emergency department use by children, 2001-2010

OBJECTIVE

Children commonly use emergency departments (EDs) for a variety of health care needs. We describe recent trends in US ED use by children.

METHODS

This is a cross-sectional analysis of the National Hospital Ambulatory Medical Care Survey, a nationally representative sample of ED visits, and US Census data between 2001 and 2010. We examined demographic trends, visit characteristics, insurance status, disposition, hospital variables, diagnoses, reason for visit, and resource use among patients younger than 19 years. Linear regression was used to evaluate significance of trends.

RESULTS

Approximately one quarter of all ED visits was made by patients younger than 19 years. Emergency department visits by children increased 14.4% between 2001 and 2010 (P = 0.04); the rate of visits increased from 36.4 to 40.6 per 100 population. Trauma is the most common reason for pediatric ED visits. Black children had the highest rate of ED use (61.9 per 100 in 2010). Visit rates by Hispanic children were relatively low but increased by 82.7% since 2001 (P = 0.00). The proportion of ED visits by Medicaid beneficiaries rose from 32.0% to 51.9% (P = 0.00). The volume and frequency of diagnostic testing, administration of intravenous fluids, medication administration, and discharge prescriptions increased. Visits with computed tomography or magnetic resonance imaging almost doubled from 3.1% of the visits in 2001 to 6.6% of the visits in 2010 (P = 0.00).

CONCLUSIONS

The use of ED by children is growing faster than population growth, and the intensity of ED care has risen sharply. Hispanic children and Medicaid beneficiaries represent the fastest growing populations of children using the ED.