Improving Administration of Prehospital Corticosteroids for Pediatric Asthma

Development of a Computable Phenotype for Prehospital Pediatric Asthma Encounters

INTRODUCTION

Asthma exacerbations are a common cause of pediatric Emergency Medical Services (EMS) encounters. Accordingly, prehospital management of pediatric asthma exacerbations has been designated an EMS research priority. However, accurate identification of pediatric asthma exacerbations from the prehospital record is nuanced and difficult due to the heterogeneity of asthma symptoms, especially in children. Therefore, this study's objective was to develop a prehospital-specific pediatric asthma computable phenotype (CP) that could accurately identify prehospital encounters for pediatric asthma exacerbations.

METHODS

This is a retrospective observational study of patient encounters for ages 2-18 years from the ESO Data Collaborative between 2018 and 2021. We modified two existing rule-based pediatric asthma CPs and created three new CPs (one rule-based and two machine learning-based). Two pediatric emergency medicine physicians independently reviewed encounters to assign labels of asthma exacerbation or not. Taking that labeled encounter data, a 50/50 train/test split was used to create training and test sets from the labeled data. A 90/10 split was used to create a small validation set from the training set. We used specificity, sensitivity, positive predictive value (PPV), negative predictive value (NPV) and macro F1 to compare performance across all CP models.

RESULTS

After applying the inclusion and exclusion criteria, 24,283 patient encounters remained. The machine-learning models exhibited the best performance for the identification of pediatric asthma exacerbations. A multi-layer perceptron-based model had the best performance in all metrics, with an F1 score of 0.95, specificity of 1.00, sensitivity of 0.91, negative predictive value of 0.98, and positive predictive value of 1.00.

CONCLUSION

We modified existing and developed new pediatric asthma CPs to retrospectively identify prehospital pediatric asthma exacerbation encounters. We found that machine learning-based models greatly outperformed rule-based models. Given the high performance of the machine-learning models, the development and application of machine learning-based CPs for other conditions and diseases could help accelerate EMS research and ultimately enhance clinical care by accurately identifying patients with conditions of interest.

Reducing Time from Pediatric Emergency Department Arrival to Dexamethasone Administration in Wheezing Patients

Introduction

Asthma exacerbations are common presentations to pediatric emergency departments. Standard treatment for moderate-to-severe exacerbations includes administration of oral corticosteroids concurrently with bronchodilators. Early administration of corticosteroids has been shown to decrease emergency department length of stay (LOS) and hospitalizations. Our SMART aim was to reduce the time from arrival to oral corticosteroids (dexamethasone) administration in pediatric patients ≥2 years of age with an initial Pediatric Asthma Severity Score >6 from 60 to 30 minutes within 6 months.

Methods

We used the model for improvement with collaboration between ED physicians, nursing, pharmacy, and respiratory therapists. Interventions included nursing education, dosage rounding in the electronic medical record, supplying triage with 1-mg tablets and a pill crusher, updates to an asthma nursing order set and pertinent chief complaints triggering nurses to document a Pediatric Asthma Severity Score in the electronic medical record and use the order set. Our primary outcome measure was the time from arrival to dexamethasone administration. Secondary outcome measures included ED LOS for discharged patients and admission rate. We used statistical process control to analyze changes in measures over time.

Results

From October 2021 to March 2022, the average time for dexamethasone administration decreased from 59 to 38 minutes. ED LOS for discharged asthma exacerbation patients rose with overall ED LOS for all patients during the study period. There was no change in the admission rate.

Conclusions

Using quality improvement methodology, we successfully decreased the time from ED arrival to administration of dexamethasone in asthma exacerbation patients from 59 to 38 minutes over 10 months.

Evaluation of the implementation of evidence-based pediatric asthma exacerbation treatments in a regional consortium of emergency medical Services Agencies

OBJECTIVE

Asthma exacerbations are a frequent reason for pediatric emergency medical services (EMS) encounters. The objective of this study was to examine the implementation of evidence-based treatments for pediatric asthma in a regional consortium of EMS agencies.

METHODS

This retrospective study applied the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) implementation framework to data from an EMS agency consortium in the Cincinnati, Ohio region. The study analyzed one year before an oral systemic corticosteroid (OCS) option was added to the agencies' protocol, and five years after the protocol change. We constructed logistic regression models for the primary outcome of Reach, defined as the proportion of pediatric asthma patients who received a systemic corticosteroid. We modeled Maintenance (Reach measured monthly over time) using time series models.

RESULTS

A total of 713 patients were included, 133 pre- and 580 post-protocol change. In terms of Reach, 3% (n = 4) of eligible patients received a systemic corticosteroid pre-OCS versus 20% (n = 116) post-OCS. Multivariable modeling of Reach revealed the study period, EMS transport time, months since implementation of OCS, and number of bronchodilators administered by EMS as significant covariates for the administration of a systemic corticosteroid. For Maintenance, it took approximately two years to reach maximal administration of systemic corticosteroids.

CONCLUSIONS

Indicators of asthma severity and time since the protocol change were significantly associated with EMS administration of systemic corticosteroids to pediatric asthma patients. The two-year time for maximal Reach suggests further work is required to understand how to best implement evidence-based pediatric asthma treatments in EMS.

Racial, Ethnic, and Socioeconomic Disparities in Prehospital Encounters for Children with Asthma

OBJECTIVE

Asthma represents one of the most common medical conditions among children encountered by emergency medical services (EMS). While care disparities for children with asthma have been observed in other healthcare settings, limited data exist characterizing disparities in prehospital care. We sought to characterize differences in prehospital treatment and transport of children with suspected asthma exacerbations by race and ethnicity, within the context of community socioeconomic status.

METHODS

We conducted a multi-agency retrospective study of EMS encounters in 2019 for children (2-17 years) with asthma and wheezing using a national prehospital database. Our primary outcomes included EMS transport and prehospital bronchodilator or systemic corticosteroid administration. Scene socioeconomic status was evaluated using the social vulnerability index. We used generalized estimating equations to estimate adjusted odds ratios (aOR) and 95% confidence intervals (95%CI) for prehospital bronchodilator use or steroid use by race and ethnicity, adjusting for age, presence of abnormal vital signs, community size, bronchodilator use prior to EMS arrival, and transport disposition.

RESULTS

We analyzed 5,266 EMS encounters (median age 8 years). Approximately half (53%) were Black non-Hispanic and 34% were White non-Hispanic. Overall, 77% were transported by EMS. In an adjusted model, Black non-Hispanic children were 25% less likely to be transported compared to White non-Hispanic children (aOR: 0.75, 95%CI: 0.58-0.96). EMS administered at least one bronchodilator to 81% of Black non-Hispanic patients, 73% of Hispanic patients, and 68% of White, non-Hispanic patients. Relative to White non-Hispanic children, EMS bronchodilator administration was greater for Black non-Hispanic children, (aOR: 1.55, 95%CI: 1.25-1.93), after controlling for scene socioeconomic status and potential confounding variables. Systemic corticosteroids were administered in 3% of all encounters. Odds of prehospital systemic corticosteroid administration did not differ significantly by race and ethnicity.

CONCLUSION

Black non-Hispanic children comprised a larger proportion of EMS encounters for asthma and were more likely to receive a bronchodilator in adjusted analyses accounting for community socioeconomic status. However, these children were less likely to be transported by EMS. These findings may reflect disease severity not manifested by abnormal vital signs, management, and other social factors that warrant further investigation.

Types and effects of feedback for emergency ambulance staff: a systematic mixed studies review and meta-analysis

BACKGROUND

Extensive research has been conducted into the effects of feedback interventions within many areas of healthcare, but prehospital emergency care has been relatively neglected. Exploratory work suggests that enhancing feedback and follow-up to emergency medical service (EMS) staff might provide staff with closure and improve clinical performance. Our aim was to summarise the literature on the types of feedback received by EMS professionals and its effects on the quality and safety of patient care, staff well-being and professional development.

METHODS

A systematic review and meta-analysis, including primary research studies of any method published in peer-reviewed journals. Studies were included if they contained information on systematic feedback to emergency ambulance staff regarding their performance. Databases searched from inception were MEDLINE, Embase, AMED, PsycINFO, HMIC, CINAHL and Web of Science, with searches last updated on 2 August 2022. Study quality was appraised using the Mixed Methods Appraisal Tool. Data analysis followed a convergent integrated design involving simultaneous narrative synthesis and random effects multilevel meta-analyses.

RESULTS

The search strategy yielded 3183 articles, with 48 studies meeting inclusion criteria after title/abstract screening and full-text review. Interventions were categorised as audit and feedback (n=31), peer-to-peer feedback (n=3), postevent debriefing (n=2), incident-prompted feedback (n=1), patient outcome feedback (n=1) or a combination thereof (n=4). Feedback was found to have a moderate positive effect on quality of care and professional development with a pooled effect of d=0.50 (95% CI 0.34, 0.67). Feedback to EMS professionals had large effects in improving documentation (d=0.73 (0.00, 1.45)) and protocol adherence (d=0.68 (0.12, 1.24)), as well as small effects in enhancing cardiac arrest performance (d=0.46 (0.06, 0.86)), clinical decision-making (d=0.47 (0.23, 0.72)), ambulance times (d=0.43 (0.12, 0.74)) and survival rates (d=0.22 (0.11, 0.33)). The between-study heterogeneity variance was estimated at σ2=0.32 (95% CI 0.22, 0.50), with an I2 value of 99% (95% CI 98%, 99%), indicating substantial statistical heterogeneity.

CONCLUSION

This review demonstrated that the evidence base currently does not support a clear single point estimate of the pooled effect of feedback to EMS staff as a single intervention type due to study heterogeneity. Further research is needed to provide guidance and frameworks supporting better design and evaluation of feedback interventions within EMS.

PROSPERO REGISTRATION NUMBER

CRD42020162600.

Acute paediatric asthma treatment in the prehospital setting: a retrospective observational study

OBJECTIVES

To describe the incidence of and patterns of 'escalated care' (care in addition to standard treatment with systemic corticosteroids and inhaled bronchodilators) for children receiving prehospital treatment for asthma.

DESIGN

Retrospective observational study.

SETTING

State-wide ambulance service data (Ambulance Victoria in Victoria, Australia, population 6.5 million) PARTICIPANTS: Children aged 1-17 years and given a final diagnosis of asthma by the treating paramedics and/or treated with inhaled bronchodilators from 1 July 2019 to 30 June 2020.

PRIMARY AND SECONDARY OUTCOME MEASURES

We classified 'escalation of care' as parenteral administration of epinephrine, or provision of respiratory support. We compared clinical, demographic and treatments administered between those receiving and not receiving escalation of care.

RESULTS

Paramedics attended 1572 children with acute exacerbations of asthma during the 1 year study period. Of these, 22 (1.4%) had escalated care, all receiving parenteral epinephrine. Patients with escalated care were more likely to be older, had previously required hospital admission for asthma and had severe respiratory distress at initial assessment.Of 1307 children with respiratory status data available, at arrival to hospital, the respiratory status of children had improved overall (normal/mild respiratory distress at initial assessment 847 (64.8%), normal/mild respiratory distress at hospital arrival 1142 (87.4%), p<0.0001).

CONCLUSIONS

Most children with acute exacerbations of asthma did not receive escalated therapy during their pre-hospital treatment from ambulance paramedics. Most patients were treated with inhaled bronchodilators only and clinically improved by the time they arrived in hospital.

Emergency Medical Services Management of Bronchospasm in the United States: A Cross-Sectional Analysis and Nationwide Quality Assessment

Background/Objective: Bronchospasm, caused by asthma and other related conditions, is a significant cause of morbidity and mortality commonly managed by emergency medical services (EMS). We aimed to evaluate the quality of prehospital management of bronchospasm by EMS in the US.Methods: The National EMS Information System Public Release Research dataset, a nationwide convenience sample of prehospital patient care report data from 2018 to 2019, was used to capture 9-1-1 activations where patients aged ≥2 years were treated and transported by EMS for suspected bronchospasm. First, we described the extent to which EMS care met eight quality measures identified from available statewide EMS protocols, existing quality measures, and national guidelines. Second, we quantified the extent of risk-standardized agency-level variation in administration of inhaled beta agonists and systemic corticosteroids using logistic regression models, accounting for patient characteristics, severity, and clustering by agencies. Third, we compared rates of completed prehospital interventions between pediatric (age <18 years) versus adult patients using two-sample t-tests.Results: A total of 1,336,988 EMS encounters for suspected bronchospasm met inclusion criteria. Median age of patients was 66 years, with only 4% pediatric; 55% were female. Advanced life support (ALS) units managed 94% of suspected bronchospasm. Respiratory rate (98%) and pulse oximetry (96%) were documented in nearly all cases. Supplemental oxygen was administered to hypoxic patients by 65% of basic life support (BLS) and 73% of ALS units. BLS administered inhaled beta-agonist therapy less than half the time (48%), compared to 77% by ALS. ALS administered inhaled anticholinergic therapy in 38% of cases, and systemic corticosteroids in 19% of cases. Pediatric patients were significantly less likely to receive supplemental oxygen when hypoxic, inhaled beta-agonists, inhaled anticholinergics, or systemic corticosteroids.Conclusions: We found important gaps in recent EMS practice for prehospital care of suspected bronchospasm. We highlight three targets for improvement: inhaled beta-agonist administration by BLS, systemic corticosteroid administration by ALS, and increased interventions for pediatric patients. These findings indicate important areas for research, protocol modification, and quality improvement efforts to improve EMS management of bronchospasm.

Implementing Oral Systemic Corticosteroids for Pediatric Asthma into EMS Treatment Guidelines: A Qualitative Study

Introduction: Respiratory distress accounts for approximately 14% of all pediatric emergency medical services (EMS) encounters, with asthma being the most common diagnosis. In the emergency department (ED), early administration of systemic corticosteroids decreases hospital admission and speeds resolution of symptoms. For children treated by EMS, there is an opportunity for earlier corticosteroid administration. Most EMS agencies carry intravenous (IV) corticosteroids; yet given the challenges and low rates of EMS pediatric IV placement, oral corticosteroids (OCS) are a logical alternative. However, previous single-agency studies showed low adoption of OCS. Therefore, qualitative study of OCS implementation by EMS is warranted.Methods: This study's objective was to explore uptake and implementation of OCS for pediatric asthma treatment through semi-structured interviews and focus groups with EMS clinicians. We thematically coded and analyzed transcripts using the domains and constructs of the Consolidated Framework for Implementation Research (CFIR) to identify barriers and facilitators that most strongly influenced OCS implementation and adoption by EMS clinicians.Results: We conducted five focus groups with a total of ten EMS clinicians from four EMS systems: one urban region with multiple agencies that hosted two focus groups, one suburban agency, one rural agency, and a mixed rural/suburban agency. Of the 36 CFIR constructs, 31 were addressed in the interviews. Most constructs coded were in the CFIR domains of the inner setting and characteristics of individuals, indicating that EMS agency factors as well as EMS clinician characteristics were impactful for implementation. Barriers to OCS adoption included unfamiliarity and inexperience with pediatric patients and pediatric dosing, and lack of knowledge of the benefits of corticosteroids. Facilitators included friendly competition with colleagues, having a pediatric medical director, and feedback from receiving EDs on patient outcomes.Conclusion: This qualitative focus group study of OCS implementation by EMS clinicians for the treatment of pediatric asthma found many barriers and facilitators that mapped to the structure of EMS agencies and characteristics of individual EMS clinicians. To fully implement this evidence-based intervention for pediatric asthma, more education on the intervention is required, and EMS clinicians will benefit from further pediatric training.