Out-of-hospital paediatric emergencies: a prospective, population-based study

Facial growth dynamics dictate optimal facemask fitting during the first year of life

AIM

The aim of this study is to prevent mask leak during ventilation in infant emergencies, appropriate facemask fitting is essential. Therefore, we investigated facial profiles during the first year of life and their correlation with the correct sizing of masks.

METHODS

This is a post hoc subgroup analysis of 32 healthy term infants, based on a prospective observational study performed from September 2018 to December 2019 in Tuebingen, Germany. In 3-monthly intervals, facial aspects were measured based on anatomical landmarks in three-dimensional frontal photographs to describe their changes across the first year of life. All infants were awake and breathing spontaneously; none required any anaesthesia.

RESULTS

In 130 3D images, mean distance between nasion and gnathion was 54 mm (3.3) measured at birth and 70 mm (3.5) at age 12 months. Gompertz models showed relevant growth-related changes in the facial profile in vertical but not horizontal direction. Vertical growth occurred mainly in the first 6 months. Boys and girls differed by an average of about 2 mm (boys >girls).

CONCLUSION

Based on our findings, it should now be verified whether the 50 mm facemasks are suitable for infants from birth to 2 months of age, respectively, the 60 mm version for infants aged three to 12 months.

Pre-hospital care for children: a descriptive study from Central Norway

BACKGROUND

Pre-hospital incidents involving pediatric and neonatal patients are infrequent, and clinical characteristics and care for these patients differ from the adult population. Lack of knowledge, guidelines, and experience can make pre-hospital pediatric care challenging, and there is limited research on the epidemiology and best practice of care for this population. We examined the pre-hospital pediatric population in the county of Sør-Trøndelag, Norway, to improve our understanding of this population in our region.

METHODS

We conducted a retrospective observational cohort study of emergency incidents involving children under twelve years of age with dispatch of Emergency Medical Services (EMS) in Sør-Trøndelag between 2018 and 2022. Incidents and patient characteristics were extracted from the Emergency Medical Communication Center (EMCC) database. In addition, data on patient characteristics and interventions for more serious incidents seen by the Helicopter Emergency Medical Service (HEMS) were included from the database LABAS. We provided descriptive statistics and estimated population incidences using Poisson regression.

RESULTS

The catchment area of EMCC Sør-Trøndelag has a population of approximately 43,000 children under the age of twelve years. During the five-year study period, there were 7005 emergency calls concerning this patient population, representing 6% of all emergency calls (total no. 108,717). Of these, 3500 (50%) resulted in the dispatch of an ambulance and/or HEMS, yielding an annual incidence of EMS dispatches of 17 per 1000 children. The three most common primary medical problems were respiratory distress, altered consciousness, and trauma. Among the 309 HEMS patients, 131 (42%) received advanced interventions from the HEMS physician. Assisted ventilation was the most frequent intervention.

CONCLUSIONS

Pediatric and neonatal patients make up a small proportion of pre-hospital patient dispatches in Sør-Trøndelag. Consequently, each EMS provider infrequently encounters children in the pre-hospital environment, resulting in less experience with pediatric advanced medical interventions. This study identifies some clinical characteristics and interventions regarding pediatric and neonatal patients that have been pointed out as focus areas for pediatric pre-hospital research.

Value-based care of older people-The impact of an acute outreach service unit on emergency medical service missions: A quasi-experimental study

BACKGROUND

Transfers to the emergency department can be burdensome for the residents of long-term residential care facilities (LTRCFs) and often lead to adverse effects. Since March 2019, a nurse-led acute outreach service unit "Mobile hospital" (in Finnish, Liikkuva sairaala, LiiSa) has been providing on-site care to LTRCF residents to reduce transfers to the emergency department.

METHODS

This study compares the numbers and acuities of emergency medical service (EMS) missions carried out in the LTRCFs of Espoo and Kauniainen during two six-month periods: before the implementation of LiiSa and with LiiSa in use. In Finland, EMS missions are divided into four categories (A-D), with category A missions being the most urgent. These categories were used to investigate the impact on mission acuities.

RESULTS

Due to the implementation of LiiSa, the number of EMS missions decreased by 16.8% (95% confidence interval 10.6%-22.6%, p < 0.001), the number of category D missions by 19.8% (7.1%-30.8%, p = 0.003) and the number of category C missions by 30.3% (17.3%-41.3%, p < 0.001). Changes in the numbers of category A and B missions were not statistically significant.

CONCLUSIONS

LiiSa helped to avoid many transfers of frail LTRCF patients to the emergency department, and it did not hinder the care of patients with true emergencies by EMSs.

Outcomes of paediatric patients who are not transported to hospital by Emergency Medical Services: a data linkage study

BACKGROUND

Data on the safety of non-transport decisions for paediatric patients attended by Emergency Medical Services (EMS) are lacking. We describe the characteristics and outcomes of paediatric non-transported patients in Victoria, Australia.

METHODS

A retrospective data linkage study of consecutive paediatric (aged <18 years) non-transported patients between January 2015 and June 2019. Patients were linked to ED, hospital admission and death records. Multivariable logistic regression analyses were used to determine factors associated with EMS recontact, ED presentation, hospital admission and an adverse event (death/cardiac arrest, intensive care unit admission or highest ED triage category) within 48 hours of the initial emergency call.

RESULTS

In total, 62 975 non-transported patients were included. The mean age was 7.1 (SD 6.0) years and 48.9% were male. Overall, 2.2% recontacted the EMS within 48 hours, 13.7% self-presented to a public ED, 2.4% were admitted to hospital and 0.1% had an adverse event, including two deaths. Among patients with paramedic-initiated non-transport (excluding transport refusals and transport via other means), 5.6% presented to a public ED, 1.1% were admitted to hospital and 0.05% had an adverse event. In the overall population, an abnormal vital sign on initial assessment increased the odds of hospital admission and an adverse event. Among paramedic-initiated non-transports, cases occurring in the early hours of the morning (04:00-08:00 hours) were associated with increased odds of subsequent hospital admission, while the odds of ED presentation and hospital admission also increased with increasing prior exposure to non-transported cases.

CONCLUSION

Adverse events were rare among paramedic-initiated non-transport cases. Vital sign derangements and attendance by paramedics with higher prior exposure to non-transports were associated with poorer outcomes and may be used to improve safety.

An emotional journey when encountering children in prehospital care: Experiences from ambulance nurses

BACKGROUND

Care encounters with children are a challenging and important task, but opportunities for such encounters are rarely available. Therefore, ambulance nurses (ANs) face difficulties in gaining experience in properly handling children, which can lead to stress for the ANs. A deeper understanding of ANs' emotions through the course of the care encounter is needed.

AIM

To describe how ambulance nurses' feel and manage their emotions before, during and after a care encounter with a child.

METHODS

A qualitative approach was adopted, with content analysis being performed on seventeen individual interviews.

FINDINGS

Three themes were identified: Feeling worried and insecure, Emotional surge, and Mixed feelings of satisfaction and concern.

CONCLUSION

The ANs experienced a range of emotions during a care encounter with children as they had little experience with it. More training and education in paediatric care could benefit ANs. The ANs use professionalism during care encounters to create a calm and secure atmosphere for families. Their will to bring about a safe journey for the child and family through the care encounter supersedes their nervousness. Reflection after a care encounter could strengthen their confidence in their professional role and reduce emotional distress in future encounters.

Paediatric frequent use of emergency medical services: a systematic review

BACKGROUND

Frequent use of emergency medical services (EMS) is recognised to be a global phenomenon, although paediatric frequent use is poorly understood. This systematic review aimed to understand how paediatric frequent use of EMS is currently defined, identify factors associated with paediatric frequent use of EMS and determine effectiveness of interventions for paediatric patients who frequently use EMS.

METHODS

Four electronic databases (Medline, CINAHL, Web of Science and PsycINFO) were searched to September 2022 for primary, peer-reviewed research studies published in English from January 2000. Studies were included that examined frequent use (>1 contact during study period) of EMS or other services with arrival via EMS. Paediatric patients were defined as <18 years of age or otherwise defined by study authors as paediatric/adolescent/children. Data were extracted using a structured proforma, and quality was assessed using the Standard Quality Assessment Criteria for Quantitative Studies but did not influence inclusion decisions. Data were presented using narrative synthesis.

RESULTS

The search resulted in 4172 unique references, with 12 papers included in the review from 7 countries. Four were EMS studies, and eight Emergency Department with arrival via EMS. All studies used retrospective designs, with no interventional studies identified. Paediatric frequent EMS users were more likely to use services for medical reasons rather than trauma, including respiratory complaints, mental health and seizures, but data on gender and ethnicity were inconclusive and silent on socioeconomic status. There was no consistency in definitions of either a paediatric patient or of frequent use.

CONCLUSION

The broad range of reasons for frequent use suggests that a single intervention is unlikely to be effective at addressing the causes of frequent use. There is a need for further research to better identify the underlying reasons for frequent EMS use among paediatric patients and to develop interventions in this population.

Outcomes of Pediatric Patients in Secondary Transport to Tertiary Hospital: A Retrospective Observational Study

OBJECTIVES

Emergency medical service (EMS) providers play an important role in determining which hospital to choose. To date, there is no evidence-based guideline to support their decisions, except for major trauma cases. Secondary transport is considered when a patient needs further investigation or treatment after primary transport, but this can delay treatment and put patients at unnecessary risk. The objective of this study was to investigate the outcomes of pediatric secondary transport patients to tertiary hospitals.

METHODS

This was a citywide population-based observational study conducted in Kobe, Japan. We reviewed the EMS registry to identify secondary transport patients younger than 19 years and investigated their clinical characteristics. We excluded cases of unknown hospital destinations, nontransported cases, and major trauma patients who followed a different protocol for a hospital destination. The primary endpoint was the hospital outcome 12 hours after transport. Because there was no link between the EMS patient transport data and the hospital medical records, a probabilistic linkage was performed to obtain the hospital outcomes. Patients who required secondary transport were compared with patients transported directly to tertiary hospitals.

RESULTS

A total of 13,720 pediatric patients were transported from the field by Kobe EMS between January 2013 and December 2015. Among them, 81 pediatric patients (0.6%) required secondary transport to tertiary hospitals within 24 hours of the primary transport, whereas a total of 3673 patients (27%) were transported directly to tertiary hospitals. Despite no apparent difference in prehospital severity, secondary transport patients were associated with higher hospitalization rates and a need for critical care compared with those who had direct transport. Seizure was the most common reason for the use of secondary transport, and 89% of the seizure patients were hospitalized after undergoing secondary transport; minor trauma was the second most common reason for the use of secondary transport, and 53% of the patients were hospitalized.

CONCLUSIONS

In this study, the characteristics of the secondary transport patients and hospital outcomes revealed a heterogeneity in pediatric prehospital transport. It is recommended that the development of pediatric EMS destination guidelines cover children's diverse conditions. Further studies are required, and linkages between prehospital and hospital data will help promote a better understanding of appropriate hospital destinations.

Out-of-Hospital Seizures in Children: A Population-Based Study

OBJECTIVES

Seizures seem to represent a frequent cause for pediatric emergency medical (EM) and emergency room (ER) contacts, but few population-based data are available. Our aim was to study the incidence, prehospital and ER treatment, and outcomes of pediatric seizures necessitating out-of-hospital care.

METHODS

We studied the out-of-hospital evaluation procedures, ER treatment, diagnostics and 2-year prognosis of all cases of pediatric (0-16 years) seizures encountered by the emergency medical services (EMS) in Helsinki, Finland, in 2012 (population 603,968, pediatric population 92,742); 251 patients were encountered by the EMS, of which 220 seen at the ER.

RESULTS

The yearly incidence of pediatric seizures necessitating EMS activation was 2.8/1000 in the pediatric population. Febrile seizures were responsible for 97 (44.1%) of the cases transported to the ER. Only a minority of patients required advanced life support measures out-of-hospital or complex diagnostics in the ER. Still, of the 220 patients seen at ER, 68 (30.9%) were hospitalized, and 106 (48.2%) had follow-up contacts scheduled.

CONCLUSIONS

Pediatric seizures were a common cause for EM and ER contacts. Advanced life support measures were seldom needed, and the prognosis was good, but seizures still required considerable resources. They often resulted in urgent EM dispatch and transport, hospitalization, follow-up visits, new medication, and complementary studies. This emphasizes the role the EMS plays in recognizing and terminating pediatric seizures and in referring these children to appropriate care.

Pediatric traumas and neighborhood socioeconomic characteristics: A population based study

BACKGROUND

Identifying pediatric populations at risk for traumas would enable development of emergency medical services and emergency departments for children. Elucidation of the nature of socioeconomic differences in the incidence of pediatric out-of-hospital emergencies is needed to overcome inequities in child health.

METHODS

We retrieved all ambulance contacts during 17.12.2014-16.12.2018 involving children (0-15 years) in Helsinki, Finland and separated traumatic and nontraumatic emergencies. We compared the incidences of these emergencies in the pediatric population with socioeconomic markers of the scene of the emergency and of the residential area of the child.

RESULTS

Of 11,742 ambulance contacts involving children 4113 (35.0%) were traumatic. Traumatic emergencies occurred more often in neighborhoods with lower median income/household (P=0.043) and were more common in children living in areas with lower median income/inhabitant (P=0.001), higher unemployment (P<0.001), and lower education (P<0.001). The associations were weaker for traumatic than nontraumatic emergencies. Higher proportion of a pediatric population in a residential area (P=0.005) had a protective effect. Exclusion of clinically unnecessary ambulance responses did not change the results.

CONCLUSION

Traumatic emergencies in children are more common in areas with lower socioeconomic status. The possible protective effect of urban planning merits further studies.

TYPE OF STUDY

Prognostic.

LEVEL OF EVIDENCE

II.

Why do infants need out-of-hospital emergency medical services? A retrospective, population-based study

Background

The challenges encountered in emergency medical services (EMS) contacts with children are likely most pronounced in infants, but little is known about their out-of-hospital care. Our primary aim was to describe the characteristics of EMS contacts with infants. The secondary aims were to examine the symptom-based dispatch system for nonverbal infants, and to observe the association of unfavorable patient outcomes with patient and EMS mission characteristics.

Methods

In a population-based 5-year retrospective cohort of all 1712 EMS responses for infants (age < 1 year) in Helsinki, Finland (population 643,000, < 1-year old population 6548), we studied 1) the characteristics of EMS missions with infants; 2) mortality within 12 months; 3) pediatric intensive care unit (PICU) admissions; 4) medical state of the infant upon presentation to the emergency department (ED); 5) any medication or respiratory support given at the ED; 6) hospitalization; and 7) surgical procedures during the same hospital visit.

Results

1712 infants with a median age of 6.7 months were encountered, comprising 0.4% of all EMS missions. The most common complaints were dyspnea, low-energy falls, and choking. Two infants died on-scene. The EMS transported 683 (39.9%) infants. One (0.1%) infant died during the 12-month follow-up period. Ninety-one infants had abnormal clinical examination upon arrival at the ED. PICU admissions (n = 28) were associated with young age (P < 0.01), a history of prematurity or problems in the neonatal period (P = 0.01), and previous EMS contacts within 72 h (P = 0.04). The adult-derived dispatch codes did not associate with the final diagnoses of the infants.

Conclusions

Infants form a small but distinct group in pediatric EMS care, with specific characteristics differing from the overall pediatric population. Many EMS contacts with infants were nonurgent or medically unjustified, possibly reflecting an unmet need for other family services. The use of adult-derived symptom codes for dispatching is not optimal for infants. Unfavorable patient outcomes were rare. Risk factors for such outcomes include quickly renewed contacts, young age and health problems in the neonatal period.

Paediatric prehospital emergencies and restrictions during the COVID-19 pandemic: a population-based study

BACKGROUND

Children are less vulnerable to serious forms of the COVID-19 disease. However, concerns have been raised about children being the second victims of the pandemic and its control measures. Therefore, we wanted to study if the pandemic, the infection control measures and their consequences to the society projected to paediatric prehospital emergency medical services (EMS) contacts.

METHODS

We conducted a population-based cohort study concerning all children aged 0-15 years with EMS contacts in the Helsinki University Hospital area during 1 March 2020-31 May 2020 (study period) and equivalent periods in 2017-2019 (control periods). We analysed the demographic characteristics, time of EMS contact, reason for EMS contact, priority of the dispatch, reason for transportation, priority of transportation, if any consultations were made or additional units required, any medication or oxygen or fluids given, if intubation was performed, and whether paramedics took precautions when COVID-19 infection was suspected.

RESULTS

The number of paediatric EMS contacts decreased by 30.4% from mean of 1794 contacts to 1369 (p=0.003). The EMS contacts were more often due to trauma (+23.7%, p<0.05), dispatched in the most urgent category (+139.9%, p=0.001), additional help and the mobile intensive care unit were more frequently requested (+43.3%, p=0.040 and+46.3%, p=0.049, respectively). However, EMS contacts resulted less often in ambulance transport (-21.1%, p<0.001). Alarmingly, there were four deaths during the study period compared with 0-2 during the control periods.

CONCLUSIONS

The number of EMS contacts decreased during the pandemic. Nevertheless, the children encountered by the EMS were more seriously ill than during the control periods.

Outcomes in children evaluated but not transported by ambulance personnel: retrospective cohort study

BACKGROUND

Not all children with an out-of-hospital emergency medical contact are transported by ambulance to the emergency department (ED). Non-transport means that after on-scene evaluation and possible treatment, ambulance personnel may advise the patient to monitor the situation at home or may refer the patient to seek medical attention by other means of transport. As selecting the right patients for ambulance transport is critical for optimising patient safety and resource use, we studied outcomes in non-transported children to identify possible risk groups that could benefit from ambulance transport.

METHODS

In a population-based retrospective cohort study of all children aged 0-15 years encountered but not transported by ambulance in Helsinki, Finland, between 1 January 2014 and 31 December 2016, we evaluated (1) 12-month mortality, (2) intensive care admissions, (3) unscheduled ED contacts within the following 96 hours after the non-transport decision and (4) the clinical status of the child on presentation to ED in the case of a secondary ED visit.

RESULTS

Of all children encountered by out-of-hospital emergency medical services, 3579/7765 (46%) were not transported to ED by ambulance. There was no mortality or intensive care admissions related to the non-transport. The risk factors for an unscheduled secondary ED visit after a non-transport decision were young age (p=0.001), non-transport decision during the early morning hours (p<0.001) and certain dispatch codes, including 'dyspnoea' (p<0.001), 'vomiting/diarrhoea' (p=0.030) and 'mental illness' (p=0.019). We did not detect deterioration in patients' clinical presentation at ED traceable to non-transport decisions.

CONCLUSIONS

Not transporting all children by ambulance after an out-of-hospital emergency medical contact was not associated with deaths, intensive care admissions or significant deterioration in general condition in our study population and healthcare system. Special attention and a formal non-transport protocol are warranted in certain subgroups, including infants.

Children in disadvantaged neighbourhoods have more out-of-hospital emergencies: a population-based study

OBJECTIVE

We wanted to study whether the socioeconomic status of a neighbourhood can predict the incidence of paediatric out-of-hospital emergencies.

METHODS

We conducted a population-based prospective study with all paediatric (0-15 years) out-of-hospital emergencies in Helsinki, Finland, in 2012-2013. We compared the geographical distribution of the emergencies in the paediatric population with those of mean income, unemployment level and educational level. The comparison was made both by the scene of the emergency and by the domicile of the patient. We also separately analysed the distribution of emergency medical (EM) contacts that were deemed medically unnecessary.

RESULTS

The incidence of out-of-hospital emergencies was higher in areas with lower socioeconomic status and among children living inside those areas. Higher mean income was associated with lower incidence (risk ratio (RR) 0.970, 95% CI 0.957 to 0.983), and lower unemployment level to higher incidence (RR 1.046, 95% CI 1.002 to 1.092) of out-of-hospital emergencies inside a district. Higher mean income was associated with lower incidence of emergencies in the paediatric population living inside a district (RR 0.983, 95% CI 0.974 to 0.993). The distribution of medically unnecessary EM contacts was similar in all areas.

CONCLUSIONS

The socioeconomic status of a neighbourhood was associated with the need for EM services (EMS) in the area, and in children living in the area. Overusing EMS for non-urgent or non-medical problems did not explain these findings. Instead, they seem to represent true differences in the incidence of paediatric emergencies.

Paediatric medical emergency calls to a Danish Emergency Medical Dispatch Centre: a retrospective, observational study

BACKGROUND

Little is known regarding paediatric medical emergency calls to Danish Emergency Medical Dispatch Centres (EMDC). This study aimed to investigate these calls, specifically the medical issues leading to them and the pre-hospital units dispatched to the paediatric emergencies.

METHODS

We performed a retrospective, observational study on paediatric medical emergency calls managed by the EMDC in the Region of Southern Denmark in February 2016. We reviewed audio recordings of emergency calls and ambulance records to identify calls concerning patients ≤ 15 years. We examined EMDC dispatch records to establish how the medical issues leading to these calls were classified and which pre-hospital units were dispatched to the paediatric emergencies. We analysed the data using descriptive statistics.

RESULTS

Of a total of 7052 emergency calls in February 2016, 485 (6.9%) concerned patients ≤ 15 years. We excluded 19 and analysed the remaining 466. The reported medical issues were commonly classified as: "seizures" (22.1%), "sick child" (18.9%) and "unclear problem" (12.9%). The overall most common pre-hospital response was immediate dispatch of an ambulance with sirens and lights with a supporting physician-manned mobile emergency care unit (56.4%). The classification of medical issues and the dispatched pre-hospital units varied with patient age.

DISCUSSION

We believe our results might help focus the paediatric training received by emergency medical dispatch staff on commonly encountered medical issues, such as the symptoms and conditions pertaining to the symptom categories "seizures" and "sick child". Furthermore, the results could prove useful in hypothesis generation for future studies examining paediatric medical emergency calls.

CONCLUSION

Almost 7% of all calls concerned patients ≤ 15 years. Medical issues pertaining to the symptom categories "seizures", "sick child" and "unclear problem" were common and the calls commonly resulted in urgent pre-hospital responses.