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Harmon I, Brailsford J, Sanchez-Cano I, Fishe J. Development of a Computable Phenotype for Prehospital Pediatric Asthma Encounters. PREHOSP EMERG CARE 2024:1-16. [PMID: 38713633 DOI: 10.1080/10903127.2024.2352583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 04/29/2024] [Indexed: 05/09/2024]
Abstract
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 2018-2021. 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 a 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.
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Affiliation(s)
- Ira Harmon
- Center for Data Solutions, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, United States of America
| | - Jennifer Brailsford
- Center for Data Solutions, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, United States of America
| | - Isabel Sanchez-Cano
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, United States of America
| | - Jennifer Fishe
- Center for Data Solutions, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, United States of America
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, United States of America
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Ramgopal S, Crowe RP, Jaeger L, Fishe J, Macy ML, Martin-Gill C. Measures of Patient Acuity Among Children Encountered by Emergency Medical Services by the Child Opportunity Index. PREHOSP EMERG CARE 2024:1-9. [PMID: 38517514 DOI: 10.1080/10903127.2024.2333493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 03/13/2024] [Indexed: 03/24/2024]
Abstract
Background: Children have differing utilization of emergency medical services (EMS) by socioeconomic status. We evaluated differences in prehospital care among children by the Child Opportunity Index (COI), the agreement between a child's COI at the scene and at home, and in-hospital outcomes for children by COI. Methods: We performed a retrospective study of pediatric (<18 years) scene encounters from approximately 2,000 United States EMS agencies from the 2021-2022 ESO Data Collaborative. We evaluated socioeconomic status using the multi-dimensional COI v2.0 at the scene. We described EMS interventions and in-hospital outcomes by COI categories using ordinal regression. We evaluated the agreement between the home and scene COI. Results: Data were available for 99.8% of pediatric scene runs, with 936,940 included EMS responses. Children from lower COI areas more frequently had a response occurring at home (62.9% in Very Low COI areas; 47.1% in Very High COI areas). Children from higher COI areas were more frequently not transported to the hospital (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.86-0.87). Children in lower COI areas had lower use of physical (OR 1.23, 95% CI 1.13-1.33) and chemical (OR 1.41, 95% CI 1.29-1.55) restraints for behavioral health problems. Among injured children with elevated pain scores (≥7), analgesia was provided more frequently to children in higher COI areas (OR 1.73, 95% CI 1.65-1.81). The proportion of children in cardiac arrest was lowest from higher COI areas. Among 107,114 encounters with in-hospital data, the odds of hospitalization was higher among children from higher COI areas (OR 1.14, 95% CI 1.11-1.18) and was lower for in-hospital mortality (OR 0.75, 95% CI 0.65-0.85). Home and scene COI had a strong agreement (Kendall's W = 0.81). Conclusion: Patterns of EMS utilization among children with prehospital emergencies differ by COI. Some measures, such as for in-hospital mortality, occurred more frequently among children transported from Very Low COI areas, whereas others, such as admission, occurred more frequently among children from Very High COI areas. These findings have implications in EMS planning and in alternative out-of-hospital care models, including in regional placement of ambulance stations.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Lindsay Jaeger
- Department of Pediatrics, Section of Emergency Medicine, University of Chicago School of Medicine, Chicago, Illinois
| | - Jennifer Fishe
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Michelle L Macy
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Riney L, Palmer S, Finlay E, Bertrand A, Burcham S, Hendry P, Shah M, Kothari K, Ashby D, Ostermayer D, Semenova O, Abo BN, Abes B, Shimko N, Myers E, Frank M, Turner T, Kemp M, Landry K, Roland G, Fishe J. EMS Administration of Systemic Corticosteroids to Pediatric Asthma Patients: An Analysis by Severity and Transport Interval. PREHOSP EMERG CARE 2023; 27:900-907. [PMID: 37428954 PMCID: PMC10592383 DOI: 10.1080/10903127.2023.2234996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/23/2023] [Accepted: 06/25/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Pediatric asthma exacerbations are a common cause of emergency medical services (EMS) encounters. Bronchodilators and systemic corticosteroids are mainstays of asthma exacerbation therapy, yet data on the efficacy of EMS administration of systemic corticosteroids are mixed. This study's objective was to assess the association between EMS administration of systemic corticosteroids to pediatric asthma patients on hospital admission rates based on asthma exacerbation severity and EMS transport intervals. METHODS This is a sub-analysis of the Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial (EASI AS ODT). EASI AS ODT is a non-randomized, stepped wedge, observational study examining outcomes one year before and one year after seven EMS agencies incorporated an oral systemic corticosteroid option into their protocols for the treatment of pediatric asthma exacerbations. We included EMS encounters for patients ages 2-18 years confirmed by manual chart review to have asthma exacerbations. We compared hospital admission rates across asthma exacerbation severities and EMS transport intervals using univariate analyses. We geocoded patients and created maps to visualize the general trends of patient characteristics. RESULTS A total of 841 pediatric asthma patients met inclusion criteria. While most patients were administered inhaled bronchodilators by EMS (82.3%), only 21% received systemic corticosteroids, and only 19% received both inhaled bronchodilators and systemic corticosteroids. Overall, there was no significant difference in hospitalization rates between patients who did and did not receive systemic corticosteroids from EMS (33% vs. 32%, p = 0.78). However, although not statistically significant, for patients who received systemic corticosteroids from EMS, there was an 11% decrease in hospitalizations for mild exacerbation patients and a 16% decrease in hospitalizations for patients with EMS transport intervals greater than 40 min. CONCLUSION In this study, systemic corticosteroids were not associated with a decrease in hospitalizations of pediatric patients with asthma overall. However, while limited by small sample size and lack of statistical significance, our results suggest there may be a benefit in certain subgroups, particularly patients with mild exacerbations and those with transport intervals longer than 40 min. Given the heterogeneity of EMS agencies, EMS agencies should consider local operational and pediatric patient characteristics when developing standard operating protocols for pediatric asthma.
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Affiliation(s)
- Lauren Riney
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine
| | | | | | | | | | - Phyllis Hendry
- University of Florida College of Medicine – Jacksonville
| | - Manish Shah
- Baylor College of Medicine, Texas Children’s Hospital
| | | | - David Ashby
- Baylor College of Medicine, Texas Children’s Hospital
| | | | - Olga Semenova
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine
| | - Benjamin N. Abo
- Lee County Emergency Medical Services, Florida
- Florida State University College of Medicine
- Sarasota County Fire Department, Florida
| | | | | | | | - Marshall Frank
- Florida State University College of Medicine
- Sarasota County Fire Department, Florida
| | | | | | | | - Greg Roland
- Nassau County Fire Rescue Department, Florida
| | - Jennifer Fishe
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine
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Zorovich EV, Kothari K, Adelgais K, Alter R, Mojica L, Salinas A, Auerbach M, Adams C, Fishe J. Prehospital Management of Pediatric Behavioral Health Emergencies: A Scoping Review. Cureus 2023; 15:e38840. [PMID: 37303422 PMCID: PMC10254945 DOI: 10.7759/cureus.38840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Pediatric behavioral health emergencies (BHE) are increasing in prevalence, yet there are no evidence-based guidelines or protocols for prehospital management. The primary objective of this scoping review is to identify prehospital-specific pediatric BHE research and publicly available emergency medical services (EMS) protocols for pediatric BHE. Secondary objectives include identifying the next priorities for research and EMS protocol considerations for children with neurodevelopmental conditions. This is a scoping review comprised of a research literature search for publications from 2012-2022 and an internet search for publicly available EMS protocols from the United States. Included publications contain data on the epidemiology of pediatric BHE or describe prehospital management of pediatric BHE. EMS protocols were included if they had advisements specific to pediatric BHE. A total of 50 research publications and EMS protocols from 43 states were screened. Seven publications and four protocols were included in this study. Research studies indicated an increase in pediatric BHE over the last decade, but few papers discuss current prehospital management (n=4). Two EMS protocols were specific to pediatric BHE or pediatric agitation, and the other two EMS protocols focused on adult populations with integrated pediatric recommendations. All four EMS protocols encouraged nonpharmaceutical interventions prior to the use of pharmacologic restraints. Although there is a substantial rise in pediatric BHE, there is sparse research data and clinical EMS protocols to support best practices for prehospital pediatric BHE management. This scoping review identifies important future research aims to inform best practices for the prehospital management of pediatric BHE.
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Affiliation(s)
- Elizabeth V Zorovich
- Pediatric Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Kathryn Kothari
- Pediatric Emergency Medicine, Baylor College of Medicine, Houston, USA
| | - Kathleen Adelgais
- Pediatric Emergency Medicine, University of Colorado School of Medicine, Aurora, USA
| | - Rachael Alter
- Emergency Medicine Services, Emergency Medicine Services for Children Innovation and Improvement Center, Austin, USA
| | - Lia Mojica
- Pediatric Emergency Medicine, Medical College of Wisconsin, Milwaukee, USA
| | - Aaron Salinas
- Emergency Medicine Services, University of Texas Rio Grande Valley, Edinburg, USA
| | - Marc Auerbach
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Yale School of Medicine, New Haven, USA
| | - Carrie Adams
- Borland Library, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Jennifer Fishe
- Pediatric Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
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Hu H, Laden F, Hart J, James P, Fishe J, Hogan W, Shenkman E, Bian J. A spatial and contextual exposome-wide association study and polyexposomic score of COVID-19 hospitalization. Exposome 2023; 3:osad005. [PMID: 37089437 PMCID: PMC10118922 DOI: 10.1093/exposome/osad005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/22/2023] [Accepted: 04/06/2023] [Indexed: 04/25/2023]
Abstract
Environmental exposures have been linked to COVID-19 severity. Previous studies examined very few environmental factors, and often only separately without considering the totality of the environment, or the exposome. In addition, existing risk prediction models of severe COVID-19 predominantly rely on demographic and clinical factors. To address these gaps, we conducted a spatial and contextual exposome-wide association study (ExWAS) and developed polyexposomic scores (PES) of COVID-19 hospitalization leveraging rich information from individuals' spatial and contextual exposome. Individual-level electronic health records of 50 368 patients aged 18 years and older with a positive SARS-CoV-2 PCR/Antigen lab test or a COVID-19 diagnosis between March 2020 and October 2021 were obtained from the OneFlorida+ Clinical Research Network. A total of 194 spatial and contextual exposome factors from 10 data sources were spatiotemporally linked to each patient based on geocoded residential histories. We used a standard two-phase procedure in the ExWAS and developed and validated PES using gradient boosting decision trees models. Four exposome measures significantly associated with COVID-19 hospitalization were identified, including 2-chloroacetophenone, low food access, neighborhood deprivation, and reduced access to fitness centers. The initial prediction model in all patients without considering exposome factors had a testing-area under the curve (AUC) of 0.778. Incorporation of exposome data increased the testing-AUC to 0.787. Similar findings were observed in subgroup analyses focusing on populations without comorbidities and aged 18-24 years old. This spatial and contextual exposome study of COVID-19 hospitalization confirmed previously reported risk factor but also generated novel predictors that warrant more focused evaluation.
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Affiliation(s)
- Hui Hu
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Francine Laden
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jaime Hart
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Peter James
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Population Medicine, Harvard Pilgrim Healthcare, Boston, MA, USA
| | - Jennifer Fishe
- Department of Emergency Medicine, University of Florida College of Medicine—Jacksonville, Jacksonville, FL, USA
| | - William Hogan
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Elizabeth Shenkman
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jiang Bian
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, USA
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Ramgopal S, Jaeger L, Cercone A, Martin-Gill C, Fishe J. The Child Opportunity Index and Pediatric Emergency Medical Services Utilization. PREHOSP EMERG CARE 2023; 27:238-245. [PMID: 35536226 DOI: 10.1080/10903127.2022.2076268] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background: The delivery of emergency medical services (EMS) is a resource-intensive process, and prior studies suggest that EMS utilization in children may vary by socioeconomic status. The Child Opportunity Index (COI) provides a multidimensional measure of neighborhood-level resources and conditions that affect the health of children. We evaluated EMS utilization and measures of acuity among children by COI.Methods: We performed a cross-sectional study using encounters for patients less than 18 years of age from 10,067 EMS agencies in 47 US states and territories contributing to the National Emergency Medical Services Information System 2019 dataset. We compared patient demographics, EMS encounter characteristics, and care provided to children stratified by ZIP code using the COI 2.0.Results: We included 1,293,038 EMS encounters (median age 10 years, IQR 3-15 years). The distributions of encounters in the five tiers of COI were 30.6%, 20.1%, 18.0%, 16.3% and 15.1%, (from Very Low to Very High, respectively). The distribution of diagnoses between groups was similar. Most measures of EMS acuity/resource use were similar between groups, including non-transport status, cardiac arrest, vital sign abnormalities, and EMS-administered procedures and medications. Among children with respiratory-related encounters, children in the Very Low group had a greater need for nebulized medications (26.4% vs 18.3% in Very High COI children). Among children with trauma, a lower proportion in the Very Low group were given analgesia (4.0% vs 7.4% in the Very High group), though pain scores were similar in all groups.Conclusion: Pediatric EMS encounters from lower COI neighborhoods occur more frequently relative to encounters from higher COI neighborhoods. Despite these differences, children from lower COI strata generally have similar encounter characteristics to those in other COI strata, suggestive of a greater number of true out-of-hospital emergencies among children from these areas. Notable differences in care included use of respiratory medication to children with respiratory diagnoses, and administration of pain medication to children with trauma.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lindsay Jaeger
- Department of Pediatrics, Section of Emergency Medicine, University of Chicago School of Medicine, Chicago, Illinois
| | - Angelica Cercone
- Division of Emergency Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer Fishe
- Division of Pediatric Emergency Medicine, Dept of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
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Fedele DA, Hollenbach J, Sinisterra M, LeFave E, Fishe J, Salloum RG, Bian J, Gurka MJ. Implementation of a pediatric asthma management program in rural primary care clinics. J Asthma 2022; 60:1080-1087. [PMID: 36194428 PMCID: PMC10115910 DOI: 10.1080/02770903.2022.2132954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Rural communities experience a significant asthma burden. We pilot tested the implementation of Easy Breathing, a decision support program for improving primary care provider adherence to asthma guidelines in a rural community, and characterized asthma risk factors for enrollees. METHODS We implemented Easy Breathing in two rural primary care practices for two years. Patient demographics, exposure histories, asthma severity, asthma medications, and treatment plans were collected. Providers' adherence to guidelines included the frequency of children with persistent asthma who were prescribed guidelines-based therapy and the frequency of children with a written asthma treatment plan on file. Clinicians provided feedback on the feasibility and acceptability of Easy Breathing using a validated survey tool and through semi-structured interviews. RESULTS Two providers implemented the program. Enrollment included 518 children, of whom 135 (26%) had physician-confirmed asthma. After enrollment into Easy Breathing, 75% of children with asthma received a written asthma treatment plan All children with persistent asthma were prescribed an anti-inflammatory drug as part of their treatment plan. Providers (n = 2) rated Easy breathing as highly acceptable (M = 4.5), feasible (M = 4.5), and appropriate (M = 4.5). Qualitative feedback was positive, with suggestions to integrate the paper-based program into the electronic health record system for broader uptake. Enrollees with asthma were more likely to have a family history of asthma and endorse exposure to tobacco smoke and cockroaches. CONCLUSIONS Easy Breathing shows promise as a decision support system that can be implemented in rural, medically underserved communities via primary care.
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Affiliation(s)
- David A Fedele
- Department of Clinical & Health Psychology, University of Florida, Gainesville, FL, USA
| | - Jessica Hollenbach
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Manuela Sinisterra
- Department of Clinical & Health Psychology, University of Florida, Gainesville, FL, USA
| | - Elizabeth LeFave
- Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Jennifer Fishe
- Department of Emergency Medicine, University of Florida, Jacksonville, FL, USA
| | - Ramzi G Salloum
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL, USA
| | - Jiang Bian
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL, USA
| | - Matthew J Gurka
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL, USA
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Guerrier C, Brailsford J, Patel S, Burcham S, Salloum RG, Martin-Gill C, Richards CT, Panchal AR, Fishe J. Emergency Medical Services Leadership Perspectives on Implementation of Evidence-Based Guidelines: A Qualitative Study. PREHOSP EMERG CARE 2022; 27:946-954. [PMID: 36149372 PMCID: PMC10060435 DOI: 10.1080/10903127.2022.2128484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/04/2022] [Accepted: 09/21/2022] [Indexed: 10/14/2022]
Abstract
Introduction: Prehospital evidence-based guidelines (EBGs) are developed to optimize clinical outcomes for emergency medical services (EMS) patients. However, widespread implementation of EBGs is often inconsistent. Therefore, this study aimed to assess the baseline knowledge and practices of EMS leaders related to EBG implementation.Methods: This was a qualitative study using focus groups to assess prehospital implementation awareness and knowledge. Participants were EMS EBG authors, EMS medical directors, and EMS professional organization leaders. Focus groups were held via video conference, audio recorded, and transcribed. Thematic coding used domains and constructs of the Consolidated Framework for Implementation Research (CFIR).Results: Six focus groups were conducted with a total of 18 participants. A total of 1,044 codes were analyzed. "Process" was the CFIR domain with the most codes (n = 350, 33.5%), followed by the "inner setting" (the EMS agency; n = 250, 23.9%), "characteristics of the intervention" (n = 203, 19.4%), "outer setting" (the health care system and community the EMS agency serves, and the broader national EMS professional context; n = 141, 13.5%), and "characteristics of individuals" (n = 100, 9.6%). The ten most frequent constructs across all domains were: reflecting and evaluating, executing, cosmopolitanism, planning, external policy and incentives, design quality and packaging, learning climate, culture, complexity, and other personal attributes.Conclusion: EMS leadership and stakeholder views on EBG implementation identified dominant themes related to the process of implementation and the culture and learning/implementation climate of EMS agencies. Opinions were mixed on the utility of the CFIR as a potential guide for EMS implementation. Further work is required to gain the frontline EMS clinician perspective on implementation and tie key themes to quantitative prehospital implementation outcomes.
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Affiliation(s)
- Christina Guerrier
- Center for Data Solutions, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida
| | - Jennifer Brailsford
- Center for Data Solutions, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida
| | - Shama Patel
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida
| | - Shannon Burcham
- Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida
| | - Ramzi G Salloum
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, Florida
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Prehospital Guidelines Consortium
| | - Christopher T Richards
- Prehospital Guidelines Consortium
- Department of Emergency Medicine, School of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Ashish R Panchal
- Prehospital Guidelines Consortium
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jennifer Fishe
- Center for Data Solutions, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida
- Prehospital Guidelines Consortium
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Fishe J, Zheng Y, Lyu T, Bian J, Hu H. Environmental effects on acute exacerbations of respiratory diseases: A real-world big data study. Sci Total Environ 2022; 806:150352. [PMID: 34555607 PMCID: PMC8627495 DOI: 10.1016/j.scitotenv.2021.150352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 09/11/2021] [Accepted: 09/11/2021] [Indexed: 05/06/2023]
Abstract
BACKGROUND The effects of weather periods, race/ethnicity, and sex on environmental triggers for respiratory exacerbations are not well understood. This study linked the OneFlorida network (~15 million patients) with an external exposome database to analyze environmental triggers for asthma, bronchitis, and COPD exacerbations while accounting for seasonality, sex, and race/ethnicity. METHODS This is a case-crossover study of OneFlorida database from 2012 to 2017 examining associations of asthma, bronchitis, and COPD exacerbations with exposures to heat index, PM 2.5 and O 3. We spatiotemporally linked exposures using patients' residential addresses to generate average exposures during hazard and control periods, with each case serving as its own control. We considered age, sex, race/ethnicity, and neighborhood deprivation index as potential effect modifiers in conditional logistic regression models. RESULTS A total of 1,148,506 exacerbations among 533,446 patients were included. Across all three conditions, hotter heat indices conferred increasing exacerbation odds, except during November to March, where the opposite was seen. There were significant differences when stratified by race/ethnicity (e.g., for asthma in April, May, and October, heat index quartile 4, odds were 1.49 (95% confidence interval (CI) 1.42-1.57) for Non-Hispanic Blacks and 2.04 (95% CI 1.92-2.17) for Hispanics compared to 1.27 (95% CI 1.19-1.36) for Non-Hispanic Whites). Pediatric patients' odds of asthma and bronchitis exacerbations were significantly lower than adults in certain circumstances (e.g., for asthma during June - September, pediatric odds 0.71 (95% CI 0.68-0.74) and adult odds 0.82 (95% CI 0.79-0.85) for the highest quartile of PM 2.5). CONCLUSION This study of acute exacerbations of asthma, bronchitis, and COPD found exacerbation risk after exposure to heat index, PM 2.5 and O 3 varies by weather period, age, and race/ethnicity. Future work can build upon these results to alert vulnerable populations to exacerbation triggers.
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Affiliation(s)
- Jennifer Fishe
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, United States of America; Center for Data Solutions, University of Florida College of Medicine - Jacksonville, United States of America.
| | - Yi Zheng
- Department of Epidemiology, University of Florida College of Medicine & College of Public Health and Health Professions, United States of America
| | - Tianchen Lyu
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Jiang Bian
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Hui Hu
- Department of Epidemiology, University of Florida College of Medicine & College of Public Health and Health Professions, United States of America
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Taneja A, Wylie T, Kalynych C, Helmi H, Fishe J. Development of a Longitudinal Research Curriculum for Pediatric Emergency Medicine Fellowship. West J Emerg Med 2022; 23:26-29. [PMID: 35060856 PMCID: PMC8782123 DOI: 10.5811/westjem.2021.10.52854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 10/04/2021] [Indexed: 11/11/2022] Open
Affiliation(s)
- Ankita Taneja
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Todd Wylie
- University of Florida College of Medicine – Jacksonville, Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Jacksonville, Florida
| | - Colleen Kalynych
- University of Florida College of Medicine – Jacksonville, Office of Educational Affairs, Jacksonville, Florida
| | - Haytham Helmi
- University of Florida College of Medicine – Jacksonville, Department of Emergency Medicine, Jacksonville, Florida
| | - Jennifer Fishe
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
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11
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Sheikh S, Fishe J, Norse A, Henson M, James D, Sher W, Lott M, Kalynych C, Hendry P. Comparing Pain Intensity Using the Numeric Rating Scale and Defense and Veterans Pain Rating Scale in Patients Revisiting the Emergency Department. Cureus 2021; 13:e17501. [PMID: 34603880 PMCID: PMC8476185 DOI: 10.7759/cureus.17501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2021] [Indexed: 11/17/2022] Open
Abstract
Objective To determine the relationship between Numeric Rating Scale (NRS) and Defense and Veterans Pain Rating Scale (DVPRS) as pain intensity measures, we compared pain scores to sociodemographic and treatment data in patients revisiting the emergency department (ED). Methods After Institutional Review Board approval, 389 adults presenting within 30 days of an index visit were enrolled. Pain scores were classified as follows: 0-3 (mild), 4-7 (moderate), and 8-10 (high). Data were analyzed using descriptive analysis. Wilcoxon rank-sum test measured the association of pain score with gender. Pain scales were correlated using Spearman correlation coefficient. Pain scale association with opioid treatment was tested via ordinal logistic regression controlling for gender, home opioid use, and if ED revisit was for pain. Results Average patient age was 49. Most patients were African American (68.4%), male (51.2%), and returned for pain (67.0%). As continuous measures, both scales were positively correlated with each other (p<0.0001). Pain score severity categories were distributed differently between the two scales (p=0.0085), decreasing by 8% in patients reporting high pain severity when using DVPRS. For both scales, the proportion of patients (1) administered opioids (p=0.0009 and p≤0.0001, respectively) and (2) discharged with opioids (p=0.0103 and p=0.0417, respectively) increased with pain severity. Discharge NRS (p=0.0001) (OR=3.2, 1.780-5.988) and DVPRS pain score categories (p<0.0001) (OR=2.7, 95% CI=1.63-4.473) were associated with revisits for pain. Conclusions Our findings demonstrate a link between NRS and administration of opioid medications and suggest that DVPRS may better differentiate between moderate and high levels of pain in the ED setting.
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Affiliation(s)
- Sophia Sheikh
- Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Jennifer Fishe
- Pediatric Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Ashley Norse
- Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Morgan Henson
- Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Divya James
- Emergency Medicine, University of Florida College of Medicine, Gainesville, USA
| | - Warren Sher
- Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Michelle Lott
- Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Colleen Kalynych
- Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Phyllis Hendry
- Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
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12
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The PAMI ED-ALT Group, Sheikh S, Schmitzberger M, Liao R, Brailsford J, Fishe J, Norse A, Webb K, Spindle N, Suffield D, Hendry P. 222 Preliminary Results of PAMI-ED ALT: An Emergency Department Opioid-Alternatives Program. Ann Emerg Med 2021. [DOI: 10.1016/j.annemergmed.2021.09.234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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13
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Pain Assessment and Management Initiative, Hendry P, Suffield D, Sheikh S, Spindle N, Schmitzberger M, Velasquez E, Lott M, Fishe J, Johnson B, Kendall Webb L, Norse A. 214 Preliminary Results From an Emergency Department Pain Coach Service and Discharge Toolkit Pilot Project During COVID-19. Ann Emerg Med 2021. [PMCID: PMC8536285 DOI: 10.1016/j.annemergmed.2021.09.226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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14
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Harris MI, Crowe RP, Anders J, D'Acunto S, Adelgais KM, Fishe J. Applying a set of termination of resuscitation criteria to paediatric out-of-hospital cardiac arrest. Resuscitation 2021; 169:175-181. [PMID: 34555488 DOI: 10.1016/j.resuscitation.2021.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 09/08/2021] [Accepted: 09/13/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Prehospital Termination of Resuscitation (TOR) protocols for adults can reduce the number of futile transports of patients in cardiac arrest, yet similar protocols are not widely available for paediatric out-of-hospital cardiac arrest (POHCA). The objective of this study was to apply a set of criteria for paediatric TOR (pTOR) from the Maryland Institute for Emergency Medical Services Systems (MIEMSS) to a large national cohort and determine its association with return of spontaneous circulation (ROSC) after POHCA. METHODS We identified patients ages 0-17 treated by Emergency Medical Services (EMS) with cardiac arrest in 2019 from the ESO dataset and and applied the applicable pTOR certeria for medical or traumatic arrests. We calculated predictive test characteristics for the outcome of prehospital ROSC, stratified by medical and traumatic cause of arrest. RESULTS We analyzed records for 1595 POHCA patients. Eighty-eight percent (n = 1395) were classified as medical. ROSC rates were 23% among medical POHCA and 27% among traumatic POHCA. The medical criteria correctly classified >99% (322/323) of patients who achieved ROSC as ineligible for TOR. The trauma criteria correctly classified 93% (50/54) of patients with ROSC as ineligible for TOR. Of the five misclassified patients, three were involved in drowning incidents. CONCLUSIONS The Maryland pTOR criteria identified eligible patients who did not achieve prehospital ROSC, while reliably excluding those who did achieve prehospital ROSC. As most misclassified patients were victims of drowning, we recommend considering the exclusion of drowning patients from future pTOR guidelines. Further studies are needed to evaluate the long-term survival and neurologic outcome of patients misclassified by pTOR criteria.
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Affiliation(s)
- Matthew I Harris
- Northwell Hofstra School of Medicine, Departments of Paediatrics and Emergency, Medicine, New Hyde Park, NY, United States.
| | | | - Jennifer Anders
- Johns Hopkins School of Medicine, Department of Paediatrics, Baltimore, MD, United States
| | - Salvatore D'Acunto
- University of Florida College of Medicine - Jacksonville, Center for Data Solutions, Jacksonville, FL United States
| | - Kathleen M Adelgais
- University of Colorado School of Medicine, Department of Paediatrics, Section of Paediatric Emergency Medicine, Aurora, CO, United States
| | - Jennifer Fishe
- University of Florida College of Medicine - Jacksonville, Center for Data Solutions, Jacksonville, FL United States; University of Florida College of Medicine - Jacksonville, Department of Emergency Medicine, Jacksonville, FL, United States
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15
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Hu H, Zheng Y, Wen X, Smith SS, Nizomov J, Fishe J, Hogan WR, Shenkman EA, Bian J. An external exposome-wide association study of COVID-19 mortality in the United States. Sci Total Environ 2021; 768:144832. [PMID: 33450687 PMCID: PMC7788319 DOI: 10.1016/j.scitotenv.2020.144832] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/14/2020] [Accepted: 12/18/2020] [Indexed: 05/21/2023]
Abstract
The risk factors for severe COVID-19 beyond older age and certain underlying health conditions are largely unknown. Recent studies suggested that long-term environmental exposures may be important determinants of severe COVID-19. However, very few environmental factors have been studied, often separately, without considering the totality of the external environment (i.e., the external exposome). We conducted an external exposome-wide association study (ExWAS) using the nationwide county-level COVID-19 mortality data in the contiguous US. A total of 337 variables characterizing the external exposome from 8 data sources were integrated, harmonized, and spatiotemporally linked to each county. A two-phase procedure was used: (1) in Phase 1, a random 50:50 split divided the data into a discovery set and a replication set, and associations between COVID-19 mortality and individual factors were examined using mixed-effect negative binomial regression models, with multiple comparisons addressed, and (2) in Phase 2, a multivariable regression model including all variables that are significant from both the discovery and replication sets in Phase 1 was fitted. A total of 13 and 22 variables were significant in the discovery and replication sets in Phase 1, respectively. All the 4 variables that were significant in both sets in Phase 1 remained statistically significant in Phase 2, including two air toxicants (i.e., nitrogen dioxide or NO2, and benzidine), one vacant land measure, and one food environment measure. This is the first external exposome study of COVID-19 mortality. It confirmed some of the previously reported environmental factors associated with COVID-19 mortality, but also generated unexpected predictors that may warrant more focused evaluation.
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Affiliation(s)
- Hui Hu
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA.
| | - Yi Zheng
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA
| | - Xiaoxiao Wen
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA
| | - Sabrina S Smith
- College of Liberal Arts and Sciences, University of Florida, Gainesville, FL, USA
| | - Javlon Nizomov
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jennifer Fishe
- Department of Emergency Medicine, College of Medicine, University of Florida, Jacksonville, FL, USA
| | - William R Hogan
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Elizabeth A Shenkman
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jiang Bian
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, USA
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16
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Tsou P, Chen KP, Wang Y, Fishe J, Gillon J, Lee C, Deanehan JK, Kuo P, Yu DTY. Diagnostic Accuracy of Lung Ultrasound Performed by Novice Versus Advanced Sonographers for Pneumonia in Children: A Systematic Review and Meta-analysis. Acad Emerg Med 2019; 26:1074-1088. [PMID: 31211896 DOI: 10.1111/acem.13818] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 05/21/2019] [Accepted: 06/12/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Childhood pneumonia is a leading cause of mortality worldwide. Growing evidence suggests that lung ultrasound (LUS) may be a reliable diagnostic alternative to chest x-ray for childhood pneumonia. However, it is unclear whether sonographer experience affects the diagnostic accuracy of LUS. We summarize the diagnostic accuracy of LUS for pneumonia and compare the performance between novice and advanced sonographers with a systematic review and meta-analysis. METHODS We searched PubMed and EMBASE from inception to February 2018 for eligible studies that evaluated the utility of LUS in children suspected of having pneumonia against the reference standard of either imaging results alone or a combination of clinical, laboratory, and imaging results. We reported the study using the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies. We used QUADAS-2 to appraise the included studies' methodologic quality. We employed a random-effect bivariate model and a hierarchical summary receiver operating characteristic curve to evaluate LUS's performance characteristics. We conducted subgroup analyses and meta-regression based on level of sonographer training to summarize and compare LUS's diagnostic accuracy for pneumonia between novice (training ≤ 7 days) and advanced sonographers. RESULTS Twenty-five studies (n = 3,353) were included in the meta-analysis. For diagnosing pneumonia, LUS demonstrated an overall sensitivity of 0.94 (95% confidence interval [CI] = 0.89 to 0.97), specificity of 0.92 (95% CI = 0.78 to 0.98), positive likelihood ratio of 12.40 (95% CI = 4.00 to 38.10), and negative likelihood ratio of 0.07 (95% CI = 0.04 to 0.12), with an area under ROC curve of 0.97 (95% CI = 0.95 to 0.98). Meta-regression revealed a significant difference in the diagnostic accuracy for pneumonia for LUS between novice and advanced sonographers (p < 0.01). CONCLUSION LUS can accurately diagnose pneumonia in children. However, this test demonstrates operator-dependent variability, with more experienced sonographers having higher diagnostic accuracy. Further work on evidence-based educational methods to train novice sonographers in LUS is required.
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Affiliation(s)
- Po‐Yang Tsou
- Department of Pediatrics Driscoll Children's Hospital Corpus Christi TX
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Kenneth P. Chen
- Division of Pulmonary Critical Care, and Sleep Medicine, San Diego UCSD Medical Center San Diego CA
| | - Yu‐Hsun Wang
- Department of Pediatrics Driscoll Children's Hospital Corpus Christi TX
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Jennifer Fishe
- Department of Emergency Medicine University of Florida College of Medicine Jacksonville FL
| | - Jason Gillon
- Department of Pediatric Emergency Medicine University of Texas at Austin Dell Medical School Austin TX
| | - Chien‐Chang Lee
- Department of Emergency Medicine National Taiwan University Hospital Taipei Taiwan
| | - Julia K. Deanehan
- Department of Pediatric Emergency Medicine Johns Hopkins School of Medicine Baltimore MD
| | - Pei‐Lun Kuo
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Daniel Ta Yo Yu
- Department of Pediatric Emergency Medicine Seattle Children's Hospital University of Washington Seattle WA
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17
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Fishe J, Finlay E, Palmer S, Hendry P. A Geospatial Analysis of Distances to Hospitals that Admit Pediatric Asthma Patients. PREHOSP EMERG CARE 2019; 23:882-886. [PMID: 30874466 DOI: 10.1080/10903127.2019.1593565] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: Pediatric care is now concentrated in urban specialty centers ("regionalization"), even for common conditions such as asthma. At the same time, rural emergency medical services (EMS) faces challenges related to adequate workforce staffing and financing. This statewide study describes how regionalization of pediatric inpatient care for asthma exacerbations affects EMS operations, particularly for rural agencies. Methods: This is a statewide cross-sectional study of EMS encounters for pediatric asthma in patients aged 2-18 years from 2011 to 2016 using Florida's EMS Tracking and Reporting System (EMSTARS) database. EMSTARS encounters were deterministically linked to Florida's Agency for Healthcare Administration (AHCA) database. We categorized AHCA hospital facilities that received included patients by whether they did or did not admit pediatric asthma patients during the study period ("admitting facility"). We used geospatial analysis to map the EMS agency's home county and the admitting facilities addresses. For each county in Florida, we calculated the average estimated EMS travel distance to the nearest admitting facility using a dasymetric mapping approach. Results: The study included a total of 11,226 EMS pediatric asthma encounters, of which 11,153 (99%) matched to an EMS home county. AHCA data was available for 3,812 (34%) patients. Most counties with distances to admitting facilities less than or equal to 15 miles were urban (31 of 39). For distances of 31-45 miles to an admitting facility, 7 of 8 of counties were rural, and for distances greater than 46 miles, all 4 counties were rural. Conclusions: In this statewide study in Florida, we found long average estimated EMS travel distances to admitting facilities for Florida's pediatric population in rural counties for pediatric asthma exacerbations. Those long distances have great implications for rural EMS operations, including pediatric destination decisions, transport times, and availability for others who call 9-1-1. Further research on bypass and secondary transport rates, and outcomes for asthma and other pediatric conditions are required to further characterize pediatric regionalization's impact on rural EMS.
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18
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VanGraafeiland B, Foronda C, Vanderwagen S, Allan L, Bernier M, Fishe J, Hunt EA, Jeffers JM. Improving the handover and transport of critically ill pediatric patients. J Clin Nurs 2018; 28:56-65. [PMID: 30016565 DOI: 10.1111/jocn.14627] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 06/25/2018] [Accepted: 07/03/2018] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES The aims of this project were to (a) determine barriers to current handover and transport process, (b) develop a new protocol and process for team-to-team handover, and (c) evaluate staff satisfaction with the new process. BACKGROUND The handover and transport of critically ill patients from the paediatric emergency department to the paediatric intensive care unit is a period of vulnerability associated with adverse events. DESIGN A mixed-methods study using a quasi-experimental design and qualitative approach. METHODS Focus groups were conducted to determine the barriers and facilitators of the current handover and transport process. Using these themes, a multidisciplinary team developed and implemented a new process including establishment of eight patient criteria for specialised transport and a standardised, interdisciplinary handover tool for team-to-team handover. Staff satisfaction was examined pre- and postintervention. RESULTS Content analysis of focus groups revealed five categories: need for improved communication, cultural dissonance among units, defects in system and processes, need for standardisation and ambiguity between providers regarding acuity. Staff members reported improvements in their perceptions of satisfaction, safety, communication and role understanding associated with the new process. CONCLUSIONS Standardisation through the establishment of severity of illness criteria and communication tools creates shared mental models and decreases risks to safety. A paradigm shift of team-to-team handover and transport is recommended. RELEVANCE TO CLINICAL PRACTICE This paper suggests the importance of improving communication during the handover and transport process through establishing standardised patient severity of illness criteria, use of standardised tools and team-to-team handover processes.
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Affiliation(s)
- Brigit VanGraafeiland
- Johns Hopkins University School of Nursing, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Cynthia Foronda
- Johns Hopkins University School of Nursing, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Sarah Vanderwagen
- Johns Hopkins University School of Nursing, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Laura Allan
- Johns Hopkins University School of Nursing, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Meghan Bernier
- Johns Hopkins University School of Nursing, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Jennifer Fishe
- Johns Hopkins University School of Nursing, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Elizabeth A Hunt
- Johns Hopkins University School of Nursing, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Justin M Jeffers
- Johns Hopkins University School of Nursing, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
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