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Ward CE, Adelgais KM, Holsti M, Jacobsen KK, Simon HK, Morris CR, Gonzalez VM, Lerner G, Ghaffari K, VanBuren JM, Lerner EB, Shah MI. Public support for and concerns regarding pediatric dose optimization for seizures in emergency medical services: An exception from informed consent (EFIC) trial. Acad Emerg Med 2024. [PMID: 38450918 DOI: 10.1111/acem.14884] [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] [Received: 10/25/2023] [Revised: 01/20/2024] [Accepted: 01/28/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Federal regulations allow exception from informed consent (EFIC) to study emergent conditions when obtaining prospective consent is not feasible. Little is known about public views on including children in EFIC studies. The Pediatric Dose Optimization for Seizures in EMS (PediDOSE) trial implements age-based, standardized midazolam dosing for pediatric seizures. The primary objective of this study was to determine public support for and concerns about the PediDOSE EFIC trial. The secondary objective was to assess how support for PediDOSE varied by demographics. METHODS We conducted a mixed-methods study in 20 U.S. communities. Participants reviewed information about PediDOSE before completing an online survey. Descriptive data were generated. Univariable and multivariable logistic regression analysis identified factors associated with support for PediDOSE. Reviewers identified themes from free-text response data regarding participant concerns. RESULTS Of 2450 respondents, 79% were parents/guardians, and 20% had a child with previous seizures. A total of 96% of respondents supported PediDOSE being conducted, and 70% approved of children being enrolled without prior consent. Non-Hispanic Black respondents were less likely than non-Hispanic White respondents to support PediDOSE with an adjusted odds ratio (aOR) of 0.57 (95% CI 0.42-0.75). Health care providers were more likely to support PediDOSE, with strongest support among prehospital emergency medicine clinicians (aOR 5.82, 95% CI 3.19-10.62). Age, gender, parental status, and level of education were not associated with support of PediDOSE. Common concerns about PediDOSE included adverse effects, legal and ethical concerns about enrolling without consent, and potential racial bias. CONCLUSIONS In communities where this study will occur, most respondents supported PediDOSE being conducted with EFIC and most approved of children being enrolled without prior consent. Support was lowest among non-Hispanic Black respondents and highest among health care providers. Further research is needed to determine optimal ways to address the concerns of specific racial and ethnic groups when conducting EFIC trials.
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Affiliation(s)
- Caleb E Ward
- George Washington University School of Medicine and Health Sciences, Children's National Hospital, Washington, DC, USA
| | - Kathleen M Adelgais
- University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Maija Holsti
- University of Utah, Primary Children's Medical Center, Salt Lake City, Utah, USA
| | | | - Harold K Simon
- Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Claudia R Morris
- Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Victor M Gonzalez
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Gonzalo Lerner
- University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | | | | | - E Brooke Lerner
- University of Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Manish I Shah
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
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Kadish CB, Lloyd JK, Adelgais KM, Ward CE, Lo CB, Truelove A, Leonard JC. Prehospital Recognition and Management of Pediatric Sepsis: A Qualitative Assessment. PREHOSP EMERG CARE 2023; 27:775-785. [PMID: 37141419 DOI: 10.1080/10903127.2023.2210217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/10/2023] [Accepted: 04/28/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND AND PURPOSE Sepsis is a life-threatening disease in children and is a leading cause of morbidity and mortality. Early prehospital recognition and management of children with sepsis may have significant effects on the timely resuscitation of this high-risk clinical condition. However, the care of acutely ill and injured children in the prehospital setting can be challenging. This study aims to understand barriers, facilitators, and attitudes regarding recognition and management of pediatric sepsis in the prehospital setting. METHODS This was a qualitative study of EMS professionals participating in focus groups using a grounded theory-based design to gather information on recognition and management of septic children in the prehospital setting. Focus groups were held for EMS administrators and medical directors. Separate focus groups were held for field clinicians. Focus groups were conducted via video conference until saturation of ideas was reached. Using consensus methodology, transcripts were coded in an iterative process. Data were then organized into positive and negative factors based on the validated PRECEDE-PROCEED model for behavioral change. RESULTS Thirty-eight participants in six focus groups identified nine environmental factors, 21 negative factors, and 14 positive factors pertaining to recognition and management of pediatric sepsis. These findings were organized into the PRECEDE-PROCEED planning model. Pediatric sepsis guidelines were identified as positive factors when they did exist and negative factors when they were complicated or did not exist. Six interventions were identified by participants. These include raising awareness of pediatric sepsis, increasing pediatric education, receiving feedback on prehospital encounters, increasing pediatric exposure and skills training, and improving dispatch information. CONCLUSION This study fills a gap by examining barriers and facilitators to prehospital diagnosis and management of pediatric sepsis. Using the PRECEDE-PROCEED model, nine environmental factors, 21 negative factors, and 14 positive factors were identified. Participants identified six interventions that could create the foundation to improve prehospital pediatric sepsis care. Policy changes were suggested by the research team based on the results of this study. These interventions and policy changes provide a roadmap for improving care in this population and lay the groundwork for future research.
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Affiliation(s)
- Chelsea B Kadish
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, Ohio
| | - Julia K Lloyd
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, Ohio
| | - Kathleen M Adelgais
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Caleb E Ward
- Children's National Hospital, George Washington University, Washington, District of Columbia
| | - Charmaine B Lo
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Annie Truelove
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Julie C Leonard
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, Ohio
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
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Harris MI, Adelgais KM, Linakis SW, Magill CF, Brazauskas R, Shah MI, Nishijima DK, Lowe GS, Chadha K, Chang TP, Lerner EB, Leonard JC, Schwartz HP, Gaither JB, Studnek JR, Browne LR. Impact of Prehospital Pain Management on Emergency Department Management of Injured Children. PREHOSP EMERG CARE 2023; 27:1-9. [PMID: 34734787 DOI: 10.1080/10903127.2021.2000683] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Provision of analgesia for injured children is challenging for Emergency Medical Services (EMS) clinicians. Little is known about the effect of prehospital analgesia on emergency department (ED) care. We aimed to determine the impact of prehospital pain interventions on initial ED pain scale scores, timing and dosing of ED analgesia for injured patients transported by EMS. METHODS This is a planned, secondary analysis of a prospective multicenter cohort of children with actual or suspected injuries transported to one of 11 PECARN-affiliated EDs from July 2019-April 2020. Using Wilcoxon rank sum for continuous variables and chi-square testing for categorical variables, we compared the change in EMS-to-ED pain scores and timing and dosing of ED-administered opioid analgesia in those who did and those who did not receive prehospital pain interventions. RESULTS We enrolled 474 children with complete prehospital and ED pain management data. Prehospital interventions were performed on 262/474 (55%) of injured children and a total of 88 patients (19%) received prehospital opioids. Children who received prehospital opioids with or without adjunctive non-pharmacologic pain management experienced a greater reduction in pain severity and were more likely to receive ED opioids in higher doses earlier and throughout their ED care. Non-pharmacologic pain interventions alone did not impact ED care. CONCLUSIONS We demonstrate that prehospital opioid analgesia is associated with both a significant reduction in pain severity at ED arrival and the administration of higher doses of opioid analgesia earlier and throughout ED care.
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Affiliation(s)
- M I Harris
- Department of Pediatrics, Northwell Hofstra School of Medicine, New Hyde Park, New York
| | - K M Adelgais
- Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - S W Linakis
- Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - C F Magill
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina
| | - R Brazauskas
- Department of Institute for Health Equity, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - M I Shah
- Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | - D K Nishijima
- Department of Emergency Medicine, University of California - Davis, Sacramento, California
| | - G S Lowe
- Department of Pediatrics, University of Texas Southwestern, Dallas, Texas
| | - K Chadha
- Department of Emergency Medicine, University at Buffalo, Buffalo, New York
| | - T P Chang
- Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - E B Lerner
- Department of Emergency Medicine, University at Buffalo, Buffalo, New York
| | - J C Leonard
- Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - H P Schwartz
- Division of Emergency Medicine, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - J B Gaither
- Department of Emergency Medicine, University of Arizona, Tucson, Arizona
| | - J R Studnek
- Mecklenburg EMS Agency, Charlotte, North Carolina
| | - L R Browne
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Nishijima DK, Tancredi DJ, Adelgais KM, Chadha K, Chang TP, Harris MI, Leonard JC, Lerner EB, Linakis SW, Lowe GS, Magill CF, Schwartz HP, Shah MI, Browne LR. Impact of Race and Ethnicity on Emergency Medical Services Administration of Opioid Pain Medications for Injured Children. J Emerg Med 2023; 64:55-61. [PMID: 36641254 DOI: 10.1016/j.jemermed.2022.10.011] [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: 06/28/2022] [Revised: 09/04/2022] [Accepted: 10/11/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Treatment with analgesics for injured children is often not provided or delayed during prehospital transport. OBJECTIVE Our aim was to evaluate racial and ethnic disparities with the use of opioids during transport of injured children. METHODS We conducted a prospective study of injured children transported to 1 of 10 emergency departments from July 2019 to April 2020. Emergency medical services (EMS) providers were surveyed about prehospital pain interventions during transport. Our primary outcome was the use of opioids. We performed multivariate regression analyses to evaluate the association of patient demographic characteristics (race, ethnicity, age, and gender), presence of a fracture, EMS provider type (Advanced Life Support [ALS] or non-ALS) and experience (years), and study site with the use of opioids. RESULTS We enrolled 465 patients; 19% received opioids during transport. The adjusted odds ratios (AORs) for Black race and Hispanic ethnicity were 0.5 (95% CI 0.2-1.2) and 0.4 (95% CI 0.2-1.3), respectively. The presence of a fracture (AOR 17.0), ALS provider (AOR 5.6), older patient age (AOR 1.1 for each year), EMS provider experience (AOR 1.1 for each year), and site were associated with receiving opioids. CONCLUSIONS There were no statistically significant associations between race or ethnicity and use of opioids for injured children. The presence of a fracture, ALS provider, older patient age, EMS provider experience, and site were associated with receiving opioids.
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Affiliation(s)
- Daniel K Nishijima
- Department of Emergency Medicine, University of California, Davis, Sacramento, California.
| | - Daniel J Tancredi
- Department of Pediatrics, University of California, Davis, Sacramento, California
| | - Kathleen M Adelgais
- Departments of Pediatrics and Emergency Medicine, University of Colorado, Aurora, Colorado
| | - Kunal Chadha
- Department of Pediatrics, University of Buffalo, Buffalo, New York
| | - Todd P Chang
- Children's Hospital of Los Angeles and Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Matthew I Harris
- Department of Pediatrics, Cohen Children's Medical Center, Zucker School of Medicine - Hofstra University, New Hyde Park, New York
| | - Julie C Leonard
- Nationwide Children's Hospital and Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - E Brooke Lerner
- Departments of Emegency Medicine and Pediatrics, University of Buffalo, Buffalo, New York
| | - Seth W Linakis
- Nationwide Children's Hospital and Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - Geoffrey S Lowe
- Department of Pediatrics, University of Texas Southwestern, Dallas, Texas
| | - Christyn F Magill
- Children's Hospital of Los Angeles and Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina
| | - Hamilton P Schwartz
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Manish I Shah
- Department of Pediatrics, Division of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | - Lorin R Browne
- Departments of Pediatrics and Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Tsao HS, Alter R, Kane E, Gross T, Browne LR, Auerbach M, Leonard JC, Ludwig L, Adelgais KM. Pediatric Emergency Care Coordination in EMS Agencies: Findings of a Multistate Learning Collaborative. PREHOSP EMERG CARE 2022; 27:1004-1015. [PMID: 36125189 DOI: 10.1080/10903127.2022.2126040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/14/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND In 2017, the Health Resources and Services Administration's Maternal Child and Health Bureau's Emergency Medical Services for Children program implemented a performance measure for State Partnership grants to increase the percentage of EMS agencies within each state that have designated individuals who coordinate pediatric emergency care, also called a pediatric emergency care coordinator (PECC). The PECC Learning Collaborative (PECCLC) was established to identify best practices to achieve this goal. This study's objective is to report on the structure and outcomes of the PECCLC conducted among nine states. METHODS This study used quantitative and qualitative methods to evaluate outcomes from the PECCLC. Participating state representatives engaged in a 6-month collaborative that included monthly learning sessions with subject matter experts and support staff and concluded with a two-day in-person meeting. Outcomes included reporting the number of PECCs recruited, identifying barriers and enablers to PECC recruitment, characterizing best practices to support PECCs, and identifying barriers and enablers to enhance and sustain the PECC role. Outcomes were captured by self-report from participating state representatives and longitudinal qualitative interviews conducted with representative PECCs at 6 and 18 months after conclusion of the PECCLC. RESULTS During the 6-month collaborative, states recruited 341 PECCs (92% of goal). Follow up at 5 months post-collaborative revealed an additional recruitment of 184 for a total of 525 PECCs (142% of the goal). Feedback from state representatives and PECCs revealed the following barriers: competition from other EMS responsibilities, budgetary constraints, lack of incentive for agencies to create the position, and lack of requirement for establishing the role. Enablers identified included having an EMS agency recognition program that includes the PECC role, train-the-trainer programs, and inclusion of the PECC role in agency licensure requirements. Longitudinal interviews with PECCs identified that the most common activity associated with their role was pediatric-specific education and the most important need for PECC success was agency-level support. CONCLUSION Over the 6-month Learning Collaborative, nine states were successful in recruiting a substantial number of PECCs. Financial and time constraints were significant barriers to statewide PECC recruitment, yet these can be potentially addressed by EMS agency recognition programs.
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Affiliation(s)
- Hoi See Tsao
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
- Emergency Medical Services for Children Innovation & Improvement Center, The University of Texas Austin, Austin, Texas
| | - Rachael Alter
- Emergency Medical Services for Children Innovation & Improvement Center, The University of Texas Austin, Austin, Texas
| | - Erica Kane
- EMS for Children, Emergency Medical Services for Children at Children's Health Alliance of Wisconsin, Milwaukee, Wisconsin
| | - Toni Gross
- Department of Emergency Medicine, Children's Hospital of New Orleans, New Orleans, Louisiana
| | - Lorin R Browne
- Department of Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, Wisconsin
| | - Marc Auerbach
- Yale University School of Medicine, New Haven, Connecticut
| | - Julie C Leonard
- Division of Emergency Medicine, Department of Pediatrics, The Ohio State University College of Medicine and the Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Lorah Ludwig
- Emergency Medical Services for Children Program, Maternal and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services, Rockville, Maryland
| | - Kathleen M Adelgais
- Emergency Medical Services for Children Innovation & Improvement Center, The University of Texas Austin, Austin, Texas
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
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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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Lerner EB, Browne LR, Studnek JR, Mann NC, Dai M, Hoffman CK, Pilkey D, Adelgais KM, Brown KM, Gaither JB, Leonard JC, Martin-Gill C, Nishijima DK, Owusu Ansah S, Shah ZS, Shah MI. A Novel Use of NEMSIS to Create a PECARN-Specific EMS Patient Registry. PREHOSP EMERG CARE 2021; 26:484-491. [PMID: 34232828 DOI: 10.1080/10903127.2021.1951407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background: Research networks need access to EMS data to conduct pilot studies and determine feasibility of prospective studies. Combining data across EMS agencies is complicated and costly. Leveraging the National EMS Information System (NEMSIS) to extract select agencies' data may be an efficient and cost-effective method of providing network-level data. Objective: Describe the process of creating a Pediatric Emergency Care Applied Research Network (PECARN) specific NEMSIS data set and determine if these data were nationally representative. Methods: We established data use agreements (DUAs) with EMS agencies participating in PECARN to allow for agency identification through NEMSIS. Using 2019 NEMSIS version 3.4.0 data for EMS events with patients 18 years old and younger, we compared PECARN NEMSIS data to national NEMSIS data. Analyzed variables were selected for their ability to characterize events. No statistical analyses were utilized due to the large sample, instead, differences of ±5% were deemed clinically meaningful. Results: DUAs were established for 19 EMS agencies, creating a PECARN data set with 305,188 EMS activations of which 17,478 (5.7%) were pediatric. Of the pediatric activations, 17,140 (98.1%) were initiated through 9-1-1 and 9,487 (55.4%) resulted in transport by the documenting agency. The national data included 36,288,405 EMS activations of which 2,152,849 (5.9%) were pediatric. Of the pediatric activations 1,704,141 (79.2%) were initiated through 9-1-1 and 1,055,504 (61.9%) were transported by the documenting agency. Age and gender distributions were similar between the two groups, but the PECARN-specific data under-represents Black and Latinx patients. Comparison of EMS provider primary impressions revealed that three of the five most common were similar with injury being the most prevalent for both data sets along with mental/behavioral health and seizure. Conclusion: We demonstrated that NEMSIS can be leveraged to create network specific data sets. PECARN's EMS data were similar to the national data, though racial/ethnic minorities and some primary impressions may be under-represented. Additionally, more EMS activations in PECARN study areas originated through 9-1-1 but fewer were transported by the documenting agency. This is likely related to the type of participating agencies, their ALS response level, and the diversity of the communities they serve.
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Kothari K, Zuger C, Desai N, Leonard J, Alletag M, Balakas A, Binney M, Caffrey S, Kotas J, Mahar P, Roswell K, Adelgais KM. Effect of Repetitive Simulation Training on Emergency Medical Services Team Performance in Simulated Pediatric Medical Emergencies. AEM Educ Train 2021; 5:e10537. [PMID: 34099990 PMCID: PMC8166302 DOI: 10.1002/aet2.10537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 05/22/2023]
Abstract
OBJECTIVE Emergency medical services (EMS) professionals infrequently transport children leading to difficulty in recognition and management of pediatric critical illness. Simulation provides an opportunity to train EMS professionals on pediatric emergencies. The objective of this study was to examine the effect of serial simulation training over 6 months on EMS psychomotor and cognitive performance during team-based care. METHODS This was a longitudinal prospective study of a simulation curriculum enrolling EMS professionals over a 6-month period during which they performed three high-fidelity simulations at 3-month intervals. The simulation scenarios included a 15-month-old seizure (T0), 1-month-old with hypoglycemia (T1), and 4-year-old clonidine ingestion (T2). All scenarios were standardized and required recognition and management of respiratory failure and decompensated shock. Scenarios were videotaped and two investigators scored EMS team interventions during simulations using a standardized scoring tool. Inter-rater reliability was assessed on 30% of videos using kappa analysis. Volumes of administered intravenous fluid (IVF) and medications were measured to assess for errors in administration. The primary outcome was the change in scenario score from T0 to T2. RESULTS A total of 135 team-based simulations were conducted over the study period (48, 40, and 47 at T0, T1, and T2, respectively). Inter-rater reliability between reviewers was very good (κ = 0.7). Median simulation score improved from T0 to T2 (24 vs 31, p < 0.001, maximum score possible = 42). The proportion of completed tasks increased across multiple categories including improved recognition of respiratory decompensation (19% vs. 56%), management of the pediatric airway (44% vs. 88%), and timeliness of vascular access (10% vs. 38%). Correct IVF administration varied by scenario (25% vs. 52% vs. 30%, p = 0.02). CONCLUSION Serial simulation improved EMS team-based care in both recognition and management of pediatric emergencies. A standardized pediatric simulation curriculum can be used to train EMS professionals on pediatric emergencies and improve performance.
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Affiliation(s)
- Kathryn Kothari
- From theDepartment of PediatricsSection of Pediatric Emergency MedicineUniversity of Colorado School of MedicineAuroraCOUSA
- theDenver Health and Hospital AuthorityDenverCOUSA
| | - Chelsea Zuger
- From theDepartment of PediatricsSection of Pediatric Emergency MedicineUniversity of Colorado School of MedicineAuroraCOUSA
| | - Neil Desai
- theEmergency DepartmentBritish Columbia Children’s HospitalVancouverBritish ColumbiaCanada
| | - Jan Leonard
- From theDepartment of PediatricsSection of Pediatric Emergency MedicineUniversity of Colorado School of MedicineAuroraCOUSA
| | - Michelle Alletag
- From theDepartment of PediatricsSection of Pediatric Emergency MedicineUniversity of Colorado School of MedicineAuroraCOUSA
| | - Ashley Balakas
- theEmergency Medical Services Education and Outreach ProgramChildren’s Hospital ColoradoAuroraCOUSA
| | - Mike Binney
- theWest Metro Fire Protection DistrictLakewoodCOUSA
| | - Sean Caffrey
- and theEMS DivisionCrested Butte Fire Protection AuthorityCrested ButteCOUSA
| | - Jason Kotas
- theEmergency Medical Services Education and Outreach ProgramChildren’s Hospital ColoradoAuroraCOUSA
| | - Patrick Mahar
- From theDepartment of PediatricsSection of Pediatric Emergency MedicineUniversity of Colorado School of MedicineAuroraCOUSA
| | - Kelley Roswell
- From theDepartment of PediatricsSection of Pediatric Emergency MedicineUniversity of Colorado School of MedicineAuroraCOUSA
| | - Kathleen M. Adelgais
- From theDepartment of PediatricsSection of Pediatric Emergency MedicineUniversity of Colorado School of MedicineAuroraCOUSA
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Goodloe JM, Topjian A, Hsu A, Dunne R, Panchal AR, Levy M, McEvoy M, Vaillancourt C, Cabanas JG, Eisenberg MS, Rea TD, Kudenchuk PJ, Gienapp A, Flores GE, Fuchs S, Adelgais KM, Owusu-Ansah S, Terry M, Sawyer KN, Fromm P, Panczyk M, Kurz M, Lindbeck G, Tan DK, Edelson DP, Sayre MR. Interim Guidance for Emergency Medical Services Management of Out-of-Hospital Cardiac Arrest During the COVID-19 Pandemic. Circ Cardiovasc Qual Outcomes 2021; 14:e007666. [PMID: 34157848 PMCID: PMC8288195 DOI: 10.1161/circoutcomes.120.007666] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jeffrey M Goodloe
- Department of Emergency Medicine, University of Oklahoma School of Community Medicine, Tulsa (J.M.G.)
| | - Alexis Topjian
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania (A.T.)
| | - Antony Hsu
- St Joseph Mercy Hospital, Ann Arbor, MI (A.H.)
| | - Robert Dunne
- Department of Emergency Medicine, St John Hospital, Detroit, MI (R.D.)
| | - Ashish R Panchal
- The Ohio State University Wexner Medical Center, Columbus (A.R.P.)
| | - Michael Levy
- University of Alaska Anchorage, Anchorage Areawide EMS (M.L.)
| | - Mike McEvoy
- EMS Coordinator - Saratoga County, NY (M.M.)
| | - Christian Vaillancourt
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada (C.V.)
| | - Jose G Cabanas
- Wake County Department of Emergency Medical Services, University of North Carolina at Chapel Hill (J.G.C.)
| | - Mickey S Eisenberg
- Department of Emergency Medicine (M.S.E., M.R.S.).,University of Washington, Seattle. King County Emergency Medical Services, Seattle, WA (M.S.E., T.D.R., P.J.K.)
| | - Thomas D Rea
- Department of Medicine (T.D.R.).,University of Washington, Seattle. King County Emergency Medical Services, Seattle, WA (M.S.E., T.D.R., P.J.K.)
| | - Peter J Kudenchuk
- Division of Cardiology (P.J.K.).,University of Washington, Seattle. King County Emergency Medical Services, Seattle, WA (M.S.E., T.D.R., P.J.K.)
| | - Andy Gienapp
- Office of Emergency Medical Services, Wyoming Department of Health, Cheyenne (A.G.)
| | - Gustavo E Flores
- Emergency and Critical Care Trainings, San Juan, Puerto Rico (G.E.F.)
| | - Susan Fuchs
- Feinberg School of Medicine, Northwestern University, Ann and Robert H. Lurie Children's Hospital, Chicago, IL (S.F.)
| | - Kathleen M Adelgais
- Department of Pediatrics, Section of Pediatric Emergency Medicine, University of Colorado School of Medicine, Aurora (K.M.A.)
| | - Sylvia Owusu-Ansah
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh (S.O.-A.), University of Pittsburgh School of Medicine, PA
| | - Mark Terry
- National Registry of Emergency Medical Technicians, Columbus, OH (M.T.)
| | - Kelly N Sawyer
- Department of Emergency Medicine (K.N.S.), University of Pittsburgh School of Medicine, PA
| | - Peter Fromm
- Mount Sinai South Nassau Hospital, Oceanside, NY (P.F.)
| | - Micah Panczyk
- University of Texas Health Science Center, Houston (M.P.)
| | | | - George Lindbeck
- Office of Emergency Medical Services, Virginia Department of Health, Richmond (G.L.)
| | - David K Tan
- Washington University School of Medicine, St Louis, MO (D.K.T.)
| | | | - Michael R Sayre
- Department of Emergency Medicine (M.S.E., M.R.S.).,Seattle Fire Department, WA (M.R.S.)
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Cheetham AL, Navanandan N, Leonard J, Spaur K, Markowitz G, Adelgais KM. Impact of prehospital pediatric asthma management protocol adherence on clinical outcomes. J Asthma 2021; 59:937-945. [PMID: 33504232 DOI: 10.1080/02770903.2021.1881969] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the frequency of EMS protocol non-adherence during pediatric asthma encounters and its association with emergency department (ED) length of stay (LOS) and hospital admission. METHODS This is a retrospective review of asthma encounters aged 2-17 years transported by EMS to a pediatric ED from 2012 to 2017. Our primary outcome was hospital admission based on prehospital protocol adherence defined as: (1) bronchodilator administration, (2) treatment of hypoxia with oxygen, or (3) administration of intramuscular (IM) epinephrine in encounters with high severity of distress. Multivariable logistic regression estimated the association between protocol non-adherence and hospital admission. RESULTS During the study period, 290 EMS encounters met inclusion criteria. Median age was 9 years (IQR 5-12), 63% were male, 40% had moderate to severe exacerbations, and 24% were admitted. Protocol non-adherence occurred in 32% of encounters with failure to administer bronchodilators in 27% and failure to administer IM epinephrine when indicated in 83%. Prehospital steroids were administered in 8% of encounters. After adjusting for covariates, protocol non-adherence was not statistically associated with likelihood of inpatient admission (OR 1.3; 95% CI: 0.6-2.6). CONCLUSIONS Among prehospital pediatric asthma encounters, EMS protocol non-adherence is common but not associated with a higher frequency of hospital admission. Hospital admission was associated with acute exacerbation severity suggesting further research is needed to develop a valid prehospital asthma severity assessment scoring tool. Supplemental data for this article can be accessed at publisher's website.
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Affiliation(s)
- Alexandra L Cheetham
- Pediatric Residency Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nidhya Navanandan
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jan Leonard
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kelsey Spaur
- University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Kathleen M Adelgais
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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11
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Adelgais KM, Hansen M, Lerner EB, Donofrio JJ, Yadav K, Brown K, Liu YT, Denslow P, Denninghoff K, Ishimine P, Olson LM. Establishing the Key Outcomes for Pediatric Emergency Medical Services Research. Acad Emerg Med 2018; 25:1345-1354. [PMID: 30312993 DOI: 10.1111/acem.13637] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 10/01/2018] [Accepted: 10/06/2018] [Indexed: 11/28/2022]
Abstract
The evidence supporting best practices when treating children in the prehospital setting or even the effect emergency medical services (EMS) has on patient outcomes is limited. Standardizing the critical outcomes for EMS research will allow for focused and comparable effort among the small but growing group of pediatric EMS investigators on specific topics. Standardized outcomes will also provide the opportunity to collectively advance the science of EMS for children and demonstrate the effect of EMS on patient outcomes. This article describes a consensus process among stakeholders in the pediatric emergency medicine and EMS community that identified the critical outcomes for EMS care in five clinical areas (traumatic brain injury, general injury, respiratory disease/failure, sepsis, and seizures). These areas were selected based on both their known public health importance and their commonality in EMS encounters. Key research outcomes identified by participating stakeholders using a modified nominal group technique for consensus building, which included small group brainstorming and independent voting for ranking outcomes that were feasible and/or important for the field.
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Affiliation(s)
| | - Kathleen M. Adelgais
- Department of Pediatrics Section of Pediatric Emergency Medicine University of Colorado School of Medicine Aurora CO
| | - Matthew Hansen
- Department of Emergency Medicine Oregon Health Sciences University PortlandOR
| | - E. Brooke Lerner
- Departments of Emergency Medicine and Pediatrics Medical College of Wisconsin Milwaukee WI
| | - J. Joelle Donofrio
- Departments of Emergency Medicine and Pediatrics University of California San Diego Rady Children's Hospital San Diego CA
| | - Kabir Yadav
- Department of Emergency Medicine Harbor‐UCLA Medical Center Torrance CA
| | - Kathleen Brown
- Department of Emergency Medicine The George Washington University School of Medicine and Children's National Medical Center Washington DC
| | - Yiju T. Liu
- Department of Emergency Medicine Harbor‐UCLA Medical Center Torrance CA
| | | | - Kurt Denninghoff
- Department of Emergency Medicine University of Arizona School of Medicine Tucson AZ
| | - Paul Ishimine
- Departments of Emergency Medicine and Pediatrics University of California San Diego Rady Children's Hospital San Diego CA
| | - Lenora M. Olson
- Division of Pediatric Critical Care Department of Pediatrics University of Utah School of Medicine Salt Lake City UT
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12
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Adelgais KM, Sholl JM, Alter R, Gurley KL, Broadwater-Hollifield C, Taillac P. Challenges in Statewide Implementation of a Prehospital Evidence-Based Guideline: An Assessment of Barriers and Enablers in Five States. PREHOSP EMERG CARE 2018; 23:167-178. [PMID: 30118367 DOI: 10.1080/10903127.2018.1495284] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Individual states, regions, and local emergency medical service (EMS) agencies are responsible for the development and implementation of prehospital patient care protocols. Many states lack model prehospital guidelines for managing common conditions. Recently developed national evidence-based guidelines (EBGs) may address this gap. Barriers to statewide dissemination and implementation of model guidelines have not been studied. The objective of this study was to examine barriers and enablers to dissemination and implementation of an evidence-based guideline for traumatic pain management across 5 states. METHODS This study used mixed methods to evaluate the statewide dissemination and implementation of a prehospital EBG. The guideline provided pain assessment tools, recommended opiate medication dosing, and indications and contraindications for analgesia. Participating states were provided an implementation toolkit, standardized training materials, and a state-specific implementation plan. Outcomes were assessed via an electronic self-assessment tool in which states reported barriers and enablers to dissemination and implementation and information about changes in pain management practices in their states after implementation of the EBG. RESULTS Of the 5 participating states, 3 reported dissemination of the guideline, one through a state model guideline process and 2 through regional EMS systems. Two states did not disseminate or implement the guideline. Of these, one state chose to utilize a locally developed guideline, and the other state did not perform guideline dissemination at the state level. Barriers to state implementation were the lack of authority at the state level to mandate protocols, technical challenges with learning management systems, and inability to track and monitor training and implementation at the agency level. Enablers included having a state/regional EMS office champion and the availability of an implementation toolkit. No participating states demonstrated an increase in opioid delivery to patients during the study period. CONCLUSION Statewide dissemination and implementation of an EBG is complex with many challenges. Future efforts should consider the advantages of having statewide model or mandatory guidelines and the value of local champions and be aware of the challenges of a statewide learning management system and of tracking the success of implementation efforts.
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13
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Adelgais KM, Brent A, Wathen J, Tong S, Massanari D, Deakyne S, Sills MR. Intranasal Fentanyl and Quality of Pediatric Acute Care. J Emerg Med 2017; 53:607-615.e2. [PMID: 28967529 DOI: 10.1016/j.jemermed.2017.05.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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: 10/05/2016] [Revised: 05/18/2017] [Accepted: 05/30/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Changes in the manner in which medications can be delivered can have significant effects on the quality of care in the acute care setting. OBJECTIVE The objective of this study was to evaluate the change in three Institute of Medicine quality indicators (timeliness, safety, and effectiveness) in the pediatric emergency department (ED) after the introduction of the Mucosal Atomizer Device Nasal™ (MADn) for opioid analgesia. METHODS This was a retrospective review of patients receiving opioid analgesia for certain conditions over a 5-year period. We compared patients receiving intravenous opioid (IVO) to those receiving intranasal fentanyl (INF). Timeliness outcomes include time from medication order to administration, time from dose to discharge, overall time to analgesia, and ED length of stay. Effectiveness outcomes include change in pain score and frequency of repeat dosing. Safety outcomes were the frequency of reversal agent administration or a documented oxygen desaturation of < 90%. Sensitivity analyses were performed to evaluate the effect of moderate sedation on all three outcomes. RESULTS During the study period, 1702 patients received opioid analgesia, 744 before and 958 after MADn introduction, of whom, 233 (24%) received INF. After MADn introduction, patients receiving INF had a shorter time to discharge from dose (109 vs. 203 min; p < 0.05) and shorter ED length of stay (168 vs. 267 min; p < 0.05). There was no difference in pain score reduction; however, repeat dosing was less frequent for patients receiving INF (16% vs. 27%). There was no use of reversal medication and no difference in the frequency of oxygen desaturations. When patients undergoing moderate sedation were removed from the analysis, there was no difference in the direction of findings for all three outcomes. CONCLUSIONS INF is associated with improved timeliness and equivalent effectiveness and safety when compared to IVO in the setting of the pediatric ED.
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Affiliation(s)
- Kathleen M Adelgais
- Department of Pediatrics, University of Colorado, School of Medicine, Aurora, Colorado
| | - Alison Brent
- Department of Pediatrics, University of Colorado, School of Medicine, Aurora, Colorado
| | - Joseph Wathen
- Department of Pediatrics, University of Colorado, School of Medicine, Aurora, Colorado
| | - Suhong Tong
- Department of Research Informatics, Children's Hospital Colorado, Aurora, Colorado
| | - Derrek Massanari
- Department of Pediatrics, University of Colorado, School of Medicine, Aurora, Colorado
| | - Sara Deakyne
- Department of Research Informatics, Children's Hospital Colorado, Aurora, Colorado
| | - Marion R Sills
- Department of Pediatrics, University of Colorado, School of Medicine, Aurora, Colorado
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14
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VanderKooy T, Spaur K, Brou L, Caffrey S, Adelgais KM. Utilization of Intravenous Catheters by Prehospital Providers during Pediatric Transports. PREHOSP EMERG CARE 2017; 22:50-57. [PMID: 28792258 DOI: 10.1080/10903127.2017.1347225] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Prehospital intravenous (IV) access in children may be difficult and time-consuming. Emergency Medical Service (EMS) protocols often dictate IV placement; however, some IV catheters may not be needed. The scene and transport time associated with attempting IV access in children is unknown. The objective of this study is to examine differences in scene and transport times associated with prehospital IV catheter attempt and utilization patterns of these catheters during pediatric prehospital encounters. METHODS Three non-blinded investigators abstracted EMS and hospital records of children 0-18 years of age transported by EMS to a pediatric emergency department (ED). We compared patients in which prehospital IV access was attempted to those with no documented attempt. Our primary outcome was scene time. Secondary outcomes include utilization of the IV catheter in the prehospital and ED settings and a determination of whether the catheter was indicated based on a priori established criteria (prehospital IV medication administration, hypotension, GCS < 13, and ICU admission). RESULTS We reviewed 1,138 records, 545 meeting inclusion criteria. IV catheter placement was attempted in 27% (n = 149) with success in 77% (n = 111). There was no difference in the presence of hypotension or median GCS between groups. Mean scene time (12.5 vs. 11.8 minutes) and transport time (16.9 vs. 14.6 minutes) were similar. Prehospital IV medications were given in 38.7% (43/111). One patient received a prehospital IV medication with no alternative route of administration. Among patients with a prehospital IV attempt, 31% (46/149) received IV medications in the ED and 23% (34/396) received IV fluids in the ED. Mean time to use of the IV in the ED was 70 minutes after arrival. Patients with prehospital IV attempt were more likely to receive IV medication within 30 minutes of ED arrival (39.1% vs. 19.0%, p = 0.04). Overall, 34.2% of IV attempts were indicated. CONCLUSIONS Prehospital IV catheter placement in children is not associated with an increase in scene or transport time. Prehospital IV catheters were used in approximately one-third of patients. Further study is needed to determine which children may benefit most from IV access in the prehospital setting.
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15
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Rappaport LD, Brou L, Givens T, Mandt M, Balakas A, Roswell K, Kotas J, Adelgais KM. Comparison of Errors Using Two Length-Based Tape Systems for Prehospital Care in Children. PREHOSP EMERG CARE 2016; 20:508-17. [PMID: 26836351 PMCID: PMC6292711 DOI: 10.3109/10903127.2015.1128027] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The use of a length/weight-based tape (LBT) for equipment size and drug dosing for pediatric patients is recommended in a joint statement by multiple national organizations. A new system, known as Handtevy™, allows for rapid determination of critical drug doses without performing calculations. OBJECTIVE To compare two LBT systems for dosing errors and time to medication administration in simulated prehospital scenarios. METHODS This was a prospective randomized trial comparing the Broselow Pediatric Emergency Tape™ (Broselow) and Handtevy LBT™ (Handtevy). Paramedics performed 2 pediatric simulations: cardiac arrest with epinephrine administration and hypoglycemia mandating dextrose. Each scenario was repeated utilizing both systems with a 1-year-old and 5-year-old size manikin. Facilitators recorded identified errors and time points of critical actions including time to medication. RESULTS We enrolled 80 paramedics, performing 320 simulations. For Dextrose, there were significantly more errors with Broselow (63.8%) compared to Handtevy (13.8%) and time to administration was longer with the Broselow system (220 seconds vs. 173 seconds). For epinephrine, the LBTs were similar in overall error rate (Broselow 21.3% vs. Handtevy 16.3%) and time to administration (89 vs. 91 seconds). Cognitive errors were more frequent when using the Broselow compared to Handtevy, particularly with dextrose administration. The frequency of procedural errors was similar between the two LBT systems. CONCLUSION In simulated prehospital scenarios, use of the Handtevy LBT system resulted in fewer errors for dextrose administration compared to the Broselow LBT, with similar time to administration and accuracy of epinephrine administration.
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16
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Adelgais KM, Kuppermann N, Kooistra J, Garcia M, Monroe DJ, Mahajan P, Menaker J, Ehrlich P, Atabaki S, Page K, Kwok M, Holmes JF. Accuracy of the abdominal examination for identifying children with blunt intra-abdominal injuries. J Pediatr 2014; 165:1230-1235.e5. [PMID: 25266346 DOI: 10.1016/j.jpeds.2014.08.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 07/02/2014] [Accepted: 08/08/2014] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the accuracy of complaints of abdominal pain and findings of abdominal tenderness for identifying children with intra-abdominal injury (IAI) stratified by Glasgow Coma Scale (GCS) score. STUDY DESIGN This was a prospective, multicenter observational study of children with blunt torso trauma and a GCS score ≥13. We calculated the sensitivity of abdominal findings for IAI with 95% CI stratified by GCS score. We examined the association of isolated abdominal pain or tenderness with IAI and that undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion, or ≥2 nights of intravenous fluid therapy). RESULTS Among the 12 044 patients evaluated, 11 277 (94%) had a GCS score of ≥13 and were included in this analysis. Sensitivity of abdominal pain for IAI was 79% (95% CI, 76%-83%) for patients with a GCS score of 15, 51% (95% CI, 37%-65%) for patients with a GCS score of 14, and 32% (95% CI, 14%-55%) for patients with a GCS score of 13. Sensitivity of abdominal tenderness for IAI also decreased with decreasing GCS score: 79% (95% CI, 75%-82%) for a GCS score of 15, 57% (95% CI, 42%-70%) for a GCS score of 14, and 37% (95% CI, 19%-58%) for a GCS score of 13. Among patients with isolated abdominal pain and/or tenderness, the rate of IAI was 8% (95% CI, 6%-9%) and the rate of IAI undergoing acute intervention was 1% (95% CI, 1%-2%). CONCLUSION The sensitivity of abdominal findings for IAI decreases as GCS score decreases. Although abdominal computed tomography is not mandatory, the risk of IAI is sufficiently high that diagnostic evaluation is warranted in children with isolated abdominal pain or tenderness.
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Affiliation(s)
- Kathleen M Adelgais
- Department of Pediatrics, University of Colorado Denver, Aurora, CO; Department of Pediatrics, University of Utah, Salt Lake City, UT.
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis School of Medicine, Davis, CA; Department of Pediatrics, University of California Davis School of Medicine, Sacramento, CA
| | - Joshua Kooistra
- Department of Emergency Medicine, Helen DeVos Children's Hospital, Grand Rapids, MI
| | - Madelyn Garcia
- Department of Emergency Medicine, University of Rochester, Rochester, NY
| | - David J Monroe
- Department of Pediatrics, Howard County Hospital, Columbia, MD
| | - Prashant Mahajan
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI
| | - Jay Menaker
- Department of Surgery, University of Maryland, Baltimore, MD
| | - Peter Ehrlich
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Shireen Atabaki
- Department of Emergency Medicine, Children's National Medical Center, Washington, DC
| | - Kent Page
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Maria Kwok
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - James F Holmes
- Department of Emergency Medicine, University of California Davis School of Medicine, Davis, CA
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17
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Adelgais KM, Browne L, Holsti M, Metzger RR, Murphy SC, Dudley N. Cervical spine computed tomography utilization in pediatric trauma patients. J Pediatr Surg 2014; 49:333-7. [PMID: 24528980 DOI: 10.1016/j.jpedsurg.2013.10.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 10/09/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND Guidelines for evaluating the cervical spine in pediatric trauma patients recommend cervical spine CT (CSCT) when plain radiographs suggest an injury. Our objective was to compare usage of CSCT between a pediatric trauma center (PTC) and referral general emergency departments (GEDs). METHODS Patient data from a pediatric trauma registry from 2002 to 2011 were analyzed. Rates of CSI and CSCT of patients presenting to the PTC and GED were compared. Factors associated with use of CSCT were assessed using multivariate logistic regression. RESULTS 5148 patients were evaluated, 2142 (41.6%) at the PTC and 3006 (58.4%) at the GED. Groups were similar with regard to age, gender, GCS, and triage category. GED patients had a higher median ISS (14 vs. 9, p<0.05) and more frequent ICU admissions (44.3% vs. 26.1% p<0.05). CSI rate was 2.1% (107/5148) and remained stable. CSCT use increased from 3.5% to 16.1% over time at the PTC (mean 9.6% 95% CI=8.3, 10.9) and increased from 6.8% to 42.0% (mean 26.9%, CI=25.4, 28.4) at the GED. Initial care at a GED remained strongly associated with CSCT. CONCLUSIONS Despite a stable rate of CSI, rate of CSCT increased significantly over time, especially among patients initially evaluated at a GED.
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Affiliation(s)
- Kathleen M Adelgais
- Department of Pediatrics, Section of Pediatric Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, CO.
| | - Lorin Browne
- Department of Pediatrics, Pediatric Emergency Medicine Section, Medical College of Wisconsin, Milwaukee, WI
| | - Maija Holsti
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Utah, Salt Lake City, UT
| | - Ryan R Metzger
- Department of Surgery, Division of Pediatric Surgery, University of Utah, Salt Lake City, UT
| | | | - Nanette Dudley
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Utah, Salt Lake City, UT
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18
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Holsti M, Adelgais KM, Willis L, Jacobsen K, Clark EB, Byington CL. Developing future clinician scientists while supporting a research infrastructure. Clin Transl Sci 2014; 6:94-7. [PMID: 23601337 DOI: 10.1111/cts.12044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Supporting clinical research is a national priority. Clinician scientists are rare and clinical trials in academic medical centers (AMC) often fail to meet enrollment goals. Undergraduate students interested in biomedical careers often lack opportunities to perform clinical research. OBJECTIVE Describe an innovative undergraduate course that supports clinical research in an AMC. METHODS The course, Clinical Research Methods and Practice, offers undergraduate students the opportunity to learn clinical research through didactic and practical experiences. The students in turn support clinician scientists' conduct of clinical studies in an AMC. Clinician scientists receive research support and participate in mentoring sessions for students. RESULTS Over seven semesters, 128 students have assisted in 21 clinical studies located in outpatient and inpatient units of two hospitals. Students identified and screened eligible patients, collected clinical data, assisted in obtaining informed consent, and transported specimens. Many of the clinician scientists have met their enrollment goals and several have been top-enrollers in multicenter clinical trials as a result of student support. CONCLUSIONS The Clinical Research Methods and Practice class addresses barriers to clinical research in AMC. This may be a model for institutions committed to mentoring students early in their career and to developing infrastructures for clinical research.
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Affiliation(s)
- Maija Holsti
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA.
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Leonard JC, Scharff DP, Koors V, Lerner EB, Adelgais KM, Anders J, Brown K, Babcock L, Lichenstein R, Lillis KA, Jaffe DM. A qualitative assessment of factors that influence emergency medical services partnerships in prehospital research. Acad Emerg Med 2012; 19:161-73. [PMID: 22320367 DOI: 10.1111/j.1553-2712.2011.01283.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Recent efforts to increase emergency medical services (EMS) prehospital research productivity by focusing on reducing systems-related barriers to research participation have had limited effect. The objective of this study was to explore the barriers and motivators to participating in research at the agency and provider levels and to solicit suggestions for improving the success of prehospital research projects. METHODS The authors conducted a qualitative exploratory study of EMS personnel using focus group and focused interview methodology. EMS personnel affiliated with the Pediatric Emergency Care Applied Research Network (PECARN) hospitals were selected for participation using a purposive sampling plan. Exploratory questioning identified identified factors that influence participation in research and suggestions for ensuring successful research partnerships. Through iterative coding and analysis, the factors and suggestions that emerged from the data were organized into a behavioral change planning model. RESULTS Fourteen focus groups were conducted, involving 88 EMS prehospital providers from 11 agencies. Thirty-five in-depth interviews with EMS administrators and researchers were also conducted. This sample was representative of prehospital personnel servicing the PECARN catchment area and was sufficient for analytical saturation. From the transcripts, the authors identified 17 barriers and 12 motivators to EMS personnel participation in research. Central to these data were patient safety, clarity of research purpose, benefits, liability, professionalism, research training, communication with the research team, reputation, administrators' support, and organizational culture. Interviewees also made 29 suggestions for increasing EMS personnel participation in research. During data analysis, the PRECEDE/PROCEED planning model was chosen for behavioral change to organize the data. Important to this model, factors and suggestions were mapped into those that predispose (knowledge, attitudes, and beliefs), reinforce (social support and norms), and/or enable (organizational) the participation in prehospital research. CONCLUSIONS This study identified factors that influence the participation of EMS personnel in research and gathered suggestions for improvement. These findings were organized into the PRECEDE/PROCEED planning model that may help researchers successfully plan, implement, and complete prehospital research projects. The authors provide guidance to improve the research process including directly involving EMS providers throughout, a strong theme that emerged from the data. Future work is needed to determine the validity of this model and to assess if these findings are generalizable across prehospital settings other than those affiliated with PECARN.
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Affiliation(s)
- Julie C Leonard
- Department of Pediatrics, Division of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis Children's Hospital, St. Louis, MO, USA.
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Leonard JC, Kuppermann N, Olsen C, Babcock-Cimpello L, Brown K, Mahajan P, Adelgais KM, Anders J, Borgialli D, Donoghue A, Hoyle JD, Kim E, Leonard JR, Lillis KA, Nigrovic LE, Powell EC, Rebella G, Reeves SD, Rogers AJ, Stankovic C, Teshome G, Jaffe DM. Factors Associated With Cervical Spine Injury in Children After Blunt Trauma. Ann Emerg Med 2011; 58:145-55. [DOI: 10.1016/j.annemergmed.2010.08.038] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Revised: 08/06/2010] [Accepted: 08/27/2010] [Indexed: 10/18/2022]
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21
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Ching CRK, Adelgais KM, Daane SP. Dog bites in Oakland, California. Plast Reconstr Surg 2004; 114:1669. [PMID: 15509985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
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Abstract
OBJECTIVE To determine the differences in resource utilization and radiation exposure between conventional radiography (ConvRad) and helical computed tomography (HCT) when used to survey the pediatric cervical spine (CSp). METHODS Patients aged 0-14 years who required CSp radiographic evaluation in addition to cranial CT were prospectively enrolled and assigned to undergo either HCT or ConvRad with adjunctive linear tomography. Outcomes of medication usage, emergency department (ED) length of stay (LOS), cervical spine radiation exposure, and imaging resource use (relative value unit [RVU]) were compared between the two groups. Data were analyzed by regression analysis with adjustment for confounders. RESULTS Of 136 patients, 64 and 72 patients were assigned to the ConvRad group and HCT group, respectively. At the discretion of the trauma team, 34% of the patients enrolled crossed between the two study arms. Odds ratio (OR), based on original assignment, was 0.8 (95% CI = 0.4 to 1.8) for difference in medication usage between the two groups. Mean LOSs were 259 minutes (95% CI = 124 to 394) and 183 (95% CI = 166 to 200) minutes for HCT and ConvRad, respectively. CSp imaging RVUs were 5.5 (95% CI = 5.1 to 5.8) for HCT and 4.0 (95% CI = 3.3 to 4.6) for ConvRad. Mean CSp radiation doses were 389 mRem (95% CI = 346 to 432) for HCT and 294 mRem (95% CI = 245 to 343) for ConvRad. Adjustment for confounders did not change the direction of the results. CONCLUSIONS As a modality to screen the pediatric CSp for blunt-force trauma, HCT results in increased radiation exposure and radiology resource use without a reduction in sedation usage or time in the ED.
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Affiliation(s)
- Kathleen M Adelgais
- Division of Pediatric Emergency Medicine, University of Utah, Salt Lake City, UT 84102, USA.
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