Medically Unnecessary Pediatric Ambulance Transports: A Medical Taxi Service?

Objective : To characterize ambulance utilization in a pediatric population and pediatric emergency physicians' judgment of the medical need for ambulance transport. Methods : A convenience sample of ambulance transports were studied prospectively during a 5-week period. Exclusion criteria included transfer from another medical facility, study physician not available, need for immediate resuscitation, or trauma team activation. A questionnaire completed by the physician assessed medical need for the ambulance based on chief complaint, general appearance, vital signs, and ambulance run sheet information. A separate questionnaire was administered to the parents regarding reasons for ambulance use and other available means of transportation. Caregivers were contacted by telephone 2–3 days later to determine the mode of transportation home and the clinical outcome. Results : Of 172 eligible patients, 92 (53%) were enrolled. Most (61%; 56/92) transports were considered medically unnecessary. Interestingly, 40% (37/92) of the subjects had no other means of transportation; 86% (32/37) of ambulance transports for this group were judged medically unnecessary. Overall, 86% (79/92) of families had not called their physician. There was no association between having spoken with the physician and medical need for an ambulance. Many (82%; 46/56) Medicaid transports were judged medically unnecessary. Overall, follow-up was achieved for 91% (85/92) of the patients. No patient for whom transport was medically unnecessary had a repeat ED visit for the same complaint or required admission. Most patients (74%; 68/92) returned home without any assistance. Among the medically unnecessary transports, 52% (32/ 60) of the caregivers cited no other means of transportation, yet 34% (11/32) of these patients returned home by private car. Conclusions : Most pediatric ambulance transports in this sample, which excluded patients requiring immediate resuscitation or trauma team care, were judged to be medically unnecessary. Caregivers often use an ambulance as a convenience or as the only means of transportation. An alternate, less resource-intensive transportation system may be more appropriate for this population.     

Strategies Used by Prehospital Providers to Overcome Language Barriers

Objective: Language barriers are commonly encountered in the prehospital setting but there is a paucity of research on how prehospital providers address language discordance. We sought to identify the communication strategies, and the limitations of those strategies, used by emergency medical services (EMS) providers when confronted with language barriers in a variety of linguistic and cultural contexts. Methods: EMS providers were queried regarding communication strategies to overcome language barriers as part of an international, multi-site, sequential explanatory, qualitative-predominant, mixed methods study of prehospital language barriers. A survey of EMS telecommunicators was administered at dispatch centers in New Mexico (United States) and Western Cape (South Africa). Semi-structured qualitative interviews of EMS field providers were conducted at agencies who respond to calls from participating dispatch centers. Survey data included quantitative data on demographics and communication strategies used to overcome language barriers as well as qualitative free-text responses on the limitations of strategies. Interviews elicited narratives of encounters with language-discordant patients and the strategies used to communicate. Data from the surveys and interviews were integrated at the point of analysis. Results: 125 telecommunicators (overall response rate of 84.5%) and a purposive sample of 27 field providers participated in the study. The characteristics of participants varied between countries and between agencies, consistent with variations in participating agencies’ hiring and training practices. Telecommunicators identified 3rd-party telephonic interpreter services as the single most effective strategy when available, but also described time delays and frustration with interpreter communications that leads them to preferentially try other strategies. In the field, all providers reported using similar strategies, relying heavily on bystanders, multilingual coworkers, and non-verbal communication. Prehospital providers described significant limitations to these strategies, including time delays, breaches of patient confidentiality, and inaccurate interpretation. Participants suggested various resources to improve communication with language-discordant patients. Conclusions: Prehospital providers rely upon similar, informal strategies for overcoming language barriers across a variety of locations, provider types, and linguistic and cultural contexts.     

Research in Prehospital Care: Overcoming the Barriers to Success

Objective. The objective of this project was to determine how investigators conduct clinical trials in the prehospital setting and to suggest how emergency medical services (EMS) systems can develop the capacity to conduct prehospital clinical research. Methods. A representative sample of U.S.-based study sites was selected from all studies registered on clinicaltrials.gov since the year 2000, where prehospital care providers conducted study-related activities in the prehospital setting. The site principal investigator and the research coordinator or EMS liaison were invited to participate in a structured discussion. A single interviewer conducted each discussion following a structured guide that generically asked for barriers and enablers to the sites’ research success and then reviewed commonly identified prehospital research barriers. Notes were taken during each discussion and reviewed for common themes. Themes were reviewed by the project team and sent for comment to all participants. Results. Discussions were held with 25 principal investigators, 9 coordinators, and 7 EMS liaisons. A total of 27 communities were represented in the discussions from 22 different states. The communities had a range of research experience from one prehospital trial to multiple trials. Key barriers were funding, ethics approval, data collection, protocol training and compliance, randomizing and blinding interventions, obtaining patient outcomes, adequate study staffing, and partnering with EMS agencies. Conclusion. This project identified many challenges to EMS research, but they were not insurmountable. Not every community can conduct every prehospital study. Communities should engage in studies that align with their values and resources. Investigators need to develop honest relationships where issues can be openly discussed and the community can collaborate on prehospital research. Learning from those who have overcome challenges may be a key to expanding the quality and quantity of EMS research.     

Comparison of Errors Using Two Length-Based Tape Systems for Prehospital Care in Children

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.     

Prevention of Pediatric Drug Calculation Errors by Prehospital Care Providers

Objective. Calculating weight-based drug doses for pediatric patients is difficult, with significant error potential. In the prehospital setting, few safeguards currently avert pediatric drug administration errors. We sought to determine whether use of a protocol-specific pediatric code card enables prehospital care providers to calculate more consistently accurate weight-based drug doses, volumes of administration, andage-appropriate endotracheal tube sizes. Methods. Questionnaires requiring calculations of medication doses, volumes, andendotracheal tube sizes were administered to prehospital care providers between June andNovember 2006 in fire department continuing education classes in the State of Maryland andthe District of Columbia. Half of the participants performed the calculations with the pediatric code card as an aid, andhalf without. Calculations done by the two groups were compared for rate andextent of errors. We evaluated the error frequency in calculations of pediatric medication doses andendotracheal tube sizes. Results. Of the 523 advanced life support prehospital care providers questioned, 246 answered questions using the pediatric code card, and277 answered questions without using the card. The mean individual percentages of correct responses were 94% for the group aided by the code card and65% for the group unaided by the card (percentage difference, 29%; 95% confidence interval [CI], 25–31%; p < 0.001). Ninety-eight percent of the aided group and23% of the unaided group calculated the correct endotracheal tube size (percentage difference, 75%; 95% CI, 70–81%; p < 0.001). Conclusions. The use of the pediatric code card enabled prehospital care providers to determine weight-based drug doses, volumes of administration, andendotracheal tube sizes more accurately than peers without access to the code card.     

Disaster Training for Prehospital Providers

Objective. To survey prehospital providers to determine 1) the quantity andformat of training recalled over the past year in chemical, biological, radiological/nuclear (CBRN), andother mass casualty events (MCEs); 2) preferred educational formats; 3) self-assessed preparedness for various CBRN/MCEs; and4) perceived likelihood of occurrence for CBRN/MCEs. Methods. A survey, consisting of 11 questions, was distributed to 1,010 prehospital providers in a system where no formal CBRN/mass casualty training was given. Results. Surveys were completed by 640 (63%) prehospital providers. Twenty-two percent (22%) of prehospital providers recalled no training within the past year for CBRN or other MCEs, 19% reported 1–5 hours, 15% reported 6–10 hours, 24% reported 11–39 hours, and7% reported receiving greater than 40 hours. Lectures anddrills were the most common formats for prior education. On a five-point scale (1: “Never Helpful” through 5: “Always Helpful”) regarding the helpfulness of training methods, median scores were the following: drills–5, lectures–4, self-study packets–3, Web-based learning–3, andother–4. On another five-point scale (1: “Totally Unprepared” through 5: “Strongly Prepared”), prehospital providers felt most prepared for MCEs–4, followed by chemical–4, biological–3, andradiation/nuclear–3. Over half (61%) felt MCEs were “Somewhat Likely” or “Very Likely” to occur, whereas chemical (42%), biological (38%), or radiation/nuclear (33%) rated lower. Conclusion. The amount of training in the past year reported for CBRN events varied greatly, with almost a quarter recalling no education. Drills andlectures were the most used andpreferred formats for disaster training. Prehospital providers felt least prepared for a radiological;/nuclear event. Future studies should focus on the consistency andquality of education provided.     

Out-of-Hospital Pediatric Patient Safety Events: Results of the CSI Chart Review

Objective: Studies of adult hospital patients have identified medical errors as a significant cause of morbidity and mortality. Little is known about the frequency and nature of pediatric patient safety events in the out-of-hospital setting. We sought to quantify pediatric patient safety events in EMS and identify patient, call, and care characteristics associated with potentially severe events. Methods: As part of the Children's Safety Initiative -EMS, expert panels independently reviewed charts of pediatric critical ambulance transports in a metropolitan area over a three-year period. Regression models were used to identify factors associated with increased risk of potentially severe safety events. Patient safety events were categorized as: Unintended injury; Near miss; Suboptimal action; Error; or Management complication (“UNSEMs”) and their severity and potential preventability were assessed. Results: Overall, 265 of 378 (70.1%) unique charts contained at least one UNSEM, including 146 (32.8%) errors and 199 (44.7%) suboptimal actions. Sixty-one UNSEMs were categorized as potentially severe (23.3% of UNSEMs) and nearly half (45.3%) were rated entirely preventable. Two factors were associated with heightened risk for a severe UNSEM: (1) age 29 days to 11 months (OR 3.3, 95% CI 1.25-8.68); (2) cases requiring resuscitation (OR 3.1, 95% CI 1.16-8.28). Severe UNSEMs were disproportionately higher among cardiopulmonary arrests (8.5% of cases, 34.4% of severe UNSEMs). Conclusions: During high-risk out-of-hospital care of pediatric patients, safety events are common, potentially severe, and largely preventable. Infants and those requiring resuscitation are important areas of focus to reduce out-of-hospital pediatric patient safety events.     

Emergency Medical Services Bypass of the Closest Facility for Pediatric Patients

Objectives: Pediatric specialty care is increasingly regionalized. It is unknown how regionalization affects emergency medical services (EMS) providers’ destination decisions for non-trauma pediatric patients. We sought to characterize the rates of bypass of the closest facility, and destination facilities’ levels of pediatric care in three diverse EMS agencies.

Methods: This is a one-year retrospective study of non-trauma pediatric patients less than 18 years of age transported by three EMS agencies (Baltimore City, Prince George’s County, and Queen Anne’s County) in 2016. A priori, a bypass was defined as transport to a facility more than 2?km farther than the distance to the closest facility. We calculated rates of bypass and categorized destination and closest facilities by their pediatric service availability using publicly available information. EMS transport distance and time were also compared for bypass and closest facility patients.

Results: The three EMS agencies in 2016 transported a total of 12,258 non-trauma pediatric patients, of whom 11,945 (97%) were successfully geocoded. Overall 43% (n?=?5,087) of patients bypassed the nearest facility, of which 87% (n?=?4,439) were transported to a facility with higher-level pediatric care than the closest facility. Both bypass rates and destination facility pediatric levels differed between agencies. Bypasses had significantly longer transport times and distances as compared to closest facility transports (p?<?0.001). For non-trauma pediatric bypasses alone, an additional 41,494 kilometers traveled, and 979?hours of EMS transport time was attributable to bypassing the closest facility.

Conclusions: This study reveals a high rate of pediatric bypass for non-trauma patients in three diverse EMS agencies. Bypass results in increased EMS resource utilization through longer transport time and distance. For non-trauma pediatric patients for whom there is little destination guidance, further work is required to determine bypass’ effects on patient outcomes.     

Child and Provider Restraints in Ambulances: Knowledge, Opinions, and Behaviors of Emergency Medical Services Providers

Background: Approximately 16,000 children are transported by ambulances each day, and there are an estimated 4,500 ambulance crashes each year. Information about emergency medical services (EMS) provider knowledge, opinions, and behaviors regarding occupant restraint is lacking. Objectives: To measure the knowledge, opinions, and behaviors of EMS personnel regarding child and provider restraint use in ambulances. Methods: A survey was given to all EMS providers in two large ambulance‐service organizations and in a hospital‐based pediatric ambulance service in a midsized urban area. Results: A total of 302 EMS providers were surveyed, for a return rate of 67.7%. Nearly half were involved in an ambulance crash at least once; of those, 7.6% were injured and 1% had patients in their care injured. The majority (91%) reported some training in child‐restraint use in ambulances, and half reported that they know a lot or very much about securing a critically ill child for transport. However, 30% did not identify the correct method of transport for a stable 2‐year‐old, and 40% did not choose the correct method of securing a child seat to the ambulance cot. Securing a child seat to the cot was viewed by 81% to not take too much time from patient care, and 63% did not view caring for a child in a car seat as difficult. Although 80% of providers regularly transported children in a car seat, 23% transported them on an adult's lap at least sometimes. Specialized pediatric‐transport providers were more likely to report safe pediatric and occupant restraint practices than were community EMS providers. Pediatric restraint behaviors were not associated with years of service or history of a crash. Two thirds of respondents reported not wearing their seatbelt on the squad bench while treating patients, and half believe that wearing a seatbelt interferes with patient care. A total of 95% report wearing seatbelts in the front seat of the ambulance. Provider seatbelt use in the patient compartment was not associated with years of service, with number of crashes, or with reporting correct use of pediatric restraints. Conclusions: This study indicates that the frequency of crashes in ambulances, and therefore the potential for injury, may be underappreciated. Current restraint practices of some of the study group are outside recommendations and may be placing at risk some children who are being transported by ambulances. This problem is complicated by the relative infrequency of pediatric ambulance transports compared with adults. Improved equipment and education may help providers safely transport pediatric patients. In addition, providers are risking their own safety by not wearing seatbelts in the rear ambulance compartment. Improved equipment may help alleviate this risk and allow providers to take care of patients safely.     

Intranasal Naloxone Is a Viable Alternative to Intravenous Naloxone for Prehospital Narcotic Overdose

Objective. To compare the prehospital time intervals from patient contact and medication administration to clinical response for intranasal (IN) versus intravenous (IV) naloxone in patients with suspected narcotic overdose. Methods. This was a retrospective review of emergency medical services (EMS) and hospital records, before and after implementation of a protocol for administration of intranasal naloxone by the Central California EMS Agency. We included patients with suspected narcotic overdose treated in the prehospital setting over 17 months, between March 2003 and July 2004. Paramedics documented dose, route of administration, and positive response times using an electronic record. Clinical response was defined as an increase in respiratory rate (breaths/min) or Glasgow Coma Scale score of at least 6. Main outcome variables included time from medication to clinical response and time from patient contact to clinical response. Secondary variables included numbers of doses administered and rescue doses given by an alternate route. Between-group comparisons were accomplished using t-tests and chi-square tests as appropriate. Results. One hundred fifty-four patients met the inclusion criteria, including 104 treated with IV and 50 treated with IN naloxone. Clinical response was noted in 33 (66%) and 58 (56%) of the IN and IV groups, respectively (p = 0.3). The mean time between naloxone administration and clinical response was longer for the IN group (12.9 vs. 8.1 min, p = 0.02). However, the mean times from patient contact to clinical response were not significantly different between the IN and IV groups (20.3 vs. 20.7 min, p = 0.9). More patients in the IN group received two doses of naloxone (34% vs. 18%, p = 0.05), and three patients in the IN group received a subsequent dose of IV or IM naloxone. Conclusions. The time from dose administration to clinical response for naloxone was longer for the IN route, but the overall time from patient contact to response was the same for the IV and IN routes. Given the difficulty and potential hazards in obtaining IV access in many patients with narcotic overdose, IN naloxone appears to be a useful and potentially safer alternative.     

Prehospital Rapid Sequence Intubation by Intensive Care Flight Paramedics

Objective: Rapid sequence intubation (RSI) is an advanced airway procedure for critically ill or injured patients. Paramedic-performed RSI in the prehospital setting remains controversial, as unsuccessful or poorly conducted RSI is known to result in significant complications. In Victoria, intensive care flight paramedics (ICFPs) have a broad scope of practice including RSI in both the adult and pediatric population. We sought to describe the success rates and characteristics of patients undergoing RSI by ICFPs in Victoria, Australia. Methods: A retrospective data review was conducted of adult (≥ 16 years) patients who underwent RSI by an ICFP between January 1, 2011, and December 31, 2016. Data were sourced from the Ambulance Victoria data warehouse. Results: A total of 795 cases were included in analyses, with a mean age of 45 (standard deviation = 19.6) years. The majority of cases involved trauma (71.7%), and most patients were male (70.1%). Neurological pathologies were the most common clinical indication for RSI (68.3%). The first pass success rate of intubation was 89.4%, and the overall success rate was 99.4%. Of the 5 failed intubations (0.6%), all patients were safely returned to spontaneous respiration. Two patients were returned via bag/valve/mask (BVM) support alone, two with BVM and oropharyngeal airway, and one via supraglottic airway. No surgical airways were required. Overall, we observed transient cases of hypotension (5.2%), hypoxemia (1.3%), or both (0.1%) in 6.6% of cases during the RSI procedure. Conclusion: A very high RSI procedural success rate was observed across the study period. This supports the growing recognition that appropriately trained paramedics can perform RSI safely in the prehospital environment.     

Knowledge Translation in the Emergency Medical Services: A Research Agenda for Advancing Prehospital Care

Little is known about knowledge translation in the practice of out-of-hospital medicine. It is generally accepted that much work is needed regarding "getting the evidence straight" in emergency medical services, given the substantial number of interventions that are performed regularly in the field but lack meaningful scientific support. Additional attention also needs to be given to "getting the evidence used," because there is some evidence that evidence-based practices are being incompletely or incorrectly applied in the field. In an effort to help advance a research agenda for knowledge translation in emergency medical services, nine recommendations are put forth to help address the problems identified.