The Practice of Pediatric Out-of-Hospital Care in the United States

1. The Practice of Pediatric Out-of-Hospital Care in the United States Elizabeth Gannon, DO, MPH AHN - Saint Vincent Hospital – Erie, PA

2. Conflicts of Interest Disclosure • Elizabeth Gannon, DO, MPH – none • Jestin N. Carlson, MD, MSc – none • N. Clay Mann, PhD, MS – none • Karen E. Jacobson, BA, NREMT-P – none • Mengtao Dai, MS – none • Caroline Colleran, DO – none • Henry E. Wang, MD, MS – none

3. Introduction • Emergency medical services (EMS) must provide care for patients of all ages in the out-of-hospital setting • Critically ill pediatric patients present to acute care settings less frequently than adults and opportunities to perform critical procedures are rarely available

4. Introduction • There are limited data on the frequency of critical procedures performed in the pediatric population • Given the complications associated with infrequently performed critical procedures in the adult population, it is essential to examine the pediatric population

5. Objective • Characterize procedural performance in out-of-hospital pediatric patients in the United States

6. Methods • Retrospective study • 2011 National Emergency Medical Services Information Systems (NEMSIS) database • NEMSIS • Collects information on 83 required “national variables” from EMS offices in each participating state • Data includes all EMS responses in patients age <18 years old(1/1/11-12/31/11)

7. Methods • Demographics • Determine the frequency of procedures that directly involve the patient • Identify critical procedures that may be required during advanced cardiac life support (ACLS) or pediatric advanced life support (PALS)

8. Methods • Critical Care Procedures • Airway-Intubation • CPR • Venous Access – IO • Venous Access – Central Line • Defibrillation-Manual • Defibrillation-Automated (AED) • Chest Decompression • Chest Tube Placement

9. Methods • Critical care procedure success and complications • Analysis • Descriptive statistics • Frequency of procedures performed per 1000 pediatric EMS responses

10. Results • There were 14,371,941 total responses in the 2011 NEMSIS database • 865,591 (6%) responses were in patients less than 18 years old

11. Demographics

12. Demographics

13. Demographics

14. Demographics

15. Results • Provider impression • Most common • Traumatic injuries • Respiratory complications • Seizures • Respiratory (0.4%) and cardiac (0.6%) arrests were rare

16. Results • There was a total of 616,913 procedures were performed in 246,016 pediatric patients • There were 0.7 procedures performed per each pediatric patient • There were 13.3 critical care procedures performed per 1000 pediatric EMS responses

17. Critical Procedures

18. Critical Procedures

19. All other procedures

20. All other procedures

21. Critical Procedure Success

22. Critical Procedure Success

23. Critical Procedure Success

24. Complications • The most common complication was esophageal intubation

25. Limitations • Study design • Retrospective study • Confounding • Reporter bias • Missing data • Voluntary database

26. Discussion • Critical procedures were performed in only 1.3% of all pediatric EMS responses • Intubation was performed in only 4.4 per 1000 total EMS responses • The overall critical care procedure success rate was 81.4% • Success rates ranged from 73-100%

27. Discussion • Inexperience with pediatric medical management could lead to adverse patient outcomes • Complications have been linked to poor outcomes in adult patients • Evaluation of EMS protocols

28. Conclusion • Pediatric patients represent a small percentage of total EMS responses nationwide • Few critical care procedures are performed during EMS responses • Procedures involving the airway have the most complications

29. References 1 .Wang HE et al. Out-of-hospital airway management in the United States. Resuscitation. 2011;82:378-385. 2 .National EMS Information System (NEMSIS) data set for 2011 – procedures for patients age less than 16. www.nemsis.org. 3. Wang HE, Balasubramani GK, Cook LJ, Lave JR, Yearly DM. Out-of-hospital endotracheal intubation experience and patient outcomes. Ann Emerg Med. 2010;55:527-37, e6. 4. Foltin GL et al. Pediatric prehospital evaluation of NYC cardiac arrest survival (PHENYCS). Pediatr Emerg Care. 2012;28:864-8. 5.Wang HE, Kupas DF, Hostler D, Cooney R, Yearly DM, Lave JR. Procedural experience with out-of-hospital endotracheal intubation. Crit Care Med. 2005;33:17178-21. 6. Ehrlich PF, Seidman PS, Atallah O, Hague A, Helmkamp J. Endotracheal intubations in rural pediatric trauma patients. J Pediatr Surg. 2004;39:1376-80. 7. Garrison HG et al. Emergency Medical Services Outcomes Project III (EMSOP III): the role of risk adjustment in out-of-hospital outcomes research. Ann Emerg Med. 2002;40:79-88. 8. Tunik MG et al. Pediatric prehospital evaluation of NYC respiratory arrest survival (PHENYCS). Pediatr Emerg Care. 2012;28:859-63. 0. Donoghue AJ, Nadkami V, Berg RA, Osmond MH, Wells G, Nesbitt L, Stiell IG; CanAm Pediatric Cardiac Arrest Investigators. Out-of-hospital pediatric cardiac arrest: an epidemiologic review and assessment of current knowledge. Ann Emerg Med 2005;46:512-22. 10. Richard J, Osmond MH, Nesbitt L, Stiell IG. Management and outcomes of pediatric patients transported by emergency medical services in a Canadian prehospital system. CJEM 2006;8:6-12. 11. Lammers R, Byrwa M, Fales W. Root causes of errors in a simulated prehospital pediatric emergency. Acad Emerg Med. 2012;19:37-47. 12. McGaghie WC, Issenberg SB, Cohen ER, et al. Does simulation- based medical with deliberate practice yield better results than traditional clinical education? a meta-analytic comparative review of the evidence. Acad Med. 2011;86:706- 711. 13. Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: pediatric advanced life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 suppl 3):S876- 908. 14. Simon HK, Sullivan F. Confidence in performance of pediatric emergency medicine procedures by community emergency practitioners. Pediatr Emerg Care. 1996;12:336-339. 15. Losek JD, Olson LR, Dobson JV, et al. Tracheal intubation practice and maintaining skill competency: survey of pediatric emergency department medical directors. Pediatr Emerg Care. 2008;24:294-299. 16. Kerrey BT, Rinderknecht AS, Geis GL, et al. Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review. Ann Emerg Med. 2012 Mar 14. 17. Green SM. A is for airway: a pediatric emergency department challenge. Ann Emerg Med. 2012 Apr 18. 18. Green SM, Ruben J. Emergency department children are not as sick as adults: implications for critical care skills retention in an exclusively pediatric emergency medicine practice. J Emerg Med. 2009;37:359-368. 19. Guilfoyle FJ, Milner R, Kissoon N. Resuscitation interventions in a tertiary level pediatric emergency department: implications for maintenance of skills. CJEM. 2011;13:90-95. 20. Mittiga et al. The Spectrum and Frequency of Critical Procedures Performed in a Pediatric Emergency Department: Implications of a Provider-Level View. Ann Emerg Med. 2013 March 61;263-70. 21. US Census Bureau http://quickfacts.census.gov/qfd/states/00000.html. Accessed 7/10/14 22. Pennsylvania Department of Health. http://www.portal.state.pa.us/portal/server.pt/community/emergency_medical_services/14138/ems_statewide_protocols/625966 23. National Highway Traffic Safety Administration. Emergency Medical Technician Paramedic: National Standard Curriculum (EMT-P). Available at http://www.nhtsa.dot.gov/people/injury/ems/EMT-P/. Accessed July 31, 2014.

30. Acknowledgements • Jestin N. Carlson, MD, MSc • N. Clay Mann, PhD, MS • Karen E. Jacobson, BA, NREMT-P • Mengtao Dai, MS • Caroline Colleran, DO • Henry E. Wang, MD, MS

31. Questions ?