Marsha Treiber

A National Assessment of Knowledge, Attitudes, and Confidence of Prehospital Providers in the Assessment and Management of Child Maltreatment

OBJECTIVE. The goal was to assess the knowledge and confidence in recognition, management, documentation, and reporting of child maltreatment among a representative sample of emergency medical services personnel in the United States. METHODS. A questionnaire was developed and pilot-tested, with the input of experts in emergency medical services and child maltreatment, to assess knowledge, attitudes, confidence, and training needs regarding assessment and treatment of child maltreatment. The questionnaire was distributed nationally to a random sample of prehospital providers by using a previously validated sampling plan. RESULTS. Of 2863 surveys sent to prehospital providers, 1237 (43%) were returned. Most prehospital providers reported receiving ≤1 hour of continuing medical education regarding child maltreatment. Most (78%) asked for additional educational opportunities, with only 3% stating that they required no additional training. Participants lacked knowledge regarding the developmental abilities of children, management of families in which child maltreatment is suspected, key elements of the history that should be noted, and the degree of suspicion necessary for reporting. CONCLUSIONS. Prehospital providers expressed confidence in their abilities to recognize and to manage cases of child abuse and neglect; however, significant deficiencies were reported in several critical knowledge areas, including identification of child maltreatment, interviewing techniques, and appropriate documentation.

Education of Out-of-Hospital Emergency Medical Personnel in Pediatrics: Report of a National Task Force

The Pediatric Education Task Force has developed a list of major topics and skills for inclusion in pediatric curricula for EMS providers Areas of controversy in the management of pediatric patients in the prehospital setting are outlined, and helpful learning tools are identified.

Pediatric ambulance utilization in a large American city: A systems analysis approach

Background Research on utilization of ambulances by pediatric patients lacks an objective, reproducible tool for the evaluation of patterns of ambulance use by both the providers and the users of this resource. Objectives 1) To develop an objective, diagnosis-based measure of appropriateness of ambulance utilization. 2) To use the measure to evaluate whether Municipal Ambulance Service dispatchers assign ambulances appropriately, and whether parents/caretakers request ambulances appropriately. Study design 1) Development of the pediatric ambulance need evaluation (PANE) tool: The consensus of an expert panel was used to assign patients arriving by ambulance to three levels of prehospital transport need based upon their ultimate hospital discharge diagnoses, and were as follows: required advanced life support ambulance (ALS); required basic life support ambulance (BLS); required a less acute mode of transport (LAT). 2) Assessment of appropriateness of ambulance assignments by EMS call-receiving operators (CRO) and of ambulance requests by parents/caretakers: Comparison of actual type of ambulance assigned and of need for ambulance, using the PANE tool and hospital admission rates as gold standards. Data collection Level of prehospital transport provided (ALS vs BLS), ultimate ED diagnosis, and ED disposition (admission vs discharge) was collected for each patient from information abstracted from the prehospital and ED records. Setting Bellevue Hospital Center and Harlem Hospital Center, two level I trauma centers in New York City, both with Pediatric Emergency Departments staffed 24 hours a day by attending physicians and residents. Patient selection Consecutive sample of 2633 patients, birth to 18 years of age, who arrived to either hospital by ambulance as primary transports from the field over a one-year period. Results 1) Development of PANE tool: At Bellevue Hospital, 7% of ED visits arrived by ambulance; at Harlem Hospital, 5% arrived by ambulance. Using these ambulance arrivals, 215 diagnoses were identified for inclusion in the PANE tool. An expert panel categorized each diagnosis as requiring ALS, BLS, or LAT, with a high level of interobserver agreement (weighted K = 0.793). As a measure of external validity of the PANE, admission rates were highest in the ALS group, next highest in the BLS group, and lowest in the LAT group (X2 for trend, P < 0.05). 2) Assessment of ambulance assignments and requests: According to the PANE tool, the sensitivity of dispatcher assignment of ALS ambulances was 72%. Therefore, 28% of patients who required an ALS ambulance received BLS care. 50% of patients assigned to an ALS ambulance did not require that level of care, and 1/3 of these were categorized by the PANE as not requiring an ambulance at all. Conclusions The PANE tool compared favorably to admission rates as a measure of the severity of illness of patients arriving by ambulance. Applying the PANE tool, we conclude that the majority of requests for ambulances are appropriate, and that the majority of the time dispatchers were able to dispatch the appropriate level of care. However, there is room for significant improvement in utilization of ambulances, and tools like the PANE will be useful in achieving this goal.

Pediatric prehospital evaluation of NYC cardiac arrest survival (PHENYCS)

Objectives The objective of this study was to describe the demographics of out-of-hospital cardiac arrests (OOHCAs) in children younger than 18 years and characteristics associated with survival among these children in New York City (NYC). Methods A prospective observational cohort of all children younger than 18 years with OOHCA in NYC between April 1, 2002, and March 31, 2003. Data were collected from prehospital providers by trained paramedics utilizing a previously validated telephone interview process. Data included Pediatric Utstein core measures and critical prehospital time intervals. Analyses utilized descriptive statistics and bivariate association with survival. Results Resuscitation was attempted on 147 pediatric OOHCA patients in NYC during the study period; outcome data were collected on these patients. The median age was 2 years; most (58%) were male. The majority of arrests occurred at home (69%). Lay bystanders witnessed 33% of all OOHCA; 68% of witnesses were family members. Bystander cardiopulmonary resuscitation (CPR) was performed on 30% of children. Median emergency medical services response time was 3.6 minutes (range, 0.4–14.4 minutes). Initial rhythm was as follows: ventricular fibrillation, 2%; asystole, 50%; pulseless electrical activity, 9.5%; other rhythms, 11.6%; no rhythm recorded, 26%. Survival was 4% to hospital discharge and was present only among witnessed arrests (6/58 witnessed vs 0/70 unwitnessed, P < 0.05). Conclusions Pediatric OOHCA survival rate is low. Witnessed arrest was the most important determinant of survival. Ventricular fibrillation was an uncommon rhythm measured by emergency medical services. The majority of arrests occurred at home. The rate of bystander CPR was low. Strategies to increase the rate of bystander CPR for children, especially by family members, are needed.

Assessment of pediatric patients by emergency medical technicians-basic.

Objective To determine whether emergency medical technicians-basic can accurately assess children and whether this ability varies with the patient’s age or diagnosis. This determination is important for educational program design for emergency medical technicians in pediatrics and for evaluation of the possibility of expanding their scope of practice. Design Retrospective chart review. Setting Pediatric emergency department in a large, urban hospital. Participants Patients (n = 2430) presenting to the pediatric emergency department via basic life support ambulance during a 12-month period. Measurements Data collected were name, age, field assessment (FA), and emergency department (ED) diagnosis. Patient’s ages were organized into five groups: infant (0–1 y), toddler (1–3 y), preschool (3–6 y), school-aged (6–11 y), and adolescent (> 11 y), and the ED diagnoses were divided into seven categories. The accuracy of the FA was compared with the ED diagnosis. We then analyzed FA accuracy by patient’s age and type of diagnosis. The χ2 contingency table analysis was used for dichotomous variables (P < 0.05). In addition, logistic regression and stratified analysis were used. Both ambulance and hospital charts were available for 2064 patients. Age ranged from birth to 19 years with a bimodal distribution at the extremes of patient age and a mean age of 8.25 (SD, 5.64). The distribution was 11.7% (241) infants, 14.7% (303) toddlers, 14.9% (307) preschool, 21.2% (437) school-aged, and 37.6% (776) adolescents. Results Overall emergency medical technician-basic assessment was accurate 81.5% (1683) of the time. There was a statistically significant variation in accuracy with both age group (χ2 = 40.07, P < 0.05) and diagnostic category (χ2 = 185.7, P < 0.05). By age group, the accuracy of field assessment was 69.7% (168) infants, 75.9% (230) toddlers, 82.7% (254) preschool, 86.7% (379) school-aged, and 84.0% (652) adolescents. By category of diagnosis, the accuracy of the field assessment was 92.4% (292) major trauma, 91.4% (478) minor trauma, 88.9% (112) psychologic and social, 85.1% (229) major medical, 81.1% (180) wheezing-associated respiratory illness, 65.4% (350) minor medical, and 57.5% (42) nonwheezing-associated respiratory illness. Conclusions Emergency medical technicians-basic were highly successful in assessing children with wheezing, serious illness, injuries, and psychologic and social conditions. Consideration should be given to expanding their scope of practice in these areas. They were less successful in assessing minor medical conditions and respiratory emergencies other than wheezing. They require additional training in these areas.

ALBUTEROLSULFATEADMINISTRATION BYEMT-BASICS: RESULTS OF ADEMONSTRATIONPROJECT

Objectives. 1) To evaluate the ability to train emergency medical technicians–basic (EMT-Bs) to accurately identify bronchospasm and, based on a treatment protocol, administer albuterol sulfate via nebulization as a standing order. 2) To measure the improvement in patient condition after treatment. Methods. Following approval by the Commissioner of Health and Institutional Review Board, EMS agencies were enrolled to participate in the study and EMT-Bs were trained using a four-hour curriculum. For each patient, a prehospital data collection form was completed including identifying data for the EMT-B, patient assessment, and history information; and pre- and posttreatment assessments and a hospital data collection form were completed including the emergency department physicians diagnosis, assessment of bronchospasm, number of albuterol treatments received in the emergency department, and final disposition of the patient. Results. During a one-year study period, EMT-Bs treated 190 patients as part of the project. Across all values patients showed a clinical improvement as a result of the therapy. Concurrence in the assessment of bronchospasm by the EMT-B with an emergency department physician was found in 87.4% of the cases. When including allergic reaction, anaphylaxis, bronchiolitis, and chronic obstructive pulmonary disease in the diagnosis list of bronchospasm, the accuracy rate increased to more than 94%. Conclusion. This study indicated EMT-Bs were highly successful in their evaluation of bronchospasm. Based on this level of accuracy, the authors suggest that it is safe for emergency medical service systems and medical directors to develop protocols that allow EMT-Bs to administer albuterol via nebulizer for bronchospasm based on their assessment.

Knowledge and attitude assessment and education of prehospital personnel in child abuse and neglect: Report of a national blue ribbon panel*☆☆☆★★★

child maltreatment, is a public health concern that has reached epidemic proportions. Prehospital providers, who often witness scenes of child abuse and neglect, can fill an essential role in identifying neglect and abuse in the home, at school, and in other locations. In October 2001, a blue ribbon panel of national experts in emergency medical services (EMS), emergency medical services for children (EMSC), and child protection services (CPS) convened to discuss the prehospital provider’s role in identifying and reporting suspected child abuse and neglect. Significantly, this marked the first time national experts from the worlds of child protection and EMSC met face-to-face to address this issue. With expertise in EMS education, pediatric emergency medicine, pediatric surgery, psychiatry and psychology, social work, legal practice, law enforcement, and fire and rescue services, the participants represented the entire continuum of care for at-risk children. When all available services are used and integrated, children are kept from falling through the cracks, and the highest quality of care possible is provided for them. Guided by research findings from a national survey conducted by the Center for Pediatric Emergency Medicine (CPEM), the panel’s goals were to:

Certified First Responder : A comprehensive model for pediatric training

The purpose of this document is to present a general approach to educating the First Responder in Emergency Pediatric Care. The First Responder is especially important in the emergency care of the sick or injured child. The majority of mortality and morbidity associated with pediatric emergencies is a result of airway and ventilatory compromise. In addition, most airway and ventilation problems can be corrected with only basic life support interventions that are within the scope of practice of the First Responder. As a result, it is of paramount importance to assure that the First Responder is adequately trained in the initial care of the pediatric patient. This document will review some of the key objectives and topics which the First Responder needs to understand in order to adequately care for children until further emergency care arrives. Templates for lesson plans and suggested activities for training the First Responder are also presented.

Pediatric prehospital evaluation of NYC respiratory arrest survival (PHENYCS).

Objective The objective of this study was to describe the demographics, epidemiology, and characteristics associated with survival of children younger than 18 years who had an out-of-hospital respiratory arrest (OOHRA) during a 1-year period in a large urban area. Methods A prospective observational cohort of consecutive children younger than 18 years with OOHRA cared for by the New York City 911 emergency medical services (EMS) system from April 12, 2002, to March 31, 2003. Following resuscitative efforts, data were collected from prehospital providers by trained paramedics using a previously validated telephone interview process. Data included Pediatric Utstein core measures and critical prehospital time intervals. Analyses used descriptive statistics and bivariate association with survival. Results Resuscitation was attempted on 109 OOHRAs during the study period. The median age was 7 years, 52% were male. Lay bystanders witnessed 56%. Most occurred at home (77%). Witnesses were family members in 59%. Bystander cardiopulmonary resuscitation (CPR) was performed in 31% of all respiratory arrests (RAs). A chronic medical condition existed in 28%. Median EMS response time was 4.4 minutes (range, 0–12 min). Overall survival was 79% to hospital discharge. Time interval to EMS arrival, witnessed arrest, bystander CPR, and ventilation method were not associated with survival. Conclusions Most OOHRAs occurred at home, and bystander CPR occurred infrequently. The majority of children in OOHRA survived. Strategies to increase the rate of bystander CPR, especially by family members, are needed. Out-of-hospital RAs are a large proportion of all arrests in children. Future studies of pediatric arrest should include RA as well as cardiac arrest.

Knowledge and attitude assessment and education of prehospital personnel in child abuse and neglect: report of a National Blue Ribbon Panel.

Violence against children, specifically in the area of child maltreatment, is a public health concern that has reached epidemic proportions. Prehospital providers, who often witness scenes of child abuse and neglect, can fill an essential role in identifying neglect and abuse in the home, at school, and in other locations. In October 2001, a blue ribbon panel of national experts in emergency medical services (EMS), emergency medical services for children (EMSC), and child protection services (CPS) convened to discuss the prehospital provider’s role in identifying and reporting suspected child abuse and neglect. Significantly, this marked the first time national experts from the worlds of child protection and EMSC met face-to-face to address this issue. With expertise in EMS education, pediatric emergency medicine, pediatric surgery, psychiatry and psychology, social work, legal practice, law enforcement, and fire and rescue services, the participants represented the entire continuum of care for at-risk children. When all available services are used and integrated, children are kept from falling through the cracks, and the highest quality of care possible is provided for them. Guided by research findings from a national survey conducted by the Center for Pediatric Emergency Medicine (CPEM), the panel’s goals were to: