Mark Xavier Cicero

INTRODUCTIONConcussion, previously considered as a form of mild traumatic brain injury (TBI), is a frequent and potentially debilitating injury for children. It is estimated that between 1.1 millio...

Pediatric patients represent a high-risk, low frequency population in emergency medical services (EMS) systems. Quality improvement (QI) is the backbone of high-quality care delivered in EMS and engagement in pediatric-specific QI work is a core domain of the National Prehospital Pediatric Readiness Project (PPRP). There is no widely accepted set of quality measures that focus on the full scope of pediatric prehospital care. Our objective was to establish core PPRP Quality Measures for a National EMS Information System (NEMSIS)-derived pediatric prehospital dashboard to support pediatric QI initiatives. We convened a 16-member technical expert panel (TEP) from national professional societies and federal entities. The TEP included physicians, nurses, EMS clinicians, federal partners, state EMS officials, and NEMSIS staff. Candidate measures were identified through a review of national resources and a survey of TEP members. The TEP employed a modified Delphi process to establish consensus priorities and scored measures based on the National Quality Forum Measure Evaluation Criteria. Candidate measures were prioritized based on scientific acceptability, importance to patient outcomes, utility in driving improvements, and feasibility of collection. Candidate measures were scored on a scale of 1 (lowest priority) to 5 (highest priority). Consensus was defined as 75% of the TEP rating a measure ≥ 4. The TEP identified 65 candidate measures. After three rounds of voting, consensus was achieved on 24 measures addressing a range of common pediatric prehospital conditions, including airway management (5 measures), trauma (4), pain control (3), respiratory emergencies (3), cardiac arrest (2), anaphylaxis (1), shock (1), seizures (1), hypoglycemia (1), newborn emergencies (1), non-transport (1), and safe transport (1). Thirteen (54%) of these measures apply to basic life support (BLS) teams. Common reasons for excluding measures included: limited scientific evidence, measure complexity, and redundancy. A TEP identified 24 quality measures in pediatric EMS that emphasize foundational practice and relevance across a range of volumes and service models. Future validation of these measures with NEMSIS data are needed to establish benchmarks of care across variably resourced EMS agencies and develop effective strategies to support adherence to high-quality pediatric prehospital emergency care.

Pediatric trauma patients have unique physiology and anatomy that impact the severity and patterns of injury. There is a need for updated, holistic guidance for Emergency Medical Services (EMS) clinicians and medical directors to optimize prehospital pediatric trauma guidelines based on evidence and best practice. This is especially pertinent to pediatric severe and inflicted trauma, where prehospital evaluation and management determine the overall quality of care and patient outcomes. This position statement addresses the prehospital evaluation and management of pediatric severe and inflicted trauma and is based on a thorough review and analysis of the current literature.

Objective: SimBox simulations allow for high-frequency open-access health care education, overcoming cost and resource barriers. Prehospital paramedics and emergency medical technician (EMT) care for children infrequently. In this study, prehospital providers evaluated pediatric SimBox simulations. Methods: This was a cross-sectional study of EMS professionals participating in a series of simulations conducted in a larger project assessing improvement of the quality of pediatric care in the prehospital setting. Participants were teams of two, which comprised a paramedic/paramedic, paramedic/EMT, or 2 EMTs. The simulations used facilitator resources, debriefing prompts, video depictions of patients and vital signs, and a low-fidelity manikin. Pediatric emergency care coordinators, EMS training officers, and/or emergency physicians facilitated simulations of seizure, sepsis with respiratory failure, and child abuse, followed by debriefings. Participants completed an online survey after the simulation and rated it in 4 domains: prebriefing, scenario content, debriefing, and overall. Ratings were trifold: “strongly agree,” “somewhat agree,” or “do not agree.” Data were analyzed by case type, participant type, location, participant reaction to simulation elements, and the debriefing. Net Promoter Scores were calculated to assess participant endorsement of SimBox. Results: There were 121 participants: 103 (87%) were paramedics, and 18 (13%) were EMTs. Participant agreement of simulation benefit for clinical practice was high, for example, “I am more confident in my ability to prioritize care and interventions” (98.4% strongly or somewhat agree), and 99.2% of participants agreed the postsimulation debriefing with facilitators “provided opportunities to self-reflect on my performance during simulation.” Overall, 97.5% strongly or somewhat agreed that the simulations “improved my comfort in pediatric acute care.” Net Promoter Score showed 65.3% were promoters of and 24% were passive about SimBox. Conclusion: SimBox simulations are associated with improved self-efficacy of prehospital care providers for care of acutely ill or injured children. The majority promotes SimBox as a learning tool.

Introduction: It remains unclear which mass-casualty incident (MCI) triage tool best predicts outcomes for child disaster victims.Study Objectives: The primary objective of this study was to compare triage outcomes of Simple Triage and Rapid Treatment (START), modified START, and CareFlight in pediatric patients to an outcomes-based gold standard using the Criteria Outcomes Tool (COT). The secondary outcomes were sensitivity, specificity, under-triage, over-triage, and overall accuracy at each level for each MCI triage algorithm.Methods: Singleton trauma patients under 16 years of age with complete prehospital, emergency department (ED), and in-patient data were identified in the 2007-2009 National Trauma Data Bank (NTDB). The COT outcomes and procedures were translated into ICD-9 procedure codes with added timing criteria. Gold standard triage levels were assigned using the COT based on outcomes, including mortality, injury type, admission to the hospital, and surgical procedures. Comparison triage levels were determined based on algorithmic depictions of the three MCI triage tools.Results: A total of 31,093 patients with complete data were identified from the NTDB. The COT was applied to these patients, and the breakdown of gold standard triage levels, based on their actual clinical outcomes, was: 17,333 (55.7%) GREEN; 11,587 (37.3%) YELLOW; 1,572 (5.1%) RED; and 601 (1.9%) BLACK. CareFlight had the best sensitivity for predicting COT outcomes for BLACK (83% [95% confidence interval, 80%-86%]) and GREEN patients (79% [95% CI, 79%-80%]) and the best specificity for RED patients (89% [95% CI, 89%-90%]).Conclusion: Among three prehospital MCI triage tools, CareFlight had the best performance for correlating with outcomes in the COT. Overall, none of three tools had good test characteristics for predicting pediatric patient needs for surgical procedures or hospital admission.

Members of an emergency department (ED) staff need to be prepared for mass casualty incidents (MCIs) at all times. Didactic sessions, drills, and functional exercises have shown to be effective, but it is challenging to find time and resources for appropriate training. We conducted brief, task-specific drills (deemed “disaster huddles”) in a pediatric ED (PED) to examine if such an approach could be an alternative or supplement to traditional MCI training paradigms. Over the course of the study, we observed an improving trend in the overall score for administrative disaster preparedness. Disaster huddles may be an effective way to improve administrative disaster preparedness in the PED. Low-effort, low-time commitment education could be an attractive way for further disaster preparedness efforts. Further studies are indicated to show a potential impact on lasting behavior and patient outcomes.

Objectives: Because of the high prevalence of Autism Spectrum Disorder (ASD) and wandering behavior, emergency medical responders (EMRs) will likely encounter children and adolescents with ASD. The objectives were to describe interactions between EMRs and children and adolescents with ASD, to evaluate EMRs' ability to recognize ASD in a simulated trauma setting, and to determine if EMRs' demographic characteristics affected their interactions with ASD youth. Methods: A study of 75 videos of a simulated school bus crash was performed. The simulation included an adolescent with ASD portrayed by an actor. Videos were coded based on 5 domains: (1) reassurance attempts by the EMR, (2) quality of the EMR's interactions, (3) EMR's elicitation of information, (4) EMR's interactions with others, and (5) EMR's recognition of a disability. Two clinicians coded the videos independently, and consensus was reached for any areas of disagreement. Results: Of 75 interactions, 27% provided reassurance to the adolescent with ASD, 1% elicited information, 11% asked bystanders for information or assistance, and 35% suggested a disability with 13% considering ASD. No differences across domains were found based on the EMR's sex. Emergency medical responders with greater than or equal to 5 years of experience were significantly more likely to elicit information than those with less than 5 years of experience, and paramedics had significantly higher total performance scores than paramedic students or those with EMT-Basic. Conclusions: Few EMRs in this study optimally interacted with adolescents with ASD or recognized a disability. These findings suggest a strong need for targeted educational interventions.