Research

The Current State of the Pediatric Emergency Medicine Workforce and Innovations to Improve Pediatric Care

Gregory W. Faris, MD, James P. Marcin, MD, MPH, Elizabeth Weinstein, MD

Abstract

Many hospitals and emergency departments lack resources to optimally care for ill and injured children, perpetuating risks of receiving fragmented and “ uneven” care. In this article, we describe the present state of our pediatric emergency medicine workforce as well as the impact that different innovations could have on the future of pediatric emergency care. Many innovative initiatives, including physician and advanced practice provider education and training, pediatric readiness recognition programs, telemedicine and in-situ simulation outreach, and community paramedicine are being utilized to help bridge access gaps and augment the reach of the pediatric emergency medicine workforce. Advocacy for reimbursement for novel care delivery models, such as community paramedicine and telemedicine, and funding for outreach education is essential. Also, better understanding of our current training models for and utilization of advanced practice practitioners in pediatric emergency medicine is crucial to understanding the diversity of workforce growth and opportunity.

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Early On-Scene Management of Pediatric Out-of-Hospital Cardiac Arrest Can Result in Improved Chances for Neurologically-Intact Survival

Paul R. Banerjee, Latha Ganti, Paul E.Pepe, Amninder Singh, Abhishek Rokab, Raf A.Vittone

Abstract

Aim: To evaluate the frequency of neurologically-intact survival (SURV) following pediatric out-of-hospital cardiac arrest (POHCA) when comparing traditional early evacuation strategies to those emphasizing resuscitation efforts being performed on-scene.

Methods: Before 2014, emergency medical services (EMS) crews in a county-wide EMS agency provided limited treatment for POHCA on-scene and rapidly transported patients to appropriate hospitals. After 2014, training strongly enhanced EMS provider comfort levels with on-scene resuscitation efforts including methods to expedite protocols on-site and control positive-pressure ventilation. Frequency of SURV (hospital discharge) was compared for the two years prior to initiating the immediate on-scene care strategy to the ensuing two years following implementation.

Results: Between 01/01/2012 and 12/31/2015, 94 children experienced POHCA. There were no significant differences before and after the on-scene focus in terms of age, sex, etiology, presenting electrocardiograph, drug infusions or bystander-performed cardiopulmonary resuscitation and total scene times actually remained similar (14.3 vs. 17.67 minutes). SURV increased significantly upon implementation of the immediate on-scene management strategy and was sustained over the next two years (0.0 % to 23%; p = 0.0013). Though statistically-indeterminate in this analysis, the improvement was associated with a shorter mean time to epinephrine administration among resuscitated patients (16.6 vs. 7.65 minutes).

Conclusion: Facilitating immediate on-scene management of POHCA can result in improvements in life-saving. Although a historically-controlled evaluation, the compelling appearance of neurologically-intact survivors was immediate and sustained. Targeted training, more efficient, physiologically-driven procedures, and trusted encouragement from supervisors, likely played the most significant roles and not necessarily extended scene times.

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The accuracy of the Broselow tape as a weight estimation tool and a drug-dosing guide – A systematic review and meta-analysis

Mike Wells, Lara Nicole Goldstein, Alison Bentley, Sian Basnett, Iain Monteith. Division of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, Johannesburg, South Africa

Objectives: The aim of this study was to systematically review the literature to analyse the accuracy of the Broselow tape as a weight estimation device and review evidence of its utility as a drug-dosing guide.

Conclusions: The Broselow tape lacked sufficient accuracy as a weight estimation and drug-dosing tool when compared to other available techniques. In addition, the Broselow tape contains insufficient drug dosing information to function as a complete resuscitation aid without additional material. The frequent rate of incorrect usage of the tape indicated that appropriate training with the tape is mandatory to reduce errors.

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Use of Fentanyl in Pediatric Trauma Patients Postimplementation of the Handtevy™ Field Guide

Lara Rappaport MD MPH, David Edwards NREMPT, Whitney Barrett MD, Aaron Eberhardt MD, Kevin McVaney MD, Kathleen Adelgais MD MPH Department of Emergency Medicine, Denver Health Medical Center, Denver CO | Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO

Objectives: To evaluate the change in prehospital fentanyl administration to children after the introduction of the Hnadtevy field guide in our hospital-based EMS system.

Conclusion: The introduction of the Handtevy™ field guide with pre-calculated doses of fentanyl resulted in an overall increase in analgesia administration. Among age and route of administration subgroups there was a substantial increase in the provision of analgesia, including specifically in those

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

 Lara D. Rappaport MD, MPH, Lina Brou MPH, Tim Givens MD, Maria Mandt MD, Ashley Balakas RN, BSN, Kelley Roswell MD, Jason Kotas NREMT & Kathleen M. Adelgais MD, MPH

Objectives: To compare two LBT systems for dosing errors and time to medication administration in simulated prehospital scenarios.

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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Comparison of Two Length-Based Tape Systems for Pediatric Resusciation

 Lara Rappaport, Maria Mandt, Timothy Givens, Ashley Balakas, Kevin Waters, Kelley Roswell, Roxanna Lefort, Kathleen Adelgais | University of Colorado & Aurora Fire Department

Background: The use of a length/weight-based tape (LBT) for equipment sizing and drug dosing for pediatric patients is recommended in a joint statement by ACS and NAEMSP. The BroselowTM tape is widely used and accepted in hospital and prehospital settings. A new system, known as HandtevyTM, allows rapid determination of critical drug doses without performing calculations. Our objective was to compare two LBT systems for accuracy of dosing and time to medication administration in simulated prehospital scenarios.

Conclusion: Handtevy™ LBT system is more accurate for dextrose administration compared to the Broselow™, preserving time to administration and accuracy of epinephrine in simulated prehospital scenarios. After comparison of both systems, the majority of PHPs indicate preference for the Handtevy™ system.

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Errors in Pediatric Pre-Hospital Simulation Scenarios

K. Adelgais MD MPH, T. Givens MD, M. Mandt MD, A. Balakas BSN, L. Rappaport MD MPH | Colorado Children’s Hospital

Objective: To compare the type and rate of errors in medication administration between two LBT systems during pediatric prehospital simulation scenarios.

Conclusion: In prehospital simulation scenarios, procedural errors are very common. The Handtevy LBT system results in fewer cognitive errors, particularly in scenarios requiring dextrose administration.

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A Comparison of Medications in 38 Pediatric EMS Protocols to Those Listed on the Broselow Length-Based Tape

Caroline Epstein EMT-B, Peter Antevy MD, Patrick Hardigan PhD., Joe DiMaggio Children’s Hospital, Hollywood, FL, Nova Southeastern University, Davie, FL

Background: Pediatric Advanced Life Support guidelines set forth by the American Heart Association recommends use of a length-based resuscitation tape (LBT) by healthcare providers. Pediatric medication errors in the pre-hospital setting have been studied by numerous investigators, occur frequently and are potentially fatal. This study seeks to compare pediatric drug dosages from large and small EMS agencies to those listed on the Broselow LBT and determine discordance rates.

Results: Thirty-eight EMS protocols were reviewed. Populations served by these agencies ranged from 291 to 2.49 million. Of medications listed in both the Broselow LBT and EMS protocol, 10% were listed at a dose at least 30% greater than that recommended by the EMS protocol. On average, 38% of EMS protocol medications were not listed on the Broselow LBT. This calculated to a total average medication discordance rate of 49% (Range 32-63%,SD 8%). We compared the average discordance of 49%, (95% CI:32%,63%) against a hypothetical measure of 10% using a test for a difference in proportions. The calculated discordance was statistically greater than a standard of 10% (p<0.001). Further analysis revealed that five medications represented 62% of the missing medications: Epinephrine 1:1000 IM, Ondansetron, Diphenhydramine, Morphine, and Albuterol. Three medications accounted for 84% of the incongruent dosages: Midazolam, Fentanyl, and Diazepam.

Conclusion: A significant discrepancy exists between the pediatric drug dosages found in 38 EMS protocols and those listed on the Broselow Length-Based Tape.

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Comparison of a Hybrid Pediatric Weight Estimation Method (Handtevy™) to the Broselow™ Length Based Tape

Peter Antevy M.D., Patrick Hardigan PhD, Robert Levy B.A. | Joe DiMaggio Children’s Hospital, Nova Southeastern University, University of South Florida College of Medicine

Objective: 1. Validate the correlation between predicted weights using the Handtevy TM age-based system and published pediatric normal weights. 2. Compare the predictive validity of the Handtevy TM LBT to the Broselow TM LBT.

Conclusion: Predicted weights from the Handtevy TM age-based weight estimation method accurately predict pediatric normal weights. A comparison of two length-based tapes demonstrates increased accuracy of the Handtevy TM LBT over the Broselow TM LBT. The Handtevy TM age-based system outperforms the Broselow TM LBT for underweight, normal weight, and obese children.

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Assessment of an Ideal Weight for Age Based Dosing Education for EMS Using Simulated Encounter

Manu Madhok, MD, Ernest Krause, BS, Andrew Flood2, PhD, David Piechota1, MD, James Lev3, BSHCAD, NREMT Emergency Department, Research and Sponsored Programs, EMS & Trauma Outreach, Children’s Minnesota

Background: In pediatric resuscitation medication dosage is weight based. During pediatric EMS calls requiring rescue medications, the patient’s weight is often unknown which leads to challenges in calculating dose and longer time to administration (TTA).

Objectives:To assess the impact of an ideal weight for age dosing education tool on the accuracy and ease of dosage calculation and TTA of resuscitation medications during simulation.

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National Pre-Hospital Guidelines for Pediatric Seizure and Traumatic Pain Management Do Not Concur with Information on the Broselow-Luten Length Based Tape

Kathleen M. Adelgais, Karl Marzec, Toni Gross, Lara D. Rappaport | University of Colorado School of Medicine

Background: The Ambulance Equipment List includes the pediatric length/weight-based tape. The Broselow-Luten Pediatric Emergency Tape (Broselow LBT) has assessment tools, equipment selection, and medication doses. Recent prehospital evidence-based guidelines (EBG) provide pediatric-specific recommendations for seizure and traumatic pain management. The purpose of this study was to examine the ability of the Broselow LBT to facilitate care per these two EBGs. We hypothesize that the Broselow LBT can correctly facilitate only a few EBG recommendations.

Conclusion: Few prehospital EBGs recommendations can be accurately followed by information on the Broselow LBT. Additional tools to facilitate pediatric care according to prehospital EBG recommendations may be necessary.

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Safety Events in the Out-of-Hospital Care of Children

Garth D. Meckler, Jeanne-Marie Guise, Matthew Hansen, Caitlin Dickenson, William Lambert, Keith O’Brien | University of British Columbia

Background: Studies in the hospital setting have identified medical errors as a significant cause of morbidity and mortality. Little is known, however, about the frequency and nature of patient safetyevents in the out-of-hospital setting, particularly among children. We sought to describe the occurrence and characteristics of out-of-hospital pediatric patient safety events.

Conclusion:Among high-risk pediatric ambulance transports, patient safety events are common, potentially severe, and preventable. Identification of patient and clinical scenarios at highest risk for safety events may provide direction for future strategies and interventions to improve care and reduce harm.

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A Comparison of On-Scene Times for Out-of-Hospital Pediatric Versus Adult Cardiac Arrest Patients in a Statewide EMS Information System

Emily Kraft, Emily Jonas, Kevin Putman, Colleen MacCallum, William Fales | Western Michigan University

Background: Compare on-scene times of transported out-of-hospital non-traumatic cardiac arrest (CA) pediatric versus adult patients using a statewide EMS information system (EMSIS).

Conclusion: This study demonstrates significantly shorter on-scene times of pediatric versus adult cardiac arrest patients. Adults were much more likely to have an arrest in a public location, have an initial shockable rhythm, and have ROSC upon ED arrival. Further studies are needed to asses any causal relationship between scene time duration and outcomes. Important limitations in this study include exclusive reliance on unverified data from a statewide EMSIS, large numbers of excluded cases including non transported patients, and lack of hospital outcome data.

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Pre-Hospital Pediatric Arrests Receiving Epinephrine (Prepare) in the United States

Eric Ernest, Manu Madhok, Peter Antevy, Andrew Flood, Lara Rappaport | Childrens Hospital and Clinics of Minnesota

Background: Current PALS algorithms recommend that epinephrine be administered in cardiac arrest. Out-of-hospital cardiac arrest survival in pediatric patients is poor; 3% for infants and 9% for children/adolescents. Despite emphasis on improving pediatric out-of-hospital care, there has been no increase in survival rates over the past 20 years. This is compared to in-hospital pediatric cardiac arrest, which has improved from 9% in 1980 to 27% in 2006. The purpose of this study was to evaluate the current rate of out-of-hospital epinephrine administration in pediatric and adult cardiac arrest cases.

Conclusion: Despite guidelines indicating epinephrine administration in cardiac arrest, actual epinephrine administration in pediatric cases was low, averaging 34.6% in pediatric cases. Furthermore the rate of epinephrine administration in pediatric cases was substantially lower than in adults. Investigation is needed to evaluate the reasons for the low rate of epinephrine administration in out-of-hospital cardiac arrests and to determine if an association exists between low epinephrine rate and survival.

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Finger Counting: An Alternative Method for Estimating Weights

Timothy P. Young, MD ⁎, Brian G. Chen, MD, Tommy Y. Kim, MD, Andrea W. Thorp, MD, Lance Brown, MD, MPH | Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Loma Linda University Children’s Hospital, Loma Linda, CA, USA

Objectives: We compared the accuracy of a conceptually simple pediatric weight estimation technique, the finger counting method, with other commonly used methods.d.

Conclusion: The finger counting method is an acceptable alternative to the Broselow method for weight estimation in children aged 1 to 9 years. It outperforms the traditional APLS method but underestimates weights compared with parental estimate and the Luscombe formula.

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