Maryland — Targeted Issue

Author(s)/Presenter(s)

Kyle A. Fratta, NRP, Jennifer N. Fishe, MD, Paige D. Anders, Jennifer F. Anders, MD

Abstract/Description

More than one million children are transported by EMS in the United States annually. In the absence of protocolized destination guidance, EMS providers rely on their judgement and experience to choose among potential destinations. EMS providers frequently choose hospitals other than the closest, and both underestimation and overestimation of pediatric patient needs are common.

Keywords

EMS, Pediatrics, Prehospital triage, Direct transport

Author(s)/Presenter(s)

Jennifer Anders, MD

Author(s)/Presenter(s)

Jennifer Anders, MD, FAAP

Author(s)/Presenter(s)

Fratta K, Fishe JN, Anders JF

Author(s)/Presenter(s)

Jennifer Anders, Ali Aledhaim, Jennifer Fishe, Jon Mark Hirshon

Abstract/Description

When patients are transported by EMS and later require subsequent transfer to another facility (secondary transport), patient care is compromised and healthcare resources wasted. Previously, the rate of secondary transport has been estimated indirectly. Using the Maryland’s comprehensive all-payers dataset for hospital based care (ED and inpatient) and comprehensive EMS dataset, we sought to directly measure secondary transport in pediatrics.

Author(s)/Presenter(s)

Fratta KA, Fishe JN, Anders JF

Author(s)/Presenter(s)

Jennifer N. Fishe, MD, Kevin J. Psoter, PhD, & Jennifer F. Anders, MD

Abstract/Description

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.

Author(s)/Presenter(s)

Fishe JN, Fratta K, Anders JF

Author(s)/Presenter(s)

Jennifer Anders, MD

Abstract/Description

Objectives: (1) Understand why and how pediatric care is regionalized and the effects on EMS systems; (2) Learn how undertriage, overtriage and secondary transport are sub-optimal for patients and EMS operations; (3) Review non-trauma pediatric conditions likely to require inpatient or specialty pediatric care; (4) Become familiar with a pilot pediatric destination tool which incorporates the available evidence base.

Author(s)/Presenter(s)

Kyle A Fratta, Jennifer N Fishe, Jennifer F Anders, Tessa G Smith

Abstract/Description

EMS protocol implementation can be a challenging endeavor given the large and diverse provider workforce. These efforts can be even more challenging given training restrictions, career and volunteer combination EMS agencies, and inconsistent work schedules. In an effort to educate as many providers as possible in a relatively short time, the community of practice educational model was used during a new evidence-based EMS protocol implementation. This model identifies providers who are enthusiastic during initial training as advocates. These advocates then continue to educate their peers going forward. This allows for the initial educational effort to continue to propagate during pilot testing and beyond. During this protocol implementation, a total of 17 educational visits were made to EMS stations and 43 providers were identified as advocates.

Author(s)/Presenter(s)

Jennifer Anders, Jennifer Fishe, Kyle Fratta

Abstract/Description

BACKGROUND: For select conditions, prehospital destination decision algorithms are widely adopted by Emergency Medical Services (EMS). Those evidence-based protocols improve patient outcomes and reduce overuse and underuse of resources. The PDTree project is a HRSA targeted issues project to develop an evidence-based tool to guide destination choice for pediatric EMS patients. OBJECTIVE: To create a pediatric prehospital destination tool (PDTree) using an expert panel of key stakeholders. METHODS: An expert panel was created to include key stakeholders from pediatric emergency medicine, emergency medicine, EMS medical directors, prehospital providers and family/patient advocates. A summary of the literature, rated using a modified-GRADE methodology provided the panel with the available evidence base. Unpublished data specific to the statewide EMS system that would serve as the decision tool testing region was also provided, including: the ten most frequent pediatric interfacility transfer conditions, summary of focused interviews with prehospital providers, and risk factors for pediatric secondary transport. From those data, 18 conditions were presented for possible inclusion on the PDTree. In a modified-Delphi process, the panel discussed all conditions in an in-person meeting, followed by anonymous voting on whether to include the item in the PDTree tool and where to place the item in the template. The threshold to include a condition was at least 75% agreement. Following the in-person meeting, a second round of consensus voting was held to refine terminology and destination decisions of items for which consensus was not yet reached. Four initial drafts of a pediatric decision tool were created, and a third round of voting selected the consensus draft. RESULTS: The consensus draft PDTree tool is presented in Figure 1. CONCLUSIONS: Using a modified-Delphi method, an expert panel crafted a consensus draft PDTree tool for pediatric prehospital destination choice. The PDTree tool will be tested by computerized resource modeling, prehospital provider simulation, and finally pilot testing in three selected EMS agencies.

Author(s)/Presenter(s)

Fratta KA, Fishe JN, Anders JF

Author(s)/Presenter(s)

Jennifer Fishe, Remle Crowe, Rebecca Cash, Nikiah Nudell, Christian Martin-Gill, Christopher Richards

Abstract/Description

Objective: As prehospital research advances, more evidence-based guidelines (EBGs) are implemented into emergency medical services (EMS) practice. However, incomplete or suboptimal prehospital EBG implementation may hinder improvement in patient outcomes. To inform future efforts, this study's objective was to review existing evidence pertaining to prehospital EBG implementation methods.

Methods: This study was a systematic literature review and evaluation following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. PubMed, EMBASE, Scopus, and Google Advanced Search were searched without language or publication date filters for articles addressing prehospital EBG implementation. Conference proceedings, textbooks, and non-English articles were excluded. GRADE was applied to the remaining articles independently by three of five study investigators. Study characteristics and salient findings from the included articles are reported.

Results: The systematic literature review identified 1,367 articles, with 41 meeting inclusion criteria. Most articles described prehospital EBG implementation (n = 24, 59%), or implementation barriers (n = 13, 32%). Common study designs were statement documents (n = 12, 29%), retrospective cohort studies (n = 12, 29%), and cross-sectional studies (n = 9, 22%). Using GRADE, evidence quality was rated low (n = 18, 44%), or very low (n = 23, 56%). Salient findings from the articles included: (i) EBG adherence and patient outcomes depend upon successful implementation, (ii) published studies generally lack detailed implementation methods, (iii) EBG implementation takes longer than planned (mostly for EMS education), (iv) EMS systems' heterogeneity affects EBG implementation, and (v) multiple barriers limit successful implementation (e.g., financial constraints, equipment purchasing, coordination with hospitals, and regulatory agencies). This review found no direct evidence for best prehospital EBG implementation practices. There were no studies comparing implementation methods or implementation in different prehospital settings (e.g., urban vs. rural, advanced vs. basic life support).

Conclusions: While prehospital EBG implementation barriers are well described, there is a paucity of evidence for optimal implementation methods. For scientific advances to reach prehospital patients, EBG development efforts must translate into EMS practice. Future research should consider comparing implementation methodologies in different prehospital settings, with a goal of defining detailed, reproducible best practices.

Author(s)/Presenter(s)

Ali Aledhaim, Jennifer Fishe, Jon Mark Hirshon, Jennifer F Anders

Abstract/Description

Objectives: Pediatric care is increasingly regionalized, increasing rates of interfacility transport (IFT). However, it is unknown what conditions most frequently require IFT. This study's objective was to identify high-frequency pediatric conditions requiring IFT.

Methods: This is a statewide retrospective observational study from 2010 to 2012 of pediatric patients (<18 years of age) who underwent IFT in Maryland. Patients were identified from the Health Care Utilization Project's database using probabilistic linkage. This study identified the 20 most common pediatric IFT conditions, and the conditions with the highest IFT rates.

Results: Probabilistic linkage was successful for 2254 records. The largest age category was 0 to 4 years (43%). The top 3 IFT conditions were asthma (13.5%), epilepsy (8.5%), and diabetes mellitus (6.6%). Diabetes mellitus had the highest IFT rate (24%), followed by appendicitis (15.5%) and internal obstruction (14.4%).

Conclusions: Specific pediatric conditions commonly require IFT and had high IFT rates in this statewide study. In addition, the largest age group undergoing IFT was young children (0 to 4 years of age). This study provides specific detail regarding conditions and ages impacted by IFT, and emergency medical services should consider incorporating these findings into transport destination algorithms. In addition, public health stakeholders should address implications of the concentration of care for these common pediatric conditions and younger age groups.

Author(s)/Presenter(s)

Kyle A. Fratta; Jennifer N. Fishe

Abstract/Description

Prehospital triage should match patient needs with hospital service availability. For emergency medical services (EMS), hospital destination choices are guided by patient condition, transport times, jurisdictional resources, local hospital capabilities, and patient/family preference. Evidence-based guidelines (EBG) have been developed to aid EMS destination choices for adult patients suffering from trauma, myocardial infarction, and stroke. However, analogous guidelines do not exist for any pediatric condition other than trauma.

Regionalization of care has concentrated pediatric specialty/critical care services, magnifying the consequences of the destination decisions of EMS and increasing rates of interfacility transport (IFT) and secondary transport. Studies have identified several specific medical conditions that frequently necessitate secondary or interfacility transport. Additionally, preventable patient harms due to secondary and interfacility transport have been identified. To avoid such harms, and better serve the definitive care needs of the estimated 1.8 million children transported by EMS annually in the USA, EBG development should be explored for pediatric conditions beyond trauma.

Author(s)/Presenter(s)

Ali Aledhaim, Jon Mark Hirshon, Jennifer Fishe, Jennifer Anders

Abstract/Description

BACKGROUND: In regionalized health care systems, pediatric patients routinely require interfacility transfer (IFT) from initial emergency care to a second acute care facility to reach definitive care. IFT is associated with patient safety risks, delays in definitive care, and increased cost. This study identifies high-frequency IFT conditions for pediatric patients from a statewide EMS system to help craft a destination decision tool for pediatric EMS patients that minimizes IFT. OBJECTIVE: To determine the diagnosis categories (DxC) mostly likely to require IFT from EDs to another acute care facility, including the most frequent conditions and those with the highest IFT rates. METHODS: IFT patients were identified from a three year sample (2010-2012) of the Maryland HCUP inpatient and ED databases. Included patients were 0-17 years of age, transferred from an ED to a second acute care facility for inpatient care, and whose admission type was classified as ‘emergent’ or ‘urgent’. Modified deterministic linkage was performed between the ED and inpatient databases with 8 required matching elements (age, admission month and year, day, gender, zip-code, diagnosis category, and insurance type) Two discriminatory elements were used to resolve between match candidates (principal diagnosis code, and health insurance carrier name). After linkage, the 20 most frequent age-adjusted DxC were identified, and stratified by age categories. IFT rates of the 20 most frequent DxC were computed using the entire IFT group, including unlinked records. RESULTS From 2010-2012 there were 1,382,743 and 293,704 pediatric patients in the ED and inpatient databases, respectively. Of those patients, 9,523 met the inclusion criteria. The linkage matched 2,152 patients (22.6% linkage rate). The 5 most frequent weighted DxC were asthma, arm fracture, psychological disorder, epilepsy and pneumonia, respectively. The 20 most frequent DxC, shown in Figure 1, cumulatively accounted for 58.7% and 75.8% of IFTs in the linked subset and the entire IFT group, respectively. The mean age of IFT patients was significantly lower than the mean of all ED patients (6.3 years vs. 7.2 years, p < 0.001). Table 1 presents IFT rates for the 20 most frequent DxC, among which the highest age-adjusted IFT rates were for diabetes mellitus (DM) with complications (24.1%), appendicitis (15.7%), and crush injury (9.5%). CONCLUSIONS: The most frequent conditions requiring emergent pediatric IFT in a statewide EMS system are asthma, arm fractures, psychological disorder, epilepsy, and pneumonia. The highest rate of pediatric IFT was seen for DM with complications, appendicitis, and crush injury. Those conditions should be considered for inclusion in prehospital pediatric direct transport protocols. Further studies should quantify harms and costs associated with pediatric IFT.