New York — PECARN

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This video demonstrates the search process, starting with finding keywords and ending with executing the search and accessing the literature. Topics covered include advanced searching techniques, using filters in PubMed, and accessing literature through open access websites like PubMed Central.

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This video explores why literature appraisal is essential to study design and knowledge translation. Topics covered include identifying appropriate appraisal tools to critique different forms of medical literature, and the methodology for literature appraisal to develop evidence-based guidelines.

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This policy provides guidance for CHaMP investigators and others involved in PECARN research regarding the development, submission and approval process of a research concept and a research protocol for the CHaMP node.

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This video examines the importance of translational research as it relates to a bi-directional process of bench to bedside as well as bedside to bench research. Topics covered include an overview of how basic research knowledge turns into new and improved methods of preventing, diagnosing, and treating disease. The video also highlights the importance of how patient care insights are transferred into hypotheses that are tested and validated in a research process.

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This video examines why dissemination of findings is important, as well as describing ways to disseminate research results. Viewers learn where to submit their work and explore key elements of a scientific presentation or publication.

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This video provides an overview on how to evaluate the role of random error within epidemiological studies. Viewers will learn about a measure of association of a sample and how to measure it, as well as how to make statistical inferences within an epidemiological study. Topics covered include hypothesis testing, P values, and quantifying sampling variability through confidence intervals.

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This video examines the origin of research ideas, identifies what makes a good research question and explores a suitable research question’s key components

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This presentation discusses human subject protections and examines ethical challenges in EMS research. Topics covered include how to conduct EMS-related studies and a review of the Emergency Exception from Informed Consent regulations.

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This video examines how research in the EMS setting differs from hospital-based research. Viewers learn about the barriers to obtaining patient consent in the prehospital environment. Finally, the presentation summarizes the differences between a cohort study and a clinical trial and how they may affect the interpretation of the findings

Author(s)/Presenter(s)

Lorin R Browne, Manish I Shah, Jonathan R Studnek, Brittany M Farrell, Linda M Mattrisch, Stacy Reynolds, Daniel G Ostermayer, David C Brousseau, E Brooke Lerner

Abstract/Description

BACKGROUND: Pediatric prehospital research has been limited, but work in this area is starting to increase particularly with the growth of pediatric-specific research endeavors. Given the increased interest in pediatric prehospital research, there is a need to identify specific research priorities that incorporate the perspective of prehospital providers and other emergency medical services (EMS) stakeholders.
OBJECTIVES: To develop a list of specific research priorities that is relevant, specific, and important to the practice of pediatric prehospital care.
METHODS: Three independent committees of EMS providers and researchers were recruited. Each committee developed a list of research topics. These topics were collated and used to initiate a modified Delphi process for developing consensus on a list of research priorities. Participants were the committee members. Topics approved by 80% were retained as research priorities. Topics that were rejected by more than 50% were eliminated. The remaining topics were modified and included on subsequent surveys. Each survey allowed respondents to add additional topics. The surveys were continued until all topics were either successfully retained or rejected and no new topics were suggested.
RESULTS: Fifty topics were identified by the three independent committees. These topics were included on the initial electronic survey. There were 5 subsequent surveys. At the completion of the final survey a total of 29 research priorities were identified. These research priorities covered the following study areas: airway management, asthma, cardiac arrest, pain, patient-family interaction, resource utilization, seizure, sepsis, spinal immobilization, toxicology, trauma, training and competency, and vascular access. The research priorities were very specific. For example, under airway the priorities were: "identify the optimal device for effectively managing the airway in the prehospital setting" and "identify the optimal airway management device for specific disease processes."
CONCLUSION: This project developed a list of relevant, specific, and important research priorities for pediatric prehospital care. Some similarities exist between this project and prior research agendas but this list represents a current, more specific research agenda and reflects the opinions of working EMS providers, researchers, and leaders.

Author(s)/Presenter(s)

Lorin R Browne, Manish I Shah, Jonathan R Studnek, Daniel G Ostermayer, Stacy Reynolds, Clare E Guse, David C Brousseau, E Brooke Lerner

Abstract/Description

BACKGROUND: The National Association of Emergency Medical Services Physicians' (NAEMSP) Position Statement on Prehospital Pain Management and the joint National Highway Traffic Safety Administration (NHTSA) and Emergency Medical Services for Children (EMSC) Evidence-based Guideline for Prehospital Analgesia in Trauma aim to improve the recognition, assessment, and treatment of prehospital pain. The impact of implementation of these guidelines on pain management in children by emergency medical services (EMS) agencies has not been assessed.
OBJECTIVE: Determine the change in frequency of documented pain severity assessment and opiate administration among injured pediatric patients in three EMS agencies after adoption of best practice recommendations.
METHODS: This is a retrospective study of children <18 years of age with a prehospital injury-related primary impression from three EMS agencies. Each agency independently implemented pain protocol changes which included adding the use of age-appropriate pain scales, decreasing the minimum age for opiate administration, and updating fentanyl dosing. We abstracted data from prehospital electronic patient records before and after changes to the pain management protocols. The primary outcomes were the frequency of administration of opioid analgesia and documentation of pain severity assessment as recorded in the prehospital patient care record.
RESULTS: A total of 3,597 injured children were transported prior to pain protocol changes and 3,743 children after changes. Opiate administration to eligible patients across study sites regardless of documentation of pain severity was 156/3,089 (5%) before protocol changes and 175/3,509 (5%) after (p = 0.97). Prior to protocol changes, 580 (18%) children had documented pain assessments and 430 (74%) had moderate-to-severe pain. After protocol changes, 644 (18%) patients had pain severity documented with 464 (72%) in moderate-to-severe pain. For all study agencies, pain severity was documented in 13%, 19%, and 22% of patient records both before and after protocol changes. There was a difference in intranasal fentanyl administration rates before (27%) and after (17%) protocol changes (p = 0.02).
CONCLUSION: The proportion of injured children who receive prehospital opioid analgesia remains suboptimal despite implementation of best practice recommendations. Frequency of pain severity assessment of injured children is low. Intranasal fentanyl administration may be an underutilized modality of prehospital opiate administration.

Keywords

anaglesia; pain; pediatrics; prehospital

Author(s)/Presenter(s)

Stacy L Reynolds, Jonathan R Studnek, Kathleen Bryant, Kelly VanderHave, Eric Grossman, Charity G Moore, James Young, Melanie Hogg, Michael S Runyon

Abstract/Description

Introduction: Fentanyl is the most widely studied intranasal (IN) analgesic in children. IN subdissociative (INSD) ketamine may offer a safe and efficacious alternative to IN fentanyl and may decrease overall opioid use during the emergency department (ED) stay. This study examines the feasibility of a larger, multicentre clinical trial comparing the safety and efficacy of INSD ketamine to IN fentanyl and the potential role for INSD ketamine in reducing total opioid medication usage.

Methods and analysis: This double-blind, randomised controlled, pilot trial will compare INSD ketamine (1 mg/kg) to IN fentanyl (1.5 μg/kg) for analgesia in 80 children aged 4-17 years with acute pain from a suspected, single extremity fracture. The primary safety outcome for this pilot trial will be the frequency of cumulative side effects and adverse events at 60 min after drug administration. The primary efficacy outcome will be exploratory and will be the mean reduction of pain scale scores at 20 min. The study is not powered to examine efficacy. Secondary outcome measures will include the total dose of opioid pain medication in morphine equivalents/kg/hour (excluding study drug) required during the ED stay, number and reason for screen failures, time to consent, and the number and type of protocol deviations. Patients may receive up to 2 doses of study drug.

Ethics and dissemination: This study was approved by the US Food and Drug Administration, the local institutional review board and the study data safety monitoring board. This study data will be submitted for publication regardless of results and will be used to establish feasibility for a multicentre, non-inferiority trial.

Keywords

ketamine; pediatric orthopaedics; pain management

Author(s)/Presenter(s)

Lorin R Browne, Jonathan R Studnek, Manish I Shah, David C Brousseau, Clare E Guse, E Brooke Lerner

Abstract/Description

OBJECTIVE: Prior studies have identified provider and system characteristics that impede pain management in children, but no studies have investigated the effect of changing these characteristics on prehospital opioid analgesia. Our objectives were to determine: 1) the frequency of opioid analgesia and pain score documentation among prehospital pediatric patients after system wide changes to improve pain treatment, and 2) if older age, longer transport times, the presence of vascular access and pain score documentation were associated with increased prehospital administration of opioid analgesia in children.
METHODS: This was a retrospective cross-sectional study of pediatric patients aged 3-18 years assessed by a single EMS system between October 1, 2011 and September 30, 2013. Prior to October 2011, the EMS system had implemented 3 changes to improve pain treatment: (1) training on age appropriate pain scales, (2) protocol changes to allow opioid analgesia without contacting medical control, and (3) the introduction of intranasal fentanyl. All patients with working assessments of blunt, penetrating, lacerating, and/or burn trauma were included. We used descriptive statistics to determine the frequency of pain score documentation and opioid analgesia administration and logistic regression to determine the association of age, transport time, and the presence of intravenous access with opioid analgesia administration.
RESULTS: Of the 1,368 eligible children, 336 (25%) had a documented pain score. Eleven percent (130/1204) of children without documented contraindications to opioid administration received opioids. Of the children with no documented pain score and no protocol exclusions, 9% (81/929) received opioid analgesia, whereas 18% (49/275) with a documented pain score ≥4 and no protocol exclusions received opioids. Multivariate analysis revealed that vascular access (OR = 11.89; 95% CI: 7.33-19.29), longer patient transport time (OR = 1.07; 95% CI: 1.04-1.11), age (OR 0.93; 95% CI: 0.88-0.98) and pain score documentation (OR 2.23; 95% CI: 1.40-3.55) were associated with opioid analgesia.
CONCLUSIONS: Despite implementation of several best practice recommendations to improve prehospital pain treatment, few children have a documented pain score and even fewer receive opioid analgesia. Children with longer transport times, successful IV placement, and/or documentation of pain score(s) were more likely to receive prehospital analgesia.

Keywords

pain score; pediatric pain; prehospital opioid analgesia

Author(s)/Presenter(s)

Patrick C Drayna, Lorin R Browne, Clare E Guse, David C Brousseau, E Brooke Lerner

Abstract/Description

OBJECTIVE: Pediatric transports comprise approximately 10% of emergency medical services (EMS) requests for aid, but little is known about the clinical characteristics of pediatric EMS patients and the interventions they receive. Our objective was to describe the pediatric prehospital patient cohort in a large metropolitan EMS system.
METHODS: This retrospective analysis of all pediatric (age <19 years) EMS patients transported from October 2011 to September 2013 was conducted by reviewing a system-wide National EMS Information System (NEMSIS)-compliant database of all EMS patient encounters. We identified the most common primary working assessments, the frequency of abnormal initial vital signs, and the interventions provided. Vital signs included systolic blood pressure (SBP), respiratory (RR) and pulse rate, Glasgow Coma Scale (GCS), pulse oximetry (Pox), and respiratory effort. We defined abnormal vital signs using previously reported age-specific standards. We identified the working assessments most frequently associated with abnormal vital signs and the working assessments associated with the most commonly performed interventions. Data were analyzed using descriptive statistics.
RESULTS: There were 9,956 pediatric transports, 8.7% of the total call volume. The most common working assessments were "other" (16.1%), respiratory distress (13.7%), seizure (12.4%), and blunt trauma (12.0%). Vital signs were documented at variable rates: RR (91.1%), GCS (82.9%), SBP (71.3%), pulse (69.4%), respiratory effort (49.7%), and Pox (33.5%). Of all transported patients, 61.5% had a documented abnormal initial vital sign. Patients with an abnormal vital sign had the same most common working assessments as those with normal vital signs. Glucometry (16.9%), medication delivery (13.6%), and IV placement (11.5%) were the most common interventions and were most often provided to patients with working assessments of seizure, asthma, trauma, altered consciousness, or "other." Cardiopulmonary resuscitation (0.4%), bag mask ventilation (0.4%), and advanced airway (0.4%) occurred rarely and were most often performed for cardiac arrest and trauma.
CONCLUSIONS: Children made up a small part of EMS providers' clinical practice; those encountered most frequently had respiratory distress, seizures, trauma, or an undefined assessment (i.e., "other"). EMS providers frequently encounter children with physiologic evidence of acute illness, although vital sign documentation was incomplete. Prehospital providers infrequently perform pediatric interventions. Describing EMS providers' interaction with children provides the opportunity to target improvements in pediatric prehospital treatment, training, and research.

Keywords

emergency medical services; pediatrics