Emergency departments (EDs) vary in their level of readiness to care for pediatric emergencies. We evaluated the effect of ED pediatric readiness on the mortality of critically ill children.
We ...conducted a retrospective cohort study in Florida, Iowa, Massachusetts, Nebraska, and New York, focusing on patients aged 0 to 18 years with critical illness, defined as requiring intensive care admission or experiencing death during the encounter. We used ED and inpatient administrative data from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project linked to hospital-specific data from the 2013 National Pediatric Readiness Project. The relationship between hospital-specific pediatric readiness and encounter mortality in the entire cohort and in condition-specific subgroups was evaluated by using multivariable logistic regression and fractional polynomials.
We studied 20 483 critically ill children presenting to 426 hospitals. The median weighted pediatric readiness score was 74.8 (interquartile range: 59.3-88.0; range: 29.6-100). Unadjusted in-hospital mortality decreased with increasing readiness score (mortality by lowest to highest readiness quartile: 11.1%, 5.4%, 4.9%, and 3.4%;
< .001 for trend). Adjusting for age, chronic complex conditions, and severity of illness, presentation to a hospital in the highest readiness quartile was associated with decreased odds of in-hospital mortality (adjusted odds ratio compared with the lowest quartile: 0.25; 95% confidence interval: 0.18-0.37;
< .001). Similar results were seen in specific subgroups.
Presentation to hospitals with a high pediatric readiness score is associated with decreased mortality. Efforts to increase ED readiness for pediatric emergencies may improve patient outcomes.
This study reports the epidemiologic features, survival rates, and neurologic outcomes of the largest population-based series of pediatric out-of-hospital cardiopulmonary arrest patients with ...prospectively collected data.
Secondary analysis of data from a prospective, interventional trial of out-of-hospital pediatric airway management conducted from 1994 to 1997 (Gausche M, Lewis RJ, Stratton SJ, et al. JAMA. 2000;283:783-790). Consecutive out-of-hospital patients from 2 large urban counties in California <12 years old or 40 kg in bodyweight who were determined by paramedics to be pulseless and apneic were included. Main outcome measures included survival to hospital discharge, patient demographics, arrest etiology, arrest rhythm, event intervals, and neurologic outcomes.
In 599 patients, 601 events were studied (54% were <1 year old, 58% were male). Return of spontaneous circulation was achieved in 29%; 25% were admitted to the hospital, and 8.6% (51) survived to hospital discharge. The most prevalent etiologies were sudden infant death syndrome and trauma; these resulted in relatively higher mortality. Respiratory etiologies and submersions followed; these resulted in relatively lower mortality. Twenty-six percent of the arrests were witnessed by citizens, and an additional 8% were witnessed by rescue personnel. Witnessed arrests had a higher survival rate (16%). Thirty-one percent of patients received bystander cardiopulmonary resuscitation, which was not demonstrated to result in improved survival rates. Arrest rhythms were asystole (67%), pulseless electrical activity (24%), and ventricular fibrillation (9%); children with the latter 2 rhythms had better survival rates. One third of the survivors (16 of 51) had good neurologic outcome, none of whom received >3 doses of epinephrine or were resuscitated for >31 minutes in the emergency department.
The 8.6% survival rate after out-of-hospital pediatric cardiopulmonary arrest is poor. Administration of >3 doses of epinephrine or prolonged resuscitation is futile.
Pediatric Readiness and Facility Verification Remick, Katherine, MD; Kaji, Amy H., MD, PhD; Olson, Lenora, PhD, MA ...
Annals of emergency medicine,
03/2016, Volume:
67, Issue:
3
Journal Article
Peer reviewed
Study objective We perform a needs assessment of pediatric readiness, using a novel scoring system in California emergency departments (EDs), and determine the effect of pediatric verification ...processes on pediatric readiness. Methods ED nurse managers from all 335 acute care hospital EDs in California were sent a 60-question Web-based assessment. A weighted pediatric readiness score (WPRS), using a 100-point scale, and gap analysis were calculated for each participating ED. Results Nurse managers from 90% (300/335) of EDs completed the Web-based assessment, including 51 pediatric verified EDs, 67 designated trauma centers, and 31 EDs assessed for pediatric capabilities. Most pediatric visits (87%) occurred in nonchildren’s hospitals. The overall median WPRS was 69 (interquartile ratio IQR 57.7, 85.9). Pediatric verified EDs had a higher WPRS (89.6; IQR 84.1, 94.1) compared with nonverified EDs (65.5; IQR 55.5, 76.3) and EDs assessed for pediatric capabilities (70.7; IQR 57.4, 88.9). When verification status and ED volume were controlled for, trauma center designation was not predictive of an increase in the WPRS. Forty-three percent of EDs reported the presence of a quality improvement plan that included pediatric elements, and 53% reported a pediatric emergency care coordinator. When coordinator and quality improvement plan were controlled for, the presence of at least 1 pediatric emergency care coordinator was associated with a higher WPRS (85; IQR 75, 93.1) versus EDs without a coordinator (58; IQR 50.1, 66.9), and the presence of a quality improvement plan was associated with a higher WPRS (88; IQR 76.7, 95) compared with that of hospitals without a plan (62; IQR 51.2, 68.7). Of pediatric verified EDs, 92% had a quality improvement plan for pediatric emergency care and 96% had a pediatric emergency care coordinator. Conclusion We report on the first comprehensive statewide assessment of “pediatric readiness” in EDs according to the 2009 “Guidelines for Care of Children in the Emergency Department.” The presence of a pediatric readiness verification process, pediatric emergency care coordinator, and quality improvement plan for pediatric emergency care was associated with higher levels of pediatric readiness.
Our goal was to assess the degree of pediatric preparedness of emergency departments in the United States.
A closed-response survey based on the American Academy of Pediatrics/American College of ...Emergency Physicians joint policy statement, "Care of Children in the Emergency Department: Guidelines for Preparedness," was mailed to 5144 emergency department medical and nursing directors. A weighted preparedness score (scale of 0-100) was calculated for each emergency department.
A total of 1489 useable surveys (29%) were received, with 62% completed by emergency department medical directors. Eighty-nine percent of pediatric (age: 0-14 years) emergency department visits occur in non-children's hospitals, 26% of visits occur in rural or remote facilities, and 75% of responding emergency departments see <7000 children per year. The vast majority of visits (89%) occur in emergency department areas shared with adult patients; 6% occur in a separate pediatric emergency department. Only 6% of emergency departments had all recommended equipment and supplies. Emergency departments frequently lacked laryngeal mask airways for children (50%) and neonatal or infant equipment. In contrast, recommended medications were more uniformly available, as were transfer policies for medical or surgical intensive care. Fifty-two percent of emergency departments reported having a quality improvement/performance improvement plan for pediatric emergency patients, and 59% of respondents were aware of the American Academy of Pediatrics/American College of Emergency Physicians guidelines. The median pediatric-preparedness score for all emergency departments was 55. Pediatric-preparedness scores were higher for facilities with higher pediatric volume, facilities with physician and nursing coordinators for pediatrics, and facilities with respondents who reported awareness of the guidelines.
Pediatric preparedness of hospital emergency departments demonstrates opportunities for improvement.
Background Public health emergencies may significantly impact emergency medical services responses to cardiovascular emergencies. We compared emergency medical services responses to out-of-hospital ...cardiac arrest (OHCA) and ST-segment‒elevation myocardial infarction (STEMI) during the 2020 COVID-19 pandemic to 2018 to 2019 and evaluated the impact of California's March 19, 2020 stay-at-home order. Methods and Results We conducted a population-based cross-sectional study using Los Angeles County emergency medical services registry data for adult patients with paramedic provider impression (PI) of OHCA or STEMI from February through May in 2018 to 2020. After March 19, 2020, weekly counts for PI-OHCA were higher (173 versus 135; incidence rate ratios, 1.28; 95% CI, 1.19‒1.37;
<0.001) while PI-STEMI were lower (57 versus 65; incidence rate ratios, 0.87; 95% CI, 0.78‒0.97;
=0.02) compared with 2018 and 2019. After adjusting for seasonal variation in PI-OHCA and decreased PI-STEMI, the increase in PI-OHCA observed after March 19, 2020 remained significant (
=0.02). The proportion of PI-OHCA who received defibrillation (16% versus 23%; risk difference RD, -6.91%; 95% CI, -9.55% to -4.26%;
<0.001) and had return of spontaneous circulation (17% versus 29%; RD, -11.98%; 95% CI, -14.76% to -9.18%;
<0.001) were lower after March 19 in 2020 compared with 2018 and 2019. There was also a significant increase in dead on arrival emergency medical services responses in 2020 compared with 2018 and 2019, starting around the time of the stay-at-home order (
<0.001). Conclusions Paramedics in Los Angeles County, CA responded to increased PI-OHCA and decreased PI-STEMI following the stay-at-home order. The increased PI-OHCA was not fully explained by the reduction in PI-STEMI. Field defibrillation and return of spontaneous circulation were lower. It is critical that public health messaging stress that emergency care should not be delayed.
Pediatric readiness scores may be a useful measure of a hospital's preparedness to care for children. However, there is limited evidence linking these scores with patient outcomes or other metrics, ...including the need for interfacility transfer. This study aims to determine the association of pediatric readiness scores with the odds of interfacility transfer among a cohort of noninjured children (< 18 years old) presenting to emergency departments (EDs) in small rural hospitals in the state of California.
Data from the National Pediatric Readiness Project assessment were linked with the California Office of Statewide Health Planning and Development's ED and inpatient databases to conduct a cross-sectional study of pediatric interfacility transfers. Hospitals were manually matched between these data sets. Logistic regression was performed with random intercepts for hospital and adjustment for patient-level confounders.
A total of 54 hospitals and 135,388 encounters met the inclusion criteria. EDs with a high pediatric readiness score (>70) had lower adjusted odds of transfer (aOR: 0.55, 95% CI: 0.33-0.93) than EDs with a low pediatric readiness score (≤ 70). The pediatric readiness section with strongest association with transfer was the "policies, procedures, and protocols" section; EDs in the highest quartile had lower odds of transfer than EDs in the lowest quartile (aOR: 0.54, 95% CI: 0.31-0.91).
Pediatric patients presenting to EDs at small rural hospitals with high pediatric readiness scores may be less likely to be transferred. Additional studies are recommended to investigate other pediatric outcomes in relation to hospital ED pediatric readiness.
Study objective Apnea is a known complication of pediatric seizures, but patient factors that predispose children are unclear. We seek to quantify the risk of apnea attributable to midazolam and ...identify additional risk factors for apnea in children transported by paramedics for out-of-hospital seizure. Methods This is a 2-year retrospective study of pediatric patients transported by paramedics to 2 tertiary care centers. Patients were younger than 15 years and transported by paramedics to the pediatric emergency department (ED) for seizure. Patients with trauma and those with another pediatric ED diagnosis were excluded. Investigators abstracted charts for patient characteristics and predefined risk factors: developmental delay, treatment with antiepileptic medications, and seizure on pediatric ED arrival. Primary outcome was apnea defined as bag-mask ventilation or intubation for apnea by paramedics or by pediatric ED staff within 30 minutes of arrival. Results There were 1,584 patients who met inclusion criteria, with a median age of 2.3 years (Interquartile range 1.4 to 5.2 years). Paramedics treated 214 patients (13%) with midazolam. Seventy-one patients had apnea (4.5%): 44 patients were treated with midazolam and 27 patients were not treated with midazolam. After simultaneous evaluation of midazolam administration, age, fever, developmental delay, antiepileptic medication use, and seizure on pediatric ED arrival, 2 independent risk factors for apnea were identified: persistent seizure on arrival (odds ratio OR=15; 95% confidence interval CI 8 to 27) and administration of field midazolam (OR=4; 95% CI 2 to 7). Conclusion We identified 2 risk factors for apnea in children transported for seizure: seizure on arrival to the pediatric ED and out-of-hospital administration of midazolam.
Background With recent trials demonstrating benefit of endovascular thrombectomy (EVT) up to 24 hours from last known well time (LKWT), emergency medical services systems must consider stroke center ...routing for patients with LKWT ≤24 hours. We sought to determine the frequency of thrombectomy by prehospital‐determined LKWT using retrospective data from a tiered regional stroke care system. Methods During the July 2018 to March 2019 study period, patients with potential large‐vessel occlusion, based on a Los Angeles Motor Scale of 4 or 5, were routed directly to a designated EVT center if within 30 minutes. We determined the frequency of thrombectomy by time intervals from prehospital‐determined LKWT to first medical contact. Results Emergency medical services transported 830 patients with acute ischemic stroke with documented prehospital‐determined LKWT ≤24 hours to EVT centers. The ≤6 hours, >6 to ≤16 hours, and >16 to ≤24 hours epochs accounted for 75%, 20%, and 5% of transports to EVT centers, respectively. Men accounted for 47% of the study population, with a median age of 77 years (interquartile range, 64–86 years) and National Institutes of Health Stroke Scale median of 11 (interquartile range, 4–20). Overall, 28.2% (234/830) received EVT. Time window–specific EVT frequencies were: ≤6 hours (29.8% of patients 187/627); >6 to ≤16 hours (24.1% of patients 39/162); and >16 to ≤24 hours (19.5% of 8/41). Conclusion In this regional stroke system with 2‐tiered routing, patients in the >6‐ to 24‐hour postonset window accounted for nearly one fourth of transports to EVT centers and 23% received thrombectomy.
Objectives
The appointment of pediatric emergency care coordinators (PECC) in emergency departments (EDs) enhances pediatric readiness, yet little is understood regarding this workforce. We describe ...PECC role characteristics, responsibilities, barriers, and threats to the role among a national cohort.
Methods
We surveyed a sample of PECCs from all regions of the United States who participated in the Emergency Medical Services for Children PECC Workforce and Trauma Collaboratives (2021–2022). EDs were categorized by annual pediatric patient volume: low (<1800), medium (1800–4999), medium‐high (5000–9999), and high (≥10,000). Trend tests were performed to explore the relationship between pediatric volume and PECC characteristics.
Results
Among 187 PECCs, 114 (61.0%) responded. The majority (75.2%) identified as a nurse. There was a significant difference in median hours per week spent on PECC activities by pediatric volume ranging from a median of 2 hours (interquartile range IQR 0.0–2.3) for low pediatric volume to 16 hours (IQR 4.0–37.0) for high pediatric volume (P < 0.001). Most respondents reported more time was needed for PECC activities (58.4%), and desired additional training to support the role (70.8%). Most (74.6%) felt the PECC position should be paid, yet 30.7% reported the role was voluntary. The most frequently assigned responsibilities were education of staff (77.2%) and oversight of quality improvement (QI) efforts (72.8%).
Conclusion
Characteristics of PECC workforce vary but PECC activities of education and QI work are common among all. There is a reported need for additional training and support. Further studies will determine the impact of PECC characteristics on pediatric readiness.
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