Pediatric emergency medicine trisk 1158

Organization

Online resource

Air Medical
Physician
Association
American
Academy of
Pediatrics



American
College of
Emergency
Physicians
American Heart
Association
American
Trauma
Society
Association of
Air Medical
Services
Commission on
Accreditation
of Medical
Transport
Systems
EMSC

Federal
Interagency
Committee on
EMS



Language Line
National
Association of
Emergency
Medical
Physicians
National
Association of
Emergency
Medical
Technicians
National
Association of
State EMS
Officials
National EMS
Advisory
Council
National
Highway

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Traffic Safety
Administration
National Registry
of Emergency
Medical
Technicians
Pediatric
Life
Advanced-Life-Support-PALS_UCM_303705_Article.jsp
Support
(PALS)
Pediatric Trauma

Society
The reports stated that the federal government should support the development of national standards for
emergency care performance measurement, the categorization of all emergency care facilities, and protocols for
the treatment, triage, and transport of prehospital patients, with emphasis on using evidence-based practices.
NHTSA has supported the development of evidence-based guidelines (EBGs) for prehospital care, discussed
further in a later section of this chapter. A gap analysis of EMS-related research was completed after the
recommendation of the IOM reports. The EMSC program supported pediatric regionalization by providing grants
to six states to fund regionalization demonstration programs in 2012.
To address standardization in EMT competency, the report recommended that all states adopt a common scope
of practice for EMS personnel. The EMS Scope of Practice Model and Education Standards maintained by the
DOT were discussed in detail earlier in this chapter. Medical direction standardization has been addressed by the
recognition of an EMS physician subspecialty.
Specifically addressing pediatric emergency care, the report stated “If there is one word to describe pediatric
emergency care in 2006, it is uneven. ” More details of the recommendations specific to pediatrics are listed here:
The emergency care workforce should receive pediatric knowledge and skills training
Pediatric competencies should be defined; EMS providers should be required to maintain those competencies
Each EMS provider organization should have a pediatric emergency care coordinator
Pediatric priorities in emergency preparedness should be enhanced
The evidence base for pediatric emergency care should be supported
Family-centered care should be fostered
An evidence-based approach should be used to improve pediatric patient safety
While many of the 2006 IOM recommendations have not been realized, significant strides have been made.
The EMS Agenda 2050, developed in 2018, and available at , continues to strive
toward the vision of a people-centered EMS system that is equitable, efficient, and evidence based.

EMS RESEARCH
It is challenging to perform quality clinical research in the EMS system. There are few large-scale, randomized
clinical studies that have been undertaken in the pediatric EMS population. The uncontrolled environment and the
urgency of injury and illness treatment often make quality data collection and informed consent more
complicated than in the ED setting. Additional barriers include monitoring adherence to study protocols,

providing ethical research training to EMS personnel, randomizing patients to treatment groups, and measuring
patient outcome data that occur once patient care has been transitioned to a hospital. In addition, a significant
amount of funding, which has been lacking, is required to overcome these barriers. Even with well-designed
research, it may be difficult to generalize the findings outside the study population and locale due to the high
level of variability within EMS systems across the United States. No two systems are designed to operate in
exactly the same way with regard to staffing, protocols, oversight, demographics, or training. This further
emphasizes the large amount of funding required to complete multicentered research that will be required to
obtain sufficient sample sizes and make results generalizable.


TABLE 134.7
PECARN PRIORITIES FOR PEDIATRIC PREHOSPITAL RESEARCH
Clinical topics

System topics

Rank

Topic

Rank

Topic

1

Airway management

1

2
3
4

Respiratory distress
Trauma
Asthma

2
3
4

5

Head trauma

Effectiveness of out-of-hospital
interventions
Knowledge and skill deterioration
Patient outcomes
Evaluation of the impact of overall
EMS
system changes on children

6
7
8
9
10
11

Shock
Pain
Seizures
Respiratory arrest
C-spine immobilization
Cardiac arrest

5

Training effectiveness

12
13

Injury prevention
Children with special healthcare
needs
Poisoning
Abuse and neglect

14
15

Successful EMS researchers have noted the large investment in relationship building that is necessary between
the research team and administrators at EMS agencies and receiving facilities. Other recommendations include
soliciting prehospital provider input during the planning phase, demonstrating to agencies and providers the
benefits of participating in the study, and providing education regarding research and human studies to the
agencies. Providing results of data collected in the field back to the EMS providers and media recognition of the
EMS agency’s research participation are also means for building strong research relationships with EMS systems.

The paucity of scientific scrutiny of EMS highlights the need for future research focusing on both EMS and
EMSC. The establishments of the federal EMSC program under the U.S. Department of Health and Human
Services, as well as the federally funded EMS for Children Innovation and Improvement Center, were important
steps to assist EMS academicians in defining a research agenda around EMSC. The PECARN has established a
research node made entirely of EMS agency research sites, as well as added EMS affiliates to each of the other
six research nodes. These efforts assist in performing needed research, as well as providing avenues for funding
these projects. As the discipline evolves, EMS leaders should resist the temptation to quickly add or require new
technologies, procedures, and protocols to prehospital care without ensuring that these modalities have proven
efficacy. There is a real concern that in an effort to aid one patient, others will suffer from unnecessary
intervention or inappropriate allocation or utilization of resources.
Research agendas have been proposed and priorities have been addressed by consensus groups, including the
IOM reports, the National EMS Research Agenda, the EMS Outcomes Project, Knowledge Translation in the
EMS, the EMS Subcommittee of the Society of Academic Emergency Medicine, and a priority list from
PECARN ( Table 134.7 ). A recent gap analysis prepared for FICEMS noted that the literature in the prehospital
setting is less rigorous than in other medical disciplines and that many prehospital interventions lack scientific
evidence, having been extrapolated from the adult hospital emergency care environment. Authors of this analysis
also reported that the majority of research agendas have been unmet, with specific deficiencies noted in
pediatrics, trauma, patient safety and quality, and education and competency assessment. The analysis serves to


inform decisions regarding policy and funding priorities, while also guiding the EMS researcher toward topics in
need of attention.

EVIDENCE-BASED GUIDELINES
NHTSA responded to the IOM report recommendation to “convene a panel … to develop evidence-based model
prehospital care protocols for the treatment, triage, and transport of patients, including children.” In 2008, the first
National EMS EBGs conference was attended by EMS stakeholders and experts in EMS, research, and EBGs.
With funding from NHTSA and EMSC, a model process for the development, implementation, and evaluation of
EMS EBGs was drafted and subsequently implemented. Using the Grading of Recommendations Assessment,
Development, and Evaluation (GRADE) process, a rigorous, validated appraisal tool to assess quality of

evidence, multidisciplinary teams embarked on creating several prehospital EBGs. In 2014, a description of the
process and three EBGs were published in Prehospital Emergency Care: prehospital seizure management,
prehospital analgesia in trauma, and air medical transportation of prehospital trauma patients.
NHTSA and EMSC have offered further funding to the NASEMSO as well as a targeted issue grant to evaluate
EMS system utilization of EBGs. Due to the labor-intensive nature of the process and the relative paucity of
strong evidence for many prehospital practices, EBGs for all conditions treated by prehospital providers may not
be available for some time. Additional efforts to promote uniformity and quality of prehospital care include the
development of Model EMS Clinical Guidelines, made public in 2014 ( ). While these guidelines do not use the same rigorous GRADE methodology, they were
developed by multidisciplinary teams of EMS experts and reviewed by multiple EMS stakeholders. They are
based on the most current standards of practice and evidence. They are available to EMS systems for adoption
and customization to address specific needs.

SUMMARY
U.S. EMS systems were initially developed to primarily treat adults with cardiovascular disease and injuries from
motor vehicle crashes; however, many advances have been made, and the prehospital needs of children are being
recognized and addressed through the leadership of the EMSC program and its strong relationship with NHTSA.
EMS systems are variable without a federal lead agency for prehospital care, but the FICEMS aims to coordinate
funding and regulations across three federal agencies. National education and scope of practice standards exist for
four levels of EMS provider. EMS systems function well with strong medical direction, and the appointment of a
pediatric coordinator within each system will ensure the best care for children in the prehospital setting. EBGs
represent a significant step toward improving quality of prehospital care through standardization and are a
tangible response to the IOM reports on emergency care in the United States.
Suggested Readings and Key References
EMS Epidemiology
Carlson JN, Gannon E, Mann NC, et al. Pediatric out-of-hospital critical procedures in the United States. Pediatr
Crit Care Med 2015;16(8):e260–e267.
Federal Interagency Committee on EMS. 2011 National EMS Assessment. (Report No. DOT HS 811 723).
Washington, DC: National Highway Traffic Safety Administration; 2012. Available online at
/>id=vpdL22iKszd4DxK9BgzOzv1k_I_3XclTyLOFol . Accessed August 10, 2015.
Hansen M, Lambert W, Guise JM, et al. Out-of-hospital pediatric airway management in the United States.

Resuscitation 2015;90:104–110.
Shah MN, Cushman JT, Davis CO, et al. The epidemiology of emergency medical services use by children: an
analysis of the National Hospital Ambulatory Medical Care Survey. Prehosp Emerg Care 2008;12(3):269–276.
Suruda A, Vernon DD, Reading J. Pre-hospital emergency medical services: a population based study of pediatric
utilization. Inj Prev 1999;5(4):294–297.
EMS Providers
National Association of State EMS Officials. National EMS Scope of Practice Model 2019 (Report No. DOT HS
812-666). Washington, DC: National Highway Traffic Safety Administration. Available online at
. Accessed March, 2020.