1/12/2012 1 Peter Antevy, MD Marianne Gausche-Hill, MD David Persse, MD Improving Integration of Pediatrics into EMS •Marianne Gausche-Hill, MD o None •David Persse, MD o None •Peter Antevy, MD o Consultant : Pediatric Emergency Standards, Inc. o Developer : Pediatric EMS Equipment Disclosures Overview • Marianne Gausche-Hill, MD – Federal and State Level – Los Angeles, CA • David Persse, MD – Large Urban EMS Department – Houston, TX • Peter Antevy, MD – Small Community EMS Department – Davie, FL
Transcript
1/12/2012
1
Peter Antevy, MD
Marianne Gausche-Hill, MD
David Persse, MD
Improving Integration of Pediatrics into EMS
•Marianne Gausche-Hill, MDo None
•David Persse, MDo None
•Peter Antevy, MDo Consultant : Pediatric Emergency Standards, Inc.
o Developer : Pediatric EMS Equipment
Disclosures
Overview
• Marianne Gausche-Hill, MD– Federal and State Level
– Los Angeles, CA
• David Persse, MD– Large Urban EMS Department
– Houston, TX
• Peter Antevy, MD– Small Community EMS Department
– Davie, FL
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Marianne Gausche-Hill, MD
Los Angeles, CA
Improving Integration of Pediatrics into EMS
Issues in Incorporating Pediatric Emergency Care Within EMS Systems
• National Associations
(NAEMSP, ACEP, NAEMTP)– Lack of advocates at a national level reflects few pediatric EMS
experts nationwide
• EMS systems– Many issues to address within EMS systems
– Pediatric issues often not considered when discussing solutions
– Poor pediatric representation within EMS system committee structure to allow for integration of pediatrics into the EMS system.
Issues in Incorporating Pediatric Emergency Care Within EMS Systems
• Hospitals– Community hospitals lack of focus on pediatrics in
general (non pediatric facilities).
– Lack of understanding of how EMS functions
– Hospital and EMS Protocols may not be in sync » eg. intubation vs. BVM, pain control
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Issues in Incorporating Pediatric Emergency Care Within EMS Systems
• Physicians in training– Limited exposure to EMS
– Poor knowledge of working parts of EMS system
– Little understanding of EMS for children issues
– Essentially an entire subset of physicians who, due to the lack of exposure/education of EMS, end up minimizing their involvement as they progress in their careers.
Issues in Incorporating Pediatric Emergency Care Within EMS Systems
• EMT/Paramedics– 10% of EMS calls are pediatric patients
– Data shows that paramedics have higher anxiety in dealing with pediatric patients, especially neonates and infants
– Knowledge gap and anxiety levels increase with time because paramedics feel that they are expected to know the information yet in practice have difficulty with a) the medicine and b) the emotion of the pediatric call
– Methods to determine children’s weights and medication volumes inadequate (increases stress of the call and further widens the confidence gap)
Solutions and Resources
• National– Recent Institute of Medicine Report
– Incorporating recommendations into action
• States – All states have partnership grants with the federal EMSC
program to improve care within states
– Incorporation of pediatric expertise on state EMS committees
• Local – Regionalization plans to include pediatric considerations
– Develop policies, procedures and protocols for children within current EMS systems
– Incorporation of pediatric expertise on local EMS committee
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Motivation for Institute of Medicine Reports on the Future of Emergency Care in the US
• Crowded EDs
• Financial burden of uncompensated care
• Fragmentation
• Inadequate surge capacity
• Personnel shortages
• Limited data on quality
• Inadequate research funding and infrastructure
• Limited preparedness for pediatric patients
Building a 21st Century Emergency Care System
• Reports released in June 2006… The Vision …– A fully integrated system of emergency care
“If there is one word to describe the current state of pediatric emergency care in 2006 it is UNEVEN.”
-IOM Report
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As the Emergency Care System Improves…
• Needs of pediatric patients addressed:– Developing standards– Protocols for triage, transport, and treatment– Developing disaster plans– Competencies in prehospital and hospital-based
emergency care– Research
Inclusion of Pediatric Concerns
• Categorization of systems based on pediatric capabilities
• Performance measurement of pediatric emergency care
• Lead agency at federal level for oversight of emergency and trauma care
Key Problems Identified
• EDs and prehospital providers may not have all essential pediatric supplies and equipment.
• Many emergency providers receive little training/retraining in pediatric emergency care.
• Many medications prescribed to children are “off label.”
• Disaster preparedness plans largely overlook the needs of children.
• Research in pediatric emergency care, especially in the prehospital setting, is sparse.
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Arming the Emergency Care Workforce with Knowledge and Skills
• Every pediatric and emergency care-related health professional credentialing and certification body should– Define pediatric competencies– Require practitioners to receive the level of training necessary
to achieve and maintain those competencies.
• DHHS & Professional organizations – Develop, evaluate, and update pediatric emergency care
clinical practice guidelines and standards of care.
• EMS agencies and hospitals– Appoint pediatric coordinators to provide pediatric leadership.
Pediatric Coordinators
• Local thought leaders who can bring about institutional change to improve care for children– Physician level: Can come from a number of disciplines –
Pediatrics , Emergency Medicine, PEM, Family Medicine
• Focus on pediatric quality/performance improvement, patient safety, continuing education, appropriate equipment, supplies, and disaster planning for EMS systems and in EDs
• Pediatric coordinators have a special interest in care of children - may be shared resource
Improving the Quality of Pediatric Emergency Care
• Hospitals and EMS systems implement evidence-based approaches to reduce errors in emergency and trauma care for children.
• EMS agencies and hospitals should integrate family-centered care into emergency care practice
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Improving Emergency Preparedness and Response for Children Involved in Disasters
• Partnership with state and regional planning bodies and emergency care provider organizations to develop strategies for addressing pediatric needs in the event of a disaster
Improving Emergency Preparedness and Response for Children Involved in Disasters
• Minimize parent–child separation.
• Improve the level of pediatric expertise on disaster response teams.
• Address pediatric surge capacity.
• Develop specific medical and mental health therapies, as well as social services, for children.
• Conduct disaster drills for a pediatric mass casualty incident.
Press release
Robert O’Connor, Past-President of NAEMSP
“EMS should be actively supported and funded”
• “NAEMSP strongly supports the IOM recommendations that EMS systems greatly benefit from physician oversight to ensure quality care and patient safety.”
• “When ambulance patients are diverted to other hospitals…it creates an unsafe healthcare environment.”
National Association of EMS Physicians
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• State governments should adopt a common scope of practice for EMS personnel, with state licensing reciprocity.
• States should require national accreditation of paramedic education programs.
• States should accept national certification as a prerequisite for state licensure and local credentialing of EMS providers.
• The American Board of Emergency Medicine should create a subspecialty certification in EMS.
IOM Recommendations Supported by NAEMSP
• EMS agencies should appoint a pediatric emergency coordinator and hospitals should appoint two pediatric emergency coordinators – one a physician – to provide pediatric leadership for the organization.
• States should strengthen the EMS workforce, requiring pediatric core competencies for prehospital care providers.
Other Important IOM Recommendations for EMS Systems in Care of Children
Specific Needs within EMS Systems Identified
• Specific Needs:– Uniform pediatric equipment guidelines for paramedics– Pediatric specific education and treatment guidelines
for prehospital personnel– Regionalization plan for rapid transport of critically ill or
injured children to specialty centers– Pediatric equipment, staffing, and policy guidelines for
emergency departments
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Possible Solutions
• Los Angeles Model
– Pediatric issues incorporated within EMS system committee structure
– Establishment of a Pediatric Advisory Council which is advisory to EMS Agency and who supplies representation to all other standing committees (Data, QI, Trauma, Base Hospital, EMS provider)
– Implemented regionalized plan for pediatric emergency care
Established 3 Levels of Pediatric Emergency Care
• EMS Transports children ≤14 years of age to only those hospitals that have met certain standards –verified by EMS
– EDAP= Emergency Department Approved for Pediatrics• An Emergency Department with specific equipment, staffing, and policies in
place to meet the immediate need of child with critical illness or injury
– PMC = Pediatric Medical Center• A hospital which has both the emergency department staffed and ready, as
well as inpatient capabilities and specialists to care for the ongoing needs of a critically ill or injured child (also called pediatric critical care center (PCCC) or pediatric regional center)
– PTC = Pediatric Trauma Center
EDAP : Regionalized System for Pediatric Emergency Care
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Physician & Nursing Coordinator for Pediatric Emergency Care
• Each EDAP has a designated Medical Director and Nurse to ensure that guidelines are being met, pediatric emergency equipment is available, a quality improvement process is in place, and that staff receive ongoing continuing education.
LA County EMS System
• In the past decade, over 250,000 children have been transported to EDAPs,
• In the same period, over 30,000 have been taken to critical care (PCCC/PMC/PTC) centers
• LA County EMS averages 27,000 EDAP transports/year
• There are 72 paramedic receiving facilities of which 44 EDAPs, 7 PMCs of which 6 are PTCs
Color Coding for Kids
• Adopted protocols which require paramedics to determine weight and dosing requirements using the Broselow Tape – must record the color zone and report it when contacting a base hospital for medical direction
• This protocol has reduced dosing errors significantly
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Other Models
• Illinois model similar to LA County EMS but initiated program statewide – hospitals can opt in and be verified by state EMS officials [about 50% of hospitals have opted in]
• New Jersey model – regulations include pediatric specific requirements for all receiving hospitals
• Tennessee model – robust regionalized plan which includes designated comprehensive pediatric regional centers which work closely with other receiving centers to ensure rapid stabilization and transfer of critically ill and injured children
Medical Direction and Caring for the Child in a Large Urban EMS System
David Persse, MD
Houston, TX
• Dilution!!!
• Most EMS Patients are:–Adults
–Stable
• Most Critical EMS Patients are:–Adults
Challenges
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• Parental “Drama”
• Adolescent “Drama”
• ….Medical Detective!
Perceptions
• Sentinel Events
• High Impact/Low Frequency Events
• Randomized Chart Reviews
• Solutions?
–Full time quality personnel
–High Level paramedic for reviews
–Outside Assistance from Experts.
Real Time CQI
• On Scene Senior Paramedics
• Real Time On-line Medical Oversight
– Pedi/EMS Physicians
Medical Oversight
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• Dedicated EMS/Peds Education Specialists
• Simulation Training?!
Education
Thank You
Peter Antevy, MD
Davie, FL
Improving Integration of Pediatrics into EMS
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Try This At Home Using Your Current Peds System
Mock Pediatric Code
Age / Length Problem Drug
5 Year Anaphylaxis Epi 1:1000
3 YearsHypoglycemi
aD25W
7 Years Seizing Midazolam
1 Year Asystole Epi 1:10,000
Weights and Medication Dosing
32 – 18 ÷ 7 =
TEST YOURSELF
Weights and Medication Dosing
Working Memory
2008, Volume 17 – No. 5
�
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What We’ve Done
1. Removal of all calculations for pediatric patients– Providers know doses in mg AND mL’s (pre-calculated)
2. Pediatric Weights : Length and Age based– Utilize the time en-route to the scene
– Significant reduction in anxiety
– No time wasted on scene = Better CPR
– Can now focus on the disease process
• Paramedics shadow Pediatric MD in the ER– 8 hours
– Group of 2 or 3
– Contractual agreement
Paramedic Shadowing Program
• Physicians / Nurses / Paramedics– Your local pediatric facility
• PALS
• PEPP
• PHTLS
• EPC
Recruit Educators
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• Local Paramedic Training Programs
• PALS / PEPP / PHTLS
Paramedics as Instructors
• Self administered– Using a Paramedic Pediatric Educator (within the department)
Regular Pediatric Mock Codes
• Program established with anesthesiology
• Pediatric OR Adult
• Monday mornings (7am)
• ETT / LMA
Airway Practice in the OR
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• Facebook
• Twitter
• Podcasts
Utilize Social Media
Questions?
Peter Antevy, MD
Marianne Gausche-Hill, MD
David Persse, MD
Improving Integration of Pediatrics into EMS
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Resources - Protocols
• National Association of EMS Physicians Model Protocols (2003)
• A Statewide Model Program to Improve Emergency Department Readiness for Pediatric Care & Illinois EMSC Facility Recognition Program – August 2009– http://www.annemergmed.com/article/S0196-
• Patient- and Family-Centered Care and the Role of the Emergency Physician Providing Care to a Child in the Emergency Department– Joint AAP/ACEP Policy Statement & AAP Technical
Report – November 2006/August 2008– http://download.journals.elsevierhealth.com/pdfs/journals/0196-
• Patient Safety in the Pediatric Emergency Care Setting– AAP Policy Statement – December 2007– http://aappolicy.aappublications.org/cgi/reprint/pediatrics;120/6/13
67.pdf
Resources – Ambulance Equipment
• Joint Policy Statement – Equipment for Ambulances
