EMS Emergency Medicine Research Journal

EMS Emergency Medicine Research Journal Research Article

Why Advanced Life Support is Dispatched for School Emergencies? The Utilization of Emergency Medical Services for Pediatric Patients Jessica O. Pinto1,*, Brian Walsh2, Ricardo Pulido3, David Feldman4 1

Medical Student at Rutgers New Jersey Medical School, Newark New Jersey

2

Department of Emergency Medicine, Morristown Medical Center, Morristown, New Jersey

3

Medical Student at New York University School of Medicine, New York, New York

4

Department of Emergency Medicine, Morristown Medical Center, Morristown, New Jersey

*

Corresponding author : Dr. Jessica Pinto, Medical Student at Rutgers New Jersey Medical School, Newark New Jersey, BA,65 Tobin Place, Colonia, NJ 07067, Tel: 732-85-1263; Email: [email protected] Received: 13-11-2017 Accepted: 18-11-2017 Published: Copyright: © 2017 Jessica O. Pinto

Abstract Introduction School healthcare is an evolving field as more children are “mainstreamed” into schools and school nurses take on more responsibilities. Very little has been written in the Emergency Medical Services (EMS) literature regarding the types of emergencies that result in EMS being called to schools. The purpose of our study is to classify the school emergencies for which Advanced Life Support (ALS) is required and determine which interventions are needed for these children. Methods

The design consists of a retrospective cohort. The setting is a large, suburban hospital-based EMS system. Prehospital medical records for patients ages 5-18 for which ALS was dispatched to a school over a 5-year period were reviewed. Calls in which ALS was “cancelled” were not included. Dispatch classification, past medical histories, medications administered, procedures performed, and patient demographics were obtained. Descriptive statistics and 95% confidence intervals were calculated. Results

Researchers collected a total of 85,579 ALS dispatches. After stratifying the data, only 486 of the collected ALS dispatches were for children at school. The most common dispatch categories were Respiratory (21%), Syncope (19%), Seizures (15%), and Trauma (14%). 60% (CI: 56-64) of patients had a past medical history (other than seasonal allergies) documented. Only 6% (CI: 4-8) of patients had a medication administered. If albuterol/atrovent are excluded, then less than 1% (0.6%, CI: 0-1.3) of patients were treated with a medication. 27% (CI: 23-32) of patients had a procedure performed. However, if IV placement and EKG are excluded, then only one patient (0.2%, CI: 0-0.6) had a procedure done, and that procedure was physical restraints. Conclusion

Although there are a wide range of conditions that result in the dispatch of ALS providers to a school, the prevalence of school children needing ALS interventions is very small. The majority of interventions are for asthma and other respiratory illnesses. This study provides support that may help guide dispatch resources and educational programs for school nurses.

Cite this article: Jessica O. Pinto. Why Advanced Life Support is Dispatched for School Emergencies? The Utilization of Emergency Medical Services for Pediatric Patients. EMS EMed j 2017, 1(1):004

Introduction The Emergency Medical Services (EMS) system in the United States originally served as a response to reduce the burden of heart disease, stroke and trauma by actively caring for critical patients and transporting them to a hospital for further treatment [1]. Prior to the Emergency Medical Services for Children (EMSC) health program, initiated in 1985, EMS training was tailored for adults, and the needs of pediatric patients received insufficient consideration [2]. Today, there still remains a lack of literature for pediatric EMS (PEMS) despite the many requests for additional research on these services [3-6]. Each year, approximately 3 million children in the United States are cared for by EMS [5]. Pediatric patients account for about 13% of all EMS transport, and about 5-7% of pediatric patients arrive at the emergency department via EMS [7,8,9]. Pediatric patients that are transported by EMS are more likely to have illnesses of greater acuity compared to those who arrive by other means [10]. Those transported by EMS also have higher admission rates, and require more immediate care upon arrival to the Emergency Department (ED) [10]. Not only is there limited literature available on PEMS, there is also very little written in the EMS literature regarding the types of emergencies that result in ALS being called for pediatric patients. Children spend a great deal of their time in school, and understanding the emergencies that take place in an academic environment and require ALS, can open the door for enhanced educational and training programs for both EMS personnel and school nurses. The purpose of this study was to classify the school emergencies for which Advanced Life Support (ALS) is required and determine which interventions are needed for these children.

Methods

Study Design and Setting This is a retrospective cohort study conducted within a large, suburban, hospital-based emergency medical services system. Researchers reviewed the prehospital medical records of patients aged 5-18 for which ALS was dispatched to an educational institution within a 5-year span. Exclusion criteria included past medical history for which the ALS dispatch was cancelled prior to arrival in the emergency department. Data Collecting and Processing

Researchers retrospectively screened 5 years worth of pre-hospital medical records of all patients’ ages 5-18 for which ALS was called to a school. Information obtained from these records included the following: the dispatch classification of the emergencies, past medical history of the patients, medications administered, procedures performed, and patient demographics. The study was retrospective; thus treat-

ments administered via ALS were performed solely at the discretion of the treating physician and treating medics. All decisions were made at the sole discretion of the ALS team at that time. Descriptive statistics and 95% confidence intervals (CI) were calculated using Microsoft Excel.

Results

Out of a total of 85,579 ALS pediatric dispatches, only 486 (0.6%) were calls for children at school. Of these 486 children, 53% (CI: 48-57) were male. The average age was 13.3 years (CI:13.0-13.7) with a standard deviation of 3.9 years (Table 1). The most commonly observed categories for ALS dispatch were respiratory (21%), syncope (19%), seizure (15%) and trauma (14%)(Figure 1). Other less frequently noted emergencies for dispatch included, allergies (11%), cardiac (8%), altered mental status (3%), ingestions (2%), and diabetes (1%). Only 5% of calls were for all other medical categories not mentioned (figure 2). Of all the patients evaluated, 60% (CI: 56-64) had a past medical history other than seasonal allergies. 6% (CI: 4-8) had medications administered; however if albuterol/atrovent are excluded than only 0.6% (CI: 0-1.3) were administered medication. Only 1 child was administered epinephrine and Benadryl, and another dexamethasone. Procedures were performed on 27% (CI: 23-32) of patients, however if IV access and obtaining an EKG are excluded then only 1 patient (0.2%) had a procedure performed, which was the application of physical restraints (Table 2). Categories

Average Age

Male Patients

Female Patients

Statistical data

13.3 years (SD:3.9) (CI:12.913.7)

256 (53%) 230 (47%) (SD:0.5) (SD: 0.5) (CI: 48-57) (CI: 43-52)

Patients with PMHx 291 (60%) (SD:0.5) (CI:56-64)

Table 1: Demographics of Pediatric ALS patients. (Percentages, standard deviations and 95% confidence intervals calculated).

Medication

Medications not Albuterol/Atrovent

Procedure

IV

EKG Other procedure

Number of 29 Patients

3

132

103

30

1

Percentage 6% (CI: 4-8)

0.6% (CI:01.3)

27% (CI: 2332)

21% (CI: 1725)

6% (CI: 4-8)

0.2% (CI: -0.20.6)

Table 2: Frequency of pre-hospital data collected on advanced life support dispatch calls for schools. (Percentages and 95% confidence intervals included).


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Figure 1: Percentage of medical categories for which Advanced life support dispatches to school were made.

Discussion Very little has been written in the EMS literature regarding the types of emergencies that result in ALS being called to schools. Our study shows that 0.6% of ALS dispatches were for children at schools; therefore 99.4% of the ALS dispatches analyzed for this study were for other purposes. Previous studies show that 13% of all EMS transport is utilized for pediatric patients,[10] which could possibly mean that fewer children are transported via ALS, however limited research has been done to compare the utilization between transport services. A comparison between the utilization of Basic Life Support (BLS) and ALS for pediatric patients is a suggested area for further research, as the use of ALS for pediatric patients is minimal.

Our study also reveals that the most prevalent emergencies were those for respiratory illnesses. This study shows that 6% of evaluated patients were administered medication, and the majority of those patients were administered albuterol or atrovent, both of which serve to treat and prevent bronchospasm. This further supports the conclusion that respiratory emergencies make up the majority of cases for which pediatric ALS intervention is called, especially since other emergencies very rarely required prehospital medication. Only one patient was administered Epinephrine and Benadryl and only one patient was given dexamethasone, further supporting that ALS intervention is very rarely dispatched for complaints other than respiratory.

Of the 10 categories for which ALS was dispatched to schools, as mentioned before, respiratory illness was the most prevalent at 21%. Following respiratory illnesses came emergencies for children who had a syncopal episode at 19%. However, those being transported for syncope required very minimal ALS intervention as no prehospital medications

were administered. This distinguishes the difference in the necessity for ALS transport between the two most prevalent categories. The remaining 8 categories all together make up 60% of total ALS transport, however no single category exceeded 15%. It is important to recognize that the majority of patients transported to the emergency department via ALS required little to no intervention. Altogether this provides support for the claim that the allocation for ALS resources can be better utilized when it pertains to school emergencies. Respiratory illnesses were the most commonly seen emergencies in this study, and chronic illnesses such as asthma are becoming more prevalent, and commonly affect school children [11]. Due to the increase in chronic illnesses in school children, the responsibilities of school nurses have risen [12,13]. With this increase in chronic illnesses it is expected that schools provide more nursing services, even at a time like the present when school nurses are overwhelmed [12,13]. The results of this study may be useful in implementing educational guidelines relevant to the allocation of dispatch resources in pediatric cases. It can also provide educational insight for school nurses who play a role in assessing the acuity of a child’s complaint. Our study in conjunction with further research in pediatric emergency care can be of great utility. Limitations

This study has several limitations and the findings should be interpreted in the context of the study design and setting. A retrospective approach provides limitations as only pre-existing data is analyzed, representing a second level of evidence compared to a prospective approach. Only a 5 year period of pre-hospital EMS records were reviewed, BLS calls and cancelled calls were not included in this study, all of which present as sampling biases and may not obtain results fully representative of the population intended for analysis. However, excluding BLS patients from this study aided in exploring the specific use of ALS, and has delivered results that are useful for educational training and resource allocations.

Conclusion

The prevalence of advanced life support dispatch to schools is very small. The majority of calls are due to concerns of asthma exacerbations or respiratory illness, and the majority of medications administered are used in treating patients with respiratory concerns. The information of this study can help guide dispatch resources for Emergency Medical Services, and educational programs for school nurses.

References

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3. Institute of Medicine. Pediatric Emergency Care: Growing Pains. Washington, DC: National Academy Press; 2006. Committee on the Future of Emergency Care in the United States Health System.

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11. Guttu M, Engelke MK, Swanson M. Does the school nurseto-student ratio make a difference? School Health. 2004, 74(1): 6-9. 12. Dabney BW, Linton M, Koonmen J. School nurses and RN to BSN nursing students: A community health partnership in Michigan. NASN Sch Nurse. 2017, 32(1): 30-32. 13. Dolatowski R, Endsley P, Hiltz C, Johansen A, Maughan E et al. School nurse workload: staffing for safe care. NASN Sch Nurse. 2015, 30(5): 290-293.


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