EXECUTIVE SUMMARY

A new joint policy statement heralds the initial step in an ambitious effort aimed at promoting pediatric readiness in the prehospital environment. The move follows in the footsteps of the successful National Pediatric Readiness Project, which continues to push for improvements in the preparedness level of EDs across the country to care for children. Backers of the new effort note they plan to use a similar blueprint in pushing for improvements in pediatric readiness in the prehospital environment.

The push is backed by multiple professional organizations, including the American College of Emergency Physicians, Emergency Nurses Association, American Academy of Pediatrics, National Association of Emergency Medical Services (EMS) Physicians, and the National Association of Emergency Medical Technicians.

The joint policy statement includes 16 distinct recommendations for EMS operations that cover such topics as the development of protocols for use with children, the acquisition of pediatric-specific equipment and supplies, the provision of pediatric-specific training, the development of policies and procedures related to pediatric patients and their families, the development of key metrics, and ongoing assessments.

Recognizing the variations in how prehospital care is delivered in the United States, the recommendations are scalable so that whether an EMS operation is small or large, everyone should be able to implement the recommendations.


After the success of the National Pediatric Readiness Project (NPRP), which led to improvements in the preparedness level of EDs across the country to care for children, there is now a push to achieve similar gains in the prehospital setting.

Like NPRP, this fresh effort is backed by multiple professional organizations, including the American College of Emergency Physicians, Emergency Nurses Association, American Academy of Pediatrics, National Association of Emergency Medical Services (EMS) Physicians, and the National Association of Emergency Medical Technicians. To start, these groups issued a joint policy statement, which makes the case that EMS systems must be able to ensure they have the infrastructure, support, equipment, and training needed to meet the unique needs of younger patients. The statement also includes a long list of specific recommendations that the authors contend EMS systems need to follow to achieve true pediatric readiness.1

The authors tell ED Management the joint policy statement is an initial step in what they hope will be a multistep process that unfolds over the coming years. For example, the NPRP was preceded by a similar joint statement that included guidelines for the care of children in the emergency setting.2

As with NPRP, the participating groups in this latest effort anticipate broad involvement on the part of emergency medicine clinicians and administrators, many of whom continue to play a key role in ensuring EDs are well prepared to meet the unique needs of children.

There was no precipitating adverse event or crisis prompting the joint policy statement; rather, it was the culmination of several years of discussion among several stakeholders, explains Brian Moore, MD, the statement’s lead author and a pediatric emergency physician in the department of emergency medicine at the University of New Mexico. After the earlier policy statement regarding the care of children in the ED and the success of the NPRP, the thinking was, “Hey, we should do this for EMS,” he explains. “There is a blueprint for what the ED piece is saying, and we should extend that to the world of EMS.”

The latest policy statement includes 16 distinct recommendations for EMS that cover such topics as the development of protocols for use with children, the acquisition of pediatric-specific equipment and supplies, the provision of pediatric-specific training, the development of policies and procedures related to pediatric patients and their families, the development of key metrics, and ongoing assessment.1

Moore, who once worked as the air ambulance medical director in Albuquerque, NM, has seen firsthand the need for more emphasis on pediatric-specific care in the prehospital environment. “One of the overarching reasons to advocate for this is seeing, often times, how nervous some prehospital providers are about the care of children,” he says. “Readiness [can] be highly variable.”

Consequently, Moore believes it is important for the relevant national professional organizations to spell out what the important parameters are for taking good care of children in the prehospital setting. “We are addressing this from a systems [perspective], knowing that the [NPRP] for EDs is having some great success with readiness and evaluation ... and [prompting] a lot of EDs to want to improve,” he shares. “They put a scoring system in place [that showed] how EDs could improve. Now, there are published data correlating ED readiness for pediatric patients with outcomes.”

In a similar fashion to the NPRP, Moore and several other statement co-authors are involved with a prehospital readiness steering committee. This group is developing an assessment tool for EMS systems so they can evaluate where their readiness is regarding care for pediatric patients. Further, Moore notes the committee is looking at how pediatric leaders and groups can best assist EMS systems with their readiness improvement. “That is really the next step, and that is in process right now,” he says.

Moore acknowledges there is wide variation in the way U.S. EMS systems operate. That creates different challenges than the NPRP effort has faced in pushing quality improvement to EDs.

“New Mexico is a very rural state, and I think we have 33 or 34 hospitals total in the state and probably 300 different EMS services, a lot of them very small or volunteer-based,” he explains. “EMS is a much more complex system.”

On the plus side, the world of pediatrics and pediatric emergency personnel often is tiny, even in large metropolitan areas, Moore observes. “People often know each other or sit in the same meetings or committees,” he says, noting there is a big opportunity for emergency clinicians and leaders to play a role in this new effort to push the concept of pediatric readiness to the EMS services with which they work.

To be sure, EMS personnel will not be starting from scratch regarding pediatric care training. Many states require paramedics obtain a certain number of hours of continuing education in pediatrics as a condition for recertification. However, the level of preparedness or readiness concerning pediatric patients can vary significantly, explains John Lyng, MD, FACEP, FAEMS, NRP, a statement co-author and emergency physician at North Memorial Health Hospital in Robbinsdale, MN. Lyng also is an EMT paramedic, and was one of the first U.S. physicians to receive board certification in EMS medicine.

After working in several states and countries, Lyng observed variability in ambulance service preparedness as far as the pediatric equipment they carried and even how it was organized. Also, Lyng found it difficult to discern who had received pediatric-focused education or understood specific protocols.

Lyng observed that while smaller EMS operations may be less prepared, size was not necessarily the determining factor. “In some cases, the smaller services that had a smaller scale could be very well prepared compared to the larger services,” he says. “It is a lot easier to turn a canoe than to turn an aircraft carrier. The larger services were sometimes challenged with making sure that they had those preparedness things in place as well.”

Consequently, Lyng sees the new joint policy statement as a good level-setting document that could set expectations across the industry regardless of service size or patient volume.

What can happen when an EMS service lacks readiness or training to care for a pediatric patient? “I have seen circumstances where, because a service may not have had a piece of pediatric-specific equipment, they have had to improvise, using an adult piece of equipment instead,” Lyng observes.

For instance, Lyng recalls instances when EMS personnel did not have pediatric-sized bag-valve masks for manual ventilation, so they had to use an adult-sized mask that fits over an entire child’s face rather than just around the child’s nose and mouth. This is a less-than-ideal way to ventilate or provide breathing assistance.

“There are reasons why we have pediatric-sized equipment. It’s because it needs to fit [a child’s] body shape and size,” Lyng explains. “When people try to improvise, they are probably well-intentioned. They want to try to do the right thing, but the best thing is to have the right equipment handy.”

In fact, Lyng is working on a revision of the national minimum recommended equipment list for ambulances. However, he stresses that along with carrying the right equipment and tools, providers have to know how to use the tools appropriately.

“It is critically important that people are trained in the motor skills of using equipment, but also the other aspects of when you need to use these different interventions and when you don’t,” he says.

Lyng notes pediatric patients tend to be different than adults in terms of how well they can compensate for illness. Further, their disease patterns are quite different. “Kids don’t have pulmonary or cardiovascular disease related to smoking like adults do, but they still have pretty significant pulmonary and cardiovascular disease sometimes. Their ability to compensate for those types of illnesses is quite a bit different,” he says. “There is important education in terms of recognizing when kids are sick. They can kind of fool you for a while, and then all of a sudden they’re really sick, and then you are behind the eight ball.”

For pediatric readiness in the ED, the NPRP emphasizes the importance of employing a pediatric emergency care coordinator. This person should focus on ensuring the department is equipped with the proper equipment, training, and policies to provide appropriate care. Lyng believes the same concept is important for EMS.

“If you don’t have someone either directly focused on this or who has that focus as part of their role ... you don’t know where you have gaps in your system,” he says. “Part of the readiness is the equipment, part of the readiness is the education, and part of the readiness is also oversight and quality assurance.” The recommendations included in the joint policy statement are scalable. Whether an EMS operation is small or large, everyone should be able to implement the recommendations, according to Lyng.

“A large service that has a larger budget might be able to afford someone to be like a pediatric emergency care coordinator full time and have that as their role. That is the type of role that could be taken on by any frontline staff member,” he says. “In fact, when I was an EMT in a small EMS service in North Dakota where I got started, I took on that role myself. That was back in the 1990s”

It was a matter of making sure that the right equipment was on hand, that it was organized correctly, and that everyone was trained in how to use it, Lyng adds. “The focus of this role can be achieved by services of different sizes.”

Katherine Remick, MD, FAAP, FACEP, FAEMS, another statement co-author, tells ED Management that several related efforts have commenced since the publication of the policy statement in January.

“The HRSA [Health Resources and Services Administration]-EMS for Children Program, in conjunction with the National Highway Traffic and Safety Administration, is supporting the development of the national Prehospital Pediatric Readiness Steering Committee,” says Remick, medical director of the San Marcos/Hays County (TX) EMS system and an executive leader with the National EMS for Children Innovation & Improvement Center.

She notes this committee includes representatives from more than 25 national professional organizations and federal partners. Further, Remick says this committee and the organizations it represents are collaborating on several specific projects. These include developing a prehospital pediatric readiness toolkit to support EMS systems to ensure day-to-day pediatric readiness. Their work also includes creating a national self-assessment of EMS agencies to identify local, regional, state, and national gaps in pediatric readiness across EMS systems.

“This is a first step in identifying the current state of prehospital pediatric emergency care such that improvement efforts can be developed and specific needs targeted,” Remick says. “The national assessment will allow us to assess the baseline level of prehospital pediatric readiness and drive improvements over time.”

The committee and partnering organizations also intend to develop additional tools, metrics, and mechanisms to support iterative improvement efforts at the local, regional, state, and national levels, Remick explains.

Additionally, Remick sees multiple opportunities for emergency clinicians to assist with these efforts. This includes outreach and creating awareness among the EMS systems with which they work, engaging in quality improvement activities across the continuum of care and collaborating on pediatric education.

Moore says he sees potential in the ability of pediatric emergency care coordinators or pediatric champions serving in EDs to work closely with similarly designated persons working in their EMS communities. “They can then have conversations about improving the care of children in the prehospital setting,” he explains.

REFERENCES

  1. Moore B, Shah MI, Owusu-Ansah S, et al. Pediatric readiness in emergency medical services systems. Ann Emerg Med 2020;75:e1-e6.
  2. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, American College of Emergency Physicians, et al. Joint policy statement — guidelines for care of children in the emergency department. Pediatrics 2009;124:1233-1243.