EMS leader’s 8-step guide to excellent pediatric care

By Sean Caffrey, NEMSMA

It is easy to find a wealth of educational material on EMS pediatric care despite the fact that most children encountered by EMS are not seriously ill or injured. How is it then that kids are a small fraction, 5 to 10 percent, of EMS patients, but command so much attention"

The reason is that effectively managing pediatric patients, including the rarely encountered critically ill pediatric patients, requires good preparation, ongoing training and comprehensive oversight by EMS services.

While the knowledge and equipment needed to take care of kids may be specialized, this should not suggest that EMS responders or response organizations are not equipped to handle sick kids.

You have likely heard "children are not small adults." While this line is certainly catchy, there is significant debate about its value within the pediatric emergency medicine community since it seems to imply that providers who take care of adults may not be skilled with children.

To the contrary, providing good care for children follows the same basic care principles as adult patients. Therefore, a more appropriate line might be "kids are patients, too," since they deserve the same level of assessment and care provided to an adult.

There are certainly some differences and special considerations, but nothing a skilled EMS practitioner can't handle. So how can leaders build these pediatric care skills for their teams"

1. Know frequent pediatric call types
The first preparatory step is knowing what to expect. The most frequent chief complaints for younger children include respiratory distress and seizures. For older children and adolescents, traumatic injury and behavioral or psychiatric complaints are the most common reasons for EMS activation.

What is most interesting, however, is that these are not the critical call types practitioners prepare for in a PALS class, nor are these the scenarios for which length-based resuscitation tapes were designed to handle.

As such, the forward-thinking EMS leader should examine their agency-specific call data to ensure that providers have the appropriate supplemental training to be well prepared for what likely constitutes the vast majority of their pediatric call volume.

2. Offline medical direction from evidence-based guidelines
Another important preparatory step is securing offline medical direction based on protocols reflecting current standards of pediatric care. Within the last few years, a number of evidenced-based guidelines have been published to assist medical directors and administrators in this area.

These pediatric EBGs represent a methodical approach to evaluating existing evidence in order to build the most effective care guidelines. While not protocols themselves, EBGs are great tools to use when building protocols and have already been implemented in a number of states.

Currently published guidelines include pediatric seizure management, as well as pain control for traumatic injuries. A respiratory distress guideline is also expected soon. Share these links and resources with your EMS medical director.

3. Medical direction from a pediatric specialist
A number of progressive services across the country, as well as a couple of states, have begun to add associate EMS medical directors for pediatric care. This trend primarily occurs in EMS services with ready access to children's hospitals. However, it may be worth contacting your regional children's hospital to see if their pediatric emergency medicine specialists are willing to participate in your medical direction system, or at least review your department's pediatric protocols.

I work closely with pediatric emergency medicine physicians and can assure you that it is great to have that level of expertise available as a resource to EMS practitioners. It is equally valuable to introduce these specialists, who often have a limited opportunity to interact outside their institutions, to EMS services throughout their region.

While it may take some effort to make this connection, you might be amazed what happens if you ask.

4. Providers need pediatric-specific tools
A final step in offline medical direction is making sure your practitioners have good tools available to implement their protocols. The most important tool is a product or method to estimate patient weight and determine drug dosages.

A pediatric drug quick-reference guide to determine fluid and drug dosage calculations needs to include information for commonly used respiratory, anti-seizure and pain medications. Many systems use pocket cards, quick-reference books, charts or apps in addition to length-based tapes that focus on resuscitation.

Last, a frequently overlooked tool is one to measure pain. As many younger children cannot use a standard zero-to-10 pain scale. Having access to a Faces, Legs, Activity, Cry and Consolability and a Wong-Baker Faces Scale are important to be able to treat pediatric pain or traumatic injuries effectively.

5. Essential pediatric equipment
Most states have minimum requirements for pediatric equipment based on nationally recommended equipment lists. As part of the work of the National EMS for Children program, your service has likely been surveyed regarding the availability of this equipment.

EMS leaders should strongly consider adding the following items:

• A set-up for pull-push fluid administration. According to the most recent sepsis and shock guidelines, children in shock should receive 20 mL/kg in the first 5 to 10 minutes. Fluid resuscitation goals are to achieve normal vital signs within the first hour of shock presentation. Infusions at this rate are simply not possible using the unregulated administration of fluid through an intravenous bag alone or through a burette system. Services should consider carrying a three-way stopcock device and 60-cc Luer lock tip syringes that can be used to quickly and accurately administer fluid during resuscitation.
• Diagnostic equipment to assess blood pressure and pulse oximetry. This includes appropriately sized blood pressure cuffs and pulse oximetry probes. In addition, automatic blood pressure cuffs, which are essential in obtaining a blood pressure on infants and toddlers, should be strongly considered. Previous teaching that blood pressure measurement is unimportant in children should be disregarded, as this vital sign is as critical to effective assessment and care of children as it is in adults.
• Mushroom-tip or BBG type suction catheters are significantly more effective than bulb syringes or traditional Yankauer rigid suction tips at removing nasal secretions, especially in young children unable to blow their noses to alleviate respiratory distress. Such a device is easier to use and less traumatic, and does not risk stimulation of a vagal response.
• Appropriate distraction and trust-building tools such as stuffed animals or search-and-find distraction books can assist children in coping with the EMS encounter.

6. Delivering pediatric care
When delivering pediatric care, it is important to consider that the most common problem with the care of children is the failure to deliver appropriate care when indicated. In some instances, practitioners may talk themselves out of essential interventions due to inadequate assessment or fear of agitating a child.

Examples of this include not obtaining vital signs and withholding essential respiratory, fluid resuscitation, glucose, pain control or spinal motion restriction. The best method to address these issues is to ensure a complete assessment, including a blood pressure, pulse oximetry, glucose measurement, pain measurement and capnography on all seriously ill children.

Simulation training improves care through practice with your service's protocols, reference materials, diagnostic tools and pediatric equipment. This is especially important considering the low volume of pediatric EMS encounters.

7. Assign a pediatric care champion
Make someone at your service responsible for preparation, equipment and training issues. In the most recent national Pediatric Readiness Assessment, over 4,000 hospital emergency department representatives across the United States were asked if they assigned a nurse or physician to the role of a pediatric care coordinator or champion to oversee pediatric readiness at their facilities.

The facilities that indicated such a role existed were found to score significantly higher on their overall readiness scores [1]. Assigning this role to an aspiring and motivated practitioner or supervisor in your organization could be just as helpful to your overall pediatric readiness.

8. Measure success
Children are a specialized patient population that require additional effort. Comprehensive review of your organization's pediatric calls is critical. Use your own electronic records, which do a great job of describing what types of patients you encounter and how well care is delivered to them.

Since critically ill children are a rare occurrence in any EMS system, the ability to evaluate and communicate findings about the care delivered on these calls, if done in an effective and non-punitive manner, will provide the opportunity for all of your practitioners to learn from these rare experiences. As such, quality improvement personnel should be sure to develop guidelines to regularly review both high-acuity and a subset of low-acuity pediatric calls.

Set up for future performance measurement success
The National EMS for Children program is in the process of approving new EMS performance measures for EMS for Children state partnerships to implement. Those measures will likely include electronic patient care reporting to the states on the NEMSIS version 3 standard, establishment of pediatric care coordinators in EMS services and competency testing of providers.

If your service implements these eight steps, your department will be well positioned to meet or exceed the expectations of these performance measures and provide great care for kids in the process.

About the author:
Sean Caffrey, MBA, CEMSO, NRP currently serves at the EMS Programs Manager for the University of Colorado School of Medicine, Pediatric Emergency Medicine Section. Sean has been certified as a paramedic since 1991and has worked in volunteer, private, hospital-based, fire-based and 3rd service EMS systems in roles from provider through department head. He currently works in conjunction with the state EMS office in Colorado, is the vice president of the EMS Association of Colorado, is a board member of the National EMS Management Association, and a member of NAEMT, NASEMSO and NAEMSP. Sean's interests include EMS system design, pediatrics, public policy, professional development and research.

Reference:

1. Gausche-Hill M, Ely M, Schmuhl P, et al. A National Assessment of Pediatric Readiness of Emergency Departments. JAMA Pediatr. 2015;169(6):527-534. doi:10.1001/jamapediatrics.2015.138.

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