Frequency of Pediatric Emergencies in Ambulatory Practices PDF

Frequency of Pediatric Emergencies in Ambulatory Practices Matthew L. Yuknis, MD,a Elizabeth Weinstein, MD,b Hannah Maxey, PhD, MPH, RDH,c Lori Price, MD,d Sierra X. Vaughn, MPH,c Tom Arkin...

Frequency of Pediatric Emergencies in Ambulatory Practices Matthew L. Yuknis, MD,a Elizabeth Weinstein, MD,b Hannah Maxey, PhD, MPH, RDH,c Lori Price, MD,d Sierra X. Vaughn, MPH,c Tom Arkins, BS, EMT-P,e Brian D. Benneyworth, MD, MSa,f BACKGROUND: Management of pediatric emergencies is challenging for ambulatory providers abstract because these rare events require preparation and planning tailored to the expected emergencies. The current recommendations for pediatric emergencies in ambulatory settings are based on 20-year-old survey data. We aimed to objectively identify the frequency and etiology of pediatric emergencies in ambulatory practices. METHODS: We examined pediatric emergency medical services (EMS) runs originating from ambulatory practices in the greater Indianapolis metropolitan area between January 1, 2012, and December 31, 2014. Probabilistic matching of pickup location addresses and practice location data from the Indiana Professional Licensing Agency were used to identify EMS runs from ambulatory settings. A manual review of EMS records was conducted to validate the matching, categorize illnesses types, and categorize interventions performed by EMS. Demographic data related to both patients who required treatment and practices where these events occurred were also described. RESULTS: Of the 38 841 pediatric EMS transports that occurred during the 3-year period, 332 (0.85%) originated from ambulatory practices at a rate of 42 per 100 000 children per year. The most common illness types were respiratory distress, psychiatric and/or behavioral emergencies, and seizures. Supplemental oxygen and albuterol were the most common intervention, with few critical care level interventions. Community measures of low socioeconomic status were associated with increased number of pediatric emergencies in ambulatory settings. CONCLUSIONS: Pediatric emergencies in ambulatory settings are most likely due to respiratory distress, psychiatric and/or behavioral emergencies, or seizures. They usually require only basic interventions. EMS data are a valuable tool for identifying emergencies in ambulatory settings when validated with external data. WHAT’S KNOWN ON THIS SUBJECT: Pediatric aPediatric dGeneral emergencies have been reported to occur weekly in Divisions of Critical Care Medicine and and Community Pediatrics, Department of Pediatrics, bDivision of Pediatric Emergency Medicine, Department of Emergency Medicine, cBowen Center for ambulatory practice settings. Current epidemiology Health Workforce Research and Policy, School of Medicine, and fDepartment of Pediatrics, Children’s Health and standards with regard to preparedness are Services Research, School of Medicine, Indiana University, Indianapolis, Indiana; and eIndianapolis Emergency based on 20-year-old survey data. Medical Service, Indianapolis, Indiana WHAT THIS STUDY ADDS: We defne the frequency Dr Yuknis conceptualized and designed the study, performed the preliminary data analysis, of pediatric emergencies occurring in ambulatory and drafted and revised the initial manuscript; Dr Weinstein coordinated and supervised the practices requiring emergency medical services collection of data and critically reviewed the manuscript; Dr Maxey coordinated and supervised transport. We also characterize the illness types the collection of data, designed and performed data analysis, and critically reviewed the and interventions needed by patients during their manuscript; Dr Price advised with the design of the study and critically reviewed the manuscript; transport from an offce-to-hospital setting. Ms Vaughn coordinated and supervised the collection of data and designed and performed data analysis; Mr Arkins coordinated and supervised the collection of data; Dr Benneyworth designed and performed data analysis and reviewed and revised the manuscript; and all authors approved the fnal manuscript as submitted. To cite: Yuknis ML, Weinstein E, Maxey H, et al. Frequency of DOI: https://doi.org/10.1542/peds.2017-3082 Pediatric Emergencies in Ambulatory Practices. Pediatrics. 2018;142(2):e20173082 Downloaded from www.aappublications.org/news by guest on June 24, 2021 PEDIATRICS Volume 142, number 2, August 2018:e20173082 ARTICLE The management of pediatric the authors of 2 studies looking at EMS or the Indiana University emergencies in an ambulatory care emergency medical services (EMS) Health critical care transport team setting can be challenging because encounters data in pediatric patients (ie, Lifeline) between January 1, they are rare events requiring attempted to better define types of 2012, and December 31, 2014, were specialized skills that need to be illnesses and required interventions. eligible. Most patients (98.7%) were performed in a time-sensitive The authors of 1 study looked transported by the Indianapolis manner. Few data exist regarding specifically at specialty pediatric EMS system. Indianapolis EMS the frequency and etiology of these critical care transports originating is the main EMS provider in the events for providers to use, likely from outpatient medical locations Indianapolis metropolitan area, because of their infrequent nature but did not include any general with a transport volume of >100 000 and lack of a widely accepted EMS transports.11 The authors of calls per year. It is a 2-tiered system definition for emergency in an the other study evaluated all EMS and serves the entire metropolitan ambulatory care setting. The authors encounters for school-aged children area. The Indianapolis EMS data of previous literature published from (age ≥5 years) from public locations contained 6 patient records with 1989 to 1995 indicated that >50% (including a subgroup of patients incomplete address information, of pediatric offices reported seeing from medical facilities) but did not which were excluded. This study was between 1 and 5 patients per week identify types of medical facilties.12 approved by the Indiana University requiring emergency treatment The authors of both of these studies Institutional Review Board. or emergency hospitalization, and used aggregated EMS data that were The primary source from which EMS similarly, a mailed questionnaire neither validated through manual transport data were obtained was the revealed that 62% of physicians review nor confirmed with other data Indianapolis EMS system. It contains in pediatric offices reported sources. basic demographic data of patients seeing at least 1 patient per week Because of the potential gaps and (age, sex, race, and ethnicity), requiring urgent treatment or inaccuracies in existing analyses, patient descriptions (including chief hospitalization.1,2 The most common we aimed to more precisely define complaint), EMS interventions before types of illnesses identified included the epidemiology of pediatric and during transport, and times from respiratory emergencies, seizures, emergencies in ambulatory call to arrival on scene and from and dehydration. Given the potential practices by matching EMS pickup leaving the scene to hospital arrival. impact of these events on patient locations to known addresses of The pickup address is determined care, the American Academy of ambulatory providers across a by the address given to the EMS Pediatrics (AAP) published a set of major metropolitan area and then dispatch by the individual requesting recommendations for ambulatory manually reviewing the matched transport. The EMS providers also care providers regarding the training records to confirm the locations. We describe the pickup location both of their staff in basic life support hypothesized that ambulatory-based in a standardized description field skills at minimum along with lists emergencies in pediatric patients (reported to the national EMS of equipment to have on hand, occur at a different frequency and are registry) and often in the free-text including supplemental oxygen and caused by other etiologies than what description of the run. The same necessary delivery devices, albuterol is currently described in the medical data were obtained from Indiana and nebulizer equipment, and literature. University Health Lifeline. These epinephrine.3 data sets are reformatted before being sent to the National Emergency In addition to the AAP’s METHODS Medical Services Information System recommendations, other groups (NEMSIS), the national EMS data have detailed strategies for This study was a retrospective registry. preparing ambulatory care offices observational study of EMS data for pediatric emergencies, all based from the Indianapolis metropolitan EMS encounters originating in on retrospective survey data.2–6 area, which includes Marion County ambulatory practices were identified Retrospective surveys are useful and small portions of surrounding by matching EMS pickup locations and commonly employed tools in counties and is divided into 9 to known provider practice gathering information from a large townships. Marion County contains addresses obtained from the Indiana group of practitioners in a small 18 hospitals, with a total of 4616 Professional Licensing Agency window of time, but inherent in beds with a density of 1 bed per and maintained for research and their design is the risk of errors 201 people.13 All patients