Manish I. Shah, MD, MS

All Publications

• Public support for and concerns regarding pediatric dose optimization for seizures in emergency medical services: An exception from informed consent (EFIC) trial ACADEMIC EMERGENCY MEDICINE Ward, C. E., Adelgais, K. M., Holsti, M., Jacobsen, K. K., Simon, H. K., Morris, C. R., Gonzalez, V. M., Lerner, G., Ghaffari, K., VanBuren, J. M., Lerner, E., Shah, M. I., Pediat Emergency Care Appl Res 2024

  Abstract

  Federal regulations allow exception from informed consent (EFIC) to study emergent conditions when obtaining prospective consent is not feasible. Little is known about public views on including children in EFIC studies. The Pediatric Dose Optimization for Seizures in EMS (PediDOSE) trial implements age-based, standardized midazolam dosing for pediatric seizures. The primary objective of this study was to determine public support for and concerns about the PediDOSE EFIC trial. The secondary objective was to assess how support for PediDOSE varied by demographics.We conducted a mixed-methods study in 20 U.S. communities. Participants reviewed information about PediDOSE before completing an online survey. Descriptive data were generated. Univariable and multivariable logistic regression analysis identified factors associated with support for PediDOSE. Reviewers identified themes from free-text response data regarding participant concerns.Of 2450 respondents, 79% were parents/guardians, and 20% had a child with previous seizures. A total of 96% of respondents supported PediDOSE being conducted, and 70% approved of children being enrolled without prior consent. Non-Hispanic Black respondents were less likely than non-Hispanic White respondents to support PediDOSE with an adjusted odds ratio (aOR) of 0.57 (95% CI 0.42-0.75). Health care providers were more likely to support PediDOSE, with strongest support among prehospital emergency medicine clinicians (aOR 5.82, 95% CI 3.19-10.62). Age, gender, parental status, and level of education were not associated with support of PediDOSE. Common concerns about PediDOSE included adverse effects, legal and ethical concerns about enrolling without consent, and potential racial bias.In communities where this study will occur, most respondents supported PediDOSE being conducted with EFIC and most approved of children being enrolled without prior consent. Support was lowest among non-Hispanic Black respondents and highest among health care providers. Further research is needed to determine optimal ways to address the concerns of specific racial and ethnic groups when conducting EFIC trials.

  View details for DOI 10.1111/acem.14884

  View details for Web of Science ID 001180760100001

  View details for PubMedID 38450918

• EMS Administration of Systemic Corticosteroids to Pediatric Asthma Patients: An Analysis by Severity and Transport Interval PREHOSPITAL EMERGENCY CARE Riney, L., Palmer, S., Finlay, E., Bertrand, A., Burcham, S., Hendry, P., Shah, M., Kothari, K., Ashby, D., Ostermayer, D., Semenova, O., Abo, B. N., Abes, B., Shimko, N., Myers, E., Frank, M., Turner, T., Kemp, M., Landry, K., Roland, G., Fishe, J. 2023; 27 (7): 900-907

  Abstract

  Pediatric asthma exacerbations are a common cause of emergency medical services (EMS) encounters. Bronchodilators and systemic corticosteroids are mainstays of asthma exacerbation therapy, yet data on the efficacy of EMS administration of systemic corticosteroids are mixed. This study's objective was to assess the association between EMS administration of systemic corticosteroids to pediatric asthma patients on hospital admission rates based on asthma exacerbation severity and EMS transport intervals.This is a sub-analysis of the Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial (EASI AS ODT). EASI AS ODT is a non-randomized, stepped wedge, observational study examining outcomes one year before and one year after seven EMS agencies incorporated an oral systemic corticosteroid option into their protocols for the treatment of pediatric asthma exacerbations. We included EMS encounters for patients ages 2-18 years confirmed by manual chart review to have asthma exacerbations. We compared hospital admission rates across asthma exacerbation severities and EMS transport intervals using univariate analyses. We geocoded patients and created maps to visualize the general trends of patient characteristics.A total of 841 pediatric asthma patients met inclusion criteria. While most patients were administered inhaled bronchodilators by EMS (82.3%), only 21% received systemic corticosteroids, and only 19% received both inhaled bronchodilators and systemic corticosteroids. Overall, there was no significant difference in hospitalization rates between patients who did and did not receive systemic corticosteroids from EMS (33% vs. 32%, p = 0.78). However, although not statistically significant, for patients who received systemic corticosteroids from EMS, there was an 11% decrease in hospitalizations for mild exacerbation patients and a 16% decrease in hospitalizations for patients with EMS transport intervals greater than 40 min.In this study, systemic corticosteroids were not associated with a decrease in hospitalizations of pediatric patients with asthma overall. However, while limited by small sample size and lack of statistical significance, our results suggest there may be a benefit in certain subgroups, particularly patients with mild exacerbations and those with transport intervals longer than 40 min. Given the heterogeneity of EMS agencies, EMS agencies should consider local operational and pediatric patient characteristics when developing standard operating protocols for pediatric asthma.

  View details for DOI 10.1080/10903127.2023.2234996

  View details for Web of Science ID 001039504800001

  View details for PubMedID 37428954

  View details for PubMedCentralID PMC10592383

• Evidence-Based Guidelines for Prehospital Pain Management: Recommendations PREHOSPITAL EMERGENCY CARE Lindbeck, G., Shah, M., Braithwaite, S., Powell, J. R., Panchal, A. R., Browne, L. R., Lang, E. S., Burton, B., Coughenour, J., Crowe, R. P., Degn, H., Hedges, M., Gasper, J., Guild, K., Mattera, C., Nasca, S., Taillac, P., Warth, M. 2023; 27 (2): 144-153

  Abstract

  This project sought to develop evidence-based guidelines for the administration of analgesics for moderate to severe pain by Emergency Medical Services (EMS) clinicians based on a separate, previously published, systematic review of the comparative effectiveness of analgesics in the prehospital setting prepared by the University of Connecticut Evidence-Based Practice Center for the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel (TEP) was assembled consisting of subject matter experts in prehospital and emergency care, and the development of evidence-based guidelines and patient care guidelines. A series of nine "patient/population-intervention-comparison-outcome" (PICO) questions were developed based on the Key Questions identified in the AHRQ systematic review, and an additional PICO question was developed to specifically address analgesia in pediatric patients. The panel made a strong recommendation for the use of intranasal fentanyl over intravenous (IV) opioids for pediatric patients without intravenous access given the supporting evidence, its effectiveness, ease of administration, and acceptance by patients and providers. The panel made a conditional recommendation for the use of IV non-steroidal anti-inflammatory drugs (NSAIDs) over IV acetaminophen (APAP). The panel made conditional recommendations for the use of either IV ketamine or IV opioids; for either IV NSAIDs or IV opioids; for either IV fentanyl or IV morphine; and for either IV ketamine or IV NSAIDs. A conditional recommendation was made for IV APAP over IV opioids. The panel made a conditional recommendation against the use of weight-based IV ketamine in combination with weight-based IV opioids versus weight-based IV opioids alone. The panel considered the use of oral analgesics and a conditional recommendation was made for either oral APAP or oral NSAIDs when the oral route of administration was preferred. Given the lack of a supporting evidence base, the panel was unable to make recommendations for the use of nitrous oxide versus IV opioids, or for IV ketamine in combination with IV opioids versus IV ketamine alone. Taken together, the recommendations emphasize that EMS medical directors and EMS clinicians have a variety of effective options for the management of moderate to severe pain in addition to opioids when designing patient care guidelines and caring for patients suffering from acute pain.

  View details for DOI 10.1080/10903127.2021.2018073

  View details for Web of Science ID 000746765200001

  View details for PubMedID 34928760

• Design of a novel clinical trial of prehospital pediatric airway management CLINICAL TRIALS Bosson, N., Hansen, M., Gausche-Hill, M., Lewis, R. J., Wendelberger, B., Shah, M., VanBuren, J. M., Wang, H. E. 2022; 19 (1): 62-70

  Abstract

  Emergency Medical Services personnel are often the first to intervene in the care of critically ill children. Airway management is a fundamental step in prehospital resuscitation, yet there is significant variation in current prehospital airway management practices. Our objective is to present a methodologic approach to determine the optimal strategy for prehospital pediatric airway management. We describe the conceptual premise for the Pediatric Prehospital Airway Resuscitation Trial, a novel Bayesian adaptive sequential platform trial. We developed an innovative design to enable comparison of the three predominant prehospital pediatric airway techniques (bag-mask-ventilation, supraglottic airway insertion, and endotracheal intubation) in three distinct disease groups (cardiac arrest, major trauma, and other respiratory failure). We used a Bayesian statistical approach to provide flexible modeling that can adapt based on prespecified rules according to accumulating trial data with patient enrollment continuing until stopping rules are met. The approach also allows the comparison of multiple interventions in sequence across the different disease states. This Bayesian hierarchical model will be the primary analysis method for the Pediatric Prehospital Airway Resuscitation Trial. The model integrates information across subgroups, a technique known as "borrowing" to generate accurate global and subgroup-specific estimates of treatment effects and enables comparisons of airway intervention arms within the overarching trial. We will use this Bayesian hierarchical linear model that adjusts for subgroup to estimate treatment effects within each subgroup. The model will predict a patient-centered score of 30-day intensive care unit-free survival using arm, subgroup, and emergency medical services agency as predictors. The novel approach of Pediatric Prehospital Airway Resuscitation Trial will provide a feasible method to determine the optimal strategy for prehospital pediatric airway management and may transform the design of future prehospital resuscitation trials.

  View details for DOI 10.1177/17407745211059855

  View details for Web of Science ID 000729496100001

  View details for PubMedID 34875893

• Impact of Prehospital Pain Management on Emergency Department Management of Injured Children PREHOSPITAL EMERGENCY CARE Harris, M. I., Adelgais, K. M., Linakis, S. W., Magill, C. F., Brazauskas, R., Shah, M. I., Nishijima, D. K., Lowe, G. S., Chadha, K., Chang, T. P., Lerner, E. B., Leonard, J. C., Schwartz, H. P., Gaither, J. B., Studnek, J. R., Browne, L. R. 2023; 27 (1): 1-9

  Abstract

  Provision of analgesia for injured children is challenging for Emergency Medical Services (EMS) clinicians. Little is known about the effect of prehospital analgesia on emergency department (ED) care. We aimed to determine the impact of prehospital pain interventions on initial ED pain scale scores, timing and dosing of ED analgesia for injured patients transported by EMS.This is a planned, secondary analysis of a prospective multicenter cohort of children with actual or suspected injuries transported to one of 11 PECARN-affiliated EDs from July 2019-April 2020. Using Wilcoxon rank sum for continuous variables and chi-square testing for categorical variables, we compared the change in EMS-to-ED pain scores and timing and dosing of ED-administered opioid analgesia in those who did and those who did not receive prehospital pain interventions.We enrolled 474 children with complete prehospital and ED pain management data. Prehospital interventions were performed on 262/474 (55%) of injured children and a total of 88 patients (19%) received prehospital opioids. Children who received prehospital opioids with or without adjunctive non-pharmacologic pain management experienced a greater reduction in pain severity and were more likely to receive ED opioids in higher doses earlier and throughout their ED care. Non-pharmacologic pain interventions alone did not impact ED care.We demonstrate that prehospital opioid analgesia is associated with both a significant reduction in pain severity at ED arrival and the administration of higher doses of opioid analgesia earlier and throughout ED care.

  View details for DOI 10.1080/10903127.2021.2000683

  View details for Web of Science ID 000733296200001

  View details for PubMedID 34734787

• A Novel Use of NEMSIS to Create a PECARN-Specific EMS Patient Registry PREHOSPITAL EMERGENCY CARE Lerner, E., Browne, L. R., Studnek, J. R., Mann, N., Dai, M., Hoffman, C. K., Pilkey, D., Adelgais, K. M., Brown, K. M., Gaither, J. B., Leonard, J. C., Martin-Gill, C., Nishijima, D. K., Owusu Ansah, S., Shah, Z. S., Shah, M. I. 2022; 26 (4): 484-491

  Abstract

  Background: Research networks need access to EMS data to conduct pilot studies and determine feasibility of prospective studies. Combining data across EMS agencies is complicated and costly. Leveraging the National EMS Information System (NEMSIS) to extract select agencies' data may be an efficient and cost-effective method of providing network-level data. Objective: Describe the process of creating a Pediatric Emergency Care Applied Research Network (PECARN) specific NEMSIS data set and determine if these data were nationally representative. Methods: We established data use agreements (DUAs) with EMS agencies participating in PECARN to allow for agency identification through NEMSIS. Using 2019 NEMSIS version 3.4.0 data for EMS events with patients 18 years old and younger, we compared PECARN NEMSIS data to national NEMSIS data. Analyzed variables were selected for their ability to characterize events. No statistical analyses were utilized due to the large sample, instead, differences of ±5% were deemed clinically meaningful. Results: DUAs were established for 19 EMS agencies, creating a PECARN data set with 305,188 EMS activations of which 17,478 (5.7%) were pediatric. Of the pediatric activations, 17,140 (98.1%) were initiated through 9-1-1 and 9,487 (55.4%) resulted in transport by the documenting agency. The national data included 36,288,405 EMS activations of which 2,152,849 (5.9%) were pediatric. Of the pediatric activations 1,704,141 (79.2%) were initiated through 9-1-1 and 1,055,504 (61.9%) were transported by the documenting agency. Age and gender distributions were similar between the two groups, but the PECARN-specific data under-represents Black and Latinx patients. Comparison of EMS provider primary impressions revealed that three of the five most common were similar with injury being the most prevalent for both data sets along with mental/behavioral health and seizure. Conclusion: We demonstrated that NEMSIS can be leveraged to create network specific data sets. PECARN's EMS data were similar to the national data, though racial/ethnic minorities and some primary impressions may be under-represented. Additionally, more EMS activations in PECARN study areas originated through 9-1-1 but fewer were transported by the documenting agency. This is likely related to the type of participating agencies, their ALS response level, and the diversity of the communities they serve.

  View details for DOI 10.1080/10903127.2021.1951407

  View details for Web of Science ID 000677898200001

  View details for PubMedID 34232828

• Critical Factors in Planning a Pediatric Prehospital Airway Trial PREHOSPITAL EMERGENCY CARE Hansen, M., Bosson, N., Gausche-Hill, M., Shah, M. I., VanBuren, J. M., Wendelberger, B., Wang, H. 2022; 26 (4): 476-483

  Abstract

  Objective: The objective of this study was to assess factors influencing the design of a pediatric prehospital airway management trial, including minimum clinically significant differences for three clinical subgroups. Methods: We conducted a virtual consensus-conference among U.S. emergency medical services (EMS) agency medical directors and researchers in the Fall of 2020. This included (1) a preconference survey, (2) an interactive live videoconference, and (3) a postconference survey. Participants were identified through co-investigator relationships and by surveying "The Eagles," a consortium of medical directors from large urban EMS systems and, subsequently, through follow up email contact based on survey responses. Results: Twenty-seven of the 34 (80%) EMS agencies we invited responded to the prewebinar survey. Of the 27 agencies, 27 (100%) use BMV, 19 (70%) use endotracheal intubation (ETI), 21 (78%) use supraglottic airways (SGA). SGA use included 14 (52%) who use the iGel, 8 (30%) who use the King laryngeal tube (LT), and 2 (7%) who use a laryngeal mask airway (LMA). Three agencies use more than one of the available SGAs. Twenty (74%) of the EMS agencies indicated they had access to an SGA suitable for pediatric patients, and 9 (33%) agencies have access to pediatric video laryngoscopy. The majority of agencies indicated that the minimum clinically significant difference for survival to change practice was 1% for cardiac arrest patients with a baseline survival assumption of 7%, 4% for respiratory failure with a baseline survival assumption of 73%, and 3% for trauma with a baseline survival assumption of 42%. Overall, these agencies responded that BVM vs. SGA is the most important comparison that would change their practice. Conclusions: This virtual consensus conference provided a new perspective on current airway management practice and identified specific factors likely to drive change in pediatric prehospital airway management. This information will be leveraged in future trial design to ensure impactful clinical trials.

  View details for DOI 10.1080/10903127.2021.1918808

  View details for Web of Science ID 000656732700001

  View details for PubMedID 33886422

• Multicenter Evaluation of Prehospital Seizure Management in Children PREHOSPITAL EMERGENCY CARE Shah, M. I., Ostermayer, D. G., Browne, L. R., Studnek, J. R., Carey, J. M., Stanford, C., Fumo, N., Lerner, E. 2021; 25 (4): 475-486

  Abstract

  Seizures are a common reason why emergency medical services (EMS) transports children by ambulance. Timely seizure cessation prevents neurologic morbidity, respiratory compromise, and mortality. Implementing recommendations from an evidence-based pediatric prehospital guideline may enhance timeliness of seizure cessation and optimize medication dosing.We compared management of pediatric prehospital seizures across several EMS systems after protocol revision consistent with an evidence-based guideline.Using a retrospective, cross-sectional approach, we evaluated actively seizing patients (0-17 years old) EMS transported to a hospital before and after modifying local protocols to include evidence-based recommendations for seizure management in three EMS agencies. We electronically queried and manually abstracted both EMS and hospital data at each site to obtain information about patient demographics, medications given, seizure cessation and recurrence, airway interventions, access obtained, and timeliness of care. The primary outcome of the study was the appropriate administration of midazolam based on route and dose. We analyzed these secondary outcomes: frequency of seizure activity upon emergency department (ED) arrival, frequency of respiratory failure, and timeliness of care.We analyzed data for 533 actively seizing patients. Paramedics were more likely to administer at least one dose of midazolam after the protocol updates [127/208 (61%) vs. 232/325 (71%), p = 0.01, OR = 1.60 (95% CI: 1.10-2.30)]. Paramedics were also more likely to administer the first midazolam dose via the preferred intranasal (IN) or intramuscular (IM) routes after the protocol change [(63/208 (49%) vs. 179/325 (77%), p < 0.001, OR = 3.24 (2.01-5.21)]. Overall, paramedics administered midazolam approximately 14 min after their arrival, gave an incorrect weight-based dose to 130/359 (36%) patients, and gave a lower than recommended dose to 94/130 (72%) patients. Upon ED arrival, 152/533 (29%) patients had a recurrent or persistent seizure. Respiratory failure during EMS care or subsequently in the ED occurred in 90/533 (17%) patients.Implementation of an evidence-based seizure protocol for EMS increased midazolam administration. Patients frequently received an incorrect weight-based dose. Future research should focus on optimizing administration of the correct dose of midazolam to improve seizure cessation.

  View details for DOI 10.1080/10903127.2020.1788194

  View details for Web of Science ID 000550088200001

  View details for PubMedID 32589502

• Paramedic-Identified Enablers of and Barriers to Pediatric Seizure Management: A Multicenter, Qualitative Study PREHOSPITAL EMERGENCY CARE Carey, J. M., Studnek, J. R., Browne, L. R., Ostermayer, D. G., Grawey, T., Schroter, S., Lerner, E., Shah, M. 2019; 23 (6): 870-881

  Abstract

  Seizures have the potential to cause significant morbidity and mortality, and are a common reason EMS are requested for a child. An evidence-based guideline (EBG) for pediatric prehospital seizures was published and has been implemented as protocol in multiple EMS systems. Knowledge translation and protocol adherence in medicine can be incomplete. In EMS, systems-based factors and providers' attitudes and beliefs may contribute to incomplete knowledge translation and protocol implementation.The purpose of this study was to identify paramedic attitudes and beliefs regarding pediatric seizure management and regarding potential barriers to and enablers of adherence to evidence-based pediatric seizure protocols in multiple EMS systems.This was a qualitative study utilizing semi-structured interviews of paramedics who recently transported actively seizing 0-17 year-old patients in three different urban EMS systems. Interviewers explored the providers' decision-making during their recent case and regarding seizures in general. Interview questions explored barriers to and enablers of protocol adherence. Two investigators used the grounded theory approach and constant comparison to independently analyze transcribed interview recordings until thematic saturation was reached. Findings were validated with follow-up member-checking interviews.Several themes emerged from the 66 interviewed paramedics. Enablers of protocol adherence included point-of-care references, the availability of different routes for midazolam, and availability of online medical control. Systems-level barriers included equipment availability, controlled substance management, infrequent pediatric training, and protocol ambiguity. Provider-level barriers included concerns about respiratory depression, provider fatigue, preferences for specific routes, febrile seizure perceptions, and inaccurate methods of weight estimation. Paramedics suggested system improvements to address dose standardization, protocol clarity, simplified controlled substance logistics, and equipment availability.Paramedics identified enablers of and barriers to adherence to evidence-based pediatric seizure protocols. The identified barriers existed at both the provider and systems levels. Paramedics identified multiple potential solutions to overcome several barriers to protocol adherence. Future research should focus on using the findings of this study to revise seizure protocols and to deploy measures to improve protocol implementation. Future research should also analyze process and outcome measures before and after the implementation of revised seizure protocols informed by the findings of this study.

  View details for DOI 10.1080/10903127.2019.1595234

  View details for Web of Science ID 000493613200014

  View details for PubMedID 30917730

• Validity of the Pediatric Early Warning Score and the Bedside Pediatric Early Warning Score in Classifying Patients Who Require the Resources of a Higher Level Pediatric Hospital PREHOSPITAL EMERGENCY CARE Studnek, J. R., Browne, L. R., Shah, M., Fumo, N., Hansen, M., Lerner, E. 2020; 24 (3): 341-348

  Abstract

  Introduction: The pediatric early warning score (PEWS) and the bedside pediatric early warning score (BPEWS) are validated tools that help determine the need for critical care in children with acute medical conditions. These tools could be used by EMS and have not been evaluated outside of the hospital. This study retrospectively tested the validity of these tools in the prehospital setting to identify children who needed a hospital with higher level pediatric resources. Methods: This was a multi-center retrospective validation of screening tools using prehospital and in-hospital data obtained from 3 EMS agencies. EMS patient records from April 1, 2013 to April 30, 2015 were used to identify subjects for this analysis. Pediatric patients were retrospectively classified using the PEWS based on the clinical information documented in the EMS medical record. Those with PEWS scores greater than 4 were matched to a subject with scores less than 4 based on age, gender, and paramedic primary impression. Hospital medical record review was then used to determine whether the patient required a hospital with higher level pediatric resources. These classifications were used to calculate sensitivity, specificity, and resultant 95% confidence intervals. The analysis was repeated for included subjects who had sufficient data to calculate BPEWS. Results: There were 386 patients enrolled. A PEWS ≥ 4 demonstrated a sensitivity of 62.8 (95% CI 53.6-71.4) and a specificity of 55.9 (95% CI 49.6-61.9) in identifying a patient who required a hospital with higher level pediatric resources. There were 44 pairs of patients that had sufficient EMS data documented to calculate a BPEWS. A BPEWS ≥ 7 demonstrated a sensitivity of 46.4 (95% CI 27.5-66.1) and a specificity of 76.7 (95% CI 64.0-86.6) to correctly classify a patient who required a hospital with higher level pediatric resources. Conclusion: In the prehospital setting neither PEWS nor BPEWS exhibited sufficient sensitivity for clinical use to accurately identify children who need a hospital with higher level pediatric resources. Further research should be conducted to identify variables that are captured by prehospital care providers and are associated with children who need a hospital with higher level pediatric resources.

  View details for DOI 10.1080/10903127.2019.1645924

  View details for Web of Science ID 000485493500001

  View details for PubMedID 31339430

• Ready for Children: Assessing Pediatric Care Coordination and Psychomotor Skills Evaluation in the Prehospital Setting PREHOSPITAL EMERGENCY CARE Hewes, H. A., Ely, M., Richards, R., Shah, M. I., Busch, S., Pilkey, D., Hert, K., Olson, L. M. 2019; 23 (4): 510-518

  Abstract

  Objective: Pediatric patients represent low frequency but potentially high-risk encounters for emergency medical services (EMS) providers. Scant information is available from EMS agencies on the frequency of pediatric skill evaluation and the presence of pediatric emergency care coordination, both which may help EMS systems optimize care for children. The objective of our study was to assess the frequency and type of methods used to assess psychomotor skills competency using pediatric-specific equipment and pediatric care coordination in EMS ground transport agencies. Methods: A web-based assessment was sent to EMS agency directors in 58 states/territories to determine the presence of pediatric care coordination defined as an individual who oversees pediatric issues (Pediatric Care Coordinator or PECC) and the process for evaluating psychomotor skills of EMS providers using of pediatric equipment. Basic demographic information of each agency was collected. Descriptive statistics, odds ratios, and 95% confidence intervals were used for analyses. Results: The response rate was 78% (8,166/10,463 agencies). Almost 80% of agencies respond to fewer than 100 pediatric calls a year; over half of the agencies are located in urban areas and provide Advanced Life Support care. Twenty-three percent (23%) of EMS agency administrators report having a PECC and 28% have plans or interest in adding one. Of those agencies with a PECC, 26% report sharing the position among several agencies. Almost half (47%) of EMS agencies evaluate pediatric psychomotor skills at least twice a year. Agencies with a PECC, those with a medium to medium high pediatric call volume and agencies located in urban areas are more likely to evaluate psychomotor skills at least twice a year. Conclusions: Although few EMS agencies currently have a PECC, there is interest among EMS agency administrators to integrate one into their system. Pediatric-specific psychomotor skills testing is more common in EMS agencies that respond to a higher pediatric call volume and have a PECC. For EMS agencies that infrequently treat children, the presence of a PECC may enhance the frequency of pediatric psychomotor skills evaluation. The presence of a PECC can potentially increase provider confidence and safety for all pediatric prehospital patients regardless of volume and location.

  View details for DOI 10.1080/10903127.2018.1542472

  View details for Web of Science ID 000473517000009

  View details for PubMedID 30380953

• Pediatric Cervical Spine Clearance A Consensus Statement and Algorithm from the Pediatric Cervical Spine Clearance Working Group JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Herman, M. J., Brown, K. O., Sponseller, P. D., Phillips, J. H., Petrucelli, P. M., Parikh, D. J., Mody, K. S., Leonard, J. C., Moront, M., Brockmeyer, D. L., Anderson, R. E., Alder, A. C., Anderson, J. T., Bernstein, R. M., Booth, T. N., Braga, B. P., Cahill, P. J., Joglar, J. M., Martus, J. E., Nesiama, J. O., Pahys, J. M., Rathjen, K. E., Riccio, A. I., Schulz, J. F., Stans, A. A., Shah, M. I., Warner, W. C., Yaszay, B. 2019; 101 (1): e1

  View details for DOI 10.2106/JBJS.18.00217

  View details for Web of Science ID 000458568900001

  View details for PubMedID 30601421

• Determinants of Pediatric EMS Utilization in Children with High-Acuity Conditions PREHOSPITAL EMERGENCY CARE Quinones, C., Shah, M. I., Cruz, A. T., Graf, J. M., Mondragon, J. A., Camp, E. A., Reddy, P., Sampayo, E. M. 2018; 22 (6): 676-690

  Abstract

  Underutilization of emergency medical services (EMS) for children with high-acuity conditions is poorly understood. Our objective was to identify differences in demographic factors and describe caregivers' knowledge, beliefs, and attitudes regarding EMS utilization for children with high-acuity conditions.This was a mixed-methods study of children with high acuity conditions, defined as requiring immediate medical or surgical intervention and intensive care admission, over a one year period. Demographic data were collected through a retrospective chart review. Qualitative analysis of semi-structured interviews from a purposive sample of caregivers was conducted until thematic saturation was achieved.Three hundred seventy-four charts were reviewed; 19 caregivers were interviewed (17 in-person, 2 via telephone). The 232 (62%) children not arriving by EMS tended to be younger (1.58 years vs. 2.31 years, p = 0.02), privately insured (30% vs. 19%, p = 0.04), and lived further from the hospital (16.80 miles vs. 12.45 miles, p = 0.001). Patient gender, ethnicity, comorbidities and caregiver language were not associated with EMS underutilization. Immediate invasive medical interventions were more often required for EMS utilizers (85% vs. 60%, p < 0.001). EMS utilizers were more likely to require intubation (78% vs. 47%, p < 0.001) and cardiopulmonary resuscitation (CPR) (26% vs. 2%, p < 0.001), and had shorter hospital stays (4.70 vs. 8.16 days; p-value < 0.001). Three principal themes determined EMS utilization: expectations, knowledge, and perceived barriers. Three principal themes determined EMS utilization: expectations, knowledge, and perceived barriers. Caretakers expected EMS would provide timely, safe transportation that expedited medical care and emotional support. Medical knowledge and prior experience with EMS influenced decision-making about arrival mode. Timeliness, cost, socioeconomic and demographic characteristics, loss of autonomy, and the logistics of EMS activation and transport were the most commonly reported barriers.Young age, private insurance status, and greater distance from the hospital were associated with EMS underutilization. Understanding caregiver expectations, knowledge, and perceived barriers may have important implications for the use of EMS for children. These findings reveal opportunities for improved public education on EMS systems to enhance appropriate EMS utilization for children with high acuity conditions.

  View details for DOI 10.1080/10903127.2018.1445330

  View details for Web of Science ID 000452485300004

  View details for PubMedID 29565717

• Implementation of a Prehospital Protocol Change For Asthmatic Children PREHOSPITAL EMERGENCY CARE Nassif, A., Ostermayer, D. G., Hoang, K. B., Claiborne, M. K., Camp, E. A., Shah, M. I. 2018; 22 (4): 457–65

  Abstract

  Respiratory distress due to asthma is a common reason for pediatric emergency medical services (EMS) transports. Timely initiation of asthma treatment, including glucocorticoids, improves hospital outcomes. The impact of EMS-administered glucocorticoids on hospital-based outcomes for pediatric asthma patients is unknown.The objective of this study was to evaluate the effect of an evidence-based pediatric EMS asthma protocol update, inclusive of oral glucocorticoid administration, on time to hospital discharge.This was a retrospective cohort study of children (2-18 years) with an acute asthma exacerbation transported by an urban EMS system to 10 emergency departments over 2 years. The investigators implemented an EMS protocol update one year into the study period requiring glucocorticoid administration for all patients, with the major change being inclusion of oral dexamethasone (0.6 mg/kg, max. dose = 10 mg). Protocol implementation included mandatory paramedic training. Data was abstracted from linked prehospital and hospital records. Continuous data were compared before and after the protocol change with the Mann-Whitney test, and categorical data were compared with the Pearson χ2 test.During the study period, 482 asthmatic children met inclusion criteria. After the protocol change, patients were more likely to receive a prehospital glucocorticoid (11% vs. 18%, p = 0.02). Median total hospital time after the protocol change decreased from 6.1 hours (95% CI: 5.4-6.8) to 4.5 hours (95% CI: 4.2-4.8), p < 0.001. Total care time, defined as time from ambulance arrival to hospital discharge, also decreased [6.6 hours (95% CI: 5.8-7.3) vs. 5.2 hours (95% CI: 4.8-5.6), p = 0.01]. Overall, patients were less likely to be admitted to the hospital (30% vs. 21%, p = 0.02) after the change. Those with more severe exacerbations were less likely to be admitted to a critical care unit (82% vs. 44%, p = 0.02) after the change, rather than an acute care floor.Prehospital protocol change for asthmatic children is associated with shorter total hospital and total care times. This protocol change was also associated with decreased hospitalization rates and less need for critical care in those hospitalized. Further study is necessary to determine if other factors also contributed.

  View details for DOI 10.1080/10903127.2017.1408727

  View details for Web of Science ID 000436977600009

  View details for PubMedID 29351496