Quality of Care and Opportunities for Improvement in Prehospital Care of Critically Ill Pediatric Patients: An Observational, Simulation-Based Study.

Abstract

Objectives: Emergency medical services (EMS) clinicians infrequently care for infants or children. Simulation allows assessment of EMS at the individual, team, and agency level. Standardized tools to evaluate EMS team performance provides educators and EMS clinicians information on the quality of clinical skills performed in pediatric prehospital scenarios, providing opportunities for reinforcement or relearning. This study utilizes skills checklists to describe EMS team performance during three pediatric emergencies and describes skill performance within each simulation. As secondary objectives we evaluated performance differences among three states, and for teams whose agency had a pediatric emergency care coordinator (PECC) compared to those that did not.

Methods: This was a prospective cohort study of EMS clinician team performance, across three standardized pediatrics simulations: Respiratory (child asthma/respiratory arrest), Cardiac (infant cardiopulmonary arrest, and Neurological (sepsis/seizure). Simulations were conducted with 11 EMS agencies in three states, video-recorded and evaluated using standardized tools. Video recordings were evaluated if they included the complete simulation and the audio was intelligible. The primary outcome was mean percent of actions performed correctly in each simulation. Using a series of ANOVAs, comparisons were made among the three simulation types, states, and, whether there was an EMS PECC in participating agencies.

Results: There were 166 simulations conducted over 30 months of which 140/163 (84.3%) were evaluated. The mean percent of actions performed correctly by teams in the Respiratory simulation was higher than for Cardiac and Neurological simulations (Respiratory = 60.9%, SD = 8.9, range = 40-78.6%; Cardiac 58.7% (SD = 11.8, range = 26.0.1-81.0%); Neurological = 54.9%, SD = 9.9, range = 34.1-72.3%; p = 0.02), and no significant difference between Cardiac and Neurological simulation performance. There were differences by participating states in the Respiratory simulation performance (p = 0.04) and Neurological simulations (p = 0.03). The study was underpowered to determine if PECC presence was associated with improved performance.

Conclusions: In high acuity pediatric simulations, EMS teams demonstrated better resuscitation performance for children with child asthma/respiratory arrest than for infants with cardiopulmonary arrest or sepsis/seizure. The gaps noted in EMS quality of care can be used to guide educational and quality of care improvement interventions.