Impact of a Pediatric Prehospital Destination Decision Support Tool (PDTree) on Emergency Medical Services Transport Patterns and Destination Choice.

Objectives: The objective of this study was to compare emergency medical services (EMS) agency transport patterns for pediatric transports, including bypass of the nearest emergency department, before and after implementation of an evidence-based decision support tool to guide EMS clinicians' pediatric transport destinations.

Methods: This is an observational cohort study comparing pediatric transports one year before and one year after implementation of the Pediatric Decision Tree (PDTree) tool in three geographically and demographically distinct fire-based EMS systems in Maryland, USA. Patients aged 0 to 17 years undergoing EMS transport from one of the three participating counties were included. Patients meeting trauma center transport criteria were excluded. Hospital pediatric capabilities were defined a priori, and geocoded scene and transport destination locations were used to determine bypass rates. Bypass patterns and distances were compared between the pre-implementation and post-implementation periods.

Results: Included pediatric patients transported from the three counties numbered 9,782 in 2019 (post-implementation) and 11,945 in 2016 (pre-implementation). After implementation of the PDTree, 48.8% of all pediatric patients underwent EMS bypass of the nearest facility compared to 42.6% before implementation (p < 0.001). While the overall rate of bypass increased, the bypass proportion transporting to the highest-level pediatric facility decreased from 63.1% to 50.1% and the proportion of bypass to intermediate pediatric facilities increased from 26.2% to 37.7% (p < 0.001).

Conclusions: Implementation of the PDTree pediatric direct transport decision support tool increased the bypass rate and, subsequently, direct transport to more pediatric capable facilities. Despite this increase in the bypass of the nearest facility, the proportion transporting to large tertiary specialty children's centers decreased, while there was a significant increase in transport to intermediate pediatric facilities. Regional and national EMS governing bodies should balance benefits of pediatric direct transport protocols with operational costs to better meet the needs of pediatric populations.