The National Pediatric Readiness Project, sponsored by emergency medical services (EMS) for Children Innovation and Improvement Center (EIIC), is a movement to ensure that all emergency departments (EDs) across the country are adequately equipped and prepared to provide quality care for pediatric patients. As part of the project, it was recommended that EDs appoint a pediatric emergency care coordinator (PECC) to manage pediatric related care.1-4 In a National Emergency Medical Services for Children Data Analysis Resource Center (NEDARC) survey that was conducted from 2013 to 2014, it was evident that the presence of PECCs in EDs was associated with higher pediatric preparedness scores (82.2 compared to 66.5).2,3
The association was persistent even after correcting for the total volume of patients. The importance of PECC is all the more vital when it comes to prehospital settings.5 In the 1997-2000 National Hospital Ambulatory Medical Care Survey, only 13% of EMS transports were pediatric runs, while pediatric visits comprised 27.3% in ED visits.6 Infrequent exposure to pediatric patients can make it challenging to maintain competency. Multiple studies have demonstrated a higher number of safety events rate in the pediatric population in the prehospital setting compared to adults.7-9
In an effort to standardize care for pediatric patients, modeling after the Pediatric Readiness Project, implementation of PECCs in EMS agencies is strongly encouraged.10,11 PECC Learning Collaborative, which was also sponsored by EIIC, set a goal of having 30% of EMS agencies implementing PECC by 2020.4 To our knowledge, Ohio is the first state that initiated PECC workshops as part of the collaborative. This survey study primarily aims to assess the efficacy of the PECC workshops in the implementation of PECCs in EMS agencies in Ohio. Secondary objectives are to identify specific positive changes after PECC implementation in EMS agencies and to identify barriers of PECC implementation.
- Pediatric BIPAP
- Pediatric Standardized Patients Enhance Paramedic Training
- Three Pillars for Pediatric Resuscitation Success
Ohio EMS for Children conducted seven workshops in six different regional locations, including Dayton, Toledo, Columbus, Akron, Youngstown, and Cincinnati from October 2017 to June 2018. During this period, the workshops were carried out in various intervals: Three (Cincinnati, Athens, Columbus) in October of 2017; two (Akron, Youngstown) in November of 2017; one (Columbus) in May of 2018; and the last one (Toledo) in June of 2018. PECC workshops focused on introductory information about PECC, but also held sessions on implementation and possible barriers of implementation.
In addition, workshops included discussion sessions on pediatric quality improvement, protocol development, and pediatric skills assessment. Each workshop lasted approximately half a day. An example of agenda is attached as Table 1.
Three or four volunteer pediatric instructors were recruited from local EMS agencies and children’s hospitals. The number of total participants was 194. IRB approval for the study was obtained at Rainbow Babies and Children’s Hospital in Cleveland, Ohio. The study used a pre and post study design.
After workshop completion, before and after status answers were collected in one survey. Once a workshop was planned at a certain location, Ohio EMSC sent out invitations to local EMS agency leadership. Representatives, mostly one but sometimes two people, of each local EMS agency participated in the workshop. Email addresses of the participants were collected at the time of workshops. Survey questions were sent out to these email addresses via Survey Monkey at a minimum of six month period after the workshops.
The survey included questions regarding prior knowledge about PECCs, presence of PECC at their agencies pre and post workshops, positive results if PECCs had been implemented, description of any barriers, how they overcame the barriers, and most, least helpful sessions during the workshop. As the majority of EMS providers receive none to limited ongoing pediatric training according to the NEADARC EMS survey, we also included a question about types of training desired.4
From August 31, 2018, to November 30, 2018, emails were sent at variable intervals. Responding to the survey was completely voluntary. No compensation was provided for answering the survey. Survey answers were collected anonymously. The IP address was the only respondent identifier. At the end of the survey period, data was collected and analyzed.
Of 194 EMS professionals who attended, email addresses of 128 were available at the time of the survey. The survey was sent out to all 128 participants with valid email addresses. Of 128, 43 (33.5%) responded. To the question about prior knowledge of PECC, 32 out of 43 (74.4%) answered no. To the question of having an already established PECC at their agency before the workshop, only 5 out of 43 (11.6%) answered yes. Of the 38 who did not have PECC before attending the workshop, 23 (60.5%) reported that they have implemented PECC.
Regarding barriers to implementation, the most common answer was a lack of resources such as pediatric checklists or guidelines. The second most common answer was the lack of financial support. The following question asked about efforts that were attempted as a result of attending the workshop. As this was an open-ended question, answers were variable. However, the most common answer was in the context of informing others at their agency about and need for PECCs (9/43, 21%).
The second most common answer was that no efforts were made (7/43, 16%). Other notable answers included buying pediatric equipment, seeking more pediatric training opportunities, and implementing pediatric QI and QA processes. At the time of the survey, a total of 28 agencies out of 43 had a PECC. Out of these 28 agencies, 20 (71.4%) answered that they are seeing positive and substantial changes at their agencies after PECC implementation. When asked to describe the changes, respondents commented about initiating pediatric targeted programs such as car seat programs, having a person to review pediatric transports for quality improvement, having more pediatric training opportunities and regularly reviewing pediatric guidelines.
One comment noted they are overall “better prepared for pediatric emergencies.” The last question of the survey asked about the types of training they would like to receive to improve pediatric care. The most common answer was in-person simulation sessions (16/43, 37%). The second most common answer was a review of pediatric procedure skills (13/43, 30%). The third most common answer was online pediatric modules.
Our study aimed to assess the effectiveness of PECC workshops in implementing PECCs in EMS agencies in the state of Ohio. 23 out of 38 (60.5%) of the people who did not have a PECC at their agencies implemented PECCs after participating in the workshop. We assumed 23 responses were from separate agencies, although we were unable to confirm due to the lack of identifiers, as most of the attendees had sent one representative to the workshops. Given no other state-level interventions were conducted during this time, the increased number of implementations was attributed to PECC workshops.
Given a relatively low number of EMS agencies that are interested in adding a PECC in the absence of any intervention (4,12), 60.5% is a significant increase. Another 71.4% of the people who have PECCs experienced positive changes at their agencies are listed in the result section.
Overall, the above results are encouraging. We also tried to identify barriers of implementation and what measures could be carried out to help EMS agencies to implement PECCs. As the most commonly identified barrier was lack of resources such as pediatric checklists or guidelines, we recommend that efforts be made to formulate and disseminate general prehospital pediatric equipment checklist and treatment protocols. To the question about the types of pediatric training they need, the three top answers were an in-person simulation, pediatric procedure skill session and online pediatric modules.
Although the first two training types require much personnel and equipment resources and face sustainability challenges, the third most common answer, online modules, may be considered for future direction. Given its reproducibility, consistency, and easy accessibility, interactive online modules are promising for continued pediatric training especially for rural agencies. These interventions will become more feasible with PECC implementations, which in turn, will lead to better patient outcome.
As mentioned earlier, the movement to implement PECCs in EMS agencies was derived from the National Pediatric Readiness Project, which had found a better pediatric readiness score in EDs with PECCs.2,3 The subsequent study revealed that higher pediatric readiness score is associated with lower mortality rate in critically ill patients.13 Although more research is needed to see patient outcomes comparing EMS agencies with PECC versus no PECC, we can be optimistic that prehospital data will replicate that of the in-hospital.
Our study carries inherent limitations of before and after study. We did not survey the rest of the agencies that did not participate in PECC workshops, leaving us with no control group. The survey response rate was 33.5%, placing the study at risk for non-response bias. It could be speculated that only the people who were satisfied with the workshop had replied. Despite the limitations, because there were no other interventions to increase the number of PECCs during this period in the state of Ohio, we cautiously conclude that conducting PECC workshops is an effective way of implementing PECCs in EMS agencies. As there is a national effort to appoint PECCs in EMS agencies, we suggest PECC workshops as a powerful initiation tool to introduce and implement PECC.
- Remick K. Gausche-Hill M, Joseph MM, et al; AMERICAN ACADEMY OF PEDIATRICS Committee on Pediatric Emergency Medicine and Section on Surgery, AMERICAN COLLEGE OF EMERGENCY PHYSICIANS Pediatric Emergency medicine Committee, EMERGENCY NURSES ASSOCIATION Pediatric Committee. Pediatric Readiness in the Emergency Department. Pediatrics. 2018; 142 (5):e20182459.
- Gausche-Hill M, Ely M, Schmuhl P et al. A National Assessment of Pediatric Readiness of Emergency Departments. JAMA Pediatr. 2015;169(6):527. doi:10.1001/jamapediatrics.2015.138.
- Remick K, Kaji AH, Olson L, Ely M, Schmuhl P, McGrath N, Edgerton E, Gausche-Hill M. Pediatric readiness and facility verification. Ann Emerg Med. 2016;67:320-328.e1. doi:10.1016/j-annermergmed.2015.07.500.
- Emergency Medical Services for Children Innovation and Improvement Center. Pediatric Emergency Care Coordinator Community of Practice (PECC CoP). Houston (TX); [accessed 2020 April 15]. https://emscimprovement.center/collaboratives/pecclc/pediatric-emergency-care-coordinat or-learning-collaborative-pecclc/.
- Remick K, Gross T, Adelgais K, Shah M, Leonard J, Gausche-Hill M. Resource Document: Coordination of Pediatric Emergency Care in EMS Systems. Prehospital Emergency Care. 2017;21(3):399-407. doi:10.1080/10903127.2016.1258097.
- Shah M, Cushman J, Davis C, Bazarian J, Auinger P, Friedman B. The Epidemiology of Emergency Medical Services Use by Children: An Analysis of the National Hospital Ambulatory Medical Care Survey. Prehospital Emergency Care. 2008;12(3):269-276. doi:10.1080/10903120802100167.
- Meckler G, Hansen M, Lambert W et al. Out-of-Hospital Pediatric Patient Safety Events: Results of the CSI Chart Review. Prehospital Emergency Care. 2017;22(3):290-299. doi:10.1080/10903127.2017.1371261.
- Duby R, Hansen M, Meckler G, Skarica B, Lambert W, Guise J. Safety Events in High Risk Prehospital Neonatal Calls. Prehospital Emergency Care. 2017;22(1):34-40. doi:10.1080/10903127.2017.1347222.
- Hoyle J, Crowe R, Bentley M, Beltran G, Fales W. Pediatric Prehospital Medication Dosing Errors: A National Survey of Paramedics. Prehospital Emergency Care. 2017;21(2):185-191. doi:10.1080/10903127.2016.1227001.
- Institute of Medicine Committee on the Future of Emergency Care in the U.S. Health System. Pediatric emergency care: growing pains. Washington, DC: National Academies Press, 2007.
- Physician Oversight of Pediatric Care in Emergency Medical Services. Prehospital Emergency Care. 2016;21(1):88-88. doi:10.1080/10903127.2016.1229826.
- Hewes H, Ely M, Richards R et al. Ready for Children: Assessing Pediatric Care Coordination and Psychomotor Skills Evaluation in the Prehospital Setting. Prehospital Emergency Care. 2018;23(4):510-518. doi:10.1080/10903127.2018.1542472.
- Ames SG, Davis BS, Marin JR, L. Fink EL, Olson LM, Gausche-Hill M, Kahn JM. Emergency Department Pediatric Readiness and Mortality in Critically Ill Children. Pediatrics. 2019;144(3):e20190568. Pediatrics. 2020;145(5):e20200542. doi:10.1542/peds.2020-0542.