EMS vs Car Asthma Outcomes - PowerPoint Presentation

EMS vs CarAsthma Outcomes by Mode of Transportationto a Pediatric ED Emily McFerren, MD Pediatric Emergency Medicine November 13, 2019

OutlinePediatric Asthma“EMS vs Car” study overview Practical applications

Pediatric Asthma Asthma prevalence among children 0-17 years old. Asthma prevalence among children in the US. “Status of Childhood Asthma in the US,” Pediatrics, 2009.

Pediatric Asthma Chief complaints of pediatric EMS runs. ED visits among children. “Characteristics of Pediatric Patients,” Prehosp Emerg Care, 2014. “Children’s ED use,” Acad Pediatr , 2015. Asthma 2.8% Resp Distress 10.9%

Pediatric Asthma 104,338 ER Visits 2.8% asthma ~ 2,500 ER Visits

Ambulance versus Car: Outcomes by Mode of Transportation to theEmergency Department for Asthma Exacerbation Sick? Treated faster? Dispositioned faster? Admitted more?

Determine if patients’:TIME TO TREATMENT (primary outcome)TIME TO DISPOSITION DETERMINATION DISPOSITION STATUSWas affected by these modes of arrival: EMS vs Car: Purpose

2-year study, Ages 2-12, Matched on asthma severity & arrival time EMS vs Car: Methods Score 1 2 3 Respiratory Rate 2-3 years 4-5 years 6-12 years > 12 years  ≤ 34≤ 30≤ 26 ≤ 23   35-39 31-35 27-30 24-27   ≥ 40 ≥ 36 ≥ 31 ≥ 28 Oxygen Requirements > 95% on room air 90-95% on room air < 90% on room air or on any oxygen Auscultation Normal breath sounds to end-expiratory wheeze only Expiratory wheezing Inspiratory and expiratory wheezing to diminished breath sounds Retractions None or intercostal Intercostal & substernal Intercostal, substernal, and supraclavicular Dyspnea Speaks in sentences, coos, and babbles Speaks in partial sentences, short cry Speaks in single words/short phrases/grunting                   Scoring Reference Pediatric Asthma Score5-78-1112-15Asthma SeverityMildModerateSevere Pediatric Asthma Score Ann Allergy Asthma Immunol. 2000

Patients brought to the ED for asthma exacerbation (Nov 2016—Oct 2018) Arriving by ambulance Eligible patients Arriving by car Excluded patients   Nearest neighbor matching: PAS category (severity) Month of arrival (seasonality) 3-hour window of arrival (diurnal variations) EMS vs Car: Methods

n = 3542 Patients brought to the ED for asthma exacerbation (Nov 2016—Oct 2018) n = 229 Arriving by ambulance n = 118 Eligible patients n = 3313 Arriving by car n = 111 Excluded patients Age (n = 26) No asthma diagnosis (n = 6) Comorbidities present (n = 5) Steroid in last 7 days (n = 44) No initial PAS recorded (n = 16) No meds given at ED visit (n = 11) Missed during first analysis (n = 3)     n = 118 Nearest neighbor matching EMS vs Car: Methods

EMS vs Car: Results   AMBULANCE group (n = 118) CAR group (n = 118) p-value Baseline demographics       Age (years) 8.5 (5.0-12.0) 7.0 (3.0-11.0) 0.03 Gender Male (%) Female (%)   78 (66.1%) 40 (33.9%) 60 (50.9%) 58 (49.1%) 0.02 Race African American (%) Caucasian (%) Other (%) 83 (70.3%) 32 (27.1%) 3 (2.6%) 70 (59.3%) 43 (36.4%) 5 (4.3%) 0.14 Clinical characteristics       Duration of illness (days) 1.0 (1.0-2.0) 2.0 (2.0-3.0) < 0.01 Median transport time (minutes) 21.0 (16.0-30.0) N/A N/A Treated in transport 1 breathing treatment 2 breathing treatments 3 breathing treatments 1 IM epi80 (67.8%)61 (51.7%)17 (14.5%)1 (0.8%)1 (0.8%)N/AN/AInitial PAS score8.0 (6.0-11.0)8.0 (6.0-10.0)0.92Initial PAS severity categoryMild (%)Moderate (%)Severe (%)54 (45.8%)44 (37.3%)20 (16.9%) 54 (45.8%) 44 (37.3%) 20 (16.9%) N/A (as groups were matched on this)

EMS vs Car: Results   Adjusted LS means (95% CI) p-value Time to Beta Agonist (minutes) Mode of transportation Ambulance Car Initial severity Mild PAS Moderate PAS Severe PAS22.7 (19.5 – 26.5)27.4 (23.7 – 31.6)43.2 (37.3 – 50.5)26.7 (22.9 – 31.1)13.4 (10.6 – 16.8)< 0.01 0.10< 0.01 Time to Steroid (minutes) Mode of transportation Ambulance Car Initial severity Mild PAS Moderate PAS Severe PAS 42.6 (37.3 – 48.5) 54.2 (48.0 – 61.2)54.6 (48.0 – 62.0) 49.9 (43.9 – 56.8)40.7 (33.5 – 49.3) < 0.01 < 0.01 0.05 Time to Disposition (minutes) Mode of transportation Ambulance Car Initial severity Mild PAS Moderate PAS Severe PAS 118.1 (106.7 – 130.8) 130.7 (118.2 – 144.4) 94.6 (85.9 – 104.1) 145.6 (131.0 – 161.8) 139.1 (118.9 – 162.8) < 0.01 0.43 < 0.01

EMS vs Car: Results Results of Disposition Status Analysis p = 0.57

EMS vs Car: ConclusionsIn our tertiary pediatric ED, patients with asthma exacerbations are not treated in a clinically significant faster way if they arrive by ambulance – regardless of their initial severity. Why?Front line staff (RNs and RTs) are unbiased in how they treat patients.Medical providers are unbiased in how they disposition patients.

Although patients coming by EMS received steroids in a statistically significant faster way, we did not think this was clinically significant (13 min). Most patients who arrived by EMS:Were not particularly ill (median PAS 8).Were African AmericanLimitations: Cannot comment on overall comparison between EMS and car patients Some interrater variability in PAS scoringResults may not generalizable to other locations EMS vs Car: Conclusions

Practical Applications Activate EMS less from schools.

Practical Applications Update EMS protocols to include PAS score. PAS SCORE PAS SCORE: MILD (5-7) PAS SCORE: MOD-SEVERE (8-12) DECADRON RECOMMEND NON-EMERGENT TRANSPORT

ResourcesAkinbami LJ, Moorman JE, Garbe PL, et al. Status of childhood asthma in the United States, 1980-2007. Pediatrics. 2009; 123 Suppl 3:S131-45. Asthma Data, Statistics, and Surveillance. https://www.cdc.gov/asthma/asthmadata.htm. Accessed 10/16/19. Drayna PC, Browne LR, Guse CE, et al. Prehospital pediatric care: opportunities for training, treatment, and research. Prehosp Emerg Care. 2015; 19(3):441-7. Lerner EB, Dayan PS, Brown K, et al. Characteristics of the pediatric patients treated by the pediatric emergency care applied research network’s affiliated EMS agencies. Prehosp Emerg Care. 2014; 18(1):52-9.Tang N, Stein J, Hsia RY, et al. Children’s Emergency Department Use for Asthma, 2001–2010. Acad Pediatr. 1997-2007. 2015 ; 15(2): 225–230.Kelly CS, Anderon CL, Pestian JP, et al. Improved outcomes for hospitalized asthmatic children using a clinical pathway. Ann Allergy Asthma Immunol. 2000; 84(5):509-16.