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Medical equipment deployment in pediatric emergency prehospital medical units in Japan
Abstract
The deployment status of pediatric emergency equipment in ambulances in Japan is unknown. To investigate the status of and issues associated with prehospital emergency medical care for pediatric patients, we conducted a descriptive epidemiological study. We carried out a Web-based survey of 767 fire defense headquarters in Japan, of which 671 responded (valid response rate, 88%). Most of the fire defense headquarters equipped all of their ambulances with oxygen masks (82%), bag-valve masks (for neonates, 83%; for children, 84%), straight laryngoscope blades (for neonates, 47%; for children 68%), blood pressure cuffs for children (91%), oximeter probes (78%), and stiff neck collars (91%); but despite the need for other equipment such as nasopharyngeal and oropharyngeal airways, and Magill forceps, they were insufficiently deployed. In Japan, prehospital emergency medical equipment deployment does not meet the needs of pediatric patients. Minimum equipment standards need to be established for pediatric prehospital care.
... It was reported that EMS providers have heightened anxiety about the transportation of severely injured or ill children [6]. In addition, Japanese ambulances are not sufficiently equipped with medical equipment for children [7][8][9]. In prehospital settings, a prompt assessment of patients according to their clinical presentation rather than a focus on vital signs is important. ...
... Measuring the vital signs of children requires dedicated equipment for children and pediatric-size devices are required to measure blood pressure and oxygen saturation in infants and children. A survey of the fire department in Japan revealed that medical equipment for children were insufficient in Japanese ambulances [7][8][9]. Second, the frequency of care by EMS providers for severely injured children is limited [5,10]. A knowledge of pediatric physiology is required to interpret children's vital signs and ELSTs will have studied features about children in their course [23]. ...
Background
Emergency medical service (EMS) providers are the first medical professionals to make contact with patients in an emergency. However, the frequency of care by EMS providers for severely injured children is limited. Vital signs are important factors in assessing critically ill or injured patients in the prehospital setting. However, it has been reported that documentation of pediatric vital signs is sometimes omitted, and little is known regarding the performance rate of vital sign documentation by EMS providers in Japan. Using a nationwide data base in Japan, this study aimed to evaluate the relationship between patients’ age and the documentation of vital signs in prehospital settings.
Methods
This study was a secondary data analysis of the Japan Trauma Data Bank. The inclusion criterion was patients with severe trauma, as defined by an Injury Severity Score ≥ 16. Our primary outcome was the rate of recording all four basic vital signs, namely blood pressure, heart rate, respiratory rate, and level of consciousness in the prehospital setting among different age groups. We also compared the prehospital vital sign completion rate, that is, the rate at which all four vital signs were recorded in a prehospital setting based on age groups. Multivariate analysis was performed to evaluate factors associated with the prehospital vital sign completion rate.
Results
We analyzed 75,777 severely injured patients. Adults accounted for 94% (71400) of these severely injured patients, whereas only 6% of patients were children. The rate of prehospital recording of vital signs was lower in children ≤5 years than in adult patients for all four vital signs. When the adult group was used as a reference, the adjusted odds ratios of vital sign completion rate in infants (0 years), younger children (1–5 years), older children (6–11 years), and teenagers (12–17 years) were 0.09, 0.30, 0.78, and 0.87, respectively.
Conclusions
Analysis of the nationwide trauma registry showed that younger children tended to have a lower rate of vital sign documentation in prehospital settings.
... I N JAPAN, INJURY is a major cause of death in children. 1 To reduce preventable deaths due to injury, it is essential that severely injured patients receive efficient and specialized prehospital emergency care by emergency medical services (EMSs). 2 Although pediatric prehospital care is an important service worldwide, previous studies have reported deficiencies in the provision of equipment and training to care for critically injured children. [3][4][5][6] In Japan, the fire defense headquarters of the local governments provide EMSs. 7 The Emergency Life-Saving Technician Law of 1991 expanded the roles of ambulance crew members to provide an advanced level of emergency care, including procedures such as airway maintenance using an airway device, removal of a foreign body from respiratory tracts using forceps, and tracheal intubation/adrenaline administration for patients with cardiac arrest under physician supervision. ...
Aim
We evaluated the status of the allocation of medical emergency equipment suitable for pediatric patients of all ages.
Methods
In 2019, we surveyed the emergency medical officers from 728 fire defense headquarters around Japan. The questionnaire was designed to evaluate the kind and size of equipment available to ambulance crews for prehospital emergency care of injured pediatric patients. A complete pediatric equipment set was defined as a set containing equipment suitable for children aged 0–14 years.
Results
Overall, 599 (82%) fire defense headquarters responded to our survey. Of these, 596 (99.5%) declared that pediatric equipment was available to ambulance crews. The allocation rates of complete pediatric sets were considerably low: blood pressure cuff, 5%; nasopharyngeal airway, 1%; oropharyngeal airway, 7%; laryngoscope, 6%; supraglottic airway device, 13%; endotracheal tube, 0.2%; and bag‐valve‐mask, 23%. Moreover, none of these fire defense headquarters had complete pediatric equipment sets for all 14 devices assessed in this study.
Conclusions
Although most Japanese ambulances can provide prehospital emergency care to pediatric patients, this survey revealed the dispersion and deficiencies in the availability of complete pediatric equipment sets.
... Various aspects of emergency medical events have previously been examined in Scandinavian studies. Little attention has; however, been paid to paediatric patients, [1][2][3][4][5][6][7][8] which is unfortunate since robust paediatric prehospital emergency data may allow evaluation of the adequacy of prehospital responses to paediatric emergencies, improvements in the preparation and training of prehospital personnel for paediatric medical issues and prioritisation of future research in this field. ...
Objectives
The aim of this study is to determine diagnostic patterns in the prehospital paediatric population, age distribution, the level of monitoring and the treatment initiated in the prehospital paediatric case.
The hypothesis was that advanced prehospital interventions are rare in the paediatric patient population.
Setting
We performed a retrospective population-based registry cohort study of children attended by a physician-staffed emergency medical service (EMS) unit (P-EMS), in the Odense area of Denmark during a 10-year study period.
Participants
We screened 44 882 EMS contacts and included 5043 children. Patient characteristics, monitoring and interventions performed by the P-EMS crews were determined.
Results
We found that paediatric patients were a minority among patients attended by P-EMS
units: 11.2% (10.9 to 11.5) (95% CI) of patients were children. The majority of the children were <5 years old; one-third being <2 years old.
Respiratory problems, traffic accidents and febrile seizures were the three most common dispatch codes. Oxygen supplementation, intravenous access and application of a cervical collar were the three most common interventions. Oxygen saturation and heart
rate were documented in more than half of the cases, but more than one-third
of the children had no vital parameters documented. Only 22% of the children had
respiratory rate, saturation, heart rate and blood pressure documented.
Prehospital invasive procedures such as tracheal intubation (n=74), intraosseous access (n=22) and chest drainage (n=2) were infrequently performed.
Conclusion
Prehospital paediatric contacts are uncommon, more frequently involving smaller children. Monitoring or at least documentation of basic vital parameters is infrequent and may be an area for improvement. Advanced and potentially life-saving prehospital interventions provide a dilemma since these likely occur too infrequently to allow service providers to maintain their technical skills working solely in the prehospital environment.
Background:
Rapid identification of the severity of injuries in the field is important to ensure appropriate hospital care for better outcomes. Vital signs are used as a field triage tool for critically ill or injured patients in prehospital settings. Several studies have shown that recording vital signs, especially blood pressure, in pediatric patients is sometimes omitted in prehospital settings compared with that in adults. However, little is known about the association between the lack of measurement of prehospital vital signs and patient outcomes. In this study, we examined the association between the rate of vital sign measurements in the field and patient outcomes in injured children.
Methods:
This study analyzed secondary data from the Japan Trauma Data Bank. We included pediatric patients (0-17 years) with injuries who were transported by emergency medical services. Hospital survival was the primary outcome. We performed a propensity-matched analysis with nearest-neighbor matching without replacement by adjusting for demographic and clinical variables to evaluate the effect of recording vital signs.
Results:
During the study period, 13,413 pediatric patients were included. There were 9,187 and 1,798 patients with and without prehospital blood pressure records, respectively. After matching, there were no differences in the patient characteristics or disease severity. Hospital mortality was significantly higher in the non-recorded group than in the recorded group (4.3% vs. 1.1%; P < .001). The multiple logistic regression analysis results showed no prehospital record of blood pressure being associated with death (odds ratio [OR], 6.82; 95% confidence interval [CI], 2.40-19.33). Glasgow Coma Scale score and Injury Severity Score were also associated with death (OR, 0.71; 95% CI, 0.63- 0.81 and OR, 1.10; 95% CI, 1.06-11.14, respectively).
Conclusions:
Pediatric patients without any blood pressure records in prehospital settings had higher mortality rates than those with prehospital blood pressure records.
Level of evidence:
Therapeutic/Care Management IV.
要旨
【目的】 病院前救護活動における小児外傷患者に対する医療資機材の装備状況を調査すること。 【対象】 2019年，全国728消防本部の救急責任者に対しアンケート調査を実施した。病院前救護における小児外傷患者に対する小児用医療資機材の配備状況を，資機材の種類とサイズをもとに調査した。0～14歳の小児傷病者の対応に必要な全サイズの医療資機材を装備している場合を完全版小児セットと定義した。 【結果】 599消防本部から回答を得た（回答率82%）。596本部（99.5%）が小児用資機材を配備していると回答した。一方で，完全版小児セットの装備率は，血圧計カフで5%，経鼻エアウェイ1%，経口エアウェイ7%，喉頭鏡6%，上気道デバイス13%，気管挿管チューブ，バッグバルブマスク23%と極めて低かった。さらに，今回調査した14種類の医療資機材のすべてにおいて完全版小児セットを装備していた消防本部はなかった。 【結語】 ほぼすべての消防本部が小児用資機材は装備していると回答したが，全年齢層の小児外傷患者に対して病院前救護を実施するため必要な小児用医療資機材の装備は不十分であった。
Prehospital care has become a well-defined specialty service in Canada, with various levels of paramedics providing specialized care to children before their arrival to hospital. The equipment required may vary according to the needs of the population being served and the level of training of the paramedics who are providing the care. The present statement provides a current list of the minimum equipment recommended for the provision of prehospital care to neonatal and paediatric patients. The most notable change to the present guideline is the addition of an automated external defibrillator, which has been added to reflect the most recent version of the paediatric advanced life support recommendations for the provision of basic life support.
Proficiency in airway management in children is difficult to acquire and maintain for prehospital providers. The laryngeal mask airway is a relatively new airway device. Its ease of use makes it an attractive potential alternative to endotracheal tubes in pediatrics. The objective of this study was to investigate whether, in simulated cardiopulmonary arrests in children, the use of laryngeal mask airway, compared with endotracheal tubes, results in shorter time to effective ventilation when performed by prehospital providers.
A randomized, crossover study was conducted in a local paramedic training program. Fifty-two emergency medical technicians agreed to participate. After a 2-hour training session, an arrest scenario was presented to each participant by using an infant-sized human patient simulator. The participants were randomly assigned first to use 1 of the 2 devices. Time to successful ventilation was recorded. Number of attempts and results were recorded. After the airway was secured successfully, the scenario was repeated with the alternative device.
The mean +/- SD length of time to effective ventilation was 46 seconds when using endotracheal tubes and 23 seconds when using laryngeal mask airway, with a mean difference of 23 seconds. The mean number of attempts to achieve effective ventilation was 1.27 when using endotracheal tubes and 1.1 when using laryngeal mask airway. There were 9 (17%) episodes of esophageal intubations and 14 (27%) episodes of right main-stem intubations in the endotracheal tube group, and there were 5 (9.5%) episodes of malposition in the laryngeal mask airway group.
In simulated pediatric arrests, the use of laryngeal mask airway, compared with endotracheal tubes, led to more rapid establishment of effective ventilation and fewer complications when performed by prehospital providers.
In 1997 a review of paramedic practice upon adult patients in the UK found many inconsistencies and deficiencies in basic care. A follow up review in 2002 identified widespread improvement in provision of equipment and skills to provide basic and advanced life support.Paediatric care was not assessed in either review. The authors conducted this study to identify current standards of care in paediatric paramedic practice and areas of potential improvement.
A questionnaire designed to determine what equipment and skills were available to paramedics for the management of common or serious paediatric emergencies was sent to chief executives of the 32 NHS Ambulance Trusts in England and Wales.
The trend of expanding and standardising practice among adult patients has not extended to paediatric practice despite national guidelines from the Joint Royal Colleges Ambulance Liaison Committee (JRCALC). Furthermore there are some serious failings in the provision of care and skills. Many Trusts have not adopted JRCALC guidelines for the management of life threatening paediatric emergencies such as asthma, meningitis, and fluid replacement in hypovolaemia.
Ambulance Trusts not meeting standards set out in the JRCALC guidelines must address their areas of deficiency. Failure to do so endangers children's lives and leaves Trusts open to criticism.
Aim:
The use of automated external defibrillators was expanded to include infants according to the 2010 cardiopulmonary resuscitation guidelines in Japan. However, deployment has been slower for pediatric patients in Japan, because there are fewer appropriate pediatric patients for automated external defibrillators than adults. This study aimed to investigate the targeted age range for pediatric defibrillation and device deployment of defibrillators for pediatric patients in prehospital emergency medical care settings in Japan, and present the issues associated with automated external defibrillators.
Methods:
We administered a web-based survey to the fire defense headquarters in Japan regarding prehospital emergency medical care for pediatric patients in June 2013. We extracted and analyzed some parts of the data related to pediatric defibrillation.
Results:
Eighty-eight percent of the fire defense headquarters responded to the survey. Sixty-two percent of the fire defense headquarters applied the expanded indication protocol for pediatric defibrillation, which included infants. Forty-three percent of the fire defense headquarters replied that their emergency medical service personnel were using semi-automatic defibrillators without a pediatric mode, whereas 21% of them were using automated external defibrillators that were not equipped with pediatric attenuators. Moreover, many of the semi-automatic defibrillators are not designed for pediatric defibrillation in patients aged <8 years.
Conclusions:
Pediatric prehospital emergency medical care in Japan is inadequately equipped for pediatric defibrillation. It will be necessary to use age-appropriate defibrillators as the targeted age range for automated external defibrillators rapidly expands to include infants.
Airway management is of major importance in prehospital emergency care. Bag-valve mask (BVM) ventilation and endotracheal intubation (ETI) have been shown to be difficult, especially when caregivers are inexperienced. Alternative methods have been studied, and supraglottic devices have been shown to provide reasonable ease of placement and effective ventilation in manikin studies and anaesthetised patients. First responders (FR) are employed by many emergency medical services (EMS) to shorten initiation of emergency care, and they are trained to provide basic CPR including BVM and use of automated external defibrillators (AED) in case of out-of-hospital cardiac arrest (OCHA). The aim of this research was to study the feasibility of manikin-trained FRs using a laryngeal tube (LT) as a primary airway method during cardiac arrest. We trained 300 FRs to use a LT during OHCA. The FRs used a LT in 64 OHCA cases. The LT was correctly placed on the first attempt in 46/64 cases (71.9%) and on the second attempt in 13/64 cases (20.3%). Insertion was reported as being easy in 55/64 cases (85.9%). Median insertion time was 23.1s, with a range of 3-240s. We found that after manikin training, the FRs inserted the LT and performed adequate ventilation with a reasonable success rate and insertion time.
The purpose of this national survey of UK ambulance services was to provide an up-to-date assessment of service provision for children in the prehospital setting and to identify the challenges faced in providing optimal services to this group.
Questionnaires were sent to clinical directors of the 16 UK NHS ambulance services in April 2009.
Questionnaires were returned by 13 (81%) respondents. Paramedics and most emergency medical technicians receive a limited amount of paediatric training. An increasing amount of equipment suitable for children is becoming available, but services for children vary depending on location. For example, paediatric airway adjuncts (short of intubation) were often lacking, and only 62% reported having pulse oximetry suitable for use in children. Four or the 13 respondents (31%) considered it 'possible or highly likely' that someone with no specific training could be the first to respond to a child in an emergency, and seven (54%) indicated that the likelihood that the first response to a child could be someone with no current qualification specific to paediatrics was 'high'. There are large areas of the country where no formal medical support is available at any time of day.
Despite improvements, paediatric care by front-line personnel is limited by resource and availability of staff with key skills. Accepted standards are often lacking. Collaborative audit, research and training initiatives should be carried out between services and acute trusts to meet local service requirements. This will reduce variation and maintain the safety of patients and quality of care.
Equipment for ground ambulances
- American Academy of Pediatrics, American College of Emergency Physicians, American College of Surgeons Committee on Trauma, Emergency Medical Services for Children, Emergency Nurses Association, National Association of EMS Physicians, National Association of State EMS Officials
Pediatric Advanced Life Support Provider Manual
- L Chameides
- R A Samson
- S Schexnayder
Chameides L, Samson RA, Schexnayder S et al. Pediatric
Advanced Life Support Provider Manual. American Heart
Association, Dallas, 2011.
Pediatric Education for Prehospital Professionals
American Academy of Pediatrics. Pediatric Education for
Prehospital Professionals, 2nd edn. Jones and Bartlett
Publishers, Sudbury, 2006.
Emergency Nurses Association, National Association of EMS Physicians, National Association of State EMS Officials. Equipment for ground ambulances
American Academy of Pediatrics, American College of
Emergency Physicians, American College of Surgeons
Committee on Trauma, Emergency Medical Services for
Children,
Emergency
Nurses
Association,
National
Association of EMS Physicians, National Association of State
EMS Officials. Equipment for ground ambulances. Prehosp.
Emerg. Care 2014; 18: 92-7.