- Email: [email protected]
Ambulance use by high-acuity patients in a pediatric ED
Ambulance Use by High-Acuity Patients in a Pediatric ED SUSANNE KOST, MD, KATHLEEN CRONAN, MD, MARC GORELICK, MD, MSCE, AND JAIME ARRUDA, BA The objective of this study was to analyze ambulance usage by highest acuity patients as compared with all patients in a suburban pediatric hospital ED. A 1-year retrospective records analysis was conducted of all highest acuity patients (those patients triaged as emergent or critical or admitted to the intensive care unit). A total of 245 patients made 270 high-acuity visits to the ED in 1995. Thirty-one (13%) of the high-acuity patients arrived via ambulance; the rest arrived via private vehicle. The 31 high-acuity patients constituted 8% of the total number of patients arriving by ambulance. There was no significant difference in ambulance usage between insurance groups in the high-acuity patients. Only high-acuity patients with neurologic symptoms (primarily seizures) had a greater relative use of EMS transportation, with 39% of these patients arriving via ambulance (odds ratio 6.6, 95% confidence interval 2.6, 16.6). High-acuity patients account for the minority of total ambulance usage in our ED. (Am J Emerg Med 2000;18:679-682. Copyright 娀 2000 by W.B. Saunders Company)
Many studies have examined the issue of inappropriate ambulance use in both adult1-5 and pediatric6-9 populations. The primary focus of these studies is on overuse of prehospital emergency medical services (EMS) by nonacute patients. However, there is little published information about underuse of ambulance services by severely ill or injured patients. Two studies focusing on the issue of ‘‘unmet need’’ as well as inappropriate ambulance use in the adult population found that well over half of the most acute patients did not use ambulance transportation.1,5 Although underuse of ambulance services among children is suggested by the relative underrepresentation of pediatric patients in the overall EMS population, accounting for about 10% of the EMS usage in areas where 30% of the emergency department (ED) visits are pediatric,10-14 there are no previous studies of ambulance use specifically among high-acuity pediatric patients. We report an analysis of ambulance usage patterns by the most acute patients as compared with all patients in our suburban pediatric ED population. The objective of this study was to quantify ambulance use by more acute patients, as well as to evaluate the roles of age, insurance status, and type of illness on ambulance use by such patients. From the A.I. duPont Hospital for Children, Wilmington, DE. Abstract presented in poster form at the National Association of EMS Physicians Mid-Year Meeting and Scientific Assembly Incline Village, NV, July 1997. Manuscript received December 3, 1999, accepted April 29, 2000. Address reprint requests to Susanne Kost, MD, A.I. duPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19899. E-mail: [email protected] Key Words: Emergency medical services, use, ambulance, health services needs. Copyright 娀 2000 by W.B. Saunders Company 0735-6757/00/1806-0008$10.00/0 doi:10-1053/ajem.2000.16290
METHODS The study took place in the ED of a suburban children’s hospital with an annual census of approximately 19,000 visits. As the only pediatric hospital in the state, it serves as a regional referral center, and has the only pediatric intensive care unit (PICU) in the county. However, the ED is not designated as a trauma center. The area is served by volunteer Basic Life Support (BLS) ambulance crews, who are backed up by professional Advanced Life Support crews (ALS) when necessary. We conducted a retrospective records analysis of all high-acuity patients who arrived in our ED in 1995. High-acuity was defined a priori as patients who received a triage designation of emergent or critical, or who were admitted to the PICU from the ED. Patients were identified through a PICU admission database, as well as a review of the ED admission database for patients triaged as critical or emergent. Triage in our ED is based on a previously established four-tier system (critical, emergent, urgent, nonurgent), with critical patients requiring immediate attention (eg, apnea, active seizure) and emergent patients requiring physician attention within 30 minutes (eg, severe respiratory distress, severe dehydration). The criteria for critical or emergent triage designations are somewhat more conservative than those used in other institutions, for example, most acute asthmatics are triaged as urgent rather than emergent. Fewer than 5% of our patients receive critical or emergent triage designations. Data collected from the ED record of high-acuity patients included: patient age, gender, type of insurance, mode of arrival (private vehicle, BLS, ALS, or helicopter), ambulance interventions, location from which transport occurred, ED triage classification, chief complaint, ED diagnosis, and disposition. In cases where a patient had more than one visit to the emergency department during the study period, only data from the first visit were included in the analysis. Diagnostic categories were assigned by the principal investigator (S.K.) based on the ED discharge diagnosis. In the case of a discharge diagnosis that could fit more than one category, group consensus was reached. The most common ‘‘overlaps’’ were respiratory distress as a result of an infectious process (all put into the respiratory category) and traumas resulting in surgery (all put into the trauma category). Statistical analyses were performed using Stata release 5.0 (Stata Corporation, College Park, TX). Proportions were compared using chi-square or Fisher’s exact test; when appropriate, odds ratios with 95% confidence intervals were calculated. Comparison of means was done using t test. An a priori level of significance of P ⬍ .05 was chosen. 679
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 6 䊏 October 2000
680
TABLE 1. ED Diagnostic Categories of the High-Acuity Patients Diagnostic Category of High-Acuity Patients
Number (%)
Ambulance
Car
% by EMS
Respiratory Diabetic ketoacidosis Trauma Neurologic Surgical Ingestion Infectious Other
99 (36%) 36 (13%) 26 (10%) 23 (8%) 23 (8%) 22 (8%) 16 (6%) 25 (10%)
11 1 4 9 1 2 1 2
88 35 22 14 22 20 15 23
11 3 15 39* 9 9 6 8
*Odds ratio 6.6 v other categories, P ⬍ .001.
The study was approved by the Clinical Research Review Committee of the Institutional Review Board of our institution. RESULTS A total of 245 patients made 270 high-acuity visits to the ED in 1995. The mean age was 5.9 years, and 52% were boys. 31 (13%) arrived via EMS transportation; the rest arrived by private vehicle. Of those who arrived via EMS, 21 arrived via BLS units, 9 via ALS units, and 1 via helicopter (ALS crew). There was no significant difference in the age of patients who arrived by ambulance (5.2 yrs) compared with those who arrived by car (6.0 yrs). During the same time period, a total of 381 patients were transported to our institution via ambulance; thus, the high-acuity patients accounted for 8% of the overall ambulance usage in 1995. The ED diagnostic categories of the high-acuity patients are shown in Table 1. The majority (36%) of patients classified as high-acuity presented with respiratory disorders. Most of these patients were diagnosed with status asthmaticus. All of those diagnosed with diabetic ketoacidosis were sent to the PICU for insulin infusion (pH ⬍7.2). The majority of those in the neurologic category were known or suspected to have had seizures. All of those listed in the surgical category were nontraumatic (eg, acute abdomen or testicular torsion); traumas were listed as such
even if they required surgery. Of the diagnostic categories considered, only high-acuity patients with neurologic symptoms (primarily seizures) had a greater relative use of EMS transportation, with 39% of these patients arriving via ambulance (odds ratio 6.6, 95% confidence interval 2.6, 16.6). Insurance information was available for 240 of the 245 high-acuity patients; 90 patients were insured by Medicaid, 15 were self-pay, and 135 had private or commercial insurance. The insurance mix of the high-acuity patients did not differ significantly from that of the overall ED population. Although Medicaid patients were more likely to use ambulance services than patients with private insurance in the overall ED population, this discrepancy did not exist for the high-acuity patients (see Fig 1). Information on ambulance interventions was available for 22 of the 31 acute patients transported by ambulance (see Table 2). Seventeen patients (77%) for whom ambulance information was available had some intervention. All of the high-acuity patients had interventions in the ED. The majority of the high-acuity patients were admitted to the hospital (see Table 3). Six patients required cardiopulmonary resuscitation (CPR) and intubation. Of these six patients, two arrived by car, two via BLS with no interventions en route, and two arrived via ALS, one of whom was successfully intubated in the field. Both patients who arrived via BLS had conditions not recognized by the ambulance crews—one in status epilepticus and one with hypovolemic shock. Two of these six patients expired in the ED, one who arrived via car and one who was successfully intubated by paramedics. DISCUSSION The results of our study show that the vast majority (87%) of the most acutely ill patients arriving in our ED in 1995 did not use the EMS system. This remarkable underuse of ambulance transportation points out that ambulance misuse may constitute not only calling an ambulance unnecessarily, but also not calling an ambulance when you need one.
FIGURE 1. Ambulance use by insurance type.
KOST ET AL 䊏 AMBULANCE USE BY HIGH-ACUITY IN A PED PATIENTS TABLE 2. Ambulance Interventions (N ⫽ 17) Patients Receiving by Diagnostic Category Intervention
Resp
Trm
Neur
DKA
Ing
Oth
N⫽ Immobilization Intubation Oxygen Intravenous catheter Medications
3
4 4
7 1 1 4 4 1
1
1
1
1
1 1
1 1
3 2
The reasons for this lack of ambulance use in sicker patients were not addressed on an individual case basis, but we can comment on age and insurance status with regard to ambulance use. Previous epidemiologic EMS studies have shown that younger patients tend to use the EMS system less than older patients10,11,13 but our study shows no association between age and ambulance usage among high-acuity patients. This discrepancy could be explained by our lack of major trauma; most of the older patients in other studies have been adolescents involved in motor vehicle crashes.10,13 Previous studies of inappropriate ambulance use in all ambulance users, including acute and nonacute patients, have shown a significantly higher rate of misuse by patients insured by Medicaid.2,3,8,9 We found a similar overrepresentation of Medicaid-insured patients among all patients transported by ambulance to our ED, but not among the most acute patients that are the focus of this study (see Fig 1). Thus, insurance does not appear to be a factor in ambulance underuse by the highest acuity patients. Indeed, subtracting the more acute patients from the overall population of ambulance users may serve to increase the proportion of apparent overuse by Medicaid patients. Pediatricians may not consider sending ill patients to the hospital by ambulance for a variety of reasons, including the perception that automobile transportation will be faster.15 Although the issue of parental reasons for not calling an ambulance has not been addressed in the literature, one could speculate that when parents are accustomed to transporting children via private vehicle, especially in our hospital’s suburban environment, they may perceive this mode of transportation to be most efficient when their children are truly ill. In a population-based study, Maio et al showed an inverse relationship between ambulance usage and access to a private vehicle.16 Parents may access EMS more commonly for sudden emergencies, such as seizures and injuries, but self-transport ill-appearing children with more chronic symptoms such as fever or dehydration.17 The TABLE 3. Disposition of High-Acuity Patients Disposition
Number
Home Regular inpatient unit ICU OR Transfer Deceased Not recorded
50 44 142 5 1 2 2
681
results of our study support this theory, in that patients with seizures and trauma had the highest rates of EMS transport, whereas patients with problems of relatively slow onset, such as diabetic ketoacidosis and infections, were significantly more likely to arrive by car than by ambulance. Another possible explanation for the lack of use of the EMS system in our population may be a lack of understanding of the ability of EMS personnel to provide not only transportation but interventions. Although our ability to comment on ambulance interventions was limited by our inability to track some of the ambulance trip sheets, we found that a large majority of high-acuity children brought by ambulance in this setting received prehospital treatment of some type, underscoring the importance of this aspect of the EMS system. Pediatricians and parents, however, may not realize what paramedics are capable of providing en route to the hospital. The potential weaknesses of our study deserve mention. Although we made an effort through the use of several data sources (ED logbook, ambulance log, PICU admission database) to identify our most acute patients, some highacuity patients may have been missed. It is also possible that some of the most acute pediatric patients were taken to other facilities in our area. Although high-acuity pediatric trauma patients are preferentially transported to the level I trauma center nearby, we feel it is unlikely that other high acuity patients are preferentially transported away from our facility, given our status as the only pediatric hospital in the state, and the only PICU within a 30 mile radius. Another potential weakness of our study is that our definition of high-acuity patients may not be accurate. Unfortunately, no scale predicting overall severity of illness in the pediatric population exists to date that is applicable in the prehospital/ED setting. However, by limiting the study population to those patients admitted to the PICU or triaged among the sickest 5% of our patient volume, we attempted to study the most acute (at presentation) subset, those in whom the need for ambulance transport would be the least questionable. In conclusion, the most acute patients in our ED failed to access prehospital services in the majority of cases. Although the reasons for this lack of ambulance use have not been addressed directly, physician and patient education in this area may be helpful. Private physicians need to be familiar with the prehospital system capabilities in their areas. They in turn must teach their patients when it is appropriate to call an ambulance. One promising step in this direction is the Office Preparedness for Pediatric Emergencies program developed under the auspices of an EMS-C grant in North Carolina.18 Pediatric emergency physicians should consider taking on the role of facilitator between EMS and the community on a national scale. Such an educational program may serve to reduce previously documented overuse of emergency medical services by low acuity patients, while improving the low rates of appropriate use by the sickest patients. REFERENCES 1. Chen JC, Bullard MJ, Liaw SJ: Ambulance use, misuse, and unmet needs in a developing emergency medical services system. Eur J Emerg Med 1996;3:73-8
682
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 6 䊏 October 2000
2. Billittier AJ, Moscati R, Janicke D, et al: A multisite survey of factors contributing to medically unnecessary ambulance transports. Acad Emerg Med 1996;3:1046-52 3. Brown E, Sindelar J: The emergent problem of ambulance misuse. Ann Emerg Med 1993;22:646-50 4. Gardner GJ: The use and abuse of the emergency ambulance service: Some of the factors affecting the decision whether to call an emergency ambulance. Arch Emerg Med 1990;7:81-9 5. Rademaker AW, Powell DG, Read JH: Inappropriate use and unmet need in paramedic and nonparamedic ambulance systems. Ann Emerg Med 1987;16:553-6 6. Rosenberg N, Knazik S, Cohen S, et al: Use of emergency medical service transport system in medical patients up to 36 months of age. Pediatr Emerg Care 1998;14:191-3 7. Foltin GL, Pon S, Tunik M, et al: Pediatric ambulance utilization in a large American city: A systems analysis approach. Pediatr Emerg Care 1998;14:254-8 8. Carmasso-Richardson K, Wilde JA, Petrack EM: Medically unnecessary pediatric ambulance transports: A medical taxi service? Acad Emerg Med 1997;4:1137-41 9. Brady WJ, Hennes H, Wolf A, et al: Pattern of basic life support ambulance use in an urban pediatric population. Am J Emerg Med 1996;14:250-3
10. Svenson JE, Nypaver M, Calhoun R: Pediatric prehospital care: Epidemiology of use in a predominantly rural state. Pediatr Emerg Care 1996;12:173-9 11. Seidel JS, Henderson DP, Ward P, et al: Pediatric prehospital care in urban and rural areas. Pediatr 1991;88:681-90 12. Johnston C, King WD: Pediatric prehospital care in a southern regional emergency medical services system. South Med J 1988;81: 1473-6 13. Tsai A, Kallsen G: Epidemiology of pediatric prehospital care. Ann Emerg Med 1987;16:284-92 14. Fifield GC, Magnuson C, Carr WP, et al: Pediatric emergency care in a metropolitan area. J Emerg Med 1984;1:594-507 15. Baker MD, Ludwig S: Pediatric emergency transport and the private practicioner. Pediatr 1991;88:691-5 16. Maio RF, Tedeschi P, Swor R, et al: Regional variation of nonrural pediatric ambulance transport rates: An ecological study. Pediatr Emerg Care 1996;12:277-82 17. Foltin GL: Critical issues in urban emergency medical services for children. Pediatr 1995;96:174-9 (suppl) 18. Frush K, Cinoman M (eds): Office Preparedness for Pediatric Emergencies. Washington, National EMSC Resource Alliance, Item 0614, 1996
Many studies have examined the issue of inappropriate ambulance use in both adult1-5 and pediatric6-9 populations. The primary focus of these studies is on overuse of prehospital emergency medical services (EMS) by nonacute patients. However, there is little published information about underuse of ambulance services by severely ill or injured patients. Two studies focusing on the issue of ‘‘unmet need’’ as well as inappropriate ambulance use in the adult population found that well over half of the most acute patients did not use ambulance transportation.1,5 Although underuse of ambulance services among children is suggested by the relative underrepresentation of pediatric patients in the overall EMS population, accounting for about 10% of the EMS usage in areas where 30% of the emergency department (ED) visits are pediatric,10-14 there are no previous studies of ambulance use specifically among high-acuity pediatric patients. We report an analysis of ambulance usage patterns by the most acute patients as compared with all patients in our suburban pediatric ED population. The objective of this study was to quantify ambulance use by more acute patients, as well as to evaluate the roles of age, insurance status, and type of illness on ambulance use by such patients. From the A.I. duPont Hospital for Children, Wilmington, DE. Abstract presented in poster form at the National Association of EMS Physicians Mid-Year Meeting and Scientific Assembly Incline Village, NV, July 1997. Manuscript received December 3, 1999, accepted April 29, 2000. Address reprint requests to Susanne Kost, MD, A.I. duPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19899. E-mail: [email protected] Key Words: Emergency medical services, use, ambulance, health services needs. Copyright 娀 2000 by W.B. Saunders Company 0735-6757/00/1806-0008$10.00/0 doi:10-1053/ajem.2000.16290
METHODS The study took place in the ED of a suburban children’s hospital with an annual census of approximately 19,000 visits. As the only pediatric hospital in the state, it serves as a regional referral center, and has the only pediatric intensive care unit (PICU) in the county. However, the ED is not designated as a trauma center. The area is served by volunteer Basic Life Support (BLS) ambulance crews, who are backed up by professional Advanced Life Support crews (ALS) when necessary. We conducted a retrospective records analysis of all high-acuity patients who arrived in our ED in 1995. High-acuity was defined a priori as patients who received a triage designation of emergent or critical, or who were admitted to the PICU from the ED. Patients were identified through a PICU admission database, as well as a review of the ED admission database for patients triaged as critical or emergent. Triage in our ED is based on a previously established four-tier system (critical, emergent, urgent, nonurgent), with critical patients requiring immediate attention (eg, apnea, active seizure) and emergent patients requiring physician attention within 30 minutes (eg, severe respiratory distress, severe dehydration). The criteria for critical or emergent triage designations are somewhat more conservative than those used in other institutions, for example, most acute asthmatics are triaged as urgent rather than emergent. Fewer than 5% of our patients receive critical or emergent triage designations. Data collected from the ED record of high-acuity patients included: patient age, gender, type of insurance, mode of arrival (private vehicle, BLS, ALS, or helicopter), ambulance interventions, location from which transport occurred, ED triage classification, chief complaint, ED diagnosis, and disposition. In cases where a patient had more than one visit to the emergency department during the study period, only data from the first visit were included in the analysis. Diagnostic categories were assigned by the principal investigator (S.K.) based on the ED discharge diagnosis. In the case of a discharge diagnosis that could fit more than one category, group consensus was reached. The most common ‘‘overlaps’’ were respiratory distress as a result of an infectious process (all put into the respiratory category) and traumas resulting in surgery (all put into the trauma category). Statistical analyses were performed using Stata release 5.0 (Stata Corporation, College Park, TX). Proportions were compared using chi-square or Fisher’s exact test; when appropriate, odds ratios with 95% confidence intervals were calculated. Comparison of means was done using t test. An a priori level of significance of P ⬍ .05 was chosen. 679
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 6 䊏 October 2000
680
TABLE 1. ED Diagnostic Categories of the High-Acuity Patients Diagnostic Category of High-Acuity Patients
Number (%)
Ambulance
Car
% by EMS
Respiratory Diabetic ketoacidosis Trauma Neurologic Surgical Ingestion Infectious Other
99 (36%) 36 (13%) 26 (10%) 23 (8%) 23 (8%) 22 (8%) 16 (6%) 25 (10%)
11 1 4 9 1 2 1 2
88 35 22 14 22 20 15 23
11 3 15 39* 9 9 6 8
*Odds ratio 6.6 v other categories, P ⬍ .001.
The study was approved by the Clinical Research Review Committee of the Institutional Review Board of our institution. RESULTS A total of 245 patients made 270 high-acuity visits to the ED in 1995. The mean age was 5.9 years, and 52% were boys. 31 (13%) arrived via EMS transportation; the rest arrived by private vehicle. Of those who arrived via EMS, 21 arrived via BLS units, 9 via ALS units, and 1 via helicopter (ALS crew). There was no significant difference in the age of patients who arrived by ambulance (5.2 yrs) compared with those who arrived by car (6.0 yrs). During the same time period, a total of 381 patients were transported to our institution via ambulance; thus, the high-acuity patients accounted for 8% of the overall ambulance usage in 1995. The ED diagnostic categories of the high-acuity patients are shown in Table 1. The majority (36%) of patients classified as high-acuity presented with respiratory disorders. Most of these patients were diagnosed with status asthmaticus. All of those diagnosed with diabetic ketoacidosis were sent to the PICU for insulin infusion (pH ⬍7.2). The majority of those in the neurologic category were known or suspected to have had seizures. All of those listed in the surgical category were nontraumatic (eg, acute abdomen or testicular torsion); traumas were listed as such
even if they required surgery. Of the diagnostic categories considered, only high-acuity patients with neurologic symptoms (primarily seizures) had a greater relative use of EMS transportation, with 39% of these patients arriving via ambulance (odds ratio 6.6, 95% confidence interval 2.6, 16.6). Insurance information was available for 240 of the 245 high-acuity patients; 90 patients were insured by Medicaid, 15 were self-pay, and 135 had private or commercial insurance. The insurance mix of the high-acuity patients did not differ significantly from that of the overall ED population. Although Medicaid patients were more likely to use ambulance services than patients with private insurance in the overall ED population, this discrepancy did not exist for the high-acuity patients (see Fig 1). Information on ambulance interventions was available for 22 of the 31 acute patients transported by ambulance (see Table 2). Seventeen patients (77%) for whom ambulance information was available had some intervention. All of the high-acuity patients had interventions in the ED. The majority of the high-acuity patients were admitted to the hospital (see Table 3). Six patients required cardiopulmonary resuscitation (CPR) and intubation. Of these six patients, two arrived by car, two via BLS with no interventions en route, and two arrived via ALS, one of whom was successfully intubated in the field. Both patients who arrived via BLS had conditions not recognized by the ambulance crews—one in status epilepticus and one with hypovolemic shock. Two of these six patients expired in the ED, one who arrived via car and one who was successfully intubated by paramedics. DISCUSSION The results of our study show that the vast majority (87%) of the most acutely ill patients arriving in our ED in 1995 did not use the EMS system. This remarkable underuse of ambulance transportation points out that ambulance misuse may constitute not only calling an ambulance unnecessarily, but also not calling an ambulance when you need one.
FIGURE 1. Ambulance use by insurance type.
KOST ET AL 䊏 AMBULANCE USE BY HIGH-ACUITY IN A PED PATIENTS TABLE 2. Ambulance Interventions (N ⫽ 17) Patients Receiving by Diagnostic Category Intervention
Resp
Trm
Neur
DKA
Ing
Oth
N⫽ Immobilization Intubation Oxygen Intravenous catheter Medications
3
4 4
7 1 1 4 4 1
1
1
1
1
1 1
1 1
3 2
The reasons for this lack of ambulance use in sicker patients were not addressed on an individual case basis, but we can comment on age and insurance status with regard to ambulance use. Previous epidemiologic EMS studies have shown that younger patients tend to use the EMS system less than older patients10,11,13 but our study shows no association between age and ambulance usage among high-acuity patients. This discrepancy could be explained by our lack of major trauma; most of the older patients in other studies have been adolescents involved in motor vehicle crashes.10,13 Previous studies of inappropriate ambulance use in all ambulance users, including acute and nonacute patients, have shown a significantly higher rate of misuse by patients insured by Medicaid.2,3,8,9 We found a similar overrepresentation of Medicaid-insured patients among all patients transported by ambulance to our ED, but not among the most acute patients that are the focus of this study (see Fig 1). Thus, insurance does not appear to be a factor in ambulance underuse by the highest acuity patients. Indeed, subtracting the more acute patients from the overall population of ambulance users may serve to increase the proportion of apparent overuse by Medicaid patients. Pediatricians may not consider sending ill patients to the hospital by ambulance for a variety of reasons, including the perception that automobile transportation will be faster.15 Although the issue of parental reasons for not calling an ambulance has not been addressed in the literature, one could speculate that when parents are accustomed to transporting children via private vehicle, especially in our hospital’s suburban environment, they may perceive this mode of transportation to be most efficient when their children are truly ill. In a population-based study, Maio et al showed an inverse relationship between ambulance usage and access to a private vehicle.16 Parents may access EMS more commonly for sudden emergencies, such as seizures and injuries, but self-transport ill-appearing children with more chronic symptoms such as fever or dehydration.17 The TABLE 3. Disposition of High-Acuity Patients Disposition
Number
Home Regular inpatient unit ICU OR Transfer Deceased Not recorded
50 44 142 5 1 2 2
681
results of our study support this theory, in that patients with seizures and trauma had the highest rates of EMS transport, whereas patients with problems of relatively slow onset, such as diabetic ketoacidosis and infections, were significantly more likely to arrive by car than by ambulance. Another possible explanation for the lack of use of the EMS system in our population may be a lack of understanding of the ability of EMS personnel to provide not only transportation but interventions. Although our ability to comment on ambulance interventions was limited by our inability to track some of the ambulance trip sheets, we found that a large majority of high-acuity children brought by ambulance in this setting received prehospital treatment of some type, underscoring the importance of this aspect of the EMS system. Pediatricians and parents, however, may not realize what paramedics are capable of providing en route to the hospital. The potential weaknesses of our study deserve mention. Although we made an effort through the use of several data sources (ED logbook, ambulance log, PICU admission database) to identify our most acute patients, some highacuity patients may have been missed. It is also possible that some of the most acute pediatric patients were taken to other facilities in our area. Although high-acuity pediatric trauma patients are preferentially transported to the level I trauma center nearby, we feel it is unlikely that other high acuity patients are preferentially transported away from our facility, given our status as the only pediatric hospital in the state, and the only PICU within a 30 mile radius. Another potential weakness of our study is that our definition of high-acuity patients may not be accurate. Unfortunately, no scale predicting overall severity of illness in the pediatric population exists to date that is applicable in the prehospital/ED setting. However, by limiting the study population to those patients admitted to the PICU or triaged among the sickest 5% of our patient volume, we attempted to study the most acute (at presentation) subset, those in whom the need for ambulance transport would be the least questionable. In conclusion, the most acute patients in our ED failed to access prehospital services in the majority of cases. Although the reasons for this lack of ambulance use have not been addressed directly, physician and patient education in this area may be helpful. Private physicians need to be familiar with the prehospital system capabilities in their areas. They in turn must teach their patients when it is appropriate to call an ambulance. One promising step in this direction is the Office Preparedness for Pediatric Emergencies program developed under the auspices of an EMS-C grant in North Carolina.18 Pediatric emergency physicians should consider taking on the role of facilitator between EMS and the community on a national scale. Such an educational program may serve to reduce previously documented overuse of emergency medical services by low acuity patients, while improving the low rates of appropriate use by the sickest patients. REFERENCES 1. Chen JC, Bullard MJ, Liaw SJ: Ambulance use, misuse, and unmet needs in a developing emergency medical services system. Eur J Emerg Med 1996;3:73-8
682
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 6 䊏 October 2000
2. Billittier AJ, Moscati R, Janicke D, et al: A multisite survey of factors contributing to medically unnecessary ambulance transports. Acad Emerg Med 1996;3:1046-52 3. Brown E, Sindelar J: The emergent problem of ambulance misuse. Ann Emerg Med 1993;22:646-50 4. Gardner GJ: The use and abuse of the emergency ambulance service: Some of the factors affecting the decision whether to call an emergency ambulance. Arch Emerg Med 1990;7:81-9 5. Rademaker AW, Powell DG, Read JH: Inappropriate use and unmet need in paramedic and nonparamedic ambulance systems. Ann Emerg Med 1987;16:553-6 6. Rosenberg N, Knazik S, Cohen S, et al: Use of emergency medical service transport system in medical patients up to 36 months of age. Pediatr Emerg Care 1998;14:191-3 7. Foltin GL, Pon S, Tunik M, et al: Pediatric ambulance utilization in a large American city: A systems analysis approach. Pediatr Emerg Care 1998;14:254-8 8. Carmasso-Richardson K, Wilde JA, Petrack EM: Medically unnecessary pediatric ambulance transports: A medical taxi service? Acad Emerg Med 1997;4:1137-41 9. Brady WJ, Hennes H, Wolf A, et al: Pattern of basic life support ambulance use in an urban pediatric population. Am J Emerg Med 1996;14:250-3
10. Svenson JE, Nypaver M, Calhoun R: Pediatric prehospital care: Epidemiology of use in a predominantly rural state. Pediatr Emerg Care 1996;12:173-9 11. Seidel JS, Henderson DP, Ward P, et al: Pediatric prehospital care in urban and rural areas. Pediatr 1991;88:681-90 12. Johnston C, King WD: Pediatric prehospital care in a southern regional emergency medical services system. South Med J 1988;81: 1473-6 13. Tsai A, Kallsen G: Epidemiology of pediatric prehospital care. Ann Emerg Med 1987;16:284-92 14. Fifield GC, Magnuson C, Carr WP, et al: Pediatric emergency care in a metropolitan area. J Emerg Med 1984;1:594-507 15. Baker MD, Ludwig S: Pediatric emergency transport and the private practicioner. Pediatr 1991;88:691-5 16. Maio RF, Tedeschi P, Swor R, et al: Regional variation of nonrural pediatric ambulance transport rates: An ecological study. Pediatr Emerg Care 1996;12:277-82 17. Foltin GL: Critical issues in urban emergency medical services for children. Pediatr 1995;96:174-9 (suppl) 18. Frush K, Cinoman M (eds): Office Preparedness for Pediatric Emergencies. Washington, National EMSC Resource Alliance, Item 0614, 1996