Version May 2024
INTRODUCTION — The emergency medical services (EMS) system, prehospital personnel and their capabilities, proper preparation and equipment for prehospital care of children, and advantages and disadvantages of different modes of transport will be reviewed here. The general approach to providing online medical direction and pediatric prehospital care considerations, including management, field triage, and transport decisions, are discussed separately. (See "Pediatric considerations in prehospital care".)
BACKGROUND — The concept of EMS encompasses many areas of emergency care, including the triage, evaluation, management, and transport of patients from the scene of an injury or illness to their arrival at an emergency care facility (the out-of-hospital or prehospital care), as well as the management within the emergency department. New areas of EMS have expanded the roles of prehospital providers to include community paramedicine (nonemergency care) and tactical EMS (emergency care in coordination with law enforcement in unsafe environments).
EMS systems date back to the 18th century when Napoleon's Surgeon-in-Chief, Barron Larrey, decreased mortality by transporting wounded soldiers rapidly to field hospitals [1]. In the United States, the EMS system formally began in 1966 with passage of the National Highway Traffic Safety Act that focused on the emergency care of trauma victims from motor vehicle crashes and tied federal funding for highway construction to development of state EMS systems.
Recognizing that children have unique anatomic, physiologic, developmental, and medical needs, the federal government passed legislation in 1984 that allocated funds for the purpose of improving the system for providing EMS for children, creating the Emergency Medical Services for Children program (EMSC; website) [2]. EMSC is a collaborative program between the Health Resources and Services Administration (HRSA), the Maternal and Child Health Bureau (MCHB), and the National Highway Traffic Safety Administration (NHTSA) and provides funding to all 50 states as well as United States territories [3].
In the United States, all states have EMS legislation, providing the basis for statewide systems. However, state agencies and local jurisdictions (eg, municipalities or counties) have established local regulations regarding the extent of services that can be provided by prehospital personnel and the procedures that they may perform on children [4].
EPIDEMIOLOGY — The epidemiology of United States pediatric EMS use has been described in a nationally representative sample taken from the National EMS Information System (NEMSIS) database of over 34 million EMS activations in 2019 [5]. Children under the age of 19 account for approximately 30 million United States emergency department visits annually, with 5 to 10 percent arriving by ambulance. Children represent approximately 6 percent of all EMS activations [5]. While a small percentage of children treated in emergency departments arrive by ambulance, they are more likely than those who arrive by other means (eg, private vehicle) to require immediate care, treatment for trauma or poisoning, and admission to the hospital ward or intensive care unit [6].
Race, urban environment, and lack of insurance are associated with EMS transport in the United States [6]. Compared with children arriving to the emergency department by other means, those arriving by EMS are predominantly infants or adolescents [7]. Infants require transport most often for acute illness, ingestions, and seizures, whereas adolescents are most often transported in association with trauma (including motor vehicle crashes, suicide attempts, and assault) or alcohol and drug intoxication [8,9].
Prehospital pediatric resuscitation is rare and most often occurs in children younger than four years of age. Thus, it is important that EMS systems provide appropriately sized equipment and personnel properly trained in management of pediatric emergencies [4,10]. However, the infrequency of prehospital pediatric resuscitation makes maintenance of skills challenging. As an example, of 1377 pediatric EMS transports in a Canadian system, only 2.4 percent involved life-threatening problems, and very few transports involved bag-mask ventilation (0.3 percent), endotracheal intubation (0.1 percent), or administration of intravenous medications (1.4 percent) [11].
ROLE OF THE LAYPERSON — The prehospital care of an injured or ill child is initiated by those who are present at the time of injury or acute illness, the "bystanders." They are the ones who access the EMS system and begin life-saving interventions, including cardiopulmonary resuscitation (CPR) until EMS arrival.
With involvement of the layperson, the crucial time between a life-threatening illness or injury and institution of emergency medical management can be reduced. Specific examples of the important role of bystanders include the following:
●In a systematic review of four studies performed during the 2019 update of the American Heart Association pediatric basic life support guidelines [12], dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) was associated with a significant improvement in the rates of bystander CPR and one-month post-cardiopulmonary arrest survival with DA-CPR [13-16]. The authors of the update recommended that emergency medical dispatch centers offer DA-CPR for presumed pediatric cardiopulmonary arrest, especially when no bystander CPR is in progress [12].
●Multiple studies have demonstrated the importance of bystander involvement in witnessed cardiac arrest [17-22]. With the introduction of automated external defibrillators, the role of the layperson has expanded beyond CPR into the management of ventricular fibrillation.
●Bystander intervention has been effective for removing a foreign body from the airway. In a study that compared bystander intervention with EMS intervention for the management of 103 children (aged 0 to 15 years) with foreign bodies in the airway, the airways were cleared before EMS arrival in 85 percent of the children, either by a bystander (47 percent) or the child (38 percent) [23]. These findings support the American Academy of Pediatrics (AAP) recommendation that new parents/primary caregivers and other laypersons who care for children (eg, teachers, day care providers) be trained in CPR [24].
THE EMS SYSTEM — The most common method of requesting EMS transport in the United States and Canada is via the 911 system. As a general rule, access to 911 is provided to the consumer through the local telephone service and routed to public safety answering points (PSAPs). The city or local community contracts with an EMS service to provide medical response and transport to 911 callers. However, 911 is not a universal emergency telephone number in other countries. As an example, 112 is the common emergency medical call number for European Union countries, while 000 is used in Australia [25,26].
Most emergency medical systems employ some version of enhanced 911, which provides the name, address, and phone number of the individual whose phone is used to place the emergency call. When cellular telephones are used to place 911 calls, the address and phone number of the cellular telephone company, rather than the caller, are provided to the public safety answering point and the dispatcher. This problem is addressed through the use of satellites that can pinpoint the exact location of the cellular telephone caller.
Types of EMS systems — Several types of EMS systems exist, and each has its own advantages and disadvantages. The three most common types are:
●City or county
●Private
●Volunteer
City/county (regional) — This type of EMS system is operated by the city, county, or regional government and is usually, but not always, integrated within the fire department, wherein the fire chief often shares and, in some cases, controls the operations and budget for the EMS division. Municipal EMS systems that operate independent of the fire and police departments are referred to as "third service." Regional systems often are funded by the local municipality, providing at least a theoretical guarantee of service to the taxpayer. Higher than average salaries and benefits often result in the retention of experienced personnel. In addition, most police and fire departments are administrated through a municipal or county system, which allows for an integrated dispatch system that can be used by police, the fire department, and EMS. Such an integrated system can help coordinate the effort during an emergency. The disadvantages of the regional system include potential budgetary concerns and delays because of governmental bureaucracy.
Private — Private ambulance companies operate in urban, suburban, and rural communities. In some cities or counties, private companies provide 911 access, and in others, they have partnership agreements with the city or county EMS systems. As an example, the city may provide 911 service to the community, whereas the private ambulance company performs all inter-facility transports. A private company seldom operates 911 access if a city or county EMS system is already in existence. Cooperation among private companies is rare, and competition may be present. Salaries usually are based upon hourly wages, and job turnover is a frequent problem. Although emergency medical technicians (EMTs) may practice under the medical director's license, most patient care is predetermined by protocols rather than by direct contact with a physician. Although this is also true for some city/county EMS systems, it is more common among the privately run systems. Also, many of the EMTs are directly licensed to practice by their state or region.
Volunteer — In rural communities, 911 access is often contracted to volunteers. Because many volunteer prehospital providers have a personal interest in EMS, their level of training usually is equal to or greater than that of the EMTs in municipal and private systems. However, their experience and training may be limited unless they have opportunities to gain experience at second jobs or via larger EMS systems in neighboring communities. In volunteer systems, particularly in rural areas, the distance between hospitals may be great, transportation times prolonged, and scope of practice necessarily broad. Medical direction often is limited, and protocols commonly are employed to assist the EMT with patient care. Problems may arise as a result of budgetary constraints because funding typically is limited in rural communities.
The Office of Rural Health Policy (ORHP), a division of the Health Resources and Services Administration (HRSA), provides a number of resources for rural communities in recognition of their unique EMS needs and challenges [27-29].
Health care providers with pediatric expertise can play an important role in the development, implementation, and supervision of EMS for children in rural communities as follows [30,31]:
●Become an emergency department's or community's Pediatric Emergency Care Coordinator
●Help prehospital providers maintain their skills with pediatric emergencies by providing continuing medical education and pediatric office rotations
●Provide education about pediatric issues from prevention to rehabilitation
●Assist with protocol writing, hospital care, and pediatric data accumulation and interpretation
●Assure appropriate pediatric resuscitation equipment is available in physician offices, transport vehicles, and receiving facilities (see "Preparing an office practice for pediatric emergencies")
●Performs pediatric care process improvement
●Serve as advocates for community and state legislation to support the goals of Emergency Medical Services for Children (EMSC)
International EMS — The World Health Organization (WHO) regards EMS systems as an integral part of any functional health care system. However, less than half of the world's countries have a formal EMS system in place [32]. If EMS exists in many poorer countries, these systems typically focus on trauma care. Implementation of an integrated trauma system has been shown to decrease mortality by 15 to 20 percent in high-income Western nations, and prehospital trauma life support programs in low- and middle-income countries improve survival rates by decreasing out-of-hospital mortality [33].
In the developed world, despite national differences in organization and funding of comprehensive EMS systems, two main models for the delivery of prehospital care have emerged with distinct characteristics. The Anglo-American model (typified by the United States and British EMS systems but also used by South Africa, Canada, and some Asian countries) centers around the philosophy of rapid transport to definitive care ("load and go"). There is limited emphasis on prehospital interventions. Systems developed around the Anglo-American model are frequently associated with public safety (eg, fire departments), and care is provided by EMTs with medical oversight. In general, countries with this strategy have a well-developed specialty of emergency medicine, and patients are transported directly to emergency departments for further stabilization and definitive care [34-38].
By contrast, the Franco-German model of EMS (used by countries including France, Germany, Greece, Austria, the Nordic countries, Malta, some Asian countries, and some United Kingdom services) focuses on scene-based stabilization and treatment ("stay and treat"). Rather than the notion of bringing the patient to the hospital, this model essentially brings the hospital to the patient. In order to accomplish this, physicians are key members of the EMS team and have the authority to provide advanced care and determine disposition in the field. Some highly specialized teams provide advanced resuscitation in the field, including resuscitative endovascular balloon occlusion of the aorta and extracorporeal membrane oxygenation. These systems are usually associated with the larger health system rather than public safety. After field treatment, patients may remain at home or, if further hospital care (inpatient) is needed, be transported directly to hospital wards rather than emergency departments [34,38-40].
Whether there is a benefit of one model of care over another is unclear. For example, A 2007 international comparison of trauma outcomes between five countries with technician-operated (advanced life support [ALS]-EMS staffed) and four countries with physician-operated (Doc-ALS staffed) systems using data from prospectively collected registries found that prehospital trauma systems that dispatch a physician to the scene had lower early trauma mortality rates, especially among patients with more severe injuries [41]. More recently, in a meta-analysis of 22 retrospective and prospective observational studies (nearly 55,000 severely injured patients), adjusted analysis that accounted for helicopter versus ground transport found a nonsignificant trend towards lower mortality for individuals who received out-of-hospital management by EMS teams lead by physicians compared to EMS teams without physicians, which suggests that rapidity of transport to definitive care may be a more influential factor than EMS team composition [42].
An emerging model of EMS care being explored in the United Kingdom is that of the emergency care practitioner (ECP) [43]. According to the National Health Service, an ECP is an allied health professional with special training who functions with significant autonomy and is capable of providing prehospital emergency care as well as community-based primary care. This model of EMS delivery is currently under consideration in other countries, including Canada, Australia, and New Zealand.
DISPATCH PERSONNEL — Dispatch operations vary widely depending upon the EMS system and the city, county, or state in which it operates. For the purpose of this discussion, central dispatch, one of the most common methods of dispatch, will be used as the prototype.
It is the responsibility of the EMS system (eg, city/county, private, or volunteer) to assign personnel to central dispatch. As a general rule, all 911 calls go through central dispatch, where select personnel forward calls to the appropriate location based on the caller's request. As an example, when a 911 call is received, the individual who receives it determines if the call is for fire, police, or EMS. If the call is for EMS, it is forwarded to trained personnel who will gather the necessary information from the caller and dispatch personnel to the scene and/or offer advice to the caller.
Most dispatch systems use some form of computer-aided protocols, which are updated on a continuous basis. Each question on the protocol must be answered before the next question appears on the computer monitor. When a caller requests an ambulance, for example, they may be asked "Is the victim breathing?" The caller must respond before the dispatcher can move to the next step in the protocol. The protocol questions proceed through the airway, breathing, and circulation guidelines of basic life support (BLS). For children in cardiac arrest, dispatcher-assisted bystander cardiopulmonary resuscitation (DA-CPR) can be performed and is associated with increased survival [12-16].
From the information that is obtained, the dispatcher determines the type of unit (advanced life support [ALS] or BLS, see below) to be dispatched and what advice should be given to the caller, including dispatcher-assisted cardiopulmonary resuscitation (CPR) instructions [44]. For critical cases, the dispatcher may remain on the line until EMS personnel arrive on scene.
Emergency medical responders (EMRs) are frequently dispatched to the scene regardless of the level of emergency. In a "tiered" system, if the injury or illness appears life-threatening, additional advanced trained personnel are dispatched, and the EMRs remain at the scene to assist with the rescue. "Non-tiered" systems dispatch their most highly trained personnel to every emergency call. Once the EMS personnel arrive at the scene, radio or cell phone contact with the base station usually is attempted.
Base station personnel — The base station typically is staffed with EMS providers who have advanced training and experience. They help the field personnel with decision-making and provide additional medical direction. Medical direction is provided by base station personnel in a variety of ways:
●Offline medical direction refers to protocols that have been created by physicians and EMS providers for use by the field personnel in the absence of active physician direction. Many pediatric prehospital protocols exist but may vary from region to region [45]. In the United States, peer-reviewed model pediatric prehospital protocols have been developed by the National Association of EMS Physicians [46] and more recently by the National Association of State EMS Officials [47]. However, adoption is voluntary and has not occurred in many jurisdictions. (See "Pediatric considerations in prehospital care", section on 'Offline medical control'.)
●Online medical direction implies immediate medical advice with each call such as a base station, located in a Level I trauma center, which is answered by physicians 24 hours per day, seven days per week. In one retrospective review, online medical direction improved the appropriateness of vascular access and cardiac monitoring in children with respiratory illness [10]. (See "Pediatric considerations in prehospital care", section on 'Online medical control'.)
●A combination of offline and online medical direction is most common, and many protocols actually direct personnel to contact medical control at specific points in the algorithm.
Supervisors — Depending upon the size and type of the EMS system, there are usually well-trained individuals designated to provide supervision, education, and quality assurance. These individuals usually are paramedics who have years of field experience and have furthered their educations in patient care. The EMS system is extremely dependent upon these individuals, and the quality of care provided to the community often is a reflection of their direction and level of expertise.
EMS direction — Each state designates an EMS director whose office is responsible for credentialing the state's EMS systems and personnel. In addition, individual EMS systems are directed medically by a local physician who oversees the practice of his or her EMS personnel. Depending on the state, EMS personnel either function under the medical license of the medical director or are state licensed themselves to practice medicine under the strict guidance of their medical director. Medical directors may limit the scope of practice for their prehospital providers but generally cannot expand it beyond what has been determined by the state.
The credentials and experience required to be an EMS medical director varies depending on the availability of resources, but many states do have minimum requirements. A large urban EMS system may have an affiliation with a local academic institution that is willing to provide financial or personnel assistance. In fact, several systems have both an adult and a pediatric medical director, in sharp contrast to many rural communities that may have to share the resources of one medical director.
The Accreditation Council for Graduate Medical Education (ACGME) has recognized EMS as a medical subspecialty and has developed requirements and core content for programs seeking accreditation through the American Board of Emergency Medicine (ABEM) [48].
TRANSPORT PERSONNEL
Education — In some countries, such as France, Germany, and Italy, prehospital advanced life support (ALS) is provided by or under the direct supervision of a physician [49]. In the United States, physicians rarely accompany paramedics during prehospital care unless in a supervisory, training, or observational role. Most prehospital care is provided by personnel who are not physicians.
In the United States, the curriculum and methods of education, testing, certification, and scope of practice of emergency medical personnel have varied dramatically from one community to the next because accreditation, certification, and licensure have been the responsibility of individual states. In an attempt to standardize training and scope of practice, the National Highway Traffic Safety Administration (NHTSA) convened a workshop in 1990 that produced a "National EMS Education and Practice Blueprint," which outlined an education agenda including standardized National EMS Core Content, education standards [50], EMS certification, and program accreditation.
The document addressed the education, training, and policies for each category of prehospital provider [51]. More recently, the NHTSA and Health Resources and Services Administration (HRSA) convened a multidisciplinary task force to develop a comprehensive national system to maximize efficiency, consistency and quality of instruction, and student competence consisting of five components [52]:
●EMS Core Content – The EMS Core Content is a comprehensive list of the domains of knowledge and skills necessary to provide out-of-hospital emergency medical care; it defines the universe of EMS knowledge and skills. The core content can be found here.
●EMS Scope of Practice Model – The EMS Scope of Practice Model provides a delineation of provider practice and licensing levels designed to guide state legislation, clarify EMS roles for the community, and promote standardization and reciprocity among states. The new Scope of Practice Model would replace the current designation of providers with four new levels of provider [53]:
•Emergency medical responder (EMR)
•Emergency medical technician (EMT)
•Advanced emergency medical technician (AEMT)
•Paramedic
The Scope of Practice Model can be found here.
●EMS Education Standards – The National EMS Education Standards consist of non-prescriptive new national standards with a set of minimum competencies, clinical behaviors, and judgments that must be met for each level of training as defined by the Scope of Practice Model and allow professional EMS educators to modify the curricula as scope changes.
●EMS education program accreditation – As of 2018, nearly 700 paramedic educational programs have been accredited by the Commission on Accreditation of Allied Health Programs (CAAHEP) upon the recommendation of the Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions (CoAEMSP). The possibility to provide accreditation of levels below that of the paramedic continue to be discussed by the national EMS community [54]. Additionally, American Academy of Pediatrics (AAP) involvement with the CoAEMSP through its sponsorship of two physician members to the board of directors has assisted in the development of pediatric-specific competencies for paramedics. Every paramedic that graduates must see at least a minimum of two patients in each pediatric age subgroup. These standards are published in the CoAEMSP Interpretations of the CAAHEP 2015 Standards and Guidelines for the Accreditation of Educational Programs in the EMS Professions, which were updated in February 2022 [55].
●EMS certification – A proposal for a universal standardized examination process for each level of provider, contingent on graduation from a nationally accredited training program, has been made.
Implementation of the EMS Education Agenda is nearly complete in every state, and national certification standards have been developed. Most (but not all) states utilize the current national standard curricula, and many require EMTs to pass the National Registry of Emergency Medical Technicians (NREMT) certification exam.
Graduation from nationally accredited (CAAHEP) paramedic educational programs is required for NREMT eligibility [54]. Continuing education requirements for recertification also vary widely from state to state [56,57].
Of note, most systems require that their EMT-Paramedic (EMT-P) personnel have at least 10 percent of their training in pediatrics. Some systems rely on the Pediatric Advanced Life Support (PALS) course for their pediatric education, whereas others create their own educational experience in pediatrics. Instead of PALS, some systems use the Pediatric Education for Prehospital Professionals (PEPP) course for pediatric education. PEPP is a two-day program available to both the basic and advanced prehospital provider.
Scope of practice — The scope of practice for EMRs, EMTs, AEMTs, and paramedics varies by level of training (table 1).
Emergency medical responder (EMR) — The EMR, by definition, is the first EMS provider to arrive on the scene. His or her presence in an EMS system, however, often depends on the resources of the community. In the new United States EMS Scope of Practice Model, "first responders" will be replaced with the designation "EMR," although the practice model remains the same. (See 'Education' above.)
The role of these providers is to initiate immediate basic life-saving care to critical patients with minimal equipment while awaiting further EMS response (table 1) [4]. These providers often are firefighters on fire trucks or police, who arrive at the scene early and begin the initial management. Most cities have more firefighters than EMS providers and fewer fires than medical emergencies. As a result, EMS systems have started to capitalize on the availability of fire personnel and have begun to introduce them to patient care. In one prospective, multicenter study of adults with out-of-hospital cardiac arrest, the use of first-responders shortened the time to definitive intervention [58]. Such studies have not been performed in children.
Emergency medical technician (EMT) — The EMT also is referred to as "Basic" or basic life support (BLS). "EMT-Basic" has been replaced with the designation "EMT" in the new United States Scope of Practice Model. They provide important life-saving interventions but are limited to basic emergency medical care and transportation and perform interventions with basic equipment like bag-valve-mask ventilators. The scope of practice of EMTs is broader than that of EMRs (table 1) [4]; however, EMTs are not trained in endotracheal tube or intravenous line placement. (See "Basic airway management in children" and "Pediatric cervical spinal motion restriction".)
EMTs are the major labor force of the EMS system in the United States [59]. They provide transport for patients with most minor illnesses and injuries and, depending on the community, may be responsible for the transport of Level I (moderate to severe) trauma patients. EMTs can transport Level I trauma patients if the scene is close to a Level I trauma center. In such circumstances, the patient's airway and spine are stabilized at the scene and they are transported to the nearest trauma center without delay; major management is deferred until arrival at the hospital. This type of transport is known as "load and go."
Advanced emergency medical technician (AEMT) — The scope of practice for the AEMT is similar to that of the paramedic (table 1). Although the United States National EMS Educational Standards recommend four levels of training, the AEMT has been less widely accepted than has the EMT or paramedic. Many states and local governments have difficulty placing AEMT in the larger scheme of prehospital care. States often permit them to certify as AEMT, only to have local governments limit their scope of practice to that of the EMT because the local government recognizes only the EMT and the paramedic.
The designation "AEMT" has replaced "EMT-Intermediate" in the new Scope of Practice Model. AEMTs provide basic and limited advanced emergency care and transport. Skills include suctioning of the intubated patient, physical assessment, and a number of procedures, such as placement of intravenous or intraosseous access and administration of fluids and a limited number of medications.
Paramedic — The paramedic provides ALS. The scope of practice of the paramedic includes that of the EMT, as well as airway management, intravenous and intraosseous access, cardiac life support, administration of system-specific and approved medications, advanced triage, and advanced newborn resuscitation (table 1). The new Scope of Practice Model does not significantly change the skills required of paramedics in the current system. However, the National EMS Education Standards allow for more deliberate and timely updates to changes in prehospital emergency care.
PEDIATRIC EMERGENCY CARE COORDINATORS — The 2006 Institute of Medicine (IOM) report on the future of emergency care in the United States health system recommends the appointment of designated individuals (eg, physician, nurse practitioner, physician assistant, or nurse with EMS medicine experience and active emergency department clinical practice or a paramedic with experience in pediatric prehospital or pediatric emergency medicine) responsible for the coordination of pediatric emergency care (ie, pediatric care coordinators [PECCs]), into EMS systems to address deficiencies in pediatric-specific medical oversight, provider education and competency, and disaster planning [27]. Specific tasks to perform collaboratively with EMS personnel and agencies for which the PECC could be beneficial include:
●Identify local and regional gaps in pediatric care
●Ensure adequate resources for pediatric prehospital care
●Identify pediatric-specific indicators to include in EMS quality improvement plans
●Provide review of pre-arrival instructions for children or caregivers
●Establish and maintain pediatric offline and online medical control
●Provide ongoing review of prehospital pediatric medications and devices
●Assist with ongoing education and training of EMS providers in pediatric prehospital care, including family-centered care
●Network to provide expertise for general pediatric readiness of general emergency departments
●Develop strategies with state and local agencies to address pediatric needs in disaster plans
It stands to reason that all EMS agencies and systems would benefit from PECCs, especially communities that represent low-frequency pediatric encounters. While the literature supports their integration, a PECC is not available within the majority of United States EMS agencies [28,29,60].
PREPARATION AND EQUIPMENT — Preparation is essential to assuring fast and appropriate patient care during an emergency. Response and transport personnel should always be ready for a pediatric emergency. The response and transport personnel who are dispatched should rehearse mock scenarios and prepare their equipment en route to the scene. Proper equipment and thoughtful preparation increase the likelihood of a good outcome.
In addition to the standard equipment and supplies determined by government agencies (eg, those needed for safe extrication of patients), there are guidelines for pediatric equipment and supplies for both basic life support (BLS) and advanced life support (ALS) ambulances (table 2) [61].
A length-based pediatric emergency measuring tape or a reference that guides pediatric drug dosing and equipment sizing based upon length or age should be available on every vehicle. The measuring tape provides a rapid estimate of a child's weight from the recumbent length and correlates the child's size with appropriate sizes of emergency equipment and doses for emergency medications [62-64].
AIR VERSUS GROUND TRANSPORT — The decision to transport a child by air or ground depends upon the condition of the child, the severity of the emergency condition, the type and location of the emergency facility, local resources, safety, the pediatric medical skillset of the potential providers, and weather conditions [4]. As a general rule, ground transport is more readily available if an emergency facility is within 20 to 30 minutes of the scene, and air transport is better if there is rough terrain or a long distance between the scene and the emergency facility. Sometimes a combination of air and ground transport is used.
Ground transportation — Ambulances used for ground transportation are categorized according to their equipment and staffing as basic life support (BLS) or advanced life support (ALS) vehicles. BLS vehicles should carry (at minimum) the equipment identified by the American College of Surgeons as essential (table 3) [4]. The staffing varies, but BLS units usually have at least two persons trained to the level of emergency medical technician (EMT). ALS vehicles should have at least one paramedic on board. In addition to meeting the standards for BLS vehicles, ALS vehicles should have intubation and vascular access equipment, a portable battery-operated monitor-defibrillator, and a variety of medications (table 4) [4].
An ALS response is required if the child has a life-threatening problem, alteration of consciousness, or respiratory distress; or potentially requires airway management or vascular access. A BLS response may be more appropriate and expeditious for limb-threatening problems and those requiring first aid, immobilization, oxygen administration, and immediate transport (ie, "load and go"). All other problems may receive a less acute mode of transport [65].
Air transportation — Air transportation, which requires specialized equipment and staffing, can occur via helicopter or fixed-wing planes. Helicopters are used more often in densely populated areas; they have the advantage of rapid, direct access to the scene [4]. In addition, helicopters can provide ALS services to large, rural areas that are unable to support independent ALS units. Helicopter response teams are usually reserved for short-range transports and those instances in which ground transport would result in unacceptable delays. The teams that operate helicopter transports are often comprised of paramedics, nurses, and occasionally physicians who are trained and experienced in the delivery of advanced cardiac life support.
Fixed-wing vehicles provide smoother, quieter, faster, and more spacious transportation [4]. However, because they require a runway for takeoff and landing, they are not capable of providing direct scene access. If distances between referral hospitals are greater than 150 miles, the patient probably should be transported by fixed-wing aircraft. Most tertiary pediatric care facilities offer fixed-wing transports through leasing agreements with local airports or airline companies.
Special considerations — During air transportation of sick neonates and children, the effects of hypoxemia, gravitational forces, expansion of trapped gases, and decreased temperature and humidity must be considered [66].
●Adequate oxygenation is best assessed with continuous pulse oximetry and adjustment of fractional inspired oxygenation concentration.
●The expansion of gases trapped in body cavities may have adverse consequences (eg, pneumothorax) if this effect of altitude is not anticipated and managed (eg, by air venting or use of pressurized cabins).
●The expansion of gases trapped in medical devices may also have adverse consequences (eg, tracheal damage from unintended expansion of an endotracheal tube cuff at altitude) and needs to be monitored actively and mitigated.
●Temperature regulation should be maintained because hypothermia and shivering increase oxygen consumption and may aggravate metabolic derangements (eg, acidosis, hypoglycemia).
●Maintenance of humidity can facilitate temperature control and fluid balance.
QUALITY IMPROVEMENT AND SAFETY — Giving attention to quality improvement programs and safety is essential to providing good patient care. A 2020 American Academy of Pediatrics (AAP) technical report serves as a template for pediatric-specific process improvement across EMS, including pediatric representation in medical oversight, operations, education, research, data management, and quality improvement [67,68]. Most EMS systems have some form of quality improvement built into their program. Specific pediatric quality improvement program areas highlighted by the 2020 multidisciplinary technical report on pediatric readiness include [67]:
●Neonatal care
●Respiratory distress and failure (including airway management)
●Trauma care (including burns)
●Child abuse and neglect
●Pain assessment and management
●Assessment and management of pediatric hypoglycemia hyperglycemia, seizures, toxicology, and environmental exposure (hypothermia/hyperthermia)
Monitoring outcomes when procedures or policies are changed is necessary to determine whether such procedures or policies are successful and is essential to providing optimal patient care and safety. A key aspect of monitoring is detailed assessment of adverse events and near misses to determine root causes and effective strategies for prevention. A large national Delphi survey of emergency medicine physicians and EMS professionals identified the following factors that were thought to contribute to safety events and errors in the out-of-hospital care of children [69]:
●Airway management [70]
●Stress and anxiety caused by decreased experience with pediatric patients [71]
●Inadequate training and experience in managing children in the prehospital environment
●Lack of experience with pediatric equipment
Delineation of the epidemiology of errors and near misses related to the prehospital care of children remains an area of emerging interest [69,72-75]. Observational studies suggest that neonates, older infants, and children suffering from cardiac arrest may be at the highest risk for errors or suboptimal care [76-78]. An excellent guide to quality improvement for EMS systems is available through the National EMS Advisory Council Committee Report and Advisory: Successful Integration of Improvement Science in EMS [68].
TRANSPORT REFUSAL — Refusal of transport by a legal guardian or a prehospital provider is an important occurrence that should be addressed with standard policies and procedures and according to the laws of the jurisdiction. Transport refusal is discussed in greater detail separately. (See "Pediatric considerations in prehospital care", section on 'Transport refusal by legal guardian' and "Pediatric considerations in prehospital care", section on 'Decision not to transport'.)
INTER-FACILITY TRANSPORT — The most common scenario that leads to an inter-facility transport involves the ill neonate, infant, or child who requires services not available at the transferring facility [79]. Depending upon the severity of the child's illness or injury, the transferring hospital will coordinate with the receiving hospital about sending a mobile intensive care unit team to pick up the child. In such a situation, the receiving hospital usually provides advice to the referring hospital awaiting the transport team's arrival.
Stabilizing the critically ill or injured patient before transfer is necessary to assure a good patient outcome. Crucial stabilization and management interventions should not wait for arrival of a pediatric transport team but should be identified and performed with assistance and offsite direction from a pediatric transport medical command physician.
Most tertiary pediatric care facilities have access to or operate a pediatric/neonatal or general critical care transport team that can go to a referring facility and help with stabilization before initiating the transport [79]. Pediatric critical care transport teams are often limited resources, however, and may not always be immediately available. The personnel that comprise the hospital transport team usually include a combination of two or more of the following transport-trained providers: physician, advanced practice provider (APP), critical care nurse or paramedic, and respiratory therapist. Most personnel are certified in pediatric and/or neonatal advanced life support (ALS) and may be current or previous staff members of the emergency department, pediatric intensive care unit, or neonatal intensive care unit.
Other circumstances that may result in an inter-facility transport include those initiated at the legal guardian/family's request or in accordance with insurance contract requirements. In these cases, involving the critical care transport team may not be necessary, and an EMS or private ambulance service with properly trained personnel can often fulfill the need.
As described above, preparation is essential to good patient care. Although most hospitals are not expected to provide tertiary pediatric care, they should be prepared to stabilize infants and children. That preparation includes having a prearranged transfer agreement that identifies the preferred tertiary pediatric care facility, mode of transport, and method of contact.
In some situations, the transport service is provided through the municipal EMS service; more commonly, the contract is assigned to a private company or hospital transport service. Large tertiary care facilities may operate their own ambulance service, including air transport, or contract for service with a private EMS company. Resources for inter-facility transfer of children are available through the Emergency Medical Services for Children (EMSC) National Resource Center on its website.
Use of a pediatric-specialized team is associated with improved survival and fewer adverse events during transport [79-81]. The use of pediatric specialized teams is recommended whenever they are available. For example, an observational study of adverse events and mortality occurring during inter-facility transports, involving 1085 infants and children (1021 transported by a pediatric team and 64 transported by a nonspecialized team), reported an overall frequency of 64 unplanned adverse events experienced by 55 children (5 percent of all patients) and 117 deaths (10 percent of all patients) [80,82]. Medical control was provided by the same group of pediatric critical care specialists for all transports. The risk of unplanned adverse events was much higher for children transported by a nonspecialized team versus a pediatric team (20 percent versus 0.5 percent; adjusted relative risk [RR] 246, 95% CI 76-796). In addition, mortality was greater among children transported by a nonspecialized team than by a pediatric team (23 percent [15 patients] versus 9 percent [92 patients]; adjusted RR 2.5, 95% CI 1.1-5.3). In this study, for every seven transports by a nonspecialized team, approximately one unexpected death occurred [82]. These differences in unexpected outcomes during transport occurred despite a significantly longer transport time for the pediatric team versus the nonspecialized team (mean time 113 versus 81 minutes, p<0.001).
ADDITIONAL RESOURCES
●EMS Agenda 2050 – EMS Agenda 2050, a technical expert panel report, provides guidance for future directions and planning for EMS in the United States.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General measures for acute poisoning treatment" and "Society guideline links: Treatment of acute poisoning caused by specific agents other than drugs of abuse".)
SUMMARY AND RECOMMENDATIONS
●Definition – The emergency medical services (EMS) system encompasses all medical care delivered prior to hospital arrival from bystander notification and first aid to advanced therapies provided by a licensed paramedic or, in some countries, a clinician. (See 'The EMS system' above.)
●Types of EMS systems – Globally, EMS systems are rudimentary in impoverished countries. In resource-rich nations, variable organization and funding strategies primarily focus around one of two delivery strategies (see 'International EMS' above):
•"Load and go," with care provided by providers who are not physicians but who have medical oversight as exemplified by the Anglo-American model
•"Stay and treat," typified by the Franco-German model with onsite care provided by trained physicians
In the United States, the organization of EMS occurs at the local and state levels with federal support from multiple agencies that provide limited funding for each state system as well as research funds targeting EMS issues. Considerable variation in prehospital provider training, certification, licensure, and continuing education as well as scope of practice currently exists, though federal efforts are underway to establish national standards. (See 'Types of EMS systems' above and 'Transport personnel' above.)
●EMS system components – Key components of the system include (see 'The EMS system' above and 'Dispatch personnel' above and 'Transport personnel' above):
•A universal telephone number to request EMS assistance (eg, 911 in the United States or Canada, 112 in European Union countries)
•Dispatch personnel to answer emergency calls and to send EMS personnel
•Dedicated and licensed EMS personnel with a predefined scope of practice (table 1) and standardized training or, in some countries, clinicians who provide prehospital care and rapid hospital transport
•Quality-improvement and safety programs to assess and advance the quality of care
●EMS for children – About 10 percent of prehospital EMS transports involve children. Thus, it is essential that EMS systems provide equipment that is of the appropriate size to use in children of various ages (table 2), personnel properly trained in prehospital pediatric emergency care, and the support of a pediatric emergency care coordinator (PECC) with EMS and pediatric emergency care expertise. (See 'Preparation and equipment' above and 'Pediatric emergency care coordinators' above.)
●Mode of transport – The decision to transport a child by air or ground depends upon the condition of the child, the severity of the emergency condition, the type and location of the emergency facility, the pediatric medical capability of the transporting personnel, local resources, safety, and weather conditions. Ground transport is more readily available if an emergency facility is within 20 to 30 minutes of the scene, and air transport is better if there is rough terrain or a long distance between the scene or transferring facility and the receiving facility. (See 'Air versus ground transport' above.)
●Interfacility transport – During inter-facility transport, critically ill or injured patients require stabilization and ongoing management before the actual physical transfer. These interventions should be identified and performed with consultation provided by a pediatric transport medical command physician. (See 'Inter-facility transport' above.)
●During inter-facility transport, use of a pediatric-specialized team is associated with significantly improved survival and fewer adverse events. Thus, whenever possible, a pediatric transport team should be used for inter-facility transportation of critically ill or injured children. (See 'Inter-facility transport' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Paul E Sirbaugh, DO, who contributed to earlier versions of this topic review.
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