MCHB Conference Webcasts
2005 EMSC Annual Grantee Meeting
April 12-13, 2005
DIANNE ATKINS: Okay. So, let's see. Okay. Well, thank you. This is, I don't know, you guys need to sort of move in; we are a small group in a pretty massive room.
And I'd like to present to you what we've done in our targeted issues grants that we called Beyond the Barriers, Project Equipped. And this basically, Beyond the Barriers are the barriers we are all familiar with is pediatric EMS, and we are sort of, pneumonic is EMS quality improvement in pediatrics.
And I do need to disclose some of my relationships. I do have research grant support as well as equipment support from Phillips Medical System, Zohls Medical System and actually equipment support from Medtronic. And I have that farther on down. And then the two federal sources of money, EMSC and now the NIH with the resuscitation outcomes.
our objectives were, number one, to develop a quality improvement for pediatric cardiac arrest for pre-hospital providers. And what we plan to do is to evaluate our statewide database of cardiac arrest to look to see where the problems were in pediatrics, especially compared with adults.
And then we wanted to develop reporting methods to disseminate this information to both the Bureau of EMS and our EMS providers.
The third objective was to develop educational methods to convey the information from objectives one and two to EMS providers and to analyze the impact of the data analysis and the instructional programs on outcomes. A pretty heady group of objectives for a three-year project, obviously.
Let's -- I'll just go through and take you through our objectives. Number one, we wanted to analyze the current algorithms that were available in the State of Iowa, and one of the first things that we did accomplish was to add the authority to our EMS providers to use pediatric capable AEDs within first responder and pediatric protocols. And we actually accomplished this in July 2002. And at the time, there was a lot of announcement to our EMS providers that we had added the AED use.
Now, 2002 is important because this actually is prior to the release of the American Heart Association guidelines on the use of the pediatric capable AEDs. That was in July of 2003.
Our second was to actually collect and analyze the cardiac arrest data from what we call the Iowa EMS Program registry which is a legislatively mandated database within the State.
And you'll notice that we did our first analysis which is January through June of 2002, and then a second analysis of January through June of 2004. And we are actually right now doing the analysis for July through December of 2004.
One of the reasons why there is such a break there is that we've been through two database collection tools. The initial construction of the database had very significant shortcomings, and that's what the June 2002 data analysis showed us. It was not user friendly and we had extraordinarily poor data quality.
A full 10 percent of all the entries had no date of birth or age. 51 percent -- and this is adult and pediatric -- had no rhythm reported or it was missing. That was one of the problems with the database. We couldn't tell whether they had just not reported the rhythm or if indeed it wasn't coming through.
78 percent of all entries had no vital signs. And again, the database would put a 0, and we couldn't tell if that's because their blood pressure was 0 and their pulse was 0 or because no data had been entered.
So actually, as the first part of our quality improvement, we went to the bureau and said, You need to develop alternate methods to collect the data. And just to give you -- the other thing we were able to do is to look at the difference of pediatric versus adult, and in that first six month period, we did have 76 children as opposed to 1200 adults. And we did see that there were some differences in the arrests of children and adults. Far fewer of the children were witnessed arrest. And that's obviously a big predictor of outcome. They were equally poor in terms of cardiac rhythm being documented. Surprisingly, more children had bystander CPR than adults.
We've seen in a lot of other pediatric data that bystander CPR is not being given to kids even when it's a family member. And so I was a little bit surprised. The other very interesting thing was that scene time in the young was substantially shorter than in the adults. Now this did confirm one of my hypothesis that I think we've all seen in pediatric emergencies, that there is a load and run sort of mind set. And perhaps they just want to get the child to the emergency room, they don't want to stop and do the skills that they have learned, the tasks that they can do for children. So we saw a substantially longer increase or a substantially shorter scene time in children.
Now -- But then throughout the end of 2002, all of 2003, we actually worked with our Bureau of EMS to develop a new data collection system. And the first thing we did, and we recommended to them and others were looking very hard at this, was to actually go with a commercially based system. And we went with -- and I was not part of the decision process, that was all within the Bureau of EMS, but we did go with a company out of Pennsylvania, Med Media, and they call their web based system Webcur, so that's what this Webcur is.
And I just want to show you the actual improvement from January to June of 2002 compared to January to June of 2004 with, number one, a well-written database, and number two, very user friendly. And what you can see is now we have almost a hundred percent recording of age and date of birth and our recording of vital signs, and I have pulse here and cardiac rhythm, are substantially higher than they were before. And this is during the early roll out when not every service was submitting their data. And I think what we are going to see is for the next six months that these numbers are actually going to improve.
Just to show you what the age ranges were for under 18, it's fairly typical for cardiac arrest. The vast majority is less than a year. I was a little bit surprised that the 8 to 14 was a little bit higher than the 14 to 18. But again, this is the first six months of 2004, I think this will look more typical as we gather more data.
Just to look at the percentage of cardiac rhythms, here the adults are blue, that children are red, on the first column is shockable, and during this particular six-month period, we did not have any shockable rhythms recorded in children. The vast majority were asystole. However in the first analyses in 2002, because these are 2004, we actually did have six children who received shocks.
Median time in time intervals in minutes, I'm not certain what these mean, I think what you can see is that the times all seem to be a little bit longer in pediatrics than in adult resuscitation. Whether that is a statistical quirk of the data, we are not certain.
I will tell you that this travel to scene includes notification to actually arrival. And we have seen that twice now in both analyses that the time from notification to roll is longer for pediatrics than it is for adults. And I'm concerned about that. I'm concerned that something is happening within the systems. They are trying to make sure they've got the pediatric equipment because they don't use it very often. They are trying to find somebody who feels absolutely comfortable. So we are going to be trying to look at that in a little bit more detail.
Our second objective was to disseminate this information, and we've done several things. One is I talk rather frequently with the bureau director and that's clearly how we started the process of the changing the database.
We've made multiple presentations to our EMS advisory counsel which is the group that actually sets the protocols.
We sent letters out to our EMS directors. We have announcements in our data analysis with actually a standard format, standard colors so that as soon as they see it's in primary colors which goes along with the logo for our hospital and -- it's pretty apparent. People now around the state know when they get this piece of paper, where it's coming from.
We now have an EMS list serve and we are starting to disseminate our information from that.
We spent a lot of time on objective three which was the production of a video and a CD demonstrating the use of an AED in children. As I started this project, what I heard was, Well if we are going to use AEDs in children, we need to do in service on our providers. My first thought was, you know, If you can use an AED in an adult, you can use a AED in a young child. You just need to make one additional decision: Is the child under 8 and do I need to use the pediatric pads? But there was a lot of concern, so we developed a pediatric video. I can't show it to you in this particular format. I have it here with me on my computer and I'm willing to show it to anybody who wants it.
We also have distributed about 150 of them to a variety of EMS providers as I go around and talk. I say, If you're interested in getting the video, and usually I can show it a little bit better, I'm certainly willing to send it to you and we've gotten a lot of feedback that indeed it is being used.
The other thing that we developed is a web site on pediatric AED use in children, and we've got several articles on there, didactic articles that we do try and keep updated. There's an annotated bibliography of the cardiac arrest literature.
The entire video also is on the web site, and it's divided up into segments that, you know, the introduction, there's a scene, obviously, then the specific instructions, so that if you have -- if you don't have fast internet access, you don't have to wait 20 minutes to get this video to load, so you can pick it out. When we developed this, high speed internet access was not as prevalent as it is right now.
There also is a pre and a post test on the video, and if you complete both the pre and the post test, we actually can offer one hour of free continuing education units. It will print out a certificate for you, and it's -- if you're in Iowa , it's an automatic -- you get those CMEs. If you're outside the State of Iowa, usually reciprocity is available and you can get it, and there also is a database for reporting cardiac arrest.
And I'm not hooked up online here, so I do have some supplementary slides, this is the first page, the home page of the web site and I should -- okay. It doesn't -- there we go. That is the URL, it's pretty easy, it's just www.kidsdefib.org. And I should say that we developed this in conjunction with the Critical Illness and Trauma foundation with Nels and Terri Terry Sanddal and they were extremely vital as we went forward with this.
But this is the home page, and you can see they are in the middle, the various additional pages so that there's one on general information, there's one on frequently asked questions, scientific information and I can't scroll down. There also is a glossary of terms, that's what I have up here. And there you can see on the left side all of the other links. Our frequently asked questions, and this is the form that you need to fill out for the pre test qualifier, and once you fill this out and you give us your E-mail, but I can assure you we have never used it unless you all E-mail us first.
Our fourth was to actually analyze our outcome, what kind of an impact were we having in the State. So a year ago November, we actually surveyed the EMS providers at their annual convention. And we just asked them if they were aware that the State protocol permitted first responders and paramedics to use automated external defibrillators in children. And I have to say, when I first got this data, I was bummed because we had put a lot of effort in the previous two and a half years to try to get this out. And as you can see here, only 26 percent of the EMS providers at the convention were aware that the Iowa protocol allowed pediatric use, and 68 percent said that no, they were not authorized to use it.
However, we compared that with the State which had no ongoing program to discuss AED use in children, and this was Montana, and I think what you can see, we looked at whether they were aware of the heart association guidelines so -- because Montana has no program whatsoever and Iowa did. And I think you can see that the vast majority of respondent's in Montana also had no idea that the heart association has now said that AED use is appropriate in children.
So, I think we have been effective, we are continuing to work on it. I think the heart association guidelines will be out in December of this year, and it will reemphasize the use of AED in children and it's going to be a lot more apparent across the nation because the guideline that came out of 2003 was sort of an inner -- sort of in between the big release of the major guidelines.
Now, does this really all make a difference? I think a lot of people have said to me, you know, children do not have ventricular fibrillation, we don't really need to worry about this, these devices, although it's not that expensive to get the pediatric equipment, it does add a slightly increased cost, so are we really doing anything? Well, along with the EMS study I was the principal investigator on the Phillips post market surveillance of their pediatric pads. They were the first to actually have FDA clearance for pediatric pads in -- actually they got the clearance probably in the spring of 2002. They really didn't start to ship until that fall.
We just asked people who used the pads to voluntarily submit the experiences with them. This was worldwide, we actually have a fair amount from the United Kingdom, so we were very dependent on people being willing to share their experiences with us.
As of six months ago, we actually just got another use within the last two weeks. But there have been 26 usages of the devices with the pediatric pads. We had eight episodes of ventricular fibrillation, and the ages ranged from five months to ten years with an average age of around three years of age.
The interesting thing and the most gratifying is that 63 percent, or actually five of those eight children, survived to hospital discharge.
The other thing is that all eight of those survived to hospital ED transfer. So they had -- they were able to make it to the ED, and a lot of these places do have -- will call in the field.
The devices, they appropriately identified all other rhythms as nonshockable. So again, no child received an inappropriate shock, which is a consideration and a fear of a lot of people.
So these are actually two -- well, they are not directly from the video, I actually -- my son who is an amateur photographer was there the day we were shooting and I'll give my son credit for taking these pictures. But these are scenes from the video that we used. We are still working on this, we are still doing the data collection from the EMS database, and we are looking to expand our study through other granting agencies to continue to stress the importance of adding a fairly small piece of equipment to the pediatric armamentarium because these children are the ones that we probably have the best chance of resuscitating from cardiac arrest. Asystole has a pretty dismal prognosis and these are the ones that we think we can resuscitate. Thank you.