Emergencies involving children are rare in comparison with those involving adults (Fleischman et al, 2011; Lammers et al, 2012). When paediatric emergencies do occur, however, paramedics are expected to be able to provide life-saving interventions, including complex skills such as intravenous (IV) and intraosseous (IO) cannulation, needle cricothyroidotomy and needle thoracocentesis (Houston and Pearson, 2010; Breon et al, 2011a). Paramedics generally receive little training or education that is specific to children's emergencies (Houston and Pearson, 2010; Breon et al, 2011a) and, across the world, paramedics report a lack of paediatric training, little exposure to paediatric emergencies and low confidence in dealing with paediatric emergencies (Breon et al, 2011b).
Standards
The Royal College of Paediatrics and Child Health (RCPCH) recently produced the fourth edition of its Facing the Future publication, which sets standards for the provision of emergency care to children (RCPCH, 2018). While these standards are aimed primarily at the care given by children's emergency departments, they raise questions about the level of care provided to children in emergency situations by ambulance services.
The RCPCH (2018) standards state that: clinicians with advanced paediatric life support (APLS) training or equivalent must be available at all times to deal with emergencies involving children; and clinicians who attend to children's emergencies should have the appropriate level of paediatric competence. They also suggest that these practitioners should attend annual learning events specific to children's emergencies.
APLS is a course designed by the Advanced Life Support Group (ALSG) that the RCPCH recommends and endorses, and it states that ‘APLS provides the knowledge and skills necessary for recognition, effective treatment and stabilisation of children with life-threatening emergencies’ (RCPCH, 2018). The ALSG (2016) describes its APLS course as ‘the international gold standard’ in paediatric emergency training courses.
For the ambulance service to be able to meet the standards set by the RCPCH, it appears that paramedics trained to the clinical standard of APLS should be available to respond to children's emergencies at all times, and that they should undertake regular updates if they are to continue to provide this level of care in their clinical practice. According to Breon et al (2011a), however, courses such as APLS do not necessarily meet the needs of prehospital clinicians.
Project aims
This project had two parts:
Methods
Donnelly and Kirk (2015), in their work on change management, suggest that for a project to be successful, it should follow the plan, do, study, act (PDSA) framework from the outset; NHS Improvement (2018) uses this model within its change model, and emphasises the need to follow a structured process.
The ‘plan’ stage of the project began with a search of the PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase and MEDLINE databases to find relevant publications from the past 10 years. An example of the search strategy used can be found in Table 1.
| Search number | Database | Search term | Results |
|---|---|---|---|
| 1 | CINAHL; EMBASE; Medline; PubMed | ((paramedic OR ambulance OR pre-hospital OR EMS OR ‘emergency medical service’) AND (paediatric OR pediatric OR child*)).ti,ab | 6414 |
| 2 | CINAHL; EMBASE; Medline; PubMed | (((paramedic OR ambulance OR pre-hospital OR EMS OR ‘emergency medical service’) AND (paediatric OR pediatric OR child*)) AND (confidence OR competence OR train* OR learn* OR education OR universit*)).ti,ab | 2262 |
| 3 | CINAHL; EMBASE; Medline; PubMed | ((((paramedic OR ambulance OR pre-hospital OR EMS OR ‘emergency medical service’) AND (paediatric OR pediatric OR child*)) AND (confidence OR competence OR train* OR learn* OR education OR universit*)) AND (resus* OR apls OR “Paediatric Advanced Life Support” OR “Advanced Paediatric Life Support” OR “Advanced Pediatric Life Support” OR “Pediatric Advanced Life Support”)).ti,ab | 42 |
Abbreviations: ti=title searched; ab=abstract searched
To ensure that any articles found were relevant, inclusion and exclusion criteria were used (Table 2). Critical Appraisals Skills Programme (CASP) (2019) tools were used in order to ensure that the evidence from the journal articles found would be interpreted correctly and could be relied upon. The literature search revealed the broad themes outlined in the following section.
| Inclusion | Exclusion | |
|---|---|---|
| Dates | 2008 to present | Pre 2008 |
| Language | English | Non-English |
| Abstract | Contains one or more key search terms | Does not contain any key search terms |
| Publication type | Peer-reviewed articles, literature reviews, book chapters | Editorials, comments |
Findings
Children's emergencies
Emergencies involving children are rare (Houston and Pearson, 2010; Fleischman et al, 2011; Lammers et al, 2012; Remick et al, 2014; Carlson et al, 2015; Dyson et al, 2015). Figures from the North West Ambulance Service (2018) reveal that, from the 2017 to 2018 financial year, approximately 10% of 999 calls were for children aged under 16 years. The picture appears to be similar in the US, where Breon et al (2011a) found that emergencies involving children accounted for 5–13% of calls to the Emergency Medical Service (EMS, the US equivalent of the ambulance service).
In addition to the number of emergencies concerning children being low, the proportion of serious cases appears to be significantly lower. Carlson et al (2015) looked at how often prehospital clinicians performed resuscitation skills on children. They concluded that critical procedures, such as endotracheal (ET) intubation, and IV and IO cannulation were very seldom performed, quoting a figure of approximately 10 interventions for every 1000 children's emergencies. Dyson et al (2015) found that, on average, paramedics were exposed to only 1.4 cardiac arrests per year, and significantly fewer cardiac arrests involving children. Deasy et al (2012) found that only 1.6% of out-of-hospital cardiac arrests were in children under 16 years of age and only 0.2% resulted from a traumatic cause. Fleischman et al (2011) surveyed paramedics and found that emergencies involving children were seen relatively rarely by paramedics working in urban environments, and extremely rarely by those serving rural areas.
Paramedic training
Children make up a diverse group and require practitioners with specific skills and expertise to meet their needs (ALSG, 2016). Despite this, ambulance clinicians receive little training or education that is specific to children's emergencies to prepare them for these (Houston and Pearson, 2010; Breon et al, 2011a).
Lammers et al (2009) used simulation to identify performance deficits in paramedics, and found multiple deficiencies in their abilities to perform the skills necessary for resuscitation in children. These included an inability to appropriately manage the airway or ventilations, incorrect calculation of the child's size or weight and incorrect calculation of medication or fluids. They concluded that skill deficiencies in dealing with children's emergencies were common in paramedics, and that targeted training and education were required to counter this.
Fleischman et al (2011) found that paramedics in both urban and rural areas reported a lack of training in children's emergencies as part of both their initial paramedic education and their ongoing training.
Paramedic confidence
Paramedics report feeling underprepared to manage emergencies relating to children, and say they lack the confidence and skills required to manage these incidents (Houston and Pearson, 2010). Remick et al (2014) found that EMS providers (paramedics and emergency medical technicians) struggle to maintain competency in the care of children, as they are required to use these skills so infrequently. They specifically reported not feeling confident when called on to manage unwell or injured children. Breon et al (2011a) also found paramedics lacked confidence in their ability to deal with children's emergencies.
Paediatric errors
Near misses and adverse events in the care of children by ambulance linicians occur relatively frequently, according to Cushman et al (2010). They found that the majority of errors could be attributed to a lack of familiarity with children, inadequate training and a lack of experience. Lammers et al (2009) describe children's emergencies as ‘low-frequency, high-risk problems’, because they are encountered rarely and carry a greater chance of difficulties occurring.
Orr et al (2008) looked at the transport of critically ill children between hospitals, and found that the incidence of unplanned events, including death, was higher in the group of children who were transported by clinicians who lacked specific training and expertise regarding children, than in the group transported by practitioners who had undergone specific training in the delivery of critical care to children.
Prehospital emergencies involving children are more likely to have ‘error producing conditions’, according to Lammers et al (2012) in their later paper. They suggest that being able to accurately calculate drug doses in a classroom may not equate to being able to make accurate calculations in high-pressure scenarios but that increased knowledge and skill gained in simulated environments are likely to reduce the incidence of errors. They also found that prehospital clinicians have less support and work in more challenging environments than their hospital-based colleagues, and that this contributes to the greater likelihood of errors. In one part of their simulated scenarios, they found fewer than 50% of clinicians gave the correct dose of medication. No one factor was found to be the cause but an overall lack of familiarity with children's emergencies was a large contributor.
Advanced paediatric life support training
Baker et al (2009) found that EMS clinicians trained in Paediatric Advanced Life Support (PALS) (the US version of APLS) were much better at performing procedural skills, such as IO cannulation and ET intubation, than their non-PALS-trained counterparts. An article by Spaite et al (2000) was initially excluded because of its age but was later included because of its relevance. Spaite et al (2000) found a significant increase in paramedics’ knowledge and comfort in managing emergencies in children with special healthcare needs and in performing PALS skills following an educational intervention; however, they found that the benefits reduced with time, which suggests that the training needs to be repeated regularly to be effective.
APLS and PALS are well established courses for in-hospital clinicians, and a number of articles refer to improvements in confidence and competence in nurses and doctors who have undertaken the training (Carcillo et al, 2009; Turner et al, 2009; Bultas et al, 2014; Roh, 2014). Breon et al (2011a), though, noted that courses such as PALS or APLS are lengthy, making them expensive, which can restrict the number of staff able to attend. They also suggested that these courses were not specific enough to the environment that paramedics work in, making them less suited to the needs of the modern ambulance service.
Paramedic-specific training
Tijssen et al (2015) compared the outcomes of children who had suffered cardiac arrests to the time on scene by paramedics, and found that length of time on scene performing interventions was associated with improved rates of survival. They found the highest rates of survival in the 10 to 35-minute on-scene time group, and found that IV and IO cannulation and the administration of fluid were associated with improved outcomes. Although some interventions, such as ET intubation and the administration of drugs, were not associated with improved survival, the researchers concluded that paramedics should be familiar with resuscitation skills specific to children if they were to be able to provide the appropriate level of care on scene.
Lammers et al (2009) concluded that skill deficiencies in dealing with children's emergencies are common in ambulance clinicians and that specific, targeted training and education are required to counter this. Fleischman et al (2011) suggest that regular simulation training that is realistic to the prehospital environment is the appropriate method to build confidence in paramedics. Breon et al (2011b) make similar conclusions, and say that to improve the situation, paramedics must have access to ‘local, affordable and relevant paediatric training opportunities’.
Education and training opportunities are needed to improve ambulance clinicians’ abilities to deal with children's healthcare needs, and simulation can be particularly effective in building confidence, especially when the simulation scenario is one that creates some anxiety in the clinician (Breon et al, 2011b). The standards of paramedics’ knowledge and skills are proportional to the frequency in which they practise those skills; given that children's emergencies occur far less often than those in adults, there is a greater likelihood of skill decay. Often this is associated with confidence but, even where practitioners are confident, errors are more likely to occur if a skill has not been practised recently (Lammers et al, 2012).
These articles and studies clearly point to a need for further education for paramedics to ensure they are able to respond effectively to emergencies involving children.
Paramedic Advanced Resuscitation of Children pilot course
The next stage of the project focused on the development, pilot and evaluation of an educational intervention. NHS Improvement (2018) emphasises the importance of measuring the outcome of any change to ensure that it is having its intended effect. Bowling (2014) suggests that questionnaires can be useful tools for evaluating this type of intervention, so these were used to produce information that could be analysed to deduce effectiveness.
Using a small group of paramedics who had recently undertaken APLS training as the peer reference group, a course outline was developed including aspects of the APLS course that were felt to be most relevant for paramedics. The peer reference group decided that the overall structure of the course should be based around three core topics—unwell children, injured children and cardiac arrest in children—as advocated by the APLS programme from the ALSG (2016); there would be opportunities within each section to explore situations that paramedics could potentially encounter in the prehospital environment.
Wyatt et al (2015) and Abelsson et al (2016) suggest that realistic simulation is an extremely useful method of training, especially when it comes to learning practical skills for use in real life. Fowler et al (2018) suggest that paramedics’ primary issue is a lack of confidence rather than a lack of knowledge when it comes to paediatric emergencies, and that simulation is an effective means to build that confidence.
For these reasons, it was felt by the peer reference group that the course should be based primarily around simulations, as opposed to more traditional teaching methods such as lectures or demonstrations. An added benefit of this approach is that focusing on the practical application of resuscitation skills allowed the course to be delivered over 1 day, rather than the 3 days required for APLS. Ambulance services often struggle to release staff for training because of stresses on finances and service performance (Stafford et al, 2014), so it was hoped that minimising the cost to the Trust would allow more paramedics to attend the course.
Simulations were created from the experiences of the peer reference group using Advanced Paediatric Life Support: a Practical Approach To Emergencies (ALSG, 2016), information from the Resuscitation Council UK (2015) and the UK Ambulance Service Guidelines from the Joint Royal College Ambulance Liaison Committee (JRCALC) (2016) to ensure that all treatment and learning points were in line with current guidelines. Paramedic Advanced Resuscitation of Children (PARC) was decided on as the course title as it would explain who the course was for, the level of training provided and the core subjects covered. The course programme is summarised in Table 3.
| Introduction and course aims | 08:00 |
| Cardiac arrest in children | 08:15 |
| Anatomical and physiological differences | 08:30 |
| Structured approach to the unwell child | 09:00 |
| Simulations: illness | 09:15 |
| Refreshment break | 10:30 |
| Structured approach to the injured child | 10:45 |
| Simulations: trauma | 11:00 |
| Lunch | 12:30 |
| Simulations: cardiac arrest | 13:00 |
| Refreshment break | 15:00 |
| Simulations: additional | 15:15 |
| End | 17:00 |
Ethical approval was sought and gained from the Trust and from the higher education institution where the author is an MSc student.
Following NHS Improvement's (2018) PDSA model, the next phase of the project should be the ‘do’ stage, where an intervention is carried out. A pilot course was scheduled, and a group of eight paramedics recruited from the local area to participate. The relatively small number was limited by the amount of clinical scenarios, the time available and the space available in the training venue. Attendance on the course was in paramedics’ own time; more than three times as many paramedics replied to express interest as could be accommodated on the pilot course, indicating that paramedics were keen to learn about this subject.
To ensure credibility, the course was delivered by the author, who is a certified APLS instructor. The paramedics involved had varying levels of experience, from less than 1 year to more than 15, with two attendees having completed Institute for Healthcare Development paramedic training as their highest level of education, four having diploma-level university education, and two with degrees, which made them broadly representative of the paramedic workforce.
NHS Improvement (2018) says ‘study’ should be the next phase, which involves analysing and evaluating the results. Evaluation is a critical part of any quality improvement project, and the Health Foundation (2019) notes that it allows for a deeper understanding of how successful an intervention has been.
To evaluate the effectiveness of the PARC course, all participating paramedics were asked to complete online questionnaires at three intervals. The first was taken before the course to establish their current level of confidence in dealing with illness, injury and cardiac arrest in children. They were asked to complete a second immediately after the course to establish if they felt it had improved their confidence in each of the subject areas and in the delivery of the specific skills. A third was sent out approximately 1 month after the course to establish whether they felt the course had benefited them in their practice.
Results and findings
All eight participants responded to the first and second questionnaires, and seven of them responded to the third. None of those surveyed had received any training in children's emergencies in the past year. All participants reported an increase in confidence as a result of attendance on the course, with 87.5% reporting that their confidence had increased ‘a lot’.
The follow-up questionnaire revealed that the majority of the seven paramedics responding had been required to deal with an emergency involving a child since the course, with only one reporting that they had not. All those who had attended a children's emergency reported they felt more confident in dealing with the incident as a result of having attended the course.
Participants were also asked to comment about how they felt the course had benefited them in dealing with children's emergencies. Five of the six who commented reported an increase in confidence as a result of attending the course, and the sixth discussed having more synchronised knowledge and an increased ability to make decisions. In the follow-up questionnaire, participants were asked for comments or suggestions. Those who responded said they felt the course had been beneficial and suggested it should be made available to all paramedics across the Trust on a regular basis.
While the sample size of the group of paramedics who undertook the training was small, it provided a useful pilot to establish that there was an enthusiasm for children's emergency training, and that the general structure and subject matter of the course were useful. It seems appropriate to conclude that the course was successful in its primary aim, namely to improve paramedics’ confidence in managing children's emergencies. A more detailed summary of the results can be seen in Table 4.
| How many years’ experience do you have as a paramedic? | |||||
|---|---|---|---|---|---|
| 0–1 year | 12.5% | 1 | |||
| 1–2 years | 37.5% | 3 | |||
| 2–5 years | 12.5% | 1 | |||
| 5–10 years | 0% | 0 | |||
| 10–15 years | 25% | 2 | |||
| 15+ years | 12.5% | 1 | |||
| Did you receive paediatric training as part of your initial paramedic training/education? | |||||
| Yes | 62.5% | 5 | |||
| No | 37.5% | 3 | |||
| Have you received any specific paediatric training in the past 12 months? | |||||
| Yes | 0% | 0 | |||
| No | 100% | 8 | |||
| In the past 12 months, within your job role, have you been required to deal with an emergency involving a severely unwell child? | |||||
| Yes | 87.5% | 7 | |||
| No | 12.5% | 1 | |||
| How confident did you feel in your ability to provide care to an unwell child in this/these situations? | |||||
| Very unconfident | Fairly unconfident | Neither confident or unconfident | Fairly confident | Very confident | |
| Pre-course | 0 | 37.5% | 25% | 37.5% | 0% |
| Post-course | 0 | 0 | 0 | 62.5% | 37.5% |
| In the past 12 months, within your job role, have you been required to deal with an emergency involving a severely injured child? | |||||
| Yes | 37.5% | 3 | |||
| No | 62.5% | 5 | |||
| How confident did you feel in your ability to provide care to an injured child in this/these situations? | |||||
| Very unconfident | Fairly unconfident | Neither confident or unconfident | Fairly confident | Very confident | |
| Pre-course | 0 | 0 | 62.5% | 37.5% | 0% |
| Post-course | 0 | 0 | 0 | 62.5% | 37.5% |
| How confident do you feel in the management of paediatric cardiac arrest? | |||||
| Very unconfident | Fairly unconfident | Neither confident or unconfident | Fairly confident | Very confident | |
| Pre-course | 0 | 50% | 25% | 25% | 0 |
| Post-course | 0 | 0 | 0 | 50% | 50% |
| Following completion of the PARC course, would you say that your confidence in dealing with paediatric emergencies in general has: | |||||
| Decreased a lot | Decreased a little | Stayed the same | Increased a little | Increased a lot | |
| Pre-course | 0 | 0 | 0 | 12.5% | 87.5% |
| Are there any particular areas in terms of paediatric emergencies that the PARC course did not adequately cover, and in which you still feel you would like further development or training? | |||||
| More on burns and drowning | |||||
| No, every thing that was covered was done with a practical demonstrations and Q and As | |||||
| Some further management of burns would be good to cover and assessing the severity of burns in children | |||||
| I felt most topics were covered very well | |||||
| Drowning | |||||
| Do you have any suggestions about how the PARC course could be improved? | |||||
| More time. A lot of content in one day. Perhaps alternate simulations with case studies to reduce repetition and to cover more content | |||||
| Only that every paramedic should attend such a course | |||||
| Possibly covering some more minor paediatric medical emergencies e.g. common rashes. This could be beneficial; however, I understand this would be difficult to include in what is already a course covering a lot of content. | |||||
| I think probably more time is required, maybe make it a 2-day course, just to be able to go through everything and have more scenario time | |||||
| Definitely should be widespread onto whole NWAS medics. And should replace non-productive mandatory training. | |||||
| Results of follow-up questionnaire (after 1 month) | |||||
| Since attending the PARC course, have you been required to attend to an unwell child? | |||||
| Yes | 86% | 6 | |||
| No | 14% | 1 | |||
| Since attending the PARC course, have you been required to attend to an injured child? | |||||
| Yes | 71% | 5 | |||
| No | 29% | 2 | |||
| Since attending the PARC course, have you been required to attend to a child in cardiac arrest? | |||||
| Yes | 29% | 2 | |||
| No | 71% | 5 | |||
| Did the PARC course improve your confidence to deal with this/these paediatric emergencies? | |||||
| Yes | 86% | 6 | |||
| No | 0% | 0 | |||
| NA (not attended any paediatric emergencies) | 14% | 1 | |||
| Please can you describe any areas in which the PARC course helped you in your ability to deal with this/these incidents | |||||
| I felt much more confident in attending an unwell child | |||||
| More confident | |||||
| Increased confidence in managing these patients with the view that sometimes the best option is just to monitor the patient rather than distress them more | |||||
| Feel much more confident to deal with any of the above situations | |||||
| Synchronised knowledge, increased ability to making right decisions, refreshed important points about assessing children | |||||
| General increased confidence | |||||
| Are there any areas in which the PARC course did not adequately help you to deal with this/these incidents and you feel you require further development? | |||||
| Those that did not need any interventions but a better knowledge of minor illnesses in children may benefit the course | |||||
| No, covered all areas that I felt I lacked confidence in treating | |||||
| Do you have any other comments or suggestions? | |||||
| Brilliant course—should be rolled out throughout the trust! | |||||
| Every year refresh | |||||
| A brilliant course that should be provided to all paramedics. The intensity of it in one day was good and its fully day practical element is worthwhile. Most paramedics benefit from the ‘learn by doing’ approach, which this course provides | |||||
| More frequently we should be able to have courses like this one | |||||
Discussion
While the majority of the feedback from the post-course and follow-up surveys was positive, participants were also asked to comment on areas where the course could be improved. Burns and drowning were mentioned several times as being areas that were not covered sufficiently in the course. Other suggestions were to include guidance around managing minor conditions, and that the simulations could be alternated with case studies, to allow for more content to be covered without some of the repetition from simulations.
There were several comments that a lot of content was fitted into one day, with one suggestion that the course could be extended over 2 days. E-learning is one method that could be used in the future to increase the amount of content while ensuring that all practical teaching can be covered in one day. E-learning was used by the ALSG (2016) to turn what was previously a 3-day APLS course into a 2-day course, with the first day of learning being completed flexibly before attending.
Conclusion and recommendations
The final part of the PDSA cycle is to ‘act’, where a decision should be made about what aspects of the project should be taken forward into the next stage (NHS Improvement, 2018). While some amendments need to be made to the PARC course to ensure that all prehospital children's emergency subjects that paramedics could be expected to encounter are adequately covered, the author recommends that the course should be made available to a wider group of paramedics’ for further evaluation, with a view to it being made available to each paramedic in the Trust on an annual basis.