Paediatric prehospital care has been identified as an area in need of improvement by the Institute of Medicine (IOM), and prehospital providers have repeatedly identified a need for increased and improved training in this area (IOM, 1995; Jewkes, 2001; Houston and Pearson, 2010). In 2008 and 2009, we conducted 9 focus groups during statewide conferences in Oregon to help better understand the needs of prehospital providers with regard to caring for children.
In part 1 of our analysis, we presented our study, methods, and the results of our focus group analysis (Breon, 2011). In part 2, we describe our analysis in the context of the evolution of paramedic training in the US and compare our challenges to those in the international community. We expand upon the existing literature and use our focus group participants’ suggestions to formulate specific suggestions to improve paediatric prehospital education.
Results
Comfort caring for children
Providers widely stated that they felt less comfortable caring for children than adults. Specifically, the management of children with special health-care needs, medication dosing, and communication with children and families were identified as areas of discomfort.
Barriers to obtaining paediatric training
Providers identified cost, distance, and time for training as significant barriers to paediatric education. This was particularly true for rural providers, many of whom are volunteers. In addition, availability of educational content specific to prehospital providers was notably lacking. Providers commented that standardized courses such as paediatric advanced life support (PALS) were not designed for the prehospital setting and seemed less relevant to their practice.
Strategies to improve paediatric education
Discussion
Our study supports prior research documenting that prehospital providers feel less comfortable providing care to children than adults and that they desire more paediatric education (Federiuk et al, 1993; Roach and Medina, 1994; Gausche et al, 1998; Glaeser et al, 2000; Jewkes, 2001; Spaite et al, 2001; Gaffney and Johnson, 2001). In addition, our results identified a number of important barriers to obtaining quality paediatric training including cost, distance, time, and availability of training opportunities.
Specific areas of interest for further training included chronic illness and emotional aspects of caring for children. Specific learning strategies identified were spending more time with children in a variety of settings, as well as the use of prehospital-focused curricula, online media, and simulation.
The challenges related to paediatric prehospital care have been well established. Recognizing the unique medical and social needs of children, the US Congress authorized the Emergency Medical Services for Children programme in 1984 to better integrate paediatric considerations into the larger EMS system. Despite this early recognition of need, a number of studies have documented inadequate training and discomfort among prehospital providers caring for children.
Following the 1993 IOM report calling for increased education and standardization of training, a number of standardized curricula incorporating paediatric content were developed in addition to stand-alone educational modules, both in the US and Europe (Phillips et al, 2000; Dawson et al, 2003; Wolfram et al, 2003; United States Department of Transportation National Highway Traffic Safety Administration, 2010).
Despite these advances, a number of recent studies document continued deficiencies in the US as well as the UK (Gausche et al, 1998; Glaeser et al, 2000; Jewkes, 2001; Gaffney and Johnson, 2001; Roberts et al, 2005; Cooper, 2005; Houston and Pearson, 2010).
US surveys
In the US, Glaeser et al (2000) conducted a national survey of registered EMS providers and noted that a majority felt least comfortable providing care to infants and toddlers, and supported additional continuing education requirements in paediatrics (Glaeser et al, 2000). The longitudinal emergency medical technician attributes and demographic study (LEADS) further corroborated these findings, suggesting that EMS providers felt well prepared in all areas except paediatrics and childbirth (Dawson et al, 2003).
One potential explanation for this discomfort is the infrequency of paediatric transports and resuscitations. The most recent data from the US suggest that 13% of EMS transports involve children under the age of 15 (Shah et al, 2008). Several studies have documented that critical paediatric resuscitation skills are likely to be required only a few times in the career of a practicing EMT (Babl et al, 2001; Burton et al, 2003; Roberts et al, 2005).
Moreover, advanced paediatric life support skills decay rapidly without practice (Gausche et al, 1998; Su et al, 2000; Babl et al, 2001; Burton et al, 2003; Wolfram et al, 2003; IOM, 2006; Youngquist et al, 2008) and paediatric continuing education requirements are minimal and variable from state-to-state.
UK surveys
Similar issues have been documented in the UK. In a survey of paramedic training managers in 2001, Gaffney and Johnson found that the average time devoted to paediatric issues during paramedic training was < 6 hours and that 12% of ambulance trusts provided no paediatric specific training. Annual updates were required by only 44% and averaged only 1.7 hours.
The study further documented poor availability of paediatric equipment on ambulances (Gaffney and Johnson, 2001). These results and a changing emphasis by the National Health Service (NHS) toward more comprehensive care by prehospital providers led to the development of paediatric specific guidelines by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) in 2006; which have resulted in significant improvements in both paediatric training and equipment as documented by a follow-up national survey published in 2010 by Houston and Pearson.
Paediatric training and equipment in the US
Similar emphasis on paediatric training and equipment has occurred in the US in the last decade. The National Standard Curriculum developed by NHTSA includes one of eight modules focusing on paediatrics for certification as an EMT-Basic; more than 50 neonatal and 100 paediatric objectives were added to the EMT-Intermediate curriculum; and additional objectives in neonatal resuscitation, paediatric medical emergencies, technology-assisted children, epidemiology, prevention, and psychosocial care of families were added to the paramedic curriculum (Dawson et al, 2003; Wolfram et al, 2003; Youngquist et al, 2008; United States Department of Transportation National Highway Traffic Safety, 2011a, b).
Unfortunately, although a majority of US states use these standardized curricula as standards for licensure for one or more EMS provider levels, there remains significant variation from state-to-state. Moreover, continuing education requirements vary widely and often emphasize ‘add-on’ courses to meet paediatric requirements, such as PALS.
The value of these courses, which are not specifically tailored to the prehospital setting, is questionable. Although several studies have documented improved provider confidence and even success rates for advanced airway management and vascular access skills following PALS training, there is no evidence of improved outcomes among paediatric patients treated by those with or without PALS certification (Losek et al, 1994; Pitetti et al, 2002; Baker et al, 2009).
The accumulating literature documenting the challenges and shortcomings of paediatric prehospital care has lead to new legislative mandates increasing continuing educational requirements for EMTS in Oregon since 2009. Although admirable, these requirements were implemented without a detailed understanding of the state's current educational opportunities or the perceived barriers and learning preferences of Oregon's EMTs.
Barriers to paediatric education
The primary barriers to quality paediatric education in our sample were attaining experience with children and accessing effective and relevant paediatric training. Accessing training was particularly difficult in rural areas where distance and cost restraints were greater.
At the same time, rural areas are positioned to benefit the most from additional training as EMS providers in these rural areas face additional challenges such as long transport times and longer periods between calls. Subjects identified medication dosing, neonatal resuscitation, cardiac arrest/arrhythmias shock, respiratory distress, sexual assault, and children with special needs or complex medical histories as areas of desired additional training.
Many of the barriers to attaining paediatric education in our population are related to the population distribution of Oregon. In this geographically large state, 82% of the transport ambulance providers are in rural areas. The colleges and hospitals that are frequently sources for instructors and training equipment, however, are primarily located in urban areas.
The lack of paediatric-specific training and education for rural providers in combination with long transport times place paediatric patients at greater risk for morbidity and mortality, and preparation of EMS personnel for paediatric emergencies is of particular concern in rural areas (Kumar et al, 1997).
Improving training
To improve access to training, respondents recommended involving local school districts, daycare centers, and paediatricians to increase their exposure to children and improve their ability to interact and communicate with children of different ages. While the efficacy of this method has not yet been proven, this is a low cost solution that draws on local resources and would be relatively simple to implement in both urban and rural areas.
Respondents also saw the internet as a potential tool to attain training, but cautioned that it must be interactive and easy to download and share with others. The use of this type of educational strategy was recently supported by a randomized controlled trial of the efficacy of asynchronous distant education using an interactive CD-ROM curriculum (Sanddal et al, 2004).
With regards to curriculum content, our participants identified a need for more training related to complex medical assessment and carin for children with complicated medical conditions as well as social aspects of caring for children. Additional areas of perceived need included: medication dosing; respiratory distress; neonatal resuscitation; sexual assault; social interaction with children; communication with distraught families, and the emotional aspect of caring for children.
Focus-group participants recommended using hands-on and interactive training whenever possible. They expressed frustration with ‘add-on courses such as paediatric advanced life support (PALS), which they perceived as less relevant to their needs and less interactive.
There was enthusiastic support for the use of simulation as an engaging and practical learning strategy. Simulation-based education has been used to train prehospital personnel (Bond et al, 2001; Lemaster, 2004; Hall et al, 2005; Barsuck et al, 2005; Gordon et al, 2005) and was endorsed by the 2006 IOM report as one of the few evidence-based educational strategies (IOM, 2006).
Limitations
Our study assessed the perceived educational needs and preferences of prehospital providers when caring for children, but it did not assess whether or not these improvements would improve outcomes for paediatric patients or improve the comfort level of providers when caring for children.
The relatively small number of participants also limits our study. Because participants were recruited from statewide conferences, our sample may be biased toward those with a greater desire for paediatric training.
While the study was designed to limit discomfort and intimidation among participants by dividing the groups based on training levels, multiple coworkers participated in the same group and it is unclear how their interactions ma have changed the group dynamics.
Finally, because our sample is limited to prehospital providers in Oregon, caution should be taken when generalizing our results to EMS education nationally, as demographic and geographic factors are likely to have influenced our findings.
Conclusion
Prehospital providers feel less comfortable providing care to children and desire more education in paediatric emergencies. Specific curricular strategies include increasing time with children, and an increased emphasis on medically complicated children and emotional aspects of caring for children.
Implementing training, care needs to be taken to assure that it is affordable and accessible to providers in different practice settings. Prehospital providers value the flexibility of online training modules and the hands-on experience of working with simulators.