Study of the level of comfort among Emergency Medical Services providers in pediatric patients care Abdullah Almutairi

Outlines Introduction Objectives Methodology Result Discussion Conclusion References Summary Introduction: Rational and literature review Objectives: Aim, primary and secondary objectives Methodology: Data collection method, Questionnaire Sample size, sampling technique Study design, area Inclusion and exclusion criteria Analysis plan Result Discussion Recommendation and limitation Conclusion Refences

Introduction EMS = pre-hospital care system, ambulance service EMS providers: EMT = diploma of 2 years Paramedic = Bacholar degree of 5 years EMS in Riyadh: Hospital based EMS Ground EMS Helicopter EMS Pediatric patient = 14 years or younger

Rational Pediatric account for 5-10% of EMS patients EMS personnel perform urgent interventions1. Pediatric are vulnerable to errors particularly in emergencies2 Low level of comfort can affect the level of care2 Reasons to assess the level of comfort Infrequent exposure No or minimal college education No or minimal postgraduate education/courses

Literature “Pediatric patients who are transported by EMS personnel are more prone to injury and acute medical problems more than any other transportation”3(Dawson, Brown, & Harwell, 2003) “EMS personnel have very limited pediatric care training and comfort comparing with nurses” 4 (Jewkes, 2001) (Dawson, Brown, & Harwell, 2003)

Aim Aim: To assess the level of comfort of pediatric patient care among pre-hospital care providers working in Emergency Medical Services Departments in Riyadh, Saudi Arabia.

Objectives Primary Secondary To assess the relation between level of comfort and the level of training of the EMS personnel (EMT VS Paramedic) To assess the relationship between the level of comfort and the years of experiencing the field Secondary To identify the differences between Air, hospital and ground emergency medical services providers level of comfort Mnn-whiteny U test= for #1 categorical vs numerical ( because its comparing categorical vs numerical in 2 groups) Kruskal wallis test H= for #2 and #3 ( because its comparing categorical vs numerical in 2 groups)

Method: Study Design This is a cross-sectional descriptive study using a questionnaire-based survey. Developed and reviewed by four Pediatric Emergency Medicine consultants Questionnaire language: English Questionnaire distribution: Handed over Corrected Item-Total Correlation (.514 - .774) More than 0.2

Questionnaire The instrument is a questionnaire of 26 questions , which assesses two parts: Respondents demographic data, 7 questions Comfort level in pediatric patient care 19 questions Likert-scale answers regarding comfort level: Very Comfortable Somewhat Comfortable Neutral Somewhat Uncomfortable Very uncomfortable

Questionnaire: First part age group, level of training years experience in the field frequency of providing care to pediatric patients? type of EMS agency? Continuous pediatric education, training? Courses in the last two years?

Second part: Patient care Pediatric patient care Suspected poisoning Suspected child abuse Seizure Respiratory emergency Cardiac Emergencies Trauma Newborn Delivery Pediatric care knowledge

Second part: Skills Performing LMA Orotracheal intubation BVM ventilation Intraosseous access Vascular access Pediatric assessment by age Access to resources within your institute Pediatric patient assessment skills Technical skills

Study setting Riyadh Saudi Arabia: EMS in King Fahad Medical City EMS in King Abdulaziz Medical City EMS in King Khaled University hospital EMS in Prince Mohammad bin Abdulaziz hospital Four Main Saudi Red Crescent authority stations

Sample size The sample size is the complete population which is 265 EMS personnel working at the designated centers Inclusion criteria: All healthcare providers working as EMS providers in the designated centers in Riyadh, Saudi Arabia. Exclusion criteria: EMS working as administrative EMS.

Data analysis All data collection sheets entered and coded in SPSS 21 The 19 questions of the 5 points Likert-scale regarding the level of comfort presented as frequency, percentage of the comfortable answers. Five points Likert-scale score is used to calculate the mean score and to compare between groups Very Comfortable= 5 Very Uncomfortable = 1 Minimum score of 19 and maximum of 95

Ethical consideration IRB approval from KAIMRC Protocol number SP17-020-R KAIMRK informed consent for cross sectional survey

Questionnaire Reliability Statistics of 210 respondents Cronbach's Alpha of Items = .940 Inter-Item correlation matrix, no –ve correlation Corrected Item-Total Correlation (.514 - .774) Cronbach‘s Alpha if item deleted = The least was .936

Results: Two hundred and ten out of 265 have completed the questionnaire with a response rate 79%. Calculating the comfort level score of all respondents with 1 (Very comfortable) to 5 (Very uncomfortable) Mean score 59.9 SD 14.5 Minimum score 26 Maximum score 95

Result: Demographics Table 1 ALL (n=210) Table 1 ALL (n=210) Age 18-29   18-29 138 (66%) 30-41 59 (28%) >=42 13 (6%) Certification EMT 119 (57%) Paramedic 91 (43%) Years in field 0-5 109 (52%) >5-10 71 (34%) >10 30 (14%) How frequent do you provide care to pediatric patient? 0/month 40 (19%) 1-10/month 118 (56%) >=11/month 51 (25%) Table 1 ALL (n=210) Pediatric medical education hours in the last year? 46 (22%) Training in the last 2 years?   No 107 (51%) PALS 45 (21%) APLS 8 (4%) Other courses 50 (24)% Type of EMS HB-EMS 122 (58%) G-EMS 63 (30%) H-EMS 25 (12%)

Level of comfort in pediatric patient care   Comfortable and somehow comfortable Likert-Scale Mean SD Pediatric patient care 67 (32%) 3.1 1.08 Suspected poisoning 75 (36%) 1.04 Suspected child abuse 2.9 1.13 Seizure 73 (35%) 1.11 Respiratory emergency   84 (40%) 3.3 0.99 Cardiac Emergencies 82 (39%) 1.14 Trauma 101 (48%) 3.4 1.15 Newborn Delivery 2.8 1.23 Pediatric care knowledge 65 (31%) 0.92 Computing the comfort level score of all respondents with 1 (Very comfortable) to 5 (Very uncomfortable) The mean score is 59.9 SD 14.5, minimum 26 maximum 95

Level of comfort in Skills and assessment   Comfortable and somehow comfortable Likert-Scale mean SD Performing LMA 65 (31%) 3 1.17 Orotracheal intubation 55 (26%) 2.8 1.27 BVM ventilation 126 (60%) 3.7 1.14 Intraosseous access 57 (27%) 2.7 1.33 Vascular access 71 (34%) 3.1 1.19 Pediatric assessment by age 3.2 1.01 Access to resources within your institute 58 (28%) 2.9 1.07 Pediatric patient assessment skills 89 (42%) 3.4 0.85 Technical skills 92 (44%) 3.3 0.91

Comparing the comfort level scores between level of training (EMT VS paramedic) A Mann-Whitney test indicated that the score of the comfort level is greater for Paramedics (Mdn = 67) than for EMTs (Mdn = 56), p = .001. Level of training Number Mean rank EMT 120 86.48 Paramedics 90 130.86 Total 210 Mann-Whitney U 3117.500000 P Value .001 Level of training Number Median EMT 120 56 Paramedic 90 67 Total 210 57

Comparing the comfort level scores between years of experience There was a statistically insignificant difference between the level of comfort score (H(2) = 11.964, p = 0.003), with a mean rank of 137.55 for experience of >10 years, 104.07 for experience of >5 -10 years and 98.61 for experience from 0 up to 5 years Years of experience Number Mean rank 0-5 years 109 97.61 >5-10 71 104.07 30 137.55 Chi-Square SumScore 10.237 P Value .006

Comparing the comfort level scores between EMS types There was a statistically significant difference between the level of comfort score (H(2) = 11.964, p = 0.003), with a mean rank of 144.82 for Helicopter-EMS, 101 for Hospital-EMS and 98.60 for Ground-EMS. Type of EMS Number Mean rank Hospital EMS 122 101 Ground EMS 63 98.60 HEMS 25 144.82 Chi-Square SumScore 11.964 P Value .003

Discussion Fieschman et al, 2011 study has shown that EMS personnel has reported7 Highest comfort level in: Airway management Trauma pediatric patient care Seizure care Lowest comfort level in: pediatric cardiac arrest newborn resuscitation Arrhythmia medication calculation (Fleischman et al., 2011). Fieschman et al, 2011 study in Oregon EMS system in the united states have shown that

Conclusion EMS providers in Riyadh, Saudi Arabia have reported limited training in pediatric patient care, infrequent exposure, and low level of comfort. Paramedics have a statistically significant difference of a higher level of comfort score than EMTs

Recommendation Implement a pediatric course in EMS colleges Adopt more pediatric course for EMS and CME personnel Frequent assignment of EMS personnel in pediatric department as a rotation to gain enough exposure

Limitation Hospital based EMS employee are not authorized to responded to emergencies which explains their infrequent exposure to pediatric patient The result of the comparison between the type of EMS is affected by the facts that: HEMS require courses in pediatrics for recruitment 95% of HEMS are paramedics (Bacholer degree)

References Bair, A., Rose, J., Vance, C., Brown, E., & Kuppermann, N. (2008). Ultrasound- assisted peripheral venous access in young children: a randomized controlled trial and pilot feasibility study. The Western Journal of Emergency Medicine, 9(4), 219– 224. Markenson D, Foltin GL. The New Emergency Medical Technician-Paramedic and Emergency Medical Technician-Intermediate Curricula: History, Changes, and Controversies. Clinical Pediatric Emergency Medicine. 1999; 1(1): 54-69. Seidel JS. Emergency Medical Services and the Pediatric Patient: Are the Needs Being Met? II. Training and Equipping Emergency Medical Services Providers for Pediatric Emergencies. Pediatrics. 1986; 78(5): 808-812 Cook RT. The Institute of Medicine Report on Emergency Medical Services for Children: Thoughts for Emergency Medical Technicians, Paramedics, and Emergency Physicians. Pediatrics. 1995; 96(1 II Suppl): 199-205.

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