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First Glasgow Coma Score (GCS) documented by emergency medical service professionals categorised by a paediatric triage model
Source publication
Objectives
To examine the severity and progression of acute illness or injury in children using vital signs obtained during ambulance transport and categorised according to a paediatric triage model.
Design
A population-based historical cohort study using data from prehospital patient medical records linked to a national civil registration databas...
Context in source publication
Context 1
... than half of the patients (66.4%) had a heart rate that was categorised as normal (green), though among toddlers (1-2 years) it was only 34.0%, whereas more patients had tachycardia (table 1). The proportion of patients with an altered level of consciousness was fairly even across age groups, with 10.1%-16.4% having a Glasgow Coma Score of less than 15 (table 2). Tachypnoea was frequently present in toddlers (1-2 years) and in preschool and school children (3-7 years), but among adolescents (8-17 years) considerably fewer had a respiratory rate outside the age-specific normal range (table 3). ...Similar publications
Background
The emergency department (ED) receives patients from all over the world every day. Hence, using various triage scales to detect sick patients and the need for early admission are essential. Triage is a process used in the ED to prioritize patients requiring the most urgent care over those with minor injuries based on medical urgency and...
Citations
... While well-characterized normal vital sign ranges exist for stable paediatric patients, there are no "normal" ranges for critically unwell children during transport; the expected values vary significantly depending on age, diagnosis, severity of illness and ongoing interventions. 5,[8][9][10][11] This makes labelling datasets for adverse events difficult. ...
Interhospital transport of critically unwell children exacerbates physiological stress, increasing the risk of deterioration during transport. Due to the nature of illness and interventions occurring in this cohort, defining “normal” vital sign ranges is impossible, which can make identifying deterioration events difficult.
A novel data-driven approach was developed to identify adverse respiratory and cardiovascular events in critically ill children during interhospital transport. In this retrospective cohort study of 1,519 transports (July 2016 to May 2021), vital signs were recorded at one-second intervals and then analysed using an adaptation of Bollinger Bands, a technique borrowed from financial market analysis. This method dynamically established each patient’s stable ranges for heart rate, blood pressure, oxygen saturation, and other respiratory parameters, and flagged adverse events when multiple parameters simultaneously fell outside their expected ranges.
Adverse respiratory events were identified when oxygen saturation deviated below a dynamically defined threshold alongside at least one additional respiratory parameter. Cardiovascular events were defined by concurrent deviations in blood pressure and heart rate. Overall, 15.6 percent of transports had one or more adverse respiratory events, and 21.5 percent had at least one adverse cardiovascular event.
To validate these labels, the number of adverse events and the cumulative duration of vital sign instability during transport were compared against clinical markers of deterioration. Each additional respiratory event was associated with increased odds of receiving respiratory support during transport and higher 30-day mortality, while each additional cardiovascular event was associated with increased odds of receiving vasoactive support during transport.
Our method detects clinically meaningful respiratory and cardiovascular adverse events during transport. The approach is readily adaptable to other high-resolution intensive care datasets, for both retrospective labelling as well as automated, real-time identification of adverse events in the clinical setting, offering a foundation for improved monitoring and early intervention in critically ill patients.
... The lack of on scene vital signs has been associated with increased mortality in the patient presenting with traumatic injury [43]. Triage systems are also dependent on documented vital signs where studies have shown incomplete triage in the paediatric patient [44,45]. B6 The patient is non-conveyed after EMS assessment triggered in 41.1% of the records and previous studies have reported between 14 and 30.3% [45,46]. ...
Background
The emergency medical service (EMS) addresses all chief complaints across all ages in various contexts. Children in EMS present a particular challenge due to their unique anatomical and physical properties, which require specific training that EMS clinicians often report lacking. This combination exposes children to incidents threatening patient safety. The most common method to highlight incidents is the incident reporting system. Studies have shown underreporting of such incidents, highlighting the need for multiple methods to measure and enhance patient safety in EMS for children. Thus, the aim of this study was to modify and adapt the current Ambulance TT for road-based EMS (ATT) to a pediatric version (pATT) with a guide containing definitions of triggers.
Methods
The adaption of the ambulance trigger tool to a version suitable for children followed a stepwise manner, including (1) a review of previous literature to pinpoint areas of risk regarding patient safety among children in EMS. (2) Three sessions of expert panel discussions via video meetings were held to evaluate each trigger of the ATT in terms of clinical relevance, comprehensibility, language and areas of risk regarding patient safety among children in EMS. (3) Clinical use of the pATT along with Retrospective Record Review (RRR). (4) Calculation of Item-level validity index and positive predictive value (PPV) for each trigger. (5) calculate inter-rater reliability between two independent record reviewers.
Results
The literature search revealed 422 respective 561 articles in Cinahl and Medline where headlines and abstracts were read to identify areas posing risks to patient safety in EMS for children. During the structured discussions, one trigger was added to the existing 19 derived from the ATT, and the trigger definitions were modified to suit children. The three most common triggers identified in the 900 randomly selected records were deviation from treatment guidelines (63.9%), incomplete documentation (48.3%), and the patient is non conveyed after EMS assessment (41.1%). The positive triggers were categorized into near miss (54.6%), no harm incident (5.8%), and harmful incident (0.4%). Inter-rater reliability testing showed excellent agreement.
Conclusion
This study demonstrates the adaptation of an existing trigger tool (ATT) to one suitable for children. It also shows that the trigger tool, along with retrospective record review, is a feasible method to evaluate patient safety in EMS, thus complementing existing methods.
... This assessment, devoid of measureable vital signs, was frequently documented in the free-text section and not in the vital signs tab in the ePPR. Previous studies have found similar problems with not recording vital signs in children [23][24][25]. It can be difficult to measure blood pressure in children-for example, readings are likely to be falsely high in crying toddlers, and an appropriately sized cuff may not be available [26]. ...
Background
Without accurate documentation, it can be difficult to assess the quality of care and the impact of quality improvement initiatives. Prehospital lack of documentation of the basic measurements is associated with a twofold risk of mortality. The aim of this study was to investigate data quality in the electronic prehospital patient record (ePPR) system in the Region of Southern Denmark. In addition, we investigated ambulance professionals’ attitudes toward the use of ePPR and identified barriers and facilitators to its use.
Method
We used an explanatory sequential mixed-methods design. Phase one consisted of a retrospective assessment of the data quality of ePPR information, and phase two included semi-structured interviews with ambulance professionals combined with observations. We included patients who were acutely transported to an emergency department by ambulance in the Region of Southern Denmark from 2016 to 2020. Data completeness was calculated for each vital sign using a two-way table of frequency. Vital signs were summarised to calculate data correctness. Interviews and observations were analysed using thematic analysis.
Results
Overall, an improvement in data completeness and correctness was observed from 2016–2020. When stratified by age group, children (<12 years) accounted for the majority of missing vital sign registrations. In the thematic analysis, we identified four themes; ambulance professionals’ attitudes, emergency setting, training and guidelines, and tablet and software.
Conclusion
We found high data quality, but there is room for improvement. The ambulance professionals’ attitudes toward the ePPR, working in an emergency setting, a notion of insufficient training in completing the ePPR, and challenges related to the tablet and software could be barriers to data completeness and correctness. It would be beneficial to include the end-user when developing an ePPR system and to consider that the tablet should be used in emergency situations.
... The distribution of physiological parameters has been recently described in normal children as well as in pre-hospital settings [9][10][11]. The centiles and distributions of continuously measured vital signs have been reported in hospitalized critically ill children [12,13]. ...
Objective
To describe comprehensively the distribution and progression of high-frequency continuous vital signs monitoring data for children during critical care transport and explore associations with patient age, diagnosis, and severity of illness.
Design
Retrospective cohort study using prospectively collected vital signs monitoring data linked to patient demographic and transport data.
Setting
A regional pediatric critical care transport team based in London, England.
Patients
Critically ill children (age ≤ 18 years) transported by the Children’s Acute Transport Service (CATS) at Great Ormond Street Hospital (GOSH) between January 2016 and May 2021 with available high-frequency vital signs monitoring data.
Interventions
None.
Main results
Numeric values of heart rate (HR), blood pressure (BP), respiratory rate (RR), oxygen saturations (SpO 2 ), and end-tidal carbon dioxide in ventilated children (etCO 2 ) were extracted at a frequency of one value per second totalling over 40 million data points. Age-varying vital signs (HR, BP, and RR) were standardized using Z scores. The distribution of vital signs measured in the first 10 min of monitoring during transport, and their progression through the transport, were analyzed by age group, diagnosis group and severity of illness group. A complete dataset comprising linked vital signs, patient and transport data was extracted from 1711 patients (27.7% of all transported patients). The study cohort consisted predominantly of infants (median age of 6 months, IQR 0–51), and respiratory illness (36.0%) was the most frequent diagnosis group. Most patients were invasively ventilated (70.7%). The Infection group had the highest average (+ 2.5) and range (− 5 to + 9) of HR Z scores, particularly in septic children. Infants and pre-school children demonstrated a greater reduction in the HR Z score from the beginning to the end of transport compared to older children.
Conclusions
Marked differences in the distribution and progression of vital signs between age groups, diagnosis groups, and severity of illness groups were observed by analyzing the high-frequency data collected during paediatric critical care transport.
... Triage models, track-and-trigger systems and early warning scores are primarily based on vital signs. However, scores are often not complete in paediatric patients in EMS settings [15][16][17][18]. In the North Denmark EMS, nearly half of the children did not have one full set of vital signs documented in their prehospital ePMR [17]. ...
... However, scores are often not complete in paediatric patients in EMS settings [15][16][17][18]. In the North Denmark EMS, nearly half of the children did not have one full set of vital signs documented in their prehospital ePMR [17]. One full set of vital signs was defined as all of the contemporaneous respiratory rate, peripheral capillary oxygen saturation (SpO 2 ), heart rate and level of consciousness. ...
... The study objective was to evaluate if the educational initiatives were associated with an increase in the proportion of paediatric patients who had at least two full sets of vital signs obtained by EMS providers prior to arrival at a hospital. The initiatives focused primarily on clinical assessment of children aged less than two years, as vital sign registration is particularly deficient in this age group [15][16][17]. A secondary study objective was to investigate if patient factors or specific situations were associated with complete vital sign registration. ...
Background:
Prehospital vital sign documentation in paediatric patients is incomplete, especially in patients ≤ 2 years. The aim of the study was to increase vital sign registration in paediatric patients through specific educational initiatives.
Methods:
Prospective quasi-experimental study with interrupted time-series design in the North Denmark and South Denmark regions. The study consecutively included all children aged < 18 years attended by the emergency medical service (EMS) from 1 July 2019 to 31 December 2021. Specific educational initiatives were conducted only in the North Denmark EMS and included video learning and classroom training based on the European Paediatric Advanced Life Support principles. The primary outcome was the proportion of patients who had their respiratory rate, peripheral capillary oxygen saturation, heart rate and level of consciousness recorded at least twice. We used a binomial regression model stratified by age groups to compare proportions of the primary outcome in the pre- and post-intervention periods in each region.
Results:
In North Denmark, 7551 patients were included, while 15,585 patients from South Denmark were used as a reference. Virtually all of the North Denmark EMS providers completed the video learning (98.7%). The total study population involved patients aged ≤ 2 months (5.5%), 3-11 months (7.4%), 1-2 years (18.8%), 3-7 years (16.2%) and ≥ 8 years (52.1%). In the intervention region, the primary outcome increased from the pre- to the post-intervention period from 35.3% to 40.5% [95% CI for difference 3.0;7.4]. There were large variations in between age groups with increases from 18.8% to 27.4% [95% CI for difference 5.3;12.0] among patients aged ≤ 2 years, from 33.5% to 43.7% [95% CI for difference 4.9;15.5] among patients aged 3-7 years and an insignificant increase among patients aged ≥ 8 years (from 46.4% to 47.9% [95% CI for difference - 1.7;4.7]). In the region without the specific educational interventions, proportions were steady for all age groups throughout the entire study period.
Conclusions:
Mandatory educational initiatives for EMS providers were associated with an increase in the extent of vital sign registration in paediatric patients ≤ 7 years. Incomplete vital registration was associated with, but not limited to non-urgent cases.
O contato com crianças em ambiente pré-hospitalar é incomum e os mais frequentes envolvem crianças menores. No Brasil, de 2000 a 2019, mais de 112 mil crianças na faixa etária de 0 a 14 anos de idade morreram por acidentes envolvendo intoxicação, afogamento, queimaduras e quedas. O objetivo deste estudo foi descrever o perfil dos pacientes de 0 a 19 anos incompletos atendidos pelo SAMU em Fortaleza no período de 2018 a 2022. Trata-se de estudo transversal, retrospectivo, exploratório e descritivo, com abordagem quantitativa, realizado de julho a setembro de 2023, com 1.291 ocorrências de pacientes entre 0 e 19 anos incompletos atendidos pelo SAMU Fortaleza. Foram atendidos 758 (59%) pacientes do sexo masculino e 533 (41%) do sexo feminino. Dentre os tipos de ocorrência atendidas, tem-se 466 (36%) clínicas, 463 (35%) por causas externas, 286 (22%) psiquiátricas, 27 (2%) gineco-obstétricas, 3 (0,2%) cirúrgicas e 46 (4%) não informadas. O sexo masculino foi mais prevalente em todas as faixas etárias e em todos os tipos de atendimento. Houve predominância dos tipos “clínico” e “causas externas” em quase todas as faixas etárias. Adolescentes homens mostraram-se mais vulneráveis à violência armada, além disso no tipo psiquiátrico, que aumentou proporcionalmente à faixa etária, observou-se grande número de pacientes com o motivo "agitado”, termo amplo e que não descreve bem o paciente. Acrescenta-se ainda que a presença constante de casos não informados abre uma lacuna sobre o motivo pelo qual estes casos não estão sendo agrupados nos outros grupos.
Background:
Various prognosticative approaches to assist in recognizing clinical deterioration have been proposed. To date, early warning scores (EWSs) have been evaluated in hospital with limited research investigating their suitability in the prehospital setting. This study evaluated the predictive ability of established EWSs and other clinical factors for prehospital clinical deterioration.
Methods:
A retrospective cohort study investigating adult patients of all etiologies attended by Queensland Ambulance Service paramedics between January 1, 2018, and December 31, 2020, was conducted. With logistic regression, several models were developed to predict adverse event outcomes. The National Early Warning Score (NEWS), Modified Early Warning Score (MEWS), Queensland Adult Deterioration Detection System (Q-ADDS), and shock index were calculated from vital signs taken by paramedics.
Results:
A total of 1,422,046 incidents met the inclusion criteria. NEWS, MEWS, and Q-ADDS were found to have comparably high predictive ability with area under the receiver operating characteristic curve (AUC-ROC) between 70% and 90%, whereas shock index had relatively low AUC-ROC. Sensitivity was lower than specificity for all models. Although established EWSs performed well when predicting adverse events, these scores require complex calculations requiring multiple vital signs that may not be suitable for the prehospital setting.
Conclusions:
This study found NEWS, MEWS, and Q-ADDS all performed well in the prehospital setting. Although a simple shock index is easier for paramedics to use in the prehospital environment, it did not perform comparably to established EWSs. Further research is required to develop suitably performing parsimonious solutions until established EWSs are integrated into technological solutions to be used by prehospital clinicians in real time.
Importance:
Early warning scores (EWSs) are designed for in-hospital use but are widely used in the prehospital field, especially in select groups of patients potentially at high risk. To be useful for paramedics in daily prehospital clinical practice, evaluations are needed of the predictive value of EWSs based on first measured vital signs on scene in large cohorts covering unselected patients using ambulance services.
Objective:
To validate EWSs' ability to predict mortality and intensive care unit (ICU) stay in an unselected cohort of adult patients who used ambulances.
Design, setting, and participants:
This prognostic study conducted a validation based on a cohort of adult patients (aged ≥18 years) who used ambulances in the North Denmark Region from July 1, 2016, to December 31, 2020. EWSs (National Early Warning Score 2 [NEWS2], modified NEWS score without temperature [mNEWS], Quick Sepsis Related Organ Failure Assessment [qSOFA], Rapid Emergency Triage and Treatment System [RETTS], and Danish Emergency Process Triage [DEPT]) were calculated using first vital signs measured by ambulance personnel. Data were analyzed from September 2022 through May 2023.
Main outcomes and measures:
The primary outcome was 30-day-mortality. Secondary outcomes were 1-day-mortality and ICU admission. Discrimination was assessed using area under the receiver operating characteristic curve (AUROC) and area under the precision recall curve (AUPRC).
Results:
There were 107 569 unique patients (52 650 females [48.9%]; median [IQR] age, 65 [45-77] years) from the entire cohort of 219 323 patients who used ambulance services, among whom 119 992 patients (54.7%) had called the Danish national emergency number. NEWS2, mNEWS, RETTS, and DEPT performed similarly concerning 30-day mortality (AUROC range, 0.67 [95% CI, 0.66-0.68] for DEPT to 0.68 [95% CI, 0.68-0.69] for mNEWS), while qSOFA had lower performance (AUROC, 0.59 [95% CI, 0.59-0.60]; P vs other scores < .001). All EWSs had low AUPRCs, ranging from 0.09 (95% CI, 0.09-0.09) for qSOFA to 0.14 (95% CI, 0.13-0.14) for mNEWS.. Concerning 1-day mortality and ICU admission NEWS2, mNEWS, RETTS, and DEPT performed similarly, with AUROCs ranging from 0.72 (95% CI, 0.71-0.73) for RETTS to 0.75 (95% CI, 0.74-0.76) for DEPT in 1-day mortality and 0.66 (95% CI, 0.65-0.67) for RETTS to 0.68 (95% CI, 0.67-0.69) for mNEWS in ICU admission, and all EWSs had low AUPRCs. These ranged from 0.02 (95% CI, 0.02-0.03) for qSOFA to 0.04 (95% CI, 0.04-0.04) for DEPT in 1-day mortality and 0.03 (95% CI, 0.03-0.03) for qSOFA to 0.05 (95% CI, 0.04-0.05) for DEPT in ICU admission.
Conclusions and relevance:
This study found that EWSs in daily clinical use in emergency medical settings performed moderately in the prehospital field among unselected patients who used ambulances when assessed based on initial measurements of vital signs. These findings suggest the need of appropriate triage and early identification of patients at low and high risk with new and better EWSs also suitable for prehospital use.
Background:
Pediatric prehospital encounters are proportionally low-frequency events. National pediatric readiness initiatives have targeted gaps in prehospital pediatric assessment and management. Regional studies suggest that pediatric vital signs are inconsistently obtained and documented. We aimed to assess national emergency medical services (EMS) data to evaluate completeness of assessment documentation for pediatric versus adult patients and to identify the documentation of condition-specific assessments.
Methods:
We performed a retrospective cross-sectional analysis of EMS encounters from the National Emergency Medical Services Information System for 2019, including all 9-1-1 encounters resulting in transport. Our primary outcome was the proportion of encounters with complete vital signs (heart rate, respiratory rate, and systolic blood pressure) documented by pediatric age category relative to adult encounters. Pediatric patients were considered as those less than 18 years old. Our secondary outcome was condition-specific assessments for encounters with respiratory emergencies, cardiac complaints, and trauma. We performed multivariable logistic regression to calculate odds ratios (OR) and 95% confidence intervals (95% CI) for vital signs documentation by age after adjusting for sex, injury status, transport type (advanced vs basic life support), census region, urbanicity, organization nonprofit status, and organization type.
Results:
Of 18,918,914 EMS encounters, 6.4% involved pediatric patients. Documentation of complete vital signs was lowest in those <1 month old (30.8%) and rose with increasing age (highest in adults; 91.8%). Relative to adults, the adjusted odds of documented complete vital signs in patients <1 month old was 0.03 (95% CI 0.03-0.03) and increased with age to 0.76 (95% CI 0.75-0.77) in those 12-17 years old. Among those patients with respiratory, cardiac, and traumatic complaints, children had lower proportions of documented pulse oximetry, monitor use, and pain scores, respectively, compared to adults.
Conclusion:
Documentation of complete vital signs and condition-specific assessments occurs less frequently in children, especially in younger age groups, as compared to adults, which is a finding that exists across urbanicity, region, and level of response. These findings provide a benchmark for clinical care, quality improvement, and research in the prehospital setting.
