Background The purpose of this national survey of UK ambulance services was to provide an up-to-date assessment of service provision for children in the prehospital setting and to identify the challenges faced in providing optimal services to this group.
Methods Questionnaires were sent to clinical directors of the 16 UK NHS ambulance services in April 2009.
Results Questionnaires were returned by 13 (81%) respondents. Paramedics and most emergency medical technicians receive a limited amount of paediatric training. An increasing amount of equipment suitable for children is becoming available, but services for children vary depending on location. For example, paediatric airway adjuncts (short of intubation) were often lacking, and only 62% reported having pulse oximetry suitable for use in children. Four or the 13 respondents (31%) considered it ‘possible or highly likely’ that someone with no specific training could be the first to respond to a child in an emergency, and seven (54%) indicated that the likelihood that the first response to a child could be someone with no current qualification specific to paediatrics was ‘high’. There are large areas of the country where no formal medical support is available at any time of day.
Conclusions Despite improvements, paediatric care by front-line personnel is limited by resource and availability of staff with key skills. Accepted standards are often lacking. Collaborative audit, research and training initiatives should be carried out between services and acute trusts to meet local service requirements. This will reduce variation and maintain the safety of patients and quality of care.
- Prehospital emergency care
- national confidential enquiry
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- Prehospital emergency care
- national confidential enquiry
A strategic review of ambulance services in England in 2005 found evidence of improvements in response times for 999 calls, training and quality of care, the standard of vehicles and equipment, and technology in control rooms and ambulances.1 Additionally, national clinical guidelines had been developed and ambulance personnel had taken on new and wider roles. However, these improvements focused on the needs of adults and largely ignored the needs of children.2–4
Approximately 5–10% of emergency calls made to the ambulance service are for children.5–7 The exposure of an individual paramedic to the proportion of children who are critically ill or injured is therefore likely to be infrequent. This raises difficulties with skill retention. In addition, responses involving children are often stressful for healthcare providers who are not specifically trained to deal with this age group. The anxiety provoked by a paediatric emergency response can generate a reluctance to intervene with treatment.8–10 A study evaluating training and comfort of basic and paramedic skills found that providers felt very well prepared in all areas except for paediatrics and childbirth.11 According to a survey sent to UK paramedic training managers, paramedics seemed ill prepared to deal with paediatric emergencies.2 More recently, Roberts et al reported some serious failings in the provision of care and skills for this group.4
The organisation of emergency care for patients and professionals has developed over the past 5 years with the delivery of unscheduled care outside hospital changing significantly. Ambulance services have progressively taken a more prominent role. This is largely due to publication by the Department of Health in 2005 of the report Taking Healthcare to the Patient: Transforming the NHS Ambulance Services1 which sets out how ambulance services can be ‘transformed from a service focusing primarily on resuscitation, trauma and acute care towards becoming the mobile health resource for the whole NHS’ (page 5). The intention is that ambulance services will provide an ‘increasing range of services crossing boundaries between primary care, diagnostics and health promotion, as well as urgent out-of-hours care’. A number of UK services are now commissioned by the local Primary Care Trust to provide an out-of-hours service to patients who need to contact a GP when their surgery is closed. These changes are potentially beneficial for children as it means they have a greater chance of being treated at home if it is more appropriate to do so; however, as Jewkes3 advocates, the risks are also obvious. The response to a critically ill or injured child in the prehospital environment must be prompt and effective,12 and the management of such children involves challenges which require specific audit if quality is to be assured.
A review of the literature identified the need for an up-to-date assessment and descriptive evaluation of service provision for children in the prehospital care setting by UK ambulance services. The purpose was to provide a picture of the care available in order to help inform future service provision and set the context for further research/confidential enquiry. The survey sought to identify and explore the barriers and challenges faced by services in providing an optimal service to this group. No such research had been conducted in the UK since that done by Roberts et al in 2005,4 nor since the restructuring of the NHS ambulance services in 2006 or the development of paediatric specific guidelines by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) in 2006.13
Clinical/medical directors from all 16 NHS ambulance service trusts in the UK were sent the questionnaire to complete, as they have primary responsibility for the clinical and patient care aspects of their services. However, it was emphasised that a multiprofessional effort may be necessary to complete the questionnaire. Respondents were also asked to indicate whether they would be happy to be contacted if further clarification of responses was required.
The survey was developed following a review of the relevant literature including papers in peer reviewed journals, previous surveys, existing standards and guidelines, and discussions with professionals experienced in this field. The final questionnaire consisted of seven sections covering: trust information, resources and equipment, medication and analgesia, processes and protocols, management of critically ill or injured children, training and audit, and opinions.
A systematic approach to the design and implementation of the survey was adopted by using key elements of Dillman's ‘total design method’ (TDM).14–16 Careful design of the survey instrument and procedure was adopted to minimise the burden on respondents and maximise their motivation to respond. For example, details that added to the impression of importance and personalisation were applied where possible and the colour blue was used for shading.14 17 Personalised correspondence was used at every stage and all letters were designed with the TDM principles that have been shown to increase survey response rates.14 For example, they were printed in colour, signed by the researcher and sent by first-class mail.
Owing to the detailed nature of the survey, questions were designed to elicit objective/factual responses and a tick response was required for most questions. However, in order to obtain opinions or examples of good practice, the questionnaire had some open-ended and Likert scale questions.
The survey was piloted by two clinical directors of ambulance services who were asked to highlight problems or areas with unclear wording, confusing design or questions that were inappropriate or impossible to answer. Several informants reviewed the final version prior to national distribution.
A pre-approach letter was sent to the clinical/medical directors in the 16 ambulance services in March 2009 before the planned distribution. In April the cover letter and survey were sent in a pre-addressed return envelope to all respondents. An email was also sent containing directions to access an electronic version of the survey. One week after the survey response deadline a reminder email, letter and replacement survey were sent to non-responders. The remaining non-responders were then contacted by telephone at 4 and 6 weeks after the initial deadline. Questionnaires were returned to the Centre for Maternal and Child Enquiries (CMACE) and the data were entered into SPSS Version 17 for analysis.
Thirteen services (81%) returned the questionnaire between April and June 2009. Of these, 77% of English services were represented. The ambulance services for Northern Ireland, Scotland and Wales all responded. Follow-up telephone interviews were undertaken with nine respondents (69%) to clarify responses and explore issues regarding the challenges and barriers documented. In the tables and text the percentage of services that responded to the questionnaire are shown, unless otherwise specified.
All services reported having at least some level of support available at the site of an accident/emergency from GPs, a hospital team or from the local British Association for Immediate Care Scheme (BASICS). However, there was great regional variation, particularly in the availability of support to provide prehospital anaesthesia; only four services (31%) reported having at least some support from all these groups. Additionally, in very few services did the support operate 24 h per day and/or in all geographical areas covered by the service.
Equipment and skills
Respondents were asked to indicate whether a range of equipment would be available in an ambulance dispatched in response to a call for a patient aged <15 years. Respondents were asked to only tick ‘yes’ if they were confident that the equipment would be found in all land ambulances.
Table 1 summarises the equipment available to, and procedures permitted by, a paramedic for monitoring and maintaining a child's airway, breathing and circulatory status and ‘other’ equipment.
All services indicated that a solo responder (ie, solo paramedic or technician), a paramedic ambulance or a double technician crewed ambulance could be sent to an emergency category A or B response involving a child (0–15 years). Six of the nine services that employed emergency care assistants (ECA) indicated that an emergency medical technician (EMT)/ECA crewed ambulance could be sent to an emergency category A or B involving a child.
Six services (46%) reported having conducted an audit on paediatric patients since January 2008. Examples included children left at home after ambulance assessment, pain management, category C children <5 years, management of asthma and the use of intraosseous needles, use of benzyl penicillin in <1 s and non-conveyance in <1 s. Only one service reported having undertaken an audit in collaboration with an acute hospital trust.
Although there was no identified budget to support training and continuing education in paediatric care in 85% of services, most (11/13, 85%) reported that their trust's clinical training programme had clearly identified opportunities for paediatric training and education. One of the remaining two respondents reported that training in child protection/non-accidental injury was provided.
The findings from a number of the ‘opinion’ questions offer the most insight into the availability of up-to-date training (figure 1). Four of the 13 respondents (31%) considered it ‘possible or highly likely’ that someone with no specific training could be the first to respond to a child in an emergency, and over half (7/13, 54%) indicated that the likelihood that the first response to a child could be someone with no current recognised and certified qualification specific to paediatric life support (above and beyond any IHCD qualification) was ‘high’. Additionally, in two of the three services where training for EMTs was not mandatory, double technician crews were able to respond to children; both of these services were in England.
Ten respondents (77%) specified that their service provided training in paediatrics as part of an in-house programme. All courses covered a range of aspects of care relating to children—for example, ABC, ‘Spotting the Sick Child’, pain management, the child Glasgow Coma Scale (GCS), child protection and non-accidental injury. Only two respondents reported that updates were required and provided to paramedics in all aspects of paediatric care annually. The majority of interviewees indicated that mandatory annual updates on paediatrics included Basic Life Support and infection control only. Table 2 provides a summary of whether an in-house course had been held in their service since January 2007 on five aspects of care. The most frequent course provided on either one or more occasion since January 2007 was on child protection/non-accidental injury. Services indicated that the majority of staff would complete the mandatory child protection training online.
Over half of services (7/13, 54%) did not provide access to a recognised certified course (eg, PHPLS, PEPP) internally or externally (ie, funded by the trust but delivered by an external facility/training centre). Four respondents indicated that the service would consider funding access to an appropriate course on a case-by-case basis.
Only three respondents (23%) considered their service's training programme as ‘part of a coordinated approach to training and education across the health economy including joint initiatives across health and social care’ (eg, with local paediatricians, local hospitals, medical students or other emergency services). Initiatives documented included external speakers and student paramedic training with local GPs, paediatricians and anaesthetists.
Barriers and challenges
Respondents were asked to document what they considered to be the three principal barriers/challenges to providing an optimal prehospital service for children. Free text responses were coded and placed into themes (table 3).
Steps in the right direction: progress made
The survey has identified a number of improvements since previous surveys in guidelines, equipment and training. However, in relation to training, most courses are conducted with little or no paediatric input and access to certified courses is dependent on local service provision. Training in child protection/non-accidental injury is, however, well delivered.
Variation in practice is reducing. Most recommended equipment, drugs and fluids are available and the number of procedures that front-line ambulance personnel are permitted to use is increasing. Although this shows that services are keeping abreast of current thinking, it remains unknown whether permitted procedures are actually taking place and whether personnel feel confident enough to undertake procedures on children. In the absence of formal data collection in prehospital care, it is important that ambulance services submit and share evidence of utilisation of the JRCALC guidelines.
Areas requiring development
Despite improvements, there remain a number of areas where the needs of ill or injured children may not be met—for example, the access to appropriate analgesia.18 In addition, there are large areas of the country in which there is no formal medical support at any time of day, making services reliant upon the small number of volunteer prehospital doctors participating when available in local BASICS schemes.
Improvements have to be made if children are to be given the ‘right care, at the right time, by the right person’.1 For example, it has to be questioned whether hypoxic children who are unresponsive to bag-mask-valve ventilation are currently being offered an acceptable standard of care in the prehospital setting. Beyond the debate about devices, the primary aim should be to ensure a secure and effective airway, oxygenation and ventilation for the patient; it is not the procedure but the outcome that is important. Hypoxia can be difficult to identify clinically in children and can lead to further deterioration. It is vital to be able to detect it and treat it early,4 yet only 62% of services reported having pulse oximetry suitable for use in children. These issues have been explored recently in the context of severely brain-injured children.19
Facing the challenges
A balance has to be struck between the requirement to prepare for an infrequent occurrence (a critically ill/injured child) and more commonly encountered paediatric health complaints. Front-line personnel also have to judge the risks of performing a procedure against the chance that it may not be successful and the possible detriment to the patient caused by the delay in transportation.
It is not uncommon for ambulance staff to experience difficulty accessing appropriate training. Financial constraints exist, and the release of staff for training has operational consequences. Such challenges can delay the adoption of appropriate treatments20 and overshadow the use of patient outcome as the standard for judging system effectiveness.21 22 These challenges occur at a time when demands on the service and individual paramedics have never been greater.4 This has led to debate because of concerns about diagnostic abilities in the prehospital arena and the potential consequences of inappropriate or inexpert intervention.23 Of concern in this study is that most respondents indicated that the first response to a child could be someone with no specific or current training.
Front-line personnel have an increasing responsibility to deliver more prehospital non-emergency treatment despite not having the necessary training. The move to leave as many children at home as possible1 must therefore have a safety net, and personnel involved must be fully aware of the risks in not transporting them. In their response to a consultation on a Department of Health report,24 the Department of Health ambulance policy team suggested that, to reduce risk, emphasis should be placed primarily on the assessment and recognition of the sick child and that advanced skills such as intubation or gaining intravenous access are secondary to the requirement for removal to definitive care. In the future, paramedics should be encouraged to use telemetry to get supportive advice from primary or secondary care. This is particularly important when making decisions that may change the child's outcome, particularly if there is a long transfer time between the scene and hospital. Future service developments should also be based upon a needs assessment that links prehospital care with outcomes. Each service should be able to assess its case mix and develop its training appropriately. Additionally, the Care Quality Commission should work collaboratively with the ambulance services, JRCALC and appropriate colleges to develop a set of standards related to the prehospital emergency care of children in the ambulance service. This will ensure that the prehospital phase of a child's care pathway is part of the continuum and not viewed in isolation.
Collaborative training, audit and research between ambulance and acute trusts would be beneficial to both prehospital and secondary care practitioners and commissioners. One way that prehospital care personnel can be involved in clinical audit/research is through participation in a Confidential Enquiry. The essential feature of these enquiries is the independent, multidisciplinary, anonymous review of cases to identify avoidable factors. The enquiry process itself can be a powerful tool ‘to educate and to drive change through the experience of participants’.25 The forthcoming CMACE Enquiry into Head Injury in Children is one that paramedics are encouraged to follow and participate in where possible.
The self-report survey was dependent upon a reliable response. As surveys were not returned by three services, the findings cannot be generalised. Effort was made to ensure comparability of the data from respondents through piloting the survey and providing guidance, yet there were still some ambiguous responses. Respondents may have misinterpreted some questions and subsequently provided incorrect responses or responses that could be misinterpreted by the researcher. As information was obtained primarily from service managers, a study (eg, a national survey or qualitative interviews) on the views of paramedics and front-line staff on the challenges and pitfalls of prehospital care issues relating to children is recommended.
The aim of this survey was to provide an up-to-date national picture on the care available to children in the prehospital setting in order to inform future service provision, practice, guideline development and further audit, research and confidential enquiry. Despite improvements, paediatric care by front-line personnel remains limited by resource and skill availability and, when assessed by comparison with national guidelines (eg, JRCALC), accepted standards are often lacking. The findings provide a basis for discussion by service planners and providers about the future provision of prehospital care for all children. Furthermore, this study highlights the requirement for robust collaborative audit in this area, in which we would include case note review, to guide training, local service requirements and resource allocation. Training initiatives should also be collaborative between ambulance services and acute trusts. This will reduce variation and maintain the safety of patients and quality of care.
The authors thank all of the respondents and their colleagues for taking the time to complete the survey. They also thank Fiona Jewkes, Mark Woolcock, Kevin Morris and Phil Hyde for providing invaluable clinical advice over the development of the questionnaire.
Funding This work was undertaken by the Centre for Maternal and Child Enquiries (CMACE) as part of Child Health Enquiry under the Confidential Enquiry into Maternal and Child Health (CEMACH) programme. The CEMACH programme of work is funded by the National Patient Safety Agency. Additional contributors to the Child Health Enquiry include the Department of Health, Social Services and Public Safety of Northern Ireland, the Isle of Man and the States of Jersey and Guernsey. The views expressed in this publication are those of the authors and not those of the funding bodies.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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