Pediatric emergency medicine trisk 4619 4619
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patient’s hospital care. Especially important aspects of documentation are serial vital signs, medical allergies,
initial evaluation and responses to interventions, and any changes en route, as well as a record of the mechanism
of injury and details that help put the incident in perspective. It is essential to have times and dosages associated
with any medications that were given.
EMS providers use paper or electronic charts to document EMS runs. Paper “run sheets” have certain
disadvantages, such as legibility challenges due to poor handwriting or carbon copies and potential misplacement
in the transfer of the patient. With the recent advancement in computers and tablets that are smaller and more
durable, many EMS providers now use some type of electronic patient care record (ePCR). Some medical centers
are able to receive ePCRs ahead of the ambulance’s arrival. ED capability to electronically access or print ePCR
records from EMS is an important part of the information transfer process. ePCRs have the potential to improve
the quality of EMS records and the timeliness of patient handoff information. The use of standardized ePCRs also
allows EMS operators to gather and analyze clinical data and to participate in clinical research. NEMSIS has
established a uniform data set used by most ePCR vendors. Health Information Exchanges have been successfully
implemented in several communities and states, allowing patients’ clinical outcomes to be distributed back to the
EMS agencies.
Telemedicine in EMS
The use of HIPAA compliant telemedicine from the scene of an accident, mass casualty scene, or other disaster
could be of benefit in a variety of ways. Scene telemedicine would have clear theoretical advantages when there
are shortages of medical staff or in medical emergencies involving infectious, biologic, or chemical emergencies.
The utility of telemedicine during transport has not yet been defined. In a simulation study by Charash et al.,
the use of telemedicine in a moving ambulance improved the care of simulated trauma patients including the time
to identify abnormal physiologic variables and the recognition rates for key signs, processes, and critical
interventions. Further research will be needed to identify which technologies and for which types of patients
telemedicine will offer the most benefit.
ISSUES IN EMS CARE
Culture of Safety
One of the most important aspects of the transit to the hospital is patient safety. EMS system safety practices also
affect EMS personnel and members of the community. EMS personnel often work long hours under unpredictable
circumstances and with limited supervision and resources. This combination can lead to preventable adverse
medical events for patients. Pediatric emergencies are low-frequency, but at times high-stakes, events that are at
high risk for adverse events and patient harm. EMS personnel are exposed to risks such as infectious diseases,
physical violence, occupational injury, and emotional stress, and the interaction of an ambulance and the general
motoring public puts both EMS providers and members of the community at risk.
Following the 1999 Institute of Medicine (IOM) report To Err Is Human , inpatient and outpatient healthcare
settings moved toward a culture of safety. Bringing these concepts to EMS, ACEP led a project, in cooperation
with NHTSA and the EMSC program, to develop a Strategy for a National EMS Culture of Safety , which was
made public in 2013. EMS leaders envision changing the status quo via a cultural shift to one in which “safety
considerations and risk awareness permeate the full spectrum of activities of EMS everywhere, every day—by
design, attitude, and habit.”
Medication errors gained immense attention after the 1999 IOM report, but little literature exists studying the
prevalence and outcomes of medication errors in the prehospital pediatric population. Both chart review and
patient simulation studies have documented medication error rates from 35% to 73% for pediatric doses of
epinephrine, atropine, diphenhydramine, and albuterol. One theme noted in these studies is the failure to use, or
incorrect usage of, length-based weight estimation tools.
A single data set does not exist to analyze the precise number of crashes involving emergency vehicles;
however, insurance companies report that approximately 10,000 ambulance crashes result in injury or death each
year. The relative risk of injury and death is high when collisions involve ambulances. An 11-year retrospective
review found that 339 fatal ambulance crashes from 1987 to 1997 resulted in a total of 405 deaths and 838
injuries to EMS patients, EMS personnel, and nonoccupant victims.
