Emergency Medical Services Clinicians’ Pediatric Destination Decision-Making: A Qualitative Study

Objective This study sought to identify factors that influence emergency medical services (EMS) clinicians’ destination decision-making for pediatric patients. We also sought EMS clinicians’ opinions on potential systems improvements, such as protocol changes and the use of evidence-based transport guidelines. Methods Thirty-six in-depth phone interviews were conducted using a semi-structured format. We utilized a modified Grounded Theory approach to understand the complicated decision-making processes of EMS personnel. Memo writing was used throughout the data collection and analysis processes in order to identify emerging themes. The research team utilized hierarchical coding of interview transcripts to organize data into sub-categories for final analysis. Results EMS clinicians cited the perceived need for specialty care, the presence of a medical home, a desire for improved continuity of care, and the availability of aeromedical transport as factors that promoted transport to a pediatric specialty center. They voiced that children with emergent stabilization needs should be transported to the closest facility, however, they did not identify any specific medical conditions suitable for transport to non-specialty centers. EMS clinicians recommended improvements in pediatric-specific education, improved clarity of hospitals’ pediatric capabilities, and the creation of a pediatric-specific destination decision-making tool. Conclusion This study describes specific factors that influence EMS clinicians’ transport destination decision-making for pediatric patients. It also describes potential systems and educational improvements that may increase pediatric transport directly to definitive care. EMS clinicians are in support of specific designations for hospitals’ pediatric capabilities and were in favor of the creation of a formal destination decision-making tool.


Introduction
Emergency medical services (EMS) clinicians (Basic and Advanced Emergency Medical Technicians and Paramedics) are tasked with assessing, treating, and transporting patients in the prehospital environment [1][2][3]. For pediatrics, the transport destination determined by the EMS clinician is a particularly important aspect of the child's overall emergency care. If a child is transported to a hospital that is not capable of providing definitive care, they must undergo interfacility transport (IFT) to another facility ("secondary transport") which both prolongs care and is associated with patient harms [4][5][6][7][8][9].
While direct transport protocols proliferate in adult populations such as ST-elevation myocardial infarction (STEMI), stroke, and psychiatric emergencies, similar guidelines and decision-making tools have not taken hold for pediatric patients with the exception of major trauma [7,10,11]. In the absence of established evidence-based guidelines (EBGs), EMS clinicians rely on their gestalt to determine the appropriate destination decision for pediatric patients. While some published literature exists regarding EMS pediatric transport patterns, little is known about how EMS clinicians make these decisions [12][13][14]. hospitals and to large tertiary care centers [15][16][17]. The regionalization of pediatric-specific resources necessitates that EMS agencies stay abreast of their local facilities' pediatric-specific capabilities. However, the confusing nature of which pediatric services are provided at which hospitals makes the destination decision difficult and introduces the possibility of under-triage (transporting children who require specialty services to a non-specialty hospital) and over-triage (transporting children to a specialty center unnecessarily) [13].
EMS clinicians have historically reported discomfort with treating pediatric patients [18][19][20][21]. Previous studies have found infrequent exposure to pediatric patients and limited pediatric-specific formal education lie at the heart of that discomfort [18][19][20]22,23]. Additionally, there is even less exposure to critically ill children and in performing advanced life support (ALS) skills and procedures [19].
As a foundation towards building evidence-based guidelines for the pediatric transport destination decisionmaking process, understanding EMS clinicians' current decision-making process is essential. Therefore, this study was designed to examine factors related to EMS clinicians' pediatric destination decision-making, including those that encourage transport to a pediatric specialty center as well as transport to local nonspecialty facilities. We also assessed EMS clinicians' opinions of ways to improve destination decisionmaking for pediatric patients.

Study design
This exploratory study utilized a modified Grounded Theory approach for data collection and analysis in order to understand the complicated decision-making processes of EMS personnel in determining transport destinations for pediatric patients [24]. We defined the research questions presented in Appendix A a priori but allowed for new themes and questions to emerge as the data collection and analysis progressed. Grounded Theory has been used previously in qualitative EMS systems research including both protocol implementation and pediatric-specific clinical research [25][26][27]. The Johns Hopkins Medicine Institutional Review Board (IRB) approved this study. Each informant provided oral consent to be interviewed and was audio recorded as part of the study. The research team kept the audio recordings, transcripts, and names of the informants confidential throughout the study, accessible only to the researchers.

Sampling and study data
Study participants were solicited from an online survey of EMS clinicians in Maryland conducted in June-August 2015. One survey question asked respondents whether or not they would be willing to volunteer for a follow-up phone interview in exchange for a $20 gift card. Among those who volunteered for the phone interview, participants were randomly selected by the researchers within three targeted demographic groups as self-identified on the online survey: clinician certification level, geographic location, and employment status. The clinician levels included were ALS, such as Advanced Emergency Medical Technicians (EMTs) and paramedics, and Basic Life Support (BLS), such as Basic EMTs and Emergency Medical Responders. Geographic location was defined by whether the participant identified his or her primary EMS station as being in a rural or urban area, and employment status consisted of whether the participant's primary EMS role was on a career or volunteer basis. Personnel were interviewed within each of the demographic sub-categories until thematic saturation within each of the six groups was reached.

Study protocol
Data were collected via a recorded telephone interview with verbal consent provided by participants. For each in-depth interview (IDI), the research team explained to the participant the study purpose, risks, and benefits. The research team created an interview guide to loosely structure the initial IDI and revised the guides as needed to best clarify questions and based on the identification of emerging themes. The guide for the IDIs provided a semi-structured format for exploring informants' experiences with and options for transporting pediatric patients in his or her jurisdiction, thoughts on the utility of creating a medical pediatric triage tool, as well as transport decisions on four hypothetical clinical scenarios created by the research team (Appendix A). The four clinical scenarios were intended to supplement the questions on the informant's experiences and designed to further elucidate the informant's decision-making process with the presentation of specific clinical details that the informant may not have recalled from his or her own transport experiences. The researchers took brief hand-written notes during each interview to document the tone. Themes were recorded for the adaptation of future IDIs and the research team transcribed the audio recording of each interview verbatim for analysis.

Data analysis
The multi-staged coding process began with line-by-line coding of transcribed interviews in order to identify potential themes. The research team then used a collaborative group process of focused coding to combine and or re-arrange the original list of codes as needed. Furthermore, we used a collaborative process of axial coding to create a codebook with the following overarching axes: 1) Factors influencing transport decisions, 2) Utilization of triage tools. Based on the codebook, the research team coded each transcript using Atlas.ti version 7 (Scientific Software Development, Berlin, Germany). Lastly, the research team used hierarchical coding to organize data into sub-categories.

Results
This study utilized qualitative data collected between August and October 2015 from 36 in-depth phone interviews with EMS personnel in Maryland. The duration of the interviews ranged from 25 minutes to 90 minutes, with an average length of 40 minutes. Among the 36 participants, 25 were male and 11 were female, 19 were ALS and 17 were BLS clinicians, 14 worked in rural locations and 22 worked in urban locations, and 21 were career and 15 were volunteer clinicians ( Table 1).

Factors that promote transport to a pediatric specialty center
We identified five factors that promoted EMS transport to a pediatric specialty center. These factors, a summary of the overall themes, and representative quotations are presented in Table 2. Clinical factors included perceived medical need for specialty care, the presence of a medical home or previously established care at a specific facility, and the desire for improved continuity of care. Operational factors included the availability of helicopter-EMS (HEMS).

Factors that promote transport to local non-specialty facilities
We identified four factors that promoted EMS transport to local non-specialty facilities. These factors, a summary of the overall theme, and representative quotations are presented in Table 3. Clinical factors included critically ill patients and EMS discomfort in treating pediatric patients. Operational factors included long transport times to specialty centers.

Other factors that weigh into destination decision-making
We identified three other factors that EMS clinicians cited as being important in their destination decision making, but did not specifically align with transport to either a pediatric specialty center or a local nonspecialty center. These factors, a summary of the overall theme, and representative quotations are presented in Table 4. These included family/caregiver destination preference, online medical direction, offline EMS clinician protocols, and confusion over specific hospitals' pediatric capabilities. "I hate to tell you this, but I didn't get a memo. I was not made aware that they were taking pediatrics."

Suggestions for improved pediatric destination decision-making
EMS clinicians offered several suggestions in order to better facilitate appropriate destination decision making for pediatric patients. These suggestions are outlined in Table 5. They included clinical improvements in pediatric-specific education as well as the creation of a pediatric-specific triage tool. Systems improvement suggestions included revision of offline EMS clinician protocols, improved clarity of hospital's pediatric capabilities, and guidance for medically complex pediatric patients or those with medical homes. "Special needs populations with children, where they have past medical history…Maybe they're potentially stable now, but do they fit in any category that should go to the specialty center right away, rather than getting evaluated locally?"

Discussion
This study aimed to elucidate key factors related to EMS clinicians' pediatric destination decision-making. A secondary aim was to highlight potential systems and educational changes that would improve pediatric destination decision making. The results outline several factors that prompt EMS clinicians to transport children to pediatric specialty facilities, however, we discovered a dearth of specific factors that prompted the transport of children to local non-specialty facilities. The EMS clinicians interviewed also provided several tangible recommendations to improve pediatric destination decision-making.
The EMS clinicians interviewed in this study repeatedly communicated their preference to transport children directly to an appropriate center whenever feasible. They cited the perceived need for specialty care as a motivating factor to choose direct transport to a pediatric specialty center. The respondents also cited a desire for continuity of care among pediatric patients. Several specifically mentioned a desire to transport a child to their medical home. This is particularly important as children with special healthcare needs (CSHCN) have a disproportionately high rate of EMS usage and more frequently require IFT [28,29]. Despite a general discomfort in providing care to pediatric patients, EMS clinicians understand the needs of both general pediatrics and CSHCN. That clinical intuition can be refined in formal education and incorporated in future EBGs. As a part of this education, EMS clinicians should be introduced to the Emergency Information Form (EIF), a simple and easy to utilize document for CSHCN endorsed by the American Academy of Pediatrics and the American College of Emergency Physicians [3,30]. If the population of children who need a pediatric capable destination is successfully identifiable by EMS clinicians and direct transport is possible, this could relieve a significant burden on local non-specialty facilities as well as patients and their families.
EMS clinicians identified only one factor that specifically promoted transport to local non-specialty facilities -children that were critically ill and required emergent stabilization. Other factors listed as promoting transport to local non-specialty facilities included EMS discomfort in caring for children and confusion over receiving hospitals' pediatric capabilities. Both of those items represent educational and operational shortcomings more so than physiologic/clinical indication for transport. Few clinicians interviewed were able to identify specific conditions that local non-specialty facilities can adequately address. While it is important in developing EBGs and transport protocols to consider acuity and complex conditions, equal emphasis should be placed on triaging children to local non-specialty or modestly capable pediatric centers when appropriate. Thus, that area represents a concrete area for improved EMS research and education.
Several operational considerations also influenced EMS transport decision-making. Predictably, those in rural settings more often cited transport time as contributing factor when transporting children to local non-specialty facilities or for utilizing HEMS for transport to a pediatric specialty center. While this input from our respondents was not unexpected, it underscores that future decision-making tools and transport protocols should take these operational issues into consideration, understanding that no EMS system is identical in either geography or resources. While clinical components and hospital capabilities may be standardizable, future decision-making tools should allow for individual EMS systems to input resource utilization specifics.
A general discomfort in treating children, especially critically-ill children, was a recurring theme in the IDIs. That discomfort and the need for pediatric-specific EMS education have been reported over the past thirty years [18][19][20][21][22]. The IDIs revealed that despite those repeated calls for prehospital pediatric education, current educational practices are still not alleviating EMS clinicians' widespread discomfort in caring for children. That issue will likely persist and potentially become more severe as pediatric hospital resources continue to become more centralized necessitating longer transport time to specialty care.
EMS clinicians also expressed variable levels of knowledge over hospitals' pediatric-specific capabilities. That knowledge varied from not knowing that a given hospital even accepted children to knowing specific hours when a pediatrician was on staff. Without any widely operative and standardizable way of classifying hospitals' pediatric-specific capabilities, the onus falls to individual EMS agencies and clinicians and requires significant experience in a geographic area of practice. During the IDIs, respondents requested specific information about their local hospitals' pediatric capabilities. This would allow for transparency of pediatric-specific capabilities and would also allow for easier destination decision-making in the prehospital arena. Respondents also requested explicit guidance on what conditions to transport to pediatric specialty centers versus local non-specialty hospitals.
The EMS clinicians included in this study were overwhelmingly in favor of the creation of a destination decision-making tool. The minority of study participants who believed that a destination decision tool was unnecessary stated that in their local practice all pediatric medical patients are transported to the closest ED. While such practices may be appropriate in more austere geographic areas, pediatric patients should be assessed and transport destination determined on a case-by-case basis by EMS clinicians and the transport destination should be tailored to best serve the patient and their family/caregivers. The clinicians in favor of a destination decision-making tool requested that such a tool include both medical and traumatic conditions, that hospitals be differentiated by their pediatric-specific resources, and that EMS clinicians are educated as to which specific patient conditions require higher levels of pediatric specialty care. Such a decision-making tool would ideally maximize the number of patients transported to a facility capable of providing those children definitive care while optimizing scarce EMS system and hospital resources.
There are limitations inherent to interview-based qualitative research including this study. First, less than 20% of those who completed the initial online survey volunteered for the phone interview and were able to be contacted to conduct an interview. Those who volunteered for the phone interview may be particularly passionate about pediatric issues and may not represent the entire population of EMS personnel in Maryland. Second, there is the possibility of a Hawthorne effect during the interviews, particularly with regards to giving answers to the clinical scenarios. To mitigate the impact of that bias, the researchers used the scenarios to glean further details of EMS personnel's decision-making processes, rather than the absolute number or percentage of informants who chose one destination or trauma category over another.

Conclusions
This study describes specific factors that influence EMS clinicians' transport destination decision-making for pediatric patients, as well as potential systems and educational improvements targeted at increasing pediatric transport to definitive care. The pediatric prehospital destination decision-making process is extremely complex and is coupled with widespread discomfort among EMS clinicians in caring for and transporting children. Improved strategies are needed for both pediatric EMS education and for the EMS destination decision-making process in order to provide quality prehospital pediatric care in an era of increasing pediatric hospital resource regionalization. EMS clinicians are in support of the creation of a formal pediatric destination decision-making tool.