ORIGINAL CONTRIBUTION paramedics, patient assessment, pediatric prehospital care, vital signs
Vital Signs as Part of the Prehospital A s s e s s m e n t of the Pediatric Patient: A Survey of Paramedics Vital signs are an integral part of the field assessment of patients. A twopart study was undertaken to determine which vital signs are taken in the field assessment of pediatric patients and to determine whether the frequency of vital signs taken is influenced by base station contact, patient's severity of illness or injury, or paramedic demographic factors such as parenting and field experience. An initial pilot study of prehospital care records (run sheets) from two base hospitals in Los Angeles County revealed that there were significant differences between field vital sign assessment in pediatric and adult patients (P < .0001). A retrospective review of 6,756 pediatric run sheets from Los Angeles County showed that the frequency of vital sign assessment varied with the age of the pediatric patient (P < .05) (ie, the frequency of vital sign assessment increased correspondingly with the age of the patient). Base hospital contact occurred in 26% of the runs; when contact was made, vital signs were more likely to be taken in all age groups studied. Vital signs often were not assessed in children less than 2 years old, even if the patient's chief complaint suggested the possibility of a major illness or trauma. The second part of the study was a field assessment survey that was distributed to 1,253 active paramedics in Los Angeles County; the results showed that paramedics were less confident in their ability to assess vital signs in children less than 2 years old. Confidence increased with age of the patient. The number of runs a provider m a d e during a 24-hour shift was the only demographic factor related to the level of provider confidence. Future emergency medical services research m u s t link field vital sign assessment to outcome to determine the value of this type of field assessment in the pediatric age group. [Gausche M, Henderson DP, Seidd JS: Vital signs as part of the prehospital assessm e n t of the pediatric patient: A survey of paramedics. Ann Emerg Med February 1990;19:173-178.]
Marianne Gausche, MD*t Deborah P Henderson, MA, RN¢ James S Seidel, MD, PhD*¢ Torrance, California From the Departments of Emergency Medicine* and Pediatrics,t Harbor-UCLA Medical Center, Torrance, California. Received for publication March 13, 1989. Revision received August 25, 1989. Accepted for publication September 28, 1989. Funded in part by a grant from the US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Maternal and Child Health and Resources Development, through the California State Department of Health, Maternal Child Health Branch (Grant no. MCH-064001-01-3, Contract to the State of California no. 87-91857). Address for reprints: Marianne Gausche, MD, Department of Emergency Medicine, Harbor-UCLA Medical Center, 1000 West Carson Street, D-9, Torrance, California 90509.
INTRODUCTION Prehospital care providers are required in most emergency medical services (EMS) systems to take vital signs on all patients. Although several studies have addressed the epidemiology of prehospital care of the pediatric patient, there is a lack of research concerning provider compliance with the use of field assessment parameters in the pediatric age group.l-a As a part of the California Emergency Medical Services for Children (EMSC) project, data were collected on the frequency of vital sign assessm e n t in pediatric and adult patients who were evaluated in the field. It was found that vital sign assessment often was omitted in the pediatric age group. A two-part study was initiated to determine 1) which vital signs, if any, were taken and under what circumstances and 2) the attitudes of prehospital care providers toward assessment of the pediatric patient. MATERIALS A N D METHODS First, a pilot study was undertaken to determine the actual frequency with which vital signs were taken in the pediatric (18 years old or younger) and the adult {19 years old or older) age groups. Prehospital care reports (run sheets) of 449 pediatric and 449 adult patients from two base hospitals in Los Angeles County during a two-month period (October and November 1987) were reviewed. The run sheets were reviewed for documentation of 19:2 February 1990
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PREHOSPITAL ASSESSMENT Gausche, Henderson & Seidel
TABLE 1. Comparison of the vital sign assessment by paramedics in adult and pediatric patients (pilot study)
Pulse (%)
Respirations (%)
No Vital Signs Taken (%)
1 (4)
21 (84)
18 (72)
4 (16)
1 (4)
7 mo - 2 yr N = 92
19 (21)
58 (63)
47 (51)
32 (34)
19 (21)
3 - 6 yr N = 82 7 - 12 yr N = 103 13 - 18 yr N = 147 0 - 18 yr (pediatric)*
37 (45)
64 (78)
59 (72)
18 (22)
35 (43)
75 (73)
87 (84)
74 (72)
14 (14)
65 (63)
119 (81)
129 (88)
122 (83)
17 (11)
112 (76)
251 (56)
359 (80)
320 (71)
85 (19)
232 (52)t
416 (93)
418 (93)
389 (87)
28
386 (86)t
Age 0 - 6 mo N = 25
> 19 yr (adult)*
Blood Pressure (%)
(6)
All Vital Signs Taken (%)
*Total number of patients in both pediatric and adult groups is 449. Some of these categories are not mutually exclusive. tp < .0001.
age, gender, w h i c h vital signs (if any) were taken, and whether base hospital contact was made. The adult and pediatric age groups were compared using ×2 analysis; differences w i t h P < .05 were considered significant. Based on these results, a two-part study was initiated to further identify differences in field assessment of pediatric and adult patients. The first part of the study consisted of a review of a larger sample of pediatric prehospital care run sheets from Los Angeles County; the second part was a survey of all paramedics active in Los Angeles C o u n t y on their views of pediatric and adult field assessment. Part 1 Los Angeles C o u n t y pediatric run s h e e t s on 6,756 p a t i e n t s were reviewed retrospectively. This sample included all pediatric runs in Los Angeles County for the three-month period of September through N o v e m b e r 1984. The age of each patient was either calculated from the date of birth or determined by the age in years, depending on information recorded on t h e r u n s h e e t . T h e p e d i a t r i c age group included patients from 0 to 18 years old. This age group was chosen because it was the same age group used in previous EMSC project research. Patients were divided into the following age groups for data analysis: 0 to 6 m o n t h s , 7 m o n t h s to 2
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years, 3 to 6 years, 7 to 12 years, and 13 to 18 years. Prehospital care runs were analyzed for the frequency of recorded blood pressure, pulse, and respirations. Other data collected included w h e t h e r base hospital c o n t a c t was made and the p a t i e n t s ' chief complaints. Chief c o m p l a i n t s were divided into m a j o r and m i n o r complaints to s i m p l i f y p r e s e n t a t i o n of the data. T h e definition of a major illness or injury included those complaints likely to be associated with an alteration in vital signs necessitating treatment: multiple trauma, head t r a u m a w i t h loss of consciousness, respiratory distress, altered level of consciousness, dead on arrival, full arrest, shortness of breath, foreign body in the airway, syncope, seizure, ingestion or overdose, chest pain, abdominal pain, and near-drowning. The definition of a minor illness or injury included those complaints that were less likely to cause an alteration in vital signs necessitating treatment: head trauma without loss of consciousness, laceration, abrasion, e x t r e m i t y fracture, dizziness, minor burns, flu symptoms, nausea, vomiting, diarrhea, extremity pain, fever, psychiatric or behavioral problems, and pregnancy. Major or minor designation of illness or injury severity was made from a list of the chief complaints on the run sheet because outcome data that could be used for
Annals of Emergency Medicine
more sophisticated measures of severity (Injury Severity Score) were not available. Data from the run sheets were entered into an IBM XT personal computer using a standard data base program. All c o m p a r i s o n s were m a d e using Fisher's exact test for outcome. P value < .05 was considered significant. Part 2 A survey form was developed to assess factors affecting the taking of vital signs as a part of the field assessm e n t of the pediatric patient. Confidence levels in providing prehospital care for pediatric versus adult patients and educational needs of the pediatric prehospital care provider in Los Angeles C o u n t y also were included on the survey. The survey was field-tested on a group of 25 prehospital care providers in San Luis Obispo C o u n t y . T h e final s u r v e y was tested in Los Angeles C o u n t y on a small group of paramedics; test or retest reliability in this group of paramedics was shown to be 84%. All 37 paramedic provider agencies in Los Angeles C o u n t y were contacted for assistance; the survey was distributed by these provider agencies to a total of 1,253 active paramedics. To e n s u r e c o n f i d e n t i a l i t y , the s u r v e y was returned by the individual paramedic in a self-addressed, stamped envelope to the EMSC project office. 19:2 February 1990
% Base Hospital Contact 60 -
5043.77
LI_9 RR
40
30
20
10
/
/
//
L O-6mo
7 m e - 2 yr
3 - 6 yr
7 - 12 yr
1 3 - 18 yr
Age Group Vital Signs Taken ~
All Vital Signs Taken
~
No Vital Signs Taken
TABLE 2. Comparison of vital sign assessment in the pediatric age group (0 to 18 years) - Study data (1984) and pilot data (1987)
Data Set Study Data N = 6,756* Pilot Data N = 449*
No Vital Signs Taken (%)
All Vital Signs Taken (%)
1,301 (19)
3,533 (52)
85 (19)
232 (52)
(P < .00011.
adult p a t i e n t s gives the following results: blood pressure, Xz = 158.7; resp i r a t i o n s , Xz = 31.9; p u l s e , Xz = 33.2; all vital signs taken, x z = 123; and no vital signs taken, Xz = 31. P v a l u e s for all c o m p a r i s o n s are less t h a n .0001. Base hospital contact and t h e c h i e f c o m p l a i n t of t h e p a t i e n t were other factors suggested by this p i l o t s t u d y to i n f l u e n c e t h e freq u e n c y of v i t a l sign a s s e s s m e n t by the prehospital care provider. These factors were evaluated in part 1 of the study as o u t l i n e d below.
RESULTS
Part 1
T h e pilot study revealed that there w e r e s i g n i f i c a n t d i f f e r e n c e s in t h e f r e q u e n c y of v i t a l sign a s s e s s m e n t b e t w e e n the pediatric and the adult age groups; v i t a l signs w e r e t a k e n m o r e f r e q u e n t l y i n a d u l t s t h a n in c h i l d r e n ( T a b l e 1). X~ a n a l y s i s for c o m p a r i s o n of field vital sign assessm e n t t a k e n b e t w e e n p e d i a t r i c and
In all, 6,756 prehospital run sheets w e r e evaluated. T h e n u m b e r of patients in the 0-to-6-month age group were 271 (4%); 7 m o n t h s to 2 years, 942 (14%); 3 to 6 years, 843 (12.5%); 7 to 12 years, 1,188 (17.6%); and 13 to 18 years, 3,512 (52%). A comparison of pilot data from 1987 and the study data with the larger sample from
*Note that "No vital signs taken" and "All vital signs taken" do not make up the entire data set; patients who had some of their vital signs taken are not included in this table but are comparable in all age groups studied.
D a t a f r o m all responses were entered into an IBM XT personal comp u t e r using a data base program developed to process this information. Fisher's exact test was used to compare high and low responses to a significance level of P < .05. Two similar q u e s t i o n s w e r e u s e d to t e s t t h e r e l i a b i l i t y of t h e p a r a m e d i c s ' responses; confidence versus the level of k n o w l e d g e and skills necessary to t a k e vital signs in the different pediatric age groups were compared using the X~ test of no relation. Responses 19:2 February 1990
F I G U R E 1. Paramedic field assessm e n t frequency of base hospital contact w h e n all or no vital signs were taken.
to t h e s e q u e s t i o n s w e r e h i g h l y related for all of the age groups studied
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PREHOSPITAL ASSESSMENT Gausche, Henderson & Seidel
% Major Illness/Injury 80 70
1
60 5¢ 4C 3C 2£ 1£
0 - 6 mo
7mo-2yr
3-6yr
7-12yr
1 3 - 1 8 yr
Age Group
FIGURE 2. Paramedic a s s e s s m e n t -m a j o r illness or i n j u r y as chief comp l a i n t w h e n no v i t a l s i g n s w e r e taken.
1984 showed no increase in the frequency of vital sign assessment from 1984 to 1987 (Table 2). The frequency of respirations, pulse, and blood pressure recording varied by age group (P < .05) except when comparing the frequency of respirations taken in the 0-to-6-months, 7-months-to-2-years, and 3-to-6-years age groups (P > .10). T h e f r e q u e n c y of b l o o d p r e s s u r e taken varied significantly among all age groups studied (P < .0001}. The frequency of pulse taken and the frequency of all vital sign assessment varied significantly by age group (P < .0001), except in children less than 2 years old: pulse, P = .04, and all vitals taken, P = .04. Base hospital contact was made 26% of the time in the pediatric age group. The frequency of base hospital contact did not vary with age, but vital signs were taken more often in all age groups when base hospital radio contact was made (Figure 1}. Vital signs were less likely to be taken, even for major illness and injuries, in the younger age groups (Figure 2). 112/176
TABLE 3. Paramedic population demographics - Los Angeles C o u n t y paramedic survey
Gender Male Female Unspecified
N
%
593 (96.1) 24 (3.9) 2
Type of Agency PubLic Private Unspecified
558 (90.4) 59 (9.6) 2
Experience (yr) Less than 2 2 - 5 More than 5
152 (24.6) 142 (22,9) 325 (52.5)
Number of Runs Per Shift 05 6 - 10 11 - 15 16 - 20
151 238 155 62
(24.6) (38.8) (25.3) (10.1)
21 - 25
7
(1.1)
Parent? Yes No
Annals of Emergency Medicine
354 (57.5) 262 (42.5)
19:2 February 1990
120 /
100
/
/
80 % 60
40 20
- - m~/f.////// O-6mo
7mo-2yr
13-18 yr
7-12yr
3-6yr
>19 yr
Age Group
•
Rarely confident
~
Confident
TABLE 4. Paramedics' views of situational factors that m a y affect vital sign
assessment of the pediatric patient
Situation Surrounding noise prevents adequate assessment (N = 617) Equipment not adequate (N = 616) Uncooperative patient (N = 616) You feel your skills are not adequate (N = 616) Child is not sick enough to require taking vital signs (N = 613) Child is too sick to waste time taking vital signs (N = 615) Parental interference (N = 616)
Part 2 Six hundred nineteen of 1,250 surveys (49.4%) were returned. Demo19:2 February 1990
Never or Occasionally Happens (%)
Frequently or Always Happens (%)
453 (73.4)
164 (26.6)
472 (76.6)
144 (23.4)
250 (40.6)
366 (59,4)
582(94.5)
34 (5.5)
485 (79.1)
128 (20.9)
542 (88.1)
73 (11.9)
569 (92.4)
47 (7.6)
graphics of the paramedics surveyed are outlined (Table 31. The paramedics' confidence and Annals of Emergency Medicine
F I G U R E 3. Paramedic survey paramedic confidence in taking vital signs. level of knowledge and skills in taking vital signs varied dramatically by age of the patient (Figure 3); confidence increased with increasing age of the patient. Parenthood, type of paramedic agency (public or private), gender of the provider, and years of paramedic experience did not prove to be significant factors in determining the paramedics' confidence in taking vital signs regardless of the patient age group. However, paramedics with more than ten runs per shift were more confident in their ability to take vital signs in children less than 2 years old (P < .03). When years of paramedic experience and number of runs per shift were corn pared, it was found that in all age groups studied, confidence was related more to the number of runs per shift than to years of paramedic experience. In addition, paramedics who believed that field experience was useful were significantly more confident in their ability to take vital signs in children less than 2 years old
(P < .oot). Responses to questions concerning 177/113
PREHOSPITAL ASSESSMENT Gausche, Henderson & Seidel
situational factors that prevent paramedics from taking vital signs in the field in pediatric patients are outlined (Table 4). Paramedics responded that pulse and r e s p i r a t i o n s were equally important in the evaluation of the pediatric trauma or medical patient. Only 75.7% of the paramedics believed that blood pressure was a useful vital sign in evaluation of pediatric medical patients, and 93.2% believed blood pressure was useful in e v a l u a t i o n of pediatric trauma patients. Temperature was believed to be useful in evaluating pediatric medical patients (76.6%) but not pediatric t r a u m a patients (24.9%}. The educational experiences that paramedics indicated were useful in improving their pediatric emergency medical education included special lectures and field experience. More than 80% of all the paramedics surveyed believed that more continuing education lectures in pediatric emergency medicine, more clinical training in pediatrics, more field experience with pediatric patients, and more frequent reviews of pediatric runs at base station meetings were needed to improve the prehospital care of children. DISCUSSION Field assessment by the paramedic differs between adult and pediatric patients. Why this difference exists is multifactorial. Factors that play significant roles in determining whether vital signs are assessed include patient age, provider confidence in field assessment skills, ongoing prehospital provider field experience (the number of runs per shift), and base hospital radio contact. Confidence in taking vital signs varied with age. As the age of the pat i e n t increased, so did the paramedics' confidence in taking that pa ~ tient's vital signs. Paramedics felt incrementally less confident in taking the vital signs in children 6 years old or younger, and the run sheet data demonstrated that they were significantly less likely to take vital signs in these young children. Severity of illness or injury did not seem to change this result. Confidence may be determined, in part, by the level of knowledge and skills and by the ongoing field experience of the paramedic. The results of 114/178
the survey, h o w e v e r , i m p l y that these factors alone do not explain the relative lack of confidence in taking vital signs in small children. Increased o p p o r t u n i t y for education and clinical exposure to children may improve the prehospitaI care providers' confidence in assessing pediatric patients. Of interest is that the frequency of vital sign assessment by paramedics did not change between the 1984 data period and the 1987 pilot study. This indicates that the educational program in place during this time span did not change the paramedics' assessment practices. Review of paramedic training programs has shown that 40% of the programs have less • than ten hours of didactic teaching in pediatrics and that 41% have less than ten hours of pediatric clinical experience. 4 In this study, more than 80% of the paramedics believed that increased clinical training time and didactic teaching time in pediatrics would improve the prehospital care of children. Environmental conditions, including surrounding noise and parental interference, were not believed by the paramedics to be hindrances in taking vital signs in the pediatric patient. Parenthood, gender of the paramedic, years of experience as a paramedic, type of provider agency, and available equipment were not found to affect the provider's perceived ability to take vital signs in the pediatric patient. In this survey, 12% of the paramedics believed that the "child was too sick to waste time on vitals," and 60% of the paramedics believed that the " u n c o o p e r a t i v e p a t i e n t " prevented t h e m from obtaining vital signs. Because more than 90% of paramedics believed that vital signs were useful in assessing both medical and trauma patients, it appears that either there are more uncooperative or sick children than adults or ill and injured children m a y be perceived as sicker than adults. Other possible obstacles to the assessment of vital signs include inexperience in caring for pediatric patients and anxiety when confronted with an ill or injured child. Further study is needed to evaluate whether prehospital care providers use other methods, such as "the way the child looks," to assess the severAnnals of Emergency Medicine
ity of illness of pediatric patients. The use of vital signs and other field procedures for assessment of pediatric patients must be studied and related to an outcome measure to determine w h e t h e r field assessment and field intervention influence morbidity and mortality. CONCLUSION It is evident from this study that paramedics often do not take complete vital signs in the pediatric patient, especially in children less than 2 years old; paramedics are not as confident in assessing vital signs of pediatric patients as they are in assessing vital signs of adult patients; and this relative lack of confidence decreases with the increasing age of the patient. Recognition of the difference in field assessment may provide the impetus to improve prehospital provider education in pediatrics and to stimulate further EMS research. F u r t h e r m o r e , e v a l u a t i o n of the usefulness of all field assessment parameters and procedures compared with the time spent in learning and performing these procedures should provide fertile fields for study.
The authors are grateful to Peter D. Christenson, PhD, for his assistance in the statistical analysis of the data and to Tricia Walker for her secretarial help in preparing this manuscript. They also thank the Department of Health Services, Los Angeles County; the Paramedic Training Institute; and the chiefs of the paramedic provider agencies in Los Angeles County for their assistance in the creation and distribution of the survey. They also give special thanks to the Los Angeles paramedics who participated in the study.
REFERENCES
1. Tsai A, Kallsen G: Epidemiologyof pediatric prehospital care. A n n Emerg M e d 1987;16: 3:284-292. 2. Seidel iS: A needs assessment of advanced life support and emergencymedical services in the pediatric patient: State of the art. Circulation 1986;74{supplIVI:IV-129-W-133. 3. Seidel JS, Hornbein M, YoshiyamaK, et al: Emergencymedical services and the pediatric patient: Are the needs being met? Pediatrics 1984;73:6:769-772. 4. Seidel JS: Emergencymedical services and the pediatric patient: Are the needs being met? II. Training and equipping emergencymedical services providers for pediatric emergencies. Pediatrics 1986~78:5:808-812. 19:2 February 1990
Vital Signs as Part of the Prehospital A s s e s s m e n t of the Pediatric Patient: A Survey of Paramedics Vital signs are an integral part of the field assessment of patients. A twopart study was undertaken to determine which vital signs are taken in the field assessment of pediatric patients and to determine whether the frequency of vital signs taken is influenced by base station contact, patient's severity of illness or injury, or paramedic demographic factors such as parenting and field experience. An initial pilot study of prehospital care records (run sheets) from two base hospitals in Los Angeles County revealed that there were significant differences between field vital sign assessment in pediatric and adult patients (P < .0001). A retrospective review of 6,756 pediatric run sheets from Los Angeles County showed that the frequency of vital sign assessment varied with the age of the pediatric patient (P < .05) (ie, the frequency of vital sign assessment increased correspondingly with the age of the patient). Base hospital contact occurred in 26% of the runs; when contact was made, vital signs were more likely to be taken in all age groups studied. Vital signs often were not assessed in children less than 2 years old, even if the patient's chief complaint suggested the possibility of a major illness or trauma. The second part of the study was a field assessment survey that was distributed to 1,253 active paramedics in Los Angeles County; the results showed that paramedics were less confident in their ability to assess vital signs in children less than 2 years old. Confidence increased with age of the patient. The number of runs a provider m a d e during a 24-hour shift was the only demographic factor related to the level of provider confidence. Future emergency medical services research m u s t link field vital sign assessment to outcome to determine the value of this type of field assessment in the pediatric age group. [Gausche M, Henderson DP, Seidd JS: Vital signs as part of the prehospital assessm e n t of the pediatric patient: A survey of paramedics. Ann Emerg Med February 1990;19:173-178.]
Marianne Gausche, MD*t Deborah P Henderson, MA, RN¢ James S Seidel, MD, PhD*¢ Torrance, California From the Departments of Emergency Medicine* and Pediatrics,t Harbor-UCLA Medical Center, Torrance, California. Received for publication March 13, 1989. Revision received August 25, 1989. Accepted for publication September 28, 1989. Funded in part by a grant from the US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Maternal and Child Health and Resources Development, through the California State Department of Health, Maternal Child Health Branch (Grant no. MCH-064001-01-3, Contract to the State of California no. 87-91857). Address for reprints: Marianne Gausche, MD, Department of Emergency Medicine, Harbor-UCLA Medical Center, 1000 West Carson Street, D-9, Torrance, California 90509.
INTRODUCTION Prehospital care providers are required in most emergency medical services (EMS) systems to take vital signs on all patients. Although several studies have addressed the epidemiology of prehospital care of the pediatric patient, there is a lack of research concerning provider compliance with the use of field assessment parameters in the pediatric age group.l-a As a part of the California Emergency Medical Services for Children (EMSC) project, data were collected on the frequency of vital sign assessm e n t in pediatric and adult patients who were evaluated in the field. It was found that vital sign assessment often was omitted in the pediatric age group. A two-part study was initiated to determine 1) which vital signs, if any, were taken and under what circumstances and 2) the attitudes of prehospital care providers toward assessment of the pediatric patient. MATERIALS A N D METHODS First, a pilot study was undertaken to determine the actual frequency with which vital signs were taken in the pediatric (18 years old or younger) and the adult {19 years old or older) age groups. Prehospital care reports (run sheets) of 449 pediatric and 449 adult patients from two base hospitals in Los Angeles County during a two-month period (October and November 1987) were reviewed. The run sheets were reviewed for documentation of 19:2 February 1990
Annals of Emergency Medicine •
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PREHOSPITAL ASSESSMENT Gausche, Henderson & Seidel
TABLE 1. Comparison of the vital sign assessment by paramedics in adult and pediatric patients (pilot study)
Pulse (%)
Respirations (%)
No Vital Signs Taken (%)
1 (4)
21 (84)
18 (72)
4 (16)
1 (4)
7 mo - 2 yr N = 92
19 (21)
58 (63)
47 (51)
32 (34)
19 (21)
3 - 6 yr N = 82 7 - 12 yr N = 103 13 - 18 yr N = 147 0 - 18 yr (pediatric)*
37 (45)
64 (78)
59 (72)
18 (22)
35 (43)
75 (73)
87 (84)
74 (72)
14 (14)
65 (63)
119 (81)
129 (88)
122 (83)
17 (11)
112 (76)
251 (56)
359 (80)
320 (71)
85 (19)
232 (52)t
416 (93)
418 (93)
389 (87)
28
386 (86)t
Age 0 - 6 mo N = 25
> 19 yr (adult)*
Blood Pressure (%)
(6)
All Vital Signs Taken (%)
*Total number of patients in both pediatric and adult groups is 449. Some of these categories are not mutually exclusive. tp < .0001.
age, gender, w h i c h vital signs (if any) were taken, and whether base hospital contact was made. The adult and pediatric age groups were compared using ×2 analysis; differences w i t h P < .05 were considered significant. Based on these results, a two-part study was initiated to further identify differences in field assessment of pediatric and adult patients. The first part of the study consisted of a review of a larger sample of pediatric prehospital care run sheets from Los Angeles County; the second part was a survey of all paramedics active in Los Angeles C o u n t y on their views of pediatric and adult field assessment. Part 1 Los Angeles C o u n t y pediatric run s h e e t s on 6,756 p a t i e n t s were reviewed retrospectively. This sample included all pediatric runs in Los Angeles County for the three-month period of September through N o v e m b e r 1984. The age of each patient was either calculated from the date of birth or determined by the age in years, depending on information recorded on t h e r u n s h e e t . T h e p e d i a t r i c age group included patients from 0 to 18 years old. This age group was chosen because it was the same age group used in previous EMSC project research. Patients were divided into the following age groups for data analysis: 0 to 6 m o n t h s , 7 m o n t h s to 2
110/174
years, 3 to 6 years, 7 to 12 years, and 13 to 18 years. Prehospital care runs were analyzed for the frequency of recorded blood pressure, pulse, and respirations. Other data collected included w h e t h e r base hospital c o n t a c t was made and the p a t i e n t s ' chief complaints. Chief c o m p l a i n t s were divided into m a j o r and m i n o r complaints to s i m p l i f y p r e s e n t a t i o n of the data. T h e definition of a major illness or injury included those complaints likely to be associated with an alteration in vital signs necessitating treatment: multiple trauma, head t r a u m a w i t h loss of consciousness, respiratory distress, altered level of consciousness, dead on arrival, full arrest, shortness of breath, foreign body in the airway, syncope, seizure, ingestion or overdose, chest pain, abdominal pain, and near-drowning. The definition of a minor illness or injury included those complaints that were less likely to cause an alteration in vital signs necessitating treatment: head trauma without loss of consciousness, laceration, abrasion, e x t r e m i t y fracture, dizziness, minor burns, flu symptoms, nausea, vomiting, diarrhea, extremity pain, fever, psychiatric or behavioral problems, and pregnancy. Major or minor designation of illness or injury severity was made from a list of the chief complaints on the run sheet because outcome data that could be used for
Annals of Emergency Medicine
more sophisticated measures of severity (Injury Severity Score) were not available. Data from the run sheets were entered into an IBM XT personal computer using a standard data base program. All c o m p a r i s o n s were m a d e using Fisher's exact test for outcome. P value < .05 was considered significant. Part 2 A survey form was developed to assess factors affecting the taking of vital signs as a part of the field assessm e n t of the pediatric patient. Confidence levels in providing prehospital care for pediatric versus adult patients and educational needs of the pediatric prehospital care provider in Los Angeles C o u n t y also were included on the survey. The survey was field-tested on a group of 25 prehospital care providers in San Luis Obispo C o u n t y . T h e final s u r v e y was tested in Los Angeles C o u n t y on a small group of paramedics; test or retest reliability in this group of paramedics was shown to be 84%. All 37 paramedic provider agencies in Los Angeles C o u n t y were contacted for assistance; the survey was distributed by these provider agencies to a total of 1,253 active paramedics. To e n s u r e c o n f i d e n t i a l i t y , the s u r v e y was returned by the individual paramedic in a self-addressed, stamped envelope to the EMSC project office. 19:2 February 1990
% Base Hospital Contact 60 -
5043.77
LI_9 RR
40
30
20
10
/
/
//
L O-6mo
7 m e - 2 yr
3 - 6 yr
7 - 12 yr
1 3 - 18 yr
Age Group Vital Signs Taken ~
All Vital Signs Taken
~
No Vital Signs Taken
TABLE 2. Comparison of vital sign assessment in the pediatric age group (0 to 18 years) - Study data (1984) and pilot data (1987)
Data Set Study Data N = 6,756* Pilot Data N = 449*
No Vital Signs Taken (%)
All Vital Signs Taken (%)
1,301 (19)
3,533 (52)
85 (19)
232 (52)
(P < .00011.
adult p a t i e n t s gives the following results: blood pressure, Xz = 158.7; resp i r a t i o n s , Xz = 31.9; p u l s e , Xz = 33.2; all vital signs taken, x z = 123; and no vital signs taken, Xz = 31. P v a l u e s for all c o m p a r i s o n s are less t h a n .0001. Base hospital contact and t h e c h i e f c o m p l a i n t of t h e p a t i e n t were other factors suggested by this p i l o t s t u d y to i n f l u e n c e t h e freq u e n c y of v i t a l sign a s s e s s m e n t by the prehospital care provider. These factors were evaluated in part 1 of the study as o u t l i n e d below.
RESULTS
Part 1
T h e pilot study revealed that there w e r e s i g n i f i c a n t d i f f e r e n c e s in t h e f r e q u e n c y of v i t a l sign a s s e s s m e n t b e t w e e n the pediatric and the adult age groups; v i t a l signs w e r e t a k e n m o r e f r e q u e n t l y i n a d u l t s t h a n in c h i l d r e n ( T a b l e 1). X~ a n a l y s i s for c o m p a r i s o n of field vital sign assessm e n t t a k e n b e t w e e n p e d i a t r i c and
In all, 6,756 prehospital run sheets w e r e evaluated. T h e n u m b e r of patients in the 0-to-6-month age group were 271 (4%); 7 m o n t h s to 2 years, 942 (14%); 3 to 6 years, 843 (12.5%); 7 to 12 years, 1,188 (17.6%); and 13 to 18 years, 3,512 (52%). A comparison of pilot data from 1987 and the study data with the larger sample from
*Note that "No vital signs taken" and "All vital signs taken" do not make up the entire data set; patients who had some of their vital signs taken are not included in this table but are comparable in all age groups studied.
D a t a f r o m all responses were entered into an IBM XT personal comp u t e r using a data base program developed to process this information. Fisher's exact test was used to compare high and low responses to a significance level of P < .05. Two similar q u e s t i o n s w e r e u s e d to t e s t t h e r e l i a b i l i t y of t h e p a r a m e d i c s ' responses; confidence versus the level of k n o w l e d g e and skills necessary to t a k e vital signs in the different pediatric age groups were compared using the X~ test of no relation. Responses 19:2 February 1990
F I G U R E 1. Paramedic field assessm e n t frequency of base hospital contact w h e n all or no vital signs were taken.
to t h e s e q u e s t i o n s w e r e h i g h l y related for all of the age groups studied
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175/111
PREHOSPITAL ASSESSMENT Gausche, Henderson & Seidel
% Major Illness/Injury 80 70
1
60 5¢ 4C 3C 2£ 1£
0 - 6 mo
7mo-2yr
3-6yr
7-12yr
1 3 - 1 8 yr
Age Group
FIGURE 2. Paramedic a s s e s s m e n t -m a j o r illness or i n j u r y as chief comp l a i n t w h e n no v i t a l s i g n s w e r e taken.
1984 showed no increase in the frequency of vital sign assessment from 1984 to 1987 (Table 2). The frequency of respirations, pulse, and blood pressure recording varied by age group (P < .05) except when comparing the frequency of respirations taken in the 0-to-6-months, 7-months-to-2-years, and 3-to-6-years age groups (P > .10). T h e f r e q u e n c y of b l o o d p r e s s u r e taken varied significantly among all age groups studied (P < .0001}. The frequency of pulse taken and the frequency of all vital sign assessment varied significantly by age group (P < .0001), except in children less than 2 years old: pulse, P = .04, and all vitals taken, P = .04. Base hospital contact was made 26% of the time in the pediatric age group. The frequency of base hospital contact did not vary with age, but vital signs were taken more often in all age groups when base hospital radio contact was made (Figure 1}. Vital signs were less likely to be taken, even for major illness and injuries, in the younger age groups (Figure 2). 112/176
TABLE 3. Paramedic population demographics - Los Angeles C o u n t y paramedic survey
Gender Male Female Unspecified
N
%
593 (96.1) 24 (3.9) 2
Type of Agency PubLic Private Unspecified
558 (90.4) 59 (9.6) 2
Experience (yr) Less than 2 2 - 5 More than 5
152 (24.6) 142 (22,9) 325 (52.5)
Number of Runs Per Shift 05 6 - 10 11 - 15 16 - 20
151 238 155 62
(24.6) (38.8) (25.3) (10.1)
21 - 25
7
(1.1)
Parent? Yes No
Annals of Emergency Medicine
354 (57.5) 262 (42.5)
19:2 February 1990
120 /
100
/
/
80 % 60
40 20
- - m~/f.////// O-6mo
7mo-2yr
13-18 yr
7-12yr
3-6yr
>19 yr
Age Group
•
Rarely confident
~
Confident
TABLE 4. Paramedics' views of situational factors that m a y affect vital sign
assessment of the pediatric patient
Situation Surrounding noise prevents adequate assessment (N = 617) Equipment not adequate (N = 616) Uncooperative patient (N = 616) You feel your skills are not adequate (N = 616) Child is not sick enough to require taking vital signs (N = 613) Child is too sick to waste time taking vital signs (N = 615) Parental interference (N = 616)
Part 2 Six hundred nineteen of 1,250 surveys (49.4%) were returned. Demo19:2 February 1990
Never or Occasionally Happens (%)
Frequently or Always Happens (%)
453 (73.4)
164 (26.6)
472 (76.6)
144 (23.4)
250 (40.6)
366 (59,4)
582(94.5)
34 (5.5)
485 (79.1)
128 (20.9)
542 (88.1)
73 (11.9)
569 (92.4)
47 (7.6)
graphics of the paramedics surveyed are outlined (Table 31. The paramedics' confidence and Annals of Emergency Medicine
F I G U R E 3. Paramedic survey paramedic confidence in taking vital signs. level of knowledge and skills in taking vital signs varied dramatically by age of the patient (Figure 3); confidence increased with increasing age of the patient. Parenthood, type of paramedic agency (public or private), gender of the provider, and years of paramedic experience did not prove to be significant factors in determining the paramedics' confidence in taking vital signs regardless of the patient age group. However, paramedics with more than ten runs per shift were more confident in their ability to take vital signs in children less than 2 years old (P < .03). When years of paramedic experience and number of runs per shift were corn pared, it was found that in all age groups studied, confidence was related more to the number of runs per shift than to years of paramedic experience. In addition, paramedics who believed that field experience was useful were significantly more confident in their ability to take vital signs in children less than 2 years old
(P < .oot). Responses to questions concerning 177/113
PREHOSPITAL ASSESSMENT Gausche, Henderson & Seidel
situational factors that prevent paramedics from taking vital signs in the field in pediatric patients are outlined (Table 4). Paramedics responded that pulse and r e s p i r a t i o n s were equally important in the evaluation of the pediatric trauma or medical patient. Only 75.7% of the paramedics believed that blood pressure was a useful vital sign in evaluation of pediatric medical patients, and 93.2% believed blood pressure was useful in e v a l u a t i o n of pediatric trauma patients. Temperature was believed to be useful in evaluating pediatric medical patients (76.6%) but not pediatric t r a u m a patients (24.9%}. The educational experiences that paramedics indicated were useful in improving their pediatric emergency medical education included special lectures and field experience. More than 80% of all the paramedics surveyed believed that more continuing education lectures in pediatric emergency medicine, more clinical training in pediatrics, more field experience with pediatric patients, and more frequent reviews of pediatric runs at base station meetings were needed to improve the prehospital care of children. DISCUSSION Field assessment by the paramedic differs between adult and pediatric patients. Why this difference exists is multifactorial. Factors that play significant roles in determining whether vital signs are assessed include patient age, provider confidence in field assessment skills, ongoing prehospital provider field experience (the number of runs per shift), and base hospital radio contact. Confidence in taking vital signs varied with age. As the age of the pat i e n t increased, so did the paramedics' confidence in taking that pa ~ tient's vital signs. Paramedics felt incrementally less confident in taking the vital signs in children 6 years old or younger, and the run sheet data demonstrated that they were significantly less likely to take vital signs in these young children. Severity of illness or injury did not seem to change this result. Confidence may be determined, in part, by the level of knowledge and skills and by the ongoing field experience of the paramedic. The results of 114/178
the survey, h o w e v e r , i m p l y that these factors alone do not explain the relative lack of confidence in taking vital signs in small children. Increased o p p o r t u n i t y for education and clinical exposure to children may improve the prehospitaI care providers' confidence in assessing pediatric patients. Of interest is that the frequency of vital sign assessment by paramedics did not change between the 1984 data period and the 1987 pilot study. This indicates that the educational program in place during this time span did not change the paramedics' assessment practices. Review of paramedic training programs has shown that 40% of the programs have less • than ten hours of didactic teaching in pediatrics and that 41% have less than ten hours of pediatric clinical experience. 4 In this study, more than 80% of the paramedics believed that increased clinical training time and didactic teaching time in pediatrics would improve the prehospital care of children. Environmental conditions, including surrounding noise and parental interference, were not believed by the paramedics to be hindrances in taking vital signs in the pediatric patient. Parenthood, gender of the paramedic, years of experience as a paramedic, type of provider agency, and available equipment were not found to affect the provider's perceived ability to take vital signs in the pediatric patient. In this survey, 12% of the paramedics believed that the "child was too sick to waste time on vitals," and 60% of the paramedics believed that the " u n c o o p e r a t i v e p a t i e n t " prevented t h e m from obtaining vital signs. Because more than 90% of paramedics believed that vital signs were useful in assessing both medical and trauma patients, it appears that either there are more uncooperative or sick children than adults or ill and injured children m a y be perceived as sicker than adults. Other possible obstacles to the assessment of vital signs include inexperience in caring for pediatric patients and anxiety when confronted with an ill or injured child. Further study is needed to evaluate whether prehospital care providers use other methods, such as "the way the child looks," to assess the severAnnals of Emergency Medicine
ity of illness of pediatric patients. The use of vital signs and other field procedures for assessment of pediatric patients must be studied and related to an outcome measure to determine w h e t h e r field assessment and field intervention influence morbidity and mortality. CONCLUSION It is evident from this study that paramedics often do not take complete vital signs in the pediatric patient, especially in children less than 2 years old; paramedics are not as confident in assessing vital signs of pediatric patients as they are in assessing vital signs of adult patients; and this relative lack of confidence decreases with the increasing age of the patient. Recognition of the difference in field assessment may provide the impetus to improve prehospital provider education in pediatrics and to stimulate further EMS research. F u r t h e r m o r e , e v a l u a t i o n of the usefulness of all field assessment parameters and procedures compared with the time spent in learning and performing these procedures should provide fertile fields for study.
The authors are grateful to Peter D. Christenson, PhD, for his assistance in the statistical analysis of the data and to Tricia Walker for her secretarial help in preparing this manuscript. They also thank the Department of Health Services, Los Angeles County; the Paramedic Training Institute; and the chiefs of the paramedic provider agencies in Los Angeles County for their assistance in the creation and distribution of the survey. They also give special thanks to the Los Angeles paramedics who participated in the study.
REFERENCES
1. Tsai A, Kallsen G: Epidemiologyof pediatric prehospital care. A n n Emerg M e d 1987;16: 3:284-292. 2. Seidel iS: A needs assessment of advanced life support and emergencymedical services in the pediatric patient: State of the art. Circulation 1986;74{supplIVI:IV-129-W-133. 3. Seidel JS, Hornbein M, YoshiyamaK, et al: Emergencymedical services and the pediatric patient: Are the needs being met? Pediatrics 1984;73:6:769-772. 4. Seidel JS: Emergencymedical services and the pediatric patient: Are the needs being met? II. Training and equipping emergencymedical services providers for pediatric emergencies. Pediatrics 1986~78:5:808-812. 19:2 February 1990
