The Trip Report: Pediatric Education in EMS

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REVIEWED THIS MONTH: Brown SA, Hayden TC, Randell KA, Rappaport L, Stevenson MD, Kim IK. Improving Pediatric Education for Emergency Medical Services Providers: A Qualitative Study. Prehosp Disaster Med, 2017 Feb; 32(1): 20–26.

This month is dedicated to educational research. Dr. Seth Brown and his coauthors recently published a manuscript examining pediatric education for EMS providers. This is a great opportunity to discuss a study design not often utilized in EMS or medical literature: the qualitative study.

Most research published in EMS and other medical literature involves quantitative studies. Quantitative studies rely on numbers to examine statistical significance. Qualitative studies don't rely on calculations; they gather information from unstructured interviews, focus groups, diaries and other methods. The information is explained, contextualized and often grouped into categories. Qualitative studies often generate hypotheses that can be tested in future quantitative studies.

Examining Education

As we are all well aware, pediatric patients make up a very small number of 9-1-1 calls. While it's fantastic that children aren't often sick or injured enough to account for a large percentage of EMS calls, this does leave us at a disadvantage when we're asked to care for a child. Many EMS providers just don't have the field experience, which makes our initial and continuing education on pediatric care that much more important.

With that in mind, the authors of this study utilized focus groups to understand how EMS providers in Kentucky felt about deficits in EMS pediatric education. They also sought to come up with suggestions on ways to improve pediatric education and training. They worked with the state EMS system to identify focus group participants. Training officers were contacted by the study team and asked to invite potential participants from their agency.

The authors chose to have separate focus groups for EMS providers who worked in urban, suburban and rural areas. They also held separate focus groups for administrative and nonadministrative personnel. We all know there are urban and rural differences, and a paramedic might not be so open to identifying deficits (in other words, criticizing) the con ed provided by their agency with their boss in the room.

They had a total of six focus groups (one for administrators and one for field providers in each of the three community types). They limited the focus groups to a maximum of 10 participants. This was also a good idea; it can get very difficult to moderate a focus group with too many participants. The focus groups lasted a total of 90 minutes and were audio-recorded and professionally transcribed.

Now, you might be thinking a maximum of 10 participants each in six focus groups would mean the study drew conclusions from just 60 people. In fact, the total number of participants was 42. Yes, compared to most EMS literature we will review here, that is a very small number. You may remember a couple months ago we reviewed a study with over 2,000 cases. Qualitative studies don't need to rely on large numbers. Actually, they typically never have a study population that is very large. This study design allows you to get a lot of in-depth information from a small number of participants.

One really interesting part of this study was that they used a "professional moderator." This was a great way to prevent any bias the study team may have from their familiarity with EMS pediatric education from altering the opinions of the focus group participants. This often adds cost to the study.

Analyzing the Data

Now we'll discuss the most difficult part of qualitative research, data analysis. In quantitative research, when you are ready to analyze your data, what is probably the most difficult part of the study (obtaining enough data to analyze) is over. In qualitative research, you have to review every focus group meeting multiple times and read notes and transcripts to come up with consistent messages, themes and categories. Luckily this is a science, so there are tested methods and strategies to analyze qualitative data. We don't have enough space to review each of these here, but an overly simplified explanation is that the authors listened to every audio recording and read every transcript multiple times until they could identify overarching categories. They drilled down on these categories to combine ideas and thoughts that were very similar. Finally they took some steps to make sure that they all agreed on the results.

When all that work was done, they were left with four major themes for deficits in pediatric EMS education: 1) suboptimal previous pediatric training and training gaps in continuing education; 2) opportunities for improved interactions with ED staff, including case-based feedback on patient care; 3) barriers to optimal pediatric prehospital care; and 4) proposed pediatric training improvements.

Under the theme of suboptimal previous pediatric training and training gaps in continuing education, the authors found PowerPoint may be overused in pediatric education, and participants reported that educators are often not very familiar with the material or how care is provided to peds in the prehospital environment.

The theme of opportunities for improved interactions with ED staff focused largely on the desire of EMS providers to know the outcomes of the patients they cared for and the difficulty with obtaining that information from the ED.

The barriers to optimal pediatric prehospital care simply restated that EMS providers don't see children very often, and when they did the focus group participants didn't feel like they were provided enough guidance on how to care for complicated patient scenarios.

Finally, proposed pediatric training improvements included increasing the frequency of training, increasing hands-on time with pediatric patients, more shadowing and observation of pediatric emergency care providers, and increasing specific content areas of medication dose calculations and administrations, IV access, airway management and resuscitation.

From these four themes the authors came up with five hypotheses they felt could improve pediatric patient care:

• More online training may help fulfill training needs;
• Obtaining more feedback in the ED;
• Implementing a more standardized pediatric training;
• Increasing training in airway maintenance, IV access, drug calculations and medication administration;
• Targeted education on special-needs and medically fragile children.

Interestingly, the authors also stated that this study was the first to identify and publish that there are concerns regarding patient handoffs from EMS providers to ED staff. This is an unfortunate error and highlights the importance of a thorough literature review. Patient handoffs have been addressed in medical literature prior to the publication of this study. The American College of Emergency Physicians has discussed the importance of an appropriate patient handoff, and we even reviewed a paper on patient handoffs in this column last month. It is possible the authors' claim was true in 2013 when the focus groups took place, but in 2017, when this paper was published, this study is not the first to discuss the importance of patient handoffs.

Finally, the authors stated that they used a professional moderator and a professional to transcribe the meetings. Unless the group of MDs and PhDs that authored this study have had this professional training, they had to pay someone. Since they specifically state these services were used to reduce bias, it's unlikely the authors did this work. They do not list a funding source for the study. Specifying a funding source, if one was used, is extremely important to put these results into context. If this study was funded by a company that produces standardized online pediatric training, we might think differently about its conclusions. I am not suggesting the authors are trying to hide anything, but I am suggesting this information should have been included in the manuscript.

Antonio R. Fernandez, PhD, NRP, FAHA, is the research director at the EMS Performance Improvement Center and an assistant professor in the Department of Emergency Medicine at the University of North Carolina–Chapel Hill. He has been a nationally certified paramedic since 2005 and completed the EMS Research Fellowship at the National Registry of Emergency Medical Technicians.