How to Get Pediatric Transport Right

It’s a cold winter Saturday, and you are working on Medic 6 with your EMT partner. You are dispatched to a private residence for a 5-year-old with difficulty breathing. When you arrive and enter the house, you find your patient in her father’s arms. The father relays the patient had been playing in the fresh snow when she started to have an asthma attack. 

Your partner pulls out a pediatric-size NRB mask, and the dad slides it over the child’s face. The child needs to be taken to the ED to be checked out and get an inhaler refill. You are familiar with treating an asthma attack, and you have the equipment and medication. But how are you going to transport dad and the 5-year-old sitting on his lap?

You look over to your partner and ask, “Do you remember which strap goes where with that new pediatric restraint device?” Your partner replies, “I don’t know. Don’t you have nieces?”

Introduction

Pediatric emergencies make up about 10% of our call volume. While they are uncommon, they can cause some of the greatest stress among EMS providers. Additionally, our “one size fits most” equipment, including our stretchers, fails to meet the need to ensure safe rides for patients from small neonates to robust tweens. In place of equipment that’s appropriately designed, sized, and crash-tested to American standards, there are several things EMS leaders can do to more safely transport pediatric patients. 

The National Highway Traffic Safety Administration (NHTSA) estimates that EMS receives more than 30 million emergency response calls and transports about 6.2 million patients annually. A NHTSA report analyzed 20 years of ground ambulance crash data (1992–2011) and highlighted several trends among serious and fatal crashes. Most crashes occurred while ground ambulances were in emergency use. Ambulance passengers (patients and providers) were more likely to be injured or killed in significant crashes than drivers.¹ 

If we reflect on why that might be, a few things come to mind. First, for most ambulances the front is designed like the front compartments of regular trucks and vans. They have airbags, seat belts, crumple zones, etc. The back compartment, however, is a different story. The back of an ambulance is a much less safe space. Equipment is often not secured. Patients may only have some stretcher restraints attached, and even then there are instances where EMS providers don’t wear their own seat belts. 

Ambulance crashes are relatively rare, but when they occur there is a high potential for injury and even death for those within (44% of patients were ejected from cots in serious crashes).² While there have been many advances in making ground ambulances safer, they have often failed to consider the special needs of our smallest patients. 

In recent years the National Association of State EMS Officials’ committee on the safe transport of children has been convening experts from EMS and industry partners to address this gap and work toward improving the safe transport of kids in ambulances.³ This committee has developed the “Safe Transport of Children by EMS: Interim Guidance” training⁴ and advocates for the development of testing standards for child-restraint devices. Many state EMS offices have incorporated this guidance into their own protocols until evidence can be collected, analyzed, and used to develop standards specifically for children. 

Tips for Pediatric Calls

Teamwork—If you know you’re going to a pediatric call where you may be transporting, just as you would mentally review the medications and/or equipment you may need, someone on the crew should likewise be thinking about setting up the pediatric restraint device on the stretcher. You do not want to be struggling to set up a device and sort out the straps correctly at 3 AM with a crying baby and anxious caregivers. These stressful, seemingly urgent moments may lead tired providers to just give up and transport children unsecured on stretchers or in a caregiver’s arms. Use your team wisely by assigning someone to set up the pediatric device while the rest of the team packages the patient.

Driver training—Ensure all emergency vehicles are operated by providers who are trained in the Emergency Vehicle Operator Course (EVOC) or its equivalent.

Know your equipment—When was the last time you looked at your pediatric devices? Your crew should train at least annually (ideally quarterly) on how to install and use all restraint devices your service provides. Reviewing equipment after pediatric calls is also a great way to refresh on infrequently used skills and equipment. For EMTs and advanced providers who maintain NREMT certifications, pediatric transport is an educational requirement. 

Safety as a part of care—It goes without saying that you should drive emergency vehicles as safely as possible, utilizing lights and sirens only when the patient’s condition warrants it. Top EMS organizations’ recently released “Joint Statement of Lights & Siren Vehicle Operations on EMS Responses” encourages EMS leaders to critically evaluate the use of emergency lights and sirens by EMS agencies.⁵ The document highlights that very few medical emergencies are time-sensitive enough to benefit from saving a few minutes of response/transport time, but alternatively there is a significant benefit to reducing the risk of a crash every time an emergency vehicle is on the road.⁵ Additionally, not only is it important to have all occupants (including providers) belted when possible, but you also want to ensure all equipment is secured and can’t become missiles in a crash.

Policies and protocols—There are no national standards that focus on pediatric restraints, but it is important to be familiar with state/local protocols and guidelines when transporting all patients. Agency policies should address general areas such as transporting unrestrained passengers and patients. Additionally, your policies should reflect that all equipment and all occupants, including family, patients, and providers, should be belted whenever possible. These policies should be developed in conjunction with your insurance provider. EMS-focused insurance providers often offer consulting services as well as training programs to ensure organizations have the necessary policies in place. 

Pediatric-Specific Devices 

Pediatric patients have unique transport needs due to their wide range of cognitive development, physical size, and weight. EMS providers must be prepared to transport patients from the smallest premature neonates to adult-size 17-year-olds. There are many different restraint devices marketed for EMS use; additionally, several state protocols allow for the use of convertible car seats, depending on the patient’s needs. 

Regardless of the device selected, EMS providers should ensure it fits well and the restraint harness is snug against the patient. Adjust the harness and then pinch the webbing to ensure the harness is not too loose. 

The 2012 NHTSA  “Working Group Best-Practice Recommendations for the Safe Transport of Children in Emergency Ground Ambulances”⁶ outlined 5 situations EMS providers may find themselves in with pediatric patients. These situations take into consideration the level of intervention or monitoring needed, as well as additional factors such as whether the patient needs spinal motion restriction and whether there are multiple patients, such as a newborn and mother, to transport safely. Each of these scenarios may require different resources and equipment. It is important that crews have plans in place for how their agency will respond before the call. 

The NASEMSO “Pediatric Transport Products for Ground Ambulances” document, last updated in 2020, has a list of currently available products for transporting children in US ground ambulances, including which situations EMS crews may use the devices in.⁷ It is critical EMS organizations consider the needs of their population and how best to prepare their crews. 

Crew-Level Readiness

Focusing on aspects of both clinical care and transportation elements specific to pediatric calls in training is paramount to seamless care for these patients. Take every opportunity to ensure you and your team are as prepared as possible. 

• Know where and how to use your pediatric restraints during a call; consider the needs of your patient and make the best decision you can in the moment.
• Debrief and learn from each call. This includes asking difficult questions about how you can do better.

Organization-Level Readiness

As a leader there are several steps you can take to protect your staff, patients, and organization in the event of a crash. 

• Review your protocols, SOPs, and training schedules. 
• Pay attention to equipment maintenance and replacement. Most pediatric transport devices do not have expiration dates; however, like most of our equipment, materials can break down over time and become less useful. Consult with manufacturers on replacement schedules. Additionally, if your community’s pediatric population is changing, evaluate if you have the correct devices to best serve your population. 
• Engage with your state/local child passenger safety and EMS for Children programs for additional resources and training opportunities. Many of these programs have trained technicians who are knowledgeable and passionate about child passenger safety. 

Conclusion

Adopting a universal culture of safety can help mitigate the stress of pediatric calls. As we look to the larger issue of safer transport, these universal practices should include implementing effective agency SOPs, having EVOC-trained drivers with conservative use of lights and sirens, securing equipment and patients in the back, and reinforcement of the fact that EMS providers should wear their seat belts when possible. EMS crews can build on these foundational practices by adding in pediatric-specific planning and training.

Pediatric calls can be some of the most stressful EMS providers experience. Taking the time now to review your child transport equipment, as opposed to waiting for a stressful scene to do so, could spell the difference between a smooth call where everything works and one you look back on with regret. 

Sidebar: Key Takeaways

• Know your equipment 
• Train drivers and crew
• Ensure restraints fit patients 
• Consider the level of care patients need
• Do the best you can with the resources you have
• Debrief and address gaps

References

1. National Highway Traffic Safety Administration. The National Highway Traffic Safety Administration and Ground Ambulance Crashes. NHTSA Office of EMS. Published April 2014. www.ems.gov/pdf/GroundAmbulanceCrashesPresentation.pdf

2. Smith N. A National Perspective on Ambulance Crashes and Safety. EMS World. 2015; 44(9). www.ems.gov/pdf/EMSWorldAmbulanceCrashArticlesSept2015.pdf  

3. National Association of State EMS Officials. Safe Transport of Children. https://nasemso.org/committees/safe-transport-of-children/

4. Busch S, Hert K, Hicken E, et al. Safe Transport of Children by EMS: Interim Guidance. NASEMSO.org. Published March 8, 2017 

5. Kupas DF, Zavadsky M, Burton B, et al. Joint Statement on Lights & Siren Vehicle Operations on Emergency Medical Services (EMS) Responses. NAEMSP.org. Published February 14, 2022

6. National Highway Traffic Safety Administration. Working Group Best-Practice Recommendations for the Safe Transport of Children in Emergency Ground Ambulances. NHTSA.gov. Published September 2012

7. National Association of State EMS Officials. Pediatric Transport Products for Ground Ambulances. NASEMSO.org. Published October 2020

Stephanie Busch, BS, AEMT, CPST, has more than 10 years of experience in the EMS and Public Health fields and currently serves as the injury-prevention manager for the state of Vermont. She is also currently an MPH student at the Johns Hopkins Bloomberg School of Public Health. She can be reached at Stephanie.a.busch@gmail.com.