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Prehospital research and evidence-based guidelines (EBGs) have grown in recent decades, yet there is still a paucity of prehospital implementation research. While recent studies have revealed EMS agency leadership perspectives on implementation, the important perspectives and opinions of frontline EMS clinicians regarding implementation have yet to be explored in a systematic approach. The objective of this study was to measure the preferences of EMS clinicians for the process of EBG implementation and whether current agency practices align with those preferences. This study was a cross-sectional survey of National Registry of Emergency Medical Technicians registrants. Eligible participants were certified paramedics who were actively practicing EMS clinicians. The survey contained discrete choice experiments (DCEs) for three EBG implementation scenarios and questions about rank order preferences for various aspects of the implementation process. For the DCEs, we used multinomial logistic regression to analyze the implementation preference choices of EMS clinicians, and latent class analysis to classify respondents into groups by their preferences. A total of 183 respondents completed the survey. Respondents had a median age of 39 years, were 74.9% male, 89.6% White, and 93.4% of non-Hispanic ethnicity. For all three DCE scenarios, respondents were significantly more likely to choose options with hospital feedback and individual-level feedback from EMS agencies. Respondents were significantly less likely to choose options with email/online only education, no feedback from hospitals, and no EMS agency feedback to clinicians. In general, respondents’ preferences favored classroom-based training over in-person simulation. For all DCE questions, most respondents (66.2% - 77.1%) preferred their survey DCE choice to their agency’s current implementation practices. In the rank order preferences, most participants selected “knowledge of the underlying evidence behind the change” as the most important component of the process of implementation. In this study of EMS clinicians’ implementation preferences using DCEs, respondents preferred in-person education, feedback on hospital outcomes, and feedback on their individual performance. However, current practice at EMS agencies rarely matched those expressed EMS clinician preferences. Collectively, these results present opportunities for improving EMS implementation from the EMS clinician perspective.

During the COVID-19 pandemic, many emergency medical services (EMS) agencies modified treatment guidelines for clinical care and standard operating procedures. For the prehospital care of pediatric asthma exacerbations, modifications included changes to bronchodilator administration, systemic corticosteroid administration, and introduction of alternative medications. Since timely administration of bronchodilators and systemic corticosteroids has been shown to improve pediatric asthma clinical outcomes, we investigated the association of COVID-19 protocol modifications in the prehospital management of pediatric asthma on hospital admission rates and emergency department (ED) length-of-stay.This is a multicenter, retrospective, observational cohort study comparing prehospital pediatric asthma patients treated by EMS clinicians from four EMS systems before and after implementation of COVID-19 interim EMS protocol modifications. We included children ages 2-18 years who were treated and transported by ground EMS for respiratory-related prehospital primary complaints, and who also had asthma-related ED discharge diagnoses. Patient data and outcomes were compared from 12 months prior to and 12 months after the implementation of interim COVID-19 prehospital protocol modifications using univariate and multivariable statistics.A total of 430 patients met inclusion criteria with a median age of 8 years. There was a slight male predominance (57.9%) and the majority of patients were African American (78.4%). There were twice as many patients treated prior to the COVID-19 protocol modifications (Despite a decrease in prehospital bronchodilator administration after COVID-19 changes to prehospital pediatric asthma management protocols, hospital admission rates and ED length-of-stay did not significantly increase. However, this finding is tempered by the marked decrease in study patients treated after COVID-19 prehospital protocol modifications. Given the potential for future waves of COVID-19 variants, further studies with larger patient populations are warranted.

Social determinants of health (SDOH) influence access to health care and are associated with inequities in patient outcomes, yet few studies have explored SDOH among pediatric EMS patients. The objective of this study was to examine the presence of SDOH in EMS clinician free text notes and quantify the association of SDOH with EMS pediatric transport decisions.This was a retrospective analysis of primary 9-1-1 responses for patients ages 0-17 years from the 2019 ESO Data Collaborative research dataset. We excluded cardiac arrests and patients in law enforcement custody. Using natural language processing (NLP) we extracted the following SDOH categories: income insecurity, food insecurity, housing insecurity, insurance insecurity, poor social support, and child protective services. Univariate and multivariable associations between the presence of SDOH in EMS records and EMS transport decisions were assessed using logistic regression.We analyzed 325,847 pediatric EMS encounters, of which 35% resulted in non-transport. The median age was 10 years and 52% were male. Slightly over half (53%) were White, 31% were Black, and 11% were Hispanic. Child protective services (SDOH documentation in the EMS narrative was rare among pediatric encounters; however, children with documented SDOH were more likely to be transported. Additional exploration of the root causes and outcomes associated with SDOH among children encountered by EMS are warranted.

Bradycardia is the most common terminal cardiac electrical activity in children, and early recognition and treatment is necessary to avoid cardiac arrest. Interventions such as oxygen, chest compressions, epinephrine, and atropine recommended by American Heart Association (AHA) Pediatric Advanced Life support (PALS) guidelines have been shown to improve outcomes (including higher survival rates) for inpatient pediatric patients with bradycardia. However, little is known about the epidemiology of pediatric prehospital bradycardia. We sought to investigate the incidence and management of pediatric bradycardia in the prehospital setting by emergency medical services (EMS).This was a retrospective study of 911 scene response prehospital encounters for patients ages 0-18 years in 2019 from the United States ESO Research Data Collaborative. We defined age-based bradycardia per the 2015 AHA PALS guidelines. We performed general descriptive statistics and a univariate analysis examining any PALS-recommended interventions in the presence of altered mental status, hypotension for age, and a first heart rate less than 60.Of 7,422,710 encounters in the 2019 ESO Data Collaborative, 1,209 patients met inclusion criteria. Most (58.5%) were male, and the median age was 2 years (interquartile range 0-13 years). One-quarter (24.7%) of patients received fluids, and bag-valve mask ventilation was the most common airway intervention (12.1% of patients). Receipt of any PALS-recommended interventions was associated with age-adjusted hypotension (odds ratio (OR) 4.0, 95% confidence interval (CI) 3.9-5.4) and altered mental status (OR 15.5, 95% CI 10.7-22.3), but not a first heart rate less than 60 bpm (OR 0.9, 95% CI 0.6-1.1).To our knowledge, this study is the first to examine the incidence and management of prehospital pediatric bradycardia. Incidence was rare, but adherence to PALS guidelines was variable. Further research and education are needed to ensure proper prehospital treatment of pediatric bradycardia.

Asthma is a heterogeneous disease with a range of observable phenotypes. To date, the characterization of asthma phenotypes is mostly limited to allergic versus non-allergic disease. Therefore, the aim of this big data study was to computationally derive asthma subtypes from the OneFlorida Clinical Research Consortium We obtained data from 2012-2020 from the OneFlorida Clinical Research Consortium. Longitudinal data for patients greater than two years of age who met inclusion criteria for an asthma exacerbation based on International Classification of Diseases codes. We used matrix factorization to extract information and K-means clustering to derive subtypes. The distributions of demographics, comorbidities, and medications were compared using Chi-square statistics. A total of 39,807 pediatric patients and 23,883 adult patients met inclusion criteria. We identified five distinct pediatric subtypes and four distinct adult subtypes. Pediatric subtype P1 had the highest proportion of black patients, but the lowest use of inhaled corticosteroids and allergy medications. Subtype P2 had a predominance of patients with gastroesophageal reflux disease, whereas P3 had a predominance of patients with allergic disorders. Adult subtype A2 was the most severe and all patients were on biologic agents. Most of subtype A3 patients were not taking controller medications, whereas most patients (>90%) in subtypes A2 and A4 were taking corticosteroids and allergy medications. We found five distinct pediatric asthma subtypes and four distinct adult asthma subtypes. Future work should externally validate these subtypes and characterize response to treatment by subtype to better guide clinical treatment of asthma.

Objective Prehospital Termination of Resuscitation (TOR) protocols for adults can reduce the number of futile transports of patients in cardiac arrest, yet similar protocols are not widely available for paediatric out-of-hospital cardiac arrest (POHCA). The objective of this study was to apply a set of criteria for paediatric TOR (pTOR) from the Maryland Institute for Emergency Medical Services Systems (MIEMSS) to a large national cohort and determine its association with return of spontaneous circulation (ROSC) after POHCA. Methods We identified patients ages 0–17 treated by Emergency Medical Services (EMS) with cardiac arrest in 2019 from the ESO dataset and and applied the applicable pTOR certeria for medical or traumatic arrests. We calculated predictive test characteristics for the outcome of prehospital ROSC, stratified by medical and traumatic cause of arrest. Results We analyzed records for 1595 POHCA patients. Eighty-eight percent (n = 1395) were classified as medical. ROSC rates were 23% among medical POHCA and 27% among traumatic POHCA. The medical criteria correctly classified >99% (322/323) of patients who achieved ROSC as ineligible for TOR. The trauma criteria correctly classified 93% (50/54) of patients with ROSC as ineligible for TOR. Of the five misclassified patients, three were involved in drowning incidents. Conclusions The Maryland pTOR criteria identified eligible patients who did not achieve prehospital ROSC, while reliably excluding those who did achieve prehospital ROSC. As most misclassified patients were victims of drowning, we recommend considering the exclusion of drowning patients from future pTOR guidelines. Further studies are needed to evaluate the long-term survival and neurologic outcome of patients misclassified by pTOR criteria.

Introduction: Pediatric hospital care is becoming increasingly regionalized, with fewer facilities providing inpatient care for common conditions such as asthma. That trend has major implications for emergency medical services (EMS) medical care and operations because EMS historically transports patients to the closest facility. This study describes EMS transport patterns of pediatric asthma patients in greater depth, including an analysis of facility bypass rates and the association of bypass with demographics and clinical outcomes. Methods: This was a retrospective study of pediatric asthma patients ages 2-18 years transported by Lee County, FL EMS between March 1, 2018 – December 31, 2019. A priori, we defined bypass as greater than five minutes extra transport time. We performed geospatial analysis and mapping of EMS pediatric asthma encounters. We used the Pediatric Destination Tree (PDTree) project’s tiered approach to characterize receiving hospital facility pediatric capability. We analyzed incidence and characteristics of bypass, and bypass and non-bypass patient characteristics including demographics, emergency department (ED) clinical outcomes, and socioeconomic disadvantage (SED). Results: From the study period, there were a total of 262 encounters meeting inclusion criteria, 254 (96.9%) of which could be geocoded to EMS incident and destination locations. Most encounters (72.8%) bypassed at least one facility, and the average number of facilities bypassed per encounter was 1.52. For all 185 bypass encounters, there was a median additional travel time of 13.5 minutes (interquartile range 7.5 – 17.5). Using the PDTree’s classification of pediatric capability of destination facilities, 172 of the 185 bypasses (93%) went to a Level I facility. Bypass incidence varied significantly by age, but not by minority status, asthma severity, or by the area deprivation index of the patient’s home address. Overall, the highest concentrations of EMS incidents tended to occur in areas of greater SED. With regard to ED outcomes, ED length of stay did not vary between bypass and non-bypass patients (P = 0.54), and neither did hospitalization (P = 0.80). Conclusion: We found high rates of bypass for pediatric EMS encounters for asthma exacerbations, and that bypass frequency was significantly higher in younger age groups. With national trends pointing toward increasing pediatric healthcare regionalization, bypass has significant implications for EMS operations.

OBJECTIVE: Asthma is a common chronic disease that disproportionately affects children and minorities, particularly African Americans. Inhaled bronchodilators are first-line treatment for asthma exacerbations, but individual bronchodilator response (BDR) varies by race and ethnicity. Studies have attempted to examine the genetic underpinnings of African American BDR, but many did not include young children and/or were not conducted when subjects were experiencing an actual asthma exacerbation. Therefore, this pilot study tested candidate single nucleotide polymorphisms’ (SNPs’) association with pediatric African American BDR during an acute asthma exacerbation. METHODS: This was a prospective study of pediatric asthma patients ages 2 – 18 years seeking care in the ED for an asthma exacerbation. We measured BDR before and after each inhaled bronchodilator treatment using both the Pediatric Asthma Severity Score (PASS) asthma severity score and spirometry, and divided patients’ BDR into equal terciles (low, medium, high). We collected genomic deoxyribonucleic acid (DNA) and examined whether 21 candidate SNPs from a review of the literature were associated with BDR using crude odds ratios and adjusted analysis (incorporating age, gender, obesity, and home tobacco smoke exposure). RESULTS: The final sample population was 53 children, with an average age of 7.2 years. The average initial PASS score (on a scale of ascending severity from 0–6) was 2.5 (standard deviation (SD) 1.6), and average initial forced expiratory volume in 1 second (FEV1) / forced vital capacity (FVC) as a percent of predicted was 75.8% (SD 10.3%). After adjusting for body mass index (BMI), age category, gender, and smoke exposure, rs912142 was associated with decreased odds of having low BDR (odds ratio (OR) 0.20, 95% confidence interval (CI) 0.02–0.92), and rs7081864 and rs7903366 were associated with decreased odds of having high BDR (OR 0.097, 95% CI 0.009–0.62) CONCLUSIONS: In a study measuring BDR in African American children during an acute asthma exacerbation, we found 3 SNPs significantly associated with BDR that provide bidirectional information regarding a child’s potential response to emergency asthma exacerbation treatment. Once validated in larger studies and implemented into practice, such information could guide pharmacogenomic evidence-based emergency asthma treatment that improves patient outcomes.

Background There are concerns about overuse of abdominopelvic-computed tomography (CTAP) in pediatric blunt abdominal trauma (BAT) given malignancy risks. This study evaluates how an evidence-based algorithm affected CTAP and hospital resource use for hemodynamically stable children with BAT. Materials and methods This is a retrospective cohort study of hemodynamically stable pediatric BAT patients one year before and after algorithm implementation. We included children less than or equal to 14 years of age treated in a Level I pediatric trauma center. We compared CTAP rates before and after algorithm implementation. Results There were 65 in the pre- and 50 in the post-algorithm implementation group, and CTAPs decreased by 27% (p = 0.02). The unadjusted and adjusted odds ratio of receiving a CTAP after algorithm implementation were 0.3 (95% CI 0.1–0.6) and 0.2 (95% CI 0.1–0.7), respectively. There were no significant missed injuries in the post cohort. ED length of stay (LOS) decreased by 53 min (p = 0.03). Conclusions An evidence-based algorithm safely decreased CTAPs for pediatric BAT with no increase in hospital resource utilization.

Introduction Current guidelines recommend that single person cardiopulmonary resuscitation (CPR) on an infant should be performed with two-fingers just below the inter-mammillary line with the hand clenched, while two-person CPR should be performed with two-thumbs with the hands encircling the chest. Those recommendations are based on literature that demonstrates higher quality chest compressions with the two-thumb technique, with concerns that this technique may compromise ventilation parameters when performed by the single rescuer. The purpose of this study is to compare the two compression techniques’ performance during CPR using both compression and ventilation parameters. Methods We performed a systematic review and meta-analysis of literature identified through a search of PubMed and One-Search comparing the quality of chest compressions and ventilation parameters between the two-thumb and two-finger techniques (Prospero registration # CRD42018087672). Results We identified 20 manuscripts examining single person infant CPR that met study criteria, with 16 that included data suitable for meta-analysis. All of the studies included in the analysis were performed on a standardized manikin. Overall, the two-thumb technique resulted in a mean difference of 5.61 mm greater compression depth compared to the two-finger technique, with 36.91% more compressions of adequate depth per national guidelines. Interestingly, ventilation parameters did not differ between the two techniques. Conclusion While recognizing that the results of this review may differ from actual clinical experience due to the lack of fidelity between manikins and actual human infants, this systematic review with meta-analysis demonstrates that when CPR is performed on a simulated infant manikin by a single rescuer, the two-thumb technique with hands encircling the chest improves chest compression quality and does not appear to compromise ventilation.

INTRODUCTION: Deciding where to transport a patient is a key decision made by emergency medical services (EMS), particularly for children because pediatric hospital resources are regionalized. Since evidence-based guidelines for pediatric transport destinations are being developed, the purpose of this study was to use a large statewide EMS database to describe current patterns of EMS providers’ transport destination decisions for pediatric patients. METHODS: This is a retrospective study of pediatric transports from 2011–2016 in EMS Tracking and Reporting System (EMSTARS), Florida’s statewide EMS database. We included patients greater than 1 day and less than or equal to 18 years who were primary EMS scene transports. Our primary outcome variable was ‘reason for choosing destination.’ We performed descriptive and comparative analysis between closest facility and all other ‘reason for choosing destination’ choices. We used geospatial analysis to examine destination choice in urban and rural counties. RESULTS: Our final study sample was 446,274, and 48.2% of patients had closest facility as their ‘reason for choosing destination.’ The next largest category was patient / family choice (154,035 patients, 35.7%). Closest facility patients were older (median age 12 versus 10 years, p

Prior studies examining prehospital characteristics related to return of spontaneous circulation (ROSC) in pediatric out-of-hospital cardiac arrest (OHCA) are limited to structured data. Natural language processing (NLP) could identify new factors from unstructured data using free-text narratives. The purpose of this study was to use NLP to examine EMS clinician free-text narratives for characteristics associated with prehospital ROSC in pediatric OHCA. This was a retrospective analysis of patients ages 0–17 with OHCA in 2019 from the ESO Data Collaborative. We performed an exploratory analysis of EMS narratives using NLP with an a priori token library. We then constructed biostatistical and machine learning models and compared their performance in predicting ROSC. There were 1,726 included EMS encounters for pediatric OHCA; 60% were male patients, and the median age was 1 year (IQR 0–9). Most cardiac arrest events (61.3%) were unwitnessed, 87.3% were identified as having medical causes, and 5.9% had initial shockable rhythms. Prehospital ROSC was achieved in 23.1%. Words most positively correlated with ROSC were “ROSC” (r = 0.42), “pulse” (r = 0.29), “drowning” (r = 0.13), and “PEA” (r = 0.12). Words negatively correlated with ROSC included “asystole” (r = −0.25), “lividity” (r = −0.14), and “cold” (r = −0.14). The terms “asystole,” “pulse,” “no breathing,” “PEA,” and “dry” had the greatest difference in frequency of appearance between encounters with and without ROSC (p < 0.05). The best-performing model for predicting prehospital ROSC was logistic regression with random oversampling using free-text data only (area under the receiver operating characteristic curve 0.92). EMS clinician free-text narratives reveal additional characteristics associated with prehospital ROSC in pediatric OHCA. Incorporating those terms into machine learning models of prehospital ROSC improves predictive ability. Therefore, NLP holds promise as a tool for use in predictive models with the goal to increase evidence-based management of pediatric OHCA.

Objective. The COVID-19 pandemic created an unprecedented strain on the health care system, and administrators had to make many critical decisions to respond appropriately. This study sought to understand how health care administrators used data and information for decision making during the first 6 mo of the COVID-19 pandemic. Materials and Methods. We conducted semistructured interviews with administrators across University of Florida (UF) Health. We performed an inductive thematic analysis of the transcripts. Results. Four themes emerged from the interviews: 1) common types of health systems or hospital operations data; 2) public health and other external data sources; 3) data interaction, integration, and exchange; and 4) novelty and evolution in data, information, or tools used over time. Participants illustrated the organizational, public health, and regional information they considered essential (e.g., hospital census, community positivity rate, etc.). Participants named specific challenges they faced due to data quality and timeliness. Participants elaborated on the necessity of data integration, validation, and coordination across different boundaries (e.g., different hospital systems in the same metro areas, public health agencies at the local, state, and federal level, etc.). Participants indicated that even within the first 6 mo of the COVID-19 pandemic, the data and tools used for making critical decisions changed. Discussion. While existing medical informatics infrastructure can facilitate decision making in pandemic response, data may not always be readily available in a usable format. Interoperable infrastructure and data standardization across multiple health systems would help provide more reliable and timely information for decision making. Conclusion. Our findings contribute to future discussions of improving data infrastructure and developing harmonized data standards needed to facilitate critical decisions at multiple health care system levels. Highlights The study revealed common health systems or hospital operations data and information used in decision making during the first 6 mo of the COVID-19 pandemic. Participants described commonly used internal data sources, such as resource and financial reports and dashboards, and external data sources, such as federal, state, and local public health data. Participants described challenges including poor timeliness and limited local relevance of external data as well as poor integration of data sources within and across organizational boundaries. Results suggest the need for continued integration and standardization of health data to support health care administrative decision making during pandemics or other emergencies.

The COVID-19 pandemic has had an impact on emergency medical services (EMS) and its guidelines, which aid in patient care. This study characterizes state and territory EMS office recommendations to EMS statewide operational and clinical guidelines and describes the mechanisms of distribution and implementation during the COVID-19 pandemic.A mixed-methods study was conducted in 2 phases. In phase 1, changes and development of COVID-19 guidance and protocols for EMS clinical management and operations were identified among 50 states, the District of Columbia, and 5 territories in publicly available online documents and information. In phase 2, structured interviews were conducted with state/territory EMS officials to confirm the protocol changes or guidance and assess dissemination and implementation strategies for COVID-19.In phase 1, publicly available online documents for 52 states/territories regarding EMS protocols and COVID-19 guidance were identified and reviewed. Of 52 (33/52) states/territories, 33 had either formal protocol changes or specific guidance for the pandemic. In phase 2, 2 state and territory EMS officials were interviewed regarding their protocols or guidance for COVID-19 and the dissemination and implementation practices they used to reach EMS agencies (response rate = 65%). Of the 34 state/territory officials interviewed, 22 had publicly available online COVID-19 protocols or guidance. Of the 22 officials with online COVID-19 protocols, all reported providing operational direction, and 19 of 22 officials reported providing clinical direction.Most states provided guidance to EMS agencies and/or updated protocols in response to the COVID-19 pandemic.

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.

Health care systems are at the front line to fight the COVID-19 pandemic. Emergent questions for each hospital are how many general ward and intensive care unit beds are needed, and additionally, how to optimally allocate these resources during demand surge to effectively save lives. However, hospital pandemic preparedness has been hampered by a lack of sufficiently specific planning guidelines. In this paper, we developed a hybrid computer simulation approach, with a system dynamic model to predict COVID-19 cases and a discrete-event simulation to evaluate hospital bed utilization and subsequently determine bed allocations. Two control policies, the type-dependent admission control policy and the early step-down policy, based on patient risk profiling, were proposed to lower the overall death rate of the patient population in need of intensive care. The model was validated using historical patient census data from the University of Florida Health Jacksonville, Jacksonville, FL. The allocation of hospital beds to low-risk and high-risk arrival patients to achieve the goal of reducing the death rate, while helping a maximum number of patients to recover was discussed. This decision support tool is tailored to a given hospital setting of interest and is generalizable to other hospitals to tackle the pandemic planning challenge.

Objective To determine the relationship between Numeric Rating Scale (NRS) and Defense and Veterans Pain Rating Scale (DVPRS) as pain intensity measures, we compared pain scores to sociodemographic and treatment data in patients revisiting the emergency department (ED). Methods After Institutional Review Board approval, 389 adults presenting within 30 days of an index visit were enrolled. Pain scores were classified as follows: 0-3 (mild), 4-7 (moderate), and 8-10 (high). Data were analyzed using descriptive analysis. Wilcoxon rank-sum test measured the association of pain score with gender. Pain scales were correlated using Spearman correlation coefficient. Pain scale association with opioid treatment was tested via ordinal logistic regression controlling for gender, home opioid use, and if ED revisit was for pain. Results Average patient age was 49. Most patients were African American (68.4%), male (51.2%), and returned for pain (67.0%). As continuous measures, both scales were positively correlated with each other (p

Child maltreatment is an important public health problem with serious consequences. Even in the face of increased research and enhanced public awareness over the last decade, the rate of child fatalities due to reported child maltreatment has increased.This study describes pediatric emergency medicine (PEM) physicians' knowledge, training, confidence, and barriers in recognition and reporting suspected child maltreatment.A nationally representative sample of PEM physician members of Pediatric Emergency Medicine Collaborative Research Committee (PEM CRC) participated.A cross-sectional 36-item survey study of PEM physicians with content domains including provider knowledge, preparedness, confidence, and barriers to identifying and reporting child maltreatment was conducted and distributed.113 of 486 members completed the survey. Confidence with recognizing and reporting child abuse (95%) was greater than in child neglect (88%). Knowledge in child maltreatment recognition and reporting was significantly correlated with confidence in reporting and recognition (p 0.001). There was a significant relationship between knowledge and confidence for respondents from states with training in child maltreatment recognition and reporting requirement as a condition of licensure and re-licensure compared to states without the requirement (p 0.01). Qualitative responses revealed insightful themes to improve child maltreatment training, recognition and reporting.Our national survey study demonstrates that PEM-trained physicians have high confidence and knowledge with the management of child maltreatment, and that inclusion of mandated child maltreatment training in residency/fellowship and mandated training for medical licensure in all states could improve child maltreatment recognition and reporting.

OBJECTIVES: To identify prodromal correlates of asthma as compared to chronic obstructive pulmonary disease and allied-conditions (COPDAC) using a multi domain analysis of socio-ecological, clinical, and demographic domains. METHODS: This is a retrospective case-risk-control study using data from Florida’s statewide Healthcare Cost and Utilization Project (HCUP). Patients were grouped into three groups: asthma, COPDAC (without asthma), and neither asthma nor COPDAC. To identify socio-ecological, clinical, demographic, and clinical predictors of asthma and COPDAC, we used univariate analysis, feature ranking by bootstrapped information gain ratio, multivariable logistic regression with LogitBoost selection, decision trees, and random forests. RESULTS: A total of 141,729 patients met inclusion criteria, of whom 56,052 were diagnosed with asthma,85,677 with COPDAC, and 84,737 with neither asthma nor COPDAC. The multi-domain approach proved superior in distinguishing asthma versus COPDAC and non-asthma/non-COPDAC controls (area under the curve (AUROC) 84%). The best domain to distinguish asthma from COPDAC without controls was prior clinical diagnoses (AUROC 82%). Ranking variables from all the domains found the most important predictors for the asthma versus COPDAC and controls were primarily socio-ecological variables, while for asthma versus COPDAC without controls, demographic and clinical variables such as age, CCI, and prior clinical diagnoses, scored better. CONCLUSIONS: In this large statewide study using a machine learning approach, we found that a multi-domain approach with demographics, clinical, and socio-ecological variables best predicted an asthma diagnosis. Future work should focus on integrating machine learning-generated predictive models into clinical practice to improve early detection of those common respiratory diseases.

BACKGROUND Childhood pneumonia is a leading cause of mortality worldwide. Growing evidence suggests that lung ultrasound (LUS) may be a reliable diagnostic alternative to chest x-ray for childhood pneumonia. However, it is unclear whether sonographer experience affects the diagnostic accuracy of LUS. We summarize the diagnostic accuracy of LUS for pneumonia and compare the performance between novice and advanced sonographers with a systematic review and meta-analysis. METHODS We searched PubMed and EMBASE from inception to February 2018 for eligible studies that evaluated the utility of LUS in children suspected of having pneumonia against the reference standard of either imaging results alone or a combination of clinical, laboratory, and imaging results. We reported the study using the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies. We used QUADAS-2 to appraise the included studies' methodologic quality. We employed a random-effect bivariate model and a hierarchical summary receiver operating characteristic curve to evaluate LUS's performance characteristics. We conducted subgroup analyses and meta-regression based on level of sonographer training to summarize and compare LUS's diagnostic accuracy for pneumonia between novice (training ≤ 7 days) and advanced sonographers. RESULTS Twenty-five studies (n = 3,353) were included in the meta-analysis. For diagnosing pneumonia, LUS demonstrated an overall sensitivity of 0.94 (95% confidence interval [CI] = 0.89 to 0.97), specificity of 0.92 (95% CI = 0.78 to 0.98), positive likelihood ratio of 12.40 (95% CI = 4.00 to 38.10), and negative likelihood ratio of 0.07 (95% CI = 0.04 to 0.12), with an area under ROC curve of 0.97 (95% CI = 0.95 to 0.98). Meta-regression revealed a significant difference in the diagnostic accuracy for pneumonia for LUS between novice and advanced sonographers (p

OBJECTIVE: Pediatric care is now concentrated in urban specialty centers (“regionalization”), even for common conditions such as asthma. At the same time, rural emergency medical services (EMS) faces challenges related to adequate workforce staffing and financing. This statewide study describes how regionalization of pediatric inpatient care for asthma exacerbations affects EMS operations, particularly for rural agencies. METHODS: This is a statewide cross-sectional study of EMS encounters for pediatric asthma in patients aged 2–18 years from 2011 to 2016 using Florida’s EMS Tracking and Reporting System (EMSTARS) database. EMSTARS encounters were deterministically linked to Florida’s Agency for Healthcare Administration (AHCA) database. We categorized AHCA hospital facilities that received included patients by whether they did or did not admit pediatric asthma patients during the study period (“admitting facility”). We used geospatial analysis to map the EMS agency’s home county and the admitting facilities addresses. For each county in Florida, we calculated the average estimated EMS travel distance to the nearest admitting facility using a dasymetric mapping approach. RESULTS: The study included a total of 11,226 EMS pediatric asthma encounters, of which 11,153 (99%) matched to an EMS home county. AHCA data was available for 3,812 (34%) patients. Most counties with distances to admitting facilities less than or equal to 15 miles were urban (31 of 39). For distances of 31–45 miles to an admitting facility, 7 of 8 of counties were rural, and for distances greater than 46 miles, all 4 counties were rural. CONCLUSIONS: In this statewide study in Florida, we found long average estimated EMS travel distances to admitting facilities for Florida’s pediatric population in rural counties for pediatric asthma exacerbations. Those long distances have great implications for rural EMS operations, including pediatric destination decisions, transport times, and availability for others who call 9–1–1. Further research on bypass and secondary transport rates, and outcomes for asthma and other pediatric conditions are required to further characterize pediatric regionalization’s impact on rural EMS.

OBJECTIVES: Pediatric behavioral health disorders and related emergency department visits are increasing, but effects on emergency medical services (EMS) are unknown. This study’s objective was to describe the statewide epidemiology of pediatric behavioral health-related EMS encounters in Florida, including mental health and substance use. METHODS: This analysis is a retrospective study of pediatric behavioral health-related EMS encounters from Florida’s statewide EMS Tracking and Reporting Systems Database from 2011–2016. Demographic, clinical, EMS, and geographic characteristics are described. We also compared characteristics between patients who did and did not receive an acute EMS behavioral / psychiatric intervention. RESULTS: There were 22,254 pediatric behavioral health-related EMS encounters during the study period, one-quarter of which were noted to have suspected or confirmed ingestion / substance use. The median age was 16 and the majority of patients were female and white. A total of 946 patients (4%) had an acute EMS behavioral / psychiatric intervention. EMS scene, ED turnaround, and total EMS time were significantly longer for intervention patients. Of the 14 counties in the top quartile of percentages of intervention patients, 7 were rural, 10 did not have any hospitals with child / adolescent psychiatric services, and 7 did not have any child psychiatrists. CONCLUSIONS: Pediatric behavioral-health related EMS encounters had a significant proportion of suspected ingestions / substance use, and we found disproportionate effects on rural agencies. Increases in EMS resource utilization (including longer EMS times) occurred in certain settings with limited behavioral health infrastructure. Those findings suggest an opportunity for community paramedicine to alleviate EMS utilization and decrease the frequency of pediatric behavioral health emergencies.

Objectives: Pediatric specialty care is increasingly regionalized. It is unknown how regionalization affects emergency medical services (EMS) providers' destination decisions for non-trauma pediatric patients. We sought to characterize the rates of bypass of the closest facility, and destination facilities' levels of pediatric care in three diverse EMS agencies. Methods: This is a one-year retrospective study of non-trauma pediatric patients less than 18 years of age transported by three EMS agencies (Baltimore City, Prince George's County, and Queen Anne's County) in 2016. A priori, a bypass was defined as transport to a facility more than 2 km farther than the distance to the closest facility. We calculated rates of bypass and categorized destination and closest facilities by their pediatric service availability using publicly available information. EMS transport distance and time were also compared for bypass and closest facility patients. Results: The three EMS agencies in 2016 transported a total of 12,258 non-trauma pediatric patients, of whom 11,945 (97%) were successfully geocoded. Overall 43% (n = 5,087) of patients bypassed the nearest facility, of which 87% (n = 4,439) were transported to a facility with higher-level pediatric care than the closest facility. Both bypass rates and destination facility pediatric levels differed between agencies. Bypasses had significantly longer transport times and distances as compared to closest facility transports (p < 0.001). For non-trauma pediatric bypasses alone, an additional 41,494 kilometers traveled, and 979 hours of EMS transport time was attributable to bypassing the closest facility. Conclusions: This study reveals a high rate of pediatric bypass for non-trauma patients in three diverse EMS agencies. Bypass results in increased EMS resource utilization through longer transport time and distance. For non-trauma pediatric patients for whom there is little destination guidance, further work is required to determine bypass' effects on patient outcomes.

Background The effects of weather periods, race/ethnicity, and sex on environmental triggers for respiratory exacerbations are not well understood. This study linked the OneFlorida network (~15 million patients) with an external exposome database to analyze environmental triggers for asthma, bronchitis, and COPD exacerbations while accounting for seasonality, sex, and race/ethnicity. Methods This is a case-crossover study of OneFlorida database from 2012 to 2017 examining associations of asthma, bronchitis, and COPD exacerbations with exposures to heat index, PM 2.5 and O 3. We spatiotemporally linked exposures using patients' residential addresses to generate average exposures during hazard and control periods, with each case serving as its own control. We considered age, sex, race/ethnicity, and neighborhood deprivation index as potential effect modifiers in conditional logistic regression models. Results A total of 1,148,506 exacerbations among 533,446 patients were included. Across all three conditions, hotter heat indices conferred increasing exacerbation odds, except during November to March, where the opposite was seen. There were significant differences when stratified by race/ethnicity (e.g., for asthma in April, May, and October, heat index quartile 4, odds were 1.49 (95% confidence interval (CI) 1.42–1.57) for Non-Hispanic Blacks and 2.04 (95% CI 1.92–2.17) for Hispanics compared to 1.27 (95% CI 1.19–1.36) for Non-Hispanic Whites). Pediatric patients' odds of asthma and bronchitis exacerbations were significantly lower than adults in certain circumstances (e.g., for asthma during June – September, pediatric odds 0.71 (95% CI 0.68-0.74) and adult odds 0.82 (95% CI 0.79-0.85) for the highest quartile of PM 2.5). Conclusion This study of acute exacerbations of asthma, bronchitis, and COPD found exacerbation risk after exposure to heat index, PM 2.5 and O 3 varies by weather period, age, and race/ethnicity. Future work can build upon these results to alert vulnerable populations to exacerbation triggers.

The risk factors for severe COVID-19 beyond older age and certain underlying health conditions are largely unknown. Recent studies suggested that long-term environmental exposures may be important determinants of severe COVID-19. However, very few environmental factors have been studied, often separately, without considering the totality of the external environment (i.e., the external exposome). We conducted an external exposome-wide association study (ExWAS) using the nationwide county-level COVID-19 mortality data in the contiguous US. A total of 337 variables characterizing the external exposome from 8 data sources were integrated, harmonized, and spatiotemporally linked to each county. A two-phase procedure was used: (1) in Phase 1, a random 50:50 split divided the data into a discovery set and a replication set, and associations between COVID-19 mortality and individual factors were examined using mixed-effect negative binomial regression models, with multiple comparisons addressed, and (2) in Phase 2, a multivariable regression model including all variables that are significant from both the discovery and replication sets in Phase 1 was fitted. A total of 13 and 22 variables were significant in the discovery and replication sets in Phase 1, respectively. All the 4 variables that were significant in both sets in Phase 1 remained statistically significant in Phase 2, including two air toxicants (i.e., nitrogen dioxide or NO2, and benzidine), one vacant land measure, and one food environment measure. This is the first external exposome study of COVID-19 mortality. It confirmed some of the previously reported environmental factors associated with COVID-19 mortality, but also generated unexpected predictors that may warrant more focused evaluation., Graphical abstract Unlabelled Image, Highlights • The first external exposome study of COVID-19 mortality • Confirmed some previously reported associations • Generated unexpected predictors that may warrant more focused evaluation

Objective: Few areas of prehospital care are supported by evidence-based guidelines (EBGs). We aimed to identify gaps in clinical and operational prehospital EBGs to prioritize future EBG development and research funding. Methods: Using modified Delphi methodology, we sought consensus among experts in prehospital care and EBG development. Five rounds of surveys were administered between October 2019 and February 2020. Round 1 asked participants to list the top three gaps in prehospital clinical guidelines and top three gaps in operational guidelines that should be prioritized for guideline development and research funding. Based on responses, 3 reviewers performed thematic analysis to develop a list of prehospital EBG gaps, with participant feedback in Round 2. In Round 3, participants rated each gap's importance using a 5-point Likert scale, and participants' responses were averaged. In Round 4, participants rank-ordered 10 gaps with the highest mean scores identified in Round 3. In Round 5, participants indicated their agreement with sets of the highest ranked gaps. Results: Of 23 invited participants, 14 completed all 5 rounds. In Rounds 1 and 2, participants submitted 65 clinical and 58 operational gaps, and thematic analysis identified 23 unique clinical gaps and 28 unique operational gaps. The final prioritized list of clinical EBG gaps was: 1) airway management in adult and pediatric patients, 2) care of the pediatric patient, and 3) management of prehospital behavioral health emergencies, with 79% of participants agreeing. The final prioritized list of operational EBG gaps was: 1) define and measure the impact of EMS care on patient outcomes, 2) practitioner wellness, and 3) practitioner safety in the out-of-hospital environment, with 86% of participants agreeing. Conclusions: This modified Delphi study identifies gaps in prehospital EBGs that, if prioritized for development and research funding, would be expected to have the greatest impact on prehospital clinical care and operations.

Background Pediatric cervical spine (CSI) and blunt cerebrovascular injuries (BCVI) are challenging to evaluate as they are rare but carry high morbidity and mortality. CT scans are the traditional imaging modality to evaluate for CSI/BCVI, but involve radiation exposure and potential future increased risk of malignancy. Therefore, we present results from the implementation of a combined CSI/BCVI pediatric trauma clinical pathway to aid clinicians in their decision-making. Methods We conducted a 2-year retrospective cohort study analyzing data pre and post implementation of the combined CSI/BCVI pathway. Data was obtained from a level 1 pediatric trauma center and included blunt trauma patients under the age of 14. We evaluated the use of cervical spine computed tomography (CT), CT angiography, and plain radiographs, as well as missed injuries and provider pathway adherence. Results We included 358 patients: 209 pre-pathway and 149 post-pathway implementation. Patient mean age was 8.9 years and 61% were male (61% males). There were no significant differences in GCS, AIS, and ISS between pre and post pathway groups. Post pathway implementation saw reduced use of cervical spine CT, although this was not clinically significant (33% vs 31%, p = 0.74). However, cervical spine radiography use increased (9% vs 16%, p = 0.03), and there was also an increase in screening for BCVI injuries with higher use of CTA (5% vs 7%, p = 0.52). A total of 12 CSI and 3 BCVI were identified with no missed injuries. Provider adherence to the pathway was modest (54%). Conclusion Implementation of a combined CSI/BCVI clinical pathway for pediatric trauma patients increased screening radiography and did not miss any injuries. However, CT use did not significantly decrease and provider adherence was modest, supporting the need for further implementation analysis and larger studies to validate the pathway's sensitivity and specificity for CSI/BCVI.

OBJECTIVES: The emergency department (ED) is a challenging setting to conduct pharmacogenomic studies and integrate that data into fast-paced and potentially life-saving treatment decisions. Therefore our objective is to present the methods and feasibility of a pilot pharmacogenomic study set in the ED that measured pediatric bronchodilator response (BDR) during acute asthma exacerbations. METHODS: This is an exploratory pilot study that collected buccal swabs for DNA and measured bronchodilator response during ED encounters for pediatric asthma exacerbations. We evaluated the study’s feasibility with a qualitative analysis of ED provider surveys and quantitatively by the proportion of eligible patients enrolled. RESULTS: We enrolled 59 out of 90 patients (65%) that were identified and considered eligible during a 5-month period (target enrollment 60 patients over 12 months). The median patient age was 7 years (interquartile range 4–9 years), 61% (N=36) were male, and 92% (N=54) were African American. Quality DNA collection was successful for all 59 patients. ED provider survey response rate was 100%. Most ED providers reported the study did not impact their workflow (98% of physicians, 88% of nurses, and 90% of respiratory therapists). ED providers did report difficulties with spirometry in the younger age group. CONCLUSIONS: Pharmacogenomic studies can be conducted in the ED setting, and enroll a younger patient population with a high proportion of minority participants. By disseminating this study’s methods and feasibility analysis, we aim to increase interest in pharmacogenomic studies set in the ED and aimed towards future ED-based pharmacogenomic decision-making.

Health care systems are at the frontline to fight the COVID-19 pandemic. An emergent question for each hospital is how many general ward and intensive care unit beds are needed and how much personal protective equipment to be purchased. However, hospital pandemic preparedness has been hampered by a lack of sufficiently specific planning guidelines. In this paper, we developed a computer simulation approach to evaluating bed utilizations and the corresponding supply needs based on the operational considerations and constraints in individual hospitals. We built a data-driven SEIR model which is adaptive to control policies and can be utilized for regional forecast targeting a specific hospital’s catchment area. The forecast model was integrated into a discrete-event simulation which modeled the patient flow and the interaction with hospital resources. We tested the simulation model outputs against patient census data from UF Health Jacksonville, Jacksonville, FL. Simulation results were consistent with the observation that the hospital has ample bed resources to accommodate the regional COVID patients. After validation, the model was used to predict future bed utilizations given a spectrum of possible scenarios to advise bed planning and stockpiling decisions. Lastly, how to optimally allocate hospital resources to achieve the goal of reducing the case fatality rate while helping a maximum number of patients to recover was discussed. This decision support tool is tailored to a given hospital setting of interest and is generalizable to other hospitals to tackle the pandemic planning challenge.

Aims and objectives The aims of this project were to (a) determine barriers to current handover and transport process, (b) develop a new protocol and process for team-to-team handover, and (c) evaluate staff satisfaction with the new process. Background The handover and transport of critically ill patients from the paediatric emergency department to the paediatric intensive care unit is a period of vulnerability associated with adverse events. Design A mixed-methods study using a quasi-experimental design and qualitative approach. Methods Focus groups were conducted to determine the barriers and facilitators of the current handover and transport process. Using these themes, a multidisciplinary team developed and implemented a new process including establishment of eight patient criteria for specialised transport and a standardised, interdisciplinary handover tool for team-to-team handover. Staff satisfaction was examined pre- and postintervention. Results Content analysis of focus groups revealed five categories: need for improved communication, cultural dissonance among units, defects in system and processes, need for standardisation and ambiguity between providers regarding acuity. Staff members reported improvements in their perceptions of satisfaction, safety, communication and role understanding associated with the new process. Conclusions Standardisation through the establishment of severity of illness criteria and communication tools creates shared mental models and decreases risks to safety. A paradigm shift of team-to-team handover and transport is recommended. Relevance to clinical practice This paper suggests the importance of improving communication during the handover and transport process through establishing standardised patient severity of illness criteria, use of standardised tools and team-to-team handover processes.

As prehospital research advances, more evidence-based guidelines (EBGs) are implemented into emergency medical services (EMS) practice. However, incomplete or suboptimal prehospital EBG implementation may hinder improvement in patient outcomes. To inform future efforts, this study's objective was to review existing evidence pertaining to prehospital EBG implementation methods.This study was a systematic literature review and evaluation following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. PubMed, EMBASE, Scopus, and Google Advanced Search were searched without language or publication date filters for articles addressing prehospital EBG implementation. Conference proceedings, textbooks, and non-English articles were excluded. GRADE was applied to the remaining articles independently by three of five study investigators. Study characteristics and salient findings from the included articles are reported.The systematic literature review identified 1,367 articles, with 41 meeting inclusion criteria. Most articles described prehospital EBG implementation (n = 24, 59%), or implementation barriers (n = 13, 32%). Common study designs were statement documents (n = 12, 29%), retrospective cohort studies (n = 12, 29%), and cross-sectional studies (n = 9, 22%). Using GRADE, evidence quality was rated low (n = 18, 44%), or very low (n = 23, 56%). Salient findings from the articles included: (i) EBG adherence and patient outcomes depend upon successful implementation, (ii) published studies generally lack detailed implementation methods, (iii) EBG implementation takes longer than planned (mostly for EMS education), (iv) EMS systems' heterogeneity affects EBG implementation, and (v) multiple barriers limit successful implementation (e.g., financial constraints, equipment purchasing, coordination with hospitals, and regulatory agencies). This review found no direct evidence for best prehospital EBG implementation practices. There were no studies comparing implementation methods or implementation in different prehospital settings (e.g., urban vs. rural, advanced vs. basic life support).While prehospital EBG implementation barriers are well described, there is a paucity of evidence for optimal implementation methods. For scientific advances to reach prehospital patients, EBG development efforts must translate into EMS practice. Future research should consider comparing implementation methodologies in different prehospital settings, with a goal of defining detailed, reproducible best practices.

Decisions for patient transport by emergency medical services (EMS) are individualized, while established guidelines help direct adult patients to specialty hospitals, no such pediatric equivalents are in wide use. When children are transported to a hospital that cannot provide definitive care, care is delayed and may cause adverse events. Therefore, we created a novel evidence-based decision tool to support EMS destination choice. A multidisciplinary expert panel (EP) of stakeholders reviewed published literature. Four facility capability levels for pediatric care were defined. Using a modified Delphi method, the EP matched specific conditions to a facility pediatric-capability level in a draft tool. The literature review and EP recommendations identified seventeen pediatric medical conditions at risk for secondary transport. In the first voting round, two were rejected, nine met consensus for a specific facility capability level, and six did not reach consensus on the destination facility level. A second round reached consensus on a facility level for the six conditions as well as revision of one previously rejected condition. In the third round, the panel selected a visual display format. Finally, the panel unanimously approved the PDTree. Using a modified Delphi technique, we developed the PDTree EMS destination decision tool by incorporating existing evidence and the expertise of a multidisciplinary panel.

Across the United States, child abuse law is governed by state statute. Pediatricians must report suspected child abuse/neglect in accordance with their state's specific reporting requirements; failure to make a timely report creates civil liability exposures and triggers criminal penalties. The pediatrician's initial report may instigate further investigation by child protective services, and the reporting pediatrician may later become involved as a critical fact witness in ensuing legal proceedings, including criminal prosecutions, custody determinations, and medical malpractice controversies. The reporting pediatrician's testimony may influence the disposition of those matters and significantly affect the well-being of the involved children. As such, dutifully reporting pediatricians promulgate and engage in peerless child advocacy.

AIM This study describes the demographic, socioeconomic, and tumor-specific characteristics of patients who refuse breast cancer surgery. MATERIALS AND METHODS This is a retrospective study of breast cancer patients from 2004-2015 captured by the National Cancer Data Base. Demographic, socioeconomic, and tumor-specific predictors were compared between patients who refused breast cancer surgery versus those who agreed to surgery, using bivariate and multivariate models. RESULTS A total of 2,445,870 patients met the inclusion criteria. On multivariate analysis, black and Asian patients had higher odds of refusing surgical treatment compared to whites (OR=2.16, CI=2.05-2.28, p

Objectives Little is known about emergency medical services' (EMS') management of pediatric asthma. This study's objective was to describe the demographic, clinical, and geographic characteristics of current EMS' management of pediatric asthma in the state with the fourth-largest pediatric population. Methods This was a retrospective observational study of EMS patients ages 2 to 18 years with an asthma exacerbation from 2011 to 2016. Patients from Florida's EMS Tracking and Reporting System were included if their EMS chief complaint indicated respiratory distress, if they received at least 1 albuterol treatment, and if they were transported to a hospital. Results A total of 11,226 patients met the inclusion criteria. The median age was 9 years, and 49% were African-American. Geospatial analysis revealed 4 rural counties with disproportionate numbers of African-American patients. In addition to albuterol, 37% of patients received ipratropium bromide and 9% received systemic corticosteroids. Adjusted logistic regression revealed that the strongest predictors of receiving systemic corticosteroids from EMS were intravenous access (odds ratio, 33.4; 95% confidence interval, 24.4-45.6) and intravenous magnesium sulfate administration (odds ratio, 5.0; 95% confidence interval, 3.4-7.3), indicating a more severe presentation. Conclusions This statewide study demonstrated low rates of EMS administration of ipratropium bromide and systemic corticosteroids, both evidence-based treatments for asthma exacerbations. Targeted EMS education should attempt to increase utilization of both those medications. In addition, the feasibility and efficacy of EMS administration of oral systemic corticosteroids for children should be explored.