Evaluating pediatric advanced life support in emergency medical services with a performance and safety scoring tool

Introduction: Pediatric out-of-hospital cardiac arrests (P-OHCA) are infrequent, have low survival rates, and often have poor neurologic outcomes. Recent evidence indicates that high-performance emergency medical service (EMS) care can improve outcomes. Objectives: To evaluate Pediatric Advanced Life Support (PALS) guideline performance in the out of hospital setting and introduce an easy-to-use tool that scores guideline compliance and patient safety. Methods: We observed EMS teams responding to standardized pediatric resuscitation simulations. Teams were dispatched to a mock assisted living home for a choking 6-year-old with a complex medical history. The child manikin was presented as unconscious and apneic, with bradycardic pulse. Teams were expected to monitor vitals; initiate airway management and cardiopulmonary resuscitation (CPR); and establish vascular access and administer epinephrine based on PALS guidelines. We developed a tool to score the quality of care for critical tasks and had a clinical expert evaluate technical performance using blinded video review. Results: We observed 34 EMS teams providing care in P-OHCA simulations. Teams were proficient at assessing vitals, using correct-sized equipment, intubation, and confirmation of tube placement. Teams were delayed in initiating positive pressure ventilation (PPV) and chest compressions. Many teams (53%) deviated from guidelines in chest compressions with 17 (50%) performing continuous compressions before establishing an advanced airway and one (3%) not performing compressions. Similarly, 20 (59%) teams deviated from medication guidelines with 12 (35%) failing to administer epinephrine, six (18%) underdosing, and two (6%) overdosing by more than 20%. Conclusion: EMS teams were successful in selecting the appropriate equipment but delayed initiating ventilations in a child with severe bradycardia. We also noted frequent use of continuous chest CC rather than the AHA recommended 15:2 ratio. We developed a scoring tool with time-based criteria that can be used to assess guideline compliance, individual performance, and/or educational effectiveness.