June 2001

Grant Results

SUMMARY

From 1997 to 2000, the University of Arizona College of Medicine developed and tested a model program to train paramedics to treat children with special health care needs at the scene instead of transporting them to an emergency facility. At the time the grant was made, such a training program did not exist.

The model program focused on needs including included severe asthma, seizure disorders, and cerebral palsy; children with those conditions may be dependent on oxygen supplementation, infusion pumps, or other technology. Investigators at the university's Arizona Emergency Medicine Research Center (AEMRC) developed the program, which paramedics could complete in a self-instruction course while on duty.

It included:

  1. A self-study manual and companion video.
  2. Eleven integrated practice case scenarios.
  3. A skills evaluation workshop.
  4. A handbook of clinical activities with a supplemental CD.

The educational program, Children with Special Health Care Needs: An EMS Challenge, continues to be available on request. Overall, 318 paramedics in Arizona received training as part of the project.

Key Findings

  • Of 52 Tucson paramedics who received training, more than three quarters (76 percent) reported that they had responded to a call involving a child with a special need.
  • After training, most of the paramedics were prepared to treat special needs children.
  • Paramedics who trained in the program were significantly more likely to administer advanced life support at the scene than those who did not.
  • Paramedics who were trained apparently made more appropriate decisions about whether to transport children to the hospital.

Funding
The Robert Wood Johnson Foundation (RWJF) supported the project with a grant of $565,971 from August 1997 to February 2000.

 See Grant Detail & Contact Information
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THE PROBLEM

Children with special health care needs constitute a substantial share of pediatric emergency room patients. In the United States, there are about 10 million children with special health care needs, who suffer from some two dozen conditions, including severe asthma, severe neurological impairment, seizure disorders, cerebral palsy, or complications of trauma.

Such children are particularly vulnerable to illness and injury, and many are dependent on tracheotomies, oxygen adjunct therapies, and infusion pumps. Malfunction of any of these supportive technologies can precipitate an emergency. Paramedics, whose major function is to provide emergency life support, should be able to manage most of the emergency problems of these children without having to transport them to an emergency facility. However, at the time this grant was made, no program existed anywhere in the United States to equip paramedics to do so.

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THE PROJECT

This grant from RWJF supported the development of a model program to train paramedics to treat children with special health care needs. The goal of the training was to enable paramedics to treat such children at the scene instead of routinely transporting them to an emergency facility.

Researchers at the AEMRC intended to develop a training program that combined off-site lectures and skills training at treatment centers for children with special needs. A Curriculum Advisory Committee, made up of local pediatricians and nurses, helped develop the program. Then, in response to requests from fire department managers, who indicated that an on-site program would be a more attractive and less costly alternative, the investigators abandoned the original off-site lecture format and adopted a self-instruction approach that paramedics could learn from while on duty.

The training program — entitled "Meeting the Challenge: Improving Emergency Medical Care for Children with Special Health Care Needs. A Self-Paced Education Program for Paramedics" — features a 244-page self-study manual, a 60-minute companion video, 11 integrated practice case scenarios, and a 68-page handbook of clinical activities. Additional hands-on practice and skills evaluation workshops were provided at various clinical training sites.

After pilot testing, both the self-instruction manual and the clinical activities handbook were revised. A CD presenting three interactive skills-based scenarios, information about emergency situations involving technological adjuncts (e.g., oxygen adjunct therapies and infusion pumps), and a reference appendix were added to the program. In total, 318 paramedics took part in some or all of the training as part of paramedic training classes in Tucson and Pima County and during special lecture sessions held at the University of Arizona Medical Center, Tucson.

To assess the effectiveness of the training program, the investigators followed 52 paramedics from the Tucson Fire Department who completed the training. The investigators tested the 52 paramedics' confidence and skills in managing special needs children after training ended and again four months later. To assess the scope and needs of children with special health care needs in the Tucson area, the investigators analyzed more than 924 emergency service runs involving special needs children in the Tucson area, and they conducted separate surveys of Tucson area parents and health care providers.

An unexpected result of the project was that special needs children got enrolled in a citywide database that provides detailed medical information for emergency responders. The database was created by the RWJF-supported Project OPEN (see Grant Results on ID# 035056) to relay medical information on elderly patients to responding emergency vehicles whenever 911 is called.

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FINDINGS

In the American Journal of Emergency Medicine (January 2000), the investigators reported these results from their study of the 52 paramedics from the Tucson Fire Department who received training:

  • More than three-quarters (76 percent) of paramedics reported that they had responded to a call involving a child with a special need. The most common calls involved children with tracheotomies, gastrostomies, Down syndrome, cerebral palsy, or seizures.
  • After training, most paramedics are prepared to treat special needs children. Eighty percent of the paramedic teams that received training were able to adequately perform 10 of 19 targeted skills. Between the pre- and posttraining surveys, paramedics became significantly more confident in their ability and knowledge to treat special needs children. Between the posttraining and follow-up surveys four months later, however, there was a significant decline in both comfort and knowledge — a pattern that is typically observed in follow-up tests for infrequently used skills, the investigators say.
  • Paramedics who trained in the program were significantly more likely to administer advanced life support at the scene to children with special needs than those who did not receive training.
  • Following training, it appears that paramedics made more appropriate decisions about whether to transport children to the hospital. A greater proportion of those transported to the hospital were then admitted in the period after paramedics received training than in the period before. Therefore, fewer children were transported unnecessarily. The difference, however, was not statistically significant.

In the journal Prehospital Emergency Care (January/March 2000), the investigators reported these findings from their analysis of 924 emergency service runs involving special needs children:

  • Less than half of all emergency calls to care for special needs children were related to the children's special health care need.
  • Seizure disorder was the most common diagnosis among children receiving an emergency response related to their special health care need. Asthma was the most common diagnosis for emergency responses not related to the child's special need.
  • Children with central nervous system abnormalities, seizures, cerebral palsy, apnea, diabetes, congenital abnormalities of the circulatory system, chromosomal abnormalities, and gastrointestinal abnormalities were more likely to have an emergency response related to their special health care need than were children with mental disorders (including attention deficit disorder) and sensory or communication disorders.

In an unpublished survey of 710 parents of children with special health care needs, the investigators found that:

  • Less than one-third (28 percent) of parents surveyed had ever called 911 about their special needs child.
  • The level of medical complexity of the children's conditions varied greatly. Nearly half of the parents said that their child used adaptive equipment, such as an apnea monitor, feeding tube, or cerebrospinal fluid shunt.
  • Deafness, blindness, mental disorders, and congenital physical or chromosomal abnormalities were the most common conditions identified among the children with special health care needs.

Communications

The investigators wrote five journal articles about the project; three have been published as of the date of this report. Three press releases were sent to 75 newspapers, emergency medical service (EMS) publications, and radio and television stations throughout Arizona, and several local television stations highlighted the project in news reports. The program was also sent to an EMS agency in Virginia for use in training emergency personnel there.

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LESSONS LEARNED

  1. Involve collaborating organizations in the development process of a project as early as possible. The investigators had to abandon the original off-site lecture format and adopt a self-instruction approach after fire department managers indicated that an on-site, self-instruction program would be more attractive to paramedics and a less costly alternative. Though the investigators were sufficiently flexible to change in midcourse, earlier collaboration might have enabled them to devise a suitable design from the outset.

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AFTER THE GRANT

The training program, Children with Special Health Care Needs: An EMS Challenge, continues to be available on request from the university, and the CD is provided on request at no cost to EMS agencies and training facilities.

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GRANT DETAILS & CONTACT INFORMATION

Project

Training of Paramedics in the Treatment of Children with Special Needs

Grantee

University of Arizona College of Medicine (Tucson,  AZ)

  • Amount: $ 565,971
    Dates: August 1997 to February 2000
    ID#:  030671

Contact

Daniel Spaite, M.D.
(520 626-5031)
dan@aemrc.arizona.edu

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Educational Materials

Battaglia N, Seng M, and Karriker KJ. Meeting the Challenge: Improving Emergency Medical Care for Children with Special Health Care Needs. A Clinical Applications Handbook for Paramedics to Accompany the Self-Paced Study Manual. Tucson, Ariz.: Arizona Emergency Medicine Research Center, 1998. 100 copies distributed.

Meeting the Challenge: Improving Emergency Medical Care for Children with Special Health Care Needs, an interactive, multimedia educational program distributed on compact disc. Tucson, Ariz.: Arizona Emergency Medicine Research Center, 1998. 145 CDs distributed.

Meeting the Challenge: Self-Study Video to Accompany the Self-Paced Study Manual, a 60-minute videotape. Tucson, Ariz.: Arizona Emergency Medicine Research Center, 1998. 18 copies distributed.

Seng M and Karriker KJ. Meeting the Challenge: Improving Emergency Medical Care for Children with Special Health Care Needs. A Self-Paced Educational Program for Paramedics. Tucson, Ariz.: Arizona Emergency Medicine Research Center, 1998. 150 copies distributed.

Articles

Spaite DW, Conroy C, Karriker KJ, Tibbitts M, Seng M, Battaglia N, and Salik RM. "Documentation of Emergency Responses for Children with Special Health Care Needs." Unpublished.

Spaite DW, Conroy C, Tibbitts M, Karriker KJ, Seng M, Battaglia N, Criss EA, Valenzuela TD, and Meislin HW. "Use of Emergency Medical Services by Children with Special Health Care Needs." Prehospital Emergency Care, 4(1): 19–23, 2000. Abstract available online.

Spaite DW, Conroy C, Tibbitts M, Karriker KJ, Seng M, Battaglia N, Valenzuela TD, Meislin HW, and Salik RM. "Improving Emergency Medical Services for Children with Special Health Care Needs: Does Training Make a Difference?" American Journal of Emergency Medicine, 19(6): 474–478, 2001. Abstract available online.

Spaite DW, Karriker KJ, Seng M, Conroy C, Battaglia N, Tibbitts M, Meislin HW, Salik RM, and Valenzuela TD. "Increasing Paramedics' Comfort and Knowledge about Children with Special Health Care Needs." American Journal of Emergency Medicine, 18(7): 747–752, 2000. Abstract available online.

Spaite DW, Karriker KJ, Seng M, Conroy C, Battaglia N, Tibbitts M, and Salik RM. "Training Paramedics: Emergency Care for Children with Special Health Care Needs." Prehospital Emergency Care, 4(2): 178–185, 2000. Abstract available online.

Brochures and Fact Sheets

Meeting the Challenge: Improving Emergency Medical Care for Children with Special Health Care Needs. An Educational Program for Paramedics (brochure). Tucson, Ariz.: Arizona Emergency Medicine Research Center, February 1998. 500 copies distributed.

Survey Instruments

"Children with Special Health Care Needs: A Survey of Paramedics." Arizona Emergency Medicine Research Center, fielded February–June 1998.

"Children with Special Health Care Needs: A Survey of Parents and Caregivers." Arizona Emergency Medicine Research Center, fielded February–May 1998.

"Children with Special Health Care Needs: Pediatrician/Clinic Survey." Arizona Emergency Medicine Research Center, fielded July 1998.

"Meeting the Challenge: Follow-Up Survey of Paramedics." Arizona Emergency Medicine Research Center, fielded March 1999.

"Meeting the Challenge: Improving Emergency Medical Care for Children with Special Health Care Needs. Post-test and Survey of Paramedics." Arizona Emergency Medicine Research Center, fielded June–November 1998.

"Meeting the Challenge: Pre-test." Arizona Emergency Medicine Research Center, fielded March–August 1998.

Sponsored Workshops

"Meeting the Challenge: Training for Newly Certified Paramedics," July 1998, Tucson, Ariz. One-day workshop attended by 17 paramedics from the Tucson Fire Department.

"Meeting the Challenge: Training for Newly Certified Paramedics," June 1999, Tucson, Ariz. One-day workshop attended by 16 paramedic students from Tucson Fire Department and private ambulance companies in Tucson, Ariz.

"Meeting the Challenge: Training for Paramedics and Firefighters," June 1999, Tucson, Ariz. One-day workshop attended by 11 paramedics and firefighters from Avra Valley Fire Department.

"Meeting the Challenge: Training for Prehospital Emergency Care Providers," June 1999, Tucson, Ariz. Continuing education base hospital workshop attended by 53 prehospital emergency care providers from southern Arizona.

Presentations and Testimony

Anish Varghese, "Children with Special Health Care Needs: A Survey of Parents and Caregivers," at the Final Student Presentations, National Institutes of Health Disadvantaged High School Student Research Program, July 1998, Tucson, Ariz.

Rose Adjei, "Children with Special Health Care Needs: Ages 5 through 9 Years," at the Final Student Presentations, National Institutes of Health Disadvantaged High School Student Research Program, July 1999, Tucson, Ariz.

Katherine J. Karriker and Daniel W. Spaite, "Self-Perceptions of Knowledge and Comfort: Which Measure Is More Sensitive?" at Evaluation 1999, Annual Meeting of the American Evaluation Association, November 1999, Orlando, Fla.

Katherine J. Karriker and Daniel W. Spaite, "Self-Perceptions of Knowledge and Comfort: Which Measure Is More Sensitive?" at Arizona Evaluation Network: Tucson Cluster, November 1999, Tucson, Ariz.

Press Kits and News Releases

A press release about the grant received by the Arizona Emergency Medicine Research Center to improve emergency care for children with special health care needs was distributed in December 1997 to 75 newspapers, EMS publications, and radio and television stations.

A press release about training paramedics at the Tucson Fire Department with the specialized curriculum to improve emergency care for children with special health care needs was distributed in November 1998 to 75 newspapers, EMS publications, and radio and television stations.

A press release discussing the collaboration between the Arizona Emergency Medicine Research Center and the Center for Aging for improving emergency dispatch information and emergency care for children with special health care needs was distributed in February 1999 to 75 newspapers, EMS publications, and radio and television stations.

Print Coverage

"Grant to Boost Emergency Care," in Tucson Citizen, December 11, 1997.

"Grant to Help Teach Better Health Care for Children," in Tucson Citizen, December 26, 1997.

"Meeting the Challenge," in The Navigator: Newsletter of Pilot Parents of Southern Arizona, Fall 1998.

"EMT Course Focuses on Children with Special Needs," in Journal of Emergency Medical Services, March 1999.

"UA Medicine, City Team Up to Improve Care of Children with Special Needs," in Lo Que Pasa, University of Arizona, June 24, 1999.

Television Coverage

"Arizona Illustrated," announcing project plans on PBS, December 1998.

News program describing the Project OPEN collaboration on KVOA (NBC), June 1999.

World Wide Web Coverage

University of Arizona's Health Net Listserv announces the Project OPEN collaboration May 17, 1999.

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Report prepared by: Janet Spencer King
Reviewed by: Richard Camer
Reviewed by: Janet Heroux
Program Officer: Terrance Keenan

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