INTRODUCTION
Emergency Medical Service (EMS) systems transport approximately 8 million children to emergency departments each year, of which 10–14% need life-saving care outside hospitals.1 Children are vulnerable to prehospital medical error and preventable harm with life-threatening consequences.2,3 Gaps in provider experience, decision-making, training and stress increase risk of error with children.4–8 Tools to support stressed providers could improve patient safety.4
Prehospital telemedicine provides remote expert consultation via video/information technology for patient care outside the hospital. Hospitals have used telemedicine to reduce errors in pediatric emergency care in low volume clinical settings.9–11 Prehospital telehealth utilization has grown slowly in the United States for primarily adult applications.12–14 Prior reports of prehospital pediatric applications have focused on pediatric specialty transport teams in interfacility transfers.15–17 In a 2016 National Public Safety Telecommunications Council (NPSTC) survey, prehospital providers felt telemedicine could benefit patients and providers, but worried implementation could have adverse effects, such as inadvertent delays in transportation to definitive care.18 Notably, this survey did not examine front-line provider perceptions or preferences for pediatric applications in emergency response systems. Therefore, we designed a pilot survey study as the initial phase of a future planned mixed-methods study to identify factors predicting pediatric telemedicine adoption by the EMS community. The pilot survey objectives were to (1) estimate prior prehospital telemedicine use, (2) describe perceptions of potential benefits and risks of pediatric prehospital telemedicine, and (3) identify preferred utilization strategies by paramedics as a key user group.
MATERIAL & METHODS
Study Design, Setting and Population
We conducted an IRB approved survey of a convenience sample of 25 Massachusetts paramedics attending a regional prehospital advanced life support course in December 2018. Paramedics were recruited following a brief presentation of the study objectives by the study principal investigator. Participants without paramedic-level certification were excluded.
Survey Development and Administration
The anonymous survey had 14 questions with 67 items total (Supplement 1). We modeled the content and format of survey questions from the NPSTC questionnaire which assessed general telemedicine applications using patient scenarios, including one pediatric scenario.16 Questions to assess benefits, risks, and utilization strategies were adapted for pediatric application (i.e. children <12 years) by study team consensus. The study team consisted of pediatric and general emergency medicine, pediatric intensive care, and prehospital expert physicians; and EMS administrators. The survey instrument was pilot-tested and modified based on feedback from three paramedics before subjects were approached for enrollment. These paramedics were excluded from participation in the final study.
Volunteer participants provided informed consent and received a $10 gift-card for completion. Study research personnel collected paper surveys at the course and transcribed data into a Research Electronic Data Capture (REDCap) database.19
Measurements
“Prehospital telemedicine” was defined as video-clips, still pictures, and/or 2-way video-conferencing among field providers and medical control (or other consultants) to enhance standard radio communication. Survey goals were to: (1) estimate prehospital telemedicine experience, (2) quantify perceived benefits and risks of telemedical communication with physicians and hospital emergency departments (EDs), and (3) identify preferred utilization strategies in diverse prehospital settings.
Demographic information included age, sex, certification, experience, and practice setting. Participants self-reported frequency, and rated confidence performing critical procedures in pediatric age-groups (5-point Likert scale) as surrogate measures of provider clinical experience and confidence with sick children.
Participants estimated frequency of prehospital telemedicine use. To assess potential benefits, we asked if telemedicine could benefit a prehospital provider caring for a child to communicate with medical control physicians/EMS systems, and EDs for various reasons. To assess potential risks, respondents rated agreement with adverse effects on a 5-point Likert scale. Participants considered utilization strategies (live-streaming video, video-clips, still pictures, no video/picture) in three case-based scenarios representing various ages and medical conditions. Here, respondents checked all theoretical practice settings (urban, suburban, and rural) where each strategy could improve care, and provided written comments.
Data Analysis
We used the Chi-square test to compare respondent age, sex, and practice duration to state paramedic data (Office of EMS) to assess sample representativeness. We summarized categorical responses with frequencies and percentages (with 95% CIs), and Likert-scale questions with medians and interquartile ranges due to non-normal distribution. As provider clinical experience and confidence with sick children could influence attitudes towards telemedicine, we tested associations between respondent confidence performing critical pediatric procedures and respondent opinion on whether telemedicine could impact outcomes with Spearman’s rank correlation coefficient. We used 95% CIs to detect differences in utilization strategy preferences. Qualitative comments were independently assessed for themes regarding perceived usefulness and ease of use of telemedicine within the Technology Acceptance Model framework by two study investigators (TB, JL) using a deductive reasoning process.20 We report selected verbatim comments to illustrate themes. We used SAS v9.4 (SAS Institute, NC, USA) for statistical tests.
RESULTS
All 25 paramedics completed surveys (100% response). The sample was largely male with >10 years of practice (Table 1). Respondents were similarly distributed for sex (p=0.41) but were older (p=0.003) and more experienced (p<0.001) than paramedics statewide.
Table 1.
Survey participant characteristics.
| Survey Participants | n = 25 (%) |
|---|---|
| Demographics | |
| Male (%)a | 23 (92%) |
| ≥ 60 years | |
| Provider experience | |
| ≥ 20 years | 13 (52%) |
| ALS/paramedic not practicing | 6 (24%) |
| Rural | 1 (4%) |
missing 1 urban response;
missing 4 urban responses;
participants could select >1 answer
Most (23/25, 92%) had performed pediatric BVM/CPR on a child < 12 years at least once, with >95% reporting at least moderate confidence (Supplement 2). In contrast, many had never performed pediatric intubation (36%) or intraosseous catheterization (40%), and reported lower median confidence than for BVM/CPR. Over 40% of respondents reported >1 year interval since their last attempt at any critical pediatric procedure.
Most respondents had never used telemedicine for patients <12 years (23/25, 92%; 95% CI 74, 99%) or older (22/24, 92%; 95% CI 73, 99%). Paramedic opinion on perceived benefits for telemedical interactions with medical control physicians/EMS systems, and hospital EDs is depicted in Table 2A, while potential risks are described in Table 2B. More providers agreed that time delays from equipment use or consultation, difficulty maintaining broadband connections, and cost were possible risks than excessive provider surveillance, medicolegal or privacy concerns. Forty percent agreed/strongly agreed telemedicine may not improve outcomes, while 60% were neutral or disagreed with this concern. There was no statistically significant association between respondent confidence in performing critical pediatric procedures and opinion on whether telemedicine could improve clinical outcomes.
Table 2.
Paramedic opinion of (A) potential benefits for interaction with medical control physicians/EMS systems and hospital EDs, and (B) potential risks of pediatric prehospital telemedicine.
| Potential Benefits | Response (n = 25) | ||
|---|---|---|---|
| % Yes | 95% CI | ||
| Medical Control Physician / EMS System | Decision support for field triage | 44% | 27 – 63 |
| Video/picture enhancing field report to Medical Control/ED | 56% | 37 – 73 | |
| Physician-assisted, real-time, critical care support for field provider | 68% | 48 – 83 | |
| Decision support on transport destination and/or modality | 36% | 20 – 56 | |
| Decision support/risk mitigation for patient transport refusal | 68% | 48 – 83 | |
| Paramedic training opportunity (live/post-incident feedback) | 80% | 60 – 92 | |
| Quality assurance of patient carea | 60% | 41 – 77 | |
| Hospital ED | Increased situational awareness of incoming critical care transports | 68% | 48 – 83 |
| Video/picture documentation of patient status pre-treatment | 72% | 52 – 86 | |
| Decision support for hospital emergency team activation | 68% | 53 – 89 | |
| Improved patient care from visualization of scene/injury mechanism | 76% | 59 – 86 | |
| Paramedic training opportunity (live/post-incident feedback) | 72% | 52 – 86 | |
| Quality assurance of patient care | 60% | 54 – 82 | |
| Potential Risks | Strongly Disagree/Disagree | Neutral | Agree/Strongly Agree |
|---|---|---|---|
| n = 25 (%) | |||
| Time to use telemedicine equipment | 2 (8%) | 4 (16%) | 19 (76%) |
| Time for ED/medical control physicians for video consultation | 3 (12%) | 6 (24%) | 16 (64%) |
| Ability to maintain high-quality broadband connection | 2 (8%) | 10 (40%) | 13 (52%) |
| Excessive surveillance of field providers | 3 (12%) | 9 (36%) | 13 (52%) |
| Medicolegal liability concerns | 4 (16%) | 9 (36%) | 12 (48%) |
| HIPPA/privacy concerns | 7 (28%) | 7 (28%) | 11 (44%) |
| Cost to purchase/maintain system, train personnel | 5 (20%) | 6 (24%) | 14 (56%) |
| May not improve medical outcome (current protocols sufficient) | 6 (24%) | 9 (36%) | 10 (40%) |
Missing 2 responses
Respondents tended to prefer video over still pictures (Supplement 3). More respondents felt prehospital applications for scene visualization, physician-assisted assessment and care could benefit rural and suburban providers than urban ones.
Thirteen (52%) respondents provided a total of 24 written comments (Supplement 4). Fourteen comments regarding perceived usefulness of pediatric telemedicine included enhanced provider report (e.g. “video…may not be ‘needed’, but [could] augment report [and] understanding”) and improved real-time provider support (e.g. “useful tool for the rural provider [with long] transport time, bridging the gap in access to care”; “focus on [provider] skill/experience level…rather than geography”). One participant commented “any tool should be available to EMS if it provides value and improved patient care regardless of the location”. Two participants advocated for provider education in lieu of technological tools, and four participants felt prehospital telemedicine may not be needed. Three comments regarding ease of use emphasized time and personnel needs related to equipment use, and two broadband availability.
DISCUSSION
While most paramedics in this pilot survey lacked prior experience with prehospital telemedicine, many felt this technology could enhance the interface with physicians and hospitals when caring for children. Understanding inexperienced user perceptions is important as their attitudes could influence future technology adoption. Perceived benefits included improved real-time support for providers and situational awareness of transports for hospitals. Potential risks emphasized telemedicine-related time delays, broadband difficulties, and cost. Paramedics generally favored video strategies for lower pediatric volume settings.
Evidence supporting prehospital telemedicine efficacy for emergency care of adults with stroke and other time-critical illnesses is growing,12,21 but pediatric applications remain understudied. Prior reports have focused on telemedicine utilization by pediatric specialty transport teams with more frequent exposure to critically ill and injured children than community EMS providers.16,17 Telemedicine has potential to support prehospital providers with limited pediatric exposure and improve pediatric patient safety. Potential mechanisms include fewer medical errors,10 enhanced remote assessment of a sick child by physicians,22 assistance with interventions,23 improved patient stabilization,9 and shortened time to definitive care.17 The respondents in this pilot survey favored pediatric applications focused on patient assessment, care delivery, and provider feedback. Prior studies have highlighted these as knowledge and experience gaps identified by prehospital providers.8
Despite the potential to address gaps in access to pediatric emergency care, recent studies suggest that telemedicine is underutilized across the emergency care spectrum. In a national survey, only 8% of EDs in the United States used pediatric telemedicine.24 Regionally, ED telemedicine utilization is more common for adults than for children.25 While similar regional data on EMS telehealth utilization are lacking, our study suggests prehospital telemedicine is uncommon in Massachusetts. This study is the first step to understanding factors that are likely to influence pediatric telemedicine adoption by key technology end-users within the prehospital community. Prehospital platforms designed and optimized with stakeholder input are warranted.
Limitations
This pilot study is limited by small sample size and selection bias. Clinical exposure was assessed by self-report which is subject to recall bias, but our results mirror prior studies.26 We found no association between provider confidence and attitudes towards telemedicine, but were underpowered to detect this. This sample was skewed toward older, experienced providers whose opinions may not fully reflect a diverse prehospital community, particularly rural/suburban providers. Respondents lacked prior clinical exposure to prehospital telemedicine, so the basis of their perceptions is unclear. However, healthcare provider attitudes are well known to influence telehealth adoption.27,28 Even if pediatric telemedicine is found to be effective and worth widespread implementation, prehospital provider attitudes will dictate ultimate technology utilization. Finally, shorter transport distances and greater hospital density in Massachusetts versus other regions29 could negatively bias opinions, assuming a greater perceived benefit for long transports. Further investigation of prehospital provider opinion from rural and suburban practice settings is needed.
CONCLUSIONS
Prehospital telemedicine use in Massachusetts is uncommon, but paramedics view potential pediatric applications, including enhanced real-time critical care support, training, and situational awareness of transports. Impacts on transport time, broadband availability, and cost should be important considerations when testing future prehospital telehealth systems. These results support further study of prehospital telemedicine as a technological intervention to improve emergency care for sick and injured children in the community.
Supplementary Material
Supplemental Digital Content 1: Paramedic survey of telemedicine use for prehospital pediatric emergency care.
Supplemental Digital Content 2: Paramedic estimates of career frequency and time since critical procedure was last performed on a child < 12 years.
Supplemental Digital Content 3: Paramedic preferences for utilization strategies in three pediatric prehospital applications in varied practice settings (urban, suburban, and/or rural).
Supplemental Digital Content 4: Participant open comments regarding telemedicine utilization strategies organized by themes (perceived usefulness and ease of use) using the Technology Acceptance Model framework.
ACKNOWLEDGEMENTS
The authors thank Boston EMS, and Massachusetts OEMS for assistance with this study. This study was supported by the National Center for Advancing Translation Sciences, National Institutes of Health (NIH), through Boston University Clinical and Translational Institute grant 1UL1TR001430. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.
REFERENCES
- 1.Shah MN, Cushman JT, Davis CO, Bazarian JJ, Auinger P, Friedman B. The epidemiology of emergency medical services use by children: an analysis of the National Hospital Ambulatory Medical Care Survey. Prehosp Emerg Care. Jul-Sep 2008;12(3):269–276. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Hansen M, Meckler G, Lambert W, et al. Patient safety events in out-of-hospital paediatric airway management: a medical record review by the CSI-EMS. BMJ open. November 11 2016;6(11):e012259. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Meckler G, Hansen M, Lambert W, et al. Out-of-Hospital Pediatric Patient Safety Events: Results of the CSI Chart Review. Prehosp Emerg Care. May-Jun 2018;22(3):290–299. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Guise JM, Meckler G, O’Brien K, et al. Patient Safety Perceptions in Pediatric Out-of-Hospital Emergency Care: Children’s Safety Initiative. J Pediatr. November 2015;167(5):1143–1148 e1141. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Hoyle JD Jr., Crowe RP, Bentley MA, Beltran G, Fales W. Pediatric Prehospital Medication Dosing Errors: A National Survey of Paramedics. Prehosp Emerg Care. Mar-Apr 2017;21(2):185–191. [DOI] [PubMed] [Google Scholar]
- 6.Vrotsos KM, Pirrallo RG, Guse CE, Aufderheide TP. Does the number of system paramedics affect clinical benchmark thresholds? Prehosp Emerg Care. Jul-Sep 2008;12(3):302–306. [DOI] [PubMed] [Google Scholar]
- 7.Guise JM, Hansen M, O’Brien K, et al. Emergency medical services responders’ perceptions of the effect of stress and anxiety on patient safety in the out-of-hospital emergency care of children: a qualitative study. BMJ open. February 28 2017;7(2):e014057. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Hansen M, Meckler G, Dickinson C, et al. Children’s safety initiative: a national assessment of pediatric educational needs among emergency medical services providers. Prehosp Emerg Care. Apr-Jun 2015;19(2):287–291. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Dayal P, Hojman NM, Kissee JL, et al. Impact of Telemedicine on Severity of Illness and Outcomes Among Children Transferred From Referring Emergency Departments to a Children’s Hospital PICU. Pediatr Crit Care Med. June 2016;17(6):516–521. [DOI] [PubMed] [Google Scholar]
- 10.Dharmar M, Kuppermann N, Romano PS, et al. Telemedicine consultations and medication errors in rural emergency departments. Pediatrics. December 2013;132(6):1090–1097. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Gattu R, Teshome G, Lichenstein R. Telemedicine Applications for the Pediatric Emergency Medicine: A Review of the Current Literature. Pediatr Emerg Care. February 2016;32(2):123–130. [DOI] [PubMed] [Google Scholar]
- 12.Winburn AS, Brixey JJ, Langabeer J 2nd, Champagne-Langabeer T. A systematic review of prehospital telehealth utilization. J Telemed Telecare. August 2018;24(7):473–481. [DOI] [PubMed] [Google Scholar]
- 13.Itrat A, Taqui A, Cerejo R, et al. Telemedicine in Prehospital Stroke Evaluation and Thrombolysis: Taking Stroke Treatment to the Doorstep. JAMA Neurol. February 2016;73(2):162–168. [DOI] [PubMed] [Google Scholar]
- 14.Tanguay A, Dallaire R, Hebert D, Begin F, Fleet R. Rural Patient Access to Primary Percutaneous Coronary Intervention Centers is Improved by a Novel Integrated Telemedicine Prehospital System. J Emerg Med. November 2015;49(5):657–664. [DOI] [PubMed] [Google Scholar]
- 15.Kofos D, Pitetti R, Orr R, Thompson A. Telemedicine in pediatric transport: a feasibility study. Pediatrics. November 1998;102(5):E58. [DOI] [PubMed] [Google Scholar]
- 16.Patel S, Hertzog JH, Penfil S, Slamon N. A Prospective Pilot Study of the Use of Telemedicine During Pediatric Transport: A High-Quality, Low-Cost Alternative to Conventional Telemedicine Systems. Pediatr Emerg Care. September 2015;31(9):611–615. [DOI] [PubMed] [Google Scholar]
- 17.Jackson EM, Costabile PM, Tekes A, et al. Use of Telemedicine During Interhospital Transport of Children With Operative Intracranial Hemorrhage. Pediatr Crit Care Med. November 2018;19(11):1033–1038. [DOI] [PubMed] [Google Scholar]
- 18.National Public Safety Telecommunications Council EMS Working Group. EMS Telemedicine Report: Prehospital Use of Video Technologies. [Report]. 2016; http://npstc.org/download.jsp?tableId=37&column=217&id=3612&file=EMS_Telemedicine_Report_Final_20160303.pdf. Accessed 01/11/2019, 2019.
- 19.Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. April 2009;42(2):377–381. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Holden RJ, Karsh BT. The technology acceptance model: its past and its future in health care. J Biomed Inform. February 2010;43(1):159–172. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Ebinger M, Audebert HJ. Switched On-Expert Advice in Prehospital Thrombolysis via Telemedicine. JAMA Neurol. February 2016;73(2):153–154. [DOI] [PubMed] [Google Scholar]
- 22.Siew L, Hsiao A, McCarthy P, Agarwal A, Lee E, Chen L. Reliability of Telemedicine in the Assessment of Seriously Ill Children. Pediatrics. March 2016;137(3):e20150712. [DOI] [PubMed] [Google Scholar]
- 23.Van Oeveren L, Donner J, Fantegrossi A, Mohr NM, Brown CA 3rd. Telemedicine-Assisted Intubation in Rural Emergency Departments: A National Emergency Airway Registry Study. Telemed J E Health. April 2017;23(4):290–297. [DOI] [PubMed] [Google Scholar]
- 24.Brova M, Boggs KM, Zachrison KS, et al. Pediatric Telemedicine Use in United States Emergency Departments. Acad Emerg Med. October 11 2018. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Zachrison KS, Hayden EM, Schwamm LH, et al. Characterizing New England Emergency Departments by Telemedicine Use. West J Emerg Med. October 2017;18(6):1055–1060. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Carlson JN, Gannon E, Mann NC, et al. Pediatric Out-of-Hospital Critical Procedures in the United States. Pediatr Crit Care Med. October 2015;16(8):e260–267. [DOI] [PubMed] [Google Scholar]
- 27.Ray KN, Felmet KA, Hamilton MF, et al. Clinician Attitudes Toward Adoption of Pediatric Emergency Telemedicine in Rural Hospitals. Pediatr Emerg Care. April 2017;33(4):250–257. [DOI] [PubMed] [Google Scholar]
- 28.Gagnon MP, Orruño E, Asua J, Abdeljelil AB, Emparanza J. Using a Modified Technology Acceptance Model to Evaluate Healthcare Professionals’ Adoption of a New Telemonitoring System. Telemed J E Health. 04/11/received 06/16/revised 06/17/accepted 2012;18(1):54–59. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Wolf LL, Chowdhury R, Tweed J, et al. State-level geographic variation in prompt access to care for children after motor vehicle crashes. J Surg Res. September 2017;217:75–83.e71. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplemental Digital Content 1: Paramedic survey of telemedicine use for prehospital pediatric emergency care.
Supplemental Digital Content 2: Paramedic estimates of career frequency and time since critical procedure was last performed on a child < 12 years.
Supplemental Digital Content 3: Paramedic preferences for utilization strategies in three pediatric prehospital applications in varied practice settings (urban, suburban, and/or rural).
Supplemental Digital Content 4: Participant open comments regarding telemedicine utilization strategies organized by themes (perceived usefulness and ease of use) using the Technology Acceptance Model framework.