Abstract. Objective: To compare pediatric ambu- lance patients transported for chief complaints of su- icide, assault, alcohol, and drug intoxication (SAAD).
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Sapien et al. • PEDIATRIC EMS
Disturbing Trends: The Epidemiology of Pediatric Emergency Medical Services Use ROBERT E. SAPIEN, MD, LYNNE FULLERTON, MA, LENORA M. OLSON, MA, KIMBERLY J. BROXTERMAN, BS, DAVID P. SKLAR, MD
Abstract. Objective: To compare pediatric ambulance patients transported for chief complaints of suicide, assault, alcohol, and drug intoxication (SAAD) with pediatric patients transported for all other chief complaints. Methods: An out-of-hospital database for the primary transporting service in an urban area was analyzed for patients 0 – 20 years of age from 1992 to 1995. Chief complaints by age, gender, and billing status were analyzed. Results: There were 17,722 transports. The SAAD group comprised 14.9% of all transports (suicide attempt 1.6%, assault 5.9%, alcohol intoxication 3.2%, and drug abuse 4.2%). The proportion of transports due to SAAD increased with age: 0 – 11-year-olds (4.2%); 11 – 16-year-olds (17.5%); and 17 – 20-year-olds (20.3%) (p = 0.0001). Genders were equally represented in the overall group, while
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HE EPIDEMIOLOGY of the pediatric emergency medical services (EMS) population has been described.1 – 7 The existing studies usually describe the pediatric EMS population by age group and major category (medical vs trauma) for transport. Of concern in this population are adolescents who are at risk for experiencing injury morbidity and mortality. In fact, trauma is the leading cause for EMS/hospital use by and death of adolescents.8 – 10 This is partially explained by the risktaking behaviors in this population such as nonuse of seat belts, fighting, alcohol use,11 and lethal weapon possession.12 Our study was conducted to evaluate the specific reason for EMS transport (i.e., chief complaint) of pediatric patients, and to provide specific information about pediatric EMS patients. Such information might provide guidance for planning From the Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM (RES, LF, LMO, KJB, DPS). Received May 21, 1998; revision received October 27, 1998; accepted November 12, 1998. Presented in part at the SAEM annual meeting, Chicago, IL, May 1998. Supported by the Asthma Academic Award (NIH-NIHLB 03247-03). Address for correspondence and reprints: Robert E. Sapien, MD, University of New Mexico School of Medicine, Department of Emergency Medicine, ACC 4-West, Albuquerque, NM 871315246.
males comprised 52.6% of the SAAD transports (p = 0.032). In the SAAD group, the majority of transports for assaults (55.9%) and alcohol (58.8%) involved males, while females were the majority in transports for suicide (52.3%) and drug abuse (66%) (p = 0.0001). Reimbursement sources differed, with those in the SAAD group less likely to be reimbursed by private or public (Medicaid, government) insurance (p < 0.0001) compared with the overall group. Conclusions: A substantial proportion of pediatric emergency medical services transports are for high-risk conditions. This patient population differs from the overall group by age distribution and reimbursement source. Key words: EMS; pediatrics; injuries; suicide; alcohol abuse; epidemiology. ACADEMIC EMERGENCY MEDICINE 1999; 6:232 – 238
interventions, especially for potential high-risk EMS patients such as those transported for violence or substance abuse. Based on existing literature, we hypothesized that the four high-risk issues of suicide, assault, alcohol, and drug intoxication (SAAD) would be leading causes of ambulance transports among older pediatric patients. We further hypothesized that patients transported for these SAAD chief complaints would be disproportionately male and more likely to have public insurance as their reimbursement source than would patients transported for other reasons.
METHODS Study Design. This was a retrospective review of EMS transports of pediatric patients, comparing patients transported with SAAD chief complaints with patients transported for other reasons. Because of the retrospective nature of this study, it was considered exempt from review by the institutional review board. Study Population and Setting. We analyzed a database of EMS transports by the ambulance service that provides 99% of emergency transports for Albuquerque, New Mexico, and the surrounding area (an urban non-inner city with rural/agricultural pockets). Records of patients less than 21 years of age who were transported during the pe-
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riod from January 1, 1992, to December 31, 1995, were included. Study Protocol. A complete description of the methods has been reported elsewhere.13 Briefly, we used the ambulance service billing database to create a transport database in which each transport was represented once. The variables analyzed included the patient’s chief complaint, age, gender, and billing status. Chief complaint was defined as the patient complaint that generated the 9-1-1 call, i.e., the primary reason for transport. Each transport was associated with one chief complaint and, in some cases, one or more secondary complaints. Secondary complaints were not evaluated in this study. Paramedics identified the chief complaint at the time of transport based on patient signs, symptoms, and self-reported medical history. Paramedics selected the chief complaint and its corresponding numeric code from a list of the 820 chief complaints used by the ambulance service. A digested version of this list is available in each transport vehicle, and the complete list is available for reference at the ambulance service office where transport reports are completed and submitted to the billing office. Chief complaints can relate to patient signs (e.g., fever), symptoms (e.g., pain), mechanism (e.g., fall), preliminary diagnosis (e.g., insulin shock), or intent (e.g., suicidal behavior). Chief complaints were grouped to create the variable ‘‘medical/traumatic cause.’’ All chief complaints were reviewed by the authors to determine whether the transport could be assigned a ‘‘medical’’ (e.g., respiratory, seizures) or ‘‘traumatic’’ (e.g., motor vehicle crash, fall, assault) cause. Chief complaints whose cause could have been either medical or traumatic, such as transports for ‘‘abdominal pain,’’ were coded as undetermined with respect to cause. We combined transports for the chief complaints of suicide, assault, alcohol intoxication, and drug intoxication to define a ‘‘violence/substance abuse’’ subgroup (SAAD). The SAAD subgroup was compared with other transports (transports for which the patients’ chief complaints were other than SAAD) by inferential analyses. The term ‘‘overall group’’ refers to the sample of all pediatric
transports, including both SAAD and other transports. Data concerning patient age and sex were available for each transport. We grouped patient age into five categories:
