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.

Prehospital high-performance cardiopulmonary resuscitation (CPR) has demonstrated remarkable improvements in the survival of adult patients after out-of-hospital cardiac arrest (OHCA). With a goal to improve pediatric survival rates, Maryland Emergency Medical Services (EMS) for Children created a pediatric-specific high-performance CPR protocol to align with the existing state protocol for adult CPR. While prehospital CPR for adults has moved toward continuous compressions, prehospital CPR for children without an advanced airway continues to adhere to American Heart Association (AHA)/International Liaison Committee on Resuscitation (ILCOR) guidance for two ventilations for every 15 compressions. The Maryland Hiccup (MH) is a novel approach to pediatric CPR. The method combines the goal of continuous compressions with AHA/ILCOR guidance for a 15:2 compression-to-ventilation ratio. In contrast to the two- to four-second pause after compression 15 of the AHA/ILCOR style, the "hiccup" of the MH method describes two brief pauses for ventilation during the upstrokes of compressions 14 and 15. We compare basic CPR quality metrics for two-rescuer high-performance CPR using the standard AHA/ILCOR 15:2 style compared to the MH style. We enrolled 38 Maryland EMS clinicians in two-person teams to perform simulated CPR on a pediatric manikin. We recorded compression and ventilation data for 76 two-minute cycles of high-performance CPR. Compression fraction was significantly improved using the MH when compared to the standard AHA style for high-performance CPR (median 98% vs 80%, p<0.001). When compressions per minute (CPM) were compared by 30-second epochs, 80% of epochs were out of range (120 CPM) using the AHA/ILCOR style, while only 32% of epochs were out of range for MH style. No significant differences were found between the two CPR styles in ventilation volume or compression depth. The MH is a novel method for pediatric basic life support two-provider CPR which improves CPR quality metrics among EMS clinicians regardless of their prior experience. The use of this method in simulation allows near-continuous compressions without the placement of an advanced airway. Future research is needed to explore whether the CPR quality improvements translate to improved patient outcomes in real-world use.