Caregiver Perspectives on Including Children in Alternative Emergency Medical Services Disposition Programs: A Qualitative Study.

OBJECTIVES: Almost half of pediatric EMS calls may be for low-acuity problems. Many EMS agencies have implemented alternative disposition programs for low-acuity patients, including transportation to clinics, substituting taxis for ambulances, and treatment in place without transport to an emergency department. Including children in such programs poses specific challenges, with one concern being potential caregiver opposition. Limited published evidence addresses caregiver perspectives on including children in alternative disposition programs. Our objective was to describe caregiver perspectives of alternative EMS disposition systems for low-acuity pediatric patients. METHODS: We conducted six virtual focus groups (one in Spanish) with caregivers. A PhD-trained facilitator moderated all groups using a semi-structured moderator guide. A hybrid inductive and deductive analytical strategy was used. Multiple investigators independently coded a deidentified sample transcript. One team member then completed axial coding of the remaining transcripts. Thematic saturation was achieved. Clusters of similar codes were grouped into themes by consensus. RESULTS: We recruited 38 participants. Participants had diverse race-ethnicity (39% non-Hispanic white, 29% non-Hispanic Black, and 26% Hispanic) and insurance status (42% Medicaid and 58% private health insurance). There was agreement that caregivers often utilize 9-1-1 for low-acuity complaints. Caregivers were generally supportive of alternative disposition programs, with some important caveats. Potential advantages of alternative dispositions included freeing up resources for more emergent cases, quicker access to care, and more cost-effective and patient-centered care. Caregivers had multiple concerns regarding the effects of alternative disposition programs, including timeliness in receiving care, capabilities of receiving sites (including pediatric expertise), and challenges to care coordination. Additional logistical concerns with alternative disposition programs for children included the safety of taxi services, the loss of parental autonomy, and the potential for inequitable implementation. CONCLUSIONS: Caregivers in our study generally supported alternative EMS dispositions for some children and identified multiple potential benefits of such programs for both children and the health care system. Caregivers were concerned about the safety and logistical details of how such programs would be implemented and wanted to retain final decision-making authority. Caregiver perspectives should be considered when designing and implementing alternative EMS disposition programs for children.

Pediatric Primary Care Provider Perspectives on Including Children in Alternative Emergency Medical Services Disposition Programs.

INTRODUCTION: Many emergency medical services (EMS) agencies have implemented alternative disposition programs for low-acuity complaints, including transportation to clinics. Our objectives were to describe pediatric primary care providers' views on alternative EMS disposition programs. METHOD: We conducted virtual focus groups with pediatric primary care providers. A hybrid inductive and deductive analytical strategy was used. Codes were grouped into themes by consensus. RESULTS: Participants identified the benefits of alternative dispositions, including continuity of care, higher quality care, and freeing up emergency resources. Participants' concerns included undertriage, difficulty managing patients not previously known to a clinic, and inequitable implementation. Commonly identified logistical barriers included inadequate equipment, scheduling capacity, and coordinating triage. DISCUSSION: Participants agreed there could be significant benefits from including clinics in EMS disposition programs. Participants identified several logistical constraints and raised concerns about patient safety and equitable implementation. These perspectives should be considered when designing pediatric alternative EMS disposition programs.

"I Felt Like I Had Something I Could Do About It": Pediatric Clinician Experiences With a Food Insecurity-Focused Produce Prescription Program.

Efforts to address food insecurity (FI) in pediatric clinics have increased over the last decade, particularly after a groundbreaking 2015 American Academy of Pediatrics policy statement supporting universal routine screening and intervening. Produce prescription programs are a novel strategy addressing FI. Limited data exist on effectiveness and feasibility in pediatric clinical settings. This study explored clinician experiences after enrolling patients who completed a produce prescription program in an urban primary-care clinic in Washington, DC. One year after program completion, the experiences of 11 clinicians were explored through qualitative interviews and coded using thematic content analysis. Identified themes explored changes in clinician knowledge, attitudes, and behaviors. Clinicians expressed that the program offered a tangible resource to address FI, building trust and strengthening their sense of self-efficacy in addressing families' concerns. Incorporation of a produce prescription intervention to address FI was feasible and well accepted by pediatric primary-care clinicians.

Emergency Medical Services Clinicians' Perspectives on Pediatric Non-Transport.

OBJECTIVES: Emergency medical services clinicians do not transport one-third of all children assessed, even without official pediatric non-transport protocols. Little is known about how EMS clinicians and caregivers decide not to transport a child. Our objectives were to describe how EMS clinicians currently decide whether or not to transport a child and identify barriers to and enablers of successfully implementing an EMS clinician-initiated pediatric non-transport protocol. METHODS: We conducted six virtual focus groups with EMS clinicians from the mid-Atlantic. A PhD trained facilitator moderated all groups using a semi-structured moderator guide. Multiple investigators independently coded a deidentified sample transcript. One team member then completed axial coding of the remaining transcripts. Thematic saturation was achieved. Clusters of similar codes were grouped into themes by consensus. RESULTS: We recruited 50 participants, of whom 70% were paramedics and 28% emergency medical technicians. There was agreement that caregivers often use 9-1-1 for low acuity complaints. Participants stated that non-transport usually occurs after shared decision-making between EMS clinicians and caregivers; EMS clinicians advise whether transport is necessary, but caregivers are responsible for making the final decision and signing refusal documentation. Subthemes for how non-transport decisions were made included the presence of agency protocols, caregiver preferences, absence of a guardian on the scene, EMS clinician variability, and distance to the nearest ED. Participants identified the following features that would enable successful implementation of an EMS clinician-initiated non-transport process: a user-friendly interface, clear protocol endpoints, the inclusion of vital sign parameters, resources to leave with caregivers, and optional direct medical oversight. CONCLUSIONS: EMS clinicians in our study agreed that non-transport is currently a caregiver decision, but noted a collaborative process of shared decision-making where EMS clinicians advise caregivers whether transport is indicated. Further research is needed to understand the safety of this practice. This study suggests there may be a need for EMS-initiated alternative disposition/non-transport protocols.

Infant Safe Sleep in the District of Columbia: Better for Both.

Sudden unexpected infant death (SUID) rates within the District of Columbia (DC) vary, with rates 3 times higher in certain geographical areas than the cumulative rate in DC and 7 times higher than the national rate. The majority SUIDs are due to unsafe sleep practices. Although safe sleep education and resources are available in these areas, the high sleep-related infant mortality suggests unmet barriers to infant safe sleep. We sought to investigate potential contributions to local infant mortality through focus groups regarding infant sleep practices among DC caregivers. In this qualitative study, caregivers were probed regarding barriers and facilitators of infant sleep practices. Data were collected until thematic saturation was reached, then coded. Themes were developed and revised in an iterative manner. Fifteen caregivers participated in three focus groups. Themes included sources of infant sleep knowledge, challenges for infant sleep, and motivators for infant sleep choice. All caregivers reported knowledge of safe sleep practices. Infant sleep practices varied, and included unsafe practices such as bed sharing, co-sleeping, and use of swings or bouncers for infant sleep. Challenges of adhering to safe sleep practices included infant needs, competing family demands, the overwhelming nature of newborn sleep, threats, and conflicting information. Motivators for infant sleep practices included better sleep, convenience, safety, tradition, and needs of the infant and caregiver. Although caregivers report knowledge of safe sleep recommendations, actual infant sleep practices vary and include unsafe sleep practices. More focused interventions are needed to address this gap between safe sleep knowledge and practice.