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PEDIATRICS Vol. 103 No. 6 June 1999, p. e81
,
From the * Intermountain Injury Control Research Center, and
Department of Pediatrics, University of Utah, Salt Lake City, Utah;
and § South Dakota Emergency Medical Services Bureau, Pierre, South
Dakota.
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ABSTRACT |
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Top
Abstract
Methods
Results
Discussion
Conclusion
References
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Objective : The purpose of this study was to ascertain whether school-based emergency medical services (EMS) incidents are different from nonschool-based EMS incidents for school-aged children.
Methods. We examined South Dakota EMS incident reports involving children ages 5 to 18 years old from 1994 through 1996 (n = 12 603). Patient characteristics, dispatch reason, primary medical complaint, injury type, contributing factor of injury, and performed interventions were analyzed.
Results. During the study period, there were 140 455 total EMS incident reports, of which 12 603 (9.0%) were for school-aged children. EMS dispatches to a school represented 755 (6.0%) of all EMS incidents for school-aged children. The number of school-based EMS incidents was highest at the beginning of the school year, whereas the number of nonschool-based EMS incidents was highest during the summer months. School-based EMS incidents peaked at noon, whereas nonschool-based EMS incidents peaked after school. For both locations, the average age of the patient was 14 years old. The dispatch reason for school-based EMS incidents differed from those for nonschool-based EMS incidents. The top three school-based EMS dispatch reasons were falls (36.2%), other trauma (27.0%), and medical illness (24.5%). Motor vehicle crashes (30.8%), medical illness (26.2%), and other trauma (11.4%) were the leading nonschool-based EMS dispatch reasons. Injuries accounted for a significantly greater proportion of school-based than nonschool-based EMS incidents (70.7% vs 62.6%). Excluding pain, the most frequent type of injury was a fracture or dislocation in school-based EMS incidents and open soft-tissue injury in nonschool-based EMS incidents. A total of 11 students sustained an injury resulting in paralysis. The body region that was most commonly injured was a lower extremity (23%) in school-based incidents, whereas the head was the most commonly injured body region in nonschool-based incidents (20%). Sports were the largest contributing factor in school-based incidents, whereas alcohol/drug use was the largest contributing factor in nonschool-based EMS incidents among school-aged children. A medical illness was the primary complaint for 206 (27.3%) of the school-based incidents and 3599 (30.4%) of the nonschool-based incidents. The chief medical complaints were breathing difficulty (18.4%), seizure (16%), and other illness (12.3%) for school-based EMS incidents. Other illness (20.0%), breathing difficulty (13.7%), and abdominal pain (12.0%) were the chief complaints for nonschool-based EMS incidents. Treatment was rendered by the EMS provider in 11 753 (93.3%) of the incidents. Frequency of EMS intervention was the same for school-based incidents and nonschool-based incidents. Transportation to a medical facility was more frequent in school-based incidents than nonschool-based incidents.
Conclusion. Compared with nonschool-based EMS incidents, school-based EMS incidents are more often attributable to injury, more often related to a sports activity, and more often result in transport to a medical facility. Understanding the characteristics of school emergencies resulting in an EMS dispatch may help emergency medical providers be better prepared for school-based incidents. School personnel may benefit from increased knowledge about the EMS system and EMS programs. In addition, EMS incident data may provide useful information about school-based injuries and may provide a means for injury surveillance. Key words: emergency medical services for children, prehospital care, school-aged children, school age injuries, school emergencies, school injuries.
Prehospital emergency medical services (EMS) agencies must
manage diverse urgent medical situations. Children account for 10% of
EMS incidents.1 The prehospital EMS needs for children are
different from adults.2-7 Furthermore, pediatric EMS
incidents differ among rural and urban areas,8,9 males and
females,8,9 age of patient,3-6 and day of
the week, month and time of call.6-8
Although much is known about school-based injuries and medical
illness,10-18 little is known about the type of
school-based trauma and medical illnesses that result in prehospital
EMS care. The purpose of this study was to ascertain whether
school-based EMS incidents are different from nonschool-based EMS
incidents for school-aged children. Increased knowledge of the types of
pediatric EMS incidents in specific settings may increase the EMS
provider's ability to manage the child's medical needs. Moreover,
increased knowledge about EMS and the interface between school health
and EMS may be beneficial to school personnel.
Data Collection
To determine the differences between school-based EMS incidents
and nonschool-based EMS incidents for school-aged children, we examined
South Dakota's statewide EMS incident reports for the most recent
years available, 1994 through 1996. South Dakota's EMS consists of 133 ambulance service agencies. Of these agencies, 64.5% are county or
city owned, 33.9% are privately or hospital owned, and 1.7% are
tribal owned. The majority of the agencies (71.4%) provide only basic
life support (BLS) services. A total of 39% of South Dakota's EMS
providers are volunteers.
For the period from 1994 to 1996, South Dakota EMS agencies reported
EMS incidents on an optical mark sense form. This form was reported as
being used for all EMS reports by 97% of the EMS agencies. Of the
remaining agencies the majority either did not use this form for
transfers or were agencies on a reservation. The South Dakota Bureau of
EMS scanned these forms into a computer database software system,
EMScan (EMS Data Systems Inc, Phoenix, AZ). As part of the scanning
process, there are user-defined filters that check for incomplete or
incompatible information. When an error is detected, the incident form
is sent back to the appropriate agency for correction of the
information. Between 10% and 20% of reports are sent back for
completion or correction of information. Most of these reports are
corrected and resubmitted. A small percentage of these reports are not
returned and therefore will not be part of the statewide EMS data. The
computerized incident report contains information on the type and
location of call, description of injury or medical incident,
contributing factors of injury, patient characteristics, and actions
taken by the EMS provider.
Analysis
The analysis was restricted to EMS dispatches for children from
5 to 18 years old. Transfers were excluded in the analysis. School-based EMS incidents were defined as dispatches to an educational facility. A description of patients and incidents for both school and
nonschool locations was formulated using the average age, gender,
history of illness, time of day, and month of year. Frequency tables
and percentages were generated for the following variables: dispatch
reason, primary medical complaint, injury type and area, contributing
factor of injury, and interventions performed. Z tests for
proportions were used to analyze whether the percentage of injury
incidents and the percentage of patients transported to a medical
facility were the same for school-based EMS incidents and
nonschool-based EMS incidents. An extension of Fisher's exact test was
used to evaluate whether the location of EMS dispatch was associated
with the dispatch reason, type of injury, and medical emergency.19
During the study period, there were 140 455 total EMS incident
reports, of which 12 603 (9.0%) were for school-aged children. Of
these, 11 848 dispatches were to a nonschool location. The primary
locations of EMS incidents for school-aged children were roadways (4100 incidents; 32.5%), homes (3717 incidents; 29.5%), and other public
areas (1205 incidents; 9.6%). EMS dispatches to a school represented
755 (6.0%) of all EMS incidents for school-aged children. The number
of school-based EMS incidents was highest at the beginning of the
school year. The summer months had the highest number of
nonschool-based EMS incidents. School-based EMS incidents peaked at
noon, whereas nonschool-based EMS incidents peaked after school (Fig
1). Dispatches to a school outside of
class hours accounted for 151 (20%) of all school-based EMS incidents.
METHODS
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Abstract
Methods
Results
Discussion
Conclusion
References
RESULTS
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Abstract
Methods
Results
Discussion
Conclusion
References
View larger version (23K):
[in a new window]
Fig. 1.
School-based EMS incidents (shaded bars) and nonschool-based EMS
incidents (unshaded bars) by time of day.
The average age of the patient was the same for both school-based and nonschool-based EMS incidents (14 years). However, the most common age was 16 years for school-based patients and 18 years for nonschool patients. Males represented 469 (60.9%) of school-based EMS incidents and 6016 (50.8%) of nonschool-based EMS incidents. The dispatch reasons for school-based EMS incidents differed from the dispatch reasons for nonschool-based EMS incidents for school-aged children (P < .001) (Table 1). The top three school-based EMS dispatch reasons were fall (36.2%), other trauma (27.0%), and medical illness (24.5%), whereas motor vehicle crashes (30.8%), medical illness (26.2%), and other trauma (11.4%) were the leading nonschool-based EMS dispatch reasons. A history of a chronic medical condition was recorded in 190 (25.2%) of school-based EMS incidents and 2649 (22.4%) of nonschool-based EMS incidents (P = .0734) (Table 2).
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Injury Incidents
Information regarding the type of medical illness or injury was available for 740 school-based incidents and 11 011 nonschool-based incidents. Injuries accounted for a significantly greater proportion of school-based EMS incidents than nonschool-based EMS incidents (70.7% vs 62.6%; P < .0001). The type of injury was associated with the location of dispatch (P < .0001) (Table 3). Excluding pain, the most frequent type of injury was a fracture or dislocation in school-based EMS incidents and open soft-tissue injury in nonschool-based EMS incidents. The most commonly injured areas were lower extremity (23%), head (18%), and upper extremity (17%) in school-based injuries; similarly the head (20%), lower extremity (18%), and upper extremity (17%) were most common in nonschool-based injuries. No contributing factor was noted in the majority of the incidents. When a contributing factor was noted, sports were the most frequently identified contributing factor for injuries in school-based incidents, whereas alcohol/drug use was the most frequently identified contributing factor for injuries in a nonschool setting (Table 4). A total of 11 students sustained an injury resulting in paralysis. Of these students, 6 had injuries attributable to sports, 2 had injuries attributable to the terrain causing a fall, and the remaining 3 had listed no contributing factor. Transportation to a medical facility of the injured child occurred more often in school-based incidents than nonschool-based incidents (91.2% vs 82.4%; P < .0001).
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Medical Incidents
A medical illness was the primary complaint for 3805 (30.2%) school-aged children. Of these, 206 (5.4%) were school-based and 3599 (94.6%) were nonschool-based. The type of medical complaint was associated with the location of the call (P < .001) (Table 5). The chief medical complaints were breathing difficulty (18.4%), seizure (16%), and other illness (12.3%) for school-based EMS incidents. Other illness (20.0%), breathing difficulty (13.7%), and abdominal pain (12.0%) were the chief complaints for nonschool-based EMS incidents. Transportation of the medically ill child to a medical facility occurred more often in school-based incidents than nonschool-based incidents (86.4% vs 78.9%; P = .0098).
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Prehospital Treatment
Treatment was rendered by the EMS provider in 11 753 (93.3%) incidents for school-aged children. There was no difference in the frequency of procedures between school-based incidents and nonschool-based incidents. Moreover, the association between procedures preformed and the type of medical or injury complaint was the same for school-based patients and nonschool-based patients. The only exception was school-based patients who had a fracture injury had a splinting procedure in 65% of the cases, compared with 48% of the cases for nonschool-based patients (P < .001).
A total of 10 248 (87.2%) of the patients received BLS interventions only. EMS crews had advanced life support (ALS) training in 38% of nonschool-based EMS incidents and 30% of school-based EMS incidents. ALS interventions were performed in only 12.0% of nonschool-based EMS incidents and 10.6% of the school-based EMS incidents (P = .2262). The most common BLS interventions were administration of oxygen, cervical immobilization, and extremity splinting. The most common ALS interventions were the establishment of a peripheral intravenous and cardiac monitoring (Table 6).
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DISCUSSION |
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Top
Abstract
Methods
Results
Discussion
Conclusion
References
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In this study, we have shown that compared with nonschool-based EMS incidents, school-based EMS incidents are more often attributable to injury, more often related to a sporting activity, and are more likely to result in transport to a medical facility. To the best of our knowledge, there has been no previous study comparing school-based EMS incidents to nonschool-based EMS incidents. These findings may better prepare EMS providers for dispatches to schools.
Injuries account for 70.7% of school-based EMS incidents and 62.6% of nonschool-based EMS incidents. Although EMS dispatches to schools are most often for injuries, this does not indicate an increased risk for an injury at a school. We estimate that the EMS injury dispatch rate to schools during school hours to be 14.1 per 100 school hours (based on minimum yearly school hours), compared with the overall rate of 30.2 EMS injury dispatches per hour for children from 5 to 18 years old. Furthermore, a previous school-based study reported that trauma accounted for 77.1% to 82.4% of all school-based emergencies.16 The percentage of school-based trauma we report is lower, possibly because we studied only school-based emergencies resulting in an EMS dispatch. This may suggest that between 6% and 12% of school-based injuries are minor and do not need significant emergency medical care.
Sports injuries occurred more frequently in school-based EMS incidents than in nonschool-based EMS incidents. In part, the higher percentage of EMS sport injury incidents at schools may be attributable to organized sporting events and physical education classes in schools. In our study, the percentage of EMS dispatches to a school for a sport injury (35.8%) falls within the range previously reported in school studies (21% to 53%).15,17
Transportation to a medical care facility occurred more often in school-based incidents than nonschool-based incidents. The frequency of transportation to a medical care facility that we report is higher than previously reported for pediatric patients.6-8 This difference may be attributable to our restriction to school-aged children. Although the number of incidents resulting in transportation to a medical care facility was different for school and nonschool locations, we were unable to ascertain the appropriateness of these transports. Previous studies have shown that children are transported inappropriately 45% to 48% of the time.20,21 The inappropriate transportation rate of school-based EMS incidents is not known. Because of this, the increased percentages of transports for school-based EMS incidents than nonschool-based EMS incidents may not indicate increased medical severity. Indeed, concern for legal responsibility may lead school employees to be more liberal in activating the EMS response. The presence of a school nurse may decrease the EMS transport rate. School nurses are used by <30% of the school districts in South Dakota and the majority of them are used only part time. We were unable to determine when a school nurse was present or whether a school nurse affects the frequency of EMS transports.
Although the use of statewide data is invaluable for comprehensive analysis, it is reliant on the reports of different EMS providers. These providers may have different coding techniques that may bias the findings. This is believed to be a minimal problem because the report forms that are used allow for little interpretation and the use of an optical form limits the information that can be coded. This limitation is evident by the high number of other trauma dispatches. Underreporting by EMS providers is a concern, but in South Dakota the state law mandates that 100% of the EMS dispatches must be reported. Except for one agency that does not report transfers and some agencies on Indian reservations, the agency compliance is high. Therefore, we believe that underreporting is minimal in our data. The bias introduced by underreporting on Indian reservations has little impact on our results, because no comparisons were done on ethnic groups. The 10% to 20% retrospective correction and completion of the forms may be a concern. However, the error corrections occur in many different fields and not necessarily the ones used in this analysis. Furthermore, if the error is not corrected, the report would not be included in the dataset. The use of South Dakota's statewide EMS incident data has allowed for a population-based comparison between school-based EMS incidents and nonschool-based EMS incidents.
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CONCLUSION |
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Top
Abstract
Methods
Results
Discussion
Conclusion
References
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In summary, school-based EMS incidents are different from nonschool-based EMS incidents involving school-aged children. This information may be useful to both EMS providers and school personnel. School personnel may benefit from increased knowledge about the EMS system and EMS programs. This may increase the information available to EMS programs, such as the Special Kids Information Program or the American College of Emergency Physicians data sheet for special needs children. The characteristics of school emergencies resulting in an EMS dispatch may help emergency medical providers be better prepared for school-based incidents. In addition, EMS incident data may provide useful information about school-based injuries and provide a means for injury surveillance.
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ACKNOWLEDGMENTS |
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This research was supported in part by Cooperative Agreement H35 MC 00024-04 from Maternal and Child Health Bureau, Health Resources and Services Administration, Public Health Service, US Department of Health and Human Services.
We thank Kurt H. Albertine, MD, for his assistance in the preparation of this manuscript.
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FOOTNOTES |
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Received for publication Oct 9, 1998; accepted Dec 22, 1998.
Reprint requests to (S.K.) 410 Chipeta Way, Suite 222, University of Utah, Salt Lake City, UT 84108. E-mail: stacey.knight{at}hsc.utah.edu
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ABBREVIATIONS |
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EMS, emergency medical services; BLS, basic life support; ALS, advanced life support.
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REFERENCES |
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Results
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Conclusion
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This article has been cited by other articles:
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  K. A. O'Hara First Aid for Seizures: The Importance of Education and Appropriate Response J Child Neurol, May 1, 2007; 22(5_suppl): 30S - 37S. [Abstract] [PDF]
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 M. F. Hazinski, D. Markenson, S. Neish, M. Gerardi, J. Hootman, G. Nichol, H. Taras, R. Hickey, R. O'Connor, J. Potts, et al. Response to Cardiac Arrest and Selected Life-Threatening Medical Emergencies: The Medical Emergency Response Plan for Schools: A Statement for Healthcare Providers, Policymakers, School Administrators, and Community Leaders Circulation, January 20, 2004; 109(2): 278 - 291. [Full Text] [PDF]
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 L Abernethy, D MacAuley, O McNally, and S McCann Immediate care of school sport injury Inj. Prev., September 1, 2003; 9(3): 270 - 273. [Abstract] [Full Text] [PDF]
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 L Abernethy and D MacAuley Impact of school sports injury Br. J. Sports Med., August 1, 2003; 37(4): 354 - 355. [Abstract] [Full Text] [PDF]
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