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Establishing outcome-driven vital signs ranges for children in the prehospital setting
Sriram Ramgopal1, Christopher M Horvat2, Michelle L Macy1
1Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
Insights
New data-driven vital sign thresholds can better identify children needing lifesaving interventions (LSIs) in emergency medical services (EMS). These refined pediatric vital sign ranges improve prehospital assessment and resource allocation for critically ill children.
Area of Science:
- Pediatric Emergency Medicine
- Prehospital Care
- Data Science in Healthcare
Background:
- Pediatric vital signs are crucial for prehospital assessment but current criteria often flag too many children as abnormal.
- This over-identification leads to a low rate of lifesaving interventions (LSIs) despite abnormal vital signs in the prehospital setting.
- There is a need for more precise, data-driven vital sign thresholds to guide clinical decisions.
Purpose of the Study:
- To establish data-driven thresholds for pediatric vital signs associated with prehospital lifesaving interventions (LSIs).
- To improve the accuracy of identifying children who require critical interventions in the prehospital setting.
- To optimize the utilization of emergency medical services (EMS) protocols and resource allocation.
Main Methods:
- Analysis of a national repository of emergency medical services (EMS) patient encounters for children (<18 years) in 2022.
- Evaluation of heart rate (HR), respiratory rate (RR), and systolic blood pressure (SBP) Z-scores and their association with LSIs.
- Application of cut point analysis to determine optimal ranges for vital signs, balancing sensitivity and specificity for LSI prediction.
Main Results:
- Over 987,000 pediatric encounters were analyzed, with LSIs occurring in 4.3% of cases.
- Heart rate, respiratory rate, and systolic blood pressure showed a U-shaped association with LSIs.
- Higher specificity criteria yielded specificities from 84.1% to 93.7%, with RR performing best; higher sensitivity criteria achieved sensitivities from 62.3% to 84.4%.
Conclusions:
- Age-adjusted vital sign ranges derived from data analysis are associated with the need for LSIs.
- These refined ranges can differentiate children at higher or lower risk for critical interventions.
- Implementing these ranges can enhance prehospital assessment, optimize protocol use, and guide transport decisions for pediatric patients.
Background:
Vital signs are frequently used in pediatric prehospital assessments and guide protocol utilization. Common pediatric vital sign classification criteria identify >80% of children in the prehospital setting as having abnormal vital signs, though few receive lifesaving interventions (LSIs). We sought to identify data-driven thresholds for abnormal vital signs by evaluating their association with prehospital LSIs.
Methods:
We evaluated prehospital care records for children (<18 years) transported to the hospital during 2022 from a large, national repository of emergency medical services (EMS) patient encounters. Predictors of interest were heart rate (HR), respiratory rate (RR), systolic blood pressure (SBP), and pulse oximetry. HR, RR, and SBP were converted to Z-scores using age-based distributional models. Our outcome was potential LSIs, defined as performance of selected respiratory procedures, resuscitative interventions, or medication administrations. Using cut point analysis, we identified higher specificity (maximal specificity with a minimum of 25% sensitivity) and higher sensitivity (maximal sensitivity with a minimum of 25% specificity) ranges for each vital sign and evaluated measures of diagnostic accuracy.
Results:
We included 987,515 children (median age 10 years, IQR 2-15 years). An LSI occurred in 4.3% (2.1% with respiratory procedures, 1.2% with resuscitative interventions, and 2.0% with medication administration). HR, RR, and SBP demonstrated a U-shaped association with LSIs. Specificities ranged from 84.1% to 93.7% for higher specificity criteria, with RR demonstrating the best performance (sensitivity 84.6%, specificity 27.0%). Sensitivities ranged from 62.3% to 84.4% for higher sensitivity criteria.
Conclusions:
Cut points for pediatric vital signs were associated with LSIs. Specific age-adjusted ranges can identify children at higher and lower risk for receipt of LSI. These ranges may be combined with other objective measures to improve the assessment of children in the prehospital setting, assist in optimizing protocol utilization, improve transport decision making, and guide destination selection.
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