Related Experiment Video
Updated: Sep 10, 2025
Prehospital Thrombolysis: A Manual from Berlin
Published on: November 26, 2013
Impact of a Pediatric Prehospital Destination Decision Support Tool (PDTree) on Emergency Medical Services Transport
Kyle A Fratta1, Kevin Psoter2, Taylor Craig2
1Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Insights
The Pediatric Decision Tree (PDTree) tool increased emergency medical services (EMS) bypass rates for pediatric patients, directing more children to intermediate care facilities. This change improved access to appropriate pediatric care following EMS transport.
Area of Science:
- Emergency Medicine
- Pediatric Care
- Health Services Research
Background:
- Emergency medical services (EMS) agency transport patterns for pediatric patients are critical for optimal outcomes.
- Bypass of the nearest emergency department (ED) is a common practice, but its appropriateness for pediatric transports requires evaluation.
- Evidence-based decision support tools can potentially standardize and improve pediatric transport decisions.
Purpose of the Study:
- To compare EMS agency transport patterns for pediatric patients before and after implementing a decision support tool.
- To assess changes in bypass rates of the nearest ED following the introduction of the Pediatric Decision Tree (PDTree).
- To evaluate the impact of the PDTree on the destination of pediatric transports based on hospital capabilities.
Main Methods:
- An observational cohort study design was employed, comparing pediatric transports over one year before and one year after PDTree implementation.
- Three distinct fire-based EMS systems in Maryland, USA, participated, including patients aged 0-17 years (excluding trauma cases).
- Bypass rates and transport destinations were analyzed using geocoded scene and hospital data, comparing pre- and post-implementation periods.
Main Results:
- The overall EMS bypass rate for pediatric patients increased from 42.6% pre-PDTree to 48.8% post-PDTree (p < 0.001).
- While bypass to highest-level pediatric facilities decreased (63.1% to 50.1%), bypass to intermediate pediatric facilities significantly increased (26.2% to 37.7%).
- The PDTree tool led to a higher rate of direct transport to more pediatric-capable facilities.
Conclusions:
- Implementation of the PDTree decision support tool increased pediatric bypass rates, facilitating direct transport to more specialized facilities.
- Despite increased bypass, transport to top-tier children's centers decreased, with a notable rise in transfers to intermediate pediatric facilities.
- EMS governing bodies should consider the benefits of direct pediatric transport protocols against operational costs to optimize care for pediatric populations.
Objectives:
The objective of this study was to compare emergency medical services (EMS) agency transport patterns for pediatric transports, including bypass of the nearest emergency department, before and after implementation of an evidence-based decision support tool to guide EMS clinicians' pediatric transport destinations.
Methods:
This is an observational cohort study comparing pediatric transports one year before and one year after implementation of the Pediatric Decision Tree (PDTree) tool in three geographically and demographically distinct fire-based EMS systems in Maryland, USA. Patients aged 0 to 17 years undergoing EMS transport from one of the three participating counties were included. Patients meeting trauma center transport criteria were excluded. Hospital pediatric capabilities were defined a priori, and geocoded scene and transport destination locations were used to determine bypass rates. Bypass patterns and distances were compared between the pre-implementation and post-implementation periods.
Results:
Included pediatric patients transported from the three counties numbered 9,782 in 2019 (post-implementation) and 11,945 in 2016 (pre-implementation). After implementation of the PDTree, 48.8% of all pediatric patients underwent EMS bypass of the nearest facility compared to 42.6% before implementation (p < 0.001). While the overall rate of bypass increased, the bypass proportion transporting to the highest-level pediatric facility decreased from 63.1% to 50.1% and the proportion of bypass to intermediate pediatric facilities increased from 26.2% to 37.7% (p < 0.001).
Conclusions:
Implementation of the PDTree pediatric direct transport decision support tool increased the bypass rate and, subsequently, direct transport to more pediatric capable facilities. Despite this increase in the bypass of the nearest facility, the proportion transporting to large tertiary specialty children's centers decreased, while there was a significant increase in transport to intermediate pediatric facilities. Regional and national EMS governing bodies should balance benefits of pediatric direct transport protocols with operational costs to better meet the needs of pediatric populations.
