Prehospital and Emergency Care Perspectives to Define Pediatric Critical Illness and Injury

TL;DR

This study explores how prehospital and hospital clinicians define pediatric critical illness to improve triage tools and decision-making in emergencies.

Contribution

The paper identifies key gaps in current pediatric triage systems and proposes a multidisciplinary approach for developing consensus-based definitions.

Findings

Clinicians highlighted limitations of existing triage tools in prehospital and mass casualty settings.

Paramedics and physicians differ in how they assess critical illness, with paramedics focusing on clinical actions and physicians on diagnostic findings.

There is a need for better alignment between prehospital and hospital-based indicators of pediatric critical illness.

Abstract

Timely identification of critically ill or injured children in prehospital and emergency settings remains a persistent challenge due to developmental variability, low case volumes in emergency medical services (EMS), and contextual limitations during field assessments. Existing frameworks to identify at-risk children often fail to capture the nuances of pediatric presentations, particularly in resource-limited or mass casualty settings. We aimed to explore prehospital and hospital-based clinician perspectives to inform a Delphi survey for the development of a consensus-driven definition of pediatric critical illness and injury.

We conducted a qualitative study using one semi-structured interview and two focus groups with participants with expertise in pediatric prehospital and hospital acute care. Participants were presented with a list of tools commonly used to assess the severity of illness in children in the emergency department and hospital-based settings. Interviews were conducted virtually, transcribed, coded using an iterative process, and thematically analyzed. We used key themes to inform the structure and priorities for a future Delphi survey.

Six of the 12 invited participants took part in the study. Five major themes emerged: 1) prehospital indicators of critical illness (e.g., seizure, intravenous placement, cardiopulmonary resuscitation; 2) in-hospital markers of severity (e.g., air medical transport, intubation, diagnostic findings); 3) perceptions of existing triage tools (e.g., limited awareness or utility among paramedics); 4) differences in assessment approaches across roles and settings; and 5) specific triage challenges during mass casualty or disaster scenarios. Paramedics emphasized clinical actions as indicators of acuity, while physicians cited diagnostic findings and broader contextual indicators. Across roles, there was more agreement on the limitations of current triage and illness severity tools than on their utility.

We gained insights into key gaps in current pediatric triage systems, including limited applicability of existing tools in prehospital settings, variability in comfort with pediatric interventions, and the lack of alignment between paramedic action-based indicators and physician reliance on diagnostic findings. Role-specific experiences influence how critical status is assessed and highlight the value of integrating multidisciplinary insight. These findings inform future work focused on the development of consensus-based outcome measures that align with decision-making across prehospital and hospital environments.

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