Abstract
Introduction:
Respiratory distress accounts for approximately 14% of all pediatric emergency medical services (EMS) encounters, with asthma being the most common diagnosis. In the emergency department (ED), early administration of systemic corticosteroids decreases hospital admission and speeds resolution of symptoms. For children treated by EMS, there is an opportunity for earlier corticosteroid administration. Most EMS agencies carry intravenous (IV) corticosteroids; yet given the challenges and low rates of EMS pediatric IV placement, oral corticosteroids (OCS) are a logical alternative. However, previous single-agency studies showed low adoption of OCS. Therefore, qualitative study of OCS implementation by EMS is warranted.
Methods:
This study’s objective was to explore uptake and implementation of OCS for pediatric asthma treatment through semi-structured interviews and focus groups with EMS clinicians. We thematically coded and analyzed transcripts using the domains and constructs of the Consolidated Framework for Implementation Research (CFIR) to identify barriers and facilitators that most strongly influenced OCS implementation and adoption by EMS clinicians.
Results:
We conducted five focus groups with a total of ten EMS clinicians from four EMS systems: one urban region with multiple agencies that hosted two focus groups, one suburban agency, one rural agency, and a mixed rural/suburban agency. Of the 36 CFIR constructs, 31 were addressed in the interviews. Most constructs coded were in the CFIR domains of the inner setting and characteristics of individuals, indicating that EMS agency factors as well as EMS clinician characteristics were impactful for implementation. Barriers to OCS adoption included unfamiliarity and inexperience with pediatric patients and pediatric dosing, and lack of knowledge of the benefits of corticosteroids. Facilitators included friendly competition with colleagues, having a pediatric medical director, and feedback from receiving EDs on patient outcomes.
Conclusion:
This qualitative focus group study of OCS implementation by EMS clinicians for the treatment of pediatric asthma found many barriers and facilitators that mapped to the structure of EMS agencies and characteristics of individual EMS clinicians. To fully implement this evidence-based intervention for pediatric asthma, more education on the intervention is required, and EMS clinicians will benefit from further pediatric training.
Keywords: Asthma, Consolidated Framework for Implementation Research, Evidence-based guidelines, Implementation Science, Pediatrics
INTRODUCTION
Asthma is the most common chronic respiratory disease in the United States (US) and is the most common chronic disease of childhood.1 Currently, it affects more than 7 million children in the US.2 Asthma exacerbations are a major source of morbidity and mortality for children with asthma.2 Systemic corticosteroids are a pillar of evidence-based treatment for asthma exacerbations,3 with several studies showing early administration of corticosteroids being associated with decreased hospital admission.4 Numerous previous studies have addressed the importance of early implementation of steroids in the emergency department. In the prehospital environment, most US EMS agencies with advanced life support units carry intravenous (IV) corticosteroidsT;5 yet given the challenges and low rates of EMS pediatric IV placement,6 oral corticosteroids (OCS) are a logical alternative. Therefore, administration of OCS, when appropriate, represents an opportunity to enhance evidence-based prehospital care of pediatric asthma exacerbations.
A previous study in Houston showed a low adoption rate for oral dexamethasone administration (18%) by a single large urban EMS agency for pediatric asthma.7 A statewide Florida study revealed that only 9% of children presenting to EMS with asthma exacerbations received steroids, and factors that influenced steroid administration were IV access and severe clinical presentation.8 As further evidence of this low rate of OCS adoption, a quality improvement initiative at Cincinnati Children’s Hospital Medical Center attempted to increase the administration of prehospital steroids in pediatric asthma patients.9 In this study, they implemented an EMS corticosteroid protocol, targeted key drivers, and introduced interventions to increase pediatric OCS administration. Although prehospital OCS administration was increased through this initiative, the study found multiple barriers and insufficient uptake of the protocol by EMS. Since systemic corticosteroids are known to improve the course of asthma exacerbations, further exploration of prehospital implementation of OCS is warranted. Therefore, the aim of this study was to qualitatively explore the uptake and implementation of OCS for pediatric asthma treatment through focus groups with EMS clinicians.
METHODS
Subject Selection & Recruitment
We conducted semi-structured interviews and focus groups with front-line EMS clinicians to identify barriers and facilitators to implementation of OCS in children with acute asthma exacerbations. EMS clinicians from the seven EMS agencies participating in the observational study “Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial” (EASI-AS-ODT, NCT03962894) were eligible to participate. Participation was solicited by email, and EMS clinicians were compensated for their time. This study was approved by both the University of Florida Institutional Review Board (#202000859) and the Cincinnati Children’s Hospital Medical Center Institutional Review Board (#2020-0906) with a waiver of written informed consent. To account for personnel schedules, interviews were conducted via virtual video conference sessions in a confidential setting. For the interviews and focus groups, each participating EMS clinician was required to be in an office or space alone, with no coworkers present. This was an attempt to eliminate bias in our interviews.
Interview guides were created based on existing clinical literature, Consolidated Framework for Implementation Research (CFIR) guidelines,10 and study team EMS subject matter expertise. Interviews were recorded and transcribed using Otter.ai. Transcripts were proofread for accuracy by the senior author (JF). Thematic coding was framed by the domains of the CFIR.10 Those domains included the outer setting, inner setting, characteristics of the individual, characteristics of the intervention, and process. For the purposes of this study and its prehospital context, we defined the inner setting as the EMS agency itself and the outer setting as the health care system and community in which the EMS agency operates. Participants were made aware of those definitions at the beginning of the focus groups / in-depth interviews.
Data were pooled from the in-depth interviews and focus groups, which in other research has enhanced data richness, and through identification of individual and group interpretations of structure and phenomena has increased trustworthiness of findings.11-14 Researchers used a blended inductive and deductive coding approach. Deductive coding was conducted using predefined codes of the CFIR. However, researchers allowed for inductive codes to present themselves throughout the coding process. Transcripts were coded by all authors separately. Researchers met iteratively throughout the coding process to reconcile codes and ensure inter-coder reliability. The coded text was then rated by the first author (KM) and senior author (JF) based on the method prescribed by Damschroder and Lowery.15 The CFIR valence (positive or negative influence) and the strength of each construct were rated on a scale of −2, −1, 0, 1, or 2. Researchers met again to reach consensus on ratings for each construct. Given that the intervention of interest (prehospital administration of OCS to children) is not widely adopted by EMS agencies,8 our sampling of agencies participating in the EASI-AS-ODT trial (all of whom do administer OCS to children) was not guaranteed to achieve thematic saturation.
RESULTS
Our results include focus group discussions from four areas: i) the greater Cincinnati, Ohio metropolitan area (mixed urban/suburban, pediatric patient volume ~10% of total 9-1-1 scene encounters), ii) Sarasota County, Florida (suburban, pediatric patient volume < 5%), iii) Walton County, Florida (rural, pediatric patient volume < 5%), and iv) Nassau County, Florida (mixed suburban/rural, pediatric patient volume 5-10%). All four agencies as part of the EASI AS ODT study had a dedicated protocol for the management of children with respiratory distress / asthma, and all agencies had a dedicated pediatric medication dosing method (either dosing card or length-based tape system). Nassau County and two agencies in the greater Cincinnati area had dedicated pediatric medical directors, and the EMS protocol committee for the greater Cincinnati area agencies also included three pediatric emergency physicians, a pediatric EMS coordinator, and a pediatric emergency medicine pharmacist. All participants were paramedics (one from Nassau County and one from Sarasota County (both in-depth interviews), three from Walton County (one focus group), and five from Cincinnati (two focus groups of two and three participants each).
Overall, participants were excited about and receptive to OCS administration; however, several barriers and facilitators were identified. Those facilitators and barriers were mapped to CFIR domains and clinical themes. Of all five CFIR domains, the domain with the greatest proportion of codes was the inner setting (38.4%), followed by characteristics of individuals (23.1%) and the outer setting (19.5%). Interestingly, the process of implementation was assigned to only 3% of codes (Table 1).
Table 1:
Proportion of thematic codes by CFIR domain
| Inner Setting: 38.4% (N=63) |
| Characteristics of Individuals: 23.1% (N=38) |
| Outer Setting: 19.5% (N=32) |
| Characteristics of the Intervention: 15.8% (N=26) |
| Process: 3% (N=5) |
| Inner setting in this context signifies the EMS agency; outer setting signifies the health care system and community in which the EMS agency operates. |
Major themes identified were pediatric calls, pediatric encounters and strategies for these encounters, paramedic personal and work experience, COVID-19 pandemic changes, and EMS education and training (Table 2). A common barrier identified was lack of pediatric experience and low volume and acuity of pediatric patients. Many participants admitted that pediatric calls were less than 10% of overall calls. One even stated, “I don’t remember the last time we actually had a pediatric asthma patient.” Participants also agreed that most of their pediatric calls came from rural and low socioeconomic areas. Another common theme was discomfort with pediatric dosing. Participants stated that many colleagues are unsure of correct dosages for OCS, so this sometimes stops them from administering them. Many noted that if they did give OCS, sometimes the children would spit them out because of their “horrible taste.” Also, participants noted that there is a lack of knowledge of the mechanism of action and downstream effects of OCS. This is likely due the fact that they are not able to witness the effects of steroids first-hand since they usually take about 1-2 hours to take effect.
Table 2:
CFIR Domains, Constructs, Valence, Theme Summary, and Representative Quotes from Most Common Thematic Codes
| Domain | Construct | Overall Valence |
Summary | Representative Quote | ||||
|---|---|---|---|---|---|---|---|---|
|
Characteristics of the
Intervention | ||||||||
| Cost | + | OCS relatively inexpensive | “It's relatively inexpensive to purchase…if it does help prevent admission, you know, there's cost savings there for the patient.” | |||||
| Evidence Strength & Quality | + | Participants aware of research on the benefits of OCS in asthma exacerbations | “I knew there were clinical trials that showed the benefit.” | |||||
| Relative Advantage | + | Providing more potential interventions for EMS viewed positively. OCS faster to administer than IV steroids | “Our biggest thing was most of these patients don't need the invasive IV needle poke[…] it just was a much safer way of administering medication for patients that don't need that higher level of care with an IV stick everything.” | |||||
| Adaptability | + | OCS easily integrated into EMS clinician workflow | “But [patient] wasn't so distressed that we went with the albuterol due to COVID.” | |||||
| Complexity | + | OCS administration viewed as relatively less complex task | “I think we treat so many asthmatic people. And I think that as far as our protocols go, the treatment regimen really isn't all that different for children than it is adults, some of the dosage is a little different.” | |||||
| Outer Setting | ||||||||
| Cosmopolitanism | + | Resources, training, and feedback available from local pediatric experts cited as extremely beneficial | “I think the hospitals involving themselves in that training and bringing pediatric folks in has been extraordinarily helpful.” | |||||
| External Policies & Incentives | + | EMS clinicians stated desire to follow best practices and stay up-to-date with evidence-based guidelines | “It's evidence based. And that is what those studies shows that we should continue to give it in these routes in these forms, you know, hey, one is better than the other, and fire departments can get it. Fantastic, then we should continue doing whatever that that thing is, at some point, they may disapprove it and say, Hey, we should really stop doing that because of this new study, then we should immediately stop it.” | |||||
| Patient Needs & Resources | + | Special ways to administer medications to children noted, including beneficial involvement of parents |
“And it's very rare for them to be okay with you, you know, talking to them and dealing with them. So it really I think it requires a ton of buy in from the parents or not buy in, but help from the parents that are there.”
“Again, the parents have a big part of that. IV starting things like that, maybe sometimes the parents can kind of hold their attention.” |
|||||
| Peer Pressure | + | EMS clinicians competitive with peers to best implement new intervention | “This next department, this other agency, their admission rate is something like 4% Oh, and the city's is 50%. Okay, yeah, no, that's not because your kids are sicker? That's because you're not giving steroids. Oh, yeah. Now we're gonna get competitive. I mean, nothing upsets you then going into a squad room and seeing a printout of your department?” | |||||
| Inner Setting | ||||||||
| Structural Characteristics | − | Low volume and acuity of most pediatric encounters, leading to lack of experience with pediatric patients | “But pediatric runs are not a huge, not a huge thing in my department. And then very serious pediatric runs are even a smaller proportion of that. So I think there's a there's really a sense of discomfort anytime we go out on a on a kid run, especially a bad one. I think the oral route of medication administration is easier. I think it takes a lot of the anxiety away from the provider. And I I absolutely I think it's sustainable and I think it's expandable.” | |||||
| Access to Knowledge & Information | +/− | General discomfort with pediatric medication dosing. Remote or online education on OCS cited as less effective. | “I hear more from people within my agency that are either hesitant to give it or this is really tragic, don't know that we're supposed to give it or are very anxious about the dosing, which we, in my particular unit, it's very easy to find, if I had to look it up. I know exactly where to find it“ | |||||
| Available Resources | − | Issues with lacking all sizes of pediatric equipment on ambulance due to space constraints | “it would be nice if we had the ability to use the capnography on smaller patients, we just carry the adult nasal cannula” | |||||
| Goals & Feedback | + | EMS clinicians do not see full effect of OCS due to brief encounter with patients, therefore feedback on patient ED outcome cited as extremely helpful | “So I and as far as perception, even when we've got 25 minute transport, probably to downtown or whatever Do you see or the [Local Children's Hospital] and it's so quick that we can't really see those effects yet. But the feedback on the steroid use, because of how important it is we have received more of that than what we would normally do. But I think that's because of the relationship with [Local Children's Hospital].” | |||||
| Culture | − | Resistance to change, especially amongst older EMS clinicians |
“The agency is split up amongst providers who have been providers for quite a while and doing things a certain way, they don’t like change”
“you noticed that there's more resistance from the older, the older guys then there are with the younger? Because I've got a lot, quite a few young medics who are get on board with this stuff much more quickly than the older guys” |
|||||
| Leadership Engagement | + | Benefits of having a dedicated pediatric medical director | “[Pediatric Medical Director] is very good about giving information back. If it's a pediatric patient, because that's her realm. If it's not a pediatric patient, there is zero feedback from [Local Academic Hospital].” | |||||
| Characteristics of Individuals | ||||||||
| Individual Identification with Organization | + | Positive outlook and relationship with EMS agency related to dedication to protocol implementation | “I think our medical director too, I mean, he's, yeah, he's really good at championing these newer changes and implementing them. So yeah, I think our whole our whole team of EMS captains and medical direction is all in on it.” | |||||
| Knowledge & Beliefs about the Intervention | +/− | Despite pediatric education, pediatric volume is low and thus difficult to train for rare circumstances | “When you go to pediatric continuing education, they want to make sure we understand how to do needle [cricothyrodotomy], and intubating kids. And all of these that if you ask physicians at [Local Children's Hospital], are extraordinarily rare circumstances. And I understand that we train for very rare circumstances in general.” | |||||
| Self-Efficacy | +/− | Confidence for treating pediatric patients varies widely in EMS clinicians | “I'm not afraid to pull out the protocol book and set it down in front of me and make sure that the dosing is correct.” “You see people waiting a lot longer than they would if it was an adult patient, they just jump in and treat. In pediatrics. I think there is some hesitation.” |
|||||
| Other Personal Attributes | + | Having experience with children in personal life assists EMS clinicians in managing pediatric patients | “I think part of the problem that providers have is that there doesn't seem to be a lot of a lot of training for how to deal with kids, I have three kids, I tend to know how to how to deal with little kids.” | |||||
| Process | ||||||||
| Executing | + | OCS easily incorporated into workflow | “I would call that success. And actually the COVID-19 pandemic…we were moving away and trying to avoid nebulizer treatments and CPAP and things like that. Having the medications that we could give without using forced oxygen and nebulizers was great. It definitely, you're definitely able to do something to help when a lot of providers were afraid to do anything.” | |||||
| Reflecting & Evaluating | + | EMS clinicians had a positive view of how OCS affected prehospital care and patient outcomes |
“I definitely liked the oral aspect of it. Like I said before, the having to put an IV in into a child is it's more difficult, it can be intimidating for the provider. And I think the more you can avoid that the better. And the steroids work. You don't have to really hurt them to administer the steroids keeps everybody calm - I think it's a great change.”
“I've read a few reports. And they've they've all been really good feedback on the oral prednisone. Just like [redacted] said, not being able to do IV access or, or IM solumedrol. It's challenging on those almost children. So I think it helps, especially avoid that” |
|||||
CFIR = Consolidated Framework for Implementation Research, ED = emergency department; EMS = emergency medical services; IV = intravenous; OCS = oral systemic corticosteroids
Another common barrier was EMS culture and resistance to change. Participants stated that some of their older colleagues were less inclined to change to a new administration technique or protocol. Protocol education was a barrier to many participants as well. Notification of protocol changes to EMS clinicians were usually by email, or a short exam that was easily forgotten. Lastly, a lack of adequate pediatric equipment on the truck was another barrier cited by participants.
Although many barriers were identified, there were also many facilitators to the administration of oral steroids. For example, a few participants stated they had laminated cards posted in their trucks to remember common pediatric dosages. Others noted that the Pediatric Respiratory Assessment Measure (PRAM) cards were extremely helpful (distributed in Cincinnati).16 With regards to the barriers to medication administration, participants gave their input on strategies they used to effectively deliver the medication. Many noted that giving the medication slowly through a syringe was helpful. Others mentioned that allowing parents to give the medication was helpful, since the parents are used to doing this at home and the child is more comfortable with the parent. Many participants stated that parents can either be a facilitator or barrier; however, most of the time they facilitate the process. Other strategies included use of distraction devices such as tablets, phones, or stuffed animals.
Regarding EMS education and training, there were many comments on a lack of knowledge of new pediatric protocols. Balancing this observation was that many participants noted having a pediatric medical director was extremely beneficial. They felt that having a pediatric medical director not only helped them gain more pediatric knowledge, but also helped with feedback about their interactions with pediatric patients. Feedback from receiving hospitals was commonly cited as a facilitator. Participants found it helpful when they had feedback from the local hospitals on their management of pediatric asthma patients, including the patient’s outcome in the hospital.
DISCUSSION
To our knowledge, this is one of the first qualitative studies exploring the uptake and implementation of OCS for the prehospital management of pediatric acute asthma exacerbations. The most common CFIR domains identified during focus groups involved characteristics of the individuals, the inner setting, and the outer setting. Those domains and the specific barriers and facilitators to OCS administration identified in this study suggest possible targets for educational interventions to increase the uptake and use of prehospital OCS for pediatric asthma patients. This study also highlights the importance of communication and feedback with EMS clinicians. Overall, study participants were very receptive and enthusiastic to transition from administration of IV corticosteroids to OCS in the prehospital setting, yet some barriers prevented wholesale implementation into their practice.
In the outer setting, facilitators identified in this study include effective communication with and feedback from local hospitals. Participants identified that feedback on their prehospital care and on patient outcomes increases their comfort in caring for pediatric patients. This is particularly important for OCS administration, as the effects of the medication are not immediate and may not be seen by EMS clinicians during transport. In the inner setting, having a pediatric medical director was also frequently identified as a facilitator. It is not feasible for every department to have a pediatric medical director, but fostering relationships with local pediatric hospitals and engaging pediatric experts in protocol design, updates, and roll-out was cited as important in increasing uptake of pediatric protocol changes.
In addition to the facilitators identified in the outer and inner settings discussed above, participants also identified positive elements related to characteristics of the intervention. Administering OCS is easily incorporated into EMS clinicians’ workflow and is preferred over starting an IV in a child since it causes less pain and agitation. Despite the unpleasant tase of the medication, distraction techniques and parental engagement were identified as helpful strategies in pediatric patients. Increasing education on these distraction techniques may help EMS personnel who are less comfortable with pediatric patients effectively administer OCS. Some participants expressed discomfort with pediatric dosing. Interventions including standardized age-based dosing (such as that recently implemented in Ohio),17 pediatric dosing apps, easily accessible protocols, or other reference tools should be considered to facilitate pediatric dosing.
A major barrier to consistent use of OCS for pediatric acute asthma exacerbations was discomfort with pediatric patients due to low numbers of pediatric calls, low acuity of pediatric patients, and lack of pediatric-focused education. These barriers mapped to the CFIR domains of outer setting, inner setting, and characteristics of individuals. Since pediatric call volume cannot be changed, those barriers can be addressed with frequent pediatric continuing education focusing on simple pediatric procedures (administering oral medication), pediatric dosing and drawing up medications, down-stream effects of OCS, and evidence for protocol changes.
This study has limitations that merit discussion. First, our sample is from four geographic areas of the United States, and thus due to the importance of geography and the heterogeneity of EMS agencies nationwide, our findings may not be generalizable to all EMS agencies. Further, the relatively small sample size of participants may bias the results due to differences in opinions and experiences, and in this study we did not reach thematic saturation. However, we employed a deductive approach with the CFIR domains and constructs as our predetermined analytical categories, and throughout the course of data collection, we did find examples of each CFIR construct. We chose the CFIR as our framework given its broad reach and applicability to multiple health care settings; however the study of implementation in prehospital medicine is relatively new and understudied, thus there may be other frameworks (e.g., Promoting Action on Research Implementation in Health Services, Theory of Diffusion, Theory of Planned Behavior) better suited to the prehospital environment.18 Lastly, we pooled data from in-depth interviews and focus groups, which while shedding light on both individual and group perceptions of phenomena, could also have introduced bias by analyzing those two types of perspectives together. However, the scheduling of in-depth interviews was due to scheduling conflicts, and therefore we chose to include those individual perspectives rather than exclude them.
CONCLUSION
This is one of the first qualitative studies to analyze EMS clinicians’ knowledge of and comfort with prehospital administration of OCS in pediatric patients with acute asthma exacerbations. This study provides a better understanding of EMS clinicians’ perspectives of OCS use and identified important facilitators and barriers to uptake of this protocol element. OCS are an important treatment in the prehospital management of acute asthma exacerbations and EMS clinicians believe that prehospital administration of OCS for pediatric asthma patients is feasible and beneficial. In addition to establishing the importance of fostering good communication and feedback, we identified potential opportunities for targeted education and training to increase the uptake of OCS administration by EMS clinicians for pediatric asthma patients.
FUNDING / FINANCIAL SUPPORT
This study’s data analysis and Dr. Fishe’s research activities were supported by a career development award from NIH/NHLBI (K23HL149991). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
PRESENTATIONS: Portions of this study were presented as a poster at the National Association of EMS Physicians Annual Meeting in San Diego, California, in January 2022.
DECLARATION OF INTEREST
The authors (KM, AC, LR, JB, JNF) report no conflicts of interest. The authors alone are responsible for the content and writing of this manuscript.
REFERENCES
- 1.Alangari A Corticosteroids in the treatment of acute asthma. Annals of Thoracic Medicine. 2014;9(4):187. doi: 10.4103/1817-1737.140120 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Soriano JB, Abajobir AA, Abate KH, Abera SF, Agrawal A, Ahmed MB, Aichour AN, Aichour I, Aichour MTE, Alam K, Alam N, et al. Global, regional, and national deaths, prevalence, disability-adjusted life years, and years lived with disability for chronic obstructive pulmonary disease and asthma, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet Respir Med (2017) 5:691–706. doi: 10.1016/S2213-2600(17)30293-X [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Cloutier MM, Baptist AP, Blake KV, Brooks EG, Bryant-Stephens T, DiMango E, Dixon AE, Elward KS, Hartesrt T, Krishnan JA, et al. 2020 focused updates to the Asthma Management Guidelines: A report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. Journal of Allergy and Clinical Immunology. 2020;146(6):1217–1270. doi: 10.1016/j.jaci.2020.10.003 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Bhogal SK, McGillivray D, Bourbeau J, Benedetti A, Bartlett S, Ducharme FM. Early Administration of Systemic Corticosteroids Reduces Hospital Admission Rates for Children With Moderate and Severe Asthma Exacerbation. Annals of Emergency Medicine. 2012;60(1):84–91.e3. doi: 10.1016/j.annemergmed.2011.12.027 [DOI] [PubMed] [Google Scholar]
- 5.Ramgopal S, Mazzarini A, Martin-Gill C, Owusu-Ansah S. Prehospital management of pediatric asthma patients in a large emergency medical services system. Pediatr Pulmonol. 2020. Jan;55(1):83–89. doi: 10.1002/ppul.24542. Epub 2019 Oct 18. [DOI] [PubMed] [Google Scholar]
- 6.Moore B, Shah MI, Owusu-Ansah S, Gross T, Brown K, Gausche-Hill M, Remick K,Adelgais K, Lyng J, Rappaport L, et al. Pediatric Readiness in Emergency Medical Services Systems. Pediatrics. 2019;145(1):e20193307. doi: 10.1542/peds.2019-3307 [DOI] [PubMed] [Google Scholar]
- 7.Nassif A, Ostermayer DG, Hoang KB, Claiborne MK, Camp EA, Shah MI. Implementation of a Prehospital Protocol Change For Asthmatic Children. Prehosp Emerg Care. 2018. Jul-Aug;22(4):457–465. [DOI] [PubMed] [Google Scholar]
- 8.Fishe JN, Palmer E, Finlay E, Smotherman C, Gautam S, Hendry P, Hendeles L. A Statewide Study of the Epidemiology of Emergency Medical Services' Management of Pediatric Asthma. Pediatr Emerg Care. 2021. Nov 1;37(11):560–569. doi: 10.1097/PEC.0000000000001743. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Riney LC, Schwartz H, Murtagh Kurowski E, Collett L, Florin TA. Improving Administration of Prehospital Corticosteroids for Pediatric Asthma. Pediatr Qual Saf. 2021;6(3):e410. Published 2021 May 19. doi: 10.1097/pq9.0000000000000410 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.The Consolidated Framework for Implementation Research- Technical Assistance for uses of the CFIR framework. Available at: https://cfirguide.org/. Accessed May 24, 2022. [Google Scholar]
- 11.Lambert SD, Loiselle CG. Combining individual interviews and focus groups to enhance data richness. J Adv Nurs. 2008. Apr;62(2):228–37. doi: 10.1111/j.1365-2648.2007.04559.x. [DOI] [PubMed] [Google Scholar]
- 12.Baillie L Exchanging focus groups for individual interviews when collecting qualitative data. Nurse Res. 2019. Apr 11. doi: 10.7748/nr.2019.e1633. Epub ahead of print. [DOI] [PubMed] [Google Scholar]
- 13.Lambert S, LoiselleC. Combining individual interviews and focus groups to enhance data richness. Journal of Advanced Nursing. 2008;62:228–37. 10.1111/j.1365-2648.2007.04559. [DOI] [PubMed] [Google Scholar]
- 14.Carter N, Bryant-Lukosius D, DiCenso A, Blythe J, J Neville AJ. The Use of Triangulation in Qualitative Research. Oncology Nursing Forum. 2014;41(5): 545–47. [DOI] [PubMed] [Google Scholar]
- 15.Damschroder LJ, Lowery JC Evaluation of a large-scale weight management program using the consolidated framework for implementation research (CFIR). Implementation Sci. 2013;8(51). 10.1186/1748-5908-8-51 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Chalut DS, Ducharme FM, Davis GM. The Preschool Respiratory Assessment Measure (PRAM): a responsive index of acute asthma severity. J Pediatr. 2000;137(6):762–8. [DOI] [PubMed] [Google Scholar]
- 17.Curry W, Gallo P. Southwest Ohio protocol. Hamilton County (OH)Fire Chief's Association. http://www.hamiltoncountyfirechiefs.com/southwest-ohio-protocol.html. Published January 1, 2022. Accessed July 22, 2022. [Google Scholar]
- 18.Nilsen P Making sense of implementation theories, models and frameworks. Implementation Science. 2015;10:53. DOI: 10.1186/s13012-015-0242-0. [DOI] [PMC free article] [PubMed] [Google Scholar]