EMS Providers' Beliefs Regarding Spinal Precautions for Pediatric Trauma Transport

Abstract

Objective: Describe prehospital Emergency Medical Services (EMS) providers' beliefs regarding spinal precautions for pediatric trauma transport. Methods: We randomly surveyed nationally certified EMS providers. We assessed providers' beliefs about specific precautions, and preferred precautions given a child's age (0–4 or 5–18 years) and presence of specific cervical spine injury (CSI) risk factors. Results: We received 5,400 responses (17%). Most were Paramedics (36%) or EMTs (22%) and worked at fire-based services (42%). A total of 47% endorsed responding to pediatric calls more than once per month. Consensus beliefs (>66% agreement) were that rigid cervical collars (68%) and long backboards with soft conforming surfaces (79%) maintain an injured pediatric spine in optimal position. Only 39% believed in the utility of the rigid long backboard to protect the pediatric spine. For most risk factors in both age categories, a rigid cervical collar with a long backboard with a soft conforming surface was the most common response (28–40% depending on age group and risk factor); however, there were no consensus beliefs. Provider-level experience, working as a patient care provider, less education, and parent status were associated with endorsing the rigid cervical collar. Factors associated with endorsing the rigid long backboard included provider level, working as a patient care provider, low pediatric call volume, and less education. Conclusions: EMS providers believe that rigid cervical collars and long backboards with soft conforming surfaces provide optimal spinal precautions. There were no consensus beliefs, however, for use of particular precautions based on age and risk factors.

Key words::

• spinal immobilization
• spinal precautions
• cervical collar
• backboard
• emergency medical service
• pediatric
• cervical spine clearance
• trauma
• prehospital

Introduction

Background

Pediatric cervical spine injury (CSI) is rare, occurring in less than 1% of children who experience blunt trauma.¹ However, the outcomes associated with CSIs can be devastating, often resulting in persistent neurologic deficit and even death.² Spinal precautions (a rigid cervical collar and immobilization on a rigid long backboard) for prehospital trauma transport have been the standard of care since the American Academy of Orthopedic Surgeons publication of Emergency Care and Transportation of the Sick and Injured in 1971,³ and was reiterated in the first edition of the American College of Surgeon's Committee on Trauma's (ACS-COT) Advanced Trauma Life Support in 1977.^4,5 While this practice largely focuses on motion restriction to maintain the spine in anatomical alignment during patient transport, it is of questionable efficacy and may not provide optimal positioning for the injured cervical spine.^6,7

Of greatest concern are the risks to the child who receives spinal precautions after blunt trauma, but is at negligible risk of CSI. Spinal precautions during prehospital transport and subsequent radiographic imaging on arrival to an emergency department (ED) are common and associated with adverse effects.^8–19 The pain and discomfort associated with the use of spinal precautions can be misinterpreted for an actual injury, and increased exposure to ionizing radiation.^8–18 The magnitude of these potential harms is noteworthy given that annually, millions of children are placed in spinal precautions after trauma, yet far less than 1% will have unstable CSIs that might conceivably benefit from spinal precautions.^2,20,21

Due to the growing awareness of the questionable efficacy and potential harms of spinal precautions for trauma transport, the ACS-COT, and the National Association of EMS Physicians (NAEMSP) approved a joint position statement in 2012 that outlined the appropriate use of spinal precautions and use of the rigid long backboard.²² Subsequently, in 2015, the American College of Emergency Physicians (ACEP) released a policy statement for EMS management of patients with potential CSI.²³ Both statements specify the use of adult-derived risk factors to determine the use of spinal precautions for trauma transport and emphasize limiting the use of the rigid long backboard and not using spinal precautions for penetrating trauma victims.²⁴ These position statements, however, are mute in regard to age, and their recommendations are based mainly on adult literature. Furthermore, these statements provide some overarching recommendations, but no definite guidelines, leaving interpretation open to local EMS jurisdictions.

Importance

Prehospital transport for children presents distinctive challenges. First, children have unique anatomical, physiologic, and developmental characteristics that make them particularly vulnerable, and they are often unable to articulate their medical problems. ²⁵ Furthermore, a secondary analysis of a cohort of children with CSI in the multicenter Pediatric Emergency Care Applied Research Network (PECARN) study demonstrated that there is inconsistency in application of spinal precautions by EMS prehospital providers, particularly in children younger than two years after blunt trauma.²⁶ This inconsistency may be due to a lack of established pediatric spinal precaution guidelines, lack of pediatric specific transport equipment, and confusion about when to use age appropriate restraint devices such as car seats during prehospital transport.

The recent changes in recommendations regarding prehospital spinal precautions and the variability in application of prehospital spinal precautions illustrate the need to further investigate EMS providers' beliefs regarding spinal precautions for children during trauma transport. EMS providers are key stakeholders in the provision of prehospital care. EMS providers' attitudes, beliefs, and training are of extreme importance to physicians and the rest of the medical community as they are often the first to interact with injured patients. Their decisions can have a significant impact on patient care and outcomes, especially for something as critical as providing appropriate spinal precautions where motion limitation may improve neurologic outcomes for children with cervical spine injuries, but inappropriate use of spinal precautions can result in harms such as exposure to radiation. The medical community must understand that guidelines may be created based on scientific evidence, but if the information is not disseminated to our EMS providers who are at the frontline of providing care, patients will not benefit and may even be harmed. Understanding EMS providers' beliefs is a vital way to identify if there are guideline inconsistencies that are creating discrepancies in when and what type of spinal precautions are used. The importance of this qualitative process was demonstrated in the study performed by Rhodes et al. where key stakeholders in the prehospital and hospital setting were able to describe factors leading to a successful implementation of a prehospital spinal immobilization guideline.²⁷

Goals of This Investigation

The primary objective of this study was to describe EMS providers' beliefs regarding best practice for prehospital spinal precautions in children following blunt trauma in the setting of recent changes in recommendations by the ACS-COT, NAEMSP, and ACEP. A sub-analysis of the two traditional devices used for spinal precautions in the prehospital setting, the rigid cervical collar and rigid long backboard, was conducted to identify factors associated with endorsing these devices. The results of this study are intended to be used to inform efforts for the development and implementation of pediatric-specific guidelines for the use of spinal precautions during trauma transport.

Methods

Study Design and Setting

Investigators from Nationwide Children's Hospital and The Ohio State University partnered with the National Registry of Emergency Medical Technicians (NREMT) for this cross-sectional investigation conducted in the summer of 2015 after ACEP's recommendations were released in January 2015. The NREMT database contains records for over 300,000 EMS professionals who possess current National EMS Certification.²⁸ At the time of this study, there were approximately 219,000 Emergency Medical Technicians (EMTs), 15,000 Advanced Emergency Medical Technicians or EMT-Intermediates (AEMTs/EMT-Is), and 87,000 Paramedics. Based on these total populations, a sample size calculation was performed assuming a three percent margin of error and a conservative 50/50 split in beliefs. With these assumptions we determined that a sample of 1,056 EMTs, 880 AEMTs, and 1,045 Paramedics, for a total of 2,981 responses was needed to achieve estimates with 95% confidence. In order to ensure that the required sample sizes would be met we assumed a conservative 10% response rate and randomly selected a sample of 10,620 nationally certified EMTs, 9,970 AEMTs, and 10,540 Paramedics for a total of 31,130 nationally certified EMS professionals to receive an electronic questionnaire.

Survey Instrument and Variable Description

Before administering the electronic questionnaire, a cognitive debrief was conducted with seven practicing EMS professionals using a protocol designed to assess the readability, interpretation of the items, and time to complete the survey. Based on the results of the cognitive interviews, the survey instrument was revised accordingly.

The final questionnaire consisted of 37 items in four main categories (see Supplemental Online Appendix 1):

1.	Work characteristics (certification level, years of EMS experience, agency type, primary service provided, primary role, community size, weekly call volume, average pediatric call volume). These items have been deployed on previous surveys administered by the NREMT and are based on the National Highway Traffic Safety Administration (NHTSA) EMS Data Definitions.
2.	Beliefs about efficacy of most commonly used pediatric devices for spinal precautions (rigid cervical collar, semi-Fowler position on a mattress gurney, supine position on a mattress gurney, long backboard with a soft conforming surface, rigid long backboard).
3.	Beliefs regarding most appropriate means of providing spinal precautions for children ages 0–4 years and children ages 5–18 years based on specific PECARN spinal injury risk factors.
4.	Demographics (gender, race/ethnicity, highest level of education completed, current parent status).

The survey instructions emphasized that EMS providers should answer the questions based on their beliefs, rather than what their EMS agency's standard operating procedures or protocols allowed. Survey questions regarding spinal precautions were stratified by CSI risk factors, which were previously identified to be associated with CSI in children in a large multicenter retrospective study conducted by PECARN.²⁹ The risk factors used for this EMS survey included those that could be identified by EMS providers in the prehospital setting: altered mental status with Glasgow Coma Score (GCS) 3–8, altered mental status with GCS 9–13, focal neurologic deficits, complaint of neck pain or tenderness to palpation of the posterior midline neck, complaint of difficulty moving neck, substantial torso injury, high risk motor vehicle crash (MVC), and axial load or diving mechanism.²⁹

For each risk factor, EMS providers were asked to choose what they believed to be the most appropriate spinal precautions for children ages 0 to 4 years and again for children ages 5 to 18 years. The two different age groups were chosen to be consistent with the recommendations of the NHTSA for the use of a car seat during EMS transport.³⁰ Participants were asked to choose from the following options: no spinal precautions, rigid cervical collar and car seat secured directly to the mattress gurney (for children 0–4 years only), rigid cervical collar secured directly to mattress gurney in semi-Fowler position, rigid cervical collar secured directly to mattress gurney in supine position, rigid cervical collar and long backboard with a soft conforming surface (full body vacuum splint), rigid cervical collar and a rigid long backboard, or unsure. As our outcome of interest, we defined a consensus of beliefs to be agreement of 66% or higher, which is a common level of agreement used in studies for establishing consensus of beliefs.^31,32

Data Collection and Analysis

This study was approved by the American Institutes for Research's Institutional Review Board and the Nationwide Children's Hospital Institutional Review Board. The initial invitation to participate and a link to access the questionnaire was sent in October of 2015 via an e-mail to 31,330 nationally certified EMS professionals. Participants were told that all responses would be confidential and that only data summarizing groups of participants would be reported. As an incentive to participate, individuals were offered the opportunity to participate in a lottery to win one of 30 Amazon gift cards worth $100 each. Following the tailored Dillman survey methodology, two reminder e-mails were sent 7 days and 14 days after the initial e-mail.³³ Data were collected using Snap 10 survey software (Snap Surveys Ltd, Portsmouth, NH) and results were exported to a Microsoft Excel (Microsoft Corp, Redmond, WA) spreadsheet. All data were de-identified during the data upload process and no identifying information was collected by the software.

Inclusion criteria consisted of EMS professionals practicing at the EMT level or higher who reported currently working for one or more EMS organizations. Descriptive statistics were calculated. A subgroup analysis was conducted for the two devices traditionally used for spinal precautions in the prehospital setting: the rigid cervical collar and rigid long backboard. An investigator-controlled forward-stepwise logistic regression modelling approach was used to identify characteristics significantly associated with the belief that the device maintains an injured pediatric spine in optimal position. Univariable and multivariable odds ratios (OR) and their respective 95% confidence intervals (95% CI) were reported. All data analyses were performed using STATA/IC 12 (StataCorp LP, College Station, TX).

Results

Characteristics of Study Participants

A total of 5,400 (17%) responses were received and 4,946 individuals met inclusion criteria which consisted of NREMT-trained EMS professionals practicing at the EMT level or higher who reported currently working for one or more EMS organizations. The number of responses received exceeded the sample size (2,981) determined a priori to be necessary for generating estimates with 95% confidence. Table 1 displays the demographic and employment characteristics of the study population. Most respondents were male (74%) and white, non-Hispanic (87%). Approximately 36% were practicing as Paramedics and 22% were EMTs. In regards to years of EMS experience, 25% had less than 5 years of EMS experience, and 30% had more than 15 years of experience. The most common agency type was fire-based (42%), followed by private (30%) and then government (13%). Most were primarily patient care providers (81%) and the majority practiced in urban settings (59%). Of the respondents, nearly half (47%) endorsed responding to pediatric calls more than once per month.

Table 1. Respondent demographics and employment characteristics

	n (%) N = 4946
Gender
Male	3,574 (74.1)
Female	1,248 (25.9)
Race/Ethnicity
White, non-Hispanic	3,996 (87.1)
Other	592 (12.9)
Age
Average (SD)	39.3 (11.7)
Certification Level
EMT	1,077 (21.8)
EMT-Intermediate	888 (17.9)
AEMT	995 (20.1)
Paramedic	1,770 (35.8)
Critical Care	216 (4.4)
Years of EMS Experience
Less than 5 years	1,214 (24.5)
5 to 15 years	2,243 (45.4)
More than 15 years	1,487 (30.1)
Agency Type
Fire	2,054 (41.7)
Private	1,474 (29.9)
Government	658 (13.4)
Hospital	567 (11.5)
Military	148 (3.0)
Tribal	25 (0.5)
Primary Service Provided
9-1-1 response with transport capability	3,512 (71.9)
9-1-1 response without transport capability	664 (13.6)
Medical transport	183 (3.8)
Air medical	118 (2.4)
Rescue	67 (1.4)
Specialty care transport	73 (1.5)
Paramedic intercept	46 (0.9)
Hazmat	8 (0.2)
Other	210 (4.3)
Primary EMS Role
Patient care provider	4,022 (81.4)
First-line supervisor	347 (7.0)
Administrator/Manager	251 (5.1)
Educator/Preceptor	212 (4.3)
Other	111 (2.2)
Weekly Call Volume
Less than 5 calls	1,190 (24.1)
5 to 19 calls	2,112 (42.8)
20 or more calls	1,632 (33.1)
Pediatric Calls
Never	262 (5.3)
Once per year or less	456 (9.3)
Between once per year and once per month	1,893 (38.4)
Between once per month and once per week	1,717 (34.9)
More than once per week	596 (12.1)
Community Size
Urban (≥ 25,000 residents)	2,882 (58.5)
Rural (< 25,000 residents)	2,043 (41.5)
Highest Level of Education Completed
High school/GED or less	364 (7.4)
Some college	1,889 (38.4)
Associate's degree	1,184 (24.0)
Bachelor's degree or higher	1,486 (30.2)
Parent
Yes	3,340 (67.8)
No	1,587 (32.2)

EMT: emergency medical technician; AEMT: advanced emergency medical technician; EMS: emergency medical services.

Main Results

A consensus of beliefs regarding devices and methods to maintain an injured pediatric spine in optimal position was reached for the rigid cervical collar and the long backboard with a soft conforming surface. A total of 68% of EMS professionals believed that a rigid cervical collar maintains an injured pediatric spine in optimal position. In addition, 79% believed the long backboard with a soft conforming surface provides optimal positioning. Most EMS professionals (61%) believed that the rigid long backboard did not maintain an optimal position (Table 2). Beliefs regarding the most appropriate means of providing pediatric spinal precautions did not reach a consensus for any of the specific risk factors regardless of age group (Table 3). For children ages 0–4 years, a rigid cervical collar and long backboard with a soft conforming surface were endorsed by a greater proportion of EMS professionals for: altered mental status with GCS 3–8 (32%), focal neurologic deficits (38%), neck pain or tenderness to palpation (29%), difficulty moving neck (28%), substantial torso injury (39%), MVC with significant mechanism of injury (40%), and axial load or diving mechanism (41%). For altered mental status with GCS 9–13, 28% of EMS professionals chose a rigid cervical collar and car seat secured to a mattress gurney while 27% chose a rigid cervical collar and long backboard with a soft conforming surface.

Table 2. Beliefs among nationally-certified EMS professionals regarding common devices and methods for maintenance of pediatric spine in optimal position

Devices/Methods for Optimal Spine Position	n (%) N = 4946
Rigid cervical collar
Yes	3,327 (67.8%)
No	1,581 (32.2%)
Semi-Fowler position on a mattress gurney
Yes	2,218 (46.1%)
No	2,598 (54.0%)
Supine on a mattress gurney
Yes	2,577 (53.3%)
No	2,256 (46.7%)
Long backboard with a soft conforming surface
Yes	3,874 (79.4%)
No	1,005 (20.6%)
Rigid long backboard
Yes	1,898 (38.7%)
No	3,007 (61.3%)

EMS: emergency medical services.

Table 3. Beliefs among nationally-certified EMS professionals regarding appropriate means of providing spinal precautions for a pediatric patient who has experienced blunt trauma by risk factor and patient age group

	Most Appropriate Means of Providing Spinal Precautions N = 4946
	Nothing	Rigid cervical collar, car seat, secured to mattress gurney	Rigid cervical collar secured to mattress gurney semi-Fowler	Rigid cervical collar secured to mattress gurney supine	Rigid cervical collar and long backboard with soft conforming surface	Rigid cervical collar and rigid long backboard	Unsure
Injury Risk Factor
Altered Mental Status (GCS 3–8)
0–4 years	315 (6.4%)	1,099 (22.4%)	387 (7.9%)	591 (12.0%)	1,559 (31.7%)	808 (16.5%)	153 (3.1%)
5–18 years	325 (6.7%)	—	598 (12.2%)	878 (18.0%)	1,555 (31.8%)	1,423 (29.1%)	111 (2.3%)
Altered Mental Status (GCS 9–13)
0–4 years	387 (8.0%)	1,340 (27.6%)	583 (12.0%)	641 (13.2%)	1,297 (26.7%)	460 (9.5%)	151 (3.1%)
5–18 years	405 (8.4%)	—	913 (19.0%)	954 (19.9%)	1,425 (29.7%)	995 (20.7%)	111 (2.3%)
Focal Neurologic Deficits
0–4 years	124 (2.5%)	833 (17.0%)	403 (8.2%)	592 (12.1%)	1,883 (38.3%)	953 (19.4%)	123 (2.5%)
5–18 years	104 (2.1%)	—	516 (10.6%)	873 (17.9%)	1,847 (37.9%)	1,444 (29.6%)	88 (1.8%)
Neck Pain or Tenderness to Palpation
0–4 years	79 (1.6%)	1,341 (27.3%)	618 (12.6%)	622 (12.7%)	1,435 (29.2%)	734 (14.9%)	86 (1.8%)
5–18 years	78 (1.6%)	—	1,084 (22.1%)	966 (19.7%)	1,494 (30.5%)	1,221 (24.9%)	60 (1.2%)
Complaint of Difficulty Moving Neck
0–4 years	150 (3.1%)	1,366 (27.8%)	612 (12.5%)	555 (11.3%)	1,383 (28.1%)	742 (15.1%)	106 (2.2%)
5–18 years	145 (3.0%)	—	1,130 (23.1%)	925 (18.9%)	1,408 (28.7%)	1,225 (25.0%)	69 (1.4%)
Substantial Torso Injury
0–4 years	365 (7.4%)	403 (8.2%)	294 (6.0%)	722 (14.7%)	1,939 (39.4%)	1,085 (22.0%)	115 (2.3%)
5–18 years	358 (7.3%)	—	323 (6.6%)	805 (16.4%)	1,725 (35.1%)	1,608 (32.7%)	92 (1.9%)
MVC with Significant Mechanism of Injury
0–4 years	57 (1.2%)	537 (10.9%)	210 (4.3%)	520 (10.6%)	1,965 (39.9%)	1,536 (31.2%)	96 (2.0%)
5–18 years	57 (1.2%)	—	306 (6.2%)	661 (13.5%)	1,746 (35.6%)	2,061 (42.0%)	80 (1.6%)
Axial Load/Diving Mechanism
0–4 years	48 (1.0%)	431 (8.8%)	304 (6.2%)	576 (11.7%)	2,006 (40.8%)	1,383 (28.2%)	164 (3.3%)
5–18 years	43 (0.9%)	—	398 (8.1%)	704 (14.4%)	1,762 (35.9%)	1,866 (38.1%)	131 (2.7%)

EMS: emergency medical services; GCS: Glasgow Coma Score; MVC: motor vehicle collision.

For children ages 5–18 years, a rigid cervical collar and long backboard with a soft conforming surface were preferred by more EMS professionals for: altered mental status with GCS 3–8 (32%), altered mental status with GCS 9–13 (30%), focal neurologic deficits (38%), neck pain or tenderness to palpation (31%), complaint of difficulty moving neck (29%), and substantial torso injury (35%). However, for MVC with significant mechanism of injury, 42% believed a rigid cervical collar and rigid long backboard were most appropriate while 36% chose a rigid cervical collar and long backboard with a soft conforming surface. For axial load or diving mechanism, 38% chose a rigid cervical collar and rigid long backboard and 36% elected the rigid cervical collar and long backboard with a soft conforming surface.

Subgroup Analysis for Traditionally Used Spinal Precaution Devices: Rigid Cervical Collar and Rigid Long Backboard

Table 4 displays a summary of characteristics associated with beliefs regarding the maintenance of an injured pediatric cervical spine in optimal position by two devices traditionally used in the prehospital setting: the rigid cervical collar and rigid long backboard. The final multivariable logistic regression model for endorsing the rigid cervical collar as a device that maintains an injured pediatric cervical spine in optimal position contained five variables: provider level, years of EMS experience, working as a patient care provider, level of education and parent status. Compared to Basic Life Support (BLS) providers (EMTs), Advanced Life Support (ALS) providers (AEMTs and Paramedics) had 33% lower odds of endorsing the rigid cervical collar (OR: 0.67, 95% CI: 0.56–0.80). Compared to those with fewer than five years of EMS experience, those with between 5 and 15 years of experience (OR: 0.75, 95% CI: 0.63–0.90) and those with more than 15 years of experience (OR: 0.63, 95% CI: 0.51–0.77) had reduced odds of endorsing the rigid cervical collar. Meanwhile, those whose primary role was providing patient care had greater odds of endorsing the rigid cervical collar (OR: 1.41, 95% CI: 1.20–1.66) compared to those in all other roles such as administrators, supervisors, and educators. Those with more than high school education demonstrated reduced odds of endorsing the rigid cervical collar. Finally, EMS professionals who were parents also had reduced odds of endorsing the rigid cervical collar (OR: 0.83, 95% CI: 0.72–0.96).

Table 4. Odds Ratios for characteristics associated with EMS providers' belief that the rigid cervical collar and rigid long backboard maintain an injured pediatric spine in optimal position

	Rigid Cervical Collar		Rigid Long Backboard
	Univariable OR	Multivariable OR	Univariable OR	Multivariable OR
	(95% CI)	(95% CI)	(95% CI)	(95% CI)
Gender
Female	Ref	—	Ref	—
Male	0.87 (0.76–1.00)	—	0.85 (0.74–0.97)^*	—
Provider Level
BLS	Ref	Ref	Ref	Ref
ALS	0.53 (0.45–0.62)^***	0.67 (0.56–0.80)^***	0.46 (0.40–0.53)^***	0.52 (0.45–0.60)^***
EMS Experience
<5 years	Ref	Ref	Ref	—
5–15 years	0.59 (0.50–0.69)^***	0.75 (0.63–0.90)^**	0.71 (0.61–0.82)^***	—
> 15 years	0.43 (0.36–0.51)^***	0.63 (0.51–0.77)^***	0.70 (0.59–0.81)^***
Agency Type
Fire	Ref	—	Ref	—
Private	1.16 (1.00–1.34)^*	—	1.04 (0.90–1.19)	—
Other	0.98 (0.84–1.13)	—	1.06 (0.92–1.22)	—
Role
Other	Ref	Ref	Ref	Ref
Patient Care Provider	1.74 (1.50–2.01)^***	1.41 (1.20–1.66)^***	1.32 (1.14–1.54)^***	1.25 (1.07–1.46)^**
Pediatric Call Volume
Never- 1 per year	Ref	—	Ref	Ref
1 per year- 1 per month	1.01 (0.84–1.21)	—	0.74 (0.62–0.88)^***	0.82 (0.68–0.98)^*
1 per month- 1 per week	0.91 (0.75–1.10)	—	0.58 (0.49–0.70)^***	0.69 (0.57–0.83)^***
>1 per week	1.07 (0.85–1.36)	—	0.64 (0.51–0.80)^***	0.78 (0.62–0.99)^*
Community Size
Urban	Ref	—	Ref	—
Rural	0.97 (0.86–1.10)	—	1.11 (0.99–1.25)	—
Education
HS/GED or less	Ref	Ref	Ref	Ref
Some college	0.74 (0.57–0.96)^*	0.71 (0.54–0.92)^*	0.71 (0.56–0.89)^**	0.73 (0.58–0.92)^**
Associates	0.58 (0.44–0.76)^***	0.60 (0.45–0.79)^***	0.51 (0.40–0.65)^***	0.57 (0.44–0.72)^***
Bachelors or higher	0.56 (0.43–0.73)^***	0.56 (0.43–0.74)^***	0.52 (0.41–0.66)^***	0.55 (0.43–0.69)^***
Parent Status
Non-parent	Ref	Ref	Ref	—
Parent	0.71 (0.62–0.81)^***	0.83 (0.72–0.96)^*	1.03 (0.91–1.17)	—

^* p < 0.05.

^** p < 0.01.

^*** p < 0.001. CI: confidence interval; OR: odds ratio; BLS: basic life support; ALS: advanced life support; EMS: emergency medical services.

A total of four characteristics were found to be significantly associated with endorsing the rigid long backboard: provider level, working as a patient care provider, pediatric call volume, and education level. ALS providers had about half the odds of endorsing the rigid long backboard compared to BLS providers (OR: 0.52, 95% CI: 0.45–0.60). After controlling for other covariates, those whose primary role was providing patient care had increased odds of endorsing the rigid long backboard (OR: 1.25, 95% CI: 1.07–1.46). EMS professionals who ran one or more pediatric calls per year had reduced odds of endorsing the rigid long backboard. Similar to the findings for rigid cervical collar, EMS professionals who had greater than high school education also demonstrated decreased odds of endorsing the rigid long backboard.

Discussion

This study is the first large, national evaluation of EMS providers' beliefs regarding the means and indications for providing spinal precautions to children during trauma transport. Based on the results of this investigation, the majority of prehospital EMS providers believed that a rigid cervical collar and a long backboard with a soft conforming surface are devices that maintain an injured pediatric spine in optimal position. Furthermore, most EMS providers did not believe that the rigid long backboard maintains the pediatric spine in optimal position.

EMS providers' belief in our study regarding the long backboard with a soft conforming surface as a device that maintains an injured pediatric spine in optimal position is supported by recent research. Several studies have shown that vacuum mattresses are superior to the rigid long backboard because the vacuum mattresses significantly reduce the amount of movement in longitudinal and lateral tilts, reduce sacral interface pressures from potentially ischemic levels generated with the backboard, and are considerably more comfortable.^34–36

Use of the rigid long backboard, however is not supported by the literature for providing neutral spine positioning. Studies have shown that children younger than eight years, due to a relatively large head size compared to the remainder of their body, require back elevation to achieve neutral position, whereas a rigid long backboard with or without a cervical collar, does not eliminate flexion in most children.^37,38 Furthermore, a study of lateral radiographs of children with and without CSI showed that the rigid long backboard did not achieve neutral position.³⁴ Our finding that the majority of EMS providers do not believe that the rigid long backboard maintains an injured pediatric spine in optimal position is consistent with the literature and the recent NAEMSP, ACS-COT, and ACEP position statements that advocate that the rigid long backboard itself is not ideal for prehospital transport and should not be the preferred surface for the transfer of patients with spinal injuries.³⁹

In 2008 and revised in 2012, NHTSA made recommendations for the proper restraint of children in ground ambulances.³⁰ These recommendations focus on the use of car seats, when available, for the transport of infants and children ages 0–4 years. For those children requiring spinal precautions, the transport recommendation is to secure the child to a size appropriate spine board and secure the board to the cot, head first, with a tether at the foot to prevent forward movement.³⁰ With the recent NAEMSP, ACS-COT, and ACEP position statements discouraging the use of rigid long backboards, pediatric EMS content experts advocated that for children who are alert and have more subtle, non-neurologic signs of cervical spine injury, a rigid cervical collar alone along with proper restraint to a gurney in a child passenger seat or in a semi-fowler position may be sufficient during prehospital trauma transport.⁴⁰ NHTSA guidelines for safe transport of children warrant further revision to incorporate the recent recommendations against the use of the rigid long backboard. With revision, the NHTSA guidelines should identify when a rigid long backboard can be avoided all together during pediatric trauma transport in favor of proper restraint to the mattress gurney with or without a car seat.

The EMS providers in this study believed in the use of a rigid cervical collar to protect the cervical spine of children. While use of a rigid cervical collar as a spinal precaution is consistent with the recent NAEMSP, ACS-COT, and ACEP position statements, its use in children is controversial. Many investigations do not support the rigid cervical collar as a device to protect the injured pediatric cervical spine. The difficulty of achieving neutral alignment when applying the cervical collar for spinal stabilization to the pediatric patient has been well documented.^{37,39,41–43} The challenge of attaining neutral positioning with rigid cervical collars is likely multifactorial; due to a child's cervical spine anatomy being very different from the adult spine and equipment not being size appropriate for smaller children.^44,45 In our subanalysis, we found that those providers who were parents, were less likely to believe in the use of rigid cervical collars. It may be that parents have more exposure to children, an innate understanding of the variation in pediatric anatomy, and the limitations of the currently available prehospital cervical collars.

Foundational to providing spinal precautions for trauma transport is the initial step of identifying children that are at increased risk for CSI. In our study, when presented with specific risk factors for CSI in children, there were no consensus beliefs among EMS providers regarding which devices or patient position is most appropriate for trauma transport. Despite studies showing that long backboards with a soft conforming surface are superior to rigid long backboards as a spinal precaution; many EMS providers favored the rigid long backboard in terms of certain risk factors such as MVC. It is possible that prehospital EMS providers perceive the rigid long backboard as more effective in its use to extricate patients due to its stability.⁴¹ The vacuum mattress, when used as an extrication tool, may be more problematic due to its non-uniform surface, large size, and comparatively high friction surface.³⁵ The vacuum mattress may also be cost prohibitive for some EMS agencies since its cost ranges from $200 to $800, whereas rigid long backboards can cost from $150 to $300. Despite the cost, the vacuum mattress remains an excellent tool that can prevent costly pressure ulcers treatment since it is not disposable and can be cleaned and reused.⁴⁶ Notwithstanding, these findings suggest that there is a wide gap in knowledge regarding when and how to best protect the spine of an injured child, and supports the need to develop and disseminate a pediatric decision support tool that guides the use of spinal precautions for prehospital trauma transport.

While recent evidence has shown that the rigid long backboard and rigid cervical collar do not effectively maintain the pediatric spine in optimal position, many EMS providers who participated in our survey endorsed these devices.^{35,37,39–41,42,43} Of concern, 53% of EMS providers in this survey reported to responding to a pediatric call less than once per month. This may be because children are less likely to be involved in traumas compared to adults or that children are less likely to use EMS after trauma. Drayna et al. reported that pediatric transports make up approximately 10% of EMS transports, a small portion of EMS providers' clinical practice. The most common pediatric calls are related to respiratory distress, seizures, trauma, or an undefined assessment.⁴⁷

The lack of clear guidelines for spinal precautions, lack of access to pediatric-specific equipment, and low exposure to pediatric EMS calls make it difficult for EMS providers to follow evidence-based practices in the prehospital environment. In an effort to identify other potential underlying factors, we used subgroup analyses to identify characteristics associated with endorsing these devices. We found that compared to BLS providers (EMTs), ALS providers (AEMTs and Paramedics) were less apt to endorse the rigid cervical collar and rigid long backboard as devices to maintain a pediatric cervical spine in optimal position. This is likely due to the more advanced education that ALS providers receive in regards to spine trauma and spinal cord injury pathophysiology, assessment, and management in pediatric patients. According to the Commission on Accreditation of Allied Health Education Programs (CAAHEP), EMTs, AEMTs, and Paramedics complete around 110, 200–400, and 1000 or more hours of training respectively.⁴⁸ When compared to EMTs, AEMTs are required to demonstrate ability to safely administer medications, gain vascular access, ventilate un-intubated patients, and perform an adequate assessment of pediatric patients. They are also required to assess, formulate, and implement a treatment plan for patients with altered mental status, respiratory distress, and chest pain. Paramedics receive all AEMT education in addition to more advanced course work and further education on age-related anatomic and physiologic variations.⁴⁹

In addition to the differences found between ALS and BLS providers, prehospital providers with fewer years of EMS experience were at greater odds of believing that the rigid cervical collar and the rigid long backboard were devices that maintain an injured pediatric spine in optimal position, in contrast to their colleagues with more years of experience in the field. A potential explanation of this difference could be that the more recently trained EMTs are likely receiving education on spinal precautions based on textbooks that may contain outdated information that have yet to incorporate the most recent recommendations regarding spinal precautions. In contrast, more experienced EMS providers, in addition to increased field exposure to caring for children, are likely receiving continuing education through standardized courses that are updated frequently to incorporate current evidence-based recommendations such as Prehospital Trauma Life Support or International Trauma Life Support.

Survey respondents whose primary role was to provide patient care were also more likely to endorse both the rigid cervical collar and the rigid long backboard for the pediatric population compared to those who primarily worked in another role such as educators, preceptors, administrators or managers, or first-line supervisors. This finding is concerning as those responsible for caring for patients may not be receiving the most up-to-date evidence-based information available. Future research is necessary to determine where the breakdown in dissemination of evidence occurs regarding prehospital spinal precautions for children.

Limitations

This study has several limitations resulting chiefly from the nature of survey investigations. First, all data were self-reported. Regardless, self-report is an appropriate method for assessing beliefs, which was the objective of this study. Despite requesting EMS providers to answer questions according to their beliefs, it is possible that information bias may have been introduced in regards to what each EMS provider is instructed to do per the organization they work for, and what kind of equipment the EMS provider has available at the time of transport. There is also a potential for selection bias in this study based on EMS provider interest in the subject, possibly attracting a disproportionate number of providers that are interested in the topic of prehospital spinal precautions. EMS providers were also not asked to report on pediatric call volume as it relates to medical versus trauma call volume. Some EMS providers may have more experience with general pediatric medical calls and less experience with pediatric trauma calls. In this case, some EMS providers may have a different perception of spinal immobilization depending on their exposure to pediatric trauma cases. Drayna et al. identified that if EMS providers rarely have the opportunity to interact with pediatric patients, they will need to have opportunities available to them outside of their practice.⁴⁷ In this respect, if EMS providers had a low interaction with pediatric patients then they may not be as informed about spinal precaution guidelines impacting children and need additional educational training. Overall, the demographic and employment characteristics of the respondents in our study were similar to those of the nationally certified population.⁵⁰ As sampling was stratified by provider level, a greater proportion of Intermediate or Advanced EMTs and Paramedics was present in our sample population compared to the total nationally certified population, which results in the potential underrepresentation of EMTs' beliefs in the descriptive analyses. Nevertheless, it should be noted that subgroup analyses controlled for provider level. Despite its limitations, the study had several strengths, including a cognitively tested questionnaire and a large sample size of 5,400 EMS prehospital providers from a large national database that includes EMS professionals from every state. Although the response rate overall was 17%, a sufficient number of EMTs and paramedics responded to allow for estimates with a 95% confidence.

Conclusions

In summary, most EMS providers believed that a long backboard with a soft conforming surface maintains an injured pediatric spine in optimal position, while a rigid long backboard alone does not. Despite existing controversy, the majority of EMS providers believed that the rigid cervical collar maintains an injured pediatric spine in optimal position. These beliefs are consistent with the positions of NAEMSP, ACS-COT, and ACEP. However, there were no consensus beliefs among EMS providers for when to use specific spinal precautions relative to known CSI risk factors in children. Further subgroup analysis demonstrated that BLS providers, those with fewer years of EMS experience and individuals whose primary role was providing patient care had greater odds of endorsing the historically used rigid cervical collar with a rigid long backboard, despite evidence that these devices do not adequately protect the pediatric spine. These findings highlight the need for further work to establish and disseminate clear guidelines for the use of spinal precautions in pediatric trauma transport; particularly because EMS providers are at the forefront of trauma care and their decision-making impacts subsequent physician decision-making.