Tia Dickson, RN, BSN

Primary Children's Hospital

Last year's respiratory season has been called the tripledemic. There’s no scientific definition for this term; it simply refers to a collision of RSV (respiratory syncytial virus), flu, and COVID-19 to the extent that it might overwhelm hospital emergency departments. Many providers are still nursing PTSD from last season. This year we have even fewer pediatric hospital beds available. And when hospitals surge, an increased demand for EMS follows. Are you ready for the respiratory season? Do you know how to protect yourself? Last year around this time we put out a detailed newsletter on airway management for clinical practice and it is a great review . . . https://www.smore.com/cyep3.

Today we'll take a look at the common culprits; RSV, flu, COVID-19, and what you can expect this year.

Andrew Pavia, MD

Emergency Medicine at the University of Utah

Excerpts from September 21, 2023 Primary Children's Pediatric Grand Rounds

While there are not many deaths from RSV, the burden really falls on medical care. Between 60,000 and 80,000 people are hospitalized nationally each year (that's nearly 1,000 children in Utah).

A few RSV stats:

• Most (68%) infants are infected in the first year of life and nearly all (97%) by age 2
• Re-infection occurs throughout lifetime
• Most serious infections occur in infants <1 and adults >65 years
• Premature infants born at <30 weeks gestation had hospitalization rates 3 times higher than term infants
• 79% of children hospitalized with RSV aged <2 years had no underlying medical conditions

RSV is not the only virus that hits this time of year. Last year was the worst respiratory season In a generation where flu, RSV, and COVID-19 overlapped bringing our pediatric healthcare system to the brink of collapse. Primary Children's did well due to heroic efforts but ripple effects in burnout and delay of other medical procedures can still be felt. In the past, RSV has been almost predictable, typically beginning December 1 but since the pandemic, our respiratory season has been variable.

It was traditionally thought that RSV did not affect adults but research has shown that to be false. In fact, RSV is often deadly for adults older than 65 years (14,000 deaths annually). The good news in this discovery is there is now a market for prevention in adults which also led to breakthroughs in pediatrics.

Where are we today on RSV prevention?

• We have active immunization with 2 available vaccines approved for adults.
• We have maternal immunization to protect babies in utero.
• 2 vaccines (Nirsevimab and Clerovimab) should soon be approved for infants. These vaccines will have several ACIP/AAP recommendations in year one. These would replace Synergist.
• 1 dose for all infants aged <8 months born or entering their first RSV season.
• As soon as possible after birth for infants born October through March.
• Additional doses may be recommended for infants who are at very high risk of severe disease.

Current barriers to prevention:

• These doses will be expensive—$495/dose list
• A provider will need to know maternal RSV vaccination status
• Insurance coverage may be delayed
• Small practices may not be able to afford to keep it in stock

The best option for right now for the general public:

• Pregnant women vaccinated showed some level of protection for their newborns up to 180 days of life with nearly 100% effectiveness for the first 30 days

Compete prevention is still a while away but we are finally seeing movement against this disease.

The treatment is supportive measures. That includes managing fever, hydration and, in babies, suctioning nasal secretions so they can breathe better is very important. EMS should brush up on your suction skills.

August 29, 2023

Kristina A. Bryant, M.D., FAAP

American Academy of Pediatrics

Each year, an estimated 9% of all U.S. children develop symptomatic influenza infection. Children of all ages may require hospitalization, although the rates are highest in those younger than age 5. Hospitalizations, intensive care unit (ICU) stays, pneumonia requiring mechanical ventilation, and neurologic complications (encephalopathy and seizures) are common with the flu.

Last year’s flu season began earlier than typically expected in many states, and the majority of children were not protected by vaccines.

Influenza immunization to reduce the overall burden of respiratory illnesses is a vital step in preserving healthcare capacity, especially when other viruses are co-circulating.

The AAP recommendations include the following:

• Everyone 6 months and older should get A flu vaccination.
• Any licensed influenza vaccine appropriate by age and health status can be used.
• The AAP does not prefer any product over another for children and adolescents who have no contraindications.

Influenza (also known as “flu”) is a contagious respiratory illness caused by influenza viruses. It can cause mild to severe illness, and at times can lead to death.

Flu symptoms and complications

• fever* or feeling feverish/chills
• cough
• sore throat
• runny or stuffy nose
• muscle or body aches
• headaches
• fatigue (tiredness)
• some people may have vomiting and diarrhea, though this is more common in children than adults

*It’s important to note that not everyone with flu will have a fever.

Many people may only require rest, extra fluids, and/or over-the-counter medications like decongestants, cough medication, and anti-fever medications to recover from the flu. The flu is caused by a virus, so antibiotics are not effective against it.

There are prescription medications called antiviral drugs that can be used to treat influenza. When used for treatment, antiviral drugs can lessen symptoms and shorten the time you are sick by 1 or 2 days. They also can prevent serious flu complications, like pneumonia. For people with a high-risk medical condition, treatment with an antiviral drug can mean the difference between a milder illness instead of a very serious illness that could result in a hospital stay.

EMS1 Greg Friese MS, NRP

EMTs and paramedics play an important role in preventing the transmission of influenza with proper PPE use and ambulance cleaning

1. Get your flu shot and use your PPE (gloves, masks and eye protection).
2. Know the signs of influenza.
3. Clean ambulance surfaces and equipment, and disinfect any surfaces the patient's droplets may have come into contact with. If this CDC statement is true, "People with flu can spread it to others up to about six feet away," which surfaces shouldn't you clean in the ambulance?

Here are ambulance surfaces that are often overlooked:

• Stretcher and cot rails
• Buckles and receivers on squad bench seatbelts
• Action counter adjacent to the patient's head
• Blood pressure cuff and stethoscope bell
• Radio controls and microphone
• Avoid touching the steering wheel or mobile data terminal while wearing the gloves you used to assess and treat the patient

Influenza patient advice

For patients who decline ambulance transport, as well as your friends and family who become ill with influenza, the influenza treatment mainstays are:

• Rest
• Fluids
• Antipyretics, like acetaminophen, for fever
• NSAIDs, like ibuprofen, for body aches
• Stay home when you're sick

Practice and teach hand hygiene and good cough etiquette

• Catch your cough and sneezes in your elbow and not your hands.
• Wash your hands regularly—before and after every patient contact—with soap and water or an alcohol-based hand sanitizer

According to the CDC

Influenza (flu) and COVID-19 are both contagious respiratory illnesses, but they are caused by different viruses. From what we know, COVID-19 spreads more easily than flu. Compared with flu, COVID-19 can cause more severe illness in some people. Compared to people with flu, people infected with COVID-19 may take longer to show symptoms and may be contagious for longer periods of time.

You cannot tell the difference between flu and COVID-19 by the symptoms alone because they have some of the same signs and symptoms. Specific testing is needed to tell what the illness is and to confirm a diagnosis.

Build your personal COVID-19 plan here

Scene safety is of the highest priority when you respond to a respiratory complaint. PPE is your scene safety! To address infection prevention and control measures, much of the guidance developed during the COVID-19 pandemic will also apply to the surge in these other respiratory viruses. Resources for guidance on disinfection and personal protective equipment (PPE) for EMS providers include:

• CDC—Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic
• Federal Healthcare Resilience Task Force, EMS/Prehospital Team PDF—Guidance for First Responder Interactions with Suspected/Confirmed COVID-19 Patients
• The Interagency Board for Emergency Preparedness and Response—PPE and decontamination
• National Highway Traffic Safety Administration, Office of EMS—Resources to protect against infection from emerging diseases

Training officers may review the topic above as a team training AND perform a simulation/skills check as directed here. Once complete, send a roster of participants to Utah.PETOS@gmail.com and those listed will be issued 1-hour of CME credit from the DHHS Office of EMS and Preparedness. For this issue you will want to also include a review of the airway management newsletter found here https://www.smore.com/cyep3.

Cold and flu season is nearly here! Help prevent a pediatric respiratory surge by spreading the word about the importance of vaccines. Access CDC resources.

A new joint policy statement on the topic of mental and behavioral health emergencies for children and youth is available. Read more.

National EMSC has a newsletter filled with fantastic pediatric information, resources, and links. Check it out!

We are excited to introduce the John Wilson autism kits that will be made available during our autism trainings. The training and kits are free to you. These kits can be stocked in the ambulance to enhance your care of neuro-divergent children.

Contact Jeff Wilson jeffwilson122615@gmail.com to set up a training.

The Medical Home Portal is a unique source of reliable information about children and youth who have special health care needs (CYSHCN); offering a “one-stop shop” for their:

· Families

· Physicians and medical home teams

· Other professionals and caregivers

PECCs, Primary Children's Hospital (PCH) emergency department received some recent feedback from an EMS crew. The crew brought in a direct admit, their reception wasn't positive, and they were required to wait for a long time before being escorted upstairs. Has this ever happened to you?

In direct response to this feedback, the leaders at Primary Children's are tweaking their process. The first step is up to you. Please educate your agencies. In order to initiate the process the crew must call before they arrive so PCH can alert their security team and streamline your reception. PCH appreciates the feedback they received and would love to hear continued comments on their QI.

The mainstream media recently tapped into the National Pediatric Readiness Assessment results and the Wall Street Journal published 2 stories that call for emergency rooms to support PECCs. Check them out.

https://www.wsj.com/health/healthcare/hospitals-emergency-rooms-cost-childrens-lives-d6c9fc23?st=pw0m3bwah0b2nl5&reflink=desktopwebshare_permalink

And

https://www.wsj.com/health/healthcare/emergency-rooms-hospitals-kids-1c41a8a8?st=glbjahasybcdido&reflink=desktopwebshare_permalink

EMSC would like to know your thoughts on these articles; both on their content and how you are currently being supported or unsupported in your PECC role. Shoot us a quick email at tdickson@utah.gov.

The federal EMS for Children leadership team is requesting some clarification and/or correction on key items with the reporter and is developing messaging with national partners to better explain pediatric recognition programs currently. We anticipate there will be at least one more article coming out from the journal on this topic.

Research has shown that we can improve outcomes for patients who have a traumatic brain injury (TBI), especially in the prehospital setting. First, we must understand the importance of managing ventilation and blood pressure. "A single saturation <90% or an episode of hypotension is associated with a 2x mortality for severe TBI patients." PECCs, look at this guideline and find ways to incorporate it into your agency and hospital protocols. The protocols are now available on the UPTN website . Click guidelines and then additional resources.

The Northern PECC workshop was held in Salt Lake City on September 1, 2023 and we had a blast! There were great presentations, hands-on learning opportunities, good discussion, and lots of food and swag. We hope you will join us for the next one in St. George in March 2024.

New performance measures aim to enhance pediatric readiness

Nine performance measures and 2 program evaluation measures have been newly revised and released by the EMSC Program. Read more.

For EMS agencies: Three Ways to Improve your EMS Agency’s Pediatric Readiness.

For hospitals: National Pediatric Readiness Project (NPRP) Toolkit

Pediatric education for the prehospital provider

Register online at www.peppsite.com. Look up classes in Utah and find the 1 that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($21.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, email Erik Andersen at erikandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

The Emergency Medical Services for Children (EMSC) Program aims to ensure emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, regardless of where they live, attend school, or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth