Factors Associated with Caregiver Decision Not to Transport Pediatric Patients Assessed by Emergency Medical Services

Objectives: Almost one third of pediatric 9-1-1 calls result in non-transport by Emergency Medical Services (EMS). It is unknown to what extent these decisions are driven by caregivers’ decisions to decline transport versus EMS advice that transport is unnecessary. Further, it is unknown whether demographic, encounter, or agency factors are associated with caregivers declining transport. Methods: We conducted a retrospective cross-sectional study with data from the national 2019 ESO Data Collaborative (a convenience sample with data from > 2,000 EMS agencies). We included 9-1-1 responses for children <18 years. The primary outcome was caregiver decision not to transport patient (per EMS documentation) compared to EMS-initiated non-transport. Descriptive data for patient dispositions were generated. Bivariable and multivariable logistic regression identified factors associated with caregiver decision not to transport. Results: Of 313,903 pediatric 9-1-1 activations, 37.2% resulted in non-transport, with 80.0% of pediatric non-transports attributable to a caregiver decision. The patient and encounter characteristics for children not transported by EMS were similar, regardless of whether the caregiver or EMS clinician made the decision not to transport. There was wide inter-agency variation in both the rate of non-transport (median 0.37, interquartile range (IQR 0.25 – 0.48)) and the proportion of these encounters attributable to a caregiver decision (median 0.82, IQR 0.68-0.94). Conclusions: In this large national dataset, pediatric non-transport by EMS was common, and in most cases non-transport was documented to result from a caregiver decision. Both the rates of non-transport and proportion of caregiver decision varied significantly between EMS agencies. Further research is needed to understand pediatric patient outcomes after non-transport and to identify the reasons for practice variability between EMS agencies. Developing standardized, evidence-based non-transport protocols for children may help reduce this potentially unwarranted clinical variation.