Improving Prehospital Protocol Adherence Using Bundled Educational Interventions

Prehosp Emerg Care. 2018 May-Jun;22(3):361-369. doi: 10.1080/10903127.2017.1399182. Epub 2018 Jan 24.


Background: Seizures and anaphylaxis are life-threatening conditions that require immediate treatment in the prehospital setting. There is variation in treatment of pediatric prehospital patients for both anaphylaxis and seizures. This educational study was done to improve compliance with pediatric prehospital protocols, educate prehospital providers and decrease variation in care.

Objective: To improve the quality of care for children with seizures and anaphylaxis in the prehospital setting using a bundled, multifaceted educational intervention.

Methods: Evidence-based pediatric prehospital guidelines for seizures and anaphylaxis were used to create a curriculum for the paramedics in the EMS system. The curriculum included in-person training, videos, distribution of decision support tools, and a targeted social media campaign to reinforce the evidence-based guidelines. Prehospital charts were reviewed for pediatric patients with a chief complaint of anaphylaxis or seizures who were transported by paramedics to one of ten hospitals, including three children's hospitals, for 8 months prior to the intervention and eight months following the intervention. The primary outcome for seizures was whether midazolam was given via the preferred intranasal (IN) or intramuscular (IM) routes. The primary outcome for anaphylaxis was whether IM epinephrine was given.

Results: A total of 1,402 pediatric patients were transported for seizures by paramedics to during the study period. A total of 88 patients were actively seizing pre-intervention and 93 post-intervention. Of the actively seizing patients, 52 were given midazolam pre-intervention and 62 were given midazolam post-intervention. Pre-intervention, 29% (15/52) of the seizing patients received midazolam via the preferred IM or IN routes, compared to 74% (46/62) of the seizing patients post-intervention. A total of 45 patients with anaphylaxis were transported by paramedics, 30 pre-intervention and 15 post-intervention. Paramedics administered epinephrine to 17% (5/30) patients pre-intervention and 67% (10/15) patients post-intervention.

Conclusion: The use of a bundled, multifaceted educational intervention including in-person training, decision support tools, and social media improved adherence to updated evidence-based pediatric prehospital protocols.

Keywords: anaphylaxis; education; emergency medical services; pediatric; seizure.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Administration, Intranasal
  • Adolescent
  • Allied Health Personnel
  • Anaphylaxis / drug therapy
  • Child
  • Child, Preschool
  • Clinical Protocols*
  • Curriculum*
  • Emergency Medical Services / standards*
  • Epinephrine / therapeutic use
  • Female
  • Guideline Adherence*
  • Hospitals, Pediatric
  • Humans
  • Hypnotics and Sedatives / administration & dosage
  • Infant
  • Injections, Intramuscular
  • Male
  • Midazolam / administration & dosage
  • Seizures / drug therapy
  • Teaching / organization & administration*


  • Hypnotics and Sedatives
  • Midazolam
  • Epinephrine