Interobserver Agreement in Pediatric Asthma Examination Findings Between Emergency Medical Services and Emergency Department Clinicians

OBJECTIVES: Asthma exacerbations constitute 10-15% of all pediatric emergency medical services (EMS) calls. There are several validated scoring tools to assess acute asthma severity, which have good inter-rater reliability and correlate with clinical outcomes in the emergency department (ED), but have not been validated with EMS clinicians. This study sought to assess the level of agreement between EMS and ED clinicians on components of asthma scoring tools to inform a prehospital asthma severity scoring tool. METHODS: We conducted a prospective observational study of children 2-18 years old transported by EMS with an impression of asthma exacerbation to five pediatric EDs. EMS and ED clinicians independently completed surveys assessing the patient's exam on arrival to the ED. Survey items were drawn from existing asthma scoring tools and refined by focus groups and a Delphi process with EMS clinicians and expert stakeholders. To determine agreement between EMS and ED clinicians regarding survey items, inter-rater reliability was calculated using Kappa and intraclass correlation coefficient for binary and ordinal variables, respectively. RESULTS: We enrolled a convenience sample of 295 children with a median age of 7 years (inter-quartile range 3-12 years). There was slight agreement among EMS and ED clinicians (κ = 0.01-0.20) for suprasternal retractions and fair agreement (κ = 0.21-0.40) for tachypnea, accessory muscle use, and elevated respiratory rate. There was poor agreement (ICC = 0-0.50) for breathlessness, work of breathing, degree of hypoxia, type of wheeze, and wheezing intensity. CONCLUSIONS: We observed limited agreement between EMS and ED clinicians when assessing children for components of asthma severity scores. Developing a prehospital asthma exacerbation severity scoring tool to guide EMS interventions may be challenging. Further research is needed to determine whether education improves EMS performance with asthma scoring tools or whether standardized EMS asthma protocols, regardless of exacerbation severity, improve patient outcomes.