ABCs of an office emergency

Key Points

• Children who need emergency treatment are often brought first to their pediatrician's office.
• Airway emergencies are most common, followed by seizures.
• Many primary care office are unprepared or underprepared to handle emergencies, because of inadequate supplies, staff training, written protocols, and participation in mock codes.
• Before deciding what emergency supplies to stock, assess the specifics of your practice.

Imagine that you are working in an outpatient pediatric practice one busy winter morning when a mother arrives with her 3-month-old infant, who is in florid respiratory distress. The mother had made an appointment the previous day for a sick visit because her daughter had had congestion and a runny nose for several days.

Today, the frazzled mother tells the receptionist, the baby is breathing fast and the child's ribs are visible when she breathes. The receptionist signs the patient in and asks the mother to have a seat in the waiting area.

Ten minutes later, the mother notes a pause in her infant's previously noisy breathing and looks down to see that her child's lips are blue. She rushes her daughter back to the desk, and the receptionist runs to find you.

By the time you get to the infant, she's once again breathing spontaneously but with deep suprasternal and subcostal retractions, grunting, and nasal flaring. You bring her to an open examination room, calling out to the receptionist to phone 911. The nurse goes in search of a pulse oximeter while you scramble to find an appropriate-sized face mask and an oxygen canister.

After several minutes, the child is placed on oxygen, and her saturation rate rises from 81% to 95%. You assess her circulation, noting that she has delayed capillary refill and a slightly sunken fontanel. She clearly needs fluids, but the office doesn't have intravenous (IV) catheters or normal saline.

After several minutes, the child is placed on oxygen, and her saturation rate rises from 81% to 95%. You assess her circulation, noting that she has delayed capillary refill and a slightly sunken fontanel. She clearly needs fluids, but the office doesn't have intravenous (IV) catheters or normal saline.

You have no choice but to wait for the local emergency medical services (EMS) to arrive to start an IV and transport the infant to the nearest emergency department.

If this baby had been brought to your office, would she have received the prompt medical attention she needed? Would the receptionist have noted her ill appearance and notified you immediately? Would your office have had the necessary emergency medications and equipment organized, up-to-date, and readily available?

Children requiring urgent or emergent treatment often are brought first to their primary-care physician. Pediatric offices encounter an average of 1 to 38 emergencies per office per year.¹ A periodic survey from the American Academy of Pediatrics (AAP) demonstrated that 73% of respondents encountered at least 1 patient per week who required emergency treatment or hospitalization.¹

Airway emergencies are by far the most common events in offices, accounting for approximately 75% of emergencies encountered in primary-care practice. One study identified the 4 most frequently seen airway emergencies, in order from most prevalent to least prevalent, as bronchiolitis, respiratory distress, asthma, and croup.² Dehydration, seizures, and anaphylaxis came next in frequency. Rarer emergencies included respiratory failure, severe trauma, foreign body/obstructed airway, shock, meningitis, sepsis, and apnea.²

Where offices fall short of preparedness

Despite the prevalence of outpatient emergencies, many primary-care offices remain unprepared or underprepared to handle these types of problems. Deficiencies include failure to stock proper equipment and medications, provide up-to-date emergency training and certification for staff, participate in regular office mock codes, and develop written protocols.

Emergency supplies. Primary-care offices often fail to keep on hand a stock of functional, well-organized, and easily accessible supplies for emergencies. A study of 52 pediatric offices that saw a total of more than 2,400 emergencies each year found that the following crucial supplies were often unavailable: oxygen (27%), IV catheters (27%), bag-valve masks (29%), and IV fluids (55%).³ Another study reported that only 27% of 38 offices stocked intraosseous needles.⁴

Staff training. Physicians, nurses, and other office staff in outpatient practices often do not keep their basic and advanced life-support training certification up to date. A 2006 study of 11 group pediatric practices in Pennsylvania found that only 39% of physicians had current certification in basic life support (BLS); only 18% had up-to-date certification in pediatric advanced life support (PALS). The study also revealed that no other office employees, including nurse practitioners and nurses, had current certification in PALS. None of the nonmedical staff-secretaries, receptionists, and office managers-had any type of life-support training.⁵

Mock codes and protocols. Although mock codes have been shown to promote emergency preparedness in inpatient facilities, they have been less studied in outpatient settings. One large randomized, controlled trial of the effects of unannounced mock codes on office emergency preparedness assigned practices to an intervention group that participated in a mock code, followed by debriefing and review of the office's equipment, and a control group that did not. The intervention group also received a resource manual that included suggestions for preparing for office emergencies, tips for running mock codes, and treatment protocols for specific emergency conditions.

The results of the study indicated that the practices in the intervention group were more likely than those in the control group to develop written office protocols for emergencies (60% vs 21%) and were more likely to undergo additional BLS, PALS, and advanced cardiac life-support training in the 6 months after the intervention. The 2 groups did not differ with regard to the proportion that conducted subsequent mock codes or other practice exercises.¹

Another study of 38 of the 40 active primary care pediatric practices in Vermont demonstrated similar results. Each practice received a video on airway management and intraosseous techniques along with a teaching session and a donated emergency resuscitation kit. In the 12 months after the intervention, more participating offices developed written emergency protocols than before the intervention (83% vs 67%) and regularly checked emergency equipment (97%).⁴

The resuscitation kits that were donated to the 38 practices included in the study comprised basic supplies needed to support airway, breathing, and circulation (bag-mask ventilators, oxygen canisters, IV catheters, and IV fluids) and basic medications (albuterol, ceftriaxone, diphenhydramine, epinephrine, and diazepam). Each kit cost less than $600. Every emergency that arose in the 38 practices in the year after the intervention was handled using only the drugs and equipment included in the donated kits.⁴