Office preparedness for childhood emergencies

When a child experiences a medical emergency, it is not surprising that parents may think first of seeking care from their pediatrician whom they know and trust. Various studies conducted at local and national levels document how often these events occur. In a relatively recent survey including outpatient pediatricians from a single medical center, 39% of 57 respondents reported seeing at least 1 emergency per month.¹ An older survey collecting information from 51 practices found that 82% saw at least 1 emergency per month and 25% experienced more than 50 emergencies per year.² Data from other older surveys showed that about two-thirds of pediatric care providers saw at least 1 child per week with an emergency who required hospitalization or urgent treatment.^3,4

Whereas these studies highlight a need for pediatrician offices to be ready to handle emergencies, available data also demonstrate that many practices, including those that have already needed to treat a critically ill child, are not adequately prepared because they lack the relevant protocols, training, and tools.^1,3-7

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The reasons for the suboptimal preparedness are varied.⁸ Some practitioners dismiss the need based on beliefs that emergencies are uncommon or can be handled adequately either by calling for emergency medical services (EMS) or because of the practice’s nearness to a hospital. Reviewing their risk-management guidelines, some practitioners wrongly come to the conclusion that having emergency equipment and medications on site increases their liability in emergency situations. Others cite prohibitive costs of maintaining the necessary equipment and medication.

In 2007, recognizing that pediatric practices may be required to provide urgent or emergent care in their offices and that patient outcomes in these situations can depend on office preparedness to deliver care, the American Academy of Pediatrics (AAP) Committee on Pediatric Emergency Medicine developed a policy statement on “Preparation for Emergencies in the Offices of Pediatricians and Pediatric Primary Care Providers.”⁸ Findings of a survey conducted about 5 years after its publication, however, showed that only about one-half of pediatricians knew the policy statement existed and only about one-quarter believed their office was in compliance.¹

This article aims to raise awareness of this critically important document. It summarizes the 8 recommendations and highlights the key supporting materials that are provided in the policy statement (Table 1), but readers are urged to read the document in its entirety.

NEXT: Recommendations

RECOMMENDATION 1

Perform a self-assessment of office readiness for emergencies based on a review of experiences of common emergent, urgent, and acute conditions treated in the office, including events involving children with special care needs.

A self-assessment that identifies the types of emergencies that have been seen in the office and the available resources both on-site and accessible through the emergency care system of which the office is part provides the foundation for enhancing readiness to handle emergencies.

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Issues to consider include the emergency response skills of office staff, the outside resources that can be called upon in the event of an emergency, and how long it takes for an EMS team to reach the office and to transfer the child to a facility for definitive emergency care. Practices also should review their risk-management company’s policy regarding emergency preparedness.

To enable identification of specific targets for improving office preparedness, the policy statement includes a 27-item self-assessment tool.

NEXT: Essential and recommended equipment

RECOMMENDATION 2

Develop an organizational plan for emergency response in the office.

This recommendation recognizes that emergency preparedness and the execution of a rapid response involve the efforts of a coordinated team whose members understand their roles and responsibilities. It emphasizes needs for assigning specific roles to individual staff; having a viable plan for responding during periods when the office is not fully staffed; developing a protocol for accessing an EMS team; and conducting mock codes to maintain readiness.

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Several of the appendices included in the guideline provide useful resources to assist staff in recognizing and responding to emergencies.

RECOMMENDATION 3

Maintain recommended emergency equipment.

The policy statement provides a list of equipment and supplies that offices should have on hand as part of emergency preparedness (Table 2). The items are categorized based on application (airway management; vascular access and fluid management; and other miscellaneous equipment and supplies) and priority (essential versus strongly suggested if EMS response time is greater than 10 minutes).

To facilitate fast retrieval and use of proper equipment if it is needed, the statement suggests keeping the articles in a designated resuscitation room or in a box that is kept in a location known to all office staff. The policy statement also suggests that the items be organized according to the size of the child. All equipment and supplies should be regularly checked to ensure all are present, functioning, and not expired.

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RECOMMENDATION 4

Maintain recommended emergency medications and use a resuscitation aid or tool that provides suggested protocols with precalculated medication doses.

The policy statement also provides a listing of office emergency drugs that are similarly identified as essential or strongly suggested depending on EMS response time (Table 3). As with the equipment, medications and fluids should be checked regularly to make sure that all are present and that expired products are replaced.

The recommendation to use a resuscitation aid or tool providing protocols with precalculated medication doses recognizes that dosing errors are a particular problem in pediatric patients.

RECOMMENDATION 5

Develop a plan to provide education and continuing medical education for all staff.

This recommendation recognizes the need for all personnel who may encounter a child in an emergency situation to have proper training to perform their duties and to maintain their knowledge and skills. Front-office staff must be able to recognize an emergency and initiate the response plan. Professional staff must be capable of providing basic airway management and initiating treatment of shock.

As identified in the policy statement, the AAP/American College of Emergency Physicians (Advanced Pediatric Life Support [APLS]: The Pediatric Emergency Medicine Resource: www.apisonline.com/default.aspx; Advanced Life Support [ALS]: bit.ly/ALS-courses), the American Heart Association (PALS: Pediatric Advanced Life Support: bit.ly/PALS-training), and the Emergency Nurses Association (ENPC: Emergency Nursing Pediatric Course: bit.ly/ENPC-course) offer relevant instructional courses.

RECOMMENDATION 6

Practice mock codes in the office on a regular basis (quarterly or biannually).

Beyond having the knowledge and skills to respond to an emergency, office staff must be able to implement their responsibilities. Rehearsing by conducting mock emergency situations provides practice for maintaining preparedness and allows identification of ways to improve the response. Practicing mock codes also has been demonstrated to improve the confidence and comfort of pediatric providers for performing life-saving skills.⁹

The mock codes should involve as many office staff as possible and, ideally, also participation of local EMS personnel. To facilitate a postexercise review and development of action plans to fine-tune the response, the policy statement recommends that one person should be designated to observe and document the event. Evaluation checklists are found in the appendices.

A sample resuscitation log that can be used for collecting information during real emergency situations that will be vital for the child’s continuity of care is also included in the guideline.

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The guideline also recommends including disaster-preparedness scenarios in the mock exercises.

RECOMMENDATION 7

Educate families about what to do in an emergency.

Family education aims to facilitate the fastest delivery of appropriate care that will optimize the outcome of a childhood emergency. It includes helping families to identify emergencies, decide where they should seek care, maintain information for children with special healthcare needs, and respond themselves by getting training in first aid and cardiopulmonary resuscitation. In addition to providing educational materials with information relevant to these topics, families should be provided with access numbers for reaching the office after hours as well as the emergency response system and poison centers. Resources available through the AAP include The Injury Prevention Program (TIPP), the first-aid chart, and an EMS information card.

RECOMMENDATION 8

Partner with EMS and hospital-based emergency providers to ensure optimal emergency care and emergency/disaster readiness for children.

The policy statement also suggests working with local EMS personnel who can provide in-office training or educational sessions as well as practice-specific input on the logistics of handling an emergency.

REFERENCES

1. Pendleton AL, Stevenson MD. Outpatient emergency preparedness: a survey of pediatricians. Pediatr Emerg Care. 2015;31(7):493-495.

2. Flores G, Weinstock DJ. The preparedness of pediatricians for emergencies in the office: what is broken, should we care, and how can we fix it? Arch Pediatr Adolesc Med. 1996;150(3):249-256.

3. Fuchs S, Jaffe DM, Christoffel KK. Pediatric emergencies in office practices: prevalence and office preparedness. Pediatrics. 1989;83(6):931-939.

4. American Academy of Pediatrics. Periodic survey #27: Emergency readiness of pediatric offices. Available at: https://www.aap.org/en-us/professional-resources/Research/Pages/PS27_Executive_Summary_EmergencyReadinessofPediatricOffices.aspx. Accessed April 20, 2017.

5. Santillanes G, Gausche-Hill M, Sosa B. Preparedness of selected pediatric offices to respond to critical emergencies in children. Pediatr Emerg Care. 2006;22(11):694-698.

6. Mansfield CJ, Price J, Frush KS, Dallara J. Pediatric emergencies in the office: are family physicians as prepared as pediatricians? J Fam Pract. 2001;50(9):757-761.

7. Heath BW, Coffey JS, Malone P, Courtney J. Pediatric office emergencies and emergency preparedness in a small rural state. Pediatrics. 2000;106(6):1391-1396.

8. American Academy of Pediatrics Committee on Pediatric Emergency Medicine; Frush K. Preparation for emergencies in the offices of pediatricians and pediatric primary care providers. Pediatrics. 2007;120(1):200-212.

9. Toback SL, Fiedor M, Kilpela B, Reis EC. Impact of a pediatric primary care office-based mock code program on physician and staff confidence to perform life-saving skills. Pediatr Emerg Care. 2006;22(6):415-422.