Pediatric Annals

EDITORIAL 

A Pediatrician's View: Know Your ABC's

William A Altemeier, III, MD

Abstract

The occasional emergency makes general pediatrics real. Just when you are lulled into boredom by well-child visits, sore throats, and diarrhea, up pops a 2 month old with 15% dehydration or a 12 year old with septic shock. These patients give new meaning to pediatric office practice. I don't think you can ever be fully ready but there is a spectrum from not being ready at all to being as ready as possible, and the latter is where we should be. But at least five conditions seem to interfere with readiness for a true emergency. These are inadequate experience/knowledge, procrastination, rationalization, and during the emergency, chaos and fear. The following are some ways of overcoming these obstacles.

The first step is office readiness:

* Avoid the common rationalization "we don't have emergencies in the office - they all go to the emergency room." This is a wish rather than a statement, and the only situation that you can fully depend on using the emergency department for an unexpected office catastrophe is when your office is close enough to be functionally part of the emergency center. Don't procrastinate on getting your office ready.

* Your front desk staff should be trained to actively screen for critically M children during sign-in and notify you or your nurse immediately if there is a question. It is poor form to have a baby with acidosis and dehydration stop breathing while waiting to be seen in your office.

* Have the right equipment for emergency treatment and resuscitation, and a system to make sure it is always there and working. Specific recommendations will be addressed in an upcoming Pediatric Annals.

* You and your clinical staff should be certified in pediatric advanced life support (PALS). This course is invaluable because it gives you organized steps to follow during the chaos of a resuscitation. "A" for airway, "B" for breathing, and "C" for circulation are a must in organizing care.

* Practice resuscitation in the office. Planned mock resuscitation exercises are common in pediatric residency programs and easily adaptable to the office. For example, one of your colleagues might create a clinical story unknown to you such as a lethargic and cyanotic 3 month old who turns out to have severe respiratory syncytial virus pneumonia. After warning your staff that your colleague will be helping you conduct a surprise resuscitation "fire drill," your colleague's nurse or colleague might unexpectedly burst into your examination area (or the waiting room if your families have a good sense of humor) carrying a doll and indicating "my baby just turned blue and I think she has stopped breathing." The individual serving as the parent would have the history (respiratory distress, poor intake, and reduced urine), physical examination findings/vital signs (cyanosis, apnea, and bradycardia), and clinical information when prompted (oxygen saturation and whatever other laboratory results you would likely do in stabilizing a baby such as this before sending to an emergency center). You then go through a mock resuscitation, calling out orders and walking through the ABC's, while sending someone to get the history. You would make sure everybody knew their role and could lay their hands on the equipment needed. You would get 100% oxygen going, intravenous or intraosseous "access," and see how long it takes for your staff to come up with a bolus of 20 cc/kg of normal saline. Then reciprocate the exercise in your colleague's office. These fire drills build teamwork, turn a slow day productive, remind everyone of what can happen, and help people deal with the confusion that is part of the real event.…

The occasional emergency makes general pediatrics real. Just when you are lulled into boredom by well-child visits, sore throats, and diarrhea, up pops a 2 month old with 15% dehydration or a 12 year old with septic shock. These patients give new meaning to pediatric office practice. I don't think you can ever be fully ready but there is a spectrum from not being ready at all to being as ready as possible, and the latter is where we should be. But at least five conditions seem to interfere with readiness for a true emergency. These are inadequate experience/knowledge, procrastination, rationalization, and during the emergency, chaos and fear. The following are some ways of overcoming these obstacles.

The first step is office readiness:

* Avoid the common rationalization "we don't have emergencies in the office - they all go to the emergency room." This is a wish rather than a statement, and the only situation that you can fully depend on using the emergency department for an unexpected office catastrophe is when your office is close enough to be functionally part of the emergency center. Don't procrastinate on getting your office ready.

* Your front desk staff should be trained to actively screen for critically M children during sign-in and notify you or your nurse immediately if there is a question. It is poor form to have a baby with acidosis and dehydration stop breathing while waiting to be seen in your office.

* Have the right equipment for emergency treatment and resuscitation, and a system to make sure it is always there and working. Specific recommendations will be addressed in an upcoming Pediatric Annals.

* You and your clinical staff should be certified in pediatric advanced life support (PALS). This course is invaluable because it gives you organized steps to follow during the chaos of a resuscitation. "A" for airway, "B" for breathing, and "C" for circulation are a must in organizing care.

* Practice resuscitation in the office. Planned mock resuscitation exercises are common in pediatric residency programs and easily adaptable to the office. For example, one of your colleagues might create a clinical story unknown to you such as a lethargic and cyanotic 3 month old who turns out to have severe respiratory syncytial virus pneumonia. After warning your staff that your colleague will be helping you conduct a surprise resuscitation "fire drill," your colleague's nurse or colleague might unexpectedly burst into your examination area (or the waiting room if your families have a good sense of humor) carrying a doll and indicating "my baby just turned blue and I think she has stopped breathing." The individual serving as the parent would have the history (respiratory distress, poor intake, and reduced urine), physical examination findings/vital signs (cyanosis, apnea, and bradycardia), and clinical information when prompted (oxygen saturation and whatever other laboratory results you would likely do in stabilizing a baby such as this before sending to an emergency center). You then go through a mock resuscitation, calling out orders and walking through the ABC's, while sending someone to get the history. You would make sure everybody knew their role and could lay their hands on the equipment needed. You would get 100% oxygen going, intravenous or intraosseous "access," and see how long it takes for your staff to come up with a bolus of 20 cc/kg of normal saline. Then reciprocate the exercise in your colleague's office. These fire drills build teamwork, turn a slow day productive, remind everyone of what can happen, and help people deal with the confusion that is part of the real event.

* Keep your experience level as high as possible. For example, think clearly before you take a job that offers no night call or inpatient responsibilities. Recently, managed care seems to have increased these positions to recruit general pediatricians who will increase their market share. The health maintenance organization then relies on urgent care or emergency centers for after hours (as described below) and contracts for inpatient services. No night or inpatient call is a powerful and seductive temptation. But you will niche yourself as a caretaker for well and mild to moderately sick outpatient children, and quickly lose skills and courage required for sicker patients. If nurse practitioners gradually increase their role in outpatient pediatric care, these jobs could be squeezed.

Now let's look at some of the common mistakes made by the pediatrician when an actual emergency is eminent or ongoing. What should you try to do when your telephone rings at 2 AM and the emergency department nurse calls to say an ambulance is on its way with a 10-year-old girl who has asthma, is cyanotic, and not moving air. And no other physician is there.

* Get your emotions under control as much as possible. Some fear is normal, and a healthy flow of adrenaline is probably an advantage. Settle down from the panic and get your plan moving. If you find yourself becoming numb or making excuses to yourself about why things won't go right, fight it. An emergency can be compared to a very important ("pop") final exam - your mood should be intense and positive but not overcome by anxiety: "I'm going to do the best I can with what I have."

* Line up whatever help you might need from other physicians or staff. This patient will almost certainly require vascular access and maybe intubation. Think about who can do these and put them on immediate notice or ask them to come in. It's less embarrassing to have them there and not need them than the reverse. Be creative: resources include anesthesia, emergency center or transport staff, or critical care or neonatal intensive care staff and surgeons.

* Get there on time. "Call me when this patient gets there" is an unwise procrastination. Tell the emergency center to have 100% oxygen and albuterol treatment by high-frequency nebulización ready. Double-check that you have what you need and know where it is when you arrive.

* Somebody must be in charge. Have you seen physicians and nurses watching in inaction when first presented with a sudden emergency? The patient's physician should declare he or she is taking charge or ask someone else to do this. This should be the most qualified person present. Emily Post's rules of etiquette and Robinson's rules of protocol can be ineffective in resuscitations. The leader should stay one step ahead and delegate responsibility to all present, irrespective of everyone's usual rank.

* Use your ABCs.

Now let's shift from the "personal" side of emergency care and look at medical systems. What impact will managed care have on emergency services? Will emergency care change?

The first thing that comes to mind are the attempts of managed care to reduce costs by decreasing medically unnecessary emergency center visits. Health maintenance organizations accomplish this by educating parents, solving problems by telephone when possible, requiring prior authorization, and charging a higher copayment for emergency compared with office visit. On the surface, we know that emergency care is more expensive than office care and that emergency rooms have many children who could and should receive their care in physicians' offices.

For example, a study of six community hospitals in Michigan found that 32% of emergency department visits were nonurgent.' But when you analyze this situation in more depth, complexities appear. First, although triage guidelines can decrease emergency department visits,2 they also can misclassify urgency for many patients.3,4 And, although copayments also divert emergency visits,5 their ultimate safety is only partially established. Second, although emergency department visits generate higher charges and average costs than office visits, the money saved by shifting patients with nonurgent illnesses is much less than it appears because of the concept of fixed and variable costs. Understanding this concept is fundamental in knowing the actual cost of care. Fixed costs are those that must be paid irrespective of the number of patients seen, such as rent; baseline nursing, physician, and support staff salaries; and costs of administration, utilities, insurance, etc. Variable costs are those connected to patient volume and include additional staff and physician salaries required to serve an increased patient volume plus clinical and office supplies, etc. Emergency departments have relatively high fixed costs because they must be ready for emergencies 24 hours a day, 7 days a week. So when you drop the volume of patients seen in emergency rooms, the variable cost will drop while fixed costs are unchanged. Thus, the average cost per visit will increase.

The Michigan study described above explored this by comparing average charge to the payor, cost to the emergency center, and marginal cost (the emergency center's cost of doing one additional visit).1 The average cost is based on all fixed and variable costs, but adding or subtracting a visit would change variable but not fixed costs. These values for the 32% of all visits classified as nonurgent were $125, $62, and $24, respectively. So reducing an unnecessary visit would only decrease actual costs by $24. The marginal cost of the next visit was $67 for semi-urgent and $148 for urgent patients. Thus, savings by diverting nonurgent visits to pediatric offices is not impressive.

There are two main points of this example. The first is to show how emergency departments can suffer financially unless they understand their costs and how this can help them adapt to managed care by providing services that are competitive with those in offices. Urgent care and emergency centers that take over all of night call, thus increasing volume and decreasing average per visit costs, are examples. One can expect a "consolidation" of emergency rooms over the next few years to save money, ie, close those least profitable and shift patients to those that remain. The impact on patients will be determined by a formula that accounts for any decrease in accessibility by closings and any increase in quality due to higher volumes and better financial status for those that survive. The second point is the importance of information technology and systems in managed care. To bid sufficiently low to be competitive without losing money and to weigh cost effectiveness of alternate strategies for management, systems that track costs are a must. Although insurance companies are developing these systems, this field is still relatively primitive. Medical information systems to track cost will be a booming industry: those who have and use this technology will be the financial winners, and we all know that information is power.

REFERENCES

1. Williams RM. The costs of visits to emergency departments. N Engl J Med. 1996,-334:642-646.

2. Derlet RE, Kinser D, Ray L, Hamilton B, McKenzie], Prospective identification and triage of nonemergency patients out of an emergency department: a 5-year study. Ann Emerg Mel 1995;25:215-223.

3. Lowe RA, Bindman AB, Ulrich SK. et al. Refusing care to emergency department of patients: evaluation of published triage guidelines. Ann Emerg Med. 1994;23:286-293.

4. Birnbaum A, Gallagher FJ, Utkewicz M, Cennis P, Carter W. Failure to validate a predictive model for refusal of care to emergency-department patients. Acad Emerg Med. 1994;1:233-217.

5. Selby JV, Fireman BH, Swain BE. Effect of a copayment on use of the emergency department in a health maintenance organization. N Engl ) Med. 1996;334:635-641.

10.3928/0090-4481-19960601-06

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