Pediatric Annals

from the guest editor 

THIS ISSUE: Managing Emergencies Part 1

Mark E Ralston, MD, MPH

Abstract

Since the 1980s, pediatric offices have been identified as poorly prepared to handle emergencies.1-5 Statements from the American Heart Association (AHA), the American Academy of Pediatrics (AAP), and the Institute of Medicine long have been available directing office pediatricians and their staff that adequate preparedness is essential to ensure appropriate initial management and stabilization of children with emergencies.6-8

Despite these recommendations, many offices remain underprepared.5 Pediatric office preparedness has been declared deficient predominantly in three areas: equipment and medications, education and training, and protocol development.

Many pediatric offices lack essential emergency equipment and medications.1-5 In a survey of office pediatricians and family practitioners in Chicago, Illinois, fewer than one-third of offices that reported one or more child per week with asthma, allergy injections (possible anaphylaxis), sepsis, status epilepticus, or sickle cell vasoocclusive crisis were equipped to treat problems related to these emergencies adequately.1 An oxygen delivery device was unavailable in 27% of pediatric offices surveyed in Fairfield County, Connecticut.4 Other unavailable emergency equipment identified in this survey included intravenous catheters (unavailable in 27% of practices); bag-valve-mask ventilation devices (29%); nebulizers (33%); epinephrine 1:10,000 (53%); and intravenous fluids (55%).4 In an AAP survey of 744 office pediatricians, length-based resuscitation tapes, used to determine proper equipment sizes, were not available in 66% of practices.12 Intraosseous needles were found missing in 63% of pediatrician and family physician offices surveyed in Wisconsin.5

Essential equipment and medications have been defined as those most likely to be needed to provide life-sustaining treatment in the first 10 minutes of an emergency.9 The AAP has provided lists of emergency equipment and medications likely to be used by pediatric offices located less than 10 minutes from emergency medical services (EMS) and within 20 minutes from the nearest appropriate hospital emergency department.9 An additional piece of equipment which should be considered for office practices is a manual defibrillator, or an automated external defibrillator with pediatric attenuator pads, which now may be used in children ages 1 to 8 with no signs of circulation.10 Essential equipment and medications should be stored together, easily accessible, checked periodically, and tailored to individual practice populations.11

The pediatric primary care provider plays a pivotal role in handling office emergencies8 but often is trained inadequately in basic and advanced life support skills.4-5,12 Furthermore, office-based providers frequently are deficient in requiring office staff to maintain certification in pediatrie cardiopulmonary resuscitation or to participate in periodic mock drills of pediatric emergencies.12 In the Connecticut survey, just 14% of eligible staff were certified in Basic Life Support (BLS) and 17% of staff were certified in Pediatric Advanced Life Support (PALS).4 The AAP survey reported that 65% of physicians were required to maintain BLS certification and 42% of physicians and 18% of office nurses were required to maintain PALS certification.12 In the same survey, 32% of office pediatricians required participation by office staff in mock codes.12 In the Wisconsin survey, the PALS certification requirement rate was 26% for office physicians and 5% for office nurses.5

Development of written protocols for office emergencies also has been identified as deficient.12 In the AAP survey, only 37% of office practices had protocols, either telephone- or office-based, to handle emergencies.12

Reasons offered by providers for lack of office preparedness indicate apathy, complacency, and misinformation.4 Perceptions include beliefs that office emergencies are rare enough that preparation is unnecessary; that there is not enough time to train adequately or assemble equipment and medications; that necessary supplies to handle an emergency are too costly; and that the office is close enough to the hospital that others can respond to the emergency.4

Pediatric office emergencies in fact are…

Since the 1980s, pediatric offices have been identified as poorly prepared to handle emergencies.1-5 Statements from the American Heart Association (AHA), the American Academy of Pediatrics (AAP), and the Institute of Medicine long have been available directing office pediatricians and their staff that adequate preparedness is essential to ensure appropriate initial management and stabilization of children with emergencies.6-8

Despite these recommendations, many offices remain underprepared.5 Pediatric office preparedness has been declared deficient predominantly in three areas: equipment and medications, education and training, and protocol development.

Many pediatric offices lack essential emergency equipment and medications.1-5 In a survey of office pediatricians and family practitioners in Chicago, Illinois, fewer than one-third of offices that reported one or more child per week with asthma, allergy injections (possible anaphylaxis), sepsis, status epilepticus, or sickle cell vasoocclusive crisis were equipped to treat problems related to these emergencies adequately.1 An oxygen delivery device was unavailable in 27% of pediatric offices surveyed in Fairfield County, Connecticut.4 Other unavailable emergency equipment identified in this survey included intravenous catheters (unavailable in 27% of practices); bag-valve-mask ventilation devices (29%); nebulizers (33%); epinephrine 1:10,000 (53%); and intravenous fluids (55%).4 In an AAP survey of 744 office pediatricians, length-based resuscitation tapes, used to determine proper equipment sizes, were not available in 66% of practices.12 Intraosseous needles were found missing in 63% of pediatrician and family physician offices surveyed in Wisconsin.5

Essential equipment and medications have been defined as those most likely to be needed to provide life-sustaining treatment in the first 10 minutes of an emergency.9 The AAP has provided lists of emergency equipment and medications likely to be used by pediatric offices located less than 10 minutes from emergency medical services (EMS) and within 20 minutes from the nearest appropriate hospital emergency department.9 An additional piece of equipment which should be considered for office practices is a manual defibrillator, or an automated external defibrillator with pediatric attenuator pads, which now may be used in children ages 1 to 8 with no signs of circulation.10 Essential equipment and medications should be stored together, easily accessible, checked periodically, and tailored to individual practice populations.11

The pediatric primary care provider plays a pivotal role in handling office emergencies8 but often is trained inadequately in basic and advanced life support skills.4-5,12 Furthermore, office-based providers frequently are deficient in requiring office staff to maintain certification in pediatrie cardiopulmonary resuscitation or to participate in periodic mock drills of pediatric emergencies.12 In the Connecticut survey, just 14% of eligible staff were certified in Basic Life Support (BLS) and 17% of staff were certified in Pediatric Advanced Life Support (PALS).4 The AAP survey reported that 65% of physicians were required to maintain BLS certification and 42% of physicians and 18% of office nurses were required to maintain PALS certification.12 In the same survey, 32% of office pediatricians required participation by office staff in mock codes.12 In the Wisconsin survey, the PALS certification requirement rate was 26% for office physicians and 5% for office nurses.5

Development of written protocols for office emergencies also has been identified as deficient.12 In the AAP survey, only 37% of office practices had protocols, either telephone- or office-based, to handle emergencies.12

Reasons offered by providers for lack of office preparedness indicate apathy, complacency, and misinformation.4 Perceptions include beliefs that office emergencies are rare enough that preparation is unnecessary; that there is not enough time to train adequately or assemble equipment and medications; that necessary supplies to handle an emergency are too costly; and that the office is close enough to the hospital that others can respond to the emergency.4

Pediatric office emergencies in fact are not rare, even though the reported frequencies of office emergencies in children vary and are fraught with methodological limitations. Prevalence data are largely retrospective,1-4,12 with questions of sampling bias.1-3 Moreover, definitions are not standardized, particularly the definition of "emergency," making estimates of prevalence difficult.

The survey of office pediatricians and family practitioners in Chicago reported 62% of office practices with more than one pediatric emergency (defined as requiring hospitalization or urgent treatment) per week and 80% of practices with at least one emergency every 3 months.1 In a survey of practices in Washington, DC, Maryland, and "Virginia, 608 emergencies (defined by specific diagnosis) were reported over a 3-year period, averaging 1.2 emergencies per office per year.2 Data from a random survey of 427 pediatricians located across the United States were extrapolated to 3.3 emergencies (defined by diagnosis) per office per year.3 The AAP survey reported an average of 2.1 office patients per week requiring emergency treatment or subsequent emergency hospitalization, which has been extrapolated to 38 emergencies per office per year.12 In the Connecticut survey of 51 offices, a median of 24 emergencies (defined broadly as "emergency" as well as by specific diagnosis) per office per year was reported.4 In this study, 82% of practices averaged at least one emergency per month, 25% of practices experienced more than 50 emergencies per year, and 14% of practices reported more than 100 emergencies per year.4

Some office practitioners have claimed that they are too busy to prepare, both in terms of assembling supplies (equipment and medications) and undergoing minimum level training to handle pediatric emergencies.4 In fact, little time expenditure is needed to either assemble appropriate supplies or receive essential training in basic and advanced life support. Ready-made pediatric emergency equipment kits are available from manufacturers. Certification in BLS is possible for office staff in 6 hours or fewer, and certification in PALS is possible for office physicians and nurses in 16 hours or fewer. Recertifications in BLS and PALS requires significantly less time (information is available on the AHA website at http://www.americanheart.org). Sample mock code drills are available.9,13

The cost of equipping an office with emergency equipment and medications depends on the desired level of preparedness. Supply lists have been developed for both minimum-level preparedness4,5,9,11,14 and high-level preparedness.4,14 Currently, a minimum-level of preparedness costs approximately $600.11

In an emergency, timing of intervention is critical. Being prepared to respond to a critically ill or injured child at the moment of presentation may be life-saving. Waiting for EMS or emergency physicians to initiate treatment of an emergent condition should not happen Early recognition and treatment of respiratory distress and shock in children is vital to preventing cardiopulmonary arrest, which is associated with dismal outcomes, including negligible survival.15 It is known that the longer the time interval between a precipitating event and the application of critical life support in a childhood emergency, the poorer the outcome of that emergency.15 Low success rates in resuscitating children in emergency departments have been attributed to failure of prehospital providers to recognize terminal events promptly and initiate advanced life support.16 In the unique setting of pediatric trauma, one study determined that a high proportion of deaths could have been prevented by early recognition of injury and appropriate treatment.17

Despite the mandate to correct what has been perceived as a general climate of under-preparedness among office providers to handle pediatric emergencies, no universally successful method for improving office preparedness has been identified. The topic has received attention in review articles,18,19 a textbook,20 an AAP manual,9 workshops at professional meetings, an online survey tool,21 and instructional resources.22,23 Still, the problem persists with no easy solution. Mail distribution of preparedness guidelines in the Wisconsin study was only minimally effective in improving preparedness.5 Unannounced mock codes performed by multidisciplinary teams (physicians, nurses, EMS providers) in primary care practices in North Carolina resulted in improved development of written protocols (60% versus 21%), improved rates of training (BLS and PALS) but no improvement in purchase of equipment and medications.24

Now office preparedness has become increasingly complex, preferably including preparation for disasters and terrorism.25 Offices and clinics might becomes sites for postdisaster care if hospitals are unable to provide services.25 Ideally an office disaster plan should be prepared.

Correcting deficiencies in office preparedness for pediatric emergencies is complex but not insurmountable. Practical tips to improve preparedness are provided in the Table (see page 846).

Ultimately, the goal is to serve the critically ill and injured children who enter the Emergency Medical Services for Children system26 through office practices. Physicians should optimize training opportunities in pediatric emergency medicine beginning in residency. Care should be given to attain and maintain BLS and PALS certifications. Effort should be made to train office nurses and other staff as first responders because their role is crucial. Written guidelines and clear channels of communication are key. All pediatric offices should have equipment and medications to satisfy at least a minimum level of emergency preparedness.

REFERENCES

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

2. Altieri M, Bellet J, Scott H. Preparedness for pediatric emergencies encountered in the practitioner's office. Pediatrics. 1990;85(5):710-714.

3. Schweich P, DeAngelis C, Duggan A. Preparedness of practicing pediatricians to manage emergencies. Pediatrics. 1991;88(2):223-229.

4. 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.

5. Walsh-Kelly CM, Bergholte J, Ersehen MJ, Melzer-Lange M. Office preparedness for pediatric emergencies: baseline preparedness and the impact of guideline distribution. Pediatr Emerg Care. 2004;20(5):289-294.

6. Standards and guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC). National Academy of Sciences - National Research Council. JAMA. 1986;255(21):2905-2989.

7. Committee on Pediatric Emergency Medicine, American Academy of Pediatrics. Emergency Medical Services for Children: The Role of the Primary Care Provider. Elk Grove Village, IL: American Academy of Pediatrics; 1992.

8. Committee on Pediatric Emergency Medical Services, Division of Health Care Services, Institute of Medicine. Emergency Medical Services for Children. Washington, DC: National Academies Press; 1993.

9. Seidel JS, Knapp JF, eds. Childhood Emergencies in the Office, Hospital and Community: Organizing Systems of Care. Elk Grove Village, IL: American Academy of Pediatrics; 2000.

10. Samson RA, Berg RA, Bingham R, et al.; Pediatric Advanced Life Support Task Force; International Liaison Committee on Resuscitation. Use of automated external defibrillators for children: an update: an advisory statement from the pediatric advanced life support task force, International Liaison Committee on Resuscitation. Circulation. 2003:107(25):3250-3255.

11. Toback SL. Preparing your office for a medical emergency. Earn Pract Manag. 2005;12(1):34-36.

12. American Academy of Pediatrics. Periodic Survey 27. Elk Grove Village, EL: American Academy of Pediatrics; 1995.

13. Roback MG, Teach SJ, First LR, Fleisher GR, eds. Handbook of Pediatric Mock Codes. St. Louis, MO: Mosby Year Book; 1998.

14. Santamaria JR Office-based emergencies. In: Gausche-Hill M, Fuchs S, Yamamoto L, eds. The Pediatric Emergency Medicine Resource. 4th ed. Sudbury, MA: Jones and Bartlett; 2004:638-672.

15. Seidel JS. A needs assessment of advanced life support and emergency medical services in the pediatric patient: state of the art. Circulation. 1986;74(6 Pt 2):IV129-33.

16. Ludwig S, Kettrick RG, Parker M. Pediatric cardiopulmonary resuscitation. A review of 130 cases. Clin Pediatr. 1984;23(2):71-75.

17. Dykes EH, Spence LJ, Young JG, et al. Preventable pediatric trauma deaths in a metropolitan region. J Pediatr Surg. 1989;24(1):107-111.

18. Shuman AJ. Be prepared: equipping your office for medical emergencies. Contemp Pediatr. 1996;13(7):2743.

19. Schexnayder SM, Schexnayder RE. 911 in your office: preparations to keep emergencies from becoming catastrophes. Pediatr Ann. 1996;25(12):664-6,668,670.

20. Barton CW. Management of Office Emergencies. New York, NY: McGraw Hill; 1999.

21. Office Preparedness Survey Tool/Office Practice Baseline Data Survey Form. 2000. Texas Emergency Medical Services for Children. Available at: http://www.ems-c.org/downloads/doc/OffPrepSurvey.doc. Accessed October 18, 2005.

22. Frush K, Cinoman M, Bailey B, et al. Office Preparedness for Pediatric Emergencies: Provider Manual. 1999. North Carolina Emergency Medical Services for Children. Available at: http://www.ems-c.org/downloads/pdf/OfficePrep. pdf. Accessed October 18, 2005.

23. Frush K, Cinoman M, Bailey B, et al. Office Preparedness for Pediatric Emergencies: Instructor Manual. 1999. North Carolina Emergency Medical Services for Children. Available at: http://www.ems-c.org/downloads/pdf/officeinstructor.pdf. Accessed October 18, 2005.

24. Bordley WC, Travers D, Scanlon P, Frush K, Hohenhaus S. Office preparedness for pediatric emergencies: A randomized, controlled trial of an office-based training program. Pediatrics. 2003;112(2):291-295.

25. Redlener I, Markenson D Disaster and terrorism preparedness: What pediatricians need to know. Dis Mon. 2004;50(1):640.

26. Krug S, Kuppermann N. Twenty years of emergency medical services for children: a cause for celebration and a call for action. Clin Pediatr Emerg Med. 2005;6(1):62-65.

27. Gausche-Hill M, Fuchs S, Yamamoto L, eds. The Pediatric Emergency Medicine Resource. 4th ed. Sudbury, MA: Jones and Bartlett; 2004.

28. Haley K, Baker P, eds. Emergency Nursing Pediatric Course: Provider Manual. 3rd ed. Park Ridge, IL: Emergency Nurses Association; 2004.

10.3928/0090-4481-20051101-04

Sign up to receive

Journal E-contents