Pediatric emergencies do occur in the primary care setting, although infrequently. However, primary care offices and clinics are often not prepared to handle common pediatric emergencies. In one study, 62% of primary care physicians, including both pediatricians and family physicians, in an urban setting report having one patient each week that typically requires emergent stabilization or further hospital treatment.1 Another study surveying 52 pediatric offices found that these offices were seeing two emergencies per month.2 Even primary care offices devoted to pediatrics need to be prepared for a sudden cardiac event that may occur in a caregiver accompanying a child or someone merely walking into the office looking for help. Survival for “bystander witnessed” shockable heart rhythms may be improved 3-fold with immediate intervention.3
Even though most emergencies present to hospitals, they are not uncommon in the primary care setting. Most primary care offices are not fully prepared for these medical emergencies, and it can be challenging to manage emergencies without adequate staff, support, tools, and protocols.4 Primary care offices can potentially decrease the risk of unfavorable outcomes by preparing for medical emergencies with the appropriate planning, equipment, training, and protocols.4,5
What Types of Pediatric Emergencies Present in the Primary Care Office?
Some of the common pediatric emergencies presenting at primary care offices include asthma exacerbations and other respiratory emergencies, seizures, sepsis/severe infection, dehydration, anaphylaxis, choking, poisoning, head injury, and, rarely, cardiac arrhythmia or arrest.6–8 With many patients opting to see a primary care physician that they know and trust, or caregivers simply not recognizing the severity of the symptoms, the office serves as the front line of emergency care where vital and lifesaving care may be required.
How to Assess the Specific Needs of an Office
The American Academy of Pediatrics (AAP) Committee on Pediatric Emergency Medicine issued a policy statement on “Preparation for Emergencies in the Offices of Pediatricians and Pediatric Primary Care Providers.”9 This policy statement recommends that primary care offices 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 health care needs. To optimize office readiness, each practice should consider the unique aspects of their office including the types of patients and emergencies that might be seen, available resources, and the resources of the larger emergency care system. A careful self-assessment of office practice and polices can help optimize office preparedness before an emergency.9 Some of the suggested considerations for self-assessment include:
How often and what type of medical emergencies have occurred or might occur in your office?
What is the emergency preparedness of your staff at different times of the day as staff changes occur?
Have nonclinical staff been trained to recognize a potential or actual emergency and act accordingly even when clinical staff are not onsite?
Are there external resources that could be used during an office emergency?
Does your practice have a written protocol for response in an office emergency?
What emergency equipment and supplies (including oxygen, airway equipment, automated external defibrillator) do you have on site? Does your staff know where to access and how to use them?
What is your emergency dosage (tape-based/dosage book) and documentation strategy?
Do staff know how to access the emergency medical services (EMS) system and what is the EMS response time?
How far is your office from the nearest emergency department (ED)?
How do you and your staff maintain skills and readiness?
Practices can reflect on the self-assessment and develop a plan to improve office preparedness relevant to anticipated emergencies in their patient populations. Practice leaders will be able to make informed decisions based on their resources, staff expertise, and proximity to nearest ED.5,9
How to Develop an Emergency Response Plan
The emergency response plan should be developed by each practice to recognize, stabilize, and transfer sick children. The emergency response plan should include recognition of emergency, protocol for EMS activation, clear roles and responsibilities during management of emergency, and maintaining preparedness through practice.9
Early recognition of emergency is vital in an effective response. Front office staff may need training to promptly recognize and notify appropriate clinical staff or react appropriately in the event no clinical staff are present. The Pediatric Assessment Triangle (PAT) is a quick and simple approach to evaluating a child based on visual and auditory clues. PAT has three components: appearance, work of breathing, and circulation. The PAT readily and reliably identifies high-acuity pediatric patients and does not require the use of any equipment.10 The office staff should be able to recognize extremely labored breathing, blue or pale color (cyanosis), noisy breathing (wheezing or stridor), altered mental status, seizure, agitation, vomiting after a head injury, and uncontrolled bleeding. If they suspect a patient has symptoms that may signal an emergency, they should alert the appropriate clinical staff for further assessment and management.9
Local EMS should be promptly notified by a staff member. Office staff must be familiar with EMS resources and activation, and be ready to give the emergency medical dispatcher the following information9:
- Age and condition of patient (with vital signs, if appropriate)
- Your office location (with directions and telephone number, if necessary)
- Level of clinical staff present
- Desired transport destination (pediatric center, local ED, other)
- Level of EMS provider required: advanced life support (ALS) or basic life support (BLS)
- If required, where personnel will be meeting EMS to assist in guiding EMS to the patient's location
The emergency response plan should include designation of the most appropriate location to manage medical emergencies, with consideration for proximity to equipment, medications, personnel, and EMS access. The plan should illustrate clear roles and responsibilities for all staff during management of emergencies, allowing for an organized approach to emergency response. A suggested model may include the following: The front office staff notifies clinical staff of emergency, activates EMS, provides family support, and notifies other patients in the office that an in-office emergency has occurred. The provider is responsible for medical decision-making, directing the team, and managing the airway. Clinical staff are assigned to gather necessary equipment, place monitors, provide oxygen and start chest compressions when appropriate. If appropriate, a nurse is assigned to obtain intravenous access and administer medication as ordered by provider. Other clinical staff, when available, should serve to document the event including recording vitals and interventions, and be available to support the team as necessary. Staff members should perform roles and responsibilities that are within their scope of practice and have the necessary training to perform their designated role.
What Equipment and Medications Are Recommended for Preparedness in a Pediatric Primary Care Office?
The AAP Committee on Pediatric Emergency Medicine recommends that every practice organize their emergency equipment in a way that facilitates access to appropriate equipment at the time of an emergency. Each office should develop a system to ensure immediate availability and regularly check the proper functioning of equipment. The committee also has provided a list of recommended emergency medications, and recommends the use of a resuscitation tool that provides suggested protocols with precalculated medication doses. Offices should also develop a system to regularly check to ensure that medications are available and expired medications are properly disposed.9
The AAP Committee on Pediatric Emergency Medicine has also provided recommendations on equipment and medications for pediatric office emergencies, classifying them as essential or strongly suggested (essential if EMS response time is ≥10 minutes).9 The essential airway equipment for pediatric office emergencies includes oxygen-delivery system, bag-valve-mask (450 mL and 1,000 mL), clear oxygen masks, breather and non-rebreather, with reservoirs (infant, child, adult), suction device, tonsil tip, bulb syringe, nebulizer (or metered-dose inhaler with spacer/mask), oropharyngeal airways (sizes 00–5), and pulse oximeter.9 They also consider the following equipment and supplies essential for office emergencies: color-coded tape or preprinted drug doses, cardiac arrest board/backboard, sphygmomanometer (infant, child, adult, thigh cuffs), splints, and sterile dressings.9
The following equipment and supplies are strongly suggested for pediatric office emergencies (essential if EMS response time is ≥10 minutes): nasopharyngeal airways (sizes 12–30F), Magill forceps (pediatric, adult), suction catheters (sizes 5–16F), Yankauer suction tip, nasogastric tubes (sizes 6–14F), laryngoscope handle (pediatric, adult) with extra batteries, bulbs, laryngoscope blades (0–2 straight and 2–3 curved), endotracheal tubes (uncuffed 2.5–5.5; cuffed 6.0–8.0), stylets (pediatric, adult), esophageal intubation detector or end-tidal carbon dioxide detector, vascular access and fluid management, butterfly needles (19–25 gauge), catheter-over-needle device (14–24 gauge), arm boards, tape, tourniquet, intraosseous needles (16 and 18 gauge), intravenous tubing, microdrip, automated external defibrillator with pediatric capabilities, spot glucose test, stiff neck collars (small/large), and heating source (overhead warmer/infrared lamp).9
The AAP Committee on Pediatric Emergency Medicine recommends that it is essential for primary care offices to have oxygen, albuterol for inhalation, epinephrine (1:1,000), and strongly suggests (essential if EMS response time is ≥10 minutes) for the following medications/fluids to be available for management of pediatric office emergencies: activated charcoal, antibiotics, anticonvulsant agents (diazepam, lorazepam), corticosteroids (parenteral/oral), dextrose (25%), diphenhydramine (parenteral, 50 mg/mL), epinephrine (1:10,000), atropine sulfate (0.1 mg/mL), naloxone (0.4 mg/mL), sodium bicarbonate (4.2%), normal saline solution or lactated Ringer's solution (500-mL bags), and 5% dextrose in 0.45 normal saline (500-mL bags).9
Although not a formal recommendation from the AAP Committee on Pediatric Emergency Medicine, to assure preparedness for an unexpected sudden cardiac event experienced by a pediatric patient or adult in the office, a person trained in BLS and the presence of an AED with adult and pediatric pads is essential.
It is recommended for primary care offices to organize the equipment and supplies so that they are readily available when necessary. Offices may choose to use a length-based or weight-based tool to determine appropriate equipment and medication dose. Office staff should be familiar with location and appropriate use of equipment. They should use closed loop communication to ensure effective communication and minimize errors.
How Can an Office Train and Prepare for Emergencies?
The AAP Committee on Pediatric Emergency Medicine recommends primary care offices to develop a plan to provide education and continuing medical education for all staff. The front-line staff need training on recognizing emergencies, activating the emergency response, and understanding EMS roles, capabilities, and access. Clinical staff should have opportunities to maintain knowledge and skills related to pediatric emergencies.9 Providers and office staff should be strongly encouraged to maintain current certification in BLS or ALS courses.5
Primary care offices can prepare and practice for office emergencies through “mock codes.” Such exercises can increase practitioner confidence and reduce anxiety to perform lifesaving care.4 All staff should participate in mock codes on a regular basis and practice as a team. Include documentation as a defined role for a staff member during the mock code. Use debriefing after the simulated experience to reflect on what went well and identify opportunities for improvement. Capturing the “mock code” on video may provide a good opportunity for education and discussion of improvement strategies. It may be beneficial to include local EMS and disaster preparedness when possible.9
Parents and families should be advised about what to do in an emergency. The discussion should include examples of situations and appropriate use of primary care advice, EMS, and poison control. Parents should be provided numbers for the emergency response system, poison control, and for after-hours advice. Parents and caregivers should be encouraged to get cardiopulmonary resuscitation and first-aid training. Encourage families of children with special health care needs to maintain updated emergency information forms.9
How to Transfer a Child Who Is Acutely Ill
Primary care offices should partner with EMS and hospital-based emergency providers to ensure safe transfer and optimal care during pediatric emergencies presenting at a primary care office.9 The office emergency response plan should include information of local EMS providers and EDs. It is important to understand the types of EMS transport and their scope of practice to determine the appropriate transport of the child who is acutely ill. Patient's records and emergency documents should be ready to accompany the patient during EMS transport. The report should include the patient's identifying information, presenting signs and symptoms, relevant past medical history, known allergies and medications, clinical findings, office interventions, and time and response to therapy, including serial vital signs.
Pediatric emergencies do present in primary care offices. It is important for every practice to perform a self-assessment of office preparedness relevant to anticipated emergencies they may encounter. Primary care offices should develop an emergency response plan to recognize, stabilize, and transfer children who are sick. They should also ensure their offices have the essential equipment, supplies, and medications readily available in case of pediatric emergencies. All office staff should have appropriate training and participate in mock codes when possible to practice and improve their emergency response. Primary care offices should partner with local EMS and EDs to ensure seamless transfer of a child who is acutely ill. Some important strategies for pediatric primary care office preparedness include parent/family education about seeking appropriate care, early recognition and stabilization of pediatric emergencies in the office, and timely transfer. Careful planning, availability of appropriate equipment and medications, staff training, and protocols for expeditious transfer to a definitive care facility will help improve outcomes for office emergencies.
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