Office preparedness for pediatric emergencies: baseline preparedness and the impact of guideline distribution

Medical Emergencies in the Primary Care Setting: An Evidence Based Practice Approach Using Simulation to Improve Readiness

BACKGROUND

Simulation is an evidenced based strategy which has been shown to impact office-based readiness to respond in a medical emergency. Medical emergencies occur in the primary care setting on a less frequent basis than in the inpatient setting. Clinicians working in primary care may benefit from an opportunity to refresh their skills.

METHODS

This descriptive pre and post survey design evidenced based project examined staff reported levels of competence and confidence when responding to an emergency in a pediatric primary care office. Simulation educators partnered with ambulatory nursing and medical leaders to create a mock code program for staff in a care network. During a 14-month period, simulations were conducted in 30 primary care sites. Staff completed pre- and post-simulation surveys to assess levels of confidence in decision-making skills and competence when managing medical emergencies.

FINDINGS

A statistically significant increase in the mean scores for both confidence and competence was demonstrated when comparing pre- and post-simulation survey results.

DISCUSSION AND APPLICATION TO PRACTICE

Simulation as an educational technique resulted in an increased level of competence and confidence of primary care office staff to respond to an emergency. Additionally, staff developed an overall heightened awareness of emergency processes and recognized of the value of simulation as an educational tool.

Pediatric in-hospital emergencies: real life experiences, previous training and the need for training among physicians and nurses

Objective

Pediatric emergencies challenge professional teams by demanding substantial cognitive effort, skills and effective teamwork. Educational designs for team trainings must be aligned to the needs of participants in order to increase effectiveness. To assess these needs, a survey among physicians and nurses of a tertiary pediatric center in Germany was conducted, focusing on previous experience, previous training in emergency care, and individual training needs.

Results

Fifty-three physicians and 75 nurses participated. Most frequently experienced emergencies were respiratory failure, resuscitation, seizure, shock/sepsis and arrhythmia. Resuscitations were perceived as being particularly precarious. Team collaboration and communication were major issues arising from previous emergency situations, but perceptions differed between physicians and nurses. Regarding previous training, physicians were accustomed to self-directed learning, whereas nurses usually attended practical courses. Both physicians and nurses rated themselves as having moderate levels of knowledge and skills for pediatric emergencies, though residents reported the significantly lowest preparedness. Both professions reported a high need for training of basic procedures and emergency algorithms, physicians even more than nurses.

Pediatric Referrals to an Emergency Department From Urgent Care Centers

OBJECTIVE

The aims of this study were to describe pediatric emergency department (ED) referrals from urgent care centers and to determine the percentage of referrals considered essential and serious.

METHODS

A prospective study was conducted between April 2013 and April 2015 on patients younger than 21 years referred directly to an ED in central Pennsylvania from surrounding urgent care centers. Referrals were considered essential or serious based on investigations/procedures performed or medications/consultations received in the ED.

RESULTS

Analysis was performed on 455 patient encounters (mean age, 8.7 y), with 347 (76%) considered essential and 40 (9%) considered serious. The most common chief complaints were abdominal pain (83 encounters), extremity injury (76), fever (39), cough/cold (29), and head/neck injury (29). Thirty-three percent of the patients received laboratory diagnostic investigations (74% serum, 56% urine), and 52% received radiologic investigations (67% x-ray, 17% computed tomography scan, 13% ultrasound, 11% magnetic resonance imaging). Forty-four percent of the patients received a procedure, with the most common being intravenous (IV) placement (66%); reduction, casting, or splinting of extremity fracture/dislocation (18%); and laceration repair (14%). The most common medications administered were IV fluids (33%), oral analgesics (30%), and IV analgesics (26%). Eighty-three percent of the patients were discharged home, 12% were hospitalized, and 4% had emergent surgical intervention. The most common primary diagnoses were closed extremity fracture (60 encounters), gastroenteritis (42), brain concussion (28), upper respiratory infection (24), and nonsurgical, unspecified abdominal pain (24).

CONCLUSIONS

Many ED referrals directed from urgent care centers in our sample were considered essential, and few were considered serious. Urgent care centers should develop educational and preparedness strategies based on the epidemiology of emergencies that may occur.

EMS Activations for School-Aged Children From Public Buildings, Places of Recreation or Sport, and Health Care Facilities in Pennsylvania

OBJECTIVES

To determine the etiology of emergency medical services (EMS) activations in 2011 to public buildings, places of recreation or sport, and health care facilities involving children aged 5 to 18 years in Pennsylvania.

METHODS

Electronic records documenting 2011 EMS activations as provided by the Pennsylvania Department of Health's Bureau of EMS were reviewed. Data elements (demographics, dispatch complaint, mechanism of injury, primary assessment) from patients aged 5 to 18 years involved in an EMS response call originating from either a public building, a place of recreation and sport, or health care facility were analyzed.

RESULTS

A total of 12,289 records were available for analysis. The most common primary assessments from public buildings were traumatic injury, behavioral/psychiatric disorder, syncope/fainting, seizure, and poisoning. The most common primary assessments from places of recreation or sport were traumatic injury, syncope/fainting, altered level of consciousness, respiratory distress, and abdominal pain. The most common primary assessments from health care facilities were behavioral/psychiatric disorder, traumatic injury, abdominal pain, respiratory distress, and syncope/fainting. When examining the mechanism of injury for trauma-related primary assessments, falls were the most common mechanism at all 3 locations, followed by being struck by an object. Of the 1335 serious-incident calls (11% of the total EMS activations meeting inclusion criteria), 61.2% were from public buildings, 14.1% from places of recreation or sport, and 24.7% from health care facilities.

CONCLUSIONS

Our identification of common EMS dispatch complaints, mechanisms of injury, and primary assessments can be used in the education of staff and preparation of facilities for medical emergencies and injuries where children spend time.

Outpatient Emergency Preparedness: A Survey of Pediatricians

OBJECTIVE

To determine outpatient pediatricians' self-reported experience with and preparation for patient emergencies, and their awareness of the American Academy of Pediatrics (AAP) policy statement on outpatient emergency preparedness.

METHODS

A 34-question cross-sectional survey of outpatient pediatric faculty and gratis faculty from the sole medical school in a metropolitan area was used to assess demographic information, training, and equipment for patient emergencies and familiarity with the AAP policy.

RESULTS

Of the 57 responses from 123 surveyed physicians (46% response rate), 23% worked in academics and 70% in private practice. At least 1 emergency per month was reported by 39%; 75% referred a patient to the emergency department or hospital at least monthly. Current Pediatric Advanced Life Support (PALS) certification was maintained by 21%, and 42% had current Basic Life Support (BLS). The majority (79%) agreed that respiratory emergencies were most common. Almost all had bag-valve mask (96%) in the office; however, only 65% had oropharyngeal airways. All reported feeling comfortable performing bag-valve mask ventilation, but only 68% reported the same comfort level with oropharyngeal airways. About half (44%) had intubation equipment, and about half (47%) had automated external defibrillators. Only 25% performed mock emergencies. About half of pediatricians (53%) reported awareness of the 2007 AAP policy guideline, and one quarter (23%) thought their office met guideline recommendations.

CONCLUSIONS

Although emergencies occur frequently in general pediatric offices, pediatricians may not have adequate emergency equipment and training. Variable preparedness reflects the need for greater awareness of and compliance with the AAP policy.

Specialty pediatric transport in primary care or urgent care settings

OBJECTIVE

We sought to describe a single center's experience with specialized critical care transport from non-hospital settings, including primary care offices and urgent care centers. We hypothesized that the majority of patients will require procedures outside the scope of practice of most EMS providers and will be better served by specialized pediatric critical care transport (SPCCT) teams.

METHODS

This study sought to retrospectively evaluate instances where children (0-18 years old) were transported by our SPCCT team from nonhospital settings, including primary care offices and urgent care centers, in 2009 and 2010. Data were extracted from a customized database and appropriate statistical tests were applied, including Fisher's exact test for categorical comparisons and Mann-Whitney U test for non-parametric data comparisons.

RESULTS

Fifty-two patients were included. Most of the children were transported for respiratory distress (78%), and many were treated with albuterol (42%) and steroids (42%) prior to the SPCCT team arrival. The most common interventions performed by the SPCCT team were obtaining IV access and administering IV fluid boluses; 4 (7.7%) patients required advanced critical care treatments unique to SPCCT. Most patients (n = 34; 65%) were directly admitted to the general care floor, but a high number of patients (n = 12; 23%; PICU = 11, NICU = 1) required pediatric or neonatal intensive care unit admission. Only 3 patients (5.7%) were discharged home without hospital admission. For the 11 patients admitted to the PICU, the median length of stay (LOS) was 2.5 days (IQR 0.14-13.2). All patients survived to hospital discharge with an additional hospital LOS of 1.3 days (IQR 0.2-6.7). Patients were billed for these critical care transports an average of $2,660.14 ± $940.

CONCLUSION

Our small cohort demonstrates infrequent application of advanced critical care interventions beyond those provided by the referring primary care office or urgent care centers. This supports the practice of SPCCT teams providing transport services for select critically ill children at primary care offices and urgent care centers, but not as a standard practice for most pediatric patients in these settings.

An education program on office medical emergency preparedness for primary care pediatricians

BACKGROUND

Pediatric clinics are ill-prepared in handling medical emergencies. Life-support education, though recommended, has not been evaluated in pediatric primary care.

PURPOSE

The objective is to evaluate effectiveness of education in improving knowledge and learner-perceived comfort in managing pediatric office emergencies.

METHODS

An education program was conducted at 6 pediatric practices. Pre-post program knowledge improvement (15-item questionnaire) and comfort (10-level Likert scale) was assessed using T tests and Cohen's d. Long-term knowledge was assessed.

RESULTS

Physicians demonstrated significant improvement in mean knowledge scores: 1.83, 95% confidence interval (CI) [0.76, 2.91], effect size (d=0.98), whereas nurses had a smaller, nonsignificant improvement: 0.59, 95% CI [-0.19, 1.37], effect size (d=0.24). A significant improvement in mean comfort scores was observed among both physicians: 1.3, 95% CI [0.9, 1.7] and nurses, 1.4, 95% CI [0.7, 2.1]. Among physicians, percentage correct answers on the knowledge test was 79% (baseline), 91% (posttest), and 80% at 3 years.

CONCLUSIONS

Education in pediatric office emergency preparedness leads to short-term knowledge improvement among physicians, but gains are not sustained.

New opportunity to improve pediatric emergency preparedness: pediatric emergency assessment, recognition, and stabilization course

The ideal first response to a life-threatening pediatric emergency includes early recognition of the emergency, activation of the appropriate emergency response system, performance of basic life support (cardiopulmonary resuscitation/automated external defibrillator treatment), and initiation of advanced life support, but the extent of resuscitation training among health care providers likely to be first at the side of a critically ill or injured child is often deficient. In the past, resuscitation courses beyond basic life support focused on training advanced providers. The Pediatric Emergency Assessment, Recognition, and Stabilization course was developed by the American Heart Association to target a broad range of health care providers who are likely to be first at the side of a child requiring resuscitation. It is hoped that training of health care providers through the Pediatric Emergency Assessment, Recognition, and Stabilization course will translate into early recognition of life-threatening pediatric emergencies and greater resuscitation success, but results will depend on the availability of instruction and the maintenance of skills.

Pediatric office emergencies

PURPOSE OF REVIEW

An emergency in the office setting can be problematic without adequate staff, support, tools, and protocols. Though many emergencies are not immediately life-threatening, one risks the 'worst case scenario' occurring if not adequately prepared. Pediatric patients are prone to respiratory distress and compromise in many emergencies, and can rapidly decompensate without adequate support. A review of the history of emergency medical services for children and the framework for office emergency preparedness offers insight into current challenges for primary care providers.

RECENT FINDINGS

Research has demonstrated that many primary care offices and clinics are ill prepared to handle common pediatric emergencies. Reliance on the Emergency Medical Services system is insufficient to assure optimal outcomes, especially given variations in the equipment, training, and experience of Emergency Medical Services providers in the care of children, and in remote areas where access may be delayed. Preparation and practice for office emergencies through 'mock code' exercises can increase practitioner confidence and reduce anxiety to perform life-saving care.

SUMMARY

Better outcomes for office emergencies can result from staff training, availability of appropriate equipment and medications, maintenance of skills via formal and informal practice, and pathways for expeditious transfer to a definitive care facility.

Preparedness of selected pediatric offices to respond to critical emergencies in children

OBJECTIVE

To determine the preparedness of pediatric offices that had activated emergency medical services (EMS) for a critically ill child requiring airway management.

METHODS

Fifteen patients who initially presented to pediatric or family practice offices but required EMS activation and cardiac and/or respiratory support were identified from a previous prospective study of airway management in children. Two to 4 years after the emergency requiring EMS activation, the offices were contacted to complete a written survey about office preparedness for pediatric emergencies.

RESULTS

Eight of 15 offices (53%) returned a survey. Pediatricians staffed all responding offices, and all offices were within 5 miles of an emergency department. Airway emergencies were the most common emergencies seen in the offices. Availability of emergency equipment and medications varied. All offices stocked albuterol, and most (7/8) had an oxygen source with a flowmeter. However, only half of the offices had a fast-acting anticonvulsant, and a quarter had no anticonvulsant. Three offices lacked bag-mask (manual) resuscitators with all appropriate sized masks, and 3 offices lacked suction. The most common reasons cited for not stocking all emergency equipment and drugs were quick response time of EMS and proximity to an emergency department.

CONCLUSIONS

Even after treating a critically ill child who required advanced cardiac and/or pulmonary support, offices were ill prepared to handle another serious pediatric illness or injury.

Drug testing of adolescents in general medical clinics, in school and at home: physician attitudes and practices

PURPOSE

To determine (1) whether physicians agree with recommendations for home and school drug screening, (2) under what circumstances physicians recommend urine drug tests for adolescents, and (3) how physicians manage adolescent patients with positive results. Few clinical practice guidelines have been published on urine drug testing of adolescents, and it is not known when physicians recommend this procedure or how they manage positive results.

METHODS

Multi-modal survey of a nationally representative sample of physicians conducted April-July 2004. We computed simple frequencies and used backwards selection logistical regression to determine if there were differences in agreement or practices among physicians from different specialties (pediatrics, family medicine, adolescent medicine) or by demographic factors (physician age, gender, practice type or location).

RESULTS

A total of 359 physicians (43% after eliminating ineligibles) completed the survey. Thirty-eight percent would recommend a drug test if were required to return to school, 41% if a parent was concerned, and 46% based on history (without a parent's concern). Forty-eight percent of physicians would share a positive drug test result with parents. A large majority (83%) disagreed with high school drug testing programs.

CONCLUSIONS

There is little consensus among physicians regarding the indications for drug testing in the general medical clinic. However, most disagree with school drug testing programs. There is little consistency among physicians in how to proceed when a urine drug test is positive. Professional organizations should consider publishing clinical practice guidelines in order to assist physicians in using this procedure effectively.