Preparation for emergencies in the offices of pediatricians and pediatric primary care providers

Pediatric Utilization of Emergency Medical Services from Outpatient Offices and Urgent Care Centers

OBJECTIVE

National efforts have highlighted the need for pediatric emergency readiness across all settings where children receive care. Outpatient offices and urgent care centers are frequent starting points for acutely injured and ill children, emphasizing the need to maintain pediatric readiness in these settings. We aimed to characterize emergency medical services (EMS) utilization from outpatient offices and urgent care centers to better understand pediatric readiness needs.

METHODS

We performed a retrospective cross-sectional analysis of EMS encounters using the National Emergency Medical Services Information System, a nationally representative EMS registry (2019-2022). We included four years of EMS encounters of children (<18 years old) that originated from an outpatient office or urgent care center. We described characteristics, including patient demographics, prehospital clinician impression, therapies, and procedures performed.

RESULTS

Of 179,854,336 EMS encounters during the study period, 164,387 pediatric encounters originated at an outpatient setting. Most EMS encounters originated from outpatient offices. Evening and weekend EMS encounters more frequently originated from urgent care centers. The most common impressions were respiratory distress (n = 60,716), systemic illness (n = 23,583), and psychiatric/behavioral health (n = 13,273). Ninety-four percent of EMS encounters resulted in transportation to a hospital.

CONCLUSIONS

EMS encounters from outpatient settings most commonly originate from outpatient offices, relative to urgent care settings, where pediatric emergency readiness may be limited. It is important that outpatient settings and providers are ready for varied emergencies, including those occurring for a behavioral health concern, and that readiness guidelines are updated to address these needs.

Improving Emergency Preparedness in Pediatric Primary Care Offices: A Simulation-Based Interventional Study

OBJECTIVES

Pediatric emergencies pose a challenge to primary care practices due to irregular frequency and complexity. Simulation-based assessment can improve skills and comfort in emergencies. Our aim was improving pediatric office emergency preparedness, as measured by adherence to the existing American Academy of Pediatrics policy statement, and quality of emergency care in a simulated setting, as measured by performance checklists.

METHODS

This was a single center study nested in a multicenter, prospective study measuring emergency preparedness and quality of care in 16 pediatric primary care practices and consisted of 3 phases: baseline assessment, intervention, and follow-up assessment. Baseline emergency preparedness was measured by checklist based on AAP guidelines, and quality of care was assessed using in-situ simulation. A report-out was provided along with resources addressing potential areas for improvement after baseline assessment. A repeat preparedness and simulation assessment was performed after a 6 to 10 month intervention period to measure improvement from baseline.

RESULTS

Sixteen offices were recruited with 13 completing baseline and follow-up preparedness assessment. Eight of these sites also completed baseline and follow-up simulation assessment. Median baseline preparedness score was 70% and follow-up was 75.9%. Median baseline simulation performance scores were 37.4% and 35.5% for respiratory distress and seizure scenarios, respectively. Follow-up simulation assessment scores were 73% and 76.9% respectively (P = .001).

CONCLUSIONS

Our collaborative was able to successfully improve the quality of care in a simulated setting in a group of pediatric primary care offices over 6 to 10 months. Future work will focus on expansion and improving emergency preparedness.

Pediatric Office Emergency Preparedness: An Intensive In-Office Training Curriculum

OBJECTIVE

Preparation is vital to improve resuscitation outcomes for children presenting to the primary care office with emergent conditions. Previous literature has provided recommendations for medications, equipment, and skills necessary to provide appropriate care. Most studies thus far demonstrated offices are unprepared according to those recommendations. We sought to provide an intensive emergency training and preparation curriculum to local primary care pediatric offices to improve their emergency readiness.

METHODS

Using a high-fidelity manikin, a simulation instructor team visited several offices and trained teams including physicians, nurse practitioners, nurses, medical assistants, front desk staff, and billing/management staff. Two emergency resuscitation simulations were performed per session with education after each scenario. The instructor team taught procedures, provided teamwork training, and provided feedback on medications, equipment, and resuscitation priorities.

RESULTS

Eight primary care pediatric offices participated in the curriculum, 36 training sessions were conducted, and 229 staff were trained. Numerous issues with medications, equipment, teamwork dynamics, and pediatric emergency resuscitation were revealed. There was always significant improvement from the first to the second simulation in each session.

CONCLUSIONS

Our intensive emergency training and preparation curriculum experience with local primary care pediatric offices highlighted discrepancies between the perceived level of office preparedness and actual experience during a simulated emergency. Office staff felt more prepared for an emergency after the training, and office medications and equipment were re-evaluated to provide a more efficient and effective resuscitation for their patients.

Low-Resource Emergency Department Visits for Children With Complex Chronic Conditions

OBJECTIVE

Reducing emergency department (ED) use in children with complex chronic conditions (CCC) is a national health system priority. Emergency department visits with minimal clinical intervention may be the most avoidable. We assessed characteristics associated with experiencing such a low-resource ED visit among children with a CCC.

METHODS

A retrospective study of 271,806 ED visits between 2014 and 2017 among patients with a CCC in the Pediatric Health Information System database was performed. The main outcome was a low-resource ED visit, where no medications, laboratory, procedures, or diagnostic tests were administered and the patient was not admitted to the hospital. χ2 Tests and generalized linear models were used to assess bivariable and multivariable relationships of patients' demographic, clinical, and health service characteristics with the likelihood of a low- versus higher-resource ED visit.

RESULTS

Sixteen percent (n = 44,111) of ED visits among children with CCCs were low-resource. In multivariable analysis, the highest odds of experiencing a low- versus higher-resource ED visit occurred in patients aged 0 year (vs 16+ years; odds ratio [OR], 3.9 [95% confidence interval {CI}, 3.7-4.1]), living <5 (vs 20+) miles from the ED (OR, 1.7 [95% CI, 1.7-1.8]), and who presented to the ED in the day and evening versus overnight (1.5 [95% CI, 1.4-1.5]).

CONCLUSIONS

Infant age, living close to the ED, and day/evening-time visits were associated with the greatest likelihood of experiencing a low-resource ED visit in children with CCCs. Further investigation is needed to assess key drivers for ED use in these children and identify opportunities for diversion of ED care to outpatient and community settings.

How general pediatricians learn procedures: implications for training and practice

The Accreditation Council for Graduate Medical Education (ACGME) requires General Pediatricians (GPeds) to learn thirteen procedures during training. However, GPeds infrequently perform these procedures in practice. We sought to determine:1) how GPeds learned procedures, 2) if GPeds self-reported achieving competence in the required ACGME procedures during training, and 3) if GPeds maintained these skills into practice. We conducted this mixed methods study from 2019-2020. 51 GPeds from central Ohio and the American Board of Pediatrics General Examination Committee were recruited via email or snowball sampling and participated in semi-structured recorded phone interviews probing procedural performance during training and current practice. Participants represented varied geographic regions and clinical settings. We employed Sawyer's 'Learn, See, Practice, Prove, Do, Maintain' mastery learning pedagogical framework as a lens for thematic analysis. Participants did not demonstrate competence in all ACGME required procedures during training, nor sustain procedural skills in practice. Most participants learned procedures through a 'see one, do one' apprenticeship model. GPeds reported never being formally assessed on procedural competence during residency. All GPeds referred out at least one procedure. GPeds also believed that skill maintenance was unwarranted for procedures irrelevant to their current practice. GPeds did not sufficiently demonstrate competence in all ACGME required procedures during training, partially suggesting why they infrequently perform some procedures. Alternatively, these required procedures may not be relevant to their practice. Pediatric residency procedures education might consider using mastery learning for practice-specific procedures and surface-level methods (learning without mastery) for other skills.

Biologics for Asthma and Allergic Skin Diseases in Children

An estimated 7 million children in the United States have asthma, which causes a significant health care burden and affects quality of life. The minority of these children have asthma that does not respond to Global Initiative for Asthma steps 4 and 5 care, and biological medications are recommended at this level in the 2019 Global Initiative for Asthma recommendations. In addition, biologics have been introduced into the care of children with allergic skin diseases. Omalizumab and mepolizumab are approved for children as young as 6 years, and benralizumab and dupilumab are approved for people aged ≥12 years. Reslizumab is approved only for people aged ≥18 years. These monoclonal antibodies may be added for appropriate patients when asthma or allergic skin diseases are not well controlled. Pediatricians and pediatric subspecialists should work together and be aware of the benefits and risks of these medications for their patients, as well as the practical implications of providing these options for their patients. This clinical report serves as an evaluation of the current literature on these types of medications in the treatment of children with asthma and allergic skin disease.

Preparedness for Pediatric Office Emergencies: A Multicenter, Simulation-Based Study

OBJECTIVES

Pediatric emergencies can occur in pediatric primary care offices. However, few studies have measured emergency preparedness, or the processes of emergency care, provided in the pediatric office setting. In this study, we aimed to measure emergency preparedness and care in a national cohort of pediatric offices.

METHODS

This was a multicenter study conducted over 15 months. Emergency preparedness scores were calculated as a percentage adherence to 2 checklists on the basis of the American Academy of Pediatrics guidelines (essential equipment and supplies and policies and protocols checklists). To measure the quality of emergency care, we recruited office teams for simulation sessions consisting of 2 patients: a child with respiratory distress and a child with a seizure. An unweighted percentage of adherence to checklists for each case was calculated.

RESULTS

Forty-eight teams from 42 offices across 9 states participated. The mean emergency preparedness score was 74.7% (SD: 12.9). The mean essential equipment and supplies subscore was 82.2% (SD: 15.1), and the mean policies and protocols subscore was 57.1% (SD: 25.6). Multivariable analyses revealed that independent practices and smaller total staff size were associated with lower preparedness. The median asthma case performance score was 63.6% (interquartile range: 43.2-81.2), whereas the median seizure case score was 69.2% (interquartile range: 46.2-80.8). Offices that had a standardized process of contacting emergency medical services (EMS) had a higher rate of activating EMS during the simulations.

CONCLUSIONS

Pediatric office preparedness remains suboptimal in a multicenter cohort, especially in smaller, independent practices. Academic and community partnerships using simulation can help address gaps and implement important processes like contacting EMS.

Emergency Medical Services for Children: Office Emergency and Disaster Readiness

Pediatricians are resources for families to provide ongoing care, education, and guidance during emergencies. They must be prepared to handle both office emergencies and local disasters. In office emergencies, readiness should focus on stabilizing life-threats until patients can be transported to an emergency department. Preparedness must also focus on providing aid in the setting of large-scale disasters in conjunction with local public health officials, hospitals, health care coalitions, emergency medical services systems, and local emergency officials, and plans should address hazards local to the area. [Pediatr Ann. 2021;50(4):e160-e164.].

Using Simulation to Measure and Improve Pediatric Primary Care Offices Emergency Readiness

INTRODUCTION

Emergencies in the pediatric primary care office are high-risk, low-frequency events that offices may be ill-prepared to manage. We developed an intervention to improve pediatric primary care office emergency preparedness involving a baseline measurement, a customized report out with action plans for improvement (based on baseline measures), and a plan to repeat measurement at 6 months. This article reports on the baseline measurement.

METHODS

This baseline measurement consisted of 2 components: preparedness checklists and in situ simulations. The preparedness checklists were completed in person to measure compliance with the American Academy of Pediatrics Policy Statement: preparation for emergencies in the offices of pediatricians and pediatric primary care providers, in the domains of equipment, supplies, medication, and guidelines. Two in situ simulations, a child in respiratory distress and a child with a seizure, were conducted with the offices' interprofessional teams; performance was scored using checklists.

RESULTS

Baseline measurements were conducted in 12 pediatric offices from October to December 2018. Wide variability was noted for compliance with the American Academy of Pediatrics recommendations (range = 47%-87%) and performance during in situ simulations (range = 43%-100%).

CONCLUSIONS

Pediatric primary care office emergency preparedness was found to be variable. Simulation can be used to augment existing measures of emergency preparedness, such as checklists. By using simulation to measure office emergency preparedness, areas of knowledge deficit and latent safety threats were identified and are being addressed through ongoing collaboration.

Simulation Training for Community Emergency Preparedness

Most infants and children who are ill and injured are cared for in community-based settings across the emergency continuum. These settings are often less prepared for pediatric patients than dedicated pediatric settings such as academic medical centers. Disparities in health outcomes exist and are associated with gaps in community emergency preparedness. Simulation is an effective technique to enhance emergency preparedness to ensure the highest quality of care is provided to all pediatric patients. In this article, we summarize the pediatric emergency care provided across the emergency continuum and outline the key features of simulation used to measure and improve pediatric preparedness in community settings. First, we discuss the use of simulation as a training tool and as an investigative methodology to enhance emergency preparedness across the continuum. Next, we present two examples of successful simulation-based programs that have led to improved emergency preparedness. [Pediatr Ann. 2021;50(1):e19-e24.].

Resident Performance of the Rapid Cardiopulmonary Assessment in the Emergency Department

OBJECTIVES

The rapid cardiopulmonary assessment (RCPA) is an essential first step in effective resuscitation of critically ill children. Pediatric residents may not be achieving competency with resuscitative skills, including RCPA. Our objective was to determine how often pediatric residents complete the RCPA for actual patients.

METHODS

This was an observational, cross-sectional study of senior residents (≥postgraduate year 2) performing the RCPA in the resuscitation area of a high-volume pediatric emergency department (PED), where pediatric residents are expected to perform the bedside examination and assessment for all medical (nontrauma) patients. Data were collected primarily by video review on a standard form. The primary outcome was completion of the RCPA, defined as both examination and verbalized assessment of the airway, breathing, and circulation. We explored the association between RCPA completion and both residency year and number of previous PED rotations.

RESULTS

Complete data were collected from one randomly selected patient for 71 (95%) of 75 of eligible senior residents who rotated in the PED between January and June 2013. Two residents (3%) performed a complete RCPA. Verbalized assessment of circulation was especially rare (7/71; 10%). There was no association between RCPA completion and year of training or previous PED experience (P > 0.05).

CONCLUSIONS

Senior pediatric resident performance of the RCPA in the resuscitation area of a high-volume PED was poor. There was no association between RCPA completion and greater resident experience, including in the PED. These findings add to a growing body of literature suggesting that pediatric residents are not achieving competency with the RCPA and resuscitation skills.

Primary Health Care Pediatricians' Self-Perception of Theoretical Knowledge and Practical Skills in Life-Threatening Emergencies: A Cross-Sectional Study

INTRODUCTION

Within out-of-hospital emergencies, Primary Health Care (PHC) pediatricians will likely be the first to provide health care at the scene of a life-threatening emergency (LTE) in children. Pediatricians should be trained to initially intervene, safely and effectively the LTEs, including the activation of Emergency Medical Systems (EMS), an adequate stabilization of patients and transport to the hospital.

STUDY OBJECTIVES

The aims of this study are to know the training received for out-of-hospital LTEs by PHC pediatricians of the Principality of Asturias (Spain) and the perception they have about their own theoretical knowledge and practical skills in a series of emergency procedures used in LTEs; also, to analyze the differences according to the geographical context of their work.

METHODS

This was a cross-sectional, descriptive, and observational study of a sample of 27 PHC pediatricians from PHC Service of Asturias, Spain, from among the total of 88 pediatricians who make up the staff of pediatricians, conducted from April through May 2019. The survey was designed ad hoc using the Curriculum in Primary Care Pediatrics (CPCP) proposed by the European Confederation of Primary Care Pediatricians (ECPCP; Europe), which indicates the theoretical and practical procedures that must be acquired by the PHC pediatricians. It is composed of 30 procedures or techniques employed in LTEs using a 11-point Likert scale rating to detect their self-perception about theoretical knowledge and practical skills from zero ("Minimum") to 10 ("Maximum").

RESULTS

There are significant differences in the mean of theoretical knowledge and practical skills in many procedures or techniques studied, depending on the different areas of work.

CONCLUSION

Asturian pediatricians are generally well-prepared to solve LTEs with a few exceptions. The degree of self-perception and acquisition of general theoretical knowledge and general practical skills in LTEs is heterogeneous, with differences according to the scope of work.

Drugs Used to Treat Pediatric Emergencies

This clinical report is a revision of "Preparing for Pediatric Emergencies: Drugs to Consider." It updates the list, indications, and dosages of medications used to treat pediatric emergencies in the prehospital, pediatric clinic, and emergency department settings. Although it is not an all-inclusive list of medications that may be used in all emergencies, this resource will be helpful when treating a vast majority of pediatric medical emergencies. Dosage recommendations are consistent with current emergency references such as the Advanced Pediatric Life Support and Pediatric Advanced Life Support textbooks and American Heart Association resuscitation guidelines.

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.

Recommendations for Prevention and Control of Influenza in Children, 2019-2020

This statement updates the recommendations of the American Academy of Pediatrics for the routine use of influenza vaccines and antiviral medications in the prevention and treatment of influenza in children during the 2019-2020 season. The American Academy of Pediatrics continues to recommend routine influenza immunization of all children without medical contraindications, starting at 6 months of age. Any licensed, recommended, age-appropriate vaccine available can be administered, without preference of one product or formulation over another. Antiviral treatment of influenza with any licensed, recommended, age-appropriate influenza antiviral medication continues to be recommended for children with suspected or confirmed influenza, particularly those who are hospitalized, have severe or progressive disease, or have underlying conditions that increase their risk of complications of influenza.

Retention of Basic Neonatal Resuscitation Skills and Bag-Mask Ventilation in Pediatric Residents Using Just-in-Place Simulation of Varying Frequency and Intensity: A Pilot Randomized Controlled Study

OBJECTIVES

Pediatric residents quickly lose neonatal resuscitation (NR) skills after initial training. Helping Babies Breathe is a skills-based curriculum emphasizing basic NR skills needed within the "Golden Minute" after birth. With this pilot study, we evaluated the feasibility of implementing a Golden Minute review and the impact on overall performance and bag-mask ventilation (BMV) skills in pediatric interns during and/or after their NICU rotation, with varying frequency and/or intensity of "just-in-place" simulation.

METHODS

During their NICU rotation, interns at 1 delivery hospital received the Golden Minute module and hands-on simulation practice. All enrolled interns were randomly assigned to weekly retraining or no retraining for their NICU month and every 1- or 3-month retraining post-NICU for the remainder of their intern year, based on a factorial design. The primary measure was the score on a 21-item evaluation tool administered at the end of intern year, which was compared to the scores received by interns at another hospital (controls).

RESULTS

Twenty-eight interns were enrolled in the intervention. For the primary outcome, at the end of intern year, the 1- and 3-month groups had higher scores (18.8 vs 18.6 vs 14.4; P < .01) and shorter time to effective BMV (10.6 vs 20.4 vs 52.8 seconds; P < .05 for both comparisons) than those of controls. However, the 1- and 3-month groups had no difference in score or time to BMV.

CONCLUSIONS

This pilot study revealed improvement in simulated performance of basic NR skills in interns receiving increased practice intensity and/or frequency than those who received the current standard of NR training.

Two-thumb-encircling advantageous for lay responder infant CPR: a randomised manikin study

OBJECTIVE

Paediatric health providers and educators influence infant mortality through advocacy and training within families and communities. This research sought to establish the efficacy and training of two-finger versus two-thumb-encircling techniques for lone responder infant chest compressions with ventilations in initially trained infant caregivers.

DESIGN

This is a randomised, cross-over educational intervention assessed on instrumented manikins using the 2015 guideline measures of quality infant cardiopulmonary resuscitation (CPR). Additional subjective data on the experience were collected through self-reporting.

SETTING

Non-healthcare community organisations and secondary school classrooms.

PARTICIPANTS

Fourteen years or older, fluent in English and had not taken infant CPR in the last 5 years.

INTERVENTIONS

Groups of eight participants were randomised to learn one technique, practised and then tested for 8 min. After a 30 min rest, the group repeated the process using the other technique.

MAIN OUTCOME MEASURES

Mean chest compression depth and rate, compression fraction, and correct hand position; tiredness and pain as reported by the caregiver.

RESULTS

The two-thumb-encircling technique achieved a deeper mean compression depth over the 8 min period (2.0 mm, p<0.01), closer to the minimum recommendation of 40 mm; the two-finger technique achieved higher percentages of compression fraction and complete recoil. Caregivers preferred the two-thumb technique (64%), and of these 70% had long fingernails.

CONCLUSIONS

The two-thumb-encircling technique improved compression depth, over an 8 min scenario, and was preferred by caregivers. This adds to the existing literature on the advantages of two-thumb-encircling as a technique for lone and team infant CPR, which counters current guidelines.

Consensus Statement on Urgent Care Centers and Retail Clinics in Acute Care of Children

This article provides recommendations for pediatric readiness, scope of services, competencies, staffing, emergency preparedness, and transfer of care coordination for urgent care centers (UCCs) and retail clinics that provide pediatric care. It also provides general recommendations for the use of telemedicine in these establishments. With continuing increases in wait times and overcrowding in the nation's emergency departments and the mounting challenges in obtaining timely access to primary care providers, a new trend is gaining momentum for the treatment of minor illness and injuries in the form of UCCs and retail clinics. As pediatric visits to these establishments increase, considerations should be made for the type of injury or illnesses that can be safely treated, the required level training and credentials of personnel needed, the proper equipment and resources to specifically care for children, and procedures for safe transfer to a higher level of care, when needed. When used appropriately, UCCs and retail clinics can be valuable and convenient patient care resources.

Pediatric Simulation Cases for Primary Care Providers: Asthma, Anaphylaxis, Seizure in the Office

Introduction

Although pediatric emergencies commonly occur in the outpatient setting, studies show that primary care providers often rely on hospitals or the emergency medical system to evaluate the distressed patient. This simulation-based curriculum addresses pediatric emergencies encountered by primary care providers. The cases were facilitated by faculty at an annual conference on urgent pediatric problems.

Methods

Three cases are included in this curriculum: asthma, anaphylaxis, and seizure. Each features a brief narrative description of the case, learning objectives, instructor notes, an example of the ideal flow of the scenario, and anticipated management mistakes. Also provided are tools on optimizing the simulation environment, teamwork and communication, and the debrief. Educational materials are included in the respective medical pathologies. The simulations can be run using a high- or low-fidelity mannequin.

Results

The simulations were carried out annually for 4 years with over 100 providers. Participants overall felt the curriculum was relevant to their practice in the realms of medical management and patient-provider communication.

Discussion

These simulation cases train primary care providers to recognize a decompensating patient, activate the emergency response system, and initiate appropriate treatment for acutely ill pediatric patients with asthma, anaphylaxis, or seizure. The cases also reinforce teamwork and communication skills with the intention of improving overall readiness in the office. The simulations have been found to be effective learning tools at the University of Washington, which continues to train outpatient providers in emergency response annually using this curriculum.

Frequency of Pediatric Emergencies in Ambulatory Practices

: media-1vid110.1542/5789654354001PEDS-VA_2017-3082Video Abstract BACKGROUND: Management of pediatric emergencies is challenging for ambulatory providers because these rare events require preparation and planning tailored to the expected emergencies. The current recommendations for pediatric emergencies in ambulatory settings are based on 20-year-old survey data. We aimed to objectively identify the frequency and etiology of pediatric emergencies in ambulatory practices.

METHODS

We examined pediatric emergency medical services (EMS) runs originating from ambulatory practices in the greater Indianapolis metropolitan area between January 1, 2012, and December 31, 2014. Probabilistic matching of pickup location addresses and practice location data from the Indiana Professional Licensing Agency were used to identify EMS runs from ambulatory settings. A manual review of EMS records was conducted to validate the matching, categorize illnesses types, and categorize interventions performed by EMS. Demographic data related to both patients who required treatment and practices where these events occurred were also described.

RESULTS

Of the 38 841 pediatric EMS transports that occurred during the 3-year period, 332 (0.85%) originated from ambulatory practices at a rate of 42 per 100 000 children per year. The most common illness types were respiratory distress, psychiatric and/or behavioral emergencies, and seizures. Supplemental oxygen and albuterol were the most common intervention, with few critical care level interventions. Community measures of low socioeconomic status were associated with increased number of pediatric emergencies in ambulatory settings.

CONCLUSIONS

Pediatric emergencies in ambulatory settings are most likely due to respiratory distress, psychiatric and/or behavioral emergencies, or seizures. They usually require only basic interventions. EMS data are a valuable tool for identifying emergencies in ambulatory settings when validated with external data.

Primary Care Office Preparedness for Pediatric Emergencies

Emergencies do occur in pediatric primary care offices. The American Academy of Pediatrics Committee on Pediatric Emergency Medicine recommends that primary care offices perform a self-assessment of office readiness for emergencies. Primary care offices should develop an emergency response plan to recognize, stabilize, and transfer sick children. They should also ensure their offices have the essential equipment, supplies, and medications readily available in case of emergencies. Primary care offices can prepare and practice for office emergencies through "mock codes" and by maintaining certification in basic and advanced life support courses. Partnership with local emergency medical services and emergency departments will allow seamless transfer of an acutely ill child. Careful planning and preparation will help improve outcomes for emergencies in the primary care setting. [Pediatr Ann. 2018;47(3):e93-e96.].

Impact on Quality When Pediatric Urgent Care Centers Are Staffed With Radiology Technologists

PURPOSE

The proliferation of pediatric urgent care centers has increased the need for diagnostic imaging support, but the impact of employing radiology technologists at these centers is not known. The purpose of this study was to evaluate radiographic impact and quality at urgent care centers with and without radiology technologists.

METHODS

A retrospective case-control study was conducted comparing 235 radiographic examinations (study) performed without and 83 examinations (control) performed with a radiology technologist at the authors' pediatric urgent care centers. Studies were evaluated for quality using a five-point, Likert-type scale (1 = poor, 5 = best) regarding field of view, presentation, and orthogonal view orientation. Studies were also evaluated for the incidence of positive results, need for repeat imaging, and discrepancies between initial study and follow-up.

RESULTS

Imaging quality comparisons between study and control groups were statistically different for field of view (3.98 versus 4.29, P = .014), presentation (4.39 versus 4.51, P = .045), and orthogonal view orientation (4.45 versus 4.69, P = .033). The incidence of repeat imaging was similar (4.7% versus 2.4%, P = 0.526), as well as the discrepancy rates (3.4 versus 2.4%, P = 1.00). The incidence of abnormal radiographic findings for the study and control groups was similar (40.9% versus 34.9%, P = .363).

CONCLUSIONS

Radiography is an important triage tool at pediatric urgent care centers. It is imperative to have optimal radiographic imaging for accurate diagnosis, and imaging quality is improved when radiology technologists are available. If not feasible or cost prohibitive, it is important that physicians be given training opportunities to bridge the quality gap when using radiographic equipment and exposing children to radiation.

Recommendations for Prevention and Control of Influenza in Children, 2017 - 2018

This statement updates the recommendations for routine use of the seasonal influenza vaccine and antiviral medications for the prevention and treatment of influenza in children. The American Academy of Pediatrics recommends annual seasonal influenza immunization for everyone 6 months and older, including children and adolescents. Highlights for the upcoming 2017-2018 season include the following:1. Annual universal influenza immunization is indicated with either a trivalent or quadrivalent (no preference) inactivated vaccine;2. The 2017-2018 influenza A (H1N1) vaccine strain differs from that contained in the 2016-2017 seasonal vaccines. The 2017-2018 influenza A (H3N2) vaccine strain and influenza B vaccine strains included in the trivalent and quadrivalent vaccines are the same as those contained in the 2016-2017 seasonal vaccines: a. trivalent vaccine contains an A/Michigan/45/2015 (H1N1)pdm09-like virus, an A/Hong Kong/4801/2014 (H3N2)-like virus, and a B/Brisbane/60/2008-like virus (B/Victoria lineage); and b. quadrivalent vaccine contains an additional B virus (B/Phuket/3073/2013-like virus [B/Yamagata lineage]);3. Quadrivalent live attenuated influenza vaccine (LAIV4) is not recommended for use in any setting in the United States during the 2017-2018 influenza season. This interim recommendation, originally made in 2016, followed observational data from the US Influenza Vaccine Effectiveness Network revealing that LAIV4 performed poorly against influenza A (H1N1)pdm09 viruses in recent influenza seasons;4. All children with an egg allergy of any severity can receive an influenza vaccine without any additional precautions beyond those recommended for any vaccine;5. All health care personnel should receive an annual seasonal influenza vaccine, a crucial step in preventing influenza and reducing health care-associated influenza infections, because health care personnel often care for individuals at high risk for influenza-related complications; and6. Pediatricians should attempt to promptly identify children suspected of having influenza infection for timely initiation of antiviral treatment, when indicated, to reduce morbidity and mortality. Best results are seen when treated within 48 hours of symptom onset.

Development of Pediatric Emergency Protocols and Communication Plans in Pediatric Radiation Oncology: Multidisciplinary Core Competencies

Supplemental Digital Content is available in the text.

Radiation therapy is an essential component of treatment for many pediatric cancers, yet the cost of maintaining a radiation facility at a dedicated pediatric center is often prohibitive. As a result, adult facilities treat pediatric patients where preparation for a pediatric emergency may be inadequate. The purpose of this quality improvement project was to develop a multidisciplinary emergency preparedness plan for a collaborative pediatric radiation oncology program at an adult community hospital with its partnering academic children’s hospital. Using a cyclical process involving multidisciplinary collaboration that combines policy development, preparation, and team-building, the authors created the protocols and processes that would support the stabilization of a pediatric emergency and facilitate transfer to the partnering children’s hospital. Further development of a communication plan outlines the flow of patient information through the multidisciplinary team during these transitions of care. Areas for future work include quantitative outcome measures to determine the effectiveness of the policies and procedures developed to prepare staff for pediatric emergencies.

Nonemergency Acute Care: When It's Not the Medical Home

The American Academy of Pediatrics (AAP) affirms that the optimal location for children to receive care for acute, nonemergency health concerns is the medical home. The medical home is characterized by the AAP as a care model that "must be accessible, family centered, continuous, comprehensive, coordinated, compassionate, and culturally effective." However, some children and families use acute care services outside the medical home because there is a perceived or real benefit related to accessibility, convenience, or cost of care. Examples of such acute care entities include urgent care facilities, retail-based clinics, and commercial telemedicine services. Children deserve high-quality, appropriate, and safe acute care services wherever they access the health care system, with timely and complete communication with the medical home, to ensure coordinated and continuous care. Treatment of children under established, new, and evolving practice arrangements in acute care entities should adhere to the core principles of continuity of care and communication, best practices within a defined scope of services, pediatric-trained staff, safe transitions of care, and continuous improvement. In support of the medical home, the AAP urges stakeholders, including payers, to avoid any incentives (eg, reduced copays) that encourage visits to external entities for acute issues as a preference over the medical home.

Pediatric Care Provided at Urgent Care Centers in the United States: Compliance With Recommendations for Emergency Preparedness

OBJECTIVES

To describe the compliance of urgent care centers in the United States with pediatric care recommendations for emergency preparedness as set forth by the American Academy of Pediatrics.

METHODS

An electronic questionnaire was distributed to urgent care center administrators as identified by the American Academy of Urgent Care Medicine directory.

RESULTS

A total of 122 questionnaires of the 872 distributed were available for analysis (14% usable response rate). The most common diagnoses reported for pediatric patients included otitis media (72%), upper respiratory illness (69%), strep pharyngitis (61%), bronchiolitis (30%), and extremity sprain/strain (28%). Seventy-one percent of centers have contacted community emergency medical services (EMS) to transport a critically ill or injured child to their local emergency department in the past year. Sixty-two percent of centers reported having an established written protocol with community EMS and 54% with their local emergency department or hospital. Centers reported the availability of the following essential medications and equipment: oxygen source (75%), nebulized/inhaled β-agonist (95%), intravenous epinephrine (88%), oxygen masks/nasal cannula (89%), bag-valve-mask resuscitator (81%), suctioning device (60%), and automated external defibrillator (80%). Centers reported the presence of the following written emergency plans: respiratory distress (40%), seizures (67%), dehydration/shock (69%), head injury (59%), neck injury (67%), significant fracture (69%), and blunt chest or abdominal injury (81%). Forty-seven percent of centers conduct formal reviews of emergent or difficult cases in a quality improvement format.

CONCLUSIONS

Areas for improvement in urgent care center preparedness were identified, such as increasing the availability of essential medications and equipment, establishing transfer and transport agreements with local hospitals and community EMS, and ensuring a structured quality improvement program.

Impact of pre-hospital care on the outcome of children arriving with agonal breathing to a pediatric emergency service in South India

BACKGROUND

Data on the prehospital interventions received by critically ill children at arrival to Paediatric Emergency Services (PES) is limited in developing countries. This study aims to describe the pre-hospital care scenario, transport and their impact on outcome in non-traumatic, acutely ill children presenting in PES with agonal breathing.

METHODS

Prospective observational study done on children aged below 15 years arriving in PES with agonal breathing due to non-trauma related causes.

RESULTS

Out of 75 children studied, 69% were infants. The duration of illness among 65% of them (75) was less than 3 days. Majority of them (81%) had received treatment prior to arrival. Government sector physicians (72%), half of them (51%) being pediatricians were the major treating doctors. 37% of the children had arrived to the Emergency in an ambulance. Cardiopulmonary Resuscitation (CPR) was given to 27% on arrival in PES. Other interventions included fluid boluses to correct shock (92%) and inotrope infusion (56%). Sepsis (24%) and pneumonia (24%) were the most common diagnoses. Out of 75, 57 (76%) children who were stabilized and shifted to PICU and among them 27 (47%) survived to discharge. Normal blood pressure (p=0.0410) and non-requirement of CPR (0.0047) and inotropic infusion (0.0459) in PES were associated with a higher chance of survival.

CONCLUSION

36% (27/75) of children who arrived to our PES with agonal breathing survived to hospital discharge. Survival was significantly better among those who did not need CPR.

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.

Recommendations for prevention and control of influenza in children, 2014-2015

The purpose of this statement is to update recommendations for routine use of seasonal influenza vaccine and antiviral medications for the prevention and treatment of influenza in children. The American Academy of Pediatrics recommends annual seasonal influenza immunization for all people 6 months and older, including all children and adolescents. Highlights for the upcoming 2014-2015 season include the following:The influenza vaccine composition for the 2014-2015 season is unchanged from the 2013-2014 season.Both trivalent and quadrivalent influenza vaccines are available in the United States for the 2014-2015 season.Annual universal influenza immunization is indicated with either a trivalent or quadrivalent vaccine (no preference).Live attenuated influenza vaccine (LAIV) should be considered for healthy children 2 through 8 years of age who have no contraindications or precautions to the intranasal vaccine. If LAIV is not readily available, inactivated influenza vaccine (IIV) should be used; vaccination should not be delayed to obtain LAIV.The dosing algorithm for administration of influenza vaccine to children 6 months through 8 years of age reflects that virus strains in the vaccine have not changed from last season.As always, pediatricians, nurses, and all other health care personnel should be immunized themselves and should promote influenza vaccine use and infection control measures. In addition, pediatricians should promptly identify clinical influenza infections to enable rapid antiviral treatment, when indicated, to reduce morbidity and mortality.

Pediatric care recommendations for freestanding urgent care facilities

Treatment of children at freestanding urgent care facilities has become common in pediatric health care. Well-managed freestanding urgent care facilities can improve the health of the children in their communities, integrate into the medical community, and provide a safe, effective adjunct to, but not a replacement for, the medical home or emergency department. Recommendations are provided for optimizing freestanding urgent care facilities' quality, communication, and collaboration in caring for children.

Pediatric office emergencies

Pediatricians regularly see emergencies in the office, or children that require transfer to an emergency department, or hospitalization. An office self-assessment is the first step in determining how to prepare for an emergency. The use of mock codes and skill drills make office personnel feel less anxious about medical emergencies. Emergency information forms provide valuable, quick information about complex patients for emergency medical services and other physicians caring for patients. Furthermore, disaster planning should be part of an office preparedness plan.

Recommendations for prevention and control of influenza in children, 2013-2014

The purpose of this statement is to update recommendations for routine use of seasonal influenza vaccine and antiviral medications for the prevention and treatment of influenza in children. Highlights for the upcoming 2013-2014 season include (1) this year's trivalent influenza vaccine contains an A/California/7/2009 (H1N1) pdm09-like virus (same as 2012-2013); an A/Texas/50/2012 (H3N2) virus (antigenically like the 2012-2013 strain); and a B/Massachusetts/2/2012-like virus (a B/Yamagata lineage like 2012-2013 but a different virus); (2) new quadrivalent influenza vaccines with an additional B virus (B/Brisbane/60/2008-like virus [B/Victoria lineage]) have been licensed by the US Food and Drug Administration; (3) annual universal influenza immunization is indicated with either a trivalent or quadrivalent vaccine (no preference); and (4) the dosing algorithm for administration of influenza vaccine to children 6 months through 8 years of age is unchanged from 2012-2013. As always, pediatricians, nurses, and all health care personnel should promote influenza vaccine use and infection control measures. In addition, pediatricians should promptly identify influenza infections to enable rapid antiviral treatment, when indicated, to reduce morbidity and mortality.

A blueprint for an office-based emergencies course

We describe the development and implementation of an office-based emergencies course for podiatric medical students. The program included a didactic session along with clinical skills stations incorporating task trainers, high-fidelity simulators, and a standardized patient. We tailored the course to the level of the junior podiatric medical student. The primary goal of this program was to provide a review on how to handle selected office-based medical emergencies. This course focused on complications of common chronic medical conditions, such as asthma, chronic obstructive pulmonary disease, diabetes, and hypertension, along with other unexpected emergencies, such as altered mental status, seizure, and syncope. In developing such a course, it is important to keep in mind the level of the learner and resources such as faculty availability and the facilities available for teaching.

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.

The role of the pediatrician in rural emergency medical services for children

In rural America, pediatricians can play a key role in the development, implementation, and ongoing supervision of emergency medical services for children (EMSC). Pediatricians may represent the only source of pediatric expertise for a large region and are a vital resource for rural physicians (eg, general and family practice, emergency medicine) and other rural health care professionals (physician assistants, nurse practitioners, and emergency medical technicians), providing education about management and prevention of pediatric illness and injury; appropriate equipment for the acutely ill or injured child; and acute, chronic, and rehabilitative care. In addition to providing clinical expertise, the pediatrician may be involved in quality assurance, clinical protocol development, and advocacy, and may serve as a liaison between emergency medical services and other entities working with children (eg, school nurses, child care centers, athletic programs, and programs for children with special health care needs).

Recommendations for prevention and control of influenza in children, 2012-2013

The purpose of this statement is to update recommendations for routine use of trivalent seasonal influenza vaccine and antiviral medications for the prevention and treatment of influenza in children. The key points for the upcoming 2012-2013 season are: (1) this year's trivalent influenza vaccine contains A/California/7/2009 (H1N1)-like antigen (derived from influenza A [H1N1] pdm09 [pH1N1] virus); A/Victoria/361/2011 (H3N2)-like antigen; and B/Wisconsin/1/2010-like antigen (the influenza A [H3N2] and B antigens differ from those contained in the 2010-2011 and 2011-2012 seasonal vaccines); (2) annual universal influenza immunization is indicated; and (3) an updated dosing algorithm for administration of influenza vaccine to children 6 months through 8 years of age has been created. Pediatricians, nurses, and all health care personnel should promote influenza vaccine use and infection control measures. In addition, pediatricians should promptly identify influenza infections to enable rapid treatment, when indicated, to reduce morbidity and mortality.

Medical transport of children with complex chronic conditions

One of the most notable trends in child health has been the increase in the number of children with special health care needs, including those with complex chronic conditions. Care of these children accounts for a growing fraction of health care resources. We examine recent developments in health care, especially with regard to medical transport and prehospital care, that have emerged to adapt to this remarkable demographic trend. One such development is the focus on care coordination, including the dissemination of the patient-centered medical home concept. In the prehospital setting, the need for greater coordination has catalyzed the development of the emergency information form. Training programs for prehospital providers now incorporate specific modules for children with complex conditions. Another notable trend is the shift to a family-centered model of care. We explore efforts toward regionalization of care, including the development of specialized pediatric transport teams, and conclude with recommendations for a research agenda.

Recommendations for prevention and control of influenza in children, 2011-2012

The purpose of this statement is to update recommendations for routine use of trivalent seasonal influenza vaccine and antiviral medications for the prevention and treatment of influenza in children. The key points for the upcoming 2011-2012 season are that (1) the influenza vaccine composition for the 2011-2012 season is unchanged from the 2010-2011 season, (2) annual universal influenza immunization is indicated, (3) a simplified dosing algorithm for administration of influenza vaccine to children 6 months through 8 years of age has been created, (4) most children presumed to have egg allergy can safely receive influenza vaccine in the office without need for an allergy consultation, and (5) an intradermal trivalent inactivated influenza vaccine has been licensed for the 2011-2012 season for use in people 18 through 64 years of age. Pediatricians, nurses, and all health care personnel have leadership roles in the prevention of influenza through vaccine use and public education. In addition, pediatricians should promptly identify influenza infections to enable rapid treatment, when indicated, to reduce childhood morbidity and mortality.

Allocating scarce resources in disasters: emergency department principles

Decisions about medical resource triage during disasters require a planned structured approach, with foundational elements of goals, ethical principles, concepts of operations for reactive and proactive triage, and decision tools understood by the physicians and staff before an incident. Though emergency physicians are often on the front lines of disaster situations, too often they have not considered how they should modify their decisionmaking or use of resources to allow the "greatest good for the greatest number" to be accomplished. This article reviews key concepts from the disaster literature, providing the emergency physician with a framework of ethical and operational principles on which medical interventions provided may be adjusted according to demand and the resources available. Incidents may require a range of responses from an institution and providers, from conventional (maximal use of usual space, staff, and supplies) to contingency (use of other patient care areas and resources to provide functionally equivalent care) and crisis (adjusting care provided to the resources available when usual care cannot be provided). This continuum is defined and may be helpful when determining the scope of response and assistance necessary in an incident. A range of strategies is reviewed that can be implemented when there is a resource shortfall. The resource and staff requirements of specific incident types (trauma, burn incidents) are briefly considered, providing additional preparedness and decisionmaking tactics to the emergency provider. It is difficult to think about delivering medical care under austere conditions. Preparation and understanding of the decisions required and the objectives, strategies, and tactics available can result in better-informed decisions during an event. In turn, adherence to such a response framework can yield thoughtful stewardship of resources and improved outcomes for a larger number of patients.