Pediatric Office Emergencies and Emergency Preparedness in a Small Rural State

Pediatric Office Emergencies and Emergency Preparedness in a Small Rural State

Barry W. Heath

ABBREVIATIONS. EMS, emergency medical services; ALS, advanced life support; BLS, basic life support; PALS, pediatric advanced life support; SD, standard deviation.

Children with varied urgent and emergent medical problems present to primary care pediatric outpatient offices for evaluation and treatment. A literature search revealed a number of analyses of pediatric office emergencies[1-5] and of preparation of pediatric offices for medical emergencies.[1-3,5-8] Differing recommendations regarding the equipment necessary to manage medical emergencies in a pediatric office setting have also been published.[9-14] To date, however, there have been no published prospective studies of pediatric medical emergencies in the outpatient setting. In addition, there has been no study of pediatric office emergencies or emergency preparedness in rural communities, the distance of which from tertiary care facilities may put a premium on these matters.

We undertook a 3-part study to identify how often pediatric offices in a small rural state encounter medical emergencies and to determine their level of preparedness for these emergencies. First, we performed a retrospective assessment of pediatric office medical emergencies and of office preparation for such emergencies in the state of Vermont. Second, in an attempt to improve the level of emergency preparedness, we provided an in-office educational program and emergency equipment donation to all study participants. Finally, we performed a 1-year prospective study of office emergencies and assessed the adequacy of the donated resuscitation kit.

METHODS

In 1997 with the cooperation of the Committee on Pediatric Emergency Medicine, Vermont Chapter of the American Academy of Pediatrics, all of the active primary care pediatric practice sites in the state of Vermont were identified. Informed consent was judged to be unnecessary at the onset of the study and was not obtained. Each office was contacted and invited to participate in the study. When an office site agreed, the local emergency medical services (EMS) providers in that service area were also invited to participate. A contact person was identified for each practice.

Retrospective Study

Office personnel (providers, nurses, and nonmedical employees) and local EMS providers participated in the retrospective study. Participants were surveyed concerning their office preparation for emergencies and the emergencies they had encountered over the past 12 months. Life support training was assessed by questionnaire, but current American Heart Association certification was not verified. The participants also answered questions regarding their office plans for medical emergencies, their practice of mock code resuscitations, the training and response time of their local EMS provider, and their interactions with local EMS providers.

Office Intervention

Videotapes detailing pediatric airway management (Pediatric Airway Management, The Education Management Subcommittee, Pediatric Airway Project, California Emergency Medical Services Authority) and intraosseous techniques (Intraosseous Line Placement and Infusion, National EMSC Resource Alliance) were sent to participating practices and EMS squads for viewing. The study team (B.W.H., J.S.C., and P.M. or J.C.) then visited each participating office site between May 1997 and May 1998.

Didactic presentations lasting a total of 90 minutes and consisting of the following elements were made:

1. Preparing and equipping the primary care pediatric office for medical emergencies and practicing mock codes resuscitations;

2. Integrating local EMS providers with the primary care pediatric office in the management of medical emergencies;

3. Recognizing and managing pediatric emergencies in the office setting, emphasizing an algorithmic “airway-breathing-circulation” approach;

4. Reviewing the contents of the donated resuscitation kit (Table 1) in a hands-on manner; and

TABLE 1. Resuscitation Kit Contents

Cost

4 drawer wheeled container $21.00

Airway and breathing

(4) Oral airways (55-, 70-, 80-, and 100-mm) $28.00

(2) Nonrebreathing masks (child, adult) $5.00

Updraft nebulizer with T-piece $2.15

Hand-held suction device $53.00

(2) Yankauer suction catheters $1.66

(2) 10 French suction catheters $1.38

(2) 14 French suction catheters $1.06

(2) Bag-mask ventilator (child, adult) $42.00

Oxygen cannister, flowmeter, cart $110.00

Vascular access and fluids

(20) IV catheters (24-, 22-, 20-, 18-, 16-gauge) $15.16

(4) 15-gauge intraosseous needles $17.16

(2) 3-way stopcock $1.50

(2) Needleless connector extension sets $5.44

(2) T-connector extension sets $1.82

(2) Arm boards $5.00

(2) Sterile gloves $3.50

Adhesive tape $0.53

(4) Povidone-iodine swabs $0.07

Normal saline 1000-mL bag $0.71

Primary IV set $1.45

150-mL Burette IV set $3.24

(4) Syringes (30- and 60-mL) $1.18

(12) Needles (25-, 20-, and 18-gauge) $6.00

(18) Syringes (1-, 3-, 5-, and 10-mL) $8.00

Resuscitation Drugs

(4) Albuterol premixed ampules $4.48

Ceftriaxone and diluent 2 g $157.00

(2) [D.sub.25] W 10-mL ampules $20.00

[D.sub.50]W 50-mL ampule $17.69

(2) Diazepam 10-mg vials $11.49

Diphenhydramine 50-mg vial $2.00

Epinephrine 1:1000 (30-mL bottle) $10.27

Epinephrine 1:10 000 (10-mL ampule) $13.25

Naloxone 10-mL vial $3.47

Drug dosage handbook $3.00

Total $578.66

IV indicates intravenous.

5. Modeling an office mock code resuscitation scenario by the study team, using the resuscitation kit.

Participants were surveyed concerning the value of this office presentation. Continuing medical education/continuing education units were offered to participants.

Prospective Study

A prospective study of office emergencies was undertaken for a 12-month period after the study team’s visit. For the purpose of this part of the study, we defined an office medical emergency as an event that required equipment and intervention beyond the usual and customary scope of pediatric office practice. In operational terms, an emergency was defined as the need to use the emergency kit provided. The reporting of emergencies was linked to kit restocking. All equipment and drugs in the donated kits were disposable. Whenever the kit was used during the study, the kit was restocked by the study team. To restock the kit, the participating office completed a form describing the emergency and requesting replacement equipment or drugs. This same form was used to restock outdated drugs. All kits had drugs that would be outdated within the 12-month prospective study.

At the end of the study, the contact person in each practice was surveyed by telephone by a member of the study team (J.S.C.). Each site was asked about office plans for emergencies, EMS involvement in office emergencies, performance of mock code resuscitations, and unreported use of the resuscitation kit. In addition, the office representative was asked about the adequacy and convenience of the kit, periodic checks of the resuscitation kit, and any modifications made or suggested for the kit.

RESULTS

Study Group

Forty active pediatric practices were identified and invited to participate. Thirty-eight office sites (95%) participated, whereas 2 practice sites declined. One practice, located in-hospital and in close proximity to the emergency department, believed that the study program would not be of benefit to them. One solo practitioner declined for unspecified reasons. Thirty-seven of 38 practices were studied retrospectively. One new practice had not started seeing patients and had no retrospective data available. Thirty-seven of 38 practices were studied prospectively, with one practice’s participation coming too late for a 12-month follow-up. Three hundred twenty-seven health professionals participated in the study in all (74 physicians, 9 nurse practitioners, 4 physician assistants, 105 registered nurses, 27 licensed practical nurses, 70 office personnel, and 38 EMS providers).

Thirty different rescue squads provided EMS for the 38 study sites. Six (20%) were staffed with full-time paid personnel, whereas 24 (80%) were staffed with volunteers or a combination of volunteers and paid personnel. Seven of the rescue squads (23%) staffed by emergency medical technicians-paramedic personnel provided advanced life support (ALS) services. Twenty-three squads (77%) staffed by emergency medical technician-intermediate personnel provided basic life support (BLS) services.

Retrospective Study

With respect to resuscitation training, 143 of the participants (49%) reported BLS certification of the 289 who could have been certified (MD, NP, PA, RN, LPN, Office). Of the 219 participants who could have been certified (MD, NP, PA, RN, LPN) in pediatric advanced life support (PALS), 58 (26%) reported such certification. Of 219 eligible participants (MD, NP, PA, RN, LPN), 26 (12%) reported certification in advanced cardiac life support. Twenty-two of 37 (67%) offices had a plan for an office medical emergency. Seventeen of 37 offices (46%) reported that EMS had been called to their office for an emergency patient transport in the past 12 months. Table 2 details office emergency equipment and resuscitation drugs before our equipment donation. Ten sites (27%) reported practicing mock code resuscitations in the previous year. EMS response and transport time are detailed in Fig 1.

[Figure 1 ILLUSTRATION OMITTED]

TABLE 2. Comparison of Pediatric Office Preparedness

1989[1] 1989[6] 1990[2] 1991[3]

Bag-mask ventilator 36% 76% 51% 80%

Oxygen 42% 74% 68% 81%

Resuscitation drugs 88% 98% 65% 73%

Intravenous catheters 25% 61% 64%

Suction device 26% 54% 63%

Laryngoscope, tubes 29% 69% 55% 65%

Intraosseous needles 9% 11%

1996[5] 1998[8] VT Pre(*)

Bag-mask ventilator 69% 90% 95%

Oxygen 75% 61% 92%

Resuscitation drugs 55% 38% 86%

Intravenous catheters 73% 71% 84%

Suction device 50% 78%

Laryngoscope, tubes 29% 36% 54%

Intraosseous needles 1% 38% 27%

(*) Before equipment donation.

There was a wide divergence of opinion among participants at each office as to the number of emergencies encountered in the previous year. A total of 178 participants from 37 study sites provided retrospective estimates of the number of emergencies in their office in the past 12 months. There was a mean of 4.8 respondents per practice (range = 2-15). Estimates of the number of emergencies ranged from 0 (82 respondents) to 100 (4 respondents). The mean estimated number of emergencies was 2.8 per site in the previous 12 months (standard deviation [SD] = 11.7). One site had major differences in estimates among its 7 respondents: 1 estimated 4 emergencies, 2 estimated 50 emergencies, and 4 estimated 100 emergencies. The mean estimated number of emergencies at this office was 6 SDs away from the mean of all sites. When this practice is excluded, the estimated number of emergencies per practice site in the previous year ranges from 0 to 6 (mean = .9; SD = .8). Interoffice agreement on the estimated number of emergency events varied from practice to practice. With the one outlying site excluded, there was exact agreement in estimates for only 10 of the study sites. For 36 study sites the reliability coefficient (R = .22) indicated poor agreement within the practices as to. the number of emergencies that occurred in the preceding 12 months.

Educational Program and Equipment Donation

All sites participated in the didactic sessions. Thirty-eight pediatric office resuscitation kits were donated. A survey after the office educational program showed that 89% of physicians rated the presentation as excellent. Eighty-eight percent of other attendees strongly agreed that the program met their personal learning objectives. All participants believed that the presentation was useful.

Prospective Study

Twenty-eight medical emergencies were reported over the 12-month study, ranging from 0 at 24 sites to 8 at 1 site (mean = .8 emergencies per practice site; SD = 1.5). Table 3 details the emergencies encountered and the equipment used. Twenty-one of 28 reported emergencies were respiratory in origin. One death (sudden infant death syndrome) was reported in this series of emergencies. Twenty-four office sites (65%) reported no medical emergencies over the 12-month study. Fig 2 details the breakdown of emergencies per office.

[Figure 2 ILLUSTRATION OMITTED]

TABLE 3. Emergencies Reported and Equipment Used

Emergencies Reported Number Equipment Used

Respiratory emergencies

(n = 21)

Asthma 10 Oxygen, mask, nebulizer,

albuterol, epinephrine

Croup 3 Oxygen, mask

Respiratory distress 3 Oxygen, mask

Airway obstruction 1 Suction

Bronchiolitis 1 Oxygen, bag-mask

Desaturation in cardiac

patient 1 Oxygen, mask

Pneumonia 1 Oxygen, mask

Respiratory arrest 1 Oxygen, bag-mask

Other emergencies (n = 7)

Seizures 2 Oxygen, mask, suction

Anaphylaxis 1 Epinephrine, diphenhydramine

Cardiopulmonary arrest Oxygen, bag-mask, IO,

(SIDS) 1 saline, tubing

Presumed hypoglycemia 1 IV, [D.sub.25]W, [D.sub.50]

W, saline, tubing

Shock 1 Oxygen, bag-mask

Trauma 1 IO

28

Total

IV indicates intravenous;

SIDS, sudden infant death syndrome;

IO, intraosseous.

In addition to restocking kits after use in emergencies, kits were restocked 52 times at 32 sites for outdated medications. Five sites (14%) did not request restock for outdated medications.

Final Telephone Survey

At the end of the study period, 31 of the study sites (83%) reported having a plan for office medical emergencies, compared with 22 sites prior to the office intervention (67%; McNemar’s test, P = .06). Twelve sites (32%) reported that local EMS providers were involved in office planning for emergencies. Eleven sites (30%) had called the local EMS providers to their office during the study. Thirty-six sites (97%) reported checking the resuscitation kit on a regular basis. Eleven of the practice sites (30%) reported performing mock codes in the study, indicating no significant change from the 10 sites of the preintervention study (McNemar’s test, P = .66).

All sites reported that the donated kit was convenient. Modifications to the kit were made at 6 sites (16%). Four kits were consolidated with existing equipment. One site added [D.sub.5]W. One site added a parenteral steroid, glucagon, and syrup of ipecac. The only other modification to the resuscitation kit suggested by the participants was the addition of a tourniquet.

There was no unreported use of the resuscitation kits during the 12-month follow-up.

DISCUSSION

Vermont is a small rural state with a population of ~600 000. The high proportion of practice sites represented in this study gives a nearly complete picture of office emergencies and emergency preparedness of an entire state’s primary care pediatric community.

Between 1989 and 1998, pediatric office preparedness for medical emergencies seems to have shown steady improvement.[1-3,5-8] Emergency preparedness of Vermont pediatricians before our equipment donation compared favorably with these previously published studies (Table 2). Before the prospective study, Vermont pediatricians had the highest reported percentage of offices with oxygen, bag-mask ventilators, and suction devices.

In the literature, estimates of the frequency of pediatric office emergencies have varied. For each published study, variations in data collection make it difficult to determine an accurate yearly rate of emergencies per office. In 1989, Fuchs et al[1] surveyed 280 physicians representing 252 practices in the Chicago area. In a 3-month period, they reported that 80% of practices had seen at least one severely ill child in the office setting. Sixty-two percent reported that they assessed in their offices more than one child each week requiring hospitalization or urgent treatment. Using severely ill or requiring hospitalization as a definition of an office emergency, this estimates a range of between 3.2 and 32.2 emergencies per office per year, respectively. One hundred seventy-five respondents from the Washington, DC, Maryland, and Virginia area reported 608 emergencies over a 3-year period, averaging 1.2 emergencies per office per year. This study defined an emergency as a specific diagnosis (severe respiratory distress, seizure, obstructed airway, shock, severe trauma, or cardiac arrest).[2] Schweich et al[3] reported a national random survey of 427 pediatricians that defined emergency by diagnosis (meningitis, severe asthma, severe dehydration, ongoing seizure, closed head trauma with change of mental status, probable epiglottitis, anaphylaxis, and cardiac arrest). Extrapolation of their data shows an average of 3.3 emergencies per office per year. In a survey of 744 office-based pediatricians, Periodic Survey 27 by the American Academy of Pediatrics reported that 73% of respondents encountered one or more patients per week requiring emergency treatment or hospitalization.[4] This extrapolates to 38 emergencies per office per year. In 1996, a Fairfield County, Connecticut survey of 51 offices examined “all emergencies” and “7 life-threatening emergencies” (status asthmaticus, upper airway obstruction, shock, anaphylaxis, severe dehydration, significant trauma, status epilepticus, endocrine emergencies, and cardiac arrest). They reported a median number of 24 emergencies per office per year (range: 1-250).[5]

The literature on this subject is based on retrospective surveys, all having varying methodological limitations. The definition of an office medical emergency can be problematic. One pediatrician’s asthma emergency may represent another pediatrician’s routine office visit. The authors of the Fairfield County study believed that there may have been interpractice variability in the estimates of office emergencies because of differences in definitions of emergent and nonemergent cases.[5] Our retrospective data showed significant variability in estimates of the number of emergencies within the same office. This raises questions concerning the accuracy of such retrospective data and the role individual bias might play in these estimates if an individual opinion represented the experience of an entire study site. Vermont pediatric practices, exclusive of one statistically outlying site, estimated that they encountered medical emergencies in their offices in a range within that reported in the literature, .9 per office site per year (SD = .8).

Although our definition of a medical emergency was arbitrary, it provided a consistent baseline for this prospective study. We emphasized recognition of altered physiology in the office educational session. Rather than using specific diagnoses, emergencies were presented in the context of the “airway-breathing-circulation” approach stressing the recognition of respiratory distress, abnormal perfusion, and cardiopulmonary failure. The restocking incentive followed by a telephone interview provided an accurate representation of the office medical emergencies in our study group. During the study, Vermont pediatricians reported less than one medical emergency per office per year, with 65% of offices reporting no office medical emergencies at all. These prospective data suggest that medical emergencies in the primary care office setting are, in fact, rare events.

It should not be surprising that the majority (75%) of the emergencies reported were respiratory in nature. Respiratory failure is a common antecedent to cardiopulmonary arrest in children. One of the educational objectives of the PALS course of the American Heart Association is the recognition and management of respiratory distress.[15] For this reason, we stressed an “airway-breathing-circulation” approach to medical emergencies in our didactic sessions.

We had hoped that this project might serve as a catalyst for practitioners to consider the management of medical emergencies as part of routine office practice. The donation of this resuscitation equipment has stimulated some pediatric practices in this direction. The kits were checked regularly at the majority of the study sites. Attention to the resuscitation kit was evidenced by requests for restocking. This perhaps represents an indication of increased awareness and preparation.

Although the practice of mock resuscitations is recognized as a valuable tool in inpatient pediatric settings, little has been written about its benefit in the outpatient setting.[16-18] Few sites practiced mock codes before the team’s visit. Despite our educational efforts, there was no significant change in the number of sites that practiced mock codes in the 12 months after our visit.

Although the content of the resuscitation kit used in this study was based on the literature describing pediatric office medical emergencies,[1-5] the contents differed from previously published recommendations.[9-14] These kits were designed to allow a provider to resuscitate and stabilize a pediatric patient over the 20- to 40-minute period that it might take to get that patient to an ALS facility. They were not meant to replace the emergency department or to turn a primary care pediatric office into an ALS facility. The kits were meant to facilitate a simple algorithmic “airway-breathing-circulation” approach to stabilizing the seriously ill pediatric patient. Although their equipment and drug list were far from exhaustive, they did meet the needs of the study group. No emergencies during the study required different drugs or equipment than those donated. Although the donated kits were modified by a small group of study participants, none of the additional contents were used during the study. The donated pediatric office resuscitation kits were sufficient for the emergency needs of all the sites during the study.

The spectrum of emergency medical care for children optimally involves the integration of primary care, EMS prehospital care, and ALS in the emergency department. We tried to encourage a dialogue between the primary care office and the prehospital EMS provider, particularly with respect to planning for office emergencies. When surveyed 1 year after our office intervention, only 32% of sites had been involved in such integrated planning, whereas 30% had called the local EMS provider to their office.

It is unreasonable to expect that a primary care pediatric office be as prepared and equipped for emergencies as a hospital emergency department. It is reasonable, however, for primary care pediatric offices to be prepared to provide immediate resuscitation and stabilization for their patients with serious medical emergencies before their transport to an ALS facility. A primary care pediatric office can be equipped at modest financial cost. The cost of the kits used in this study was [is less than] $600. Adequate preparation for emergencies requires not only a financial commitment but also a time commitment. The time necessary for education, planning, and practice is a scarce commodity in a busy primary care office. Pediatricians in busy primary care clinics may find it difficult to devote time to prepare for events that occur quite infrequently.

CONCLUSION

Serious medical emergencies are rare events in the primary care pediatric office, occurring less than once per office per year. Although infrequent, these medical emergencies have the potential for serious morbidity and mortality. The most common emergency situations encountered are respiratory in origin. All of the reported emergencies in this study were managed using the donated equipment kit. We provided a pediatric office emergency preparedness program that was sufficient for the needs of pediatric practices in a small rural state.

ACKNOWLEDGMENT

This work was supported by a grant from the Children’s Miracle Network.

REFERENCES

[1.] Fuchs S, Jaffe D, Christoffel K. Pediatric emergencies in office practices: prevalence and office preparedness. Pediatrics. 1989;83:931-939

[2.] Altieri M, Bellet J, Scott H. Preparedness for pediatric emergencies encountered in the practitioner’s office. Pediatrics. 1990;85:710-714

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

[4.] American Academy of Pediatrics. Periodic Survey 27. Elk Grove Village, IL: American Academy of Pediatrics; 1995

[5.] Flores G, Weinstock D. The preparedness of pediatricians for emergencies in the office. Arch Pediatr Adolesc Med. 1996;150:249-256

[6.] Barth E, Parr A, Ginsburg C. Emergency office supplies: a survey of 80 general pediatric offices in Dallas, Texas. Pediatr Infect Dis J. 1989;8: 400-401

[7.] American Academy of Pediatrics, Ambulatory Care Quality Improvement Program (ACQIP). Exercise 2: Office Emergency Procedures. Elk Grove Village, IL: American Academy of Pediatrics; 1995

[8.] Shetty A, Hutchinson S, Mangat R, Peck P. Preparedness of practicing pediatricians in Louisiana to manage emergencies. South Med J. 1998; 91:745-748

[9.] American Academy of Pediatrics, Committee on Pediatric Emergency Medicine. Singer J, Ludwig S. Emergency Medical Services for Children: The Role of the Primary Care Provider. Elk Grove, IL: American Academy of Pediatrics; 1992:38-39

[10.] Hodge D. Pediatric emergency office equipment. Pediatr Emerg Care. 1998;4:212-214

[11.] Sapien R, Hodge D. Equipping and preparing the office for emergencies. Pediatr Ann. 1990;19:659-667

[12.] Seidel J. Preparing for pediatric emergencies. Pediatr Rev. 1995;16: 466-471

[13.] Schexnayder S, Schexnayder R. 911 in your office: preparations to keep emergencies from becoming catastrophes. Pediatr Ann. 1996;25:664-666

[14.] Altemeier W. A pediatrician’s view: know your ABC’s. Pediatr Ann. 1996;25:312-313

[15.] American Heart Association, Committee on Pediatric Resuscitation. In: Chameides L, Hazinski M, eds. Pediatric Advanced Life Support. Dallas, TX: American Heart Association; 1997

[16.] Roback M, Teach S, First L, Fleisher G. Handbook of Pediatric Mock Codes. St Louis, MO: Mosby Yearbook, Inc; 1998

[17.] Bishop-kurylo D, Masiello M. Pediatric resuscitation: development of a mock code program and evaluation tool. Pediatr Nurs. 1995;21:333-336

[18.] Cappelle C, Paul R. Educating residents: the effects of a mock code program. Resuscitation. 1996;31:107-111

Barry W. Heath, MD(*); Jean S. Coffey, RN, MSN([double dagger]); Patrick Malone, BA, EMT-I([subsections]); and James Courtney, BS, REMT-P([subsections])

From the (*) Department of Pediatrics, University of Vermont College of Medicine, Burlington, Vermont; the ([double dagger]) Children’s Health Care Service, Fletcher Allen Health Care, Burlington, Vermont; and the [subsections] Office of Emergency Medical Services, Vermont Department of Health, Burlington, Vermont.

Received for publication Dec 7, 1999; accepted Feb 15, 2000.

Reprint requests to (B.W.H.) Fletcher Allen Health Care, 419 Burgess, 111 Colchester Ave, Burlington, VT 05401. E-mail: barry.heath@vtmednet.org

COPYRIGHT 2000 American Academy of Pediatrics

COPYRIGHT 2001 Gale Group