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Preparing an office practice for pediatric emergencies

Preparing an office practice for pediatric emergencies
Literature review current through: Jan 2024.
This topic last updated: Aug 07, 2023.

INTRODUCTION — This topic will discuss how to prepare an office practice for pediatric emergencies.

BACKGROUND — Pediatric providers deliver a variety of services to children and their families, including, on occasion, triage and treatment of childhood emergencies. Infants and children with potentially life-threatening illnesses and injuries are sometimes taken to primary care offices by parents or caregivers who are seeking help from healthcare professionals they know and trust. When this occurs, the office and staff need to be prepared to provide initial stabilization and when necessary, life-saving care [1]. The consequences of being unprepared are serious; initial treatment provided in the office may mean the difference between life and death. Appropriate stabilization of pediatric emergencies and timely transfer to an appropriate facility for definitive care are important responsibilities of every medical provider who cares for children.

EPIDEMIOLOGY — Emergency conditions in infants and children coming to medical office settings are relatively frequent, but the actual number varies significantly depending upon practice characteristics [2]. As an example, more than 2400 life-threatening pediatric emergencies per year were reported in a telephone survey of 51 pediatric offices in one suburban county of Connecticut (an average of 24 emergencies per office per year) [3]. In a survey of pediatricians and family medicine providers who practice in an urban setting, almost two-thirds of those who responded reported that they cared for at least one child who required hospitalization or urgent care each week, and 80 percent had cared for at least one severely ill patient in the past three months [4] In a separate survey of pediatricians, 73 percent reported one or more emergencies per week [5].

Several studies have been conducted to identify the types of pediatric emergencies that are most often encountered in the office setting [3-6]. Respiratory emergencies, seizures, infections (especially in young infants), and shock/dehydration are reported most often, and serious traumatic injuries have also been noted [4-6]. Based upon estimates from surveys of general pediatricians, the most commonly encountered emergency conditions in an office from most to least frequent include [6,7]:

Respiratory emergencies including asthma

Neurologic emergency including seizures

Sepsis or severe infection

Dehydration

Anaphylaxis

Choking

Head trauma

Cardiopulmonary arrest

However, the type of pediatric emergencies encountered in a given office will vary significantly depending on prevalence of disease within a given geographical area, the proximity of the practice to a facility with pediatric resuscitation capability, the numbers and types of chronic medical conditions cared for by the practice, the practice culture with respect to evaluating children with acute illness in the office, and the severity of disease within individual patients.

Because of the frequency of emergency conditions in children coming to office-based settings, pediatric care providers need to ensure that pediatric specific resources are available to provide initial resuscitation.

OFFICE PREPAREDNESS — The steps to prepare an office for handling a pediatric emergency involve [1]:

Office-based self-assessment

Development of a written response plan

Training for all office staff

Effective surveillance and triage for critically ill or injured children who come to the office

Immediate availability of appropriate pediatric resuscitation equipment and medications by medical personnel trained in their use

Effective communication with emergency medical services and assurance of safe transport to a higher level of pediatric care

In office practices near facilities with pediatric resuscitation capability, the focus should be on brief stabilization of life-threatening conditions and rapid transfer. In practices that are remote to definitive care and with only basic emergency medical services, the office staff need to be able to provide extended resuscitation care.

Office-based self-assessment — The table provides sample questions that may be useful when performing an office-based self-assessment (table 1). An office-based self-assessment provides practitioners with information necessary to optimize readiness for pediatric emergencies [8]. The goal of the assessment is to determine the following:

The types of pediatric emergencies most likely to be encountered in the office given the provider's patient population and past experience

Office resources available to respond to pediatric emergencies on site

Emergency medical services capability (basic life support, advanced life support, or both) and response time to the practice

The closest facility that can provide a higher level of pediatric resuscitation (eg, closest general emergency department) along with the best means of communication with that facility and expected transport time

The closest facility that can provide definitive pediatric care (eg, free-standing children's hospital) along with the best means of communication with that facility and expected transport time

Response plan — The practice should develop a written response plan and obtain appropriate pediatric training, equipment, and medications to support effective office-based stabilization and transfer of the critically ill or injured child. The response plan is best developed by convening representative members of the office team and discussing each step that is required to assure appropriate management of an office emergency. Roles are assigned to each team member in advance of the event (these should not exceed a standard scope of practice). The response plan should also cover times when the office is open, but staffing is limited to ensure that patient stabilization occurs while external assistance is sought [9].

A comprehensive response plan should address the following:

Recognition and triage of a pediatric emergency – Nonclinical personnel (eg, the receptionist) are often the first office staff to assess the patient. They should receive basic training regarding signs and symptoms of common pediatric emergencies, including those associated with respiratory distress, shock, seizures, and altered mental status. (See 'Triage' below.)

Periodic surveillance of children in the waiting room and examination rooms by clinical personnel, such as the head nurse, is also advisable.

Internal notification – The practice should establish a system to rapidly notify appropriate office staff, especially clinical personnel, of an emergency.

EMS activation – A staff member should expeditiously access the local emergency medical services (EMS) system when an emergency is recognized. Staff who are given this role need to know the phone number to access EMS and have a clear understanding of the capability of their local emergency medical service agency (see 'Office-based self-assessment' above). They should also provide the following information to the EMS dispatcher [1,8,10]:

Office address and practice location within the building

Where to access the building and/or meet personnel (eg, security) who will escort them to the patient, including where to park the ambulance

Child's age, medical condition, and if available, vital signs and weight

Type of EMS provider needed (basic life support or advanced life support)

The caller should not hang up until the EMS dispatcher has all of the above information, has had the opportunity to ask follow-up questions, and has hung up first.

Posting of scripted instructions near telephones can give prompts that encourage clear and informative communication with the EMS dispatcher. (See 'Additional resources' below.)

Office resuscitation — Staff should decide where the child should be resuscitated (eg, designated examination room, ideally with wide enough access for an EMS stretcher), how resuscitation equipment and medications are organized, and who is responsible for bringing them to the patient. (See 'Emergency equipment and medications' below.)

Resuscitation roles should be outlined in the response plan [1]. As an example, a practice may decide to use an approach such as:

The receptionist notifies the local EMS system, then provides support to family members.

The physician directs resuscitation efforts and controls the airway.

One nurse is responsible for intravenous access and drug administration and another nurse or medical assistant is designated to provide chest compressions; and a nursing assistant records events and interventions (eg, medications given) as they occur.

Each member of the team needs to have the training to ensure that they can perform their assigned clinical duties.

The response plan should also address who is in charge of the resuscitation if there are times in which there is no physician in the office.

Use of a code documentation sheet can assist in rapidly capturing key information about the resuscitation, such as clinical personnel involved, all interventions performed, timing of interventions, time that EMS was called, time that EMS arrived, time that EMS departed, and equipment used. A copy of the code documentation sheet is an efficient method of supplementing the documentation that should go with the patient when they are transferred to definitive care. (See 'Documentation' below and 'Additional resources' below.)

Patient transfer — The response plan should identify the preferred EMS provider and the preferred destination facility for EMS transport. In some situations (eg, child with severe trauma), regional EMS protocols will mandate the facility that should receive the patient. Important telephone numbers (eg, EMS provider, receiving hospital emergency departments) should be posted prominently to facilitate verbal communication. The plan should reinforce that a written patient care record should be generated during the resuscitation and accompany the patient as part of the transfer process. (See 'Documentation' below.)

Mock resuscitation — Testing of the response plan through periodic simulated resuscitations maintains readiness for pediatric emergencies and permits updating of the response plan based upon team performance [11,12]. Low fidelity simulations (eg, role play, use of a baby doll as a patient, live child volunteer) are as effective as high fidelity exercises in teaching nontechnical teamwork skills and role clarity and are easy to implement in any office setting [13].

Limited evidence also suggests that low fidelity simulation can be as effective as high fidelity simulation in teaching technical resuscitation skills. As an example, in a crossover trial of high versus low fidelity simulation for training 16 neonatal fellows, overall resuscitation performance was not different regardless of the type of simulation [14]. Though this study addresses neonatal resuscitation rather than general pediatric resuscitation, it provides useful information related to "performance and practicing skills" in a low fidelity setting, which is much more available to officer providers than high fidelity simulation.

In addition, performing mock resuscitations in conjunction with emergency providers and local EMS teams is a proven method for enhancing office readiness for pediatric emergencies [11,12,15,16].

Training — The effective management of a seriously ill or injured child requires training of the pediatric office staff in the proper use of emergency equipment and medication. A list of training courses and representative training costs are shown in the table (table 2).

The American Academy of Pediatrics recommends that all certified pediatric providers (eg, physicians, nurse practitioners, physician assistants, nurses) at a minimum have training in basic life support [1] (see "Pediatric basic life support (BLS) for health care providers" and "Basic airway management in children"). Furthermore, a more advanced level of training (eg, The Pediatric Advanced Life Support or equivalent) is strongly encouraged for staff who work in offices that do not have ready access to advanced life support resources through their local emergency medical services system or institution. (See "Pediatric advanced life support (PALS)".)

EMS providers and office staff can create opportunities to improve communication and develop teamwork skills that will facilitate the transfer of care at the time of a true emergency. Some practices also find it helpful to review actual cases, to invite local EMS providers to participate in simulated drills, and to provide continuing education addressing the most common problems seen in their offices.

Triage — Triage in pediatric practices consists of two scenarios:

Children already in the office – A seriously ill or injured child, or one whose condition is deteriorating in the office, needs to be evaluated, treated, and transferred emergently rather than waiting his or her turn. All office staff, both clinical and nonclinical, should know signs and symptoms of respiratory distress, shock, seizures, and altered mental status and know how to initiate the office response plan [1]. (See 'Response plan' above.)

Periodic surveillance by experienced clinical personnel (eg, head nurse) of children who are in the waiting area or examination rooms provides additional opportunity to recognize and respond to an office emergency [1,10].

Telephone triage – Each practice should have a specific set of formal guidelines for telephone communication that allows users to determine the degree of illness of the child and the appropriate disposition (care at home, office evaluation, emergency department evaluation). Commercial telephone triage algorithms are available with a series of specific and directed questions for each chief complaint or set of presenting symptoms [17]. Every staff member who is responsible for fielding parent/primary caregiver telephone calls should be trained in the use of such a protocol, with clear instructions for when to refer the call to the physician. All telephone calls should be documented, and any advice given to the family included in the patient's chart. Many pediatric providers subscribe to call centers that provide after-hours telephone advice and triage. The American Academy of Pediatrics has provided guidance on the safe operation of these centers [18].

Emergency equipment and medications — The Committee on Pediatric Emergency Medicine for the American Academy of Pediatrics have provided lists that delineate the essential and strongly suggested emergency equipment and medications that should be available in offices that care for children (table 3) [1].

Essential equipment (eg, oxygen delivery system and masks, bag-valve mask, suction, pulse oximeter, epinephrine [1 mg/mL or 1:1000]) should be available in all pediatric practices. Strongly suggested supplies (eg, equipment for endotracheal intubation, equipment to establish vascular access, intravenous medications, automated external defibrillator with pediatric capabilities) are considered essential if response time for an advanced life support ambulance is >10 minutes. Pediatric providers may obtain prepackaged emergency kits from commercial medical suppliers (eg, Armstrong Medical Industries Inc, Banyan International Corporation). An emergency medical services equipment provider or a pediatric hospital may also be able to help with procurement [8].

Utilizing a system that helps clinical staff rapidly determine the appropriate equipment size and emergency medication dosing for children during emergency care is strongly encouraged. The Broselow® Pediatric Emergency Tape and the Broselow™ Pediatric Resuscitation System are widely used in the United States. Trials of physician use during simulated pediatric resuscitations suggest that these clinical tools significantly reduce medication and equipment sizing errors [19,20]. Web-based education on the proper use of the Broselow tape further decreases the frequency of medication dosing errors [15]. Although evidence is limited, charts or manuals with equipment size and medication dosing (including dose in mg/kg, drug formulation, and volume to administer) organized by patient weight are alternative resources that may be useful [21]. Local emergency departments may provide guidance on available systems and assist with ordering materials.

Regardless of how resuscitation supplies are organized, it is essential that all clinical staff have a working knowledge of the system in use. Mock resuscitations provide a low stakes environment to test the effectiveness of the storage system and resuscitation resources for quickly guiding clinicians to the appropriately sized equipment and proper medication doses. (See 'Mock resuscitation' above.)

Organization of pediatric resuscitation supplies should be individualized based on the practice's response plan. (See 'Response plan' above.) Options include [22]:

Stocked resuscitation room

Portable resuscitation pack that utilizes a backpack, toolbox, or tackle box

Portable resuscitation cart

A designated member of the office staff should regularly and frequently inspect the pediatric resuscitation supplies and ensure that they are complete, medications are not expired, and equipment is functioning properly [22-24]. Hospital pharmacies in the region may permit exchange of medications that are within six months of expiration to help reduce the cost of restocking resuscitation medications in the office.

Securing the resuscitation supplies with a plastic lock or other rapidly removable device helps ensure availability of necessary materials during a resuscitation by avoiding use of contents for routine patient care and by reminding staff to restock and check expiration dates on medications and equipment after an emergency response has occurred.

In addition to procuring, organizing, and maintaining these supplies, practice leadership must ensure that personnel are properly trained in their use within the office setting. (See 'Response plan' above and 'Training' above.)

Transport of the critically ill child — Safe transport of a critically ill or injured child involves moving the patient to a higher level of care, in as stable a condition as possible, with personnel in attendance who can provide care if the condition of the patient should deteriorate during transport. A clear understanding of the different types of EMS transport personnel and their scope of practice is essential when deciding the best mode of transport for a child with an office emergency. (See "Prehospital pediatrics and emergency medical services (EMS)", section on 'Scope of practice'.)

In general, an advanced life support response is required if the child has a life-threatening problem, alteration of consciousness, or respiratory distress, or potentially requires airway management or vascular access. A basic life support response may be more appropriate and expeditious for limb-threatening problems and those requiring first-aid, immobilization, oxygen administration, and immediate transport (eg, "load and go"). In some instances, the pediatric provider may choose to accompany the child during transport. However, they should only do so with the support of appropriate personnel (eg, paramedic, nurse) and in an ambulance that allows for the provision of emergency care.

Unless an advanced pediatric facility is nearby, initial transfer to a local hospital emergency department by emergency medical services is usually preferred. Once stabilized, the child can then undergo transport to an advanced pediatric center via a pediatric interfacility transport team [25].

Telephone contact between the pediatric provider and the physician at the receiving facility is essential and should include:

Data identifying the child (name, age, sex)

A brief history of the illness and relevant past medical history

Clinical findings, including serial vital signs

Any interventions performed by office staff and the response to therapy

A written record should accompany the patient and should include all of the above information as well as the name and phone number of the referring medical provider [26]. (See 'Documentation' below.)

Safe transport of the critically ill or injured patient does not include the parent/primary caregivers' car, a taxicab, bus, or other transit vehicle without medical supervision and equipment. The benefit of trained personnel and proper equipment during transport outweighs the risk of waiting for emergency medical services personnel to arrive [22]. Furthermore, deterioration or death of the patient during transport without adequate equipment and personnel is the responsibility of the sending physician when nonmedical means of transportation are used [27].

Documentation — A patient care record should be generated during the resuscitation. This record should be clear and legible. Use of a preformatted code documentation sheet can assist in rapidly capturing key information about the resuscitation [1]. Important components include:

Clinical personnel involved (including names of the emergency medical services [EMS] personnel and ambulance company)

Initial patient condition

Patient assessment with serial vital signs and presumptive diagnosis

All interventions performed, including medication doses and size of equipment used

Timing of interventions

Patient response to treatment and interventions

Patient condition upon departure

Time that EMS was called, time that EMS arrived, and time that EMS departed

Time of call to receiving facility, name of receiving physician, and content of discussion

Communication with the family

A copy of the resuscitation documentation sheet is an efficient method of supplementing the documentation that should go with the patient when they are transferred to definitive care.

ADDITIONAL RESOURCES — The following resources are available as appendices to the American Academy of Pediatrics Policy Statement [1]:

Office-based self-assessment tool

Reception desk emergency card

Calling EMS for an office emergency

Important emergency telephone numbers

Mock resuscitation evaluation forms

Mock resuscitation sample scenarios

Resuscitation documentation form

An online "user's guide" is available to teach the appropriate use of the Broselow pediatric resuscitation tape [28].

Rapid overviews and algorithms provide guidance for office-based, disease-specific treatment plans, including anaphylaxis (table 4), status asthmaticus (algorithm 1), status epilepticus (table 5), shock (algorithm 2), and pediatric advanced life support (algorithm 3 and algorithm 4 and algorithm 5).

Pediatric basic life support, assessment and management of respiratory distress, failure, shock, cardiac arrhythmias, and hypoglycemia are also discussed separately. (See "Pediatric basic life support (BLS) for health care providers" and "Pediatric advanced life support (PALS)" and "Approach to hypoglycemia in infants and children", section on 'Immediate management'.)

SUMMARY AND RECOMMENDATIONS

Epidemiology – Office visits by children requiring emergency care are common. The most commonly encountered emergency conditions presenting to a pediatric primary care office include (see 'Epidemiology' above):

Respiratory emergencies including asthma

Neurologic emergency including seizures

Sepsis or severe infection

Dehydration

Anaphylaxis

Choking

Head trauma

Cardiopulmonary arrest

Office preparedness – The steps to prepare an office for handling a pediatric emergency involve:

Office-based self-assessment (table 1) (see 'Office-based self-assessment' above)

Development of a written response plan (see 'Response plan' above)

Training for all office staff (see 'Training' above and 'Mock resuscitation' above)

Effective surveillance and triage for critically ill or injured children who come to the office or whose parents/primary caregivers contact the office by telephone (see 'Triage' above)

Immediate availability of appropriate pediatric resuscitation equipment and medications (table 3) (see 'Emergency equipment and medications' above)

Teaching how to call and to communicate with emergency medical services (see 'Transport of the critically ill child' above)

At a minimum, all certified pediatric providers (eg, physicians, nurse practitioners, physician assistants, nurses) should have training in basic life support; advanced life support training (eg, Pediatric Advanced Life Support) is strongly encouraged for staff who work in offices that do not have ready access to advanced life support resources through their local emergency medical services system or institution.

Periodic mock codes performed in primary care offices are an effective method to increase resuscitation skills and decrease staff anxiety around managing critically ill children until EMS arrives. (See 'Mock resuscitation' above.)

In addition to obtaining, organizing, and maintaining appropriate pediatric emergency equipment and medications (table 3), office medical staff must also receive ongoing training in their proper use. (See 'Training' above and 'Mock resuscitation' above and 'Emergency equipment and medications' above.)

Safe transport – After providing emergency stabilization, the pediatric provider is responsible for assuring safe transport of the critically ill or injured child to a higher level of pediatric care, communicating with the receiving physician, and providing complete documentation. (See 'Transport of the critically ill child' above and 'Documentation' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Karen Frush, MD, and William C Bordley, MD, MPH who contributed to earlier versions of this topic review.

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