Emergency medical services for children: a general pediatrician's perspective

Sala de emergência em pediatria: casuística de um hospital universitário

OBJETIVO: Descrever a casuística de pacientes pediátricos atendidos em sala de emergência pediátrica de um hospital universitário. MÉTODOS: Estudo retrospectivo descritivo de 1º de janeiro até 31 de dezembro de 2004, com crianças de zero a 14 anos, avaliadas quanto a dados epidemiológicos, hipótese diagnóstica, intubação orotraqueal, óbito, destino e duração da internação. Os pacientes foram divididos em quatro grupos: Não Óbitos; Óbitos <24 horas, Óbitos >24 horas e transferidos para outros hospitais. RESULTADOS: Foram atendidas 203 crianças; 59,1% meninos; média de idade 3,4 anos; 65% previamente hígidos. O diagnóstico mais freqüente foi insuficiência respiratória (31,1%). Dentre os 22 óbitos, 3,5% ocorreram nas primeiras 24 horas e 7,4% após estas primeiras 24 horas; 172 crianças (84,7%) evoluíram para alta após período médio de internação de 19,2 dias. Nove (4,4%) foram transferidas para outros hospitais. Das 203 crianças atendidas, 50 (24,6%) foram intubadas à admissão e 86 (42,4%) necessitaram internação em unidade de terapia intensiva pediátrica. CONCLUSÕES: Os pacientes que evoluíram para óbito precoce eram mais jovens e com diagnóstico de choque. Nos pacientes que evoluíram para óbito após 24 horas do atendimento inicial, predominaram meninas, com doenças prévias e insuficiência respiratória. Aqueles que sobreviveram ao atendimento de emergência eram, em maior freqüência, meninos mais velhos e com doenças respiratórias. Houve necessidade significativa de procedimento invasivo (intubação orotraqueal) e internação subseqüente em unidade de terapia intensiva, o que reforça a necessidade de equipamentos adequados e profissionais especializados no setor.

Impact of a pediatric primary care office-based mock code program on physician and staff confidence to perform life-saving skills

BACKGROUND

Previous studies have described that pediatric offices are ill-prepared for medical emergencies. Pediatric "mock codes" have been utilized to increase the emergency preparedness of inpatient medical units for several decades. These practice drills have been shown to both increase practitioners' confidence and decrease anxiety during actual resuscitations. Although the use of mock codes is recommended in the outpatient setting, these benefits have yet to be demonstrated for office-based practitioners.

OBJECTIVE

We conducted this study to determine whether mock codes performed in pediatric primary care offices increase practitioner confidence to perform life-saving skills.

METHODS

Pediatric group practices participated in a clinical trial of an office-based, 2-step, emergency preparedness training. First, physicians and staffs attended a 1-hour didactic program which included staff education, office emergency protocols, emergency equipment and medications, and guidelines on instituting a mock code program. Second, each practice participated in a 10-15-minute mock code exercise. The drill was conducted by pediatric advanced life support instructors. After the code, a 30-minute feedback session was conducted which reviewed office coordination, individual skill performance, and approach to resuscitation. Each participating practice also received an infant manikin and a text complete with several mock codes scenarios written specifically for the pediatric primary care office. Evaluation of the intervention consisted of 2 components. (1) Pre- and postintervention completion of a self-administered survey assessed participants' comfort in emergency situations and confidence to perform specific life-saving skills, using an ordinal scale: 1 = "strongly agree" to 5 = "strongly disagree". (2) Practices were contacted by telephone 12 months after the training to determine whether they had implemented improvements in emergency preparedness, including instituting mock codes, preparing a written emergency protocol and purchasing new emergency equipment and medications.

RESULTS

Eleven group pediatric practices participated, which were representative of urban, suburban, and rural offices in southwestern Pennsylvania. Ninety-seven of a total 164 (59%) physicians and staff members completed both pre- and postintervention surveys. Practitioner participants were analyzed in 2 groups. Group 1 consisted of physicians, nurse practitioners, and physician assistants; group 2 consisted of registered nurses, licensed practical nurses, and medical assistants. Comparison of pre- versus postintervention surveys in both of these groups revealed significant improvement in reported confidence to perform resuscitation skills that were included in the mock code after the training: airway positioning (group 1, 67% vs. 94%, P < 0.001; group 2, 55% vs. 75%, P = 0.003), airway suctioning, (group 1, 64% vs. 88%, P = 0.005; group 2, 27% vs. 51%, P < 0.001), and bag-mask assisted ventilation (group 1, 82% vs. 91%, P = 0.003; group 2, 39% vs. 71%, P < 0.001). In addition, group 1 reported more confidence in their ability to place an intraossesous line (24% vs. 39%, P = 0.003) and group 2 showed a significant increase in their confidence to administer oxygen (65% vs. 84%, P < 0.001). As a result of the mock code, 83% of all participants, both medical and nonmedical staffs, and 96% of physicians felt less anxious about medical emergencies in the office. Twelve months after the conclusion of the program, 18% of offices had conducted 1 or more mock codes, 64% of offices had written an emergency protocol, and 27% of offices had acquired essential resuscitation medications or equipment.

CONCLUSIONS

The results of this study support the recommendation that mock codes should be performed in the pediatric primary care setting to improve practitioner confidence and decrease practitioner anxiety.

The Pediatric Emergency Care Applied Research Network (PECARN): rationale, development, and first steps

Since its formal recognition as a medical specialty, the field of pediatric emergency medicine has made substantial advances with respect to its scope and sophistication. These advances have occurred in clinical practice as well as in the research base to improve clinical practice. There remain, however, many areas in emergency medical services for children (EMSC) in the out-of-hospital, emergency department (ED), and hospital settings that suffer from a lack of data to guide practice. In an effort to expand the quality and quantity of research in pediatric emergency care, the Pediatric Emergency Care Applied Research Network (PECARN) was created in October of 2001. PECARN is the first federally funded national network for research in EMSC and is the result of cooperative agreement grants funded through the Health Resources and Services Administration with the purpose of developing an infrastructure capable of overcoming inherent barriers to EMSC research. Among these recognized barriers are low incidence rates of serious pediatric emergency events, the need for large numbers of children from varied backgrounds to achieve broadly representative study samples, lack of an infrastructure to test the efficacy of pediatric emergency care, and the need for a mechanism to translate study results into clinical practice. PECARN will serve as a national platform for collaborative research involving the continuum of care within the EMSC system, including out-of-hospital care, patient transport, ED and in-hospital care, and rehabilitation. This article describes the history of EMSC, the need for a national collaborative research network in EMSC, the organization and development of PECARN, and the work plan for the network.

Regional after-hours urgent care provided by a tertiary children's hospital

BACKGROUND

Ambulatory presentation to a tertiary pediatric emergency department (ED) is not convenient for many families. Yet many primary care pediatricians (PCPs) desire after-hours urgent care for their patients as an alternative to extended office hours or care by general emergency medicine providers at community hospitals.

OBJECTIVE

To describe a regional, community-based pediatric urgent care network (PUCN).

METHODS

The PUCN consists of 4 models: 1) pediatric emergency medicine faculty in a community hospital ED; 2) general pediatricians in a community hospital ED; 3) general pediatricians in a freestanding urgent care center; and 4) general pediatricians in a community hospital-based urgent care center. Physician staffing at all 4 sites is managed by our tertiary children's hospital. Billing records were reviewed and a questionnaire was mailed to 55 PCP practices in our metro area.

RESULTS

Year 2001 visits totaled 37 143. Minor trauma, ear complaints, and viral illnesses accounted for 70% of visits. Current Procedural Terminology codes for visits, reflecting complexity levels 1, 2, 3, 4, and 5 were billed at the following frequency: 1%, 35%, 44%, 17% and 3%, respectively. A total of 2.2% of visits required admission or transfer. Mean collection rates ranged from 37% to 68% across the 4 sites. Break-even average hourly patient volumes ranged from 1.1 (site 4) to 1.9 (sites 1 and 3). A total of 110 PCPs, representing all 55 practices, responded to the questionnaire: 81% reported their patients used the PUCN often, 85% felt that communication between the PUCN and their practice was good, and 99% reported overall satisfaction with the network.

CONCLUSIONS

The PUCN effectively addresses the needs of regional PCPs; however, the cost-effectiveness of such a program depends on billing practices, local collection rates, and site-specific staffing patterns.