Pediatric office emergencies

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.

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.

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.].

Preparedness of Dammam primary health care centers to deal with emergency cases

OBJECTIVES:

The objective of the study was to assess the availability of human and nonhuman resources for emergency medical services (EMSs) at the primary health care (PHC) level.

MATERIALS AND METHODS:

A cross-sectional study with mixed research methods (quantitative and qualitative) was carried out in governmental PHC centers in Dammam, Eastern Province of Saudi Arabia, between September 2014 and January 2015. Using systematic random sampling technique, 13 out of 26 PHC centers were included in the study. The study consisted of two main parts: The first involved the completion of an observational checklist to assess the availability and adequacy of human and nonhuman resources (workforce, emergency infrastructure, equipment, drugs and supporting facilities). The second part involved face-to-face interviews with key informants of nurses from the emergency room (ER) in the sampled centers.

RESULTS:

Analysis of the checklist showed that the total number of physicians “actually” present ranged from 2 to 8 per center and nurses actually present were 4–11 whereas the officially assigned number was 3–12 physicians and 8–17 nurses per center. Only 2 out of 13 (15.4%) centers had a place reserved for EMS in each male and female section. Only 4 (30.8%) PHC centers had a male ER located on the ground floor, near the entrance, and with a separate ramp. None of the centers had the emergency drugs such as metergotamine, calcium chloride, and naloxone. Regarding ER equipment, none of the studied centers had cervical collars, mouth gags, or a tracheostomy sets. Only one (7.6%) center had a functioning fully equipped ambulance. Five (38.46%) centers were equipped with electrocardiogram and X-ray machines. In the interviews, the informants confirmed the deficiencies identified in the checklist.

CONCLUSION:

Resources for EMS at Dammam PHC centers were deficient in infrastructure and supporting facilities.

Barriers Facing Primary Health Care Physicians When Dealing with Emergency Cases in Jeddah, Saudi Arabia

OBJECTIVES

To estimate the prevalence of emergency cases reporting to Primary Health Care centers (PHC), Jeddah, Saudi Arabia and to explore the barriers facing PHC physicians when dealing with such emergency cases.

METHODS

A cross-sectional analytic study, where all physicians working in the PHC of the Ministry of Health (MOH) in Jeddah; were invited to participate (n=247). The study period was from July 2013 till December 2013. Data were collected through two sources. 1- A self-administered questionnaire used to determine the physicians' perceived competence when dealing with emergency cases. 2- A structured observation sheet used to evaluate availability of equipment, drugs, ambulances and other supporting facilities required to deal with emergency cases.

RESULTS

The response rate was 83.4%. The physicians' age ranged between 25 and 60 years with a mean ±SD of 34.4±7.5 years. Majority of them (83.5%) did not attend ATLS courses at all whereas 60.7% never attended ACLS courses. The majority (97.1%) had however attended BLS courses. Physicians in the age group 36-45 years, non-Saudi, those who had SBFM, those who reported experience in working in emergency departments and physicians who reported more working years in PHCCs (>5 years) had a significant higher score of perceived level of competence in performing emergency skill scale than others (P<0.05). The prevalence of emergency cases attending PHC in Jeddah (2013) was 5.2%.

CONCLUSION

Emergency services at PHC in Jeddah are functioning reasonably well, but require fine tuning of services and an upgrade in their quality.

Specialty pediatric transport in primary care or urgent care settings

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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 radiology perspective: needs and tools for management of life-threatening events

Studies have shown that life-threatening contrast agent reactions in adults are very rare, and even less common in children. The rarity of severe allergic reactions to contrast material challenges educators to achieve radiology resident competency in this setting. However, using a simulated anaphylactic contrast reaction paradigm, we have drawn two conclusions: (1) Residents are insufficiently prepared to recognize and manage these life-threatening events and (2) with an interactive, computer-based tool we can significantly improve resident performance in these situations. Simulation is a growing tool in medicine and allows standardized resident exposure to uncommon events in a setting that is conducive to resident education without fear of repercussions (see Ruddy and Patterson in this issue of Pediatric Radiology). More important, simulation provides a cornerstone in patient safety resident education without putting patients at risk.