Dr Medina is chair of the the Department of Community and General Pediatrics, Cleveland Clinic Children's, Cleveland, Ohio.

Michelle P Medina, MD, FAAP

On what was one of the coldest days that winter, a 4-day-old infant was brought to one of our ambulatory practices, bradycardic and hypothermic. The many hours following that involved a perfect storm of emergency medical service (EMS) units stuck in snow, multiple teams directing care, and the lack of warming equipment exhausted and frustrated a team of usually high-functioning professionals.

	How could this event have gone so wrong? What did we do-or not do-that contributed to the disorganization? Fortunately, the baby arrived in the intensive care unit optimally resuscitated, and discharged with no apparent sequelae, but this event led us to a focused effort to enhance our office emergency preparedness.

Pediatric offices are often the entry point in the continuum of emergency services. A recent survey in 2015 showed that almost half of pediatricians referred a patient to the emergency department (ED) or hospital one or more times every week. More than a third reported that patients required emergency treatment in the office before transfer.

	A retrospective review of ED transfers in 2015 showed that patients transferred from an ambulatory clinic are often young (median age, 18 months) and experiencing respiratory distress, with a high level of acuity. Almost 60% are subsequently admitted.

 Although there is great variability in practice, these statistics underscore the importance of office preparedness in the face of a critically ill child.

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	In 2007, the American Academy of Pediatrics (AAP) published a comprehensive policy statement that outlined recommended steps and tools for office emergency preparedness.

 The guidelines emphasized not only the necessary equipment, staff training, and office protocols, but also the importance of collaborating with local EMS providers and advocacy. When the local EMS team finally came to pick up our baby, we realized that they did not carry infant warming equipment, either. By working with the city, and using this event as an opportunity for advocacy, every city EMS unit is now equipped with an infant warming blanket.

	Emergency preparedness still begins with the pediatrician’s office. We realized that our experience was not unique. In the same survey we cited,

 despite the recognition that office emergencies were relatively common, only a quarter of respondents practiced mock emergencies in the office-a key recommendation within the AAP policy statement. Whereas half of practices were aware of the policy, only 23% believed that their office met the guidelines.

	To put a solution together that addressed the AAP recommendations and what we believed were key communication issues in our event, we involved many stakeholders in our large healthcare system. The set of actions that evolved from this collaboration include: standardizing emergency supplies in each practice, accompanied by a Quick Emergency card of basic resuscitation steps that prioritize seeking help as soon as the emergency is identified; ensuring that every team member completes basic life support (BLS) certification; establishing protocols that anticipate both pediatric and adult emergencies, which also emphasize the availability of automated electronic defibrillators (AEDs); guiding mock resuscitation sessions at regular intervals; standardizing documentation of emergency events leading to better tracking and review; and encouraging advocacy within all our communities.

We realized the fruit of our efforts when our post-drill surveys showed not only an increase in the teams’ comfort and confidence in code situations, but, more importantly, when they called out the improved communication within the team. This finding is similar to those of other studies that evaluated the impact of a mock code program within practices.

 Not surprisingly, asking practices to go through mock codes as a team led to other organized efforts to become more prepared for emergencies.

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	Our practices identified the need to organize the storage and accessibility of emergency equipment. All AEDs were clearly marked so a frantic caregiver could easily get to them. Bag-valve-mask equipment was made easy to reach and was labeled for the appropriate age use. Advocacy efforts led to emergency medical technicians (EMTs) completing rotations in our pediatric department. Protocols to communicate better with accepting hospitalists and ED staff were also developed. Physicians, nurses, and clerical staff came together to problem solve around how to identify, quickly intervene, and get sick children to the right place for care.

	Focusing on emergencies became our platform to address the far more important goals of situational awareness, team integration, and effective communication. As we build increasingly matrixed systems of care that surround our littlest of patients, having addressed these goals inspires us with confidence that we can do so with the child’s safety at top of mind.

	1. Pendleton AL, Stevenson MD. Outpatient emergency preparedness: a survey of pediatricians. 

	2. Dapaah-Siakwan F, Kaj B, Daga A, Kaur I. Transition of care: pediatric ambulatory center to emergency department. 

	3. American Academy of Pediatrics Committee on Pediatric Emergency Medicine; Frush K. Preparation for emergencies in the offices of pediatricians and pediatric primary care providers. 

	4. Bordley WC, Travers D, Scanlon P, Frush K, Hohenhaus S. Office preparedness for pediatric emergencies: a randomized, controlled trial of an office-based training program. 

	5. Toback SL, Fiedor M, Kilpela B, Reis EC. Impact of a pediatric primary care office-based mock code program on physician and staff confidence to perform life-saving skills. 

Articles

Focusing on emergencies became our platform to address the far more important goals of situational awareness, team integration, and effective communication. As we build increasingly matrixed systems of care that surround our littlest of patients, having addressed these goals inspires us with confidence that we can do so with the child’s safety at top of mind.

Michelle P Medina, MD, FAAP

Articles

Be ready for an in-office 911