Seth Toback

 Prepare your office for a medical emergency 

 Emergencies in pediatric offices are not uncommon, but far too few practices are prepared to respond. Implementing an emergency office protocol and a mock code programlike those detailed here just might save a life.

 Emergencies take place in medical offices more often than you might think. Some pediatric practices average at least one emergency a month.

 In one study of 52 pediatric offices, a median of 24 emergencies occurred per practice per year.

 A 1995 survey by the American Academy of Pediatrics found that pediatricians saw an average of 2.1 patients per week who required emergency treatment or hospitalization.

 Despite these numbers, studies show that a significant number of pediatric offices are ill prepared to handle an emergency

most often because the necessary equipment or staff education is lacking. In several individual studies, fewer than two thirds of offices surveyed had a definitive plan for an emergency.

 The authors of these studies agree that an excellent way to prepare for an emergency is to conduct mock codes, yet little has been written on how to establish a mock code program in the office setting.

 Many pediatricians are familiar with mock codesa drill that simulates the resuscitation of a critically ill patientfrom their residency training. Initially a learning tool used solely at major hospitals, these exercises reinforce skills learned in basic and advanced life- support coursesskills that typically need refreshing given the infrequent nature of cardiopulmonary arrest in children. Mock codes have been shown to improve performance and reduce anxiety during emergencies in inpatient settings.

 Only recently, though, has information been published that describes the use of mock codes in outpatient as well as inpatient settings.

 This article describes how the practice where I work established an emergency preparedness program in our busy pediatric offices, using several publications as information resources.

 The first step in getting prepared is making sure your office is equipped for a true emergency. Recommendations for emergency equipment for a pediatric office vary greatly. Recent articles in the medical literature recommend prepackaged equipment kits starting at $490 or "a la carte" lists of emergency medications and equipment ranging from $546 to $647.

 The same articles offer more extensive equipment listswhich may include costly items such as a cardiac defibrillatorranging from $1,564 to $6,162. (For a review of how to best equip your office, see "

Be prepared: Equipping your office for medical emergencies

 Decisions about what equipment to purchase should be based on the staff's level of comfort using the equipment and medications, the availability of emergency transport systems, and the office's proximity to an emergency department (ED). Our office, for example, is about 10 minutes from a community ED and 30 minutes from a tertiary care children's hospital, and emergency medical services (EMS) arrival time is 10 to 15 minutes. Our list of emergency medical equipment and medications appears in Table 1.

 A new potential addition to this list is the automated external defibrillator (AED), which the FDA has approved for use in children. The AED can analyze a cardiac rhythm and, if necessary, defibrillate the patient by means of an electrical charge delivered through self-adhesive pads. Ease of use has accounted for its presence at a growing number of public places, such as on commercial aircraft and in government office buildings. If your practice is in a large office building, investing in an AED could conceivably benefit all employees and patrons of that establishment. Several models are available starting at approximately $3,000. (See the below for more about 

 Of course, the right equipment is only useful in trained hands. Regrettably, pediatricians' offices have fallen short in this area, too. Although, ideally, all office employees should be trained in BLS and PALS, a 1996 study showed that only 14% of eligible office staff were certified in basic life support (BLS) and only 17% were certified in pediatric advanced life support (PALS).

 Our office strongly encourages all staff to become certified and to stay certified,* and the regular practice of mock codes is the best way to reinforce skills and knowledge learned through a BLS or PALS course.

*For information on BLS and PALS training, contact the American Heart Association (214-373-6300; 

 ), the National Red Cross (202-737-8300; 

 ), or the American Academy of Pediatrics (800-433-9016 ext. 6795; 

 When developing a protocol for emergencies, consider the physical layout of your office and the location and number of employees. Your office may, for example, have a treatment room where all emergency equipment and medicines could be stored; this room could be designated the location of choice for an emergency. If no such room exists, perhaps the room closest to the waiting room or the largest examination room could be designated for this purpose.

 At our office, the emergency protocol (a copy appears on page 113) is based on the size of our treatment room, which is large enough to treat a child in respiratory distress but not big enough to handle a full resuscitation. So a child in mild to moderate respiratory distress is brought to the treatment room, but a child in an exam room who is in severe respiratory distress or otherwise at risk of going into cardiopulmonary arrest is not moved; emergency supplies are brought to the patient. Our protocol includes a schematic of the office itselfa visual reminder that the treatment room is the location of choice for most emergencies. We post the protocol in several visible places in the office.

 As part of your office's protocol, each staff member should be assigned a specific role to assume during an emergency. An office with a limited number of staff may need to give each employee a greater number of responsibilities than an office with more workers.

 Each type of medical professional in a pediatric officeincluding physicians, nurse practitioners, registered nurses, and medical assistantshas a different skill set. Before assigning roles, it is important to assess those skills and answer such questions as: Who in the office can obtain IV access? Who knows how to set up the nebulizer? Who has had experience with pediatric emergencies? A questionnaire used in our office to assess a staff member's skills is shown on page 114.

 The first person to see patients in the officeusually the person sitting at the front deskshould be trained to screen for acutely ill children during sign-in and should have easy access to a nurse or physician if there is cause for concern.

 Careful observation of the child's general level of consciousness, work of breathing, and skin color can quickly alert a trained receptionist to an impending emergency.

The front desk can also play an important role in alerting waiting patients about potential delays because of an emergency. Similarly, the employee at the checkout desk can be designated to dial 911 (or the local EMS phone number) once an emergency has been identified. The employee should describe the nature and location of the emergency and, if possible, relay the child's age, weight, condition, vital signs, and probable destination. If your office is difficult to find, consider having the staff member meet the ambulance at the front door and take the EMS crew to the patient.

 The ancillary staff member in charge of bringing each patient from the waiting room into the office may be the ideal person to place an acutely ill child in a pre-assigned room, such as a treatment room, or may know of the closest available examination room. In our office, medical assistants are responsible for placing an ill child in the treatment room and alerting physicians and nurses to the emergency. They are also charged with obtaining necessary equipment that is not in the room.

 Employees should alert the entire office to an emergency in a standardized way. If, for example, a febrile child begins convulsing in an examination room or a child becomes syncopal during a blood draw, our office protocol directs the staff member who witnesses the event to tell one of the medical assistants, who will then inform the other doctors and nurses, or to shout "I need help in Room ." In this way, the staff knows not only that there is an emergency but where to bring the appropriate equipment. A larger pediatric office may choose to have a designated employee go from room to room alerting each physician or nurse to the presence of an acutely ill child.

 The staff must also be assigned a role for the code itself. Here again, each office will have staff with a range of skills and competencies, which can be assessed in advance by means of the staff questionnaire (Figure 1). The print issue lists the responsibilities of each code member in our office; these formal roles can be easily modified for different practices.

For example, one of the "physician" roles could be filled by a nurse practitioner, nurse, or physician assistant, and one of the "nurse" roles could be filled by a medical assistant, respiratory therapist, or EMS worker. (You can encourage the involvement of local EMS by inviting them to participate in a scheduled drill.)

(Table 2, "The makeup of roles on the code team," available in the print edition, adapted from Roback MG, Teach SJ, First LR, et al (eds): 

. St. Louis, Mosby Year Book, 1998. Used with permission)

 To achieve the most realistic mock resuscitation possible, the equipment used in practice should be the same as that used in a real emergency. Most of the equipment can be purchased inexpensively from medical suppliers. Equipment and supplies with past expiration dates can be obtained from hospitals or regional PALS instructors. All equipment should be recycled and stored for future mock codes. More expensive items, such as intraosseous (IO) needles and carbon dioxide detectors, can simply be displayed during the mock code, while the participant describes to the person reviewing the simulation how the piece of equipment is used during an actual emergency. Newer mannequins can be used to demonstrate emergency skills such as placement of an endotracheal tube or IO line.

 The price of a resuscitation mannequin varies greatly by model. A basic full-length CPR mannequin starts at $800 to $900 for an adult, $500 for a child, and $100 for an infant. "Torso-only" versions are available for $175 (adult) and $165 (child). More advanced mannequinsthe kind used to practice intubation and IO placement skillsstart at $1,125 for the infant size; the child and adult models can be quite expensive. Less expensive intubation, head-and-neck only models can be purchased for $1,300 for an adult version and $440 for an infant model. For more information on these and other products, see Laerdal products at 

 (800-431-1055) and Healthsafety products at 

 Emergency medicines required in the mock code need not be opened and used, but the actual drugs should be on hand so that the participants can familiarize themselves with the shape and color of the vials. The physicians should be prepared to estimate a dose based on the child's weight, and the nursing staff should be ready to calculate the volume of drug that will be administered and describe how it is to be given.

 Initiating a mock code program may evoke considerable anxiety among the staff. To minimize this, we recommend a stepwise approach to starting the program. Ideally, begin by having staff members attend a BLS or PALS program (depending on their background) to formally review the airway, breathing, circulation (ABC) approach to resuscitation. Next, schedule an office meeting to discuss the proposed emergency protocol. Each member of the staff should come away with a clear understanding of what role he or she is to play in an emergency (that role should be reviewed with that person individually at a later time). This meeting may also be a good time to review the location and proper use of emergency equipment, demonstrating techniques as simple as how to connect the oxygen tank to the face mask and start the flow of oxygen. This preparatory session can be completed in as little as 30 minutes.

 Announce the time and date of the first mock code in advance to the entire office; subsequent exercises may go unannounced. Set aside a 60-minute block from patient time, either before or after lunch or at the end of the day. When I run a mock code, I test the staff's use of the entire emergency protocol, not just the resuscitation itself. I start with the mannequin in the waiting room and have the front desk staff respond to the "sick child."

 The office member acting as the mock code director (MCD) will be responsible for preparing the mannequin (and is usually the person directing the code in an actual resuscitation situation). The MCDa physician or a nurseshould be currently certified in PALS so her (or his) commentary on running the code is accurate and detailed. She should possess enthusiasm and enjoy teaching; being a PALS instructor is a great advantage.

 Either the MCD or the office staff can write the scenario for the mock code. The cases should be simple and focus on the ABCs of resuscitation. Alternatively, texts can be purchased with code scenarios that describe the progression of the case, optional complications, expected interventions, and the main objectives.

 Our office uses the text by Roback and colleagues because the scenarios, written for a hospital setting, can be easily modified for use in an office practice.

 After preparing the mannequin for the first mock code, the MCD should briefly discuss how the resuscitation team is to interact. She should stress that the mannequin is to be approached and treated as if it were a real patient. For example, participants should feel the mannequin's wrist to acquire a pulse and slip on the appropriate size blood pressure cuff to measure BP.

 The MCD orchestrates the flow of the code, which should last no more than 15 minutes. It begins with the MCD relaying a brief history of the "patient's" illness. Although the MCD knows the complete patient history, she should disclose information only when proper examination steps have been completed or appropriate questions asked. Requiring the team to elicit information and describe details of a simulated procedure is essential.

 It is also the job of the MCD to describe the patient's response to each procedure or medication. This means that allowances exist for the mock patient to become critically ill if certain steps are neglected or to improve if treatment is appropriate. Variations and complications in each scenario can be thought out in advance or simply incorporated into the flow of the code in accordance with the team's actions. The MCD may choose to end the scenario when the teaching points of the case have been brought out and acted on, regardless of the patient's outcome.

 An often neglected yet critical part of any emergency is proper documentation. Detailed and accurate information about a resuscitation is vital for ongoing care and for safe transfer of the patient.

Create a documentation sheet for emergencies (Figure 2), keep copies near the emergency equipment, and use the sheet during an actual emergency. Put a completed copy in the patient's chart and give one to EMS. During a mock code, a formal checklist can be used to determine if and how well each aspect of resuscitation is followed (Figure 3, available in the print edition, adapted from Roback MG, Teach SJ, First LR, et al (eds): 

. St. Louis, Mosby Year Book, 1998. Used with permission).

 After a mock resuscitation, allot 15 to 30 minutes for review. The review should focus on how participants acted as a team and how well they met the objectives of the scenario. Because the goal of the mock code is to increase the staff's confidence during an emergency, the MCD should, initially, stress the positive aspects of the exercise, focusing on a few main points related to the team's performance and stressing the basics of resuscitation. Time permitting, a technical review of resuscitation skills is of benefit. Last, each participant should receive individual feedback on how well he or she performed. The reviewer should keep in mind the relative inexperience of any participants so as not to discourage future efforts.

 Quality assurance and quality improvement are key features of any well-organized, long-term mock code program. Records should be kept of the office location (if there is more than one office in the practice), date, scenario used, participants, and staff performance. Notes should be taken on how well the emergency protocol alerted the office to the situation, how well the staff initiated treatment, what the strengths and weaknesses of the resuscitation were, and how smoothly the patient was delivered into the care of the EMS crew. By re-evaluating these notes, the MCD can offer insight into the office's preparedness for emergencies and make suggestions for improvement. Emergency protocols should be revised as needed based on the office's experiences with mock codes and real emergencies.

 Mock codes should be practiced as often as a busy pediatric office can schedule them. This may be once a month or a quarter or, at the least, every six months. Emergency equipment and drugs must be updated and reordered periodically, so make sure that a nurse routinely checks this equipment and restocks any missing or expired medications.

 Because teamwork is so integral to the plan, any changes in staff will require some retraining and, possibly, a reassignment of responsibilities. In our office, for example, new staff members are shown the location of the posted office emergency plan, assigned a role, and trained in that role by me.

 All staff members certified in life-saving skills should make every attempt to be recertified every two years. Financial compensation for recertification coursework provides a great incentive for keeping certification up to date.

 The pediatrician's office is often the first place an acutely ill child is seen. Parents may be unaware of the severity of their child's illness or trying to avoid a trip to the ED. Only by properly equipping your practice, educating staff, and practicing life-saving skills can you help keep an office emergency from becoming a tragedy.

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 	2.	Flores G, Weinstock D: The preparedness of pediatricians for emergencies in the office. 

 Elk Grove Village, Ill., American Academy of Pediatrics, 1995 

 	4.	Fuchs S, Jaffe D, Christoffel K: Pediatric emergencies in office practices: Prevalence and office preparedness. 

 	5.	Altieri M, Bellet J, Scott H: Preparedness for pediatric emergencies encountered in the practitioner's office. 

 	6.	Schexnayder S, Schexnayder R: 911 in your office: Preparations to keep emergencies from becoming catastrophes. 

 	7.	Shetty AK, Hutchinson SW, Mangat R, et al: Preparedness of practicing pediatricians in Louisiana to manage emergencies. 

 	9.	Sapien R, Hodge D: Equipping and preparing the office for emergencies. 

 	10.	Schuman AJ: Be prepared: Equipping your office for medical emergencies. 

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 	12.	Wheeler D, Kiefer M, Poss W: Pediatric emergency preparedness in the office

 	13.	Wheeler D: Emergency medical services for children: A general pediatrician's perspective. 

 	14.	Bishop-Kurylo D, Masiello M: Pediatric resuscitation: Development of a mock code program and evaluation tool. 

 	15.	Cappelle C, Paul R: Educating residents: The effects of a mock code program. 

 	16.	Smith N, Crnkovic A: Weekly mock codes. 

Childhood Emergencies in the Office, Hospital, and Community: Organizing Systems of Care.

 Elk Grove Village, Ill., American Academy of Pediatrics, 2000 

Office Preparedness for Pediatric Emergencies, Provider Manual.

 Emergency Medical Services for Children Program (Section 1910, PHS Act), Health Resources and Services Administration, Department of Health and Human Services, 1997 

 	19.	Gallagher C: Before the Call: How EMS Outreach Can Help Kids. 

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 THE AUTHOR is a pediatrician in private practice in Pittsburgh, Pa. He is a paid instructor in pediatric advanced life support for the American Heart Association who teaches in affiliation with the Children's Hospital of Pittsburgh.

 The automated external defibrillator is a significant breakthrough for out-of-hospital resuscitation for adults and children older than 8 years who weigh more than 55 pounds. Two self-adhesive chest electrodes are applied to the patient's chest, allowing the AED's microprocessor to analyze cardiac rhythms. The AED then uses audio and visual prompts to guide the user to administer a shock if one is appropriate, often (depending on the model) by depressing a single button.

 FDA regulations require a physician's prescription before an AED can be purchased. Although AEDs are so user friendly that most untrained rescuers can operate them, the American Heart Association (AHA) nonetheless recommends that all potential users receive AED and CPR training, which is available through the AHA Heartsaver AED Course. (The pediatric advanced life-support course also reviews how to use an AED.) The AHA recommends that local EMS be notified of the type of AED and its location and that a physician be available to ensure proper maintenance of the AED.

 Agilent Technologies produces one AED model, the FR2, which is distributed by Heartstream ( 

 ). It's a popular choice for pediatric offices because it is small and easy to use and allows users to train using different scenarios. It also features a biphasic energy wave capable of defibrillating with a much lower dose of non-escalating energy (150 joules) than AEDs that use monophasic energy. The price of this product starts at $3,125.

 Last year, the FDA approved the FR2 with newly developed attenuated defibrillation pads for use on children 8 years old 

 than 55 pounds. The pads, which cost $84 a pair, reduce the energy of a 150 J dose shock by two thirds, to 50 J. The AHA has not endorsed the use of the FR2 with attenuated defibrillation pads but does call it a "very encouraging development" that requires further review.

 For more information on AEDs, contact the American Heart Association ( 

 ) at 888-277-5463. For information on AED pricing and starting an AED program, contact Agilent Technologies ( 

  Any staff member who encounters a child in need of emergency treatment is to immediately alert the rest of the office, either by sending a medical assistant to notify other staff or by shouting "I need help in Room  "

  Any child in the waiting room who is in mild to moderate respiratory distress is to be brought immediately to the treatment room and attended to by the nearest available physician. If this room is unavailable, the child is to be placed in the closest available examination room.

  Any child in an examination room who is in mild to moderate respiratory distress is to be brought into the treatment room, if available.

  Any child in the waiting room in severe respiratory distress or found to have a decreased level of consciousness is to be brought into the closest available examination room.

  If a child being seen in an examination room is in severe respiratory distress or has a decreased level of consciousness, any resuscitation should take place in that room. The medical assistants are to obtain all emergency medical equipment and bring it to that location.

Articles

Emergencies in pediatric offices are not uncommon, but practices are seldom prepared to respond. Implementing an emergency office protocol and a mock code program?like those detailed here?might save a life.