AAP News: To prepare for acute interventions, you need a written plan, staff training

January 1, 2010

At some point in your career, a child will become critically ill, requiring resuscitation or other acute intervention in the office.

"At some point in your career it will happen to you," Alice Ackerman, MD, MBA, FAAP, told office-based pediatricians attending the American Academy of Pediatrics (AAP) 2009 National Conference and Exhibition. A child will become critically ill, requiring resuscitation or other acute intervention in the office, she said.

Studies have found that family medicine and pediatric practices see between 1 patient per month to 1 patient per week who require some kind of stabilization or hospitalization, said Ackerman, pediatrics intensivist, chair of the pediatrics department at Carilion Clinic Children's Hospital in Roanoke, Virginia, and member of AAP's Committee on Pediatric Emergency Medicine (COPEM).

But most pediatric primary care practitioners believe such incidents are rare, she indicated. Further, a survey found that most practices say it's costly to prepare for the emergencies, and that "they might enhance their liability risk if they have medications and equipment in-house to take care of some of these emergencies," she said.

Ackerman noted that a number of studies have found offices remain unprepared for the next emergency even after treating a child who has required advanced cardiac or pulmonary support.

She also cited research conducted in North Carolina in which practices, after participating in mock emergencies and an EMS debriefing, made some improvements, but were no more likely than a control group to buy new medication and equipment to deal with emergencies.

Sometimes such incidents are tragic, and they often have several factors in common, Ackerman said.

Many times there are communication issues, Ackerman said. For example, a parent doesn't call the night before when the child becomes ill or doesn't tell the receptionist or triage person that there is something wrong. A teenager hasn't told his parent or coach that he is using his asthma inhaler very frequently.

Pediatricians can do better by "providing the training, the equipment, the personnel and engaging in enough practice so we are prepared," she said.

She pointed to the 2007 statement by AAP's COPEM on office emergencies at http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;120/1/200, which calls for having a clear written response plan for identifying who should carry out which tasks and for training staff in emergency procedures. That includes educating the person at the front desk so that he or she can identify the patient who might be deteriorating. Those steps are especially needed, she said, for periods when the office may be poorly staffed.

The COPEM also suggests drills to prepare office staff for an emergency. It lists the office equipment and medications that should be kept on hand and calls for regularly checking to see that those items are not outdated.

The AAP statement also recommends training for providers in basic life support or even advanced life support, such as Pediatric Advanced Life Support (PALS). Ackerman recommends training in advanced life support, especially if EMS response is not likely to occur within 5 to 10 minutes of an emergency.

Another important element, Ackerman said, is preparing parents so they know when to call and where to go, making children less likely to show up with severe trauma.

One of the best recommendations, she said, is to partner with the local EMS department. A practice might, for example, ask EMS to do a trial run to the office.

In addition, Ackerman said: "Oftentimes [EMS is] very happy to come out, talk to the office, show you what they have, what they can do and understand what your expectations are, what kinds of children you might be seeing in your practice, especially if you have kids with chronic or high-technology needs."