CLINIC EMERGENCY READINESS PROGRAM For Pediatrics

Transcription

1 CLINIC EMERGENCY READINESS PROGRAM For Pediatrics *Making Your Clinic Ready For a Pediatric Emergency* 2012 Version 2a

2 F. Keith Battan MD FAAP Program director, CERP training Colorado Permanente Medical Group Attending Pediatrician Special thanks for creative impulse and program start-up to: Margaret Ferguson MD FAAP Colorado Permanente Medical Group Director, Pediatric Hospitalists For questions about content, please contact: Keith Battan Office Fax

3 Table of Contents I. Program description -- What is CERP?...4 A. Faculty. 4 B. Program objectives..4 C. Program curriculum II. III. IV. Pre-arrival preparation -- "How to be prepared when a sick child arrives".5 A. Boundaries of clinic responsibility..5 B. Resuscitation team composition..5 C. Equipment readiness 6 D. Staff training...7 Infant and Child Resuscitation - "What to do upon patient arrival" 7 A. Appropriate resuscitation location..7 B. Resuscitation of the infant and child.7 1. Predetermined roles of the resuscitation team.7 2. Method for providing oxygen IV or IO (intraosseous) lines 8 4. Fluid volumes Warming equipment and documentation Transporting the sick child out Where & how to send the child A. Transport methods Privately-owned vehicle KP ambulance hub (3099) Aeromedical...10 B. Hospital destination Which child to which hospital?..11 V. Miscellaneous A. AED use.11 B. Facility Cor system - changing the culture C. Pediatric equipment and medication list 12 D. Courses available for training 12 VI. Credits and website..13 Glossary Appendices..14 Checklist for annual performance..14 3

4 I. Program description -- What is CERP? The Clinic Emergency Readiness Program (CERP) for pediatric emergencies is designed to address the needs of primary care clinics to stabilize and arrive at an appropriate disposition of the infrequent but high-acuity infant or child who exhibits altered mental status or cardiopulmonary instability. CERP training is done in an informal atmosphere in order to maximize learning, and is meant to prepare providers for the compromised infant or child who arrives at your clinic and needs resuscitation prior to being transported to a receiving ED or hospital. Evaluations of CERP done at pediatric and Family Medicine clinics to date have been excellent. The program is also is also intended to be a top-to-bottom effort to help each clinic provide a systems approach to sicker children: pre-arrival preparation, personnel training, equipment lists, documentation, and quality assurance. Participants are intended to be primarily the providers who would be involved in resuscitation of an infant, child, or teen: ie physicians, mid-level providers, and nurses. LPNs and MA s are welcome when sufficient faculty is available. This is not PALS by any means, but rather a course done at a level appropriate for all clinic providers. A. Faculty Continuity and hospital-based pediatricians with an interest in stabilization and resuscitation help teach the course. The program/course director is fellowship-trained in pediatric emergency medicine, and formerly Associate Director of the Emergency Department and Associate Director of the Trauma Program at Children s Hospital, and started and directed the PALS and EMS education program for 15 years prior to joining CPMG. Other faculty B. Program Objectives Help clinics to develop internal plans and processes for simulating high-risk, low-volume events like pediatric resuscitation, as well as ensuring that appropriate equipment and QA is in place. Update clinics on current techniques for stabilization of pediatric patients prior to EMS arrival and transport to hospital. C. Program Curriculum Prior to training, a handout will be distributed to staff for study so that content is known before the course. A pre-test is given which everyone is to complete before the course. 4

5 Initial visit 30 minutes Interactive lecture, entire group Review techniques for rapid assessment and recognition of unstable pediatric patients Review pre-test Discuss pertinent cases which illustrate the systematic approach to clinic assessment and stabilization of high-acuity patients Review appropriate transport mode and hospital destination minutes Mock cors, small groups of 6-8 Review 2-3 mock scenarios with multidisciplinary clinic teams Establish team dynamics, including team leadership, responsibilities, communication and rapid identification of high-acuity patients Group members are encouraged to ask questions and use this slow code opportunity to clarify issues about resuscitation and stabilization Evaluations and wrap-up Second Visit (~ 6 months after first training) 25 minutes Update lecture, entire group Review resuscitation techniques Review process changes made by clinic since the first session and answer questions minutes - Mock cor scenarios Review 2-3 mock scenarios with multidisciplinary teams using practice equipment Evaluations and Wrap-up II. Pre-arrival preparation -- "How to be prepared when a sick child arrives" A. Boundaries of clinic responsibility On-grounds emergencies: Clinic should have a plan for patients of all ages experiencing emergencies on the clinic s campus. Plans should include: Boundaries to which team will respond. i.e. outside a defined area, such as the clinic s parking lot, 911 should be called for EMS to respond and transport, rather than clinic s resuscitation (cor) team bringing the patient into the clinic. 5

6 Paging system: Clinic should have system for identifying: 1. Nature of emergency Cor 0 vs nurse stat 2. Age of patient pediatric age range should be pre-determined (e.g. < years old) 3. Location of emergency B. Resuscitation (cor) team composition Team composition: i.e. who should respond? Ideally two RNs, two other health care partners, lead physician, and one other support physician. Administrator or security if available. A clinic member should be assigned to support the family and explain what is happening. C. Equipment readiness The emergency cart includes equipment and drugs for all ages. Ensure that all pediatric equipment and supplies are available, including at a minimum: Broselow length-based emergency tape Assortment of oral airways from premie to adult sizes Magill forceps Assortment of endotracheal tubes from premie to adult sizes Self-inflating bags in sizes for infants, children, teens IV and IO catheters in assorted sizes. Normal saline IV bags IV dextrose 5, 10, and 60 cc syringes Tape, alcohol, gauze pads Blanket and hat for infant unless kept readily elsewhere See Appendix A: Emergency cart Equipment and Medication List Suction should be readily available, including flexible and Yankauer ( tonsil tip ) suction tips. A free-standing mobile oxygen source, typically an E-cylinder, must be readily available. Pressure should be checked regularly and documented by a check-off system. A monitor-defibrillator with pediatric paddles/adaptors is typically found on the top shelf of the emergency cart. The preferred hands-off patches are available in the cart. Ensure that all staff who may have to use this device actually knows how to use it with familiarity. Most have built-in AEDs (automated external 6

7 defibrillators, see section V), which require specific training for use. If a separate AED exists in the clinic the same training considerations apply. Medications for infant and child resuscitation are contained within the KP emergency cart. Have provision for readily obtaining IV lorazepam or rectal diazepam from pharmacy or any other medication not stocked in clinic. Medications should be integrated with the separate anaphylaxis kit, see KP protocol for contents. 7

8 D. Staff training All staff involved in care of patients from newborns to age 18 years should undergo initial CERP training, and then participate in refresher training 6-18 months later. Studies indicate psychomotor skills attenuation occurs after six months, so moc cors at that minimum interval make sense. CERP revisits every two years can provide resuscitation updates. Consider doing scavenger hunts as practice for finding equipment and supplies. Studies show that resuscitative competency is dependent on at a minimum simply knowing where things are. A CERP champion should be identified in each clinic who can help to provide moc cors or other resuscitation training during staff meetings or by arrangement, sometimes on an ad hoc basis when time permits in the clinic. Measuring competency can be done by scoring moc cors for completeness of resuscitation, including documentation, timeliness of resuscitative measures, early notification of EMS or x3099, and appropriate disposition. A qualified clinician or CERP instructor can serve as mentor for this activity. Front desk training: Registration personnel should be taught to recognize children in distress. Signs to recognize include: Poor color, respiratory distress, altered mental status, stridor or audible wheezing with distress, seizures, and active bleeding. Prior experience and competency of new hires should be determined. An ongoing training program and refresher modules should be offered regarding pediatric emergencies. III. Infant and Child Resuscitation - "What to do upon patient arrival" A. Appropriate resuscitation location. A stabilization area or room should be kept readily available. Typically this is a treatment room where the emergency cart is kept or can be quickly brought. A CPM, oximetry, oxygen, and suction are kept there. The resuscitation documentation form should be immediately available. If an unstable child is identified at registration or outside the clinic area, he or she should be brought immediately to this room. If a child being seen in a clinic exam room becomes unstable, they should be transferred to the stabilization/treatment room. It may be helpful for current resuscitation algorithms to be mounted on the wall. B. Resuscitation of the infant and child 8

9 1. Predetermined roles of resuscitation team The compromised child will receive optimal care if the resuscitation team has pre-determined roles, as follows: Team leader Does the physical assessment, and directs team members. Typically the team leader is the physician with the most experience with resuscitation that is available Airway management Positions the head and applies oxygen. Does airway maneuvers as indicated Documentation Keeps paper log of vital signs and interventions, including CPR, medications, and fluids IV access RN who establishes IV or IO access, begins IV fluids Monitor placement applies monitor patches and oximetry leads Preparation of medications or supplies Prepares IV meds to be delivered or other interventions needed, gives to access RN for delivery Notification of EMS or x3099 Calls 911 or 3099 at the direction of the team leader with pt identification, presumptive diagnosis or impression, and desired destination (3099) A clinic member should be assigned to support the family and explain the child s status and interventions. The lead physician examines the patient and directs the team. He or she doesn t perform procedures, unless no one else on the team can do the procedure, so as to minimize distractions to critical thinking. 2. Method for providing oxygen: Nasal cannula -- for fairly stable children who need just a small amount of supplemental oxygen. Not often used during resuscitations. Blow-by oxygen can deliver supplemental oxygen. This can be done by oxygen tubing with nothing on the end held close to the pt s nose and mouth. A typical self-inflating bag cannot deliver blow-by oxygen. Masks: A simple mask delivers a variable amount of inspired oxygen at high flow rates. Patients can potentially re-breathe their CO2 and become hypercarbic unless a non-rebreather mask is used, which is preferred. Bag-mask ventilation. Delivers almost all the benefits of endotracheal intubation (ETI) with only slight risk of aspiration. ETI: For skilled and practiced practitioners 3. IV or IO (intraosseous) lines Intravenous access should be established for any child: 9

10 Needing or potentially needing IV medications or fluids. Who has the potential for deterioration during transport or before arrival at the receiving facility IO (intraosseous) access should be established whenever the child is in or near arrest or is in status seizures, and IV access cannot be established. 4. IV fluid Fluid volumes should be dependent on the physical exam. The object of Circulatory assessment is to rule in or out poor perfusion, ie shock, and that this determination can be done at bedside by hands-on exam. BP decline is a late sign of shock. There are six signs of C assessment. If two or more are abnormal, the pt is in shock. Color HR CFT: < or = 2 seconds Pulses Warmth of extremities Mental status Poor perfusion (delayed capillary refill, cool extremities, etc) should prompt an IV fluid bolus of 20 ml/kg of body weight. Further boluses should again be dependent on the clinical exam of circulation during reassessment. Neither over nor under fluid resuscitate. Critically ill children will in general be transported before a second bolus can be undertaken. 5. Warming equipment and documentation Warming equipment -- lights and chemical heating packs are generally not available. Blankets and hats for infants are. Children that cool during resuscitation or during their compromising event do not survive as well as their normothermic counterparts. So efforts should be made to conserve body heat, consistent with adequate exposure for examination. Documentation of the resuscitation should be done on a paper charting form, which should be always available for ready use in the stabilization/treatment room. It can be transferred to HealthConnect later. A smart text is available: CRITICALLY ILL CHILD CO (type peds crit in the smart text box and this chart template that is very friendly to resuscitation documentation will populate) A copy of the record should be made available including demographics to the transporting crew. Please see the CERP handout for more content related to resuscitation. 10

11 IV. Transporting the sick child out Where & how to send the child Use the following guidelines to determine how and where to transport a child to a hospital. The goal is to ensure safe timely arrival of the pt to the inpatient setting, in a cost-effective fashion. In general, the transport mode elected should be consistent with the acuity required in the hospital setting. A. Transport methods A child may be transported by one of the following methods: POV (Privately Owned Vehicle) KP Ambulance hub (x3099) 911 (local EMS) Aeromedical (for example, Flight for Life and AirLife) Use these descriptions to determine the best method: 1. Privately owned vehicle (for example, parent s car) o Pro: Inexpensive, allows parental versatility o Con: No monitoring, deterioration possible, lengthy delays possible, medicolegal risk to transferring provider. (i.e. if pt deteriorates during transport by car sending physician bears responsibility) o Guideline: Only for pts with minimal risk of deterioration, e.g. pts who have cellulitis requiring admission for IV antibiotics. Should not be used if pt is on oxygen, or has received an epinephrine nebulizer, or albuterol for wheezing, and as above) 2. KP ambulance hub (x3099) o Pro: Can help choose and arrange BLS or ALS ambulance. Control over destination is retained (911 paramedics may override your destination desire), no need for repatriation, costs minimized compared to 911 or especially aeromedical transport. o Con: Prolonged arrival interval at times. Minimum generally 30 minutes. Can be delayed at peak times. o BLS guideline: Generally stable children, no need for ALS meds, nebs or interventions. E.g. psych admissions, stable asthmatic children receiving infrequent nebs and on room air; o ALS: Higher acuity children and infants. E.g. hypoxia requiring oxygen treatment; any AMS at time of transfer; ongoing IV resuscitation, more than 3 nebs given in < 2 hr interval; stridor post-racemic epi neb, multitrauma or limb-threatening transfers (These children need to be transferred 11

12 to an appropriate verified trauma center. Children s is a Level I center. Any significant injuries requiring admission, or potential NAT) (local EMS) o Pro: Rapid arrival, usually within 6 min. Can perform ALS (active airway management, ALS meds, etc). o Con: Loss of destination control. Paramedics function under their base station medical control and will generally take pt to closest appropriate facility unless they concur with desired destination and have time to transport the child there. Greater resource use to system. Variable experience levels with pediatrics. o Guideline: Need for immediate transport; ongoing critical resuscitation, s/p arrest or near-arrest in clinic, need for advanced airway management not available in clinic. 4. Aeromedical (for example, Flight For Life or AirLife) o Pro: Rapid transport from clinic to hospital assured. Can be activated by Control of destination retained. Generally sophisticated care. o Con: Flight risk to air crew members and pt must be justified by pt s acuity. May not be faster than ground ambulance to receiving hospital when time to bring rotor-wing aircraft to clinic, load, and arrival at destination is combined. Very high costs to system. o Guideline: Use only when enhanced outcome can be justified in view of drawbacks above. E.g. peak traffic times when ground transport would be delayed and might adversely affect outcome; directed admissions to specialty center when ground ambulance might result in adverse outcome. B. Hospital Destination Depending on the situation, the child may be transported to one of the following hospitals: Colorado Children s Hospital Rocky Mountain Hospital for Children at P SL The closest appropriate hospital The goal is to match the right child to the right facility, and considering family convenience. Avoid placing inappropriately high-acuity patients at facilities other than CHC or RMHC. General guidelines are below. The guidelines are dynamic. The most current version is on the website (see glossary), and are always subject to change. When in doubt, discuss with the hospitalist. See the primary care website for contact numbers. V. Miscellaneous 12

13 A. What about AED's? Automated external defibrillators are present in most or all KP clinics. They are indicated for use in adults and in children down to age 12 mos. Their software is very sophisticated, and is both sensitive and specific, i.e. an AED will not shock a child who doesn t need it, and it will not fail to shock a child who has a rhythm which would benefit from defibrillation. Providers should not fail to pay close attention to the priorities of opening and maintaining a patent airway, and optimizing breathing and circulation of the child while the AED is being applied. The AED of course only attends to the issue of whether the child needs an electrical shock or not, which occurs in <30% of full cardiopulmonary arrests. An AED often provides the most sophisticated analysis of dysrhythmias for adults and children and should be used accordingly. Staff should receive initial and ongoing training in its use. B. Facility Cor system - institutionalizing the culture of emergency readiness Each facility and both FP and pediatrics departments that see infants, children, and teens should adopt a comprehensive and ongoing program aimed at ensuring that children who enter the facility with physiologic impairment of any type (AMS, airway obstruction, respiratory distress or failure, shock, etc) can be rapidly identified, stabilized, and transferred to an appropriate facility. A facility-wide ongoing program of moc cors, quality assurance of equipment, staff, and review of resuscitations must be done. C. Pediatric equipment list See the KP nursing website for a current list of what is on the emergency cart. Remember that equipment lists can be updated, check with your nursing manager and kp.org under nursing guidelines for any updates. Be aware that the separate anaphylaxis kit is on the emergency cart D. Courses available for training 1. Basic Life Support (BLS). AHA sponsored. Good performance of basic life performance skills allows for better outcomes when ALS interventions become necessary. Staff should be current in pediatric BLS. 13

14 2. PALS Providers including mid-levels, pediatricians and ideally FPs should be current in PALS. Currently the course is largely computer-based, which has helped to decrease the significant variation in didactic methods and sophistication used in teaching PALS in the metro area. Efforts should be made to take the course where faculty has a background in pediatric resuscitation and education. 3. ENPC The Emergency Nurses Association offers this course, the Emergency Nursing Pediatric Course. It offers pediatric nurses an extensive background in emergency preparation for infants and children. 4. TNCC Trauma Nursing Core Curriculum. Aimed at emergency nurses who desire more background in trauma care. Would be of limited value to clinic-based RNs except in the rare case that they were seeing many injuries. 5. NRP Aimed at delivery-room neonatal resuscitation. Limited value to clinic-based pediatricians. Would be useful to hospitalists seeing newborns. IV. Credits and Website References A. North Carolina EMS for Children. We are indebted to this program for inspiration by some of their office emergency materials. EMS-C is a national program, developed through a series of grants implemented via Health and Human Service s office of Maternal and Child Health which has been dedicated to improving the outcomes of children entering the emergency care system. The author (FKB) was the medical director for three Colorado EMS-C grants. B. Cover page artwork by Paul Fox, son of Dr Margaret Ferguson and Randy Fox. C. The CERP handbook and current appendices are available at: 14

15 GLOSSARY AED ALS AMS BLS Cor CPM EMS IO KP Moc cors automated external defibrillator Advanced Life Support Altered mental status Basic Life Support Refers to cardiopulmonary resuscitation, as in Cor 0. cardiopulmonary monitor (refers to monitor/defibrillator/aed device) Emergency Medical Services. Paramedics and Emergency Medical Technicians, often as part of a fire department. Intraosseous. A needle placed directly into bone marrow, functions as an IV. Kaiser Permanente Simulated resuscitations. Drills using manikins and scenarios, directed by a lead clinician. CHECKLIST OF ANNUAL PERFORMANCE [] Training: 1.CERP update: 6 months after initial training, then every 6 mos to 2 years 2. Moc cors done by clinic staff every 4-6 months. 3. Ensure that new hires are oriented to emergency response protocols. [] CQI: 1. Ensure that nurse stat system is working appropriately 2. Ensure that all resuscitative equipment is checked regularly: suction, oxygen, emergency cart supplies, paper record 3. Review all resuscitations for appropriateness of care. Dr Battan is available to review any cases [] AED: 1. All staff who are BLS or ALS providers should be familiar with AED indications and application. COPYRIGHT Copyright 2012 FK Battan. Any part of this may be used by members of Colorado Permanente Medical Group or Kaiser Permanente. Others by permission only. 15