Preparedness Are you prepared for this? Personal reflections The Children's Mercy Hospital 2015 2 Emergency Pediatric Office Preparedness: Ready or Not? Chris Kennedy, MD Professor of Pediatrics, UMKC Division of Emergency Services Director Simulation Based Research Plan for Today Case discussions Preparedness Planning/Equipment Disaster role The Children's Mercy Hospital 2015 3 4 Ready? Case 1 Capable? Case 2 A 15 month old boy checks into the reception desk of your office with his mother. The child is here for an acute care appointment because he woke up with a fever. Unfortunately you are already running 30 minutes behind so the family is asked to sit in the waiting room. 5 minutes later the mother yells from her seat that her child is shaking. What should happen now? Is your office ready for this event? A 4 month old child is scheduled for a routine visit this am. Upon check in mother states that she is glad she scheduled this appointment because her child is not eating due to a cold and breathing hard. Will the receptionist be concerned by this statement? Will the child be assessed right away? 5 6 1
Involved? Case 3 There is a category 4 tornado that hits 10 miles from your office that decimates the surrounding region. Your office is undamaged except for loss of power, and internet access. You get a call from EMS asking you if your office can see patients. How will you/your office respond? I have no financial relationships to disclose or conflicts of interest to resolve Disclosure 7 8 Objectives: At the end of today s lecture, participants will be able to: 1. Analyze the challenges of office prepraredness. 2. Learn ways to develop readiness. 3. List the needed skills and equipment required to be prepared for pediatric office emergencies Pediatric office based emergencies are really rare events, aren t they? Practice dependent Survey results from 51suburban practices 24 events per office per year A separate survey of pediatricians 73% reported 1 or more per week 9 10 Most often encountered Office readiness data Office based emergencies from most to least frequent Respiratory emergencies including asthma Neurologic including seizures Severe infection/sepsis Dehydration Anaphylaxsis A 1985 survey revealed that offices were not prepared 42% equipped with oxygen 35% with bag mask devices The good news more offices ready in 2011 98% oxygen and 96% with bag mask devices 11 12 2
I just renewed my PALS, I am ready aren t I? These courses are intended to provide the knowledge and skills training but not to provide true competence. Readiness requires planning, preparation, practice System Team Individual team members What works Plan/conduct an office-based readiness assessment Process that is streamlined and familiar Practice to train staff for their roles all staff A 2007 AAP consensus outlines these needs 13 14 Office-based readiness assessment The goal is to determine: Types of emergencies most commonly encountered Office resources available EMS capability, response time Closest facility than can provide higher level of pediatric resuscitation Definitive care The Response Plan Written and should detail equipment, staff training, and medications processes Developed by convening representative members of office team and discuss steps in managing emergencies Roles should be outlined/assigned Include times when staffing varies 15 16 Additional plan needs Recognition and triage Internal notification EMS activation Office resuscitation process/location/roles Documentation Office resuscitation roles Receptionist- Triage in the waiting area/ notifies the local EMS system, then provides support to family members. Physician- Directs resuscitation efforts and controls the airway. Nurse 1- Responsible for patient triage, intravenous access and drug administration Nurse 2 or Medical Assistant- provides CPR; and a nursing assistant records events and interventions (eg, medications given) as they occur. 17 18 3
Recognition Labored breathing Blue or pale color Noisy breathing or stridor Altered mental status Seizure Agitation (child or parent) Uncontrolled bleeding Example role: Reception desk Resuscitation Process Where will the child be resuscitated? How will equipment and medications be organized? Who/how will equipment and medications get to the patient Vomiting (after a head injury) Notify EMS Copy documents for transfer 19 20 Process: Equipment Group equipment by type- Should include Bag-mask and Oxygen Should omit intubation equipment Vascular access Medication box Consider focus on IM/PO/Aerosol medications IM meds- Midazolam/Epinephrine PO Steroids Aerosol albuterol/epinephrine Process:Equipment Organization Have a streamlined plan for differing sizes of equipment and know how it works Could be a mini practice session Cart based set up alllow the equipment to move to the patient Remove furniture from Small exam rooms 21 22 Preparation: Education All staff BLS/CPR course AHA/Red Cross Nurses PEARS/ Emergency Nursing Pediatric Course/ PALS Physicians PALS/ APLS Staff preparation-skills All should be practiced on a planned schedule with an observer to provide feedback Practice should include retreival/assembly and usage of equipment Airway management and oxygen delivery Vascular access Medication delivery CPR/AED/Choking 23 24 4
Practice Mock codes have been shown to improve team function/job satisfaction and patient outcomes. Deliberate observation and debriefing can help to improve staff readiness and planning by identifying gaps and remedies Contact local EMS/Children s Hospital to discuss help with equipement/training Documentation Consider using a standardized process Provides prompts Include only salient information This role takes practice Have it ready for EMS/transport 25 26 EMS planning 2007 by American Academy of Pediatrics Committee on Pediatric Emergency Medicine Pediatrics 2007;120:200-212 Be familiar with local resources Crisis communication- clear, simple, limited Include age/weight/condition/vital signs Office address and directions Advanced life support or BLS needed Do not hang up until EMS dispatch has verified information 28 Emergency Information Forms If complex patients are cared for in the practice consider using an EIF(see resource slide for link). This form was developed by AAP and ACEP Provides EMS or any physician with a quick summary of medical problems, clinical baseline, medications disaster needs and phone numbers Filled out and updated regularly by primary care Carried by family when traveling Disaster Planning Children s needs often underserved so pediatricians must be ready Consider discussing this with families (see resource link for family readiness kit) Plan for power outages/record compromise How will you help other/get help when needed to care for your families Work with local EMS/hospitals in your region 29 30 5
Case 1 needs Stabilize a seizure patient-skills Airway/breathing Vascular Access Medications Transfer/EMS Case 2 This baby, when evaluated, has a respiratory rate of 68, with intercostal and subcostal retractions. Pulse oximetry, if available, reads 82% Needs high flow oxygen ASAP Transfer to definitive care? 31 32 Summary Children requiring emergency care commonly present An office assessment and plan needed Roles/equipment/planning/documentation/EMS call Nonclinical personnel maybe the 1 st line of triage Equipment needs include knowning where and how it works Periodic mock codes are an effective to way increase resuscitation skills and decreased staff anxiety Care includes proper/safe transport Resources This is the policy statement and planning resource: http://pediatrics.aappublications.org/content/pediatrics/120/1/200.full.pdf This is the comprehensive manual for office emergencies: http://www.ncems.org/pdf/emsc/manual.pdf This is the family disaster resource: https://www.aap.org/en-us/documents/disasters_family_readiness_kit.pdf This is a great resource for doctors and families: https://www.healthychildren.org/english/pages/default.aspx This is an excellent Canadian video about office prepardenss http://www.officeemergencies.ca/video This is the link to the EIF form: https://www.aap.org/en-us/about-the-aap/committees-councils- Sections/section-hematology-oncology/Documents/emergency_info_form.pdf 33 34 References 1 American Academy of Pediatrics Committee on Pediatric Emergency Medicine, Frush K. Preparation for emergencies in the offices of pediatricians and pediatric primary care providers. Pediatrics 2007; 120:200. Klig JE, O'Malley PJ. Pediatric office emergencies. Curr Opin Pediatr 2007; 19:591. Flores G, Weinstock DJ. The preparedness of pediatricians for emergencies in the office. What is broken, should we care, and how can we fix it? Arch Pediatr Adolesc Med 1996; 150:249. Fuchs S, Jaffe DM, Christoffel KK. Pediatric emergencies in office practices: prevalence and office preparedness. Pediatrics 1989; 83:931. American Academy of Pediatrics. Periodic survey 27. American Academy of Pediatrics, Elk Grove Village, IL. 1995. http://www.aap.org/research/periodicsurvey/ps27exm.htm (Accessed on July 19, 2010). Schweich PJ, DeAngelis C, Duggan AK. Preparedness of practicing pediatricians to manage emergencies. Pediatrics 1991; 88:223. References 2 Pendleton AL, Stevenson MD. Outpatient Emergency Preparedness: A Survey of Pediatricians. Pediatr Emerg Care 2015; 31:493. Massachusetts EMSC Task, Force. Office Preparedness for Pediatric Emergencies, 2nd, O'Malley, P (Eds), Massachusetts Department of Public Health, 2002. Bordley, WC, Frush, KS, Cinoman, M. Pediatrics. In: Management of Office Emergencies, Barton, CW (Eds), McGraw-Hill, New York 1999. p.323. Committee on Pediatric Emergency Medicine. Your office as an emergency care site. In: Emergency Medical Services for Children, Singer, J, Ludwig, S (Eds), American Academy of Pediatrics, Elk Grove Village 1992. p.31. Hobgood C, Sherwood G, Frush K, et al. Teamwork training with nursing and medical students: does the method matter? Results of an interinstitutional, interdisciplinary collaboration. Qual Saf Health Care 2010; 19:e25. Finan E, Bismilla Z, Whyte HE, et al. High-fidelity simulator technology may not be superior to traditional low-fidelity equipment for neonatal resuscitation training. J Perinatol 2012; 32:287. 35 36 6
References 3 Bordley WC, Travers D, Scanlon P, et al. Office preparedness for pediatric emergencies: a randomized, controlled trial of an office-based training program. Pediatrics 2003; 112:291. Toback SL, Fiedor M, Kilpela B, Reis EC. Impact of a pediatric primary care officebased mock code program on physician and staff confidence to perform life-saving skills. Pediatr Emerg Care 2006; 22:415. Schmitt, BD. Pediatric Telephone Protocols: Office Version, 12th, American Academy of Pediatrics, Elk Grove Village 2009. American Academy of Pediatrics. A report from the provisional section on pediatric telephone care and the Committee on Practice and Ambulatory Medicine. November, 1998. http://www.aap.org/sections/telecare/11_98.pdf (Accessed on July 19, 2010). Shah AN, Frush K, Luo X, Wears RL. Effect of an intervention standardization system on pediatric dosing and equipment size determination: a crossover trial involving simulated resuscitation events. Arch Pediatr Adolesc Med 2003; 157:229. References 4 Agarwal S, Swanson S, Murphy A, et al. Comparing the utility of a standard pediatric resuscitation cart with a pediatric resuscitation cart based on the Broselow tape: a randomized, controlled, crossover trial involving simulated resuscitation scenarios. Pediatrics 2005; 116:e326. Lerner C, Gaca AM, Frush DP, et al. Enhancing pediatric safety: assessing and improving resident competency in life-threatening events with a computer-based interactive resuscitation tool. Pediatr Radiol 2009; 39:703. Hodge D 3rd. Pediatric emergency office equipment. Pediatr Emerg Care 1988; 4:212. Wheeler DS, Kiefer ML, Poss WB. Pediatric emergency preparedness in the office. Am Fam Physician 2000; 61:3333. Sapien R, Hodge D 3rd. Equipping and preparing the office for emergencies. Pediatr Ann 1990; 19:659. 37 38 References 5 King B. "Interfacility" transport from the home or office. Pediatr Emerg Care 1997; 13:164. Schuman, AJ. Be prepared: Equipping your office for medical emergencies. Contemp Pediatr 1996; 13:27. Baker MD, Ludwig S. Pediatric emergency transport and the private practitioner. Pediatrics 1991; 88:691. www.nhtsa.dot.gov/people/injury/ems/interfacility/index.htm/ (Accessed on January 24, 2010). Frush, K. Study packet for the correct use of the Broselow pediatric emergency tape. Enhancing Pediatric Safety. www.ncdhhs.gov/dhsr/ems/pdf/kids/deps_broselow_study.pdf/ (Accessed on January 24, 2010). Thank You For more information about our presentation, please contact: Chris Kennedy, MD ckennedy@cmh.edu 39 40 Q & A The following slides are for your use Outline some of the roles needed for a resuscitation Create a badging or outline of the setup 41 42 7
Office based care code blue roles The purpose of this is to begin the process to develop a simpler process. This will focus on communicating the roles and what each role needs to perform. I think it would be helpful to describe how the roles are designated Codes in the Pediatric Office How roles are assigned? Code badge system You could set up the cart to have hanging badges or what ever you wish to designate the role When the badges are gone the roles are filled Each badge should have only the most salient skills as bulleted text of steps I have started this process in outlining what these might look like in the following slides The Children's Mercy Hospital 2015 Cart Manager Nurse Role Charge Nurse o Acts as manager of Broselow Cart/weight-based (Code Cart) AED?, airway equipment, medications, IV and phlebotomy supplies o Prepares and labels necessary medications o If IV access available, verify IV fluids to be used in Code Blue o Work together with Beside Nurse to set up IV fluid administration o Restocks Broselow Cart Crowd control Assist with patient care Manage family when needed Assist with disposition Review Code Blue documentation Bedside Nurse -Nurse Role You should decide how this role is assigned Recorder Nurse role o Assessment and collection of data o Performs chest compressions, as needed o Obtain vital signs or delegate to care assistant/lpn o Administer medications o Assist with procedures o Initiate placement of IV o Obtain labs o Call nursing report to the receiving facility o Records events on Code Blue documentation forms, ensuring complete documentation of event o Monitors and records vital signs Baseline assessments Medications administered IV fluids administered Procedures Equipment/supplies Collection of labs and results 8
Care Assistant/LPN Physician Team Leader o Obtain Broselow Cart (Code Cart) and bring to location of Code Blue o Monitor placement o Retrieve extra supplies, as needed o Performs chest compressions, as needed o Assist with patient care, as directed o Support family o Team leader who directs/collaborates/monitors/ evaluates Code Blue event o Identifies heart rhythm o States patient assessments o Orders medications to be administered o Orders procedures to be completed o Speaks to accepting facility for transfer Respiratory Therapist o Help maintain patent airway throughout Code Blue event o Oxygen set up o Provide bag-mask ventilation o Suction the airway, as needed o Assist with CPR Receptionist Triage needs upon families presenting to sign in or when out in the waiting room. Call for EMS Makes copies of any records of events 53 2007 by American Academy of Pediatrics Committee on Pediatric Emergency Medicine Pediatrics 2007;120:200-212 9
Committee on Pediatric Emergency Medicine Pediatrics 2007;120:200-212 Committee on Pediatric Emergency Medicine Pediatrics 2007;120:200-212 2007 by American Academy of Pediatrics 2007 by American Academy of Pediatrics SELF-ASSESSMENT OF OFFICE PREPAREDNESS FOR PEDIATRIC EMERGENCIES As you answer these questions, you may be better able to identify those areas in which your office preparedness can be enhanced. What emergencies have you experienced in the office setting? How often have office emergencies occurred in your practice? What is your office setting (freestanding office, clinic based, health center based, hospital based, other)? Are there resources outside your office on which you could call during an office emergency (eg, security, other medical or dental professionals in the same building, hospital code team)? 2007 by American Academy of Pediatrics Committee on Pediatric Emergency Medicine Pediatrics 2007;120:200-212 58 What are the high and low staffing points during the times when your office is open? (Include nights and weekends if applicable.) What is the emergency readiness of the staff present during those times? (Include first aid, CPR, BLS, ALS, PALS, APLS, Emergency Nurse Pediatric Course, other continuing medical education, etc.) Have nonclinical staff been trained to recognize a potential or actual emergency? What anticipatory guidance and education do you provide parents regarding injury prevention, first aid and CPR training, recognizing and responding to emergencies, and accessing EMS? How far is your office from a site of definitive care, such as the nearest ED, or the nearest pediatric center? How long does it take for EMS to respond to a 9-1-1 call from your office? 59 60 10
Is your waiting room under direct observation or screened frequently by a clinical staff member? Is it childproofed? Has EMS ever been to visit your office for a nonemergency call or to receive experience in evaluating pediatric patients? Does your practice have a written protocol for response in an office emergency? Does that protocol cover times of low staffing? Do all staff members know how to access the EMS system? Staff members should be able to give the location and directions to the office, level of clinical staff present, age and condition of child (including vital signs if appropriate), desired transport location, and the level of emergency response (ALS or BLS) required. What level of provider comes when you call 9-1-1: first responder, BLS, or ALS? Does your local EMS have the necessary equipment and expertise to manage children? What is the point of entry for your local 9-1-1 response team (ie, the facility to which they are required by field protocol to bring a pediatric patient)? Do you have specific telephone triage protocols for nonclinical and clinical staff? If EMS does not go directly to a pediatric center on a 9-1-1 call, how do you emergently transport a child to the desired pediatric center when necessary? 61 62 Does your office use oxygen? If so, how is it supplied? Do all clinical staff members know how to operate the oxygen canister and know where the key is kept? Does your practice care for any children who are technology dependent or have special health care needs? Do you have need for any additional equipment or expertise if a technology-dependent child should have an emergency in your office? What emergency dosage strategy do you use in the office (code card, length-based tape, dosage book, no strategy)? What airway equipment do you stock? Do all staff members know how to locate, choose, and use the appropriate size of equipment for any given child? What equipment and supplies do you have on site to provide you and your staff with universal precautions? 63 Do you have written office protocols for common office emergencies such as respiratory distress, anaphylaxis, sepsis, dehydration, and supraventricular tachycardia? How do you document events during an office emergency (assigned role, tape recorder, retrospective, other)? How do you and your staff maintain skills and readiness? (Examples include attending nursery deliveries, moonlighting in urgent care or pediatric ED, being a PALS or APLS instructor, holding regular mock office codes and scavenger hunts for infrequently used equipment, providing expert review of pediatric runs for your local EMS th ) 64 11