This report presents findings from Periodic Survey #27 which explored the state of readiness for common emergencies of office-based pediatric practices. This survey was initiated by the Committee on Pediatric Emergency Medicine; the findings will assist the COPEM in developing programs for continuing education regarding: 1) initial office management of common pediatric emergencies, 2) training of office staff, and 3) the availability of the equipment/medications necessary to handle such emergencies.

PS#27 was an eight-page self-administered questionnaire sent to a random sample of 1,614 active US. FAAPs. The original mailing and four follow-up mailings to recontact nonrespondents were conducted from August 1994 to December 1994. After five mailings we received a total of 1089 completed questionnaires for a response rate of 67.5%.

Frequency/Type of Emergencies in Pediatric Offices:

Pediatricians see an average of 2.1 patients in their offices who require emergency treatment or subsequent emergency hospitalization during an average work week; 27% see no emergency patients and 68% see between 1 and 5 such patients per week. The most frequently named condition that may require emergency treatment in a pediatric office is severe asthma:

• 74% of pediatricians have seen an average of 8.0 patients with severe asthma during the past year.

• The next most frequently named emergency condition seen in pediatric offices is servere respiratory distress (60% of pediatricians saw an average 4.4 patients with this condition).

• 50% of pediatricians saw 2.5 patients with severe dehydration in their offices during the past year.

Written Guidelines for Emergencies in Pediatric Offices:

More pediatricians have written protocols to handle telephone emergencies than have protocols to handle pediatric emergencies that occur in the office.

• Nearly half of pediatricians who practice in office-based ambulatory settings (46%) say their office has written guidelines for office personnel on assessing the urgency of patients' medical needs via the telephone; only 5% do not know.

• 68% of those who have such guidelines say the guidelines detail appropriate action to be taken depending on whether the physician, a nurse or only the receptionist is available to answer telephone calls.

• Fewer pediatricians in office settings (31%) have written guidelines for office personnel on assessing the urgency of patients' medical needs in the reception area.

• Most of those pediatricians (82%) say the guidelines detail instructions in recognizing emergencies and the appropriate action to be taken depending on which staff is available.

• More than one-third (37%) have a written protocol for the appropriate action to be taken for patients who have emergencies while undergoing diagnosis or treatment in the office.

• Most (78%-86%) say these protocols include instructions on how or when to access various local Emergency Medical Services for children.

Emergency Preparedness of Office Staff:

Only one-third (32%) of office-based pediatricians require their office staff to participate in periodic mock drills of pediatric emergencies. Few require their nonmedical office personnel to be certified (or maintain certification) in pediatric CPR:

• 25% of pediatricians say their offices require secretaries or receptionists to be certified in pediatric CPR; 21% require certification to be maintained.

• 31% of pediatricians require office managers to be certified in pediatric CPR; 25% require them to maintain their certification.

• 77% of pediatricians require nurses in their offices to be certified in pediatric CPR and 62% require these staff to maintain certification.

• 89% of pediatricians say their offices require physicians to be certified in pediatric CPR and 65% require these staff to maintain certification.

Twenty-eight percent of office-based pediatricians say the nurses in their offices are required to be certified in pediatric advanced life support (APLS, PALS); 72% say physicians are so required. Only 18% say nurses are required to maintain their certification and 42% say physicians are required to maintain their certification in pediatric ALS.

Emergency Equipment Available in Pediatric Offices:

The AAP Committee on Pediatric Emergency Medicine (COPEM), in its 1992 manual, Emergency Medical Services for Children (EMS-C): The role of the Primary Care Provider, lists specific emergency equipment/supplies that it recommends pediatric offices have available.

• 92% of pediatricians said they have oxygen masks available in their office.
• 89% of pediatricians said their office has an oxygen source with flowmeter.
• 86% said they have available oral airways.
• 85% have bag-valve-mask resuscitators readily available in their office.
• 84% of pediatricians have butterfly needles readily available.
• 82% have IV boards, tape, alcohol swabs, tourniquets readily available in their office.
• Nearly all pediatricians (97%) have blood pressure cuffs of all sizes available.
• 96% of pediatricians have a sphygmomanometer available in their office.

Least often available in pediatric offices is a Doppler (reported by 26% of pediatricians), over guidewire catheters (33%), and length-based resuscitation tape (34%). Pediatricians report a wide range of other emergency equipment and supplies available in their offices.

Emergency Medications Available in Pediatric Offices:

Recommended pediatric emergency medications most frequently named as being readily available in pediatric offices include:

• aqueous adrenaline - 1:1000 (reported by 92% of pediatricians).
• albuterol for inhalation (91% of pediatricians reported).
• parenteral antibiotics (reported by 82%of pediatricians).

Least often named are activated charcoal (42%) and L-epinephrine/vaponephrine (nebulizer) (51%). Other medications were reported by a range of pediatricians.

Three-fourths of pediatricians said their office has a specific schedule for inspecting the expiration dates and supply levels of the emergency medications available, 13% said their office did not have an inspection schedule, and 12% did not know of the existence of such a schedule.

Nearly all pediatricians (91%) said their offices do NOT stock ALL of the emergency equipment or medications recommended in the AAP EMS-C manual. Three-fourths of pediatricians said their offices did not stock all the recommended emergency equipment or medications because they could rely on the quick response time of their local emergency medical services for children system. Sixty-four percent said the proximity of their office to an ED equipped to handle pediatric emergencies made it unnecessary to have all the equipment/medications on hand. About one-half (53%) said there were too few emergencies in their office to warrant the investment in all the equipment/medications. While only one-third (35%) of pediatricians agreed that it is too expensive to stock the recommended medications due to their short shelf life and 16% agreed that it is too time consuming for their staff to maintain and inspect the emergency equipment, a large portion of respondents (22% and 26%, respectively) had no opinion.

Summary

Overall, less than one-half of pediatricians have written protocols to handle emergencies, either via telephone or in person, in pediatric offices. Even fewer pediatricians require their staff to participate in emergency drills, CPR training, or pediatric advanced life support training. Most pediatricians do not have all the emergency equipment or supplies recommended by the COPEM in its most recent EMC-S manual primarily because of the infrequency of office emergencies, the rapid response time of local EMS-C systems, and proximity to emergency departments equipped to handle pediatric emergencies.