Pediatric Office Emergency Preparedness: An Intensive In-Office Training Curriculum : Pediatric Emergency Care

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Pediatric Office Emergency Preparedness

An Intensive In-Office Training Curriculum

Spanos, Stephanie MD

Editor(s): Rutman, Lori E. MD, MPH, Associate Editor

Author Information
Pediatric Emergency Care 38(8):p 392-398, August 2022. | DOI: 10.1097/PEC.0000000000002702

Abstract

In 2007, the American Academy of Pediatrics (AAP) Committee on Pediatric Emergency Medicine published a statement of recommendations for pediatric primary care provider's emergency preparedness.1 The statement included details regarding the importance of preparation, emergency protocols, and provided lists of medications, equipment, and skills necessary to properly care for a pediatric emergency in the office. Instructions were provided on how to perform office mock codes and included assessment sheets, recorder sheets, and patient scenarios. Medication and equipment lists included parameters for those considered essential versus suggested based on office demographics.

Numerous studies before publication of the statement found pediatric primary care offices were unprepared to properly care for a variety of emergencies.2–5 Santillanes et al2 found that even after taking care of a critically ill patient, the offices had not prepared themselves to handle another critically ill patient. Many offices lacked medications and equipment considered essential in the AAP statement, and only 1 of 8 offices participated in mock codes. Bordley et al3 found that after unannounced mock codes in pediatric offices, those offices were more likely to develop a written emergency response plan and to obtain additional life support training. However, there was no difference between intervention and control groups for the purchase of new equipment and medications nor implementation of additional mock codes.3 Similarly, Toback et al4 performed mock codes in the office and at follow-up discovered that most participants had designed written emergency protocols, but few conducted further mock codes or purchased essential medications and equipment. Walsh-Kelly et al5 did not find an improvement in office preparation after sending preparedness guidelines to offices requesting such information.

The literature after publication of the AAP statement is sparse. A recent survey by Pendelton and Stevenson6 in 2015 revealed only half of the respondents were aware of the AAP statement, a quarter felt their office met preparation guidelines, and a quarter were performing mock codes.

We sought to provide intensive emergency training and preparation assistance to local primary care pediatric offices to improve their emergency readiness. With multiple mock code visits and education sessions for each office, we were able to identify deficiencies in medications, equipment, and experience. We worked with small teams, so everyone would receive training and experience emergencies in their office with their level of preparedness. We provided feedback and assistance with emergency protocols, teamwork training, and medication and equipment supply. To our knowledge, this intensive training and curriculum are novel in the literature.

METHODS

The primary instructor presented a pediatric office emergency preparedness lecture at a local pediatric medicine conference and offered an in-office training curriculum to the audience. This included mock codes, also termed simulations. Interested office representatives discussed the office needs for emergency preparation with the primary instructor and appointments were made for office assessment and training. Participants for each training session were organized by the office manager.

The primary instructor visited each office before initiation of training sessions to perform an assessment of their emergency preparedness. Concepts included office layout, location including elevator dependence, designated resuscitation room if present, emergency mobile kits, and variability in office staffing. In addition, the content, organization, and storage of emergency equipment and emergency medications were reviewed. Offices were advised not to prepare for training sessions so that their experience would be more realistic. The primary instructor also met with interested staff to explain the curriculum and answer questions. Before training sessions, a greeting letter was sent to all office staff explaining the curriculum and expectations.

Physicians were sent an electronic link to an online anonymous survey for completion before their training session. Questions included their perception of quality and quantity of office emergencies, estimate of their office's medication and equipment preparation, previous life support training, and their estimate of emergency medical system (EMS) arrival time.

For each training session, 3 instructors went to the office: the primary instructor, who is also a pediatric emergency medicine physician and trained simulation educator, and 2 healthcare simulation educators who assisted with education, controlled the high-fidelity manikin, and controlled medication and equipment supply exchange. A high-fidelity manikin (Laerdal SimBaby or SimJunior) was used allowing participants to examine their patient, auscultate heart and lung sounds, appreciate patient vocalizations, palpate pulses, and perform procedures on either the manikin or a task trainer as appropriate. Some of the offices were closed during training sessions and others continued to operate an open clinic. A sign for “simulation training in progress” was positioned, so clinic patients would be aware of the office training.

At the beginning of each training session, the instructor team introduced the participants to the manikin and allowed them to touch and listen to the manikin to become acquainted. Participants were also advised that during simulations, they should find their medications and equipment and show them to the instructor team and a simulation supply would be provided in exchange. This allowed the office to maintain their supplies unopened, while still knowing how to locate and use the equipment or medication to administer an intervention to the patient. The primary instructor then met with the participants to review goals for the session, which were based on crisis resource management, a common simulation education model. Goals included evaluation of and improvement of teamwork performance, such as role clarity, personnel support, resources such as medications and equipment, communication, and situational awareness. Participants were assured that the curriculum was not an individual assessment nor would any individual performance be reported. The participants were advised to keep their experience confidential to protect the emotional safety of all participants. The instructor team collected information throughout the training sessions and a cumulative curriculum assessment was provided to the office as a compilation of all knowledge gained, in a confidential manner, so individual and team performances were protected.

For each training simulation, the primary instructor presented to the front desk with a high-fidelity manikin acting as a mother with a sick patient. The front desk greeted her and the simulation began. The instructor team noted how the patient moved from the front desk through the office, how the front desk staff reacted to a sick patient, how additional staff was alerted, and how the team gathered for a resuscitation. The instructor staff then controlled the manikin, exchanged medications and supplies, and otherwise remained quiet and observed the office response to a pediatric emergency. Times to specific interventions were recorded, such as emergency kit arrival, contacting EMS, obtaining vital signs, conducting airway and cardiac interventions when indicated, times to medication delivery after requested, and times to equipment interventions when requested. Instructors observed and recorded teamwork dynamics and communication. Instructors recorded medication and equipment complications, what supplies were present or lacking, as well as staff requests during the simulation. After the first simulation, the participants were able to ask questions in the patient room and education and feedback were provided immediately. The primary instructor then met with the participants in a conference room to review the first simulation. Topics of conversation included how to improve teamwork dynamics such as intervention efficiency, task overload, and communication. There was a review with the front desk staff of all of their possible tasks, including a discussion of recording. A recorder sheet was provided to use for the second simulation. There was a discussion of medication and equipment preparation and organization, as well as what the participants thought would improve their office readiness. Education was provided for indications of specific medications and preparation of medications that require knowledge and experience to administer.

A second simulation of a different case scenario was then initiated at the front desk with the instructor/mother and her sick child. The instructor team performed the same tasks as with the first simulation. After the second simulation, the participants again received education in the room immediately followed by a discussion with the primary instructor in the conference room. Similar topics of conversation were covered, as well as a comparison of the 2 simulations. Training sessions were designed to last 2 hours, which included an introduction discussion, 2 mock code simulations, and 2 feedback education discussions. In addition, all participants received an electronic link to an online anonymous survey to complete about their emergency simulation experience. Questions referenced how beneficial the training was for them, how often they would like to have similar training, and any comments were elicited.

Several simulation case scenarios were prepared, including infant and child aged patients, so that office staff would experience different emergencies and a variety of emergency preparation objectives would be addressed. After the offices had completed a series of training sessions, all of the information was presented to the office in a cumulative confidential assessment format. Some offices requested the primary instructor present the cumulative assessment in an office conference format.

After completion of the simulation training sessions, the primary instructor remained available to work with the offices to continually assist with their preparation. This has included answering questions, development of a specific recorder sheet, office specific drug cards, office specific emergency algorithms, procedure laboratories, and offering ongoing simulation training.

RESULTS

Eight primary care pediatric offices in an urban setting enrolled in the curriculum. The offices have a majority of physician estimated EMS ALS (Advanced Life Support) arrival times of 5 to 10 minutes (Fig. 1). The offices are near to general hospitals, with estimated times for arrival to their emergency departments ranging 5 to 20 minutes. The offices are also close to a tertiary care pediatric hospital, with estimated arrival time to the pediatric emergency department ranging 20 to 45 minutes.

F1
FIGURE 1:
Percent of physicians (y) with reported EMS arrival time to office (x).

Thirty-six training sessions were conducted, which trained 229 office staff. Fifty physicians participated. Team sizes were most often 6 or 7 participants (Fig. 2). Teams consisted of physicians, nurse practitioners, nurses, medical assistants, front desk staff, and billing/management staff (Table 1).

F2
FIGURE 2:
Number of sessions (y) with number of team members (x).
TABLE 1 - Number of Physicians, Nurse Practitioners, and Nurses Per Office
Office MD NP RN
1 11 0 2
2 5 2 0
3 2 0 2
4 7 0 6
5 5 2 0
6 6 1 0
7 7 0 0
8 7 1 2

Before training sessions, the presimulation survey was completed by 30 physicians (60%). There were a variety of reported emergencies seen in the offices yearly, with the majority as respiratory emergencies. Dehydration, seizure, and anaphylaxis were also commonly reported (Fig. 3). Most physicians reported that they thought their office stocked an adequate supply of emergency medications (87%) and equipment (73%). Most physicians were not sure whether their front office personnel were trained to recognize a patient emergency. Half of physicians thought that their front office personnel had a procedure to alert staff and get help for a patient emergency, although almost half were not sure. Most physicians either do not have or were not sure whether they have office medical emergency protocols, such as guidelines for anaphylaxis or asthma. Only 2 physicians reported practicing mock codes, and their frequency was once yearly. Forty-three percent of physicians are Pediatric Advanced Life Support certified and 77% are Basic Life Support certified (Table 2).

F3
FIGURE 3:
Reported emergency conditions seen yearly (y axis is number of physicians reporting each emergency).
TABLE 2 - Survey Responses Before Simulated Resuscitations
Yes, % No, % Unsure, %
Do you think your office stocks an adequate supply of emergency medications? 86.7 13.3
Do you think your office stocks an adequate supply of emergency equipment? 73.3 26.7
Are your front office staff trained to recognize a patient emergency? 33.3 20 46.7
Do your front office staff have a procedure to alert medical staff and get help? 50 10 40
Does your office have medical emergency protocols for interventions? 13.3 46.7 40
BLS certified physicians 76.7 23.3
PALS/APLS certified physicians 43.3 56.7
BLS indicates Basic Life Support; PALS, Pediatric Advanced Life Support.

One hundred eight participants (47%) completed the postsimulation training survey and each professional member of the team was represented. Almost all (98%) reported that the training would benefit how they perform their job in an emergency. In addition, 99% reported the training will benefit their office emergency preparation. There is variability as to how often, but all participants reported that they would like to participate in the training again (Fig. 4).

F4
FIGURE 4:
Percent (y) responses to “I would like to participate in this training again.”

Cumulative assessment feedback for the office training sessions arose from themes observed during the resuscitations and was subdivided by objectives, observations, and suggestions for improvement. Each office had very specific personalized observations and suggestions. Most observations, however, were experienced repetitively in all of the offices and those will be discussed here (Table 3, brief summary points, https://links.lww.com/PEC/A901).

Objective 1: Front Desk: Early Emergency Recognition

Front desk staff were often unsure of what questions to ask the parent to discern an emergent versus nonemergent situation. They were hesitant regarding how much information to obtain about insurance, demographics, patient history, or parental concerns. There were delays in emergency recognition with nonspecific chief complaints, such as colds or gastroenteritis, and quicker recognition with more emergent sounding concerns, such as trouble breathing or lethargy.

Objective 2: Front Desk: Quickly Alert Medical Staff for Emergency Help

The offices typically did not have an established method for the front desk to alert medical staff for emergency assistance. There were a variety of options depending on the office layout and the option chosen was dependent on the front desk receptionist and their level of panic. If the charting desk was close to the front desk, often the receptionist would stand and call to them for help. If the two were far apart, they would either send someone else to get help or call using a phone to the charting desk and hope medical staff would answer.

Objective 3: Rapid Transfer From Waiting Room to a Resuscitation Room

Transfer of a patient from the waiting room to a resuscitation room was always fastest when the front desk quickly recognized an emergency and asked the parent to come back immediately with the patient. They looked for an open room and called for medical staff as they were walking back. There was always a delay when the front desk staff were not sure what would be appropriate actions or they obtained insurance and demographic information instead of seeking medical staff and emergency interventions.

Objective 4: Designate a First Choice for a Resuscitation Room

All of the offices desired to transfer the patient from the waiting room to a patient room to provide crowd control and privacy. Some had designed a procedure room to also function as a resuscitation room and had stocked its cabinets with emergency supplies. All offices had a mobile emergency kit or cart so that an emergency resuscitation could be initiated anywhere. One frequent limitation was the position of the bed, which was often not movable and limited access to the patient.

Objective 5: Equipment for First 15 Minutes of Resuscitation Should Be Quickly Available and used

Most teams knew where the mobile emergency kit was stored and it arrived quickly to the resuscitation room when requested. However, the majority did not know what supplies were in the kit, were not familiar with its organization, and their first time seeing it was during the training sessions. This lack of familiarity caused a significant delay with timely interventions. This led to frustration and extra time and energy expended in what was already a stressful situation.

Some offices had purchased premade emergency kits but found during the resuscitation that these were designed to be compact and it was not easy to find supplies quickly. In addition, the premade kits were designed primarily for adults, so pediatric sizes were often limited or missing.

The teams discovered that once opened, keeping the kit organized was difficult. Often supplies were spread on the floor, which made it awkward for the team to move around. Counter space was limited. When the teams tried putting the kit in the hallway to leave more space in the room, it became difficult for the team members to hear each other, the members were running back and forth, and the physicians had to leave bedside, which left them feeling task overloaded, stressed, and distracted.

Few staff members knew what was stored in storage cabinets or closets, so there was a delay in finding supplies not located in the mobile emergency kit. In large offices, equipment was stored in multiple locations, which also slowed retrieval.

Many staff were not familiar with the names and use of emergency supplies, so there was a delay due to a need for explanation. For example, the intraosseous (IO) needle was commonly requested, but the majority of staff did not know what the IO was, so much time was spent looking for it and explaining its use. Often times, it was in the mobile emergency kit but had been taken out because the staff were not aware of its importance. There were also delays in starting an intravenous (IV) line and IV fluids because staff did not know what supplies were required.

In some cases, equipment pieces that were intended to work together had been purchased from different manufacturers and therefore did not fit together, thus rendering the equipment unusable.

All of the offices stocked an automated external defibrillator (AED). Most staff were not familiar with how to operate it. Most often, the AED had adult pads plugged in during storage, and teams did not recognize the differences between adult and pediatric pads. Often, the pediatric patient would have received adult pad cardiac analysis and electricity because the teams were not aware they owned or should change to pediatric pads. Teams also discovered that the adult plug could be difficult to remove.

All of the offices stocked nasal cannulas, simple facemasks, ambulatory self-inflating bag-valve-mask devices, and portable oxygen tanks. Few offices also stocked nonrebreather masks. Some of the offices only had low oxygen flow valves, which limited use of a bag-valve-mask device. There was often difficulty in finding the correct mask size for the patient, as a variety of sizes were either missing, in storage, or hard to find in the mobile kit. There was a very common misconception that the ambulatory self-inflating ventilation bag-valve-mask device could be used as blow-by without actively squeezing the bag to overcome the valve.

Most offices did not stock Magill forceps and did not have any tool for removal of aspirated foreign bodies. All of the offices stocked suction devices and nebulizers. Few offices had oropharyngeal airways, but of those offices, very few staff knew what they were, their indications, and how to use them. All of the offices had a portable pulse oximeter that was quickly used during simulation scenarios. Most of the offices stocked endotracheal tube intubation supplies, but few physicians were comfortable attempting intubation, and most offices lacked medications appropriate for intubation and the intubated patient. All physicians were interested in stocking laryngeal mask airway devices once demonstrated by instructor staff. None of the offices stocked stopcocks for the IV/IO, but all requested to purchase one after being shown how to use one by the instructors. All of the offices stocked glucometers, but in only one simulation scenario did the office use it.

There was always an improvement from the first simulation to the second simulation with time to interventions and communication about emergency supplies. Staff felt more comfortable asking for help and physicians had a better understanding of what their staff knew and were comfortable doing during the second resuscitation. The staff were able to find and assemble equipment faster with the second resuscitation.

Objective 6: Medications for First 15 Minutes of Resuscitation Should Be Quickly Available and used

The offices stocked epinephrine 1:10,000, but few knew how to assemble it for administration because they were not familiar with Abboject technology. Thus, there were often significant delays to the patient receiving epinephrine 1:10,000, or it was not given at all. There were also time delays because physicians were not sure of epinephrine dosing and calculations and they did not use a drug dosage resource. Some physicians tried to use epinephrine 1:1000 instead but struggled with calculations and lacked the syringe size necessary to administer such a small volume. There was also commonly a delay in epinephrine delivery because staff were not sure which epinephrine to retrieve when the office stocked epinephrine autoinjectors, epinephrine 1:1000, and epinephrine 1:10,000. Commonly, the physician was not specific but simply asked for epinephrine, which lead to time delays for clarifications and sometimes an incorrect dose was given because the concentration of epinephrine had not been checked.

Panic and multitasking lead to problems remembering correct medication dosages and performing correct dosing calculations during the resuscitation. Medications in these instances were given to the patient in wrong doses. Although office resources were often available to assist with drug dosing and interventions, teams were often not aware of them, and office staff were not able to help with finding or confirming dosages. Some offices had drug dosage resources designed for hospital use and therefore were confused by nonapplicable medications and varied dosages based on different indications.

There were delays because of medication nomenclature. Often when physicians asked for medications using their common or brand names, such as Ativan, the staff assigned to find the medication were not familiar with the drug name, such as lorazepam. In addition, medications were kept in refrigerators, cabinets, and a mobile emergency kit, which caused additional delays.

Offices that stocked midazolam for intranasal use had one vial of 2 mg/2 mL, which would have been inadequate dosing for patients larger than 10 kg. Those offices were not aware that their supply of midazolam was insufficient to administer maximum dosage (10 mg). There was also a delay in treating seizures for offices that did not stock nasal midazolam. Intravenous lorazepam requires refrigeration and IV placement, and rectal diazepam requires access to the rectum during a seizure, all of which contributed to a delay in or lack of treatment.

All of the offices stocked antibiotic that could be administered for septic shock; however, none of the offices gave the simulated patient antibiotic for septic shock cases. Rationale included the time for preparing and administering the medication, as well as a perceived need to obtain a blood culture first.

Oxygen therapy was often appropriately initiated, but as the need for respiratory support increased, the amount of oxygen delivery was variably increased. Sometimes oxygen tubing was not switched as the devices were changed. For example, nasal cannulas were appropriately applied, but when the teams transitioned to face masks or bag valve mask support, the oxygen administration was left at 2 L/min or oxygen tubing remained with the nasal cannula and was not transferred to the new device. This led to insufficient oxygenation of critical patients.

Objective 7: IV or IO: Rapid Placement and Initiation of IV Fluids

Most physicians were not comfortable with IV (intravenous) placement and admitted that although they could perform IV placement on the simulation manikin, they were unsure of their abilities to place an IV on a patient, especially a sicker and likely dehydrated child.

Some offices stocked IO needle devices, but none of the physicians had used them on a patient in the office. Most staff were not familiar with an IO and did not know what to look for when asked to find one. The IO was introduced to all participants in-between simulations and physicians felt better about their abilities to place an IO as opposed to an IV, and staff felt comfortable finding and using the IO. Instruction was provided on application of local anesthetic for IO placement on the awake patient.

All offices had IV fluid and tubing but most staff were not familiar with the location or assembly of the IV tubing or priming lines. Participants requested their office design IV start kits with saline flushes to ease their IV placement readiness.

Some offices had an IV pole attached to their emergency cart, but it was variably used. Many of the staff that had an IV pole in the office did not know they had one or know its purpose. In addition, some carts were large, so putting the cart and therefore IV pole next to the patient was difficult in a small patient room. Often, a staff member was assigned to hold the IV bag.

Objective 8: Timely Activation of Appropriate EMS Team

Teams were focused on patient resuscitation, so there was often a delay in calling EMS. In addition, support staff were not sure when to call EMS or which team to request. The staff did not want to interrupt resuscitations to inquire, so this difficulty in communication led to significant delays in EMS activation. After discussion between simulations, support staff inquired early, physicians appreciated the reminder, and early activation of EMS was achieved.

Some offices have intrinsic delays for EMS arrival such as hidden office location, multiple similar appearing buildings nearby, elevator access delay, and difficult access after regular hours. Some require key pad access in the evenings and offices have minimal staffing, so it was difficult for staff to assist EMS with entry. Support staff was instructed to provide specific location descriptors and to assist with EMS entry to the office to facilitate faster EMS arrival. In addition, the offices discussed creative options to help EMS access the office especially during minimal staff evening hours, such as using other parents to open doors and elevators.

Objective 9: Obtaining All Vital Signs and Noting Trends of Change

Heart rate, respiratory rate, and pulse oximetry were most often obtained, while vital signs such as blood pressure and temperature were less often obtained. If blood pressure was obtained, it was often not repeated to assess for a trend. Noticing changes in vital signs and pulse presence was often neglected, which delayed initiation of cardiopulmonary resuscitation (CPR) and other critical interventions.

Objective 10: Overcome Mind Blanks and Task Overload During an Emergency

Team members often experienced mind blanks for necessary interventions during the resuscitation. Physicians and key team members struggled to perform simultaneous multiple tasks and reported feeling overwhelmed. During the first simulation, many team members were not sure how to help, what to do, what to anticipate, and were not comfortable asking questions. Team leaders also did not know what their team members were able to do or what tasks they were comfortable performing. After discussion during debriefing, there was a significant improvement for the second simulation with teamwork, task distribution, necessary intervention implementation, better communication, less sensation of being overwhelmed, many more tasks were accomplished, and the team performed far more effectively and efficiently. The team members reported feeling improved clarity in their thinking, communication, task anticipation, and completion.

The first simulation often lacked a recorder, and those asked to record often did not know what to write. A recorder information sheet was provided by the simulation team and the task delegated to a team member during the debriefing session. Most often, the task was given to a front desk clerk, which allowed the nurses and techs to assist with medical interventions. The second simulation therefore always had a recorder with the recorder sheet, which assisted in organized tracking of interventions and important patient changes. The team could easily review their interventions and provide a quick detailed report for EMS for efficient transfer of care.

Many offices have resource cards and papers associated with their emergency kits, but staff were often unaware of their presence and unfamiliar with their use. Many resources require some familiarity to be efficiently used during an emergency. As part of the debriefing, there was review of their resources with improved effective utilization during the second simulation. In addition, the height-based weight and medication resource tape was rarely used during the first simulation, but after demonstration during debriefing, it was always used for the second simulation. This provided less guessing and errors of weight, medication dosing, and equipment sizing.

Objective 11: Continuous, Effective CPR

Compressions were most often started once the team noticed the loss of a pulse. In addition, they were often continued for bradycardia of heart rate less than 60. However, there was variable memory of the correct compressions to ventilations ratio. Staff struggled with patient positioning for adequate mask seal and providing effective compressions. Physicians often checked and corrected mask seals, ventilations, and compressions technique. There was a common misconception that the self-inflating airway bags could be used for blow-by and staff did not realize that there is a closed valve that must be overcome for oxygen to be delivered to the patient.

As mentioned previously, many teams were unsure of how to use the AED. They were not aware of having both adult and pediatric pads, as well as when either is appropriate to use. Teams experienced time delays with application of the AED, allowing it to move through its steps, and gained understanding of its interruption to continuous CPR.

A backboard was rarely used during compressions, because most staff were not aware that it would be helpful for effective compressions. Most offices do not have a designated backboard, but they do have hard boards for other purposes and papooses that could be used. In addition, a stool was often not used for the compressor despite its availability in the office.

DISCUSSION

These office experiences reflect those of practices in an urban environment with short EMS ALS arrival times and close proximity to both general hospitals and a tertiary care pediatric hospital. Their level of preparation for medications and equipment would likely differ from offices in other locations. However, offices anywhere can evaluate their own emergency preparedness and identify areas where they may have similar challenges or changes to be made. The offices who participated in this training curriculum were able to simulate resuscitation experiences designed to prepare them for the first 5 to 10 minutes. The experiences highlighted the importance of a focus on office emergency preparation, even with short EMS arrival times. Because of problems with communication and delays in calling EMS, the patient was in the office for significantly longer periods of time than the teams desired or expected. By creating a recorder sheet with a task of EMS activation and designating a recorder with empowerment to initiate EMS contact, the time to EMS activation significantly improved with the second simulations.

The physicians reported a broad range of emergencies, highlighting the importance of considering multiple different scenarios when considering office emergency preparedness. Most emergencies are respiratory, and this is reflected in the discomfort with IV placement, IV medications, and delays to those interventions because they are uncommon in their daily practice. This also reflects the importance of practicing uncommon procedures on a routine basis, such as reviewing how to place an IV, locate and administer IV medications, and administration of IV fluids. Additional consideration should be given to replacing IV medications with intranasal, intramuscular, and oral medications when able, especially with seizures where IV placement is even more difficult and timely medication administration is imperative.

The training curriculum provided an avenue for office teams to experience realistic emergencies. This elucidated the reality of office preparation, and there was a discrepancy between how the physicians reported their medication and equipment preparation in the presimulation survey versus what was experienced during the simulated emergencies. In addition, although an office stocked medications and equipment, there were time delays for interventions due to a lack of familiarity with those medications and equipment. In addition, this provided an experience for the front office staff to learn about recognition of an emergency, how to activate an emergency response, and how to move the patient to a treatment room. The curriculum allowed for experience, reflection, and discussion giving physicians a better understanding of the comfort and abilities of their staff with office emergencies. All of the participants reported significant improvement in their confidence in their role during an emergency, and those who had not had a role previously now understood how they can assist the team.

In addition to creating a recorder sheet for the offices (Addendum 1, https://links.lww.com/PEC/A902), the primary instructor created an office emergency algorithm book and a medication resource book specific for each office. These resources were designed after recognition of the difficulty of mind blanks during the resuscitation, difficulty performing dosage calculations while multitasking, difficulty remembering what medications are available in the office, discomfort for front office staff not knowing how to record or help during the emergency, and a lack of office specific resources available publicly. All offices can reflect upon their office needs and create similar resources specific for their office.

Our intensive emergency training and preparation assistance to local primary care pediatric offices highlighted significant discrepancies between the perceived level of office preparedness and actual experience during a simulated emergency. The lessons learned are applicable to all pediatric offices. Every office could designate a lead staff member or team to oversee emergency preparedness, including routinely checking equipment and medications for functionality and expiration. The leads can oversee staff continued training and education. In addition, new hires can benefit from similar training, so they will know how to perform during an emergency. Simulation training can be performed in all offices, whether by high- or low-fidelity manikins. All office staff can benefit from practice, and with practice will come more efficient and effective interventions for critical emergency patients in the office.

ACKNOWLEDGMENTS

The authors thank Nanette Dudley, MD, reviewer, and Intermountain Simulation staff, especially Nancy Bardugon, RN, MSN, and Ashley Cassity Sandoval, BSN, RN.

REFERENCES

1. Frush K; American Academy of Pediatrics Committee on Pediatric Emergency Medicine. Preparation for emergencies in the offices of pediatricians and pediatric primary care providers. Pediatrics. 2007;120:200–212.
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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;112:291–295.
4. Toback S, Fiedor M, Kilpela B, et al. Prepare your office for a medical emergency. Contemp Pediatrics. 2002;19:107–121.
5. Walsh-Kelly CM, Bergholte J, Erschen MJ, et al. Office preparedness for pediatric emergencies: baseline preparedness and the impact of guideline distribution. Pediatr Emerg Care. 2004;20:289–294.
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Keywords:

office emergency preparedness; office emergencies; simulation

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