The presentation of a child requiring emergency care or resuscitation in the ambulatory pediatric office is an uncommon event but can be distressing when it does occur. In data from several decades ago, it was suggested that many pediatric offices saw multiple children requiring emergency intervention each week.1 However, in a more recent study, researchers suggests that such emergencies are far less frequent, with <1% of pediatric emergency medical services (EMS) transports originating from the office setting.2 In this issue of Pediatrics, Abulebda et al3 examine preparedness for and performance during these events and report that, in a selected group of practices, appropriate equipment was present in 82% of practices, whereas only 57% were prepared with policies and protocols addressing such events, including regular self-assessments and drills. In an evaluation of office responses, assessed during simulated patient presentations of asthma and seizure, it was found that appropriate measures were performed in 60% to 70% of the simulations, independent of the preparedness scores.
The preparedness of the ambulatory pediatric offices for emergencies has been discussed in American Academy of Pediatrics Policy Statements for many years, most recently in 2007,4 with recommended lists of essential and suggested equipment and medications and suggestions for regular practice by using “mock codes.” However, implementation of these recommendations has been far from universal, with offices citing the cost of equipment and supplies as well as a lack of access to training and evaluation as significant barriers to implementation. In addition, the infrequent occurrence of these emergencies makes maintenance of resuscitation skills even more difficult without frequent practice.
Required degrees of preparedness also vary with the location of the individual practice, response time of EMS, and proximity of the nearest emergency department. Pediatric offices in more rural areas, which are farther from these services, will require more equipment and more skills to provide optimal emergency care to children living in these under-resourced areas.
Emergencies requiring immediate intervention in children usually involve respiratory distress, seizures, or psychiatric issues,2 as opposed to sudden cardiac arrest, suggesting that preparedness in the ambulatory pediatric setting should be focused on these issues. As the discussion about the optimal criteria for office preparedness continues, it will be important to consider the ability to respond to these more common situations, in which the cost-benefit analysis reveals the greatest return on investment. Training and equipment for addressing respiratory compromise, including oxygen and the appropriate delivery systems as well as subcutaneous epinephrine and albuterol for inhalation, will enable a prompt and skilled response to those events most commonly seen in pediatric offices. Other medications used in cardiac resuscitation will be used far less frequently, and maintenance of these supplies may be cost prohibitive for every pediatric office. For those offices in which EMS response time is hampered by distance or other travel issues, preparedness may need to include the ability to employ intravenous fluids and medications to stabilize and support a child after the initial response to the acute emergency. In addition, support of the parents and family during emergency care in the office should not be neglected. In all cases, in addition to responding to the child, pediatric offices need to have a protocol in place to promptly activate the EMS system to bring additional staff and resources to assist in stabilization and transportation to a higher level of care. Finally, because the opportunity to obtain real-life experience in responding to these emergencies is (fortunately) limited, preparedness should include simulated practice sessions, which can be used to improve provider confidence, preparation, and performance.5
Ambulatory pediatric offices differ greatly in resources and training as well as in the availability of EMS services. To provide for equitable distribution of emergency preparedness, training, equipment, and staffing, guidance should be aimed to meet the needs of the patients served, with the goal of providing the optimal outcome for children faced with a sudden emergency. In discussion of recommendations, one should consider the likely conditions requiring this response, availability of resources beyond the pediatric office, and ongoing training and support needed to maintain provider skills at the level needed for a successful response to any pediatric emergency.
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2020-038463.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.