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Pediatric Emergencies in the Office: Are Family Physicians as Prepared as Pediatricians?
STUDY DESIGN: We performed a cross-sectional random mail survey of physicians.
POPULATION: Surveys were sent to 187 family physicians and 129 pediatricians practicing in North Carolina with 75% and 86% response rates, respectively. The 169 total respondents were in community practices regularly treating children and were included for analysis.
OUTCOMES MEASURED: We measured the incidence of 8 types of pediatric emergencies, the availability of 11 items for resuscitation and stabilization, whether the physician had Pediatric Advanced Life Support (PALS) training in the previous 2 years, whether the office ever conducted a mock emergency, and beliefs about the importance of preparing for and providing emergency care to children.
RESULTS: Six types of pediatric emergencies were seen in one third or more of all practices during the year. The average practice saw 4 or more pediatric emergencies in a year (family physicians = 3.8 vs pediatricians = 4.9, P <.001). Family physicians had fewer resuscitation and stabilization items than pediatricians (5.7 vs 8.6 items, P <.001) and were less prepared in terms of PALS training (19% vs 51%, P <.001). Those with PALS training were more likely to have an intraosseous needle and Broselow tape and to have conducted a mock code. Family physicians considered it is less important than pediatricians to provide such care or to be prepared to do so.
CONCLUSIONS: Pediatric emergencies in the office are likely for either specialty. Family physicians may be less prepared, and they discount the importance of the problem and the need for preparation.
Pediatric emergencies are serious events that occur more commonly than many physicians think.1 Recent studies have described adverse outcomes that can result when children with medical emergencies are directed to physicians’ offices by managed care plans.2-5 However, little is known about the incidence or types of pediatric emergencies encountered or whether physicians are adequately prepared to treat them in their offices.
A few studies have estimated incidence but used different definitions of emergency, and there is considerable variation in the estimates of their occurrence. A study of pediatric practices in Vermont reported only 1 office emergency per practice per year,6 while a study in Connecticut reported that 82% of pediatric practices saw at least 1 child emergency per month.7 A Chicago study reported that 62% of pediatricians and family physicians saw at least 1 child a week who required urgent treatment or hospitalization.8 In a national sample, 68% of office-based pediatricians reported seeing 1 to 5 emergencies per week.9
The literature describing preparedness is limited principally to pediatricians and suggests that their skills in resuscitation and stabilization need improvement.7 ,9-12 Other than the Chicago study8 and one done in northern France,13 there are no studies of the frequency and nature of pediatric emergencies in family physicians’ offices, and little is known about how well prepared the typical family physician is to treat child emergencies. The Chicago study reported that the offices of family physicians were better stocked with resuscitation drugs than those of pediatricians but did not assess the training of physicians or their office staffs to deal with the medical emergencies of chidren.8 The French study is of little help in understanding the problem in the United States.13
In our study, we sought to understand: (1) both the incidence and variety of pediatric emergencies in the practices of family physicians and pediatricians in North Carolina; (2) how prepared physicians of each specialty were to treat such emergencies; (3) whether they believed they should provide emergency service; and (4) how important they felt it was to be prepared for pediatric emergencies.
Methods
We mailed a survey in late 1995 to a random sample of family physicians and pediatricians across North Carolina. The survey asked 25 questions about the prevalence and management of pediatric emergencies occurring in a physician’s office in 1995. The sample was randomly drawn from a database of 3184 family physicians and pediatricians licensed by the North Carolina Medical Board.
Survey Design and Procedures
The survey questions were developed by a group of family practice, pediatric, and emergency physicians. Our pilot study indicated a lower response rate for family physicians (58%) than for pediatricians (83%) and that fewer family physicians were regularly providing pediatric primary care (71% vs 100%). Accordingly, we mailed surveys to 250 family physicians and 150 pediatricians to obtain power sufficient to detect effect sizes with less than 5% error. Table 1 shows the sampling design and response rates for the 2 physician specialty groups.
Measures
The key variables are the occurrence of emergencies encountered by the practice, preparedness for emergencies through the availability of resuscitation and stabilization items, training for emergencies, and the perceived importance of providing and preparing for emergency care.
Emergency Occurrence and Preparedness
The variety of emergency occurrences was measured using 8 questions that asked whether specific pediatric emergencies were presented to the physician in the office setting during the last 12 months Table 2. Preparedness for pediatric emergencies was measured with 11 questions that asked whether specific stabilization and resuscitation items were immediately available to the physician in the office Table 3. The items were selected by experts and are regularly included in Pediatric Advanced Life Support (PALS) training. The responses allowed for this series of questions were “yes,” “no,” and “don’t know.” Answers other than “yes” were taken to mean that the item was not immediately available.
Occurrence of and preparedness for pediatric emergencies were analyzed as individual variables and as composite indexes. The composite index for the variety of emergency occurrences was created by assigning 1 point for each “yes” answer to whether a specific type of emergency occurred. This index, which we call the Emergency Occurrence Score (EOS), was an unweighted number with values ranging from 0 to 8, where a score of 8 was the greatest variety of occurrence (ie, all the types of emergencies occurred during the year). Similarly, an Emergency Preparedness Score (EPS) was created by assigning 1 point to each affirmative answer regarding the availability of specific stabilization and resuscitation items, with a range for the score of 0 to 11 (11 = optimal availability of resuscitation equipment).
Training for Emergencies
We asked 2 questions that assessed the training of physicians and office staff to deal with the emergencies of children. Specifically, we asked, “Have you taken a PALS or APLS (Advanced Pediatric Life Support) certification or instructor course in the last 2 years?” and “Has your office ever conducted a ‘mock’ or practice pediatric emergency?”
Perceived Importance of Preparedness
We measured respondents’ opinions on the importance of being prepared for a pediatric emergency and providing emergency services in the office. The specific questions were: “How important is it to you that your office or practice setting be prepared to stabilize a true pediatric emergency?” and “How important is it to you that your practice provides emergency care to critically ill children in your office?” We coded the ordinal responses for both questions on a scale from 1 through 4 (4 = very important).
Analysis
Our analysis contrasted family physicians and pediatricians. Statistical significance for all contrasts was set, a priori, at P less than .05. Cross-tabular analyses with chi-squares were used to compare percentage responses by specialty on the individual variables measuring occurrence and preparedness, mock emergencies, and PALS training. We also used a chi-square to examine the relationship between preparedness and PALS training. Independent-sample t tests were used to compare means by specialty on the 2 composite indices (EOS and EPS). Independent-sample t tests were also used to compare mean values for the questions on the believed importance of providing care to critically ill children and being prepared to stabilize them.
Two post-hoc hypotheses were suggested. One was whether family physicians and pediatricians differed on their knowledge of the availability of resuscitation items (ie, the number of “don’t know” responses). Another was whether physicians who reported seeing patients with respiratory emergencies had oxygen and a mask with which to administer it. Respiratory emergencies were defined as respiratory or cardiac arrest, foreign body in airway, asthma flare, and moderate to severe croup.
Results
Occurrence of Pediatric Emergencies
Table 2 presents the reported occurrence of pediatric emergencies in the office during the course of a year. Pediatric emergencies involving respiratory problems or cardiac arrest were seen in 4% of all practices, 2% in those of family physicians, and 7% in those of pediatricians. This difference was not statistically significant. Similar percentages (approximately 11%) of family physicians and pediatricians saw at least 1 child with a foreign body in the airway.
Each of the other 6 conditions were seen in a third or more of all family physician practices in the course of a year and in three fifths or more of pediatric practices. Asthma flares were the most commonly seen condition, occurring in 93% of both family practice and pediatric offices. More than 90% of both family physicians and pediatricians encountered at least 1 respiratory emergency. Approximately two thirds of the physicians in both specialties (64% of family physicians and 71% of pediatricians) commonly encountered allergic reactions.
There was no pediatric emergency condition that family physicians were statistically more likely to encounter than pediatricians. Pediatricians were significantly more likely to see severe croup (75% vs 48%), seizure (62% vs 33%), dehydration (85% vs 64%), and serious febrile illnesses (82% vs 65%). The average pediatric practice saw at least 4 of each of these child emergencies in the course of a year.
Family physicians saw fewer children with medical emergencies than did pediatricians. The mean EOS score was 3.8 for family physicians versus 4.9 for pediatricians (P <.001).
Emergency Preparedness
Table 3 shows emergency preparedness, as measured by the immediate availability of resuscitation items. The items are listed in increasing order of availability.
Ninety-six percent of all practices reported that they had oxygen immediately available; 88% had resuscitation drugs; and 86% had intravenous (IV) fluids. However, 27% had no appropriate way of administering IV fluids or drugs (no child-sized IV catheter or intraosseous needle). Family physicians were significantly less likely than pediatricians to have child-sized IV catheters, a pediatric bag-valve mask, an oral/nasal pediatric airway, or suction and pediatric catheters. Family physicians were also less likely to have available an intraosseous needle, a pediatric laryngoscope and endotracheal tube, a Broselow tape, or continuous pulse oximetry. In regard to having resucitation items, both family physicians and pediatricians were certain about the availability of oxygen, IV fluids, and continuous pulse oximetry. No family physicians or pediatricians responded “don’t know” on any of these items. Physicians were most uncertain about whether they had a Broselow tape (34% chose the “don’t know” responses) and an intraosseous needle (17% chose “don’t know”). Family physicians were significantly less likely than pediatricians to know whether they had a Broselow tape (43% vs 20%, respectively), an intraosseus needle (24% vs 5%, respectively), and suction and pediatric catheters (14% vs 5%, respectively).
Of those who encountered respiratory emergencies, a fifth of the physicians had no child-sized mask for administering oxygen. Family physicians were less likely to have one than pediatricians (30% did not vs 4%, respectively).
Family physicians were substantially less prepared for child emergencies, according to the inventory of immediately available items. The mean EPS was 5.7 for family physicians versus 8.6 for pediatricians (P <.001). Four-fifths of all physician offices had never conducted a mock or practice pediatric emergency. Only 6% of family physician offices had conducted a mock emergency versus 40% of pediatric offices (P <.001). Approximately one third of all physicians had taken a PALS training course during the previous 2 years. Less than a fifth of family physicians reported taking PALS training, compared with half of the pediatricians (P <.01).
There is a positive relationship between PALS training and preparedness. Those who had PALS training were significantly more likely to have a Broeslow tape available than those who did not (58% vs 21%, P <.001) and also were more likely to have an intraosseous needle (62% vs 24%, P <.001). Those who had PALS training were more than twice as likely to have practiced for a pediatric emergency (30% vs 13%, P <.01).
Beliefs About Preparing for Pediatric Emergencies in the Office
Family physicians and pediatricians differed in opinion on the importance of providing emergency care to critically ill children in their offices. Family physicians thought it less important to provide this service than did pediatricians. Family physicians rated providing care to critically ill children in their offices between “not very important” and “somewhat important.” The mean importance score for family physicians was 2.8 versus 3.5 for pediatricians (P <.001), with 4.0 being “very important.”
Physicians of both specialties attached less importance to providing care to critically ill children than being prepared to do so but differed by specialty on this dimension as well. Pediatricians thought it was more important to be prepared for these events (mean for family physicians = 3.4 vs 3.7 for pediatricians, P <.05), but the difference may not be clinically relevant. Each rated being prepared to stabilize a true pediatric emergency between “somewhat important” and “very important.”
Discussion
Although our study was conducted in only one state, we know of no reason the North Carolina experience would be unique. In contrast to the few previous studies, we asked about specific types of emergencies. We found that family physicians encounter a smaller variety of office pediatric emergencies than do pediatricians, but none of these events are unusual for either, and many are common for both. Only respiratory or cardiac arrest might be considered rare for family physicians (annually experienced by less than 5% of practices), but the 2% of family physicians in our sample would equal 40 cases per year in North Carolina. One in 10 family physicians treated a child with a foreign body in the airway, which would be more than 200 occurrences for family practice offices yearly in the state.
A third of those family physicians who regularly treat children can expect to encounter at least 1 pediatric seizure in their office during the year. Two thirds or more are likely to encounter children with seriously high fevers, dehydration, allergic reactions, or asthma attacks. Concern about office preparedness for these emergencies is warranted.
Our data suggest that family physicians’ practices may not be appropriately equipped. Having an oxygen tank is of little use if there is no mask to administer it. We do not recommend intubation in the office setting. Most emergency medicine experts agree that the key to airway management in out-of-hospital settings is positive-pressure ventilation through use of a bag-valve-mask, but the correct size is required. Similarly, there must be quick and sure means to administer fluids and IV drugs in the proper doses. The intraosseous needle may be the safest and fastest way, but less than 1 in 7 family physicians had this item. Doses for children vary greatly and quick information aids (such as the Broselow tape, which indicates drug dose and device size according to body length) may not be available. Familiarity and skill with these 2 items could be acquired in PALS training.
It is puzzling that family physicians think it less important to provide emergency care to critically ill children in their offices than do pediatricians. It may be that they think it is not appropriate for them to treat such emergencies or that such emergencies do not happen often enough to be of concern. Perhaps most of their data are anecdotal, and they simply have seen little information on the incidence, variety, or severity of pediatric office emergencies. Might they generalize their proficiency with adult emergencies to those of children? Some may believe that training in Advanced Cardiac Life Support provides sufficient skill to handle pediatric emergencies, but the techniques, doses, and device sizes for infants and young children are quite different from those for older children, adolescents, and adults.
Our study provides evidence that family physicians and pediatricians should assess the likelihood of children with serious medical emergencies presenting in their offices. As Trachtenbarg14 recently suggested, they should evaluate their own unique patient mix and be prepared accordingly. Both family physicians and pediatricians should evaluate the likelihood of seeing more pediatric emergencies because of managed care. Our study may help them judge their need for continuing training. Many states have developed specific training programs through the Emergency Medical Services for Children (EMS-C) program,* funded by the federal Maternal and Child Health Bureau. PALS training courses are commonly available. Our current and future work involves promoting and conducting such training.
Conclusions
Though no primary care office can be as well equipped as a hospital emergency department, the cost of basic equipment should not be prohibitive. It can cost less than $600 to prepare an office.15 In terms of time, PALS training is a 2-day course with refreshers every 2 years, and a mock emergency in the office can take less than an hour. Emergencies are by no means as common as ear infections; however, they do occur, and the consequences of being unprepared are serious. Family physicians need many skills. These data demonstrate that preparedness to stabilize and resuscitate children in emergency office encounters should be part of their repertoire.
Acknowledgments
Our study was funded by the North Carolina Office of Emergency Medical Services, Division of Facilities Services, Department of Health and Human Services, through a grant from the US Department of Health and Human Services. We thank Bob Bailey, Director of the North Carolina Office of Emergency Medical Services, for his assistance and support. We thank also Zoe Yetman (East Carolina University) for her attention to detail in managing the survey and Matthew Curry and Kevin Gross for reviewing the final manuscript.
Related Resources
- Emergency Medical Services for Children
- Maintained by the EMSC program, which is primarily supported and jointly administered by the U.S. Department of Health and Human Services’ Health Resources and Services Administration and the U.S. Department of Transportation’s National Highway Traffic Safety Administration. The site offers information on education and training, national and state activities, funding opportunities, and family education resources for injury control and prevention. http://www.ems-c.org
- American Academy of Pediatrics‹a comparison of APLS and PALS training and telephone numbers for both programs. " target="_blank">http://www.aap.org/profed/nrp/aplscom.htm>
- The components of the 14-hour APLS course may be found at " target="_blank">http://www.aap.org/profed/nrp/aplsccreq.htm>
- American Academy of Family Physicians (AAFP)‹Pediatric Advanced Life Support: A Review of the AHA Recommendations by Inis Jane Bardella, M.D. This article summarizes information from the PALS program but does not serve as a replacement for completing a PALS course. http://www.aafp.org/afp/991015ap/1743.html
- AAFP CME page‹Location and dates of PALS courses http://www.aafp.org/afp/calendar/cmecours.html
1. Wheeler DS, Kiefer ML, Poss WB. Pediatric emergency preparedness in the office. Am Fam Physician 2000;61:3333-42.
2. Young GP, Lowe RA. Adverse outcomes of managed care gatekeeping. Acad Emerg Med 1997;4:1129-36.
3. Viner KM, Bellino M, Kirsch TD, Kivela P, Silva JC. Managed care organization authorization denials: lack of patient knowledge and timely alternative ambulatory care. Ann Emerg Med 2000;35:272-76.
4. Tintinalli JE. Analysis of insurance payment denials using the prudent layperson standard. Ann Emerg Med 2000;35:291-93.
5. Derlet RW, Young GP. Managed care and emergency medicine: conflicts, federal law, and California legislation. Ann Emerg Med 1997;30:292-300.
6. Heath BW, Coffey JS, Malone P, Courtney J. Pediatric office emergencies and emergency preparedness in a small rural state. Pediatrics 2000;106:1391-96.
7. 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 Pediatri Adolesc Med 1996;150:249-56.
8. Fuchs S, Jaffe DM, Christoffel KK. Pediatric emergencies in office practices: prevalence and office preparedness. Pediatrics 1989;83:931-39.
9. Periodic Survey of Fellows #27. Emergency readiness of pediatric offices. Chicago, Ill: American Academy of Pediatrics; 1995.
10. Altieri M, Bellet J, Scott H. Preparedness for pediatric emergencies encountered in the practitioner’s office. Pediatrics 1990;85:710-14.
11. Schweich PJ, DeAngelis C, Duggan AK. Preparedness of practicing pediatricians to manage emergencies. Pediatrics 1991;88:223-29.
12. Shetty AK, Hutchinson SW, Mangat R, Peck GQ. Preparedness of practicing pediatricians in Louisiana to manage emergencies. South Med J 1998;91:745-48.
13. Martinot A, Fourier C, Hue V, Leclerc F, Cedex L. Family practitioner preparedness for pediatric emergencies. Arch Pediatr Adolesc Med 1997;151:530-31.
14. Trachtenbarg D. Pediatric emergencies: preparedness and prevention. Am Fam Physician 2000;61:3237-38.
15. Schexnayder SM, Schexnayder RE. 911 in your office: preparations to keep emergencies from becoming catastrophes. Pediatr Ann 1996;25:664-66,68, 70, passim.
STUDY DESIGN: We performed a cross-sectional random mail survey of physicians.
POPULATION: Surveys were sent to 187 family physicians and 129 pediatricians practicing in North Carolina with 75% and 86% response rates, respectively. The 169 total respondents were in community practices regularly treating children and were included for analysis.
OUTCOMES MEASURED: We measured the incidence of 8 types of pediatric emergencies, the availability of 11 items for resuscitation and stabilization, whether the physician had Pediatric Advanced Life Support (PALS) training in the previous 2 years, whether the office ever conducted a mock emergency, and beliefs about the importance of preparing for and providing emergency care to children.
RESULTS: Six types of pediatric emergencies were seen in one third or more of all practices during the year. The average practice saw 4 or more pediatric emergencies in a year (family physicians = 3.8 vs pediatricians = 4.9, P <.001). Family physicians had fewer resuscitation and stabilization items than pediatricians (5.7 vs 8.6 items, P <.001) and were less prepared in terms of PALS training (19% vs 51%, P <.001). Those with PALS training were more likely to have an intraosseous needle and Broselow tape and to have conducted a mock code. Family physicians considered it is less important than pediatricians to provide such care or to be prepared to do so.
CONCLUSIONS: Pediatric emergencies in the office are likely for either specialty. Family physicians may be less prepared, and they discount the importance of the problem and the need for preparation.
Pediatric emergencies are serious events that occur more commonly than many physicians think.1 Recent studies have described adverse outcomes that can result when children with medical emergencies are directed to physicians’ offices by managed care plans.2-5 However, little is known about the incidence or types of pediatric emergencies encountered or whether physicians are adequately prepared to treat them in their offices.
A few studies have estimated incidence but used different definitions of emergency, and there is considerable variation in the estimates of their occurrence. A study of pediatric practices in Vermont reported only 1 office emergency per practice per year,6 while a study in Connecticut reported that 82% of pediatric practices saw at least 1 child emergency per month.7 A Chicago study reported that 62% of pediatricians and family physicians saw at least 1 child a week who required urgent treatment or hospitalization.8 In a national sample, 68% of office-based pediatricians reported seeing 1 to 5 emergencies per week.9
The literature describing preparedness is limited principally to pediatricians and suggests that their skills in resuscitation and stabilization need improvement.7 ,9-12 Other than the Chicago study8 and one done in northern France,13 there are no studies of the frequency and nature of pediatric emergencies in family physicians’ offices, and little is known about how well prepared the typical family physician is to treat child emergencies. The Chicago study reported that the offices of family physicians were better stocked with resuscitation drugs than those of pediatricians but did not assess the training of physicians or their office staffs to deal with the medical emergencies of chidren.8 The French study is of little help in understanding the problem in the United States.13
In our study, we sought to understand: (1) both the incidence and variety of pediatric emergencies in the practices of family physicians and pediatricians in North Carolina; (2) how prepared physicians of each specialty were to treat such emergencies; (3) whether they believed they should provide emergency service; and (4) how important they felt it was to be prepared for pediatric emergencies.
Methods
We mailed a survey in late 1995 to a random sample of family physicians and pediatricians across North Carolina. The survey asked 25 questions about the prevalence and management of pediatric emergencies occurring in a physician’s office in 1995. The sample was randomly drawn from a database of 3184 family physicians and pediatricians licensed by the North Carolina Medical Board.
Survey Design and Procedures
The survey questions were developed by a group of family practice, pediatric, and emergency physicians. Our pilot study indicated a lower response rate for family physicians (58%) than for pediatricians (83%) and that fewer family physicians were regularly providing pediatric primary care (71% vs 100%). Accordingly, we mailed surveys to 250 family physicians and 150 pediatricians to obtain power sufficient to detect effect sizes with less than 5% error. Table 1 shows the sampling design and response rates for the 2 physician specialty groups.
Measures
The key variables are the occurrence of emergencies encountered by the practice, preparedness for emergencies through the availability of resuscitation and stabilization items, training for emergencies, and the perceived importance of providing and preparing for emergency care.
Emergency Occurrence and Preparedness
The variety of emergency occurrences was measured using 8 questions that asked whether specific pediatric emergencies were presented to the physician in the office setting during the last 12 months Table 2. Preparedness for pediatric emergencies was measured with 11 questions that asked whether specific stabilization and resuscitation items were immediately available to the physician in the office Table 3. The items were selected by experts and are regularly included in Pediatric Advanced Life Support (PALS) training. The responses allowed for this series of questions were “yes,” “no,” and “don’t know.” Answers other than “yes” were taken to mean that the item was not immediately available.
Occurrence of and preparedness for pediatric emergencies were analyzed as individual variables and as composite indexes. The composite index for the variety of emergency occurrences was created by assigning 1 point for each “yes” answer to whether a specific type of emergency occurred. This index, which we call the Emergency Occurrence Score (EOS), was an unweighted number with values ranging from 0 to 8, where a score of 8 was the greatest variety of occurrence (ie, all the types of emergencies occurred during the year). Similarly, an Emergency Preparedness Score (EPS) was created by assigning 1 point to each affirmative answer regarding the availability of specific stabilization and resuscitation items, with a range for the score of 0 to 11 (11 = optimal availability of resuscitation equipment).
Training for Emergencies
We asked 2 questions that assessed the training of physicians and office staff to deal with the emergencies of children. Specifically, we asked, “Have you taken a PALS or APLS (Advanced Pediatric Life Support) certification or instructor course in the last 2 years?” and “Has your office ever conducted a ‘mock’ or practice pediatric emergency?”
Perceived Importance of Preparedness
We measured respondents’ opinions on the importance of being prepared for a pediatric emergency and providing emergency services in the office. The specific questions were: “How important is it to you that your office or practice setting be prepared to stabilize a true pediatric emergency?” and “How important is it to you that your practice provides emergency care to critically ill children in your office?” We coded the ordinal responses for both questions on a scale from 1 through 4 (4 = very important).
Analysis
Our analysis contrasted family physicians and pediatricians. Statistical significance for all contrasts was set, a priori, at P less than .05. Cross-tabular analyses with chi-squares were used to compare percentage responses by specialty on the individual variables measuring occurrence and preparedness, mock emergencies, and PALS training. We also used a chi-square to examine the relationship between preparedness and PALS training. Independent-sample t tests were used to compare means by specialty on the 2 composite indices (EOS and EPS). Independent-sample t tests were also used to compare mean values for the questions on the believed importance of providing care to critically ill children and being prepared to stabilize them.
Two post-hoc hypotheses were suggested. One was whether family physicians and pediatricians differed on their knowledge of the availability of resuscitation items (ie, the number of “don’t know” responses). Another was whether physicians who reported seeing patients with respiratory emergencies had oxygen and a mask with which to administer it. Respiratory emergencies were defined as respiratory or cardiac arrest, foreign body in airway, asthma flare, and moderate to severe croup.
Results
Occurrence of Pediatric Emergencies
Table 2 presents the reported occurrence of pediatric emergencies in the office during the course of a year. Pediatric emergencies involving respiratory problems or cardiac arrest were seen in 4% of all practices, 2% in those of family physicians, and 7% in those of pediatricians. This difference was not statistically significant. Similar percentages (approximately 11%) of family physicians and pediatricians saw at least 1 child with a foreign body in the airway.
Each of the other 6 conditions were seen in a third or more of all family physician practices in the course of a year and in three fifths or more of pediatric practices. Asthma flares were the most commonly seen condition, occurring in 93% of both family practice and pediatric offices. More than 90% of both family physicians and pediatricians encountered at least 1 respiratory emergency. Approximately two thirds of the physicians in both specialties (64% of family physicians and 71% of pediatricians) commonly encountered allergic reactions.
There was no pediatric emergency condition that family physicians were statistically more likely to encounter than pediatricians. Pediatricians were significantly more likely to see severe croup (75% vs 48%), seizure (62% vs 33%), dehydration (85% vs 64%), and serious febrile illnesses (82% vs 65%). The average pediatric practice saw at least 4 of each of these child emergencies in the course of a year.
Family physicians saw fewer children with medical emergencies than did pediatricians. The mean EOS score was 3.8 for family physicians versus 4.9 for pediatricians (P <.001).
Emergency Preparedness
Table 3 shows emergency preparedness, as measured by the immediate availability of resuscitation items. The items are listed in increasing order of availability.
Ninety-six percent of all practices reported that they had oxygen immediately available; 88% had resuscitation drugs; and 86% had intravenous (IV) fluids. However, 27% had no appropriate way of administering IV fluids or drugs (no child-sized IV catheter or intraosseous needle). Family physicians were significantly less likely than pediatricians to have child-sized IV catheters, a pediatric bag-valve mask, an oral/nasal pediatric airway, or suction and pediatric catheters. Family physicians were also less likely to have available an intraosseous needle, a pediatric laryngoscope and endotracheal tube, a Broselow tape, or continuous pulse oximetry. In regard to having resucitation items, both family physicians and pediatricians were certain about the availability of oxygen, IV fluids, and continuous pulse oximetry. No family physicians or pediatricians responded “don’t know” on any of these items. Physicians were most uncertain about whether they had a Broselow tape (34% chose the “don’t know” responses) and an intraosseous needle (17% chose “don’t know”). Family physicians were significantly less likely than pediatricians to know whether they had a Broselow tape (43% vs 20%, respectively), an intraosseus needle (24% vs 5%, respectively), and suction and pediatric catheters (14% vs 5%, respectively).
Of those who encountered respiratory emergencies, a fifth of the physicians had no child-sized mask for administering oxygen. Family physicians were less likely to have one than pediatricians (30% did not vs 4%, respectively).
Family physicians were substantially less prepared for child emergencies, according to the inventory of immediately available items. The mean EPS was 5.7 for family physicians versus 8.6 for pediatricians (P <.001). Four-fifths of all physician offices had never conducted a mock or practice pediatric emergency. Only 6% of family physician offices had conducted a mock emergency versus 40% of pediatric offices (P <.001). Approximately one third of all physicians had taken a PALS training course during the previous 2 years. Less than a fifth of family physicians reported taking PALS training, compared with half of the pediatricians (P <.01).
There is a positive relationship between PALS training and preparedness. Those who had PALS training were significantly more likely to have a Broeslow tape available than those who did not (58% vs 21%, P <.001) and also were more likely to have an intraosseous needle (62% vs 24%, P <.001). Those who had PALS training were more than twice as likely to have practiced for a pediatric emergency (30% vs 13%, P <.01).
Beliefs About Preparing for Pediatric Emergencies in the Office
Family physicians and pediatricians differed in opinion on the importance of providing emergency care to critically ill children in their offices. Family physicians thought it less important to provide this service than did pediatricians. Family physicians rated providing care to critically ill children in their offices between “not very important” and “somewhat important.” The mean importance score for family physicians was 2.8 versus 3.5 for pediatricians (P <.001), with 4.0 being “very important.”
Physicians of both specialties attached less importance to providing care to critically ill children than being prepared to do so but differed by specialty on this dimension as well. Pediatricians thought it was more important to be prepared for these events (mean for family physicians = 3.4 vs 3.7 for pediatricians, P <.05), but the difference may not be clinically relevant. Each rated being prepared to stabilize a true pediatric emergency between “somewhat important” and “very important.”
Discussion
Although our study was conducted in only one state, we know of no reason the North Carolina experience would be unique. In contrast to the few previous studies, we asked about specific types of emergencies. We found that family physicians encounter a smaller variety of office pediatric emergencies than do pediatricians, but none of these events are unusual for either, and many are common for both. Only respiratory or cardiac arrest might be considered rare for family physicians (annually experienced by less than 5% of practices), but the 2% of family physicians in our sample would equal 40 cases per year in North Carolina. One in 10 family physicians treated a child with a foreign body in the airway, which would be more than 200 occurrences for family practice offices yearly in the state.
A third of those family physicians who regularly treat children can expect to encounter at least 1 pediatric seizure in their office during the year. Two thirds or more are likely to encounter children with seriously high fevers, dehydration, allergic reactions, or asthma attacks. Concern about office preparedness for these emergencies is warranted.
Our data suggest that family physicians’ practices may not be appropriately equipped. Having an oxygen tank is of little use if there is no mask to administer it. We do not recommend intubation in the office setting. Most emergency medicine experts agree that the key to airway management in out-of-hospital settings is positive-pressure ventilation through use of a bag-valve-mask, but the correct size is required. Similarly, there must be quick and sure means to administer fluids and IV drugs in the proper doses. The intraosseous needle may be the safest and fastest way, but less than 1 in 7 family physicians had this item. Doses for children vary greatly and quick information aids (such as the Broselow tape, which indicates drug dose and device size according to body length) may not be available. Familiarity and skill with these 2 items could be acquired in PALS training.
It is puzzling that family physicians think it less important to provide emergency care to critically ill children in their offices than do pediatricians. It may be that they think it is not appropriate for them to treat such emergencies or that such emergencies do not happen often enough to be of concern. Perhaps most of their data are anecdotal, and they simply have seen little information on the incidence, variety, or severity of pediatric office emergencies. Might they generalize their proficiency with adult emergencies to those of children? Some may believe that training in Advanced Cardiac Life Support provides sufficient skill to handle pediatric emergencies, but the techniques, doses, and device sizes for infants and young children are quite different from those for older children, adolescents, and adults.
Our study provides evidence that family physicians and pediatricians should assess the likelihood of children with serious medical emergencies presenting in their offices. As Trachtenbarg14 recently suggested, they should evaluate their own unique patient mix and be prepared accordingly. Both family physicians and pediatricians should evaluate the likelihood of seeing more pediatric emergencies because of managed care. Our study may help them judge their need for continuing training. Many states have developed specific training programs through the Emergency Medical Services for Children (EMS-C) program,* funded by the federal Maternal and Child Health Bureau. PALS training courses are commonly available. Our current and future work involves promoting and conducting such training.
Conclusions
Though no primary care office can be as well equipped as a hospital emergency department, the cost of basic equipment should not be prohibitive. It can cost less than $600 to prepare an office.15 In terms of time, PALS training is a 2-day course with refreshers every 2 years, and a mock emergency in the office can take less than an hour. Emergencies are by no means as common as ear infections; however, they do occur, and the consequences of being unprepared are serious. Family physicians need many skills. These data demonstrate that preparedness to stabilize and resuscitate children in emergency office encounters should be part of their repertoire.
Acknowledgments
Our study was funded by the North Carolina Office of Emergency Medical Services, Division of Facilities Services, Department of Health and Human Services, through a grant from the US Department of Health and Human Services. We thank Bob Bailey, Director of the North Carolina Office of Emergency Medical Services, for his assistance and support. We thank also Zoe Yetman (East Carolina University) for her attention to detail in managing the survey and Matthew Curry and Kevin Gross for reviewing the final manuscript.
Related Resources
- Emergency Medical Services for Children
- Maintained by the EMSC program, which is primarily supported and jointly administered by the U.S. Department of Health and Human Services’ Health Resources and Services Administration and the U.S. Department of Transportation’s National Highway Traffic Safety Administration. The site offers information on education and training, national and state activities, funding opportunities, and family education resources for injury control and prevention. http://www.ems-c.org
- American Academy of Pediatrics‹a comparison of APLS and PALS training and telephone numbers for both programs. " target="_blank">http://www.aap.org/profed/nrp/aplscom.htm>
- The components of the 14-hour APLS course may be found at " target="_blank">http://www.aap.org/profed/nrp/aplsccreq.htm>
- American Academy of Family Physicians (AAFP)‹Pediatric Advanced Life Support: A Review of the AHA Recommendations by Inis Jane Bardella, M.D. This article summarizes information from the PALS program but does not serve as a replacement for completing a PALS course. http://www.aafp.org/afp/991015ap/1743.html
- AAFP CME page‹Location and dates of PALS courses http://www.aafp.org/afp/calendar/cmecours.html
STUDY DESIGN: We performed a cross-sectional random mail survey of physicians.
POPULATION: Surveys were sent to 187 family physicians and 129 pediatricians practicing in North Carolina with 75% and 86% response rates, respectively. The 169 total respondents were in community practices regularly treating children and were included for analysis.
OUTCOMES MEASURED: We measured the incidence of 8 types of pediatric emergencies, the availability of 11 items for resuscitation and stabilization, whether the physician had Pediatric Advanced Life Support (PALS) training in the previous 2 years, whether the office ever conducted a mock emergency, and beliefs about the importance of preparing for and providing emergency care to children.
RESULTS: Six types of pediatric emergencies were seen in one third or more of all practices during the year. The average practice saw 4 or more pediatric emergencies in a year (family physicians = 3.8 vs pediatricians = 4.9, P <.001). Family physicians had fewer resuscitation and stabilization items than pediatricians (5.7 vs 8.6 items, P <.001) and were less prepared in terms of PALS training (19% vs 51%, P <.001). Those with PALS training were more likely to have an intraosseous needle and Broselow tape and to have conducted a mock code. Family physicians considered it is less important than pediatricians to provide such care or to be prepared to do so.
CONCLUSIONS: Pediatric emergencies in the office are likely for either specialty. Family physicians may be less prepared, and they discount the importance of the problem and the need for preparation.
Pediatric emergencies are serious events that occur more commonly than many physicians think.1 Recent studies have described adverse outcomes that can result when children with medical emergencies are directed to physicians’ offices by managed care plans.2-5 However, little is known about the incidence or types of pediatric emergencies encountered or whether physicians are adequately prepared to treat them in their offices.
A few studies have estimated incidence but used different definitions of emergency, and there is considerable variation in the estimates of their occurrence. A study of pediatric practices in Vermont reported only 1 office emergency per practice per year,6 while a study in Connecticut reported that 82% of pediatric practices saw at least 1 child emergency per month.7 A Chicago study reported that 62% of pediatricians and family physicians saw at least 1 child a week who required urgent treatment or hospitalization.8 In a national sample, 68% of office-based pediatricians reported seeing 1 to 5 emergencies per week.9
The literature describing preparedness is limited principally to pediatricians and suggests that their skills in resuscitation and stabilization need improvement.7 ,9-12 Other than the Chicago study8 and one done in northern France,13 there are no studies of the frequency and nature of pediatric emergencies in family physicians’ offices, and little is known about how well prepared the typical family physician is to treat child emergencies. The Chicago study reported that the offices of family physicians were better stocked with resuscitation drugs than those of pediatricians but did not assess the training of physicians or their office staffs to deal with the medical emergencies of chidren.8 The French study is of little help in understanding the problem in the United States.13
In our study, we sought to understand: (1) both the incidence and variety of pediatric emergencies in the practices of family physicians and pediatricians in North Carolina; (2) how prepared physicians of each specialty were to treat such emergencies; (3) whether they believed they should provide emergency service; and (4) how important they felt it was to be prepared for pediatric emergencies.
Methods
We mailed a survey in late 1995 to a random sample of family physicians and pediatricians across North Carolina. The survey asked 25 questions about the prevalence and management of pediatric emergencies occurring in a physician’s office in 1995. The sample was randomly drawn from a database of 3184 family physicians and pediatricians licensed by the North Carolina Medical Board.
Survey Design and Procedures
The survey questions were developed by a group of family practice, pediatric, and emergency physicians. Our pilot study indicated a lower response rate for family physicians (58%) than for pediatricians (83%) and that fewer family physicians were regularly providing pediatric primary care (71% vs 100%). Accordingly, we mailed surveys to 250 family physicians and 150 pediatricians to obtain power sufficient to detect effect sizes with less than 5% error. Table 1 shows the sampling design and response rates for the 2 physician specialty groups.
Measures
The key variables are the occurrence of emergencies encountered by the practice, preparedness for emergencies through the availability of resuscitation and stabilization items, training for emergencies, and the perceived importance of providing and preparing for emergency care.
Emergency Occurrence and Preparedness
The variety of emergency occurrences was measured using 8 questions that asked whether specific pediatric emergencies were presented to the physician in the office setting during the last 12 months Table 2. Preparedness for pediatric emergencies was measured with 11 questions that asked whether specific stabilization and resuscitation items were immediately available to the physician in the office Table 3. The items were selected by experts and are regularly included in Pediatric Advanced Life Support (PALS) training. The responses allowed for this series of questions were “yes,” “no,” and “don’t know.” Answers other than “yes” were taken to mean that the item was not immediately available.
Occurrence of and preparedness for pediatric emergencies were analyzed as individual variables and as composite indexes. The composite index for the variety of emergency occurrences was created by assigning 1 point for each “yes” answer to whether a specific type of emergency occurred. This index, which we call the Emergency Occurrence Score (EOS), was an unweighted number with values ranging from 0 to 8, where a score of 8 was the greatest variety of occurrence (ie, all the types of emergencies occurred during the year). Similarly, an Emergency Preparedness Score (EPS) was created by assigning 1 point to each affirmative answer regarding the availability of specific stabilization and resuscitation items, with a range for the score of 0 to 11 (11 = optimal availability of resuscitation equipment).
Training for Emergencies
We asked 2 questions that assessed the training of physicians and office staff to deal with the emergencies of children. Specifically, we asked, “Have you taken a PALS or APLS (Advanced Pediatric Life Support) certification or instructor course in the last 2 years?” and “Has your office ever conducted a ‘mock’ or practice pediatric emergency?”
Perceived Importance of Preparedness
We measured respondents’ opinions on the importance of being prepared for a pediatric emergency and providing emergency services in the office. The specific questions were: “How important is it to you that your office or practice setting be prepared to stabilize a true pediatric emergency?” and “How important is it to you that your practice provides emergency care to critically ill children in your office?” We coded the ordinal responses for both questions on a scale from 1 through 4 (4 = very important).
Analysis
Our analysis contrasted family physicians and pediatricians. Statistical significance for all contrasts was set, a priori, at P less than .05. Cross-tabular analyses with chi-squares were used to compare percentage responses by specialty on the individual variables measuring occurrence and preparedness, mock emergencies, and PALS training. We also used a chi-square to examine the relationship between preparedness and PALS training. Independent-sample t tests were used to compare means by specialty on the 2 composite indices (EOS and EPS). Independent-sample t tests were also used to compare mean values for the questions on the believed importance of providing care to critically ill children and being prepared to stabilize them.
Two post-hoc hypotheses were suggested. One was whether family physicians and pediatricians differed on their knowledge of the availability of resuscitation items (ie, the number of “don’t know” responses). Another was whether physicians who reported seeing patients with respiratory emergencies had oxygen and a mask with which to administer it. Respiratory emergencies were defined as respiratory or cardiac arrest, foreign body in airway, asthma flare, and moderate to severe croup.
Results
Occurrence of Pediatric Emergencies
Table 2 presents the reported occurrence of pediatric emergencies in the office during the course of a year. Pediatric emergencies involving respiratory problems or cardiac arrest were seen in 4% of all practices, 2% in those of family physicians, and 7% in those of pediatricians. This difference was not statistically significant. Similar percentages (approximately 11%) of family physicians and pediatricians saw at least 1 child with a foreign body in the airway.
Each of the other 6 conditions were seen in a third or more of all family physician practices in the course of a year and in three fifths or more of pediatric practices. Asthma flares were the most commonly seen condition, occurring in 93% of both family practice and pediatric offices. More than 90% of both family physicians and pediatricians encountered at least 1 respiratory emergency. Approximately two thirds of the physicians in both specialties (64% of family physicians and 71% of pediatricians) commonly encountered allergic reactions.
There was no pediatric emergency condition that family physicians were statistically more likely to encounter than pediatricians. Pediatricians were significantly more likely to see severe croup (75% vs 48%), seizure (62% vs 33%), dehydration (85% vs 64%), and serious febrile illnesses (82% vs 65%). The average pediatric practice saw at least 4 of each of these child emergencies in the course of a year.
Family physicians saw fewer children with medical emergencies than did pediatricians. The mean EOS score was 3.8 for family physicians versus 4.9 for pediatricians (P <.001).
Emergency Preparedness
Table 3 shows emergency preparedness, as measured by the immediate availability of resuscitation items. The items are listed in increasing order of availability.
Ninety-six percent of all practices reported that they had oxygen immediately available; 88% had resuscitation drugs; and 86% had intravenous (IV) fluids. However, 27% had no appropriate way of administering IV fluids or drugs (no child-sized IV catheter or intraosseous needle). Family physicians were significantly less likely than pediatricians to have child-sized IV catheters, a pediatric bag-valve mask, an oral/nasal pediatric airway, or suction and pediatric catheters. Family physicians were also less likely to have available an intraosseous needle, a pediatric laryngoscope and endotracheal tube, a Broselow tape, or continuous pulse oximetry. In regard to having resucitation items, both family physicians and pediatricians were certain about the availability of oxygen, IV fluids, and continuous pulse oximetry. No family physicians or pediatricians responded “don’t know” on any of these items. Physicians were most uncertain about whether they had a Broselow tape (34% chose the “don’t know” responses) and an intraosseous needle (17% chose “don’t know”). Family physicians were significantly less likely than pediatricians to know whether they had a Broselow tape (43% vs 20%, respectively), an intraosseus needle (24% vs 5%, respectively), and suction and pediatric catheters (14% vs 5%, respectively).
Of those who encountered respiratory emergencies, a fifth of the physicians had no child-sized mask for administering oxygen. Family physicians were less likely to have one than pediatricians (30% did not vs 4%, respectively).
Family physicians were substantially less prepared for child emergencies, according to the inventory of immediately available items. The mean EPS was 5.7 for family physicians versus 8.6 for pediatricians (P <.001). Four-fifths of all physician offices had never conducted a mock or practice pediatric emergency. Only 6% of family physician offices had conducted a mock emergency versus 40% of pediatric offices (P <.001). Approximately one third of all physicians had taken a PALS training course during the previous 2 years. Less than a fifth of family physicians reported taking PALS training, compared with half of the pediatricians (P <.01).
There is a positive relationship between PALS training and preparedness. Those who had PALS training were significantly more likely to have a Broeslow tape available than those who did not (58% vs 21%, P <.001) and also were more likely to have an intraosseous needle (62% vs 24%, P <.001). Those who had PALS training were more than twice as likely to have practiced for a pediatric emergency (30% vs 13%, P <.01).
Beliefs About Preparing for Pediatric Emergencies in the Office
Family physicians and pediatricians differed in opinion on the importance of providing emergency care to critically ill children in their offices. Family physicians thought it less important to provide this service than did pediatricians. Family physicians rated providing care to critically ill children in their offices between “not very important” and “somewhat important.” The mean importance score for family physicians was 2.8 versus 3.5 for pediatricians (P <.001), with 4.0 being “very important.”
Physicians of both specialties attached less importance to providing care to critically ill children than being prepared to do so but differed by specialty on this dimension as well. Pediatricians thought it was more important to be prepared for these events (mean for family physicians = 3.4 vs 3.7 for pediatricians, P <.05), but the difference may not be clinically relevant. Each rated being prepared to stabilize a true pediatric emergency between “somewhat important” and “very important.”
Discussion
Although our study was conducted in only one state, we know of no reason the North Carolina experience would be unique. In contrast to the few previous studies, we asked about specific types of emergencies. We found that family physicians encounter a smaller variety of office pediatric emergencies than do pediatricians, but none of these events are unusual for either, and many are common for both. Only respiratory or cardiac arrest might be considered rare for family physicians (annually experienced by less than 5% of practices), but the 2% of family physicians in our sample would equal 40 cases per year in North Carolina. One in 10 family physicians treated a child with a foreign body in the airway, which would be more than 200 occurrences for family practice offices yearly in the state.
A third of those family physicians who regularly treat children can expect to encounter at least 1 pediatric seizure in their office during the year. Two thirds or more are likely to encounter children with seriously high fevers, dehydration, allergic reactions, or asthma attacks. Concern about office preparedness for these emergencies is warranted.
Our data suggest that family physicians’ practices may not be appropriately equipped. Having an oxygen tank is of little use if there is no mask to administer it. We do not recommend intubation in the office setting. Most emergency medicine experts agree that the key to airway management in out-of-hospital settings is positive-pressure ventilation through use of a bag-valve-mask, but the correct size is required. Similarly, there must be quick and sure means to administer fluids and IV drugs in the proper doses. The intraosseous needle may be the safest and fastest way, but less than 1 in 7 family physicians had this item. Doses for children vary greatly and quick information aids (such as the Broselow tape, which indicates drug dose and device size according to body length) may not be available. Familiarity and skill with these 2 items could be acquired in PALS training.
It is puzzling that family physicians think it less important to provide emergency care to critically ill children in their offices than do pediatricians. It may be that they think it is not appropriate for them to treat such emergencies or that such emergencies do not happen often enough to be of concern. Perhaps most of their data are anecdotal, and they simply have seen little information on the incidence, variety, or severity of pediatric office emergencies. Might they generalize their proficiency with adult emergencies to those of children? Some may believe that training in Advanced Cardiac Life Support provides sufficient skill to handle pediatric emergencies, but the techniques, doses, and device sizes for infants and young children are quite different from those for older children, adolescents, and adults.
Our study provides evidence that family physicians and pediatricians should assess the likelihood of children with serious medical emergencies presenting in their offices. As Trachtenbarg14 recently suggested, they should evaluate their own unique patient mix and be prepared accordingly. Both family physicians and pediatricians should evaluate the likelihood of seeing more pediatric emergencies because of managed care. Our study may help them judge their need for continuing training. Many states have developed specific training programs through the Emergency Medical Services for Children (EMS-C) program,* funded by the federal Maternal and Child Health Bureau. PALS training courses are commonly available. Our current and future work involves promoting and conducting such training.
Conclusions
Though no primary care office can be as well equipped as a hospital emergency department, the cost of basic equipment should not be prohibitive. It can cost less than $600 to prepare an office.15 In terms of time, PALS training is a 2-day course with refreshers every 2 years, and a mock emergency in the office can take less than an hour. Emergencies are by no means as common as ear infections; however, they do occur, and the consequences of being unprepared are serious. Family physicians need many skills. These data demonstrate that preparedness to stabilize and resuscitate children in emergency office encounters should be part of their repertoire.
Acknowledgments
Our study was funded by the North Carolina Office of Emergency Medical Services, Division of Facilities Services, Department of Health and Human Services, through a grant from the US Department of Health and Human Services. We thank Bob Bailey, Director of the North Carolina Office of Emergency Medical Services, for his assistance and support. We thank also Zoe Yetman (East Carolina University) for her attention to detail in managing the survey and Matthew Curry and Kevin Gross for reviewing the final manuscript.
Related Resources
- Emergency Medical Services for Children
- Maintained by the EMSC program, which is primarily supported and jointly administered by the U.S. Department of Health and Human Services’ Health Resources and Services Administration and the U.S. Department of Transportation’s National Highway Traffic Safety Administration. The site offers information on education and training, national and state activities, funding opportunities, and family education resources for injury control and prevention. http://www.ems-c.org
- American Academy of Pediatrics‹a comparison of APLS and PALS training and telephone numbers for both programs. " target="_blank">http://www.aap.org/profed/nrp/aplscom.htm>
- The components of the 14-hour APLS course may be found at " target="_blank">http://www.aap.org/profed/nrp/aplsccreq.htm>
- American Academy of Family Physicians (AAFP)‹Pediatric Advanced Life Support: A Review of the AHA Recommendations by Inis Jane Bardella, M.D. This article summarizes information from the PALS program but does not serve as a replacement for completing a PALS course. http://www.aafp.org/afp/991015ap/1743.html
- AAFP CME page‹Location and dates of PALS courses http://www.aafp.org/afp/calendar/cmecours.html
1. Wheeler DS, Kiefer ML, Poss WB. Pediatric emergency preparedness in the office. Am Fam Physician 2000;61:3333-42.
2. Young GP, Lowe RA. Adverse outcomes of managed care gatekeeping. Acad Emerg Med 1997;4:1129-36.
3. Viner KM, Bellino M, Kirsch TD, Kivela P, Silva JC. Managed care organization authorization denials: lack of patient knowledge and timely alternative ambulatory care. Ann Emerg Med 2000;35:272-76.
4. Tintinalli JE. Analysis of insurance payment denials using the prudent layperson standard. Ann Emerg Med 2000;35:291-93.
5. Derlet RW, Young GP. Managed care and emergency medicine: conflicts, federal law, and California legislation. Ann Emerg Med 1997;30:292-300.
6. Heath BW, Coffey JS, Malone P, Courtney J. Pediatric office emergencies and emergency preparedness in a small rural state. Pediatrics 2000;106:1391-96.
7. 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 Pediatri Adolesc Med 1996;150:249-56.
8. Fuchs S, Jaffe DM, Christoffel KK. Pediatric emergencies in office practices: prevalence and office preparedness. Pediatrics 1989;83:931-39.
9. Periodic Survey of Fellows #27. Emergency readiness of pediatric offices. Chicago, Ill: American Academy of Pediatrics; 1995.
10. Altieri M, Bellet J, Scott H. Preparedness for pediatric emergencies encountered in the practitioner’s office. Pediatrics 1990;85:710-14.
11. Schweich PJ, DeAngelis C, Duggan AK. Preparedness of practicing pediatricians to manage emergencies. Pediatrics 1991;88:223-29.
12. Shetty AK, Hutchinson SW, Mangat R, Peck GQ. Preparedness of practicing pediatricians in Louisiana to manage emergencies. South Med J 1998;91:745-48.
13. Martinot A, Fourier C, Hue V, Leclerc F, Cedex L. Family practitioner preparedness for pediatric emergencies. Arch Pediatr Adolesc Med 1997;151:530-31.
14. Trachtenbarg D. Pediatric emergencies: preparedness and prevention. Am Fam Physician 2000;61:3237-38.
15. Schexnayder SM, Schexnayder RE. 911 in your office: preparations to keep emergencies from becoming catastrophes. Pediatr Ann 1996;25:664-66,68, 70, passim.
1. Wheeler DS, Kiefer ML, Poss WB. Pediatric emergency preparedness in the office. Am Fam Physician 2000;61:3333-42.
2. Young GP, Lowe RA. Adverse outcomes of managed care gatekeeping. Acad Emerg Med 1997;4:1129-36.
3. Viner KM, Bellino M, Kirsch TD, Kivela P, Silva JC. Managed care organization authorization denials: lack of patient knowledge and timely alternative ambulatory care. Ann Emerg Med 2000;35:272-76.
4. Tintinalli JE. Analysis of insurance payment denials using the prudent layperson standard. Ann Emerg Med 2000;35:291-93.
5. Derlet RW, Young GP. Managed care and emergency medicine: conflicts, federal law, and California legislation. Ann Emerg Med 1997;30:292-300.
6. Heath BW, Coffey JS, Malone P, Courtney J. Pediatric office emergencies and emergency preparedness in a small rural state. Pediatrics 2000;106:1391-96.
7. 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 Pediatri Adolesc Med 1996;150:249-56.
8. Fuchs S, Jaffe DM, Christoffel KK. Pediatric emergencies in office practices: prevalence and office preparedness. Pediatrics 1989;83:931-39.
9. Periodic Survey of Fellows #27. Emergency readiness of pediatric offices. Chicago, Ill: American Academy of Pediatrics; 1995.
10. Altieri M, Bellet J, Scott H. Preparedness for pediatric emergencies encountered in the practitioner’s office. Pediatrics 1990;85:710-14.
11. Schweich PJ, DeAngelis C, Duggan AK. Preparedness of practicing pediatricians to manage emergencies. Pediatrics 1991;88:223-29.
12. Shetty AK, Hutchinson SW, Mangat R, Peck GQ. Preparedness of practicing pediatricians in Louisiana to manage emergencies. South Med J 1998;91:745-48.
13. Martinot A, Fourier C, Hue V, Leclerc F, Cedex L. Family practitioner preparedness for pediatric emergencies. Arch Pediatr Adolesc Med 1997;151:530-31.
14. Trachtenbarg D. Pediatric emergencies: preparedness and prevention. Am Fam Physician 2000;61:3237-38.
15. Schexnayder SM, Schexnayder RE. 911 in your office: preparations to keep emergencies from becoming catastrophes. Pediatr Ann 1996;25:664-66,68, 70, passim.