Impact of a pediatric primary care office-based mock code program on physician and staff confidence to perform life-saving skills.

BACKGROUND: Previous studies have described that pediatric offices are ill-prepared for medical emergencies. Pediatric "mock codes" have been utilized to increase the emergency preparedness of inpatient medical units for several decades. These practice drills have been shown to both increase practitioners' confidence and decrease anxiety during actual resuscitations. Although the use of mock codes is recommended in the outpatient setting, these benefits have yet to be demonstrated for office-based practitioners. OBJECTIVE: We conducted this study to determine whether mock codes performed in pediatric primary care offices increase practitioner confidence to perform life-saving skills. METHODS: Pediatric group practices participated in a clinical trial of an office-based, 2-step, emergency preparedness training. First, physicians and staffs attended a 1-hour didactic program which included staff education, office emergency protocols, emergency equipment and medications, and guidelines on instituting a mock code program. Second, each practice participated in a 10-15-minute mock code exercise. The drill was conducted by pediatric advanced life support instructors. After the code, a 30-minute feedback session was conducted which reviewed office coordination, individual skill performance, and approach to resuscitation. Each participating practice also received an infant manikin and a text complete with several mock codes scenarios written specifically for the pediatric primary care office. Evaluation of the intervention consisted of 2 components. (1) Pre- and postintervention completion of a self-administered survey assessed participants' comfort in emergency situations and confidence to perform specific life-saving skills, using an ordinal scale: 1 = "strongly agree" to 5 = "strongly disagree". (2) Practices were contacted by telephone 12 months after the training to determine whether they had implemented improvements in emergency preparedness, including instituting mock codes, preparing a written emergency protocol and purchasing new emergency equipment and medications. RESULTS: Eleven group pediatric practices participated, which were representative of urban, suburban, and rural offices in southwestern Pennsylvania. Ninety-seven of a total 164 (59%) physicians and staff members completed both pre- and postintervention surveys. Practitioner participants were analyzed in 2 groups. Group 1 consisted of physicians, nurse practitioners, and physician assistants; group 2 consisted of registered nurses, licensed practical nurses, and medical assistants. Comparison of pre- versus postintervention surveys in both of these groups revealed significant improvement in reported confidence to perform resuscitation skills that were included in the mock code after the training: airway positioning (group 1, 67% vs. 94%, P < 0.001; group 2, 55% vs. 75%, P = 0.003), airway suctioning, (group 1, 64% vs. 88%, P = 0.005; group 2, 27% vs. 51%, P < 0.001), and bag-mask assisted ventilation (group 1, 82% vs. 91%, P = 0.003; group 2, 39% vs. 71%, P < 0.001). In addition, group 1 reported more confidence in their ability to place an intraossesous line (24% vs. 39%, P = 0.003) and group 2 showed a significant increase in their confidence to administer oxygen (65% vs. 84%, P < 0.001). As a result of the mock code, 83% of all participants, both medical and nonmedical staffs, and 96% of physicians felt less anxious about medical emergencies in the office. Twelve months after the conclusion of the program, 18% of offices had conducted 1 or more mock codes, 64% of offices had written an emergency protocol, and 27% of offices had acquired essential resuscitation medications or equipment. CONCLUSIONS: The results of this study support the recommendation that mock codes should be performed in the pediatric primary care setting to improve practitioner confidence and decrease practitioner anxiety.

Microvascular thrombosis in pediatric multiple organ failure: Is it a therapeutic target?

PURPOSE: To discuss the current rationale for the use of specific and nonspecific therapies for thrombotic microangiopathy in thrombocytopenia-associated pediatric multiple organ failure syndromes. Methods: Pertinent PubMed and MEDLINE citations and proceedings of recent critical care meeting presentations were reviewed. RESULTS: Critical care clinicians have reported using antithrombin III concentrate, protein C concentrate, activated protein C, prostacyclin and its analogues, heparin, tissue factor pathway inhibitor concentrate, plasma infusion, plasma exchange, whole blood exchange, pentoxifylline, tissue plasminogen activator, urokinase, and streptokinase with perceived therapeutic benefits in patients with thrombocytopenia-associated multiple organ failure, including those with thrombotic thrombocytopenic purpura/hemolytic uremic syndrome, disseminated intravascular coagulation syndrome, and secondary thrombotic microangiopathy syndrome without prolonged prothrombin time/activated partial thromboplastin time. CONCLUSION: Assuming that underlying disease is remediable, a consensus has developed that thrombotic microangiopathy is a therapeutic target in children with thrombocytopenia-associated multiple organ failure syndromes. Studies are warranted to delineate efficacious use of specific and nonspecific therapies to prevent and reverse thrombotic microangiopathy in these patients.