Dayae Jeong, Subhrata Verma, Anushka Weeraratne, Marina Atalla, Mohammed Hassan-Ali, April J.Kam,5

1 Department of Pediatrics, University of Toronto, Toronto M5S 1A1, Canada

2 Department of Pediatrics, University of Western, London N6A 3K7, Canada

3 Department of Pediatrics, McMaster University, Hamilton L8S 4K1, Canada

4 Department of Health Sciences, McMaster University, Hamilton L8S 4K1, Canada

5 Division of Pediatric Emergency Medicine, McMaster University, Hamilton L8S 4K1, Canada

Dear editor,

Family physicians often serve as the primary resource for parents seeking medical treatment for their children, and it is not uncommon for children with medical emergencies to be brought into primary care offices instead of local emergency departments(EDs).Although estimated incidence rates of pediatric emergencies in primary care offices vary based on the definition used, the number of patients seen, and clinic location,[1-3]any healthcare provider who sees pediatric patients should be ready for immediate medical intervention to minimize adverse outcomes.[4,5]Various studies in the USA have shown that outpatient offices are not adequately prepared for pediatric emergencies,whether that is defined as stocking recommended equipment, having policies for the transport of patients to EDs, engaging in mock codes, or being certified in Advanced Pediatric Life Support (APLS) or Basic Life Support (BLS).[1-3]This deficit in preparedness exists despite the presence of multiple nation- and state-wide guidelines on the subject, including a policy by the American Academy of Pediatrics.[3]Limited information exists on the preparedness of primary care physicians for pediatric emergencies in other nations.

In Canada, the Canadian Paediatric Society (CPS)had previously published a position statement on this topic, titled “Guidelines for Paediatric Emergency Equipment and Supplies for a Physician’s Office” in 2009.This statement suggested implementation of mock codes, written protocols outlining transportation of children to EDs, training in Pediatric Advanced Life Support (PALS) or APLS and Neonatal Resuscitation Program (NRP), and provided a detailed list of recommended emergency medications and supplies.[6]We surveyed family physicians across multiple Canadian provinces and territories to assess the level of preparedness for pediatric emergencies in outpatient offi ces.

Our survey

In total, 1,869 randomly selected family physicians were asked to participate in our survey: 750 from Ontario and 1,119 distributed across nine provinces and two territories (Figure 1).Quebec was excluded as we were unable to provide the survey in French, and Nunavut excluded as we were unable to successfully obtain a list of physicians.The survey questionnaire was designed by investigators at the McMaster Children’s Hospital in Hamilton, Canada and consisted of 14 questions probing clinic characteristics, accessibility of emergency resources, incidence of pediatric emergencies(defined as a patient visit resulting in hospitalization or immediate medical intervention), and preparedness for such emergencies based on the CPS guidelines.It was distributed and completed in 2017, using the Dillman survey method.[7]

Of the 1,869 surveys sent, 206 were included in our final analysis giving a response rate of 11.0%(Figure 1).About 44.7% of respondents were male and 55.3% female.About 72.3% of respondents practised in an urban location (population greater than 10,000),ref lecting the general demographics of family physician practice within Canada.[8]The majority of respondents reported seeing 11-20 children per week (41.2%),followed by fewer than ten (29.4%), 21-40 (21.6%) and greater than 40 (7.8%).Similarly, it has previously been reported that pediatric patients make up approximately 10% or less of family physicians’ practices in the USA.[9]

Figure 1.Flowchart of responses from each province and responses which were excluded from data analysis.

A high proportion (60.7%) of respondents reported that they had experienced a pediatric emergency within the year 2017.A breakdown of these emergencies is provided in Table 1.Despite this apparent frequency, only 4.4% of respondents had read the then-active CPS guidelines on this topic, and only 12.6% were aware that they existed.General adherence to the guidelines was poor: 3.9% of respondents had an official protocol outlining safe transport of children to the hospital, 6.3% participated in mock codes for pediatric emergencies, and only 34.0% and 30.6% of physicians were trained in PALS/APLS and NRP, respectively.About 2.9% of physicians reported stocking all of the equipment suggested in the statement, and only 53.4% reported stocking a minimum of half.There was a large variation in the actual items that were stocked.

Table 1.Characteristics of the pediatric emergencies experienced by respondents and accessibility of emergency resources

DISCUSSION

Explaining low emergency preparedness rates

The large discrepancy in the proportion of Canadian family physicians who have experienced pediatric emergencies and those who are adequately prepared for one is consistent with previously reported data from the USA.[1-3]

Firstly, one explanation for this discrepancy may be that family physicians are more familiar with guidelines published by associations specif ic to their practice, such as the College of Family Physicians of Canada (CFPC), than those published by the pediatric-specific agencies including the CPS.Although the CFPC has addressed the general management of in-offi ce emergencies, there is a gap in knowledge as these guidelines do not contain recommendations specific to the pediatric population.[10,11]Secondly, family physicians with prompt access to emergency services (including nearby EDs and rapid emergency medical services [EMS] response) may feel that extensive preparation for emergencies is not required.[2]Lastly, the f inancial burden is a signif icant limitation as the estimated cost of the equipment and resuscitation training suggested by the CPS is over 3,000 Canadian dollars (as of December 2020), not including the additional costs of replenishing expired products.

Strategies for change

There is a clear need for improvement in the current state of preparedness for pediatric emergencies.This study demonstrated this demand in Canada, even while a set of guidelines on the topic was publicly available,similar to previous studies in the USA.[1-3]There are no direct data on outcomes of children who experience emergencies in underprepared facilities, but the inferior outcomes that result from delayed care in such situations should act as a sufficient motivator for change.[4,5]We propose several solutions that can be advocated for and implemented at a range of organizational levels.

On an individual level, we encourage all healthcare providers who work with children to familiarize themselves with existing guidelines on emergency preparedness and stay up-to-date in basic resuscitation certif ications.Individual clinics and practices should ensure that essential resuscitation equipments and medications are available.On an organizational level, it would be benef icial for pediatric associations to create guidelines on this subject or update existing ones, with a focus on addressing both pediatricians and general practitioners.A collaborative statement with family physician bodies may also improve dissemination of information.

Limitations

Our study is limited by our low response rate and inability to include Quebec and Nunavut.This restricts the generalizability of our data, and ability to conduct further statistical analyses, such as identifying relationships between clinic demographics or accessibility of EMS and measurements of emergency preparedness.We postulate that our low response rate may have been secondary to poor awareness of this topic and low intrinsic incentive to complete the survey.Secondly, a response bias may have skewed our results as physicians who responded to our survey were likely those who were better prepared.

CONCLUSIONS

There is a high incidence of pediatric emergencies in primary care offi ces, and any healthcare provider who sees children should be ready for immediate medical intervention in the case of an emergency.Rates of physician preparedness for pediatric emergencies have been shown to be low despite the presence of current or previously published guidelines on the topic.There is a need for increased discussion and action regarding this subject globally at all levels spanning from the individual to national organizations.

Funding:None.

Ethical approval:Not needed.

Conf licts of interest:No any benef its have been received from a commercial party related directly or indirectly to the study.

Contributors:DJ proposed and wrote the f irst draft.All authors contributed to the design and interpretation of the study and to further drafts.