Certain emergencies elicit an immediate, conditioned response. When someone yells “Fire!” for example, most people look for an emergency exit or a fire extin-

guisher. However, emergency situations in medical offices do not engender the same type of Pavlovian reaction. Although most medical training, including family medi- cine training, involves learning how to deal with emer- gency situations, that education has a tendency to wane after graduation. Once physicians are in private practice, with the demands of seeing patients, maintaining emer- gency certification becomes a lower priority than dealing with day-to-day issues. Many primary care physicians do not invest time in maintaining active certification in car- diopulmonary resuscitation (CPR), much less advanced life support. However, medical emergencies do occur in physicians’ offices, including asthma exacerbations, chest pain, hypoglycemia, anaphylaxis, and impaired con- sciousness, among others.1 Outpatient facilities must be prepared to deal with these situations.

This article describes the emergency preparedness program that our practice, Community Volunteers in Medicine, designed and implemented. Our practice is a busy, mostly volunteer-staff clinic providing medical and dental care as well as ancillary services such as nutri- tion and diabetes education, and last year we conducted

26,000 visits. Given this patient volume, we felt that everyone on our staff needed to be prepared to deal with medical emergencies. In addition, because we have many volunteer staff who have retired from previous careers, are more than 60 years of age, and have medical issues, we felt it prudent to have measures in place to care for those who help us care for patients.

We recognize that our model may require adaptation for use in other offices depending on the number of staff (including physicians, other providers, and nursing staff), role assignment, proximity to an emergency department (ED), response times of local emergency medical services (EMS), the level of care providers are capable of adminis- tering (basic versus advanced life support), and state laws regarding who may provide emergency services. Still, we offer an emergency preparedness model befitting a family medicine office.

Condition C: An emergency preparedness program

We named our emergency preparedness program “Condi- tion C” to avoid the popularized term “code blue,” which could alarm patients in the office and waiting room. The algorithm on page 14 summarizes the steps involved in our program, which has two major components. ➤

A scavenger hunt format engages staff members in the process of reviewing sup- plies that might be needed in an emergency.

Mock code situations allow physicians and staff members to practice their emer- gency response.

Scavenger hunt. The program begins with a review of all available emergency equipment in the office utilizing an engaging scavenger hunt format. Both nursing and medical staff participate in finding and reviewing the medi- cations and equipment that might be needed in an emergency situation (see the checklist of recommended emergency supplies). Because our office is staffed mostly by volunteers and not all items can be stored within a crash cart or emergency box, the scavenger hunt helps ensure that all staff members are able to access these items in an expedient manner and that the practice is fully equipped. Once staff identify the items, they inspect medications to make sure none have expired and review equipment use. It is imperative that staff know how to use oxygen tanks, injectable epinephrine, and other equipment correctly.

Additionally, Condition C cards with com- mon emergency situations and the appropriate interventions are located in each exam room and stored with the emergency equipment. The scavenger hunt confirms the presence of these cards.

Mock codes. The program also involves mock code situations followed by a debriefing to discuss staff members’ roles and potential issues that arose during the exercise. We do not inform staff ahead of time that a Condition C is going to be simulated. To mimic the most likely scenario in an office setting, we plant a volunteer in the waiting room or exam room and ask him or her to simulate shortness of breath or acute chest pain. This tests whether our office staff is alert to patients’ needs. The goal is to have someone call a Condition C in a timely manner, followed by a rapid response by staff with the appropriate emergency equip- ment. We try to perform these mock emergen- cies at least two times per year.

allowing the front office staff to see patients who are not directly visible from their desk.

Additional issues identified through our mock code exercises included slow response times among staff, diffi- cultly finding necessary items, poor documentation of the episode, and slow-downs in patient flow in other parts of the practice. We created the scavenger hunt to improve the ability to find needed items. To improve documenta- tion, we introduced an “Emergency Nursing Record” (see page 16). This flow sheet includes patient information, emergency type, vital signs, review of systems, necessary interventions, and medications. In the event a patient

EMERGENCY PREPAREDNESS

requires transfer to the ED, we send a copy of this sheet with the patient. In general, this sharing of information helps streamline and improve patient care.

Immediately following mock emergencies, staff mem- bers meet to debrief and discuss problems in how the team responded. This allows all those involved to voice concerns and suggest improvements. Utilizing a debrief- ing form (see the “Mock Trial Evaluation Form,” page 18), we analyze each situation individually. These debrief- ing sessions help us troubleshoot the program. During a recent mock emergency, we discovered that multiple med- ications in our emergency box were expired. As a result,

Medications

  Acetaminophen (rectal suppositories)

  Albuterol

  Aspirin, chewable

  Ceftriaxone (Rocephin)

  Corticosteroids, parenteral

  Dextrose 25% and 50%

  Diazepam, parenteral (Valium)

  Diphenhydramine, oral and parenteral (Benadryl)

  Epinephrine injection (EpiPen and EpiPen Jr.)

  Flumazenil (Romazicon)

  Lorazepam, sublingual (Ativan)

  Morphine (MS Contin)

  Naloxone (Narcan)

  Nitroglycerin spray

  Saline, normal

  Glucagon

  Atropine

  Lidocaine

Other

  ECG machine

  Condition C cards

  Fire extinguisher

  Panic button

Note: Prices may vary depending on make, model, quantity ordered, and relationships with medical supply companies or hospitals. Med- ications are not priced here as quantities will vary based on needs assessment, office size, and proximity to an emergency department.

we revised our system of monitoring medications used for emergencies and assigned a staff member to this task.

An additional obstacle to running mock emergen- cies in a busy practice is pushback from staff who say it interrupts patient flow and disrupts those working in the clinic. This was the case at our practice, and getting buy-in was difficult at first. Attitudes changed, however, after a true medical emergency transpired, and our staff witnessed that things went smoothly. In this instance, a patient presented with chest pain and was having an acute myocardial infarction. Condition C was called. The patient was given aspirin, nitroglycerin, and oxygen. The electrocardiogram and flow sheet were copied and sent with the patient to the ED. The emergency physician subsequently called to compliment our clinic for the pre-

hospital care. By the time the patient reached the ED, the ST elevations were already resolving.

Worth the effort

Although implementing an emergency preparedness program is challenging, we believe it is a worthwhile and necessary addition to all family medicine offices. While infrequent, emergency situations do occur in office set- tings, and this program equips us to provide the best possible care for our patients. Implementing an office emergency preparedness program removes the anxiety of dealing with unusual issues, keeps necessary medications and equipment current and in working condition, and identifies problems prior to an actual emergency so that

A mock emergency evaluation form can help practices identify problems in their response prior to an actual emergency.

Creating an emer- gency prepared- ness program takes time but is worth the effort.

Having a program in place can reduce the anxiety associated with emergency

MOCK EMERGENCY EVALUATION FORM

Date of mock emergency: ___________________________________

situations and ultimately improve patient care.

they can be resolved. It also reduces the risk of malpractice suits arising from poor emergency care in an office setting.

The old adage “practice makes perfect” seems applicable. Though perfection is impos- sible, all clinicians and staff members must practice their response to medical emergen- cies in the outpatient setting so they are pre- pared should an actual emergency arise. Your

patient’s life may someday depend on it.

1.Toback SL. Medical emergency preparedness in office practice. Am Fam Phys. 2007;75(11):1679-1684.

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