Confidence in performance of pediatric emergency medicine procedures by community emergency practitioners

Abstract

Objective: To survey a cohort of physicians who work in general community emergency departments (ED) in order to assess their comfort levels in performing urgent and emergent medical procedures on children.

Methods: One hundred seventeen emergency physicians were surveyed at 23 institutions within the referral base of Hasbro Children's Hospital, a tertiary care pediatric ED. Physicians rated their comfort levels (4-point scale: 1 = comfortable, 2 = moderately comfortable, 3 = uncomfortable but would perform in an emergency, 4 = uncomfortable and would never perform) for all procedures in which the American Academy of Pediatrics recommends competence for pediatric emergency physicians.

Results: Sixty (51%) physicians completed the survey. Residency training included internal medicine, family practice, surgery, general practice, pediatrics, and emergency medicine, while only 32 (53%) were Board certified in emergency medicine. All respondents treated pediatric patients. Over 25% were uncomfortable (level 3 or 4) with performing certain potentially life-saving pediatric procedures. These included cardioversion, defibrillation, external pacing, nasal intubation, needle cricothyrotomy, rapid sequence intubation, laryngoscopy, tracheostomy replacement, chest tube placement, vascular cutdowns, emergency childbirth, pericardiocentesis, intraosseous line placement, infant subdural and ventriculoperitoneal (V-P) shunt taps, and upper airway foreign body removal. Over 25% of respondents were also uncomfortable with non-life-saving procedures such as temperomandibular joint (TMJ) reductions, tooth reinsertions, rape evaluations, suprapubic taps, tympanocentesis, retrograde urethrograms, thoracentesis, paraphimosis reduction, ear foreign body removal, and pain management.

Conclusion: While emergency physicians within the catchment area of a tertiary care children's hospital feel comfortable with most pediatric procedures, they express a significant degree of discomfort with many potentially life-saving skills. Because of the infrequent need for many of these interventions in children, the high levels of discomfort are not surprising. These procedures may most comfortably be performed at pediatric centers but can be accomplished well at all EDs if personnel are adequately trained. A strong working relationship with pediatric emergency centers and an enhanced teaching of these procedures may increase comfort levels with these potentially life-saving measures.