The Emergency Physician and the Office-Based Pediatrician: An EMSC Team

ANTICIPATORY GUIDANCE

The office-based pediatrician should provide every patient and parent with information about appropriate access to the out-of-hospital system. Use of 911, a poison information resource, a method of obtaining after-hours advice, and a plan for responding to emergencies should be a part of the anticipatory guidance program offered in the medical home. Such a plan should include advice on how to recognize emergencies, where to obtain training in cardiopulmonary resuscitation, first aid, and injury prevention, when to call an emergency access number or the private office, the need for consent for treatment of minors, the need for a physician referral to access emergency services in some health plans, and what facility to access in a true emergency. When appropriate, the issues of advance directives and do-not-resuscitate (DNR) orders should be discussed with the family by the pediatrician before an emergency occurs.

It is the emergency physician's responsibility to reinforce proper access to triage and emergency advice as a part of discharge planning and coordination of ongoing care.

CARE MANAGEMENT

Coordination of services between the medical home and the emergency department is an essential element of quality care. The office-based pediatrician is ultimately responsible for continuity of care. The rapid increase in use of managed care plans has created barriers to timely access to emergency care for many patients. Managed care programs have a commitment to control cost, and one method of accomplishing this is to limit access to emergency care. Primary and emergency care professionals should work with managed care organizations to assure that seamless emergency care is included in health care contracts. The emergency physician and the office-based pediatrician should strive to reduce unnecessary emergency visits while providing comprehensive emergency care. An effective triage system that is mutually agreed on by both clinicians is an essential part of emergency care. Priorities for triage must include the parent's and patient's perception of an emergency, as well as identifying emergent and urgent needs. Triage decisions may, when appropriate, include urgent care alternatives to emergency care. Protocol-driven after-hours call systems are becoming a popular alternative for care management and triage. These services can be a valuable resource when quality and outcomes are monitored by medical oversight. Pediatric care managers should respond promptly to emergency department calls to prevent needless emergency department visits or delays in care. Likewise, the primary care clinician should be notified promptly when their patients are seen in the emergency department. The pediatrician and emergency physician must work together with third-party payors to eliminate barriers to care for true emergencies while being attentive to health care costs.

COMMUNICATION

The office-based pediatrician should make every effort to have background information on children with chronic diseases and special needs available to assist with appropriate emergency management. When addressing emergency problems of children with special needs, a detailed medical history, including status of advanced directives and DNR orders, may be required. Medical identification jewelry and patient-held emergency information summaries should be used to identify special care needs. The office-based pediatrician should notify the emergency care physician when referring pediatric patients. When feedback from the emergency physician may involve an on-call designee, the pediatrician who refers a patient for emergency care should notify the on-call designee also. The emergency physician is responsible for providing timely and legible feedback to the medical home about the treatment and disposition of the patient. Facsimile technology allows the emergency physician and the medical home to share information and management plans. Appropriate safeguards to access of records should be considered when there is electronic transfer of patient records. The medical home of the patient is the ideal setting for follow-up and ongoing care. The emergency physician should inform the office-based pediatrician of problems identified during the emergency department visit and discuss changes in medical management. The office-based pediatrician is responsible for coordinating care and accepting the patient in follow-up.

QUALITY EMERGENCY CARE

To offer a continuum of comprehensive emergency care for children, primary care health professionals must be prepared to manage pediatric emergencies. The same is true of out-of-hospital ambulance systems, general hospital emergency departments, interhospital transport systems, critical care, and inpatient and rehabilitative services. The office-based pediatrician should have knowledge of the pediatric capabilities of the emergency care system. Pediatricians should work to correct any deficiencies in the emergency care system in their communities. An emergency-ready medical home includes having the skills, medications, supplies, and equipment necessary for stabilization of a child's condition in an emergency, and preparation of the child for transport. Appropriate emergency care in the medical home is influenced by the time ordinarily necessary to access the emergency medical services system and the distance to definitive emergency care. Emergency departments must have appropriate equipment, supplies, and properly trained staff to manage pediatric emergencies. Assurance of a pediatric-ready emergency care system is the joint responsibility of the office-based pediatric health professional and the emergency physician. In large urban areas with organized emergency medical services (EMS) programs, involvement of pediatricians in prehospital care may be limited. However, many systems may need consultation from both the pediatrician and emergency physician. Both can offer valuable assistance with prehospital personnel education, assistance with pediatric emergency care protocols, and review of ambulance equipment and drugs. State, county, or municipal health departments often have the legal responsibility to provide prehospital EMS systems for a jurisdiction. Assurance that children's needs are met in these systems requires professional oversight and advocacy.