Thesis Nurs. 1997 C769p
c.2
Coogan, Cynthia S.

Preparedness of Rural Health

Preparedness of rural
health clinics in
1997.

Crawford, Forest, and Venango Counties for
Pediatric Medical Emergencies

by
Cynthia S. Coogan RN, BSN

Submitted in Partial Fulfillment of the Requirements

for the Master of Science in Nursing Degree

Approved by:

W6-

.///// VM'C'
_____
Mary J/tSu^KeIler/ Ph.D., CRNP, RN

Date

Committee Chairperson of

Edinboro University of Pennsylvania
/_________________

Date

Z/uanet Geisel, Ph.D., RN

Committe Member
Edinboro University of Pennsylvania

Charles Edwards, Ph.D.

'

bate

Committe Member
Edinboro University of Pennsylvania

C
i\ f) V- k?

c

C-

Preparedness of Rural Health Clinics in
Venango, Crawford, and Forest Counties for
Pediatric Medical Emergencies.

Abstract

The purpose of this research study was to determine
if rural health clinics were adequately prepared for

pediatric medical emergencies. Preparedness was
determined based on availability of minimal basic

equipment, medications, and training as identified by the
Committee of Pediatric Emergency Medicine guidelines
(AAP, 1992). This study focused on rural health clinics

in Crawford, Forest, and Venango counties. Eleven clinics

participated. It was found that none of the clinics had

every piece of equipment, two of 11 (18%) had all

medications, and 18% had all the staff with Basic life
support certification. The preparedness scores ranged
from 35% to 89%, with no clinics reporting all the items

recommended for minimal preparedness.

Recommendations included increasing education of
primary care providers to better prepare the rural health
clinic environment. Further research studies, more

published literature, and legislation to establish

criteria for minimal equipment, medications, and training
were identified to improve preparedness.
ii

Acknowledgments

I would like to take this opportunity to express my

sincere appreciation to all those people who helped to
make this thesis possible. I would like to thank the

members of my thesis committee; Dr. Mary Lou Keller, Dr.
Janet Geisel, and Dr. Charles Edwards for their time,
energy, and direction. I would also like to thank Dr.
Alice Conway for her expert guidance and insight into

this important topic.

Thanks to Union City Memorial Hospital for piloting
my phone survey and to all the rural health clinics in
Crawford, Forest, and Venango counties which took the

time to participate in this study.
Lastly, I would like to thank my husband Terry, son

T.J., mother Judy, and friends Debbie, Mary Beth, Sue,

and Cheryl for their encouragement, patience, and

tolerance for listening to this thesis over the past
months.

iii

Table of Contents

Content

Page

Abstract

ii

Acknowledgment

iii

List of Tables

vi

Chapter I (Introduction)

1

Statement of the Problem

2

Theoretical Framework

2

Purpose of the Study

4

Assumptions

5

Definition of Terms

5

Limitations

9

Summary

9

Chapter II (Review of Literature)

11

Preguidelines

11

Guidelines

19

Postguidelines

20

Summary

23
25

Chapter III (Methodology)

Operational Definitions

25

Research Design

26

Sample

26

Data Collection

28
iv

Table of Contents

Content

Page

Data Analysis

28

Informed Consent

29

Summary

30

Chapter IV (Analysis of Data)

31

Participation

31

Total percentages

32

Preparedness scores

39

Preparedness for airway management

41

Preparedness for intubation

41

Preparedness for fluid management

44

Summary

44

47

Chapter V (Conclusion)
Discussion

47

Comparison of studies

48

Implications

56

Recommendations

58

Appendix
A: COPEM Guidelines

61

B: Telephone Survey

64

C: Script

69

v

Table of Contents

Page

Content

70

References

vi

List of Tables

Table/Title

Page

1: Survey Results for Equipment..
2: Survey Results for Medications

33
36

3: Survey Results for Training, Emergency Plan, and
Experienced Emergencies in last year.........

37

4 : Pediatric Medical Emergencies in last year

38

5: Preparedness Scores for Pediatric Medical
Emergencies

40

6: Preparedness Scores for Airway Management

41

7 : Preparedness Scores for Intubation

43

8: Preparedness Scores for Fluid Management

45

9: Distance to Emergency Room and Ambulance Response
Times

46

10: Comparison of Fuchs, Jaffee, and Christoffel (1989)
study findings to Current Rural Health Clinic

study

50

11: Comparison of Altieri, Belief, and Scott (1990) study
findings to Current Rural Health Clinic study

51

12: Comparison of Schweich, DeAngelis, and Duggan (1991)
study findings to Current Rural Health Clinic

study

54

13. Comparison of Flores and Weinstock (1996) study

findings to Current Rural Health Clinic study
vii

56

1

Chapter I

Introduction
The rural health clinic is of great importance to the
community in which it serves. Many rural health clinics

are located several miles from hospital and emergency

department services and are the closest place for
parents to seek care for a sick child. In times of
pediatric emergencies, Seidel (1986) found that

outcomes were directly related to the interval between
the precipitating event and critical support.
Recent changes in how patients access care will

directly affect primary care providers in rural health
clinics. Insurance companies, such as Alliance Health

Network, require participants to notify their primary
care provider prior to going to the emergency room
(Smith, 1996). Because of these changes the rural

health clinics will be caring for more acutely ill

children and more emergency situations. At the same
time Seidel (1986) found that outcomes in pediatric
resuscitations in the hospital and prehospital settings

is poor; unsuccessful resuscitation is the rule rather

than the exception. Schweich, DeAngelis, & Duggan
(1991) suggest that the information we obtain about

preparedness for common pediatric emergencies can help

2

us plan ways to improve resources. Educational updates,

recommendations for basic equipment, and management of
emergencies would be included. This information can be

of great benefit for the primary care providers in
rural health clinics. It can help identify strengths

and weaknesses and offer ways to improve services.

Statement of the Problem
Research has demonstrated that physicians office

settings are inadequately prepared for pediatric
medical emergencies. Unpreparedness for pediatric
medical emergencies is directly related to poor
outcomes in pediatric recussitation.

Theoretical Framework

Nightingale’s Environmental Theory of Nursing was

developed in the mid-1800's (Nightingale, 1992). The
core concept of her theory is the environment. She

defines the environment as all the external conditions
and influences affecting the life and development of an

organism and is capable of preventing, suppressing or
contributing to disease or death. With her experiences

during the Crimean War she focused on improving the
environment and because of this the death rate in
soldiers went from 42 per 100 to a low 22 per 1000

(Torres, 1980). This was evidence that by controlling

3

the environment you can have drastic outcomes for

improved health.

Nightingale (1992) stresses, throughout her Notes
on Nursing, that children have special needs because
they have a greater susceptibility to becoming

seriously ill quickly. Nightingale recorded that one of
every seven infants in England perished before the age

of seven and two in every five died before they were

five years old (Nightingale, 1992, p.6). She felt that
many deaths of children could be prevented with control
of the environment.

Nightingale states that the duty of every nurse is
prevention (Nightingale, 1992, p. 71). Her focus on
prevention was concentrated within the surgical

environment which she felt could be a determining
factor whether a patient would live or die. This

outcome was directly related to the patients physical
environment and within control of the nurse.

The environment of the rural health clinic can be
viewed within the context of Nightingales1 theory.
Proper pediatric emergency equipment, medications and

training of the staff are components under
environmental control. With control of the environment
through preparation for a pediatric medical emergency,

4

rural health clinics can provide optimal treatment to a
seriously ill child. Optimal treatment at the time of a
pediatric medical emergency would directly affect the
outcome for the child.

If this research study identifies that rural
health clinics are not prepared for pediatric

emergencies then implementation of Nightingale’s theory
would involve adjustments to inadequate environments.

This study would make recommendations for adjustments
in the rural clinic environment which will make it

safer for the pediatric patients who experience a

medical emergency.

Purpose of the study
The purpose of this study is to determine if rural
health clinics in Crawford, Forest, and Venango

counties are prepared for pediatric medical
emergencies. This study will focus on preparedness with

minimal basic equipment, medication, and training which

can promote positive outcomes following a pediatric
medical emergency.
Assumptions.

The assumptions for this study are that:
1

Rural health clinics care for pediatric

patients.

5

2. A rural heath clinic nurse or primary care
provider will answer the questions honestly.
3. By identifying preparedness the primary care
providers will be interested in improving their ability

to handle pediatric emergencies.

Definition of Terms

The definitions of the terms utilized in this
study have been obtained through the literature and are

identified as follows:
1. Rural Pennsylvania: The United States (U.S.)
Census Bureau defines rural as a municipality with a

population less than 2,500 and not contiguous to a
built-up urbanized area. If at least 50% of the
residents in the county fit this description, then the

Center for Rural Pennsylvania considers the county to
be predominately rural. Venango and Crawford counties

are listed as predominately rural, and Forest County is
identified as 100% rural, based on the 1990 Census

, (U.S. Census Bureau, 1990).

2. Pediatrics: Medical science relating to care of
children and treatment of their diseases (Thomas,

1986).

3. Primary Care Providers: Includes pediatricians,
family physicians, internists, nurse practitioners, and

6

physician assistants who provide comprehensive health
care services to meet the needs of the whole person
(Noble, 1996).

4 . Primary Care: Comprehensive health care that

patients receive from the same health care provider

over a longitudinal period of time (Noble, 1996).
5. Pediatric Medical Emergency: Acute/emergent

presentation occurs with no prior warning. The
presentation can also represent the initiation of a

critical time period in which intervention must occur

if treatment is to be successful (Luten, & Eoltin,
1993, p.6).
6. Pediatric Emergency Medical Equipment: Any
necessary equipment required to provide initial

treatment following a pediatric medical emergency

(American Academy of Pediatrics [AAP], 1992).
7. Basic Life Support for health care providers
(Course C)(BLS): Documented completion of a eight hour

course which teaches background information about
normal and dysfunctional cardiovascular anatomy and

physiologyA the principles of prevention and

recognition of acute cardiovascular disease, and the

technical aspects, including performance skills, of
cardiopulmonary management. There are three courses (A,

7

B, and C)r but only ths
more advanced ”C" module is

recommended for health care professionals. It includes
material on both adult and pediatric management.

Instruction includes adult one-rescuer BLS, child tworescuer BLS, and pediatric foreign body airway
obstruction management (American Heart Association
[AHA], 1990).

8. Advanced Cardiac Life Support (ACLS):

Documented completion of a 16 hour course, which

emphasizes the recognition and treatment of
cardiopulmonary failure, respiratory distress, and

shock in the adult patient (AHA, 1987).

9. Pediatric Advanced Life Support (PALS)

(offered

by the AAP and the AHA): Documented completion of a 16
hour course. It has been developed to teach management

during the early minutes after critical presentation of

the neonate, infant, child, or adolescent who has
suffered a severe, life-threatening medical crisis. It

provides the information needed for recognizing the
child at risk of cardiopulmonary arrest, strategies for
preventing cardiopulmonary arrest in pediatrics, and

reinforcement of the cognitive and psychomotor skills
necessary for resuscitating and stabilizing the infant

8

or child in respiratory failure, shock,
or

cardiopulmonary arrest (AAP, 1992).
10. Advanced Pediatric Life Support (APLS)
(offered by the AAP and the American College of

Emergency Physicians): Documented completion of a 20

hour course which provides detailed survey on the
evaluation and management of pediatric medical and

surgical emergencies. The course content is primarily
oriented toward emergency diagnosis and response.

Knowledge and practice of pediatric resuscitation
during the early minutes are reviewed. This experience
is incorporated into the care of specific illnesses and

trauma for the period the patient is being stabilized
in the Emergency Department (AAP, 1992).

Limitations

The limitations to this study are that there have
only been four published studies investigating the
preparedness of office pediatricians for dealing with

medical emergencies. Of these four studies, three were
completed in the late 1980’s and one was done in 1996.

There have been no studies which have investigated the
preparedness of the primary care providers in the rural

health care clinics for pediatric emergencies. Another
limitation was the use of a convenience sample which is

9

three rural counties in
Pennsylvania which may not
reflect national trends. A further limitation was that
only 11 rural health clinics gave informed consent and

met all the criteria to be included in this study. This
small sample may not represent the entire population.

The criteria for equipment and training that was

identified for minimal preparedness was based on
criteria from the most recent standard textbook

guidelines (AAP, 1992).
Summary
Rural health clinics will be providing critical

support for pediatric emergencies. The amount of
preparation of these clinics will have a direct impact
on the outcome of the pediatric emergency. This study

is intended to evaluate the preparedness of rural
health clinics for these emergencies. The assumptions,
definitions, and limitations have been identified in

relation to this study.
Nightingales’ theory can help us better prepare

rural health clinic environments for pediatric medical
rgencies

Adequate training, basic medical eguipment

and medications allows the rural health clinic to

obtain the optimal environment. This preparation
increases their ability to perform in a pediatric

10

medical emergency. With the goal of preparing all rural
health clinics for potential pediatric medical

emergencies we may give a critically ill pediatric
patient a better chance of survival.

11

Chapter II

Review of Literature

This historical review of the literature

identifies studies conducted to determine office

preparedness for pediatric medical emergencies. The

framework for this review of literature will focus
first on studies conducted prior to published

guidelines from the AAP. This review will then look at
the only study conducted since the 1992 published

guidelines to determine their impact on office
preparedness for pediatric medical emergencies.
Preguidelines

In 1988 the American Academy of Pediatrics
Committee on Pediatric Emergency Medicine (COPEM)
published a statement on the Pediatrician’s role in
emergency medical services for children. They stated
that primary care pediatricians needed to establish

networks with hospital-based pediatricians, emergency
physicians, pediatric surgeons, and other pediatric
rnadical and pediatric surgical specialists so that

there is clearly assigned responsibility for provision
of pediatric emergency care. This statement also

identified the importance of specific objectives of
emergency medical services for children (EMS-C). This

12

EMS-C system would be comprehensive and designed to

meet the unique needs of children and should be
constant even though available resources may vary from
region to region. COPEM felt that for an EMS-C system

to be most effective, practitioners needed to develop

the knowledge, skills, attitudes, and experience
necessary to provide essential life support for ill and
injured children (AAP, 1992).

In 1989, Fuchs, Jaffee, and Christoffel conducted
the first study which investigated the frequency with

which physicians encountered pediatric emergencies in
the office setting. This study was designed to assess

the availability of specific equipment, medications and
resuscitation training of the office staff. They also

determined the characteristics of practitioners and
practices that are related to preparedness for
pediatric emergencies, and provided information that

suggested future research relevant to the development

of guidelines for office preparedness. This study was
conducted on a sample of 780 pediatricians and family

practice physicians within a 40 mile radius of Chicago

which included city, surrounding suburbs and few if any
rural areas. There were 280 participants in this study
and the respondent rate was 36%.

13

Preparedness scores were obtained by a point
scale. The researcher gave one point for specified

items present in the office and two points for items
essential for pediatric emergencies (Fuchs et al.,

1989). The total maximum possible score was 156. They
found that the overall preparedness score was 53.7.

This study also measured the items required to manage

acute asthma, anaphylaxis, sickle cell vasoocclusive
crisis, status epilepticus, sepsis, and trauma. The

data demonstrated that fewer than one third of the
offices were fully equipped to treat these emergencies.
Two factors found to contribute significantly to

overall preparedness scores were type of practice and
ACLS certification. The large multispecialty practices
with physicians trained in ACLS scored 112.8 for

preparedness compared with solo practices lacking ACLS

certification which scored 38.1.
Family practitioners tended to have a more
complete stock of medications as compared to

pediatricians. Respondents reported that each week they
examined more than one child in their offices who

required emergency treatment or subsequent
hospitalization. Many pediatric emergencies involved
disturbance in respiration and most cardiopulmonary

14

arrests in children are the result of hypoxia (Fuchs et

al., 1989). Variables such as distance to the hospital,

paramedic response time, number of years in practice,
number of critically ill patients seen per week or in a

three month period, and BLS or advanced trauma life
support (ACLS) certification did not contribute

significantly to preparedness scores.

Limitations for their study were identified as
respondent return rate and geographic location. Because

of limitations they considered their report to be
exploratory. Fuchs et al. (1989) felt there was no bias

which preparedness would have been underestimated. They
identified the need for further study to broaden the

generlizability of available information to office
emergency care. They also stated that the data

suggested the need for guidelines for office
preparedness which could address issues of physician
training and regional and local variations, as well as

specifying office equipment and medications necessary
and desirable for effective intervention in unexpected
pediatric emergencies (Fuchs et al., 1989).

Altieri, Belief, and Scott (1990) conducted their
study throughout metropolitan Washington DC. This study
looked at private pediatric office readiness for

15

emergencies with respect to equipment, education, and

prior experiences with emergencies in the primary care
setting. This survey agreed with the Fuchs et al.,

(1989) study, that life-threatening emergencies do
occur in pediatric offices. The most commonly

identified pediatric medical emergencies were
respiratory distress and seizures (Altieri et al.
1990) . Patients with obstructed airways and shock were

not uncommon. Cardiac arrests and major trauma were
seen rarely in the office setting. These findings

substantiate the Fuchs et al. (1989) study that the

most common office emergencies are severe respiratory
distress.

Altieri et al. (1990) found that only 50% of the
physicians had a predetermined or formalized plan for
managing such emergency cases. BLS certification by

some member of the office staff was 77% and 25% had an
office staff member with ACLS. They made the following

recommendations to pediatricians and any physicians
caring for children in an office setting to help them

prepare; it should be the goal of all practices caring
for children to have all staff trained and certified
with the American Heart Association (AHA) in

cardiopulmonary resuscitation, basic life support.

16

Physicians should take advanced cardiac life support
courses such as PALS, or APLS, and have a formal

emergency plan and assign each office staff member a
specific task. These assignments would include making
emergency equipment available to the physician and

accessing emergency medical services.
A list of recommended equipment and medications

was developed by Altieri et al.(1990) that should be
available to any practitioner rendering care to the

pediatric patient. They state that this list would need

to be revised to accommodate practices in rural
settings and areas with prolonged emergency medical
response times. They also recommend that office

practitioners be familiar with the community emergency
services available and their level of training

(Altieri, et al., 1990).
A study designed to determine how well prepared

and confident non-hospital-based pediatricians are to

manage pediatric medical emergencies was conducted by
Schweich, DeAngelis, and Duggan (1991). They received
427 completed questionnaires from 1000 randomly
selected, non -hospital-based pediatricians across the

United States Fifty percent of these were located
within one mile of an emergency department. They found

17

that more than half of the pediatricians surveyed
stated that at least 50% of their office visits were
for acute illnesses such as meningitis, severe asthma,

severe dehydration, and status epilepticus in the
office.
Schweich et al. (1991) determined medications and
equipment needed for stabilization of airway,

breathing, and circulation. They specifically measured

the availability of oxygen, bag-valve-mask, suction,

oropharyngeal or nasopharyngeal airways, laryngoscope,
and endotracheal tubes, blood pressure cuff, and

intravenous fluids in each of the practices in their

sample. The results determined that solo practice

pediatricians had only 16% of each piece of equipment

and medication listed, group practice had 74%, and
health maintenance organizations had the most at 84%.

In the conclusion of their study, they, like Fuchs et

al.

(1989), found that solo practice pediatricians had

the least equipment and medications compared to larger
groups which were more likely to have each piece of

equipment.
Schweich, et al.

(1991)/ found that pediatric

confidence in managing the initial stabilization of
emergencies was directly related to availability of

18

equipment in the office. Pediatricians in solo or group
practices with equipment were significantly more

confident than those in the same setting without the
equipment. Pediatricians who had equipment reported ■a

confidence rating of 75% for meningitis as compared

with a solo practice without equipment reporting a

confidence rating of 40%. Physicians that recently
finished residency or had APLS, or ACLS training

reported higher confidence ratings for all pediatric

medical emergencies. They also found that 50% of all
physicians reported higher confidence levels when they

were in the emergency room as compared to the office
setting. Pediatricians who had all the basic equipment

no matter what type of primary site were found to be
much more confident managing emergencies. They also

found that 28% of the physicians reported confidence in
managing cardiopulmonary arrest and only 25% reported

confidence for epiglottis.

The recommendations made by Schwich et al.(1991),
emphasize the importance of education in order to keep
the pediatrician and his/her staff prepared for

emergencies. They also stress the need for guidelines
to determine equipment needed for common office
emergencies (Schweich, et al., 1991).

19

Guidelines
In 1992 the AAP published a manual, Emergency

Medical Services for Children: The Role of the Primary
Care Provider. The Committee on Pediatric Emergency
Medicine (COPEM), stated that inadequate attention has

been given to the office as an emergency care site
(AAP, 1992) . Many physicians report multiple medical

emergencies in the office such as anaphylaxis,
seizures, insulin reactions, shock, obstructed airways,

and respiratory distress (AAP, 1992). Physicians are
responsible to ensure that staff have the knowledge,
training, and resources to respond to office

emergencies (AAP, 1992). The COPEM suggested the
development of a triage program for pediatric practice

including telephone and waiting room guidelines,
identifying the appropriate actions for the staff to
take at the time of a medical emergency. COPEM stated

that enrollment in BLS should be mandatory for all

office employees and the medical office personnel
should be able to initiate advanced life support (ALS),

so they need courses in PALS or APLS. COPEM suggests,

that individual practices should make a list of
illnesses and treatments which would include

respiratory distress, including stridor and wheezing;

20

shock, including dehydration and sepsis; anaphylaxis;
seizures; insulin reactions; apnea and syncope.

Development of specific protocols with step-by-step
instructions for managing each illness was recommended.
They suggest assigning roles prior to an emergency so

everyone is aware of their responsibility during an
emergency. The COPEM developed guidelines which

identified the basic equipment and medication needed to
treat the most common medical emergencies. They stress

the importance of inspecting expiration dates on
medication and equipment weekly or biweekly and to

document this information. A drug dosage chart based on
height or weight of the child should be readily

available and equipment should be organized based on

size. COPEM stated that the key point is organization
prior to an office emergency so that the situation can

go as smoothly as possible.
Post guide lines.

In March 1996, the latest study was published
about office preparedness for pediatric emergencies
(Flores, & Weinstock, 1996). This study was conducted
in Fairfield County located in Connecticut which is the
in the United States. Fairfield
most affluent county
population with many children,
county contains a large

21

numerous pediatric office practices, and no children’s
hospital (Flores, & Weinstock, 1996).

This study found that 82% of the practices

surveyed experienced at least one pediatric medical
emergency monthly (Flores, & Weinstock, 1996). Analysis

of office preparedness to care for the most common
life threatening pediatric emergencies was included in

this study. Flores and Weinstock used the research
findings of Altieri, Belief, and Scott (1990), which

identified status asthmaticus, upper airway
obstruction, shock, trauma, status epilepticus,

endocrine emergency, and cardiac arrest as the most
common pediatric emergencies. Flores and Weinstock
(1996), identified four categories to evaluate the
preparedness of an office practice to care for each of

the seven most common pediatric emergencies. The first
category looked at the presence of the minimum

equipment including medications needed to stabilize and
initially manage the patient. The second category
identified the presence of a combination of the minimum
required equipment and training such as BLS or PALS.
Presence of equipment reflecting a high level of
preparedness was the third category and the fourth

22

category was the presence of equipment and training
reflecting a high level of preparedness.

Flores and Weinstock (1996) found that 73% of the
pediatric offices were well equipped for status
asthmaticus . Fewer than one third of the offices were

prepared for each of the remaining six emergencies, and
only 6% of the offices demonstrated preparedness for

endocrine and cardiac emergencies. Most offices did not
have the equipment or training to be considered
prepared at a high level for any of the identified
emergencies.

Flores and Weinstock (1996) resurveyed the office
practitioners after collection and analysis of data to

determine reasons given by pediatricians for lack of
office preparedness. Pediatricians identified most
often that emergencies rarely occur in the office

setting. Another reason stated by pediatricians was

that they did not have the time to assemble equipment,
medications, and to train staff. Cost was also

identified as a deterrent for having equipment,

medications and staff training. Pediatricians with
offices in close proximity to a hospital stated they
had no need for emergency equipment because of

23

location. The last reason identified was the perception

of adequate preparation.
Flores and Weinstock (1996), make the following

recommendations to increase office preparedness. They
suggest that residents should be educated about
preparation for pediatric emergencies that commonly
occur in the office and the importance of maintaining

PALS certification. Continuing medical education

courses need to be offered, focusing on emergency
office preparedness with refresher skills. Flores and

Weinstock (1996) acknowledge that guidelines have been
published by the COPEM of the AAP and the Institute of
Medicine for recommended equipment and training but

they feel that more publication in the pediatric
journals would increase pediatric awareness.
Summary

This historical literature review has focused on
office preparedness for pediatric medical emergencies,

The samples identified in these studies were located
mainly in cities and urban areas with very little
representation from rural populations.

Four research studies have been conducted to
for pediatric medical
determine office preparedness
of the studies were conducted in
emergencies. Three

24

1980. These studies all recommended that guidelines be
developed to help pediatric and physician offices to

become better prepared with equipment, medications, and

training. The Committee on Pediatric Emergency Medicine
published guidelines, in 1992, in response to these

research findings. In 1996 the study conducted by

Flores and Weinstock, reported that even with the COPEM

1992 guidelines available, office preparedness for
pediatric emergencies continues to be a major problem.

25

Chapter III

Methodology
This descriptive study was designed to gather

baseline data to determine ■preparedness of rural health
clinics in Crawford, Forest, and Venango counties for

pediatric medical emergencies. This research study

measured the presence or absence of minimal basic
equipment, medications, and training as identified by

the COPEM in 1992. The researcher did not manipulate
the variables in anyway.
Operation Definitions

The operational definitions are defined by the

researcher and determine the criteria for inclusion in
this study:

1. A rural health clinic is (a) any office or

clinic that is located within a rural community at
least 10 miles from a hospital,

(b) managed by a

primary care provider, and (c) cares for pediatric

patients.
2. Pediatric Emergency Medical Equipment for
minimal preparedness is identified by the COPEM

guidelines (AAP, 1992)

(Appendix A) .

26

3. Medications for minimal preparedness for
pediatric medical emergencies is identified by the

COPEM guidelines (AAP, 1992) (Appendix A) .

Research Design
A non-experimental design was utilized for this

descriptive research study. Ratio data was collected

and analyzed. This descriptive study was devised to
ascertain if rural health clinics in Crawford, Forest,

and Venango counties are prepared with minimal medical
equipment, medications, and training needed for initial

stabilization of pediatric medical emergencies. The
study utilized a questionnaire based on standard

guidelines for equipment, medications, and training
required for minimum preparedness for pediatric medical

emergencies identified by the COPEM (AAP, 1992)

(Appendix A).
Sample

A convenience sample of 37 rural health clinics

located in Crawford, Forest, and Venango counties was
utilized for this descriptive study. The sample was
obtained by calling the physicians referral service at

,. -i papf-pr
Medical Center, and
Northwest Medical
Center, Meadville
utdu
..
relations department at Titusville Area
the
community reiaiiuno
Medical Center, Oil City Campus
Hospital. Northwest

27

along with the Franklin Campus are located in Venango
County. Meadville Medical Center, and Titusville Area
Hospital are located in Crawford County. These
hospitals offer the only emergency services located in
these counties.
A list of current primary care providers that

refer to each of the hospitals was obtained from the

referral services of each hospital. They identified
type and general proximity of each clinic to their
hospital. This information allowed for a preliminary
elimination of clinics located within a 10 mile radius
to any of the hospitals. Current physicians directories

were utilized from each of the hospitals to cross

reference with the list obtained from the referral
services.

The first criteria to be met for this nonexperimental descriptive study was that the clinic must

be located in a rural community at least 10 miles away
from any hospital with emergency room services. The
second criteria for inclusion in this study was that
the clinic is managed by a primary care provider. The

third criteria necessary to be included in this study
for pediatric patients.
was that the clinic must care

28

Data Collection

Descriptive data was collected by a telephone
survey. This survey was developed from information
obtained from the literature review. Basic emergency
equipment, medications, and training for offices as

suggested by the COPEM and latest guidelines on
pediatric life support were measured by this survey.
This survey consists of 52 yes/no questions, and 10

general questions. It was submitted to a pediatric

nurse specialist for expert review. The survey was

revised as per expert recommendations.

The revised survey was piloted at a Northwestern
Pennsylvania hospital emergency room on 12/8/97 with

the nursing supervisor. The survey took 15 minutes to
complete. The pilot also demonstrated the survey to be
understandable (Appendix B) .

Data Analysis.

The data analysis involved:
1. Calculating total percentages of all the

clinics for the presence of (a) each piece of
available medication, (c) an
equipment, (b) each
of office staff with Basic
Emergency plan, (d) number

Life Support (BLS) certification,
staff with

(e) number of office

Advanced Cardiac Life Support(ACLS)

29

certification,

(f) number of office staff with
Pediatric Advanced Life Support (PALS) certification,

(g) percentage of offices experiencing one or more
pediatric medical emergency within the last year, and
(h) percentage of each type of pediatric medical
emergency.

2. Obtaining preparedness scores by listing (a)

minimal recommended medical equipment,

(b) minimal

recommended medications, (c) minimal recommended

training required for initial stabilization of
pediatric medical emergencies.

3. The percentage of clinics that were prepared
for (a) airway management,

(b) intubation, and (c)

fluid management were determined.

Informed Consent.
Informed consent was obtained with the use of
a script (Appendix C). The script was designed to

introduce the researcher and to identify the purpose of
It informed
this study to potential participants.
participants that information obtained by the survey
Participation was
was anonymous and confidential.
could change their mind about
voluntary and they
during the study by verbal
participation at any time
researcher (Appendix C) .
notification to the

30

Summary
This descriptive study determined if rural health
clinics in Crawford, Forest, and Venango counties were
prepared for pediatric medical emergencies. The sample
consisted of clinics located in rural communities that

provide care to pediatric patients. These clinics were
located at least 10 miles from the nearest hospital
with emergency services.

Data was collected by a telephone survey which was

reviewed by a specialist in the field of pediatrics and
piloted for understanding at a hospital emergency room
not affiliated with the counties being studied.

Informed consent was obtained prior to administering
the telephone survey. This consent was included within
the script (Appendix C).
The data collected from this descriptive study

identified the percentage of clinics prepared and not

prepared with recommended equipment, medications, and
training. Data identified the percentage of clinics
prepared for airway, fluid, and intubation management.

Trends in the rural health clinics for office
for thoes emergencies were
emergencies and preparedness
identified from the research results.

31

Chapter IV
Analysis of Data

This chapter evaluates the data collected to
determine preparedness of rural health clinics in
Crawford, Forest, and Venango counties for pediatric
medical emergencies. The data was collected

by the

researcher with use of the telephone survey (Appendix

B) .

Participation
Thirty-seven rural health clinics located in
Crawford, Forest, and Venango counties were identified

as potential participants for purposes of this study.

From the 37 rural health clinics first included in this
study 18 did not meet the study criteria outlined. Of
those 18 clinics 16 were located within 10 miles from a

hospital with emergency room services and two were
eliminated because they did not care for pediatric
patients. There were eight refusals to participate in

this study. These eliminations reduced the sample size
to 11 rural health clinics located in Crawford, Forest,
and Venango counties which met all the criteria and
be included in this study. The
gave informed consent to
participation rate for this study was 42%.

32

Total percentages

The data collected from the telephone
survey
demonstrated that of the 11 rural health
clinics
surveyed, none (0%) had each piece of equipment (Table
1), and only one out of 11 (9%) had all of the
medications (Table 2) . The total percentage of clinics
with an emergency plan was 82%, nine out of 11 (Table

3). Rural health clinics that reported all office staff

with Basic Life Support (BLS) certification was two out

of 11 (18%). All (100%) of the 11 clinics reported some
staff member certified in BLS. Advanced Cardiac Life
Support (ACLS) certification for primary care providers

was 100%, with three registered nurses trained from all
the clinics (27%). Primary care providers with PALS
certification was six out of 11 (55%) and nursing staff

with PALS certification was 9% or only 1 out of 11

(Table 3).
Two clinics out of 11 (18%) reported experiencing
pediatric medical emergencies within the last year,
Both clinics identified respiratory distress as the
pediatric medical emergency they experienced. They

identified status asthmaticus, meningitis, and
anaphylactic shock as the other types of pediatric
medical emergencies (Table 4).

33

Table 1

Survey—Results for Equipment
Item

Yes—No

% of clinics

with item
Oxygen

9

2

82%

Infant mask

8

3

73%

Child mask

9

2

82%

Adult mask

9

2

82%

Infant Bag-Valve-Mask

7

4

64%

Child Bag-Valve-Mask

8

3

73%

Adult Bag-Valve-Mask

11--- 0

100%

Oxygen Cannulas

7

4

64%

Nebulizer

8

3

73%

Suction

7

4

64%

Suction Catheters

6

5

55%

Oral Airways

9

2

82%

Miller Blades

8

3

73%

Laryngoscope

9

2

82%

Endotracheal Tubes

7

4

64%

34

Table 1

(continued)

Survey Results for Equipment
Item

Yes—No

% of clinics

with item
Stylets

8

3

73%

Magill Forcepts

2

9

18%

Intraosseous Needles

4

7

36%

Intravenous Catheters

10--- 1

91%

Butterfly Needles

11--- 0

100%

Intravenous Arm Boards

5

6

45%

Tape

11--- 0

100%

Alcohol Swabs

10--- 1

91%

Tourniquet

9

2

82%

Pediatric Drip Chambers

4

7

36%

Intravenous Tubing

11--- 0

100%

Ringers & Normal Saline

10--- 1

91%

Blood Pressure Cuffs

7

4

64%

Nasogastric Tubes

4

7

36%

Feeding Tubes

5

6

45%

Foley Catheters

7

4

64%

35

Table 1 (continued)

Survey Results for Equipment

Item

Yes—No

% of clinics

with item
Broselow Tape

3

8

27%

Pediatric Backboard

6

5

55%

Association Handbook

8

3

73%

Monitor/Defibrillator

3

8

27%

Pulse Oximeter

5

6

45%

American Heart

36

Table 2

Survey Results for Medications

Item

Yes—No

% of clinics

with item

Albuterol

10--- 1

91%

Epinephrine

8---- 3

73%

Sodium Bicarbonate

8

3

73%

50% Dextrose

7

4

64%

Atropine

8

3

73%

Lorazepam

5

6

45%

Sterile Water

10--- 1

91%

Methylprednisone

11--- 0

100%

37

Table 3
Survey_Re suits—far Training , Emergency Plan , and
Experienced Emergencies in last year

Item

Yes—No

% of clinics
with item

Training of some staff member
Basic Life Support

11--- 0

100%

11--- 0

100%

6

5

55%

2

9

18%

1--- 10

9%

Advanced Cardiac

Life Support

Pediatric Advanced
Life Support
Advanced Pediatric

Life Support
Mock Codes
Emergency Plan

9

2

82%

Experienced Emergencies

2

9

18%

all staff members with
Note - Two clinics reported
certification.
Basic Life Support

38

Table 4
Pediatric Medical Emergencie s Experienced in last year

Clinics

G

# of emergencies

2

Types of emergencies

1. Respiratory Distress
2. Anaphylactic Shock

M

3

1. Respiratory Distress

2. Status Asthmaticus
3. Meningitis

39

Preparedness scores

Preparedness scores were determined by the total number
of each piece of minimal basic equipment, medications,
and training to the level of PALS (Table 5). The total
score possible for minimal preparedness for pediatric

medical emergencies was 46. The rural health clinic
scores ranged from 16 to 41 which represented item

preparedness scores of 35% to 89%. Three of the 11
clinics scored 41 out of 46 (89%) and one clinic scored

17 (37%). No clinics reported having all the items
recommended for minimal preparedness for pediatric

medical emergencies (Table 5) .

Preparedness scores for the two clinics which

reported pediatric medical emergencies were 40 (87%)

for Clinic M and 30 (65%) for Clinic G. Clinic M
reported the most emergencies, with three experienced
during the last year. Clinic M scored 87% for minimal
preparedness (Table 5). They also reported having a

portable monitor defibrillator, and pulse oximeter
which demonstrates a higher level of preparedness.

(27%) had a portable monitor
Three clinics of the 11
(45%) had a pulse
defibrillator and five of the 11
oximeter (Table 1)•

40

Table 5
Preparedness Scores for Pediatric Medical Emergencies
Clinic

Possible score

of 46

% of total equipment,
medications, & training

F

32

70%

G

30

65%

H

17

37%

I

41

89%

J

41

89%

K

41

89%

L

16

35%

M

40

87%

N

34

74%

0

32

70%

P

33

72%

41

Preparedness for airway management
Preparedness scores for airway management were
based on survey questions five
to 16 for a possible
score of 12 (Appendix B) . The scores ranged from two to
12 (Table 6) . The number of rural health clinics
prepared for airway management with all the equipment
was three out of 11 (27%). Three clinics scored 11 out

of 12 (92%), and two clinics scored two out of 11
(18%). Seven (64%) had scores ranging from 10 to 11

which equates to 83% and 100% of the equipment
available for airway management (Table 6) .

Preparedness for intubation
Preparedness scores for intubation were based on

survey questions 17 to 21 (Appendix B) for a possible
score of five and the scores ranged from zero to five
(Table 7). The survey demonstrated that only one clinic

out of the 11 had each item. The most frequently
occurring score from the 11 clinics out of the possible

five was four. This represents having 80% of the items
for intubation. Two
required for minimal preparedness
of the equipment available
of the 11 clinics had none
for pediatric intubation (Table 7).

42

Table 6

Preparedness Scores for Airway Management
Clinic

Possible score

of 12

% of the

equipment available

F

7

58%

G

8

73%

H

2

18%

I

12

100%

J

12

100%

K

12

100%

L

2

18%

M

11

92%

N

11

92%

0

11

92%

P

10

83%

43

Table 7

Preparedness Scores for Intubation
Clinic

Possible score

of 5

% of the
equipment available

F

5

100%

G

3

60%

H

0

0%

I

4

80%

J

4

80%

K

4

80%

L

0

0%

M

4

80%

N

4

80%

0

2

40%

P

4

80%

44

Preparedness for fluid management
Preparedness scores for fluid management were
based on survey questions 22 to 31 for a possible score
of 10 (Appendix B). There were no rural health clinics

which reported having all the items identified for

preparedness of fluid management (Table 8). Scores from
the 11 clinics ranged from six to nine. These are
represented by the clinics having 60% to 90% of the

equipment available for fluid management (Table 8).

Summary

The analysis from this baseline data has
demonstrated that rural health clinics surveyed in
Crawford, Forest, and Venango counties are not prepared

for pediatric medical emergencies, according to the

COPEM (AAP, 1992). This level of unpreparedness by
rural health clinics for pediatric medical emergencies
is alarming. The clinics are located with a range of 10

to 20 miles from the nearest hospital with emergency

room services. They reported ambulance response times
ranging from three to fifteen minutes (Table 9). When
experiencing a pediatric medical emergency, precious
minutes and availability of basic equipment,
,. . .
medications,
ano training
Lidinmy can make the difference

between life and death.

45

Table 8

Preparedness Scores for Fluid Management
Clinic

Possible score

% of equipment

of 10

available

F

7

70%

G

8

80%

H

6

60%

I

8

80%

J

8

80%

K

8

80%

L

7

70%

M

9

90%

N

7

70%

0

8

80%

P

9

90%

46

Table 9

Distance to ■Emerflgncy Room £l Ambulance Response Time
Clinic

Miles from emergency

room service

Ambulance response
time in minutes

F

12

5-8

G

16

8

H

12

I

20

5

J

20

5

K

20

5

L

15

3-5

M

10

5-10

N

14

3-5

0

20

3-5

P

10

3-5

5-15

47

Chapter V
Conclusion

The purpose of this study was to determine if
rural health clinics in Crawford, Forest, and Venango

counties were prepared for pediatric medical
emergencies. This study focused on the availability of
minimal basic equipment, medications, and training as

recommended by the Committee of Pediatric Emergency
Medicine (COPEM). This chapter compares results from
this study to past studies identified in the literature
review. Recommendations are made based on study results

and Nightingale’s theory of Nursing (Nightingale,

1992).
Discussion

The results from this descriptive study
demonstrated that rural health clinics in Crawford,
Forest, and Venango counties were not prepared for
pediatric medical emergencies. The item preparedness

scores ranged from 16 (35%) to 41 (89%) from a possible
score of 46. This study identified no clinics with all

the recommended equipment, medications, and training

(Tables 1, 2, and 3).

48

Cornparison of studies
Past studies identified by the literature review
demonstrated that approximately one-third (33%) of
clinics were prepared for pediatric medical emergencies
(Altieri, Belief, & Scott, 1990; Flores, & Weinstock,

1996; Fuchs, Jaffe, & Christoffel, 1989; Schweich,
DeAngelis, & Duggan, 1991). These studies identified by

the literature review obtained their samples from
cities and urban areas with very few if any rural areas
included. The present study is the first to focus on

measuring preparedness of rural areas for pediatric

medical emergencies.

The first study to determine preparedness of
physician offices for pediatric medical emergencies was
conducted by Fuchs, Jaffee, and Christoffel in 1989.

Fuchs et al.

(1989) found scores for preparedness

ranging from five to 136 from a maximum score of 156.

They identified the mean score for overall preparedness
as 53.7 (34%). Fuchs et al. determined that many
pediatric emergencies were respiratory in nature. Their
study identified that 91% of the offices reported

caring for asthma emergencies greater than one patient

a week. They evaluated the availability of equipment
and medications related to airway management. Of the

49

280 participants, 117 (42%)

of offices surveyed had

availability of oxygen, bag-valve-mask 100
(36%),
epinephrine 246 (88%), and inhalation agents 123 (44%).
In comparison the results from the current study found

no clinics with all the equipment recommended for
minimal preparedness. The scores identified from the

current study ranged from 16 (35%) to 41 (89%) out of
46 (100%) . The current study found that respiratory

distress was reported by both Clinic G and M as
occurring during the last year (Table 4). It also
identified from the 11 rural health clinics surveyed

that oxygen was available in 9 (82%) of the clinics.
Bag-valve-mask capability for infants and children 8

(73%), and 9 (82%) respectively from the 11 clinics

surveyed. Eight (73%) of the clinics reported having
epinephrine, and 10 (91%) had inhalation agents,

nebulizers were available in 8 (73%) of the clinics

surveyed (Tables 1 and 2) . Comparisons are depicted in
Table 10.

Altieri, Belief, and Scott (1990) found that only

50% of the 175 physicians surveyed had a predetermined
Clinics in
plan for managing pediatric emergencies,
certification by some office staff
their study reported
in basic life support (BLS) »as 135 (77%) and 44

50

(25%) had an office staff member with advanced cardiac
life support (ACLS) . In comparison this rural health
clinic study determined that 9 (82%) of the 11 clinics
reported having an emergency plan (Table 3). The

current study identified that 100% of the clinics had

someone certified in BLS and ACLS (Table 11).

Table 10

Comparison of Fuchs, Jaffee, and Christoffel (1989)
study findings to Current Rural Health Clinic study.

Measured Items

Fuchs, Jaffee,

Rural Health

& Christofel

Clinic

Sample size

280

11

Respondent rate

36%

42%

Preparedness Score

34%

0%

Oxygen

42%

82%

Bag-Valve-Mask

36%

64% infant

73% child
Epinephrine

Inhalation agents
Nebulizer

88%

73%

44%

91%

unknown

73%

51

Table 11

Comparison of Altieri. ■Bellet r and Scott (1990) study

findings to Current Rural Health Clinic study.

Measured Items

Altieri, Belief,

& Scott

Rural Health

Clinic

Sample size

175

11

Respondent rate

40%

42%

Emergency plan

50%

82%

BLS certification

77%

100%

ACLS certification

25%

100%

PALS certification

unknown

55%

Note. Basic Life Support (BLS), Advanced Cardiac Life
Support (ACLS), and Pediatric Advanced Life Support
(PALS). These scores were based on certification by

some office staff member.

52

chweich, DeAngelis, and Duggan conducted

a study determining how

prepared and confident non­

hospital-based pediatricians
were to manage pediatric
medical emergencies. Four-hundred-twenty-seven office
based pediatricians participated in the Schweich et al.

(1991) study. From the 427 offices, 346 (81%), reported

availability of oxygen, they also reported bag-valvemask capabilities in 342 (80%) of the offices, suction
present in 269 (63%), oral airways 346 (81%), blood

pressure cuffs 256 (60%), and intravenous fluids 282

(66%) in the practices they surveyed. The proportion of
pediatricians having each piece of equipment or drug

available in the office ranged from 47 (11%) to 414
(97%) . They further included in their study

relationships between availability of equipment and the
type of practice. They determined that larger group

practices had more complete availability of equipment

and medications. Eighty-four percent for health
maintenance organizations and 74% for group practice
pediatricians, compared to 16% for solo practice

pediatricians. In comparison the current study found
rural health clinics 9 (82%) reported
that from the 11
availability of oxygen, bag-valve-maaks were available
for infants

in 8 (64%) and children 9 (82%) of the

53

clinics surveyed. The
survey also found that suction
was present in 7 (64%) of the
11 clinics, oral airways
in 9 (82%) , blood pressure cuffs in 7 (64%),
intravenous fluids 10 (91%), from the 11 clinics
surveyed (Table 1). This current study did not

specifically measure the rural health clinics to
determine if they were solo or group practices. The
current study did determine that no rural health

clinics reported having each piece of equipment and
medication available the range was 16 (35%) to 41 (89%)
out of 46 (100%)

(Table 5). The current data suggests

that rural health clinics

were less prepared for

pediatric medical emergencies than solo practice

physicians. Table 12 depicts the comparison findings.
Flores and Weinstock conducted their study in 1996.

They surveyed 51 pediatric offices, 42 (82%) reported
at least one pediatric medical emergency monthly. Their
research determined that 37 (73%) of the 51 pediatric

offices were prepared for status asthmaticus. The
number of clinics prepared for upper airway obstruction

was 31 (61%), and three offices (6%) for endocrine
emergencies, and cardiac arrests. They determined that
total staff members.
the 51 offices had 481

54

Table 12

Comparison of Schweich. -DeAngelis, and Duggan (1991)

study findings to Current Rural Health Clinic study*
Measured Items

Schweich, DeAngelis
& Duggan

Rural Health
Clinic

Sample size

427

11

Respondent rate

54%

42%

Oxygen

81%

82%

Bag-Valve-Mask

80%

64% infant

73% child
Suction

63%

64%

Oral airways

81%

82%

Blood pressure cuffs

60%

64%

Intravenous fluids

66%

91%

HMO

84%

0%

Group practices

74%

0%

Solo practices

16%

0%

Note* Health Maintenance

Organizations (HMO).

Type of practice

55

Of all the eligible staff 67 (14%)
were certified in
basic life support (BLS) and 82
(17%) in pediatric
advanced life support (PALS).
The rural health clinic
study had in comparison 11 participants. Two clinics
from the 11 reported experiencing pediatric medical

emergencies during the last year. Clinic G reported
respiratory distress, anaphylactic shock and Clinic M

reported respiratory distress, status asthmaticus, and
meningitis (Table 4). The rural health clinic study

found three clinics which had all (100%) of the

required equipment for minimal preparedness for airway
management which is three of the 11 (27%)

(Table 6).

Scores of preparedness for intubation from a possible
five ranged from zero to five. With one clinic
identified from the 11 (9%) with all the equipment

available (Table 7). Airway and intubation management
can be compared to the results of the Flores, and
Weinstock study because they are essential elements to

the stabilization of status asthmaticus and respiratory
distress. The rural

health clinic study found at least

of the 11 clinics (100%) had
one staff member in each
staff member with
BLS and six clinics (55%) reported a

PALS (Table 3). Comparisons

13.

are represented in Table

56

Table 13
Compa ri s on—of Flores and Weinstock (1996) study

finding.s—Lq—Current Rural Health Clinic study.
Measured Items/
Preparedness Scores

Flores &

Rural Health

Weinstock

Clinic

Sample size

51

11

Respondent rate

98%

42%

Status Asthmaticus

73%

Upper airway obstruction

61%

27%

Airway management

9%

Intubation
BLS certification

17%

100%

PALS certification

17%

55%

Note, Basic Life Support (BLS) and Pediatric Advanced

Life Support (PALS).

57

Implications
Rural health clinics are located in areas where
the availability of health care is limited. This study

identified clinics located 10 to 20 miles from the
nearest hospital with emergency room services. They
reported ambulance response times ranged from three to

15 minutes (Table 9) . Time is a crucial factor when a

child is experiencing a pediatric medical emergency.
Florence Nightingale first identified the factor of

time in her Notes on Nursing written in 1859.
Nightingale states that children have increased
susceptibility to becoming seriously ill quickly

(Nightingale, 1992, p.6). The quickness at which a
child becomes ill makes it vital for the rural health

clinics to be prepared for a pediatric medical
emergency.

Nightingale’s theory is based on controlling the

environment to achieve the best possible outcome for
the patient. Rural health clinics can control their
environment by having minimal basic equipment,
medications, and training for pediatric medical

Rural health clinics that are not prepared
emergencies.
with minimal recommended equipment, medications, and

limited in their ability to treat
training are severely

58

and stabilize a pediatric
patient. This unpreparedness
will result in loss of time between initial treatment

and ability to transport the patient to an emergency
room equipped to give extensive care. The initial
treatment is vital to the outcome following a pediatric
medical emergency. Rural health clinics must be

prepared prior to any emergency to ensure the best

possible outcome.
Recommendations

This study has demonstrated that the rural health
clinic environment is not prepared for pediatric

medical emergencies. Nightingale proved during the
Crimean War that by controlling the environment you

could improve patient outcomes (Torres, 1980). Primary
focus must be placed on improving the environment of

the rural health clinic.
The first factor to identify is who is in control

of the rural health clinic environment. This study
identified primary care providers as having the ability
to change and improve the rural health clinic
Schwich, DeAngelis, & Duggan (1991), and
environment
determined that education is
Flores & Weinstock (1996)
should be to educate primary care
the answer. The goal
majority of rural health
providers to the fact that a

59

clinic environments are not
prepared for pediatric
medical emergencies.

Awareness of the problem appears to be minimal,
because only four published studies have been conducted

and very little information has been written in the
journals and medical publications. Primary care

providers are not alerted to this potential hazard.
The problem with not identifying unpreparedness prior

to an emergency occurring in a rural health clinic
environment is that it places the pediatric patients at
greater risk of a poor outcome such as death following
an emergency situation.

The recommendations are as follows:
1. Education should be aimed at making primary
care providers aware of the 1992 Committee of Pediatric

Emergency Medicine (COPEM) guidelines published by the

American Academy of Pediatrics (AAP). This can be done
by (a) including the guidelines within school curricula
for graduating primary care providers, (b) including

the topic of preparedness for pediatric medical
emergencies in seminars focused toward the primary care

publications in medical
providers, and (c) more
office preparedness for pediatric
journals about

medical emergencies.

60

2. Additional research studies
are needed
especially (a) repeated studies focusing
on rural
health clinics with a larger and more diverse sample
(b) further research studies comparing and contrasting

urban and rural health clinics.

3. Legislation needs to establish a set of
criteria for minimal basic equipment, medications, and
training for rural health clinics which would make all

clinics achieve and maintain a minimal standard of
preparedness for pediatric medical emergencies.
In conclusion, the focus on improving the rural

health clinic environment would allow rural health
clinics to perform at an optimal level during pediatric
emergencies. Providing an optimal environment which has

all the minimal basic equipment, medications, and
training, the primary care provider could assure their
pediatric patients of the best chance for survival

following an emergency.

61

Appendix A

COPEM Guidelines
for minimal preparedness
for pediatric medical
emergencies (AAP, 1992).

Equipment
A. Airway Management

1. Oxygen source with flowmeter.

2. Oxygen masks - infant, child, and adult.
3. Bag-valve-mask, self-inflating with

reservoir for an infant, child, and adult.
4 . Nebulizer for aerosolation.

5. Nasal cannulas for infant, child and adult.
6. Suction

wall or machine.

7. Suction catheters

sizes 8F, 10F, 14F.

8. Laryngoscope handle with Miller blades sizes
0, 1, 2, 3.
9. Replacement batteries and bulbs for

laryngoscope.
10. Endotracheal tubes, uncuffed in sizes 3.0,

& 8.0.
3.5, 4.0, 4.5, 5.0, 6.0, 7.0,
11. Small and large stylets.

12. Magill forceps.
B. Fluid management

needles - 15 and 18 gauge.
1. Intraosseous

62

2. IV catheters, short, over the needle - 20,
22, 24 gauge.

3. Butterfly needles in 21, 23, and 25 gauge.
4 . IV boards.

5. Tape.

6. Alcohol swabs.

7. Tourniquet.
8. Pediatric (micro) drip chambers.

9. IV tubing.
10. Ringer’s lactate, normal saline.
C. Miscellaneous equipment

1. Blood pressure cuffs for infant, child, and
adult.

2. Nasogastric tubes sizes 10 and 14 French.
3. Feeding tubes sizes 3 and 5 French.
4. Foley urine catheters sizes 8 and 10 French.
5. Broselow tape.

6. Pediatric backboard.
7. Handbook of Emergency Cardiac care for
healthcare providers (AHA) .

D. Optional equipment
1. Portable monitor defibrillator.
2. Pulse oximeter.

63

Medications

1. Albuterol 0.5% for inhalation.
2. Epinephrine in 1:1000 and 1:10,000

concentration.
3. Sodium bicarbonate for infusion dosages infant

4.2%, and pediatric 8.4%.
4. D50.
5. Atropine O.lmg/ml.
6. Lorazepam 2mg/ml.
7. Sterile water.

8. Methylprednisone.

64

Appendix B
Telephone survey of basic Emergency equipment for offices as suggested by
the American Academy of Pediatrics and the Latest guidelines on Pediatric
Life Support.
Telephone surveyor will circle the response given.
Identify title of the person answering the survey.

1. Does your office care for pediatric patients?

Yes

No

If no stop here.

2. How many miles are you located from the closest hospital with emergency
services?

If closer than 10 miles stop here.
3. How long does it usually take for an ambulance to respond to an emergency in

your office?
4. Does your office have a plan for pediatric emergencies?

Yes

No

Airway Management

5. Does your office have an oxygen source with a flow meter?

Yes

No

6. Does your office have oxygen masks for an infant?

Yes

No

7. Does your office have oxygen masks for a child?

Yes

No

8. Does your office have oxygen masks for an adult?

Yes

No

9 Does your office have a self-inflating bag-valve-mask resuscitator with
reservoir for an infant (240 ml.)?

Yes

No

10. Does your office have a self-inflating bag-valve-mask resuscitator with

reservoir for a child (500 ml.)?

Yes

No

66

24 gauge?

Yes

No

21 gauge?

Yes

No

23 gauge?

Yes

No

25 gauge?

Yes

No

25. Does your office have IV boards?

Yes

No

26. Does your office have tape?

Yes

No

27. Does your office have alcohol swabs?

Yes

No

28. Does your office have a tourniquet?

Yes

No

29. Does your office have pediatric (micro) drip chambers?

Yes

No

30. Does your office have IV tubing?

Yes

No

Ringer’s lactate?

Yes

No

Normal saline?

Yes

No

Infants?

Yes

No

Children?

Yes

No

Adults?

Yes

No

10 French?

Yes

No

14 French?

Yes

No

Yes

No

24. Does your office have butterfly needles?

31. Does your office have:

Miscellaneous equipment
32. Does your office have blood pressure cuffs for

33. Does your office have nasogastric tubes in sizes.

34. Does your office have feeding tubes in sizes.
3 French?

67

5 French?

Yes

No

35. Does your office have Foley urine catheters in sizes:
8 French?

Yes

No

10 French?

Yes

No

36. Does your office have Broselow tape?

Yes

No

37. Does your office have a pediatric backboard?

Yes

No

38. Does your office have a handbook of Emergency Cardiac Care for Healthcare
Providers (American Heart Association)?

Yes

No

39. Does your office have a portable monitor defibrillator?

Yes

No

40. Does your office have a pulse oximeter?

Yes

No

Yes

No

1 : 1000 concentration?

Yes

No

1 : 10,000 concentration?

Yes

No

Infant 4.2%?

Yes

No

pediatric 8.4%

Yes

No

44. Does your office have D50?

Yes

No

45. Does your office have Atropine 0. Img/ml?

Yes

No

46. Does your office have Lorazepam 2mg/ml?

Yes

No

47. Does your office have sterile water?

Yes

No

48. Does your office have Methylprednisolone?

Yes

No

Optional equipment

Emergency Medications
41. Does your office stock Albuterol (0.5%) for inhalation?

42. Does your office stock Epinephrine in

43. Does your office stock Sodium bicarbonate for infusion in

68

49. Are any of the office employees certified in Basic Life Support (BLS)?
Yes

No

If yes whom?

PCP

Nurse

Office staff

Lab staff

50. Is the primary care provider or any nursing staff certified in Advanced Life

Support (ALS)

in your office? Yes

No

If yes whom?

PCP

Nurse

51. Is the primary care provider or any nursing staff certified in Pediatric

Advanced Life

Support (PALS) in your office?

Yes

No

If yes whom? PCP

Nurse
52. Is the primary care provider or any staff certified in APLS?
If yes whom?

PCP

Yes

No

Yes

No

Nurse

53. Has your office ever experienced a pediatric emergency?
If Yes what type or types of emergency/emergencies.

54. Do you ever have any mock codes in your office and then critique them?

Yes

No

If Yes how often?

55. Do you have anything else you would like to comment on?

69

Appendix C
Script
Hello, my name is Cindy Coogan. I am a registered

nurse and family nurse practitioner student at Edinboro

University of Pennsylvania.
I am conducting a survey to identify preparedness

of rural health clinics in Crawford, Forest, and
Venango counties for pediatric medical emergencies.

Past studies have determined that only about one-third

of the offices caring for pediatric patients are
prepared for pediatric medical emergencies. There have

been no studies conducted which have focused on the
preparedness of rural health clinics.

Participating clinics will be anonymous and all
responses will be confidential. Do I have your consent
that you are willing to participate in this survey? Can

we make arrangements that will be most convenient for
you to take 15 minutes to answer the questions in this

survey? If you decide at any time that you do not wish
to participate in this survey please notify me.
Would you like me to mail you a summary of the

data collected when I complete this study?

70

References

Altieri, M., Bellet, J., & Scott, H. (1990).
Preparedness for Pediatric Emergencies encountered in
the Practitioner’s office. Pediatrics, 85, 710-714.
American Academy of Pediatrics Committee On
Pediatric Emergency Medicine (1992). Emergency medical

services for children: The role of the primary care

provider

USA: Author.

American Heart Association. (1990). Healthcare
Providers Manual for Basic Life Support, (ISBN 0-87493-

602-0) . Dallas: Author.
American Heart Association.

(1987). Textbook of

Advanced Cardiac Life Supports (2nd ed.). (ISBN 087493603-9). Dallas: Author.

Flores, G., Weinstock, D. (1996). The preparedness
of Pediatricians for emergencies in the office: What is

broken, should we care, and how can we fix it? Archives.
of Pediatric. and Adolescent—Medi,c.inee. 150, 249-256.
(1989).
Fuchs, S., Jaffe, D., & Christoffel, K.

pediatrics. 83, 931-939.
Luten, r., & Foltin, G. (Eds.). (1993). Pediatric
care (3rd ed.). Arlington,
resources. for prehespitaX
Virginia: National Center For Education In Maternal And

Child Health.

71

Nightingale, F.

(1992). Notes on Nursing: What it

is, and what it is not. Commemorative Edition.
Philadelphia: J.B. Lippincott Company.

Noble, J.

(1996). Primary Care: Skills and

concepts. In C. Berkowitz (Ed.), Pediatrics; A primary
care approach (pp. 1-9). Los Angeles, California: W.B.
Saunders Company.
Schuman, A. (1993). The latest guidelines on

pediatric life support. Contemporary Pediatrics, 10,

25-44.
Schweich, P., DeAngelis, C., & Duggan, A. (1991).
Preparedness of practicing Pediatricians to manage

ernergencies. Pediatrics.^. 88, 223-229.
Siedel, J. (1986). A needs assessment of advanced
life support and emergency medical services in the
pediatric patient: state of art. Pediatric life

support. 74, 129-133.
Smith, J., CEO of Alliance Health Network,

(1996).

Lecture in Trends and Issues in Health Care. October 1.
Thomas, C. (Ed.). (1986). Taber's Cyclopedic
Medical Dictionary. (15th ed.). Philadelphia: F.A. Davis

Company.

72

Torres, G. (1980). Florence Nightingale. In E. H.

Hiatt (Ed.), Nursing theories; The base for

professional nursing practice (pp. 27-38). New Jersey:
Prentice-Hall, Inc..