Tensing Maa1, Daniel J Scherzer2, Ilana Harwayne-Gidansky3, Tali Capua4, David O Kessler5, Jennifer L Trainor6, Priti Jani7, Becky Damazo8, Kamal Abulebda9, Maria Carmen G Diaz10, Rana Sharara-Chami11, Sushant Srinivasan12, Adrian D Zurca13, Ellen S Deutsch14, Elizabeth A Hunt15, Marc Auerbach16. 1. Division of Pediatric Critical Care Medicine, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, Ohio. Electronic address: Tensing.Maa@nationwidechildrens.org. 2. Division of Pediatric Emergency Medicine, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, Ohio. 3. Division of Pediatric Critical Care Medicine, Stony Brook Children's Hospital, Stony Brook, NY. 4. Pediatric Emergency Medicine, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel. 5. Pediatric Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY. 6. Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill. 7. Department of Pediatrics, Section of Critical Care Medicine, Comer Children's Hospital, University of Chicago, Chicago, Ill. 8. California State University Chico, Chico, Calif. 9. Division of Pediatric Critical Care Medicine, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Ind. 10. Division of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Del. 11. Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut, Lebanon. 12. Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisc. 13. Division of Pediatric Critical Care Medicine, Penn State College of Medicine, Hershey, Pa. 14. Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pa. 15. Departments of Anesthesiology and Critical Care Medicine, Pediatrics and Health Informatics, Johns Hopkins University School of Medicine, Baltimore, Md. 16. Departments of Pediatrics and Emergency Medicine, Yale University, New Haven, Conn.
Abstract
BACKGROUND: Multi-institutional, international practice variation of pediatric anaphylaxis management by health care providers has not been reported. OBJECTIVE: To characterize variability in epinephrine administration for pediatric anaphylaxis across institutions, including frequency and types of medication errors. METHODS: A prospective, observational, study using a standardized in situ simulated anaphylaxis scenario was performed across 28 health care institutions in 6 countries. The on-duty health care team was called for a child (patient simulator) in anaphylaxis. Real medications and supplies were obtained from their actual locations. Demographic data about team members, institutional protocols for anaphylaxis, timing of epinephrine delivery, medication errors, and systems safety issues discovered during the simulation were collected. RESULTS: Thirty-seven in situ simulations were performed. Anaphylaxis guidelines existed in 41% (15 of 37) of institutions. Teams used a cognitive aid for medication dosing 41% (15 of 37) of the time and 32% (12 of 37) for preparation. Epinephrine autoinjectors were not available in 54% (20 of 37) of institutions and were used in only 14% (5 of 37) of simulations. Median time to epinephrine administration was 95 seconds (interquartile range, 77-252) for epinephrine autoinjector and 263 seconds (interquartile range, 146-407.5) for manually prepared epinephrine (P = .12). At least 1 medication error occurred in 68% (25 of 37) of simulations. Nursing experience with epinephrine administration for anaphylaxis was associated with fewer preparation (P = .04) and administration (P = .01) errors. Latent safety threats were reported by 30% (11 of 37) of institutions, and more than half of these (6 of 11) involved a cognitive aid. CONCLUSIONS: A multicenter, international study of simulated pediatric anaphylaxis reveals (1) variation in management between institutions in the use of protocols, cognitive aids, and medication formularies, (2) frequent errors involving epinephrine, and (3) latent safety threats related to cognitive aids among multiple sites.
BACKGROUND: Multi-institutional, international practice variation of pediatric anaphylaxis management by health care providers has not been reported. OBJECTIVE: To characterize variability in epinephrine administration for pediatric anaphylaxis across institutions, including frequency and types of medication errors. METHODS: A prospective, observational, study using a standardized in situ simulated anaphylaxis scenario was performed across 28 health care institutions in 6 countries. The on-duty health care team was called for a child (patient simulator) in anaphylaxis. Real medications and supplies were obtained from their actual locations. Demographic data about team members, institutional protocols for anaphylaxis, timing of epinephrine delivery, medication errors, and systems safety issues discovered during the simulation were collected. RESULTS: Thirty-seven in situ simulations were performed. Anaphylaxis guidelines existed in 41% (15 of 37) of institutions. Teams used a cognitive aid for medication dosing 41% (15 of 37) of the time and 32% (12 of 37) for preparation. Epinephrine autoinjectors were not available in 54% (20 of 37) of institutions and were used in only 14% (5 of 37) of simulations. Median time to epinephrine administration was 95 seconds (interquartile range, 77-252) for epinephrine autoinjector and 263 seconds (interquartile range, 146-407.5) for manually prepared epinephrine (P = .12). At least 1 medication error occurred in 68% (25 of 37) of simulations. Nursing experience with epinephrine administration for anaphylaxis was associated with fewer preparation (P = .04) and administration (P = .01) errors. Latent safety threats were reported by 30% (11 of 37) of institutions, and more than half of these (6 of 11) involved a cognitive aid. CONCLUSIONS: A multicenter, international study of simulated pediatric anaphylaxis reveals (1) variation in management between institutions in the use of protocols, cognitive aids, and medication formularies, (2) frequent errors involving epinephrine, and (3) latent safety threats related to cognitive aids among multiple sites.
Authors: Alberto Martelli; Rosario Ippolito; Martina Votto; Maria De Filippo; Ilaria Brambilla; Mauro Calvani; Fabio Cardinale; Elena Chiappini; Marzia Duse; Sara Manti; Gian Luigi Marseglia; Carlo Caffarelli; Claudio Cravidi; Michele Miraglia Del Giudice; Maria Angela Tosca Journal: Acta Biomed Date: 2020-09-15