Enhancing Pediatric Patient Safety

1
Enhancing Pediatric Patient Safety

• Karen Frush MD, FAAP
• Susan Hohenhaus MA, RN, FAEN
• A Report to the
• 2006 EMSC Grantee Meeting

2

• Leape L Error in Medicine. JAMA
  1994272(23)1851-1857.
• Epidemic of errors in healthcare
• Most errors are made by good but fallible
  people, working in a challenged and imperfect
  system.

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Challenges in PediatricEmergency Care

• ED is high risk, highly complex environment
• Lack of standardized dosing or equipment sizing
• Limited opportunity for prescription monitoring
• Lack of pediatric trained emergency providers
• Emotional stress of pediatric care
• Hectic, chaotic, interruptions and time
  limitations
• challenged and imperfect system
• in pediatric emergency care

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Patterns of Error and System Improvement

• Systems failure as a common cause of error
• Lack of standardization leads to many errors in
  pediatric emergency care
• Simplification and redundancy can improve system
  and minimize cognitive load of human providers

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The Use of Resuscitative Aids in Pediatric
Emergency Care

• Pre-calculated dosing charts have been used
  extensively to reduce error
• Requires known weight
• Broselow Resuscitation Tape is the only method
  currently combining the two
• Available for 15 years
• Available in EDs, offices and ALS vehicles across
  U.S.

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Use of the Broselow Resuscitation Tape Pro vs
Con

• When properly implemented, the Tape incorporates
  many facets of sound systems.
• Weight estimation and manual dose calculation
  bypassed pre-calculated dose, pre-determined
  equipment size
• Allows for double-checking (lb/kg)
• Used beyond the ED reduced radiation dose of CT
  scans
• Allows the clinicians to focus on assessment,
  prioritization, intervention and communication
• Shown to reduce deviation from recommended dose
  range
• Shah N, Frush K, Luo X, Wears R Impact of an
  intervention standardization system on pediatric
  dosing and equipment sizing. Arch of Pediatr
  Adolesc Med. 2003157229-236.

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Use of the Broselow Resuscitation Tape Pro vs
Con

• Problems with tape itself
• Hohenhaus SM, Frush KS. Pediatric patient safety
  common problems in the use of resuscitative
  aids for simplifying pediatric emergency care. J
  Emerg Nurs 2004.Feb30(1)49-51
• Morgan N, Fortner C, Luo X, Frush KS.
  Opportunities for improvement in medication
  administration during a simulated pediatric
  emergency event. Qual and Safety in Healthcare
  2006.15(3)
• Problems in use of tape
• Not used often difficult to locate intuitive
  yet rarely used correctly
• Recurrent patterns of incorrect use
• Incorrect measurement, measure from wrong end
• Tape used to get weight, then doses calculated

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Main Objective of the Duke EPPS EMSC Project

• To develop and evaluate a web-based educational
  course and training program to increase the
  appropriate use of the Broselow Resuscitation
  Tape in order to decrease error in pediatric
  emergency stabilization events.
• Frush K. Hohenhaus S. Luo X, Gerardi M,
  Weibe RA. Evaluation of a Web-based education
  program on reducing medication dosing error a
  multi-center, randomized controlled trial.
  Pediatr Emerg Care. 2006 Jan22(1)62-70

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EPPS Methods and Evaluation

• Multi-center randomized controlled trial
• Observational study, comparing medication dosing
  error pre and post-intervention (web-based
  module)
• Conducted on-site, low-fidelity simulated
  pediatric stabilization scenario pre and post
  all videotaped
• Emphasis on decision-making, not skills
• 88 participants pre-intervention 86
  post-intervention at 3 sites Attending MD,
  Fellows, Residents, RNs, EMT-Ps

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EPPS Results

• No significant difference observed in demographic
  characteristics of the 2 groups.
• After the educational intervention, average
  (12.6 vs. 24.9) and median (7.1 vs. 20.1)
  dosing deviation summary were significantly lower
  in education group than in control group (P
  0.0002).
• Education group demonstrated a lower average (16
  vs. 20 seconds) and lower median (15 vs. 18
  seconds) dosing time summary than control group.
  (P 0.02).
• Analysis of each medication prescribed indicated
  that decrease in dosing deviation and dosing time
  in education group was most obvious for several
  specific medications dopamine, dextrose,
  vecuronium

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EPPS CONCLUSIONS

• The Web-based education program on the proper use
  of the Broselow Pediatric Resuscitation Tape can
  improve dosing accuracy and reduce dosing time.
• Barriers to use
• Proprietary product defects cant be easily
  corrected
• Clinicians resistance to standardization
• JCAHO mandate on standard infusions

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Products Supported by Grant Funding

• Website http//dukehealth1.org/deps
• Study Packet for the use of the Broselow Tape
  (new addendums in 2006 for new Tape and other CCK
  resuscitation guidelines)
• Practical Guide to Pediatric Emergency Readiness
  Conducting Simulations in the Clinical Setting
• Pediatric Mass Casualty Guidelines PAT,
  JUMPSTART, color-coded antidotes
• Much more work to do

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Improving Patient Safety in Pediatric Emergency
Care Consensus Meeting of PEM Experts

• Two multidisciplinary meetings (2004 and 2005)
• Met to discuss pediatric patient safety issues
  such as lack of standardized approach to
  medication administration pediatric specific
  quality indicators, team training (CRM), culture
  of safety
• Recommendations for partnerships need for
  conference calls and additional meetings need
  for further development of guidelines and studies
  specific to pediatric patient safety in emergency
  care across the continuum

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Ongoing efforts to improve Patient Safety

• COPEM and ACEP statements
• ENA
• PECARN
• AHRQ grants M Patterson
• AAP Safer Healthcare for Kids
• Individual institutions
• Walk rounds CHOP
• Team training DUHS

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Summary

• Pediatric emergency care continues to be very
  challenging
• Evidence suggests that standardization and the
  use of tools and techniques to support consistent
  use could enhance pediatric patient safety
• Tools exist but there is still reluctance to
  fully utilize them or educate consistently
• Need further development, revision and validation
  of tools and educational programs that support
  their use

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Many Thanks

• EMSC
• Bob Weibe, MD
• Mike Gerardi, MD
• Xuemei Luo, PhD
• Our partnership groups (AAP, COPEM, ACEP, ENA,
  ISMP and others)