Annual EMSC Grantee Meeting

Completed EMSC Grant Summaries:

Enhancing Pediatric Patient Safety

Grant Presentation

June 20 – 22, 2006

KAREN FRUSH: One of the jobs of Chief Resident when you do that along the way is to learn AV. I’m very young but that was so long ago now that I don’t know if I can do it again, so thank you very much. I really appreciate the opportunity to be here, to talk to you a little bit about some of the lessons we learned from our enhancing pediatric patient safety grant, and before I start, I want to acknowledge Sue Hohenhouse who’s here. Raise your hand, Sue, who is the project director working with us in this whole project. Before I get into some of the lessons that we learned, I want to just take a minute to remind you about the problem of medical error. I think we probably don’t need any of us to be reminded of this, and we’re reminded, and are quite aware since the Institute of Medicine report was published, now, 7, 8 years ago, but Lucian Leaps who I think is really one of the leaders in patient safety. We’re really working in an era of this epidemic of errors in healthcare, and we are all very aware just from looking at our daily work about the problem of medical errors.

If you think about it, you’ve probably, at least witnessed, if not been involved in or committed, if we want to use that word, an error in medicine sometime recently, but we don’t make errors in medicine because we’re bad people, and I think that’s really important to remember. We’re good people. Those of us who go into healthcare, we’re very well–intentioned. We work hard. We’re very dedicated, but we’re good people who are fallible people. We work in a system that’s very challenged, and very imperfect. Just think about this system of pediatric emergency care that we work in. Think for a minute about the emergency departments where we work. Think about the high-risk, highly complex environment that we face everyday when we provide emergency care for children. The ED is chaotic and hectic with interruptions all the time. We have time limits. We work in a second-to-second, minute-by-minute mode many times. In pediatrics, when we take care of children in an emergency setting, we struggle, because we don’t have a lot of standards in terms of standardization of our medications and equipment, and that’s a big issue, and that’s what we’re going to be talking about a lot.

There are a lot of kids who are taken care of in this country by people who haven’t had specific training in the care of kids, and sometimes in environments in non-children’s hospitals where people don’t even really want to care of kids right then, but that’s the situation that they’re in, and it’s not that they don’t want to because they’re bad people. It’s because they don’t do it very often, and it’s a scary thing, and when you’re taking care of kids, there’s an emotional component, as well, and so people shy away from that a little bit, so we’ve got all these challenges in pediatric emergency care, and for those people who have done a lot thinking and really lead this effort in patient safety, they’ve recognized patterns of error, and have helped us understand some of the things that we can undo to improve these systems that we work in, so that we, as humans, working in those systems are not put in a place, in a situation that makes it easier for us to make a mistake than to do the right thing.

So, we need to understand some of these concepts so we can build safety into the systems in which we work. So, things like standardization are very important as we’ll talk about, things like simplification or redundancy, building an opportunity into the system to double check what we do. Those are very important concepts that I want you to keep in mind. We thought about those concepts a lot when we reviewed some of the resuscitative aids that are out there to help us as clinicians providing pediatric emergency care. There are a number of pre-calculated dosing charts that exist, and this talk about simplification. Why in the world would we try to perform a mathematical calculation while we’re doing chest compressions, or putting in an ET tube, or doing the other myriad of tasks that we need to be done at the time of the resuscitation? We don’t need to take on that cognitive load of trying to do a math equation, and so we’ve recognized that we need to have pre-calculated doses that are ready for us to point to and to use. So, there are tools, there are charts that have been developed with these pre-calculated doses. Those calculations, though, depend on the weight of the child, don’t they?

So, if any of us in this room went into the hospital and, god forbid, needed a dose of Epi, we’d all get an amp of Epi, but we know that when we take care of children that a child who weighs five kilos gets a different dose than a child who weighs 10 kilos, who weighs 12 kilos, who weighs 15 kilos. So, weight is critically important to us, and as we’ve looked at the tools out there, there aren’t very many tools that allow us to determine both weight and go ahead and use that weight and perform a calculation to have the dose already determined for us. The Broselow tape is one of those, one of the few tools, if the only tool. And the Broselow tape was developed over 15 years ago now. And it’s available across the country. In our travels, we’ve seen that it is available in almost every ED and lots of offices as well as in advanced life support vehicles across the country. The tape incorporates a lot of these concepts that help improve safety.

And so, I want to talk to you just for a minute about some of the things that we see as pros and cons about the tape. And help you understand why we did the project we did looking at educating people about the use of the tape. If properly implemented, and that’s a big if, if properly implemented, the tape does incorporate a lot of those concepts. And it does provide a weight ballpark, not exact, but it provides a weight that’s closer to the weight of the child than the adult standard that’s out there. Even given the issues of obesity, it’s not an exact weight. We don’t have time to use a scale. We don’t have a scale available to us on the side of the road when we’re providing care before we get to the hospital. When you ask a room full of people, experts in pediatric care, what the weight of a child is and have a child in front of them, it’s amazing, the guestimates that you get.

And so, it’s been shown that correlating weight to height provides you at least a ballpark. That’s a reasonable weight to work with, with the pre-calculated dose that the tape allows double-checking, redundancy. It has a pre-calculated dose of medicine in a color zone that the nurse can check and the doctor can check. It allows us redundancy and double-checking related to this common problem that we have in terms of weight in kilos or weight in pounds. Many kids get either double the dose or half the dose because we continue to speak in kilos and in pounds.

So, lots of redundancy built into this system, the color coded concept has been used for emergency care and beyond that, in radiology, we can use those same color zones in a safety way to reduce radiation doses to kids who are getting CT scans. Basically, this tape takes away the need to perform the cognitive skills and allows us to focus on assessment, prioritizing the interventions that we need to help children at the time of emergency. I’ve referenced studies that describe these concept and details in your handouts so that you have these. There are problems with this tape. Remember I said, it’s a big if, if used appropriately. In our studies, we found that the tape is not used appropriately. Many times, it can’t be found. Sometimes, it’s used to measure from the wrong end. The makers of the tape thought that it was intuitive and didn’t need education out there. It says, on one end of the tape, measure from this end. And we’ve observed many times, measuring from the wrong end. It gets you into the wrong color zone, the wrong doses of medicine. We’ve observed it being used in a child who’s in a car seat, who’s sitting. And it’s used to measure from the head to the hip because the child wasn’t standing.

So, there are issues with how the tape is used and a very common mistake in using the tape is to use it to get only the weight and then go ahead and calculate your own dose of medicine rather than skipping that step of having the dose provided. So, our thought was that, of all the resuscitative aids out there, the Broselow tape does provide a weight, does provide pre-calculated doses that can help us improve safety and yet it’s not even being used appropriately many times. So, we undertook this project with the objective of developing and evaluating a web-based educational program to train people in appropriate use of the tape; and through the appropriate use of the tape, to be able decrease dosing error in pediatric emergency care.

Here’s the reference again of the article that was published, describing in detail, the study. I’m going to very briefly go over the study. This was a multi-centered randomized controlled study based on on-site simulated events. We had 88 participants in this study divided among three sites: Texas, New Jersey, Pennsylvania. We went on-site and videotaped a simulation, a child with an emergency situation. We then divided the group randomly into two groups. One group received the web-based education of how you use the tape. One group was the control group. We then went back to those study sites and put all participants through, again a simulated event and videotaped them. Because the idea was we wanted to evaluate the impact of the education, not just on knowledge, but on behavior on the actual performance of those who had been educated. After we did the experiment, that is, we educated half of the group; half the group was kept as control.

We went back and evaluated and found that for the education group, those who had completed the web-based education, there was a significant decrease in dosing deviation. That is, a significant decrease in medication dosing error, and those residents, fellows, physicians, those practitioners and paramedics who had gone through the educational modules. There was also a decrease, not quite as significant but there was a decrease in time to dosing. In adults, time is myocardium, and in children, time is airway, and in an emergency situation, seconds count. So, the time that it took for people to come up with the dose of medicine was measured as one that was found to be less in the education group.

We looked at this comparison across all medications that were used in the scenario and we found that it was most significant with a couple of particular medications. You can imagine certainly that with dopamine and the child in the scenario required dopamine and a dopamine drip started in the ED and all the way to being transferred to the PICU. The timing that it took to start the dopamine was significantly lower in the group using the tape. For a couple of particular medications, the dosing itself, dosing error was significantly less. With dextrose, with used of D25 and actually I have to disclose an error here. Your handout said Vecuronium; that’s an error. And in the spirit of medical error and transparency and disclosure, that medicine was actually Lorazepam. So, make that correction please in your handout. So, we found significant improvement both in terms of dosing error and time to dose in a common stabilization scenario using mannequins at three separate sites: at children hospital and a couple of non-children hospitals. So, we concluded from the study that the web-based educational program on proper use of the tape can improve dosing accuracy and reduce dosing time. And that’s great. It can help us improve safety.

But there are some problems. One of the problems that we all know about is the tape is a proprietary product. And we’ve had limited ability to give input and to make suggestions of ways to improve the tape. And I already mentioned a couple of the things that are problems with the tape. One of the big problems with the tape that exists is that the medications are calculated out to milligrams for the doctor order. But the nurse doesn’t draw out medications in milligram does he or she? Medicines are drawn up in ccs and the calculations aren’t carried out to the number of cc’s that that number of kilogram equals. That’s the big problem.

Interestingly, we found resistance to the use of the tape and the standardization, it’s interesting to me still that people who take care of kids feel like that they don’t need a tool to guesstimate weight. But that’s what we’re trained to do and we should do it, or that we shouldn’t calculate. There’s actually a comment along the way that one physician holds his residents to a higher standard than to use an aid to pre-calculated doses; that we’re trained and we need to be able to do that. So, we got a little bit of work to do still in helping us all understand again this concept of safety and why it is a good thing to use a standard dose that was calculated at the time other than when you’re doing compressions.

There are issues with the joint commission that I’m sure you’re familiar with. We’ve had people visited by the joint commission who were told they can’t use the tape because it has some fusions with the rule of six. I think you’re all familiar that the joint commission has made a mandate that there will be no more calculations that we need standard infusions. Unfortunately, we have no standard concentrations for infusions in children. And so, the joint commission has actually addressed this fact with the question about the Broselow tape as one of their frequently asked questions on their website. You can use the Broselow tape. You just can’t use the part of it that has information about infusions because it’s based on an equation rule of six rather than a standard concentration. We’re still trying to help the joint commission understand that again, we don’t’ have standard concentrations yet. That is where we need to get to. I’m sorry. Let’s see to back this up.

And so, the things that were developed through this grant, number one is a website. And it’s still an active site. As a matter of fact, we just had a couple of inquiries from the site last night. I invite you to go to it. You’ll see on the site that the study packet is still available for appropriate use of the tape, including information about the new tape that was just released. We are continuing to work on products to be available through this site including a practical guide to pediatric emergency readiness that is conducting simulations in the real clinical setting that will be available soon. And you’ll see a link to some information that relates color-coding to mass casualty response in terms of color-coded antidotes.

So that’s what we accomplished through this project and an update to where we are at this point. I think it’s very fair to say that there’s a lot more work to do in improving safety in pediatric emergency care. With some carry over from the grant, we were able to host two meetings of pediatric emergency care experts from across the country to talk about things like standardization of medication, dosing in children, as well as other things, developing a culture of safety in pediatric emergency care, looking at issues like quality indicators for pediatric care. This group was represented by folks from ACEP, (inaudible) from AAP, ENA, ISMP and other expert groups across the country. The group certainly feels the need to continue to meet, to continue to develop together methods where we can continue to improve safety in pediatric emergency care.

And there are ongoing efforts that I just want to acknowledge quickly COPEM and ACEP have put out position statements related to safety of children in the emergency care setting, as has ENA. Some work now going on within PECARN. I think, Dr. Kuppermann spoke yesterday; you’re familiar with PECARN. There’s an HRQ Grant that Mary Patterson from Cincinnati has obtained looking at team training in the emergency care setting using high fidelity simulation. The AAP is starting a webinar, this fall, late summer to fall, where there’ll be hour-long lectures from people across the country within the next couple of years about topics on pediatric safety. And individual institutions are doing a lot of work, many more than are named here.

But I want to acknowledge Kathy Shaw from CHOP and we do safety walk grounds in many institutions. She’s developed a unique form of patient safety walk grounds in the ED at the Children’s Hospital in Philadelphia. They’re very, very willing to share their methodology and the progress they’ve made. So please feel free to contact her. We are continuing to do work in team training, how do we deliver care as a team, work with mutual respect across the team, and develop a culture of psychological safety so everyone feels free to speak up if they’re concerned about the safety of a child.

So in summary, pediatric emergency care continues to be very challenging. It’s a hectic, chaotic challenging situation. We do have evidence that suggests that standardization in the use of tools and techniques that we use appropriately and consistently can actually improve pediatric patient safety. There are some tools that exist. I think it’s fair to say the tools that exist need work and maybe we need to develop other ones. And as we develop new tools, we certainly need to validate them and provide education in their use because despite the fact that it may seem intuitive, it’s always good to provide information related to the appropriate use of the tool.

In closing, I’d like to thank EMSC for the opportunity to carry out this study and to begin this work in safety in pediatric emergency care. Special thanks to Bob Weeb and Mike Girardi who are co-investigators for the grant, and (inaudible) our statistician and to many, first of all, the folks who volunteered and signed the consent and allowed us to videotape them and watch their performance as well as to many others who’ve helped us along the way. Thanks very much.