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Wnorowska JH, Naik V, Ramgopal S, Watkins K, Hoffmann JA. Characteristics of pediatric behavioral health emergencies in the prehospital setting. Acad Emerg Med 2024; 31:129-139. [PMID: 37947152 PMCID: PMC10922610 DOI: 10.1111/acem.14833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/19/2023] [Accepted: 11/03/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE Approximately 10% of emergency medical services (EMS) encounters in the United States are behavioral health related, but pediatric behavioral health EMS encounters have not been well characterized. We sought to describe demographic, clinical, and EMS system characteristics of pediatric behavioral health EMS encounters across the United States and to evaluate factors associated with sedative medication administration and physical restraint use during these encounters. METHODS We conducted a retrospective cross-sectional study of pediatric (<18 years old) behavioral health EMS encounters from 2019 to 2020 using the National Emergency Medical Services Information System. Behavioral health encounters were defined using primary or secondary impression codes. We used multivariable logistic regression to identify factors associated with sedative medication administration and physical restraint use. RESULTS Of 2,740,271 pediatric EMS encounters, 309,442 (11.3%) were for behavioral health. Of pediatric behavioral health EMS encounters, 85.2% of patients were 12-17 years old, 57.3% of patients were female, and 86.6% of encounters occurred in urban areas. Sedative medications and physical restraints were used in 2.2% and 3.0% of pediatric behavioral health EMS encounters, respectively. Sedative medication use was associated with the presence of developmental, communication, or physical disabilities relative to their absence (adjusted odds ratio [aOR] 3.38, 95% confidence interval [CI] 2.93-3.91) and with encounters in the West relative to the South (aOR 1.23, 95% CI 1.16-1.32). Physical restraint use was associated with encounters by patients 6-11 years old relative to those 12-17 years old (aOR 1.35, 95% CI 1.27-1.44), the West relative to the South (aOR 3.49, 95% CI 3.27-3.72), and private nonhospital EMS systems relative to fire departments (aOR 3.39, 95% CI 3.18-3.61). CONCLUSIONS Among pediatric prehospital behavioral health EMS encounters, the use of sedative medications and physical restraint varies by demographic, clinical, and EMS system characteristics. Regional variation suggests opportunities may be available to standardize documentation and care practices during pediatric behavioral health EMS encounters.
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Affiliation(s)
- Julia H Wnorowska
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Vishal Naik
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Sriram Ramgopal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Kenshata Watkins
- Divison of Pediatric Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| | - Jennifer A Hoffmann
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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Wells M, Henry B, Goldstein L. Weight Estimation for Drug Dose Calculations in the Prehospital Setting - A Systematic Review. Prehosp Disaster Med 2023; 38:471-484. [PMID: 37439214 PMCID: PMC10445115 DOI: 10.1017/s1049023x23006027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/31/2023] [Accepted: 06/08/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND Weight estimation is required to enable dose calculations for weight-based drugs administered during emergency care. The accuracy of the estimation will determine the accuracy of the administered dose. This is an important matter of patient safety. The objective of this systematic review was to collect, review, evaluate, and create a synthesis of the current literature focusing on the accuracy of weight estimation in the prehospital environment. METHODS This systematic review followed the PRISMA guidelines. Studies were identified and included if they were peer reviewed, full length, published in English, and contained original data. Studies utilizing any form of weight estimation methodology in the prehospital setting (in children or adults) were included. Data on the quality of the studies and accuracy of the weight estimation systems were extracted. Common themes were also identified. RESULTS Twenty-five studies met the inclusion criteria, with only nine studies (36.0%) containing useful weight estimation accuracy data. The overall quality of the studies was poor. The Broselow tape and paramedic estimates were the most studied methods of weight estimation, but there was insufficient evidence to support conclusions about accuracy. The major themes identified included the importance of accurate weight estimation and drug dosing as critical matters of patient safety, and the need for training to ensure these processes are performed accurately. CONCLUSIONS There were limited robust data identified on the accuracy of different weight estimation methods used in the prehospital setting. Future high-quality clinical research in this area is of critical importance to ensure patient safety in the prehospital environment.
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Affiliation(s)
- Mike Wells
- Department of Emergency Medicine and Critical Care, Herbert Wertheim College of Medicine, Florida International University, Miami, FloridaUSA
| | - Brendon Henry
- Department of Emergency Medicine and Critical Care, Herbert Wertheim College of Medicine, Florida International University, Miami, FloridaUSA
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Piekarski F, Noone S, Engelhardt T, Hellmich M, Wittenmeier E, Quintao V, Arnold P, Goobie SM, Zacharowski K, Kaufmann J. Evaluation of a Pre-Filled Table and a Flowchart-Based Algorithm as Cognitive Aids to Reduce Deviations in Dose Calculation for Intraoperative Red Blood Cell Transfusions in Children-An International Web-Based Simulation. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050815. [PMID: 37238363 DOI: 10.3390/children10050815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/14/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND Transfusion of red blood cell concentrate can be life-saving, but requires accurate dose calculations in children. AIMS We tested the hypothesis that cognitive aids would improve identification of the correct recommended volumes and products, according to the German National Transfusion guidelines, in pediatric transfusion scenarios. METHODS Four online questionnaire-based scenarios, two with hemodynamically stable and two with hemodynamically unstable children, were sent to German and international pediatric anesthetists for completion. In the two stable scenarios, participants were given pre-filled tables that contained all required information. For the two emergency scenarios, existing algorithms were used and required calculation by the user. The results were classified into three categories of deviations from the recommended values (DRV): DRV120 (<80% or >120%), as the acceptable variation; DRV 300 (<33% or >300%), the deviation of concern for potential harm; and DRV 1000 (<10% or >1000%), the excessive deviation with a high probability of harm. RESULTS A total of 1.458 pediatric anesthetists accessed this simulation questionnaire, and 402 completed questionnaires were available for analysis. A pre-filled tabular aid, avoiding calculations, led to a reduction in deviation rates in the category of DRV120 by 60% for each and of DRV300 by 17% and 20%, respectively. The use of algorithms as aids for unstable emergencies led to a reduction in the deviation rate only for DRV120 (20% and 15% respectively). In contrast, the deviation rates for DRV300 and DRV1000 rose by 37% and 16%, respectively. Participants used higher transfusion thresholds for the emergency case of a 2-year-old compromised child than for the stable case with a patient of the same age (on average, 8.6 g/dL, 95% CI 8.5-8.8 versus 7.1 g/dL, 95% CI 7.0-7.2, p < 0.001) if not supported by our aids. Participants also used a higher transfusion threshold for unstable children aged 3 months than for stable children of the same age (on average, 8.9 g/dL, 95% CI 8.7-9.0 versus 7.9 g/dL, 95% CI 7.7-8.0, p < 0.001). CONCLUSIONS The use of cognitive aids with precalculated transfusion volumes for determining transfusion doses in children may lead to improved adherence to published recommendations, and could potentially reduce dosing deviations outside those recommended by the German national transfusion guidelines.
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Affiliation(s)
- Florian Piekarski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, 60590 Frankfurt, Germany
| | - Stephanie Noone
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, 60590 Frankfurt, Germany
| | - Thomas Engelhardt
- Department for Anesthesia, Montreal Children's Hospital, Montreal, QC 1001, Canada
| | - Martin Hellmich
- Institute for Medical Statistics, Informatics, and Epidemiology (IMSIE), University Hospital Cologne, University of Cologne, 50923 Cologne, Germany
| | - Eva Wittenmeier
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Vinicius Quintao
- Discipline of Anesthesiology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo 05403-010, Brazil
| | - Philip Arnold
- The Jackson Rees Department of Anaesthesia, Alder Hey Children's Hospital, Liverpool L12 2AP, UK
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children's Hospital, Boston, MA 02115, USA
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, 60590 Frankfurt, Germany
| | - Jost Kaufmann
- Department for Paediatric Anaesthesia, Children's Hospital Cologne, 50735 Cologne, Germany
- Faculty for Health, University of Witten/Herdecke, 58455 Witten, Germany
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Ward CE, Taylor M, Keeney C, Dorosz E, Wright-Johnson C, Anders J, Brown K. The Effect of Documenting Patient Weight in Kilograms on Pediatric Medication Dosing Errors in Emergency Medical Services. PREHOSP EMERG CARE 2023; 27:263-268. [PMID: 35007470 DOI: 10.1080/10903127.2022.2028045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Objectives: Up to 40% of children who receive a medication from emergency medical services (EMS) are subject to a dosing error. One of the reasons for this is difficulties adjusting dosages for weight. Converting weights from pounds to kilograms complicates this further. This is the rationale for the National EMS Quality Alliance measure Pediatrics-03b, which measures the proportion of children with a weight documented in kilograms. However, there is little evidence that this practice is associated with lower rates of dosing errors. Therefore, our objective was to determine whether EMS documentation of weight in kilograms was associated with a lower rate of pediatric medication dosing errors.Methods: We conducted a retrospective cross-sectional study of children 0-14 y/o in the 2016-17 electronic Maryland Emergency Medical Services Data System that received a weight-based medication. Using validated age-based formulas, we assigned a weight to patients without one documented. Doses were classified as errors and severe errors if they deviated from the state protocol by >20% or >50%, respectively. We compared the dosage errors in the two groups and completed secondary analyses for specific medications and age groups.Results: We identified 3,618 cases of medication administration, 53% of which had a documented weight. Patients with a documented weight had a significantly lower overall dose error rate than those without (22 vs. 26%, p<.05). A sensitivity analysis in which we assigned a weight to those patients with a weight recorded did not significantly change this result. Sub-analyses by individual medication showed that only epinephrine (34 vs. 56%, p<.05) and fentanyl (10 vs. 31%, p <.05) had significantly lower dosing error rates for patients with a documented weight. Infants were the only age group where documenting a weight was associated with a lower dosing error rate (33 vs. 53% p<.05).Conclusion: Our findings suggest that documenting a weight in kilograms is associated with a small but significantly lower rate of pediatric dosing errors by EMS. Documenting a weight in kilograms appears particularly important for specific medications and patient age groups. Additional strategies (including age-based standardized dosing) may be needed to further reduce pediatric dosing errors by EMS.
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Affiliation(s)
- Caleb E Ward
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia, USA.,The George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA
| | - Michael Taylor
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Clare Keeney
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Emily Dorosz
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | | | - Jennifer Anders
- Maryland Institute for Emergency Medical Services Systems, Baltimore, Maryland, USA.,Department of Pediatrics, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Kathleen Brown
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia, USA.,The George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA
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Kaufmann J, Engelhardt T. The German Guidelines for Medication Safety in Pediatric Emergencies. Paediatr Anaesth 2022; 32:1084-1090. [PMID: 35816399 DOI: 10.1111/pan.14524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 07/06/2022] [Indexed: 11/27/2022]
Abstract
Medication errors are a significant threat to the safety of patients of all ages. These errors are more common in children than in adults due to age specific drug dosages, drug dilutions and individual dose calculation based on body weight. In addition, it may be necessary to rapidly administer several potentially harmful or even life-threatening drugs during the emergency situation. It is not possible to provide specialized pediatric emergency teams for every prehospital or intra-hospital emergency and technical resources are frequently not identical to those of a specialized facility further increasing the risk of medication errors. This narrative review of the German Guidelines for Medication Safety in Pediatric Emergencies introduces the main principles for medication safety in pediatric emergencies and the highlights its most important pragmatic measures and recommendations.
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Affiliation(s)
- Jost Kaufmann
- Department for Paediatric Anaesthesia, Children's Hospital Cologne, Cologne, Germany
- Faculty for Health, University Witten/Herdecke, Witten, Germany
| | - Thomas Engelhardt
- Department of Anaesthesia, Montreal Children's Hospital, Montreal, QC, Canada
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