Effect of a Mobile App on Prehospital Medication Errors During Simulated Pediatric Resuscitation: A Randomized Clinical Trial

How Intuitive Is the Administration of Pediatric Emergency Medication Devices for Parents? Objective Observation and Subjective Self-Assessment

BACKGROUND

to assess the intuitiveness of parents' administration of pediatric emergency devices (inhalation, rectal, buccal, nasal, and auto-injector).

METHODS

We invited parents without prior experience to administer the five devices to dummy dolls. We observed whether the parents chose the correct administration route and subsequently performed the correct administration procedures without clinically relevant errors. We interviewed parents for their self-assessment of their own administration performance and willingness to administer devices in actual emergencies.

RESULTS

The correct administration route was best for the inhalation device (81/84, 96% of parents) and worst for the intranasal device (25/126, 20%). The correct administration procedures were best for the buccal device (63/98, 64%) and worst for the auto-injector device (0/93, 0%). Their own administration performance was rated to be best by parents for the inhalation device (59/84, 70%) and worst for the auto-injector device (17/93, 18%). The self-assessment of the correct administration overestimated the correct administration procedures for all the devices except the buccal one. Most parents were willing to administer the inhalation device in an emergency (67/94, 79%), while the fewest were willing to administration procedures the auto-injector device (28/93, 30%).

CONCLUSIONS

Intuitiveness concerning the correct administration route and the subsequent correct administration procedures have to be improved for all the devices examined. The parents mostly overestimated their performance. Willingness to use a device in an actual emergency depended on the device.

Impact of a Mobile App (LoAD Calc) on the Calculation of Maximum Safe Doses of Local Anesthetics: Protocol for a Randomized Controlled Trial

BACKGROUND

Local anesthetics (LAs) are regularly used to alleviate pain during medical or surgical procedures. Their use is generally considered safe, but exceeding the maximum recommended doses can lead to LA systemic toxicity, a rare but potentially lethal complication. Determining maximum safe doses is therefore mandatory before performing local anesthesia, but rules are often unclear and the factors affecting dose calculation are numerous. Mobile health apps have been shown to help clinical decision-making, but most currently available apps present significant limitations. The Local Anesthetics Dose Calculator (LoAD Calc) app was designed to overcome these limitations by taking all relevant parameters into account. Before deploying this app in a clinical setting, it should be tested to determine its effectiveness and whether clinicians would be willing to use it.

OBJECTIVE

The primary objective will be to evaluate the effectiveness of the LoAD Calc app through written simulated cases. The secondary objective will be to determine whether physicians find this app easier, faster, and safer than the methods they generally use.

METHODS

We describe a parallel-group randomized controlled trial protocol. Anesthesiologists working at the Geneva University Hospitals will be invited to participate. Participants will be asked to compute the maximum dose of LA in 10 simulated clinical cases using 3 different LAs. The maximum safe dose will be determined manually using the same calculation rules that were used to develop LoAD Calc, without using the app itself. An overdose will be considered any dose higher than the correct dose, rounded to the superior integer, while an underdose will be defined as the optimal calculated dose minus 20%, rounded to the inferior integer. Randomization will be stratified according to current position (resident vs registrar). The participants allocated to the LoAD Calc (experimental) group will use the LoAD Calc app to compute the maximum safe LA doses. Those allocated to the control group will be asked to use the method they generally use. The primary outcome will be the overall overdose rate. Secondary outcomes will include the overdose rate according to ideal and actual body weight and to each specific LA, the overall underdose rate, and the time taken to complete these calculations. The app's usability will also be assessed.

RESULTS

A sample size of 46 participants will be needed to detect a difference of 10% with a power of 90%. Thus, a target of 50 participants was set to allow for attrition and exclusion criteria. We expect recruitment to begin during the winter of 2023, data analysis in the spring of 2024, and results by the end of 2024.

CONCLUSIONS

This study should determine whether LoAD Calc, a mobile health app designed to compute maximum safe LA doses, is safer and more efficient than traditional LA calculation methods.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/53679.

Adverse Safety Events in Emergency Medical Services Care of Children With Out-of-Hospital Cardiac Arrest

Importance

Survival for children with out-of-hospital cardiac arrest (OHCA) remains poor despite improvements in adult OHCA survival.

Objective

To characterize the frequency of and factors associated with adverse safety events (ASEs) in pediatric OHCA.

Design, Setting, and Participants

This population-based retrospective cohort study examined patient care reports from 51 emergency medical services (EMS) agencies in California, Georgia, Oregon, Pennsylvania, Texas, and Wisconsin for children younger than 18 years with an OHCA in which resuscitation was attempted by EMS personnel between 2013 and 2019. Medical record review was conducted from January 2019 to April 2022 and data analysis from October 2022 to February 2023.

Main Outcomes and Measure

Severe ASEs during the patient encounter (eg, failure to give an indicated medication, 10-fold medication overdose).

Results

A total of 1019 encounters of EMS-treated pediatric OHCA were evaluated; 465 patients (46%) were younger than 12 months. At least 1 severe ASE occurred in 610 patients (60%), and 310 patients (30%) had 2 or more. Neonates had the highest frequency of ASEs. The most common severe ASEs involved epinephrine administration (332 [30%]), vascular access (212 [19%]), and ventilation (160 [14%]). In multivariable logistic regression, the only factor associated with severe ASEs was young age. Neonates with birth-related and non-birth-related OHCA had greater odds of a severe ASE compared with adolescents (birth-related: odds ratio [OR], 7.0; 95% CI, 3.1-16.1; non-birth-related: OR, 3.4; 95% CI, 1.2-9.6).

Conclusions and Relevance

In this large geographically diverse cohort of children with EMS-treated OHCA, 60% of all patients experienced at least 1 severe ASE. The odds of a severe ASE were higher for neonates than adolescents and even higher when the cardiac arrest was birth related. Given the national increase in out-of-hospital births and ongoing poor outcomes of OHCA in young children, these findings represent an urgent call to action to improve care delivery and training for this population.

"ChatGPT, Can You Help Me Save My Child's Life?" - Diagnostic Accuracy and Supportive Capabilities to Lay Rescuers by ChatGPT in Prehospital Basic Life Support and Paediatric Advanced Life Support Cases - An In-silico Analysis

BACKGROUND

Paediatric emergencies are challenging for healthcare workers, first aiders, and parents waiting for emergency medical services to arrive. With the expected rise of virtual assistants, people will likely seek help from such digital AI tools, especially in regions lacking emergency medical services. Large Language Models like ChatGPT proved effective in providing health-related information and are competent in medical exams but are questioned regarding patient safety. Currently, there is no information on ChatGPT's performance in supporting parents in paediatric emergencies requiring help from emergency medical services. This study aimed to test 20 paediatric and two basic life support case vignettes for ChatGPT and GPT-4 performance and safety in children.

METHODS

We provided the cases three times each to two models, ChatGPT and GPT-4, and assessed the diagnostic accuracy, emergency call advice, and the validity of advice given to parents.

RESULTS

Both models recognized the emergency in the cases, except for septic shock and pulmonary embolism, and identified the correct diagnosis in 94%. However, ChatGPT/GPT-4 reliably advised to call emergency services only in 12 of 22 cases (54%), gave correct first aid instructions in 9 cases (45%) and incorrectly advised advanced life support techniques to parents in 3 of 22 cases (13.6%).

CONCLUSION

Considering these results of the recent ChatGPT versions, the validity, reliability and thus safety of ChatGPT/GPT-4 as an emergency support tool is questionable. However, whether humans would perform better in the same situation is uncertain. Moreover, other studies have shown that human emergency call operators are also inaccurate, partly with worse performance than ChatGPT/GPT-4 in our study. However, one of the main limitations of the study is that we used prototypical cases, and the management may differ from urban to rural areas and between different countries, indicating the need for further evaluation of the context sensitivity and adaptability of the model. Nevertheless, ChatGPT and the new versions under development may be promising tools for assisting lay first responders, operators, and professionals in diagnosing a paediatric emergency.

TRIAL REGISTRATION

Not applicable.

Prehospital Recognition and Management of Pediatric Sepsis: A Qualitative Assessment

BACKGROUND AND PURPOSE

Sepsis is a life-threatening disease in children and is a leading cause of morbidity and mortality. Early prehospital recognition and management of children with sepsis may have significant effects on the timely resuscitation of this high-risk clinical condition. However, the care of acutely ill and injured children in the prehospital setting can be challenging. This study aims to understand barriers, facilitators, and attitudes regarding recognition and management of pediatric sepsis in the prehospital setting.

METHODS

This was a qualitative study of EMS professionals participating in focus groups using a grounded theory-based design to gather information on recognition and management of septic children in the prehospital setting. Focus groups were held for EMS administrators and medical directors. Separate focus groups were held for field clinicians. Focus groups were conducted via video conference until saturation of ideas was reached. Using consensus methodology, transcripts were coded in an iterative process. Data were then organized into positive and negative factors based on the validated PRECEDE-PROCEED model for behavioral change.

RESULTS

Thirty-eight participants in six focus groups identified nine environmental factors, 21 negative factors, and 14 positive factors pertaining to recognition and management of pediatric sepsis. These findings were organized into the PRECEDE-PROCEED planning model. Pediatric sepsis guidelines were identified as positive factors when they did exist and negative factors when they were complicated or did not exist. Six interventions were identified by participants. These include raising awareness of pediatric sepsis, increasing pediatric education, receiving feedback on prehospital encounters, increasing pediatric exposure and skills training, and improving dispatch information.

CONCLUSION

This study fills a gap by examining barriers and facilitators to prehospital diagnosis and management of pediatric sepsis. Using the PRECEDE-PROCEED model, nine environmental factors, 21 negative factors, and 14 positive factors were identified. Participants identified six interventions that could create the foundation to improve prehospital pediatric sepsis care. Policy changes were suggested by the research team based on the results of this study. These interventions and policy changes provide a roadmap for improving care in this population and lay the groundwork for future research.

Impact of a clinical decision support system on paediatric drug dose prescribing: a randomised within-subject simulation trial

BACKGROUND

Drug dosing errors are among the most frequent causes of preventable harm in paediatrics. Due to the complexity of paediatric pharmacotherapy and the working conditions in healthcare, it is not surprising that human factor is a well-described source of error. Thus, a clinical decision support system (CDSS) that supports healthcare professionals (HCP) during the dose prescribing step provides a promising strategy for error prevention.

METHODS

The aim of the trial was to simulate the dose derivation step during the prescribing process. HCPs were asked to derive dosages for 18 hypothetical patient cases. We compared the CDSS PEDeDose, which provides a built-in dose calculator to the Summary of Product Characteristics (SmPC) used together with a pocket calculator in a randomised within-subject trial. We assessed the number of dose calculation errors and the time needed for calculation. Additionally, the effect of PEDeDose without using the built-in calculator but with a pocket calculator instead was assessed.

RESULTS

A total of 52 HCPs participated in the trial. The OR for an erroneous dosage using the CDSS as compared with the SmPC with pocket calculator was 0.08 (95% CI 0.02 to 0.36, p<0.001). Thus, the odds of an error were 12 times higher while using the SmPC. Furthermore, there was a 45% (95% CI 39% to 51%, p<0.001) time reduction when the dosage was derived using the CDSS. The exploratory analysis revealed that using only PEDeDose but without the built-in calculator did not substantially reduce errors.

CONCLUSION

Our results provide robust evidence that the use of the CDSS is safer and more efficient than manual dose derivation in paediatrics. Interestingly, only consulting a dosing database was not sufficient to substantially reduce errors. We are confident the CDSS PEDeDose ensures a higher safety and speeds up the prescribing process in practice.

Effectiveness of Mobile Medical Apps in Ensuring Medication Safety Among Patients With Chronic Diseases: Systematic Review and Meta-analysis

BACKGROUND

Along with the rapid growth of the global aging society, the mobile and health digital market has expanded greatly. Countless mobile medical apps (mmApps) have sprung up in the internet market, aiming to help patients with chronic diseases achieve medication safety.

OBJECTIVE

Based on the medication safety action plans proposed by the World Health Organization, we aimed to explore the effectiveness of mmApps in ensuring the medication safety of patients with chronic diseases, including whether mmApps can improve the willingness to report adverse drug events (ADEs), improve patients' medication adherence, and reduce medication errors. We hoped to verify our hypothesis through a systematic review and meta-analysis.

METHODS

The meta-analysis was performed in strict accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and included literature searched from 7 databases-PubMed, Web Of Science, Embase, CINAHL, China National Knowledge Infrastructure, Wanfang, and SinoMed. The publication time was limited to the time of database establishment to April 30, 2022. Studies were screened based on inclusion and exclusion criteria. The data extracted included authors, years of publication, countries or regions, participants' characteristics, intervention groups, and control groups, among others. Our quality assessment followed the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions, Version 6.3. RevMan 5.2 software (Cochrane Collaboration) was used to analyze the statistical data, and a sensitivity analysis was performed to assess data stability. The degree of stability was calculated by using a different statistical method and excluding large-sample studies from the analysis.

RESULTS

We included 8 studies from 5 countries (China, the United States, France, Canada, and Spain) that were published from January 1, 2014, to December 31, 2021. The total number of participants was 1355, and we analyzed the characteristics of included studies, each app's features, the risk of bias, and quality. The results showed that mmApps could increase ADE reporting willingness (relative risk [RR] 2.59, 95% CI 1.26-5.30; P=.009) and significantly improve medication adherence (RR 1.17, 95% CI 1.04-1.31; P=.007), but they had little effect on reducing medication errors (RR 1.54, 95% CI 0.33-7.29; P=.58).

CONCLUSIONS

We analyzed the following three merits of mmApps, with regard to facilitating the willingness to report ADEs: mmApps facilitate more communication between patients and physicians, patients attach more importance to ADE reporting, and the processing of results is transparent. The use of mmApps improved medication adherence among patients with chronic diseases by conveying medical solutions, providing educational support, tracking medications, and allowing for remote consultations. Finally, we found 3 potential reasons for why our medication error results differed from those of other studies.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42022322072; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=322072.

Can apps be used to formulate fluid therapy plans in veterinary medicine?

BACKGROUND

Formulating sophisticated fluid therapy plans can be complicated and time consuming. Consequently, veterinarians in the field who lack experience, time, or confidence may formulate suboptimal fluid therapy plans.

OBJECTIVES

Compare conventional and app-guided fluid therapy plans for simulated cases of neonatal calf diarrhea.

PARTICIPANTS

Third and fourth year veterinary students (n = 55) from The University of Sydney.

METHODS

We developed a web app to assist fluid therapy formulation (http://calfaid.com) that was evaluated in a randomized case simulation trial. Participants were instructed to perform fluid therapy calculations and formulate an integrated fluid therapy plan for case scenarios using conventional methods and using the fluid therapy app. Responses were scored by a blinded study investigator using an a priori scoring guide and groups (conventional vs. app-guided) were compared using linear mixed models.

RESULTS

On average, total scores for app-guided fluid therapy calculations were 20.6% points higher (95% confidence interval [CI], 14.1-27.1) than calculations completed using the conventional method (88.2% vs. 67.5%, respectively). On average, total scores for app-guided integrated fluid therapy plans were 14.2% points higher (95% CI, 6.3-22.2; 65.8% vs. 51.2%). Eighty percent of respondents indicated they would prefer to use the app-guided method over the conventional method.

CONCLUSION AND CLINICAL IMPORTANCE

Our findings suggest that fluid therapy plans can be improved using apps.

Factors Influencing Medication Errors in the Prehospital Paramedic Environment: A Mixed Method Systematic Review

INTRODUCTION

There is limited research available on safe medication management practices in EMS practice, with most evidence-based medication safety guidelines based on research in nursing, operating theatre and pharmacy settings. Prevention of errors requires recognition of contributing factors across the spectrum from the organizational level to procedural elements and patient characteristics. Evidence is inconsistent regarding the incidence of medication errors and multiple sources also state that errors are under-reported, making the true magnitude of the problem difficult to quantify. Definitions of error also vary, with the specific context of medication errors in prehospital practice yet to be established. The objective of this review is to identify the factors influencing the occurrence of medication errors by EMS personnel in the prehospital environment.

METHODS AND ANALYSIS

The review included both qualitative and quantitative research involving interventions or phenomena related to medication safety or medication error by EMS personnel in the prehospital environment. A search of multiple databases was conducted to identify studies meeting these inclusion criteria. All studies selected were assessed for methodological quality, however this was not used as a basis for exclusion. Each stage of study selection, appraisal and data extraction was conducted by two independent reviewers, with a third reviewer deciding any unresolved conflicts. The review follows a convergent integrated approach, conducting a single qualitative synthesis of qualitative and "qualitized" quantitative data.

RESULTS

56 articles were included in the review, with case reports and qualitative studies being the most frequent study types. Qualitative analysis revealed seven major themes: organizational factors (with reporting as a sub-theme), equipment/medications, environmental factors, procedure-related factors, communication, patient-related factors (with pediatrics as a sub-theme) and cognitive factors. Both contributing factors and protective factors were identified.

DISCUSSION

The body of evidence regarding medication errors is heterogenous and limited in both quantity and quality. Multiple factors influence medication errors occurrence; knowledge of these is necessary to mitigate the risk of errors. Medication error incidence is difficult to quantify due to inconsistent measure, definitions and contexts of research conducted to date. Further research is required to quantify the prevalence of identified factors in specific practice settings.

Usability Testing and Technology Acceptance of an mHealth App at the Point of Care During Simulated Pediatric In- and Out-of-Hospital Cardiopulmonary Resuscitations: Study Nested Within 2 Multicenter Randomized Controlled Trials

BACKGROUND

Mobile apps are increasingly being used in various domains of medicine. Few are evidence-based, and their benefits can only be achieved if end users intend to adopt and use them. To date, only a small fraction of mobile apps have published data on their field usability and end user acceptance results, especially in emergency medicine.

OBJECTIVE

This study aims to determine the usability and acceptance of an evidence-based mobile app while safely preparing emergency drugs at the point of care during pediatric in- and out-of-hospital cardiopulmonary resuscitations by frontline caregivers.

METHODS

In 2 multicenter randomized controlled parent trials conducted at 6 pediatric emergency departments from March 1 to December 31, 2017, and 14 emergency medical services from September 3, 2019, to January 21, 2020, the usability and technology acceptance of the PedAMINES (Pediatric Accurate Medication in Emergency Situations) app were evaluated among skilled pediatric emergency nurses and advanced paramedics when preparing continuous infusions of vasoactive drugs and direct intravenous emergency drugs at pediatric dosages during standardized, simulation-based, pediatric in- and out-of-hospital cardiac arrest scenarios, respectively. Usability was measured using the 10-item System Usability Scale. A 26-item technology acceptance self-administered survey (5-point Likert-type scales), adapted from the Unified Theory of Acceptance and Use of Technology model, was used to measure app acceptance and intention to use.

RESULTS

All 100% (128/128) of nurses (crossover trial) and 49.3% (74/150) of paramedics (parallel trial) were assigned to the mobile app. Mean total scores on the System Usability Scale were excellent and reached 89.5 (SD 8.8; 95% CI 88.0-91.1) for nurses and 89.7 (SD 8.7; 95% CI 87.7-91.7) for paramedics. Acceptance of the technology was very good and rated on average >4.5/5 for 5 of the 8 independent constructs evaluated. Only the image construct scored between 3.2 and 3.5 by both participant populations.

CONCLUSIONS

The results provide evidence that dedicated mobile apps can be easy to use and highly accepted at the point of care during in- and out-of-hospital cardiopulmonary resuscitations by frontline emergency caregivers. These findings can contribute to the implementation and valorization of studies aimed at evaluating the usability and acceptance of mobile apps in the field by caregivers, even in critical situations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03021122; https://clinicaltrials.gov/ct2/show/NCT03021122. ClinicalTrials.gov NCT03921346; https://clinicaltrials.gov/ct2/show/NCT03921346.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-019-3726-4.

Impact of a Mobile App on Paramedics' Perceived and Physiologic Stress Response During Simulated Prehospital Pediatric Cardiopulmonary Resuscitation: Study Nested Within a Multicenter Randomized Controlled Trial

BACKGROUND

Out-of-hospital cardiac arrests (OHCAs) are stressful, high-stake events that are associated with low survival rates. Acute stress experienced in this situation is associated with lower cardiopulmonary resuscitation performance in calculating drug dosages by emergency medical services. Children are particularly vulnerable to such errors. To date, no app has been validated to specifically support emergency drug preparation by paramedics through reducing the stress level of this procedure and medication errors.

OBJECTIVE

This study aims to determine the effectiveness of an evidence-based mobile app compared with that of the conventional preparation methods in reducing acute stress in paramedics at the psychological and physiological levels while safely preparing emergency drugs during simulated pediatric OHCA scenarios.

METHODS

In a parent, multicenter, randomized controlled trial of 14 emergency medical services, perceived and physiologic stress of advanced paramedics with drug preparation autonomy was assessed during a 20-minute, standardized, fully video-recorded, and highly realistic pediatric OHCA scenario in an 18-month-old child. The primary outcome was participants' self-reported psychological stress perceived during sequential preparations of 4 intravenous emergency drugs (epinephrine, midazolam, 10% dextrose, and sodium bicarbonate) with the support of the PedAMINES (Pediatric Accurate Medication in Emergency Situations) app designed to help pediatric drug preparation (intervention) or conventional methods (control). The State-Trait Anxiety Inventory and Visual Analog Scale questionnaires were used to measure perceived stress. The secondary outcome was physiologic stress, measured by a single continuous measurement of the participants' heart rate with optical photoplethysmography.

RESULTS

From September 3, 2019, to January 21, 2020, 150 advanced paramedics underwent randomization. A total of 74 participants were assigned to the mobile app (intervention group), and 76 did not use the app (control group). A total of 600 drug doses were prepared. Higher State-Trait Anxiety Inventory-perceived stress increase from baseline was observed during the scenario using the conventional methods (mean 35.4, SD 8.2 to mean 49.8, SD 13.2; a 41.3%, 35.0 increase) than when using the app (mean 36.1, SD 8.1 to mean 39.0, SD 8.4; a 12.3%, 29.0 increase). This revealed a 30.1% (95% CI 20.5%-39.8%; P<.001) lower relative change in stress response in participants who used the app. On the Visual Analog Scale questionnaire, participants in the control group reported a higher increase in stress at the peak of the scenario (mean 7.1, SD 1.8 vs mean 6.4, SD 1.9; difference: -0.8, 95% CI -1.3 to -0.2; P=.005). Increase in heart rate during the scenario and over the 4 drugs was not different between the 2 groups.

CONCLUSIONS

Compared with the conventional method, dedicated mobile apps can reduce acute perceived stress during the preparation of emergency drugs in the prehospital setting during critical situations. These findings can help advance the development and evaluation of mobile apps for OHCA management and should be encouraged.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03921346; https://clinicaltrials.gov/ct2/show/NCT03921346.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-019-3726-4.