Case study: How paramedics enhanced dosage accuracy for resuscitations

By The Agency for Healthcare Research and Quality (AHRQ)

What They Did | Did It Work? | How They Did It | Adoption Considerations

Summary

In 2003, Los Angeles County required the Los Angeles County Emergency Medical Services Agency paramedics to use an established tool (known as the Broselow® tape) to measure the weight of children aged 12 years and younger to determine correct drug dosing for resuscitation. Although the tape is a well-known tool for determining pediatric medication doses, it is not commonly used by paramedics in out-of-hospital emergency situations. After the change, paramedics who used the tape delivered correct epinephrine (adrenaline) doses to children experiencing cardiac arrest 57 percent of the time, more than twice the previous rate of 28-percent accuracy.

Evidence Rating

Moderate: The evidence consists of pre- and post-implementation comparisons of dosing accuracy, which shows a clear link between the program and improved results. The retrospective nature of the review limited the analysis to data that had actually been recorded; these data did not document the degree of communication between paramedics and hospital ED personnel.

Developing Organizations

Harbor-UCLA Medical Center, Department of Emergency Medicine

Los Angeles Biomedical Research Institute

Los Angeles County Emergency Medical Services Agency

Date First Implemented

2003

Patient Population

Age > Child (6-12 years); Vulnerable Populations > Children; Age > Infant (1-23 months); Newborn (0-1 month); Preschooler (2-5 years)

What They Did

Problem Addressed

Incorrect recording or estimates of a child’s weight frequently leads to incorrect medication dosing, one of the most frequently reported errors in pediatric emergency departments (ED)¹ and in medical emergency situations outside hospitals.² In Los Angeles County in 2003, the medication dosing error rate exceeded 70 percent.²

• Drug dosing critical in pediatric emergency cases: Epinephrine (adrenaline) is the most frequently used resuscitation medication in infants and children experiencing cardiac arrest or anaphylaxis (a severe, whole-body allergic reaction). Although there is little variation in epinephrine doses administered to adults in cardiac arrest, the appropriate pediatric dosage is based almost entirely on weight. If too little is administered, the drug is ineffective and the resuscitation effort fails, if too much is administered, there is a risk of intracranial hemorrhage and hypertension.³
• Lack of experience among paramedics: Because paramedics infrequently care for critically ill children, they lack experience in determining a child’s weight and his or her appropriate dosage, which is compounded by the high-stress nature of emergency situations such as cardiac arrest. In one study, only 7 percent of all paramedic calls involved patients aged 14 years or younger.⁴
• Proven tool to help, but rarely used by paramedics: Since the 1980s, the Broselow® tape has been used to help clinicians rapidly estimate body weight and correct drug doses in children, but it is rarely used by emergency medical services providers nationwide. However, when paramedics estimated pediatric weights using the tool in a classroom setting, they were able to determine epinephrine doses accurately 95 percent of the time.²

Description of the Innovative Activity

In 2003, Los Angeles County required the Los Angeles County Emergency Medical Services Agency paramedics to use the Broselow® tape on children up to age 12 to determine correct drug dosing in pediatric resuscitation. Although the tape is a well-known tool for determining pediatric medication doses, it is not commonly used by paramedics in out-of-hospital emergency situations. Key elements of the program are described below:

• Training: Paramedics and hospital ED personnel are trained to use the tape and to communicate about dosing decisions during pediatric resuscitations. (See the Planning and Development section for more information about training.)
• Communication and coordination: The paramedic in the field uses the tape to measure the child and determine which “color zone” applies. The paramedic then routinely confers with hospital ED personnel by radio.
• Dosing decisions: The ED determines the correct epinephrine dose; each color zone corresponds to a color-coded drug-dosing and resuscitation equipment chart. References at each color bar on the tape indicate what emergency resuscitation equipment size to use, and references at each weight zone on the tape show correct, precalculated medication dosages. Designated resuscitation equipment and medications are often contained in corresponding, color-coded containers in each ambulance.
• Review: Emergency medical services and hospital officials regularly review dosages and use of the tape after pediatric medical emergencies to assess performance and improve delivery of care in the field.

References/Related Articles

Kaji A, Gausche-Hill M, Conrad H, et al. Emergency medical services system changes reduce pediatric epinephrine dosing errors in the prehospital setting. Pediatrics. 2006;118(4):1493-1500. [PubMed] Available at: http://www.pediatrics.org/cgi/content/full/118/4/1493.

Frush K, Hohenhaus S. Study packet for the correct use of the Broselow® Pediatric Emergency Tape: enhancing pediatric patient safety, Duke University Medical Center. Department of Health and Human Services, Health Resources and Services Administration Maternal Child Health Bureau Grant # 5 H70 MC 00002-01-03. Available at: http://bcrt.ca/wp-content/uploads/2009/08/Broselow-Kit.pdf.

Hashikawa A, Juhn Y, Homme J, et al. Does length-based resuscitation tape accurately place pediatric patients into appropriate color-coded zones? Pediatr Emerg Care. 2007;23(12): 856-61. [PubMed] Available at: http://www.pec-online.com/pt/re/pec/abstract.00006565-200712000-00002.htm

Contact the Innovator

Amy H. Kaji, MD, PhD, MPH
Department of Emergency Medicine
Harbor-UCLA Medical Center
1000 W Carson St. Box 21
Torrance, CA 90509
(310) 222-3500
E-mail: akaji@emedharbor.edu

Did It Work?

Mandated use of the tool increased dosing accuracy significantly.

• Dosing accuracy more than doubles: Before mandating use of the tape, only 28 percent of children (29 of 104 cases) who experienced cardiopulmonary arrest received the correct first dose of epinephrine from Los Angeles Emergency Medical Services Agency paramedics. After the mandate went into place, 57 percent (21 of 37 children) received the appropriate dose. Similar results are seen when comparing the frequency of dosing within 20 percent of the correct level. Before the mandate, 44 percent (46 of 104) of children received a dose that was within 20 percent of the correct dose. After the mandate, the corresponding figure was 65 percent (24 of 37 children).
• Accuracy expected to improve for use of other drugs and equipment in pediatric emergencies: Although no hard data are available, mandated use of the tape should also lead to improvements in dosing of other emergency drugs administered to children, including antiseizure and sedation medication. The mandate should also improve selection of appropriately sized resuscitation equipment for children, such as tubes and ventilators.

Evidence Rating

Moderate: The evidence consists of pre- and post-implementation comparisons of dosing accuracy, which shows a clear link between the program and improved results. The retrospective nature of the review limited the analysis to data that had actually been recorded; these data did not document the degree of communication between paramedics and hospital ED personnel.

How They Did It

Context of the Innovation

Los Angeles County officials were concerned about the low accuracy of dosing by paramedics during high-stress pediatric resuscitation efforts and hoped that tools that reduce reliance on memory and error-prone calculations would have the potential to decrease medication errors and increase survival.

In the past, Los Angeles County paramedics had received some training in use of the Broselow® tape and were encouraged to use it for children up to age 12 years, but in practice relatively few paramedics used the tool. Nor did paramedics have the tools to accurately determine a child’s weight even when they consulted with hospital personnel before administering epinephrine in the field.

To address this issue, Los Angeles County adopted a tool in 2001 for drug dosing in pediatric resuscitations called LA Kids. This program was aimed at simplifying and standardizing prehospital pediatric drug administration through use of the Broselow® tape. By 2003, all emergency medical services paramedics had received training, after which time use of the tape was made mandatory.

Los Angeles County officials decided to track the accuracy of epinephrine dosing by paramedics before and after the mandate and enlisted research assistance from the Department of Emergency Medicine at Harbor-UCLA Medical Center, the Los Angeles Biomedical Research Institute, and the Departments of Medicine and Pediatrics of the David Geffen School of Medicine at University of California Los Angeles. Approval for this study was obtained from the institutional review board at Harbor-UCLA Medical Center and from the Western Regional Institutional Review Board, which reviews research protocols for the Los Angeles County Emergency Medical Services Agency.

If the study showed improvement in the accuracy of epinephrine dosing, officials hoped use of the tape would also lead to reduction of errors of other emergency medications administered by paramedics to pediatric patients.

Planning and Development Process

Key elements in the planning and development process include the following:

• Joint paramedic and hospital personnel training: Los Angeles County paramedics and ED hospital personnel (in Los Angeles County’s case, the hospital personnel were mobile intensive care nurses) were both trained in the use of the Broselow® tape and color zones for drug dose and resuscitation equipment determinations in the field. The training was conducted by a physician and nurse educators from the Department of Emergency Medicine at Harbor-UCLA Medical Center. As a part of this training, paramedics were taught to verbally report the color to hospital ED personnel, and hospital personnel were taught to repeat back the dosage to the paramedics as an extra step to confirm dose accuracy before administration of the first resuscitation dose. Once existing personnel received this initial training, ongoing instruction and reminders about use of the tape was made a part of the emergency medical services agency’s regular training regimen.
• Purchase and deployment of equipment: Paramedics and hospital personnel were supplied with the tape and color-coded precalculated drug-dosing reference charts. Each of the county’s 200 ambulances was equipped with five tapes and reference charts.
• Quality improvement oversight: A quality improvement process was instituted to track the performance of paramedics and ED personnel in documenting the color zone for each child evaluated in the field. Emergency medical services data forms and original paramedic run reports were collected and reviewed. The correct first dose of epinephrine that should have been administered to each patient was calculated according to Los Angeles County prehospital care treatment guidelines and the weight determined with the Broselow® tape (if available), the parental weight estimate recorded in the field, or the weight recorded in the ED. How often conferencing actually occurred between paramedics and hospital ED personnel was not recorded.

Resources Used and Skills Needed

• Staffing: The program requires no new staff, as paramedics and hospital ED personnel participate as part of their regular duties.
• Costs: A Broselow® tape and accompanying chart costs about $80 each, which means that Los Angeles County spent approximately $80,000 on 1,000 tapes and charts (5 for each of 200 ambulances). The cost of training paramedics and hospital personnel in the use of the Broselow® tape is not known; training costs will vary by county or municipality, based on the size of the emergency medical services department.

Funding Sources

Agency for Healthcare Research and Quality
Health Resources and Services Administration; State of California - Emergency Medical Services
National Center for Research Resources

The study was funded by a National Center for Research Resources grant awarded to the General Clinical Research Center at the Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center. Funds for training and acquisition of the Broselow® tapes and charts came from the county’s emergency medical services agency budget.

Tools and Other Resources

Information on how to properly use the Broselow® tape, written by Duke University Medical Center and the U.S. Department of Health and Human Services Health Resources and Services, is available at http://www.ncdhhs.gov/dhsr/EMS/pdf/kids/DEPS_Broselow_Study.pdf.

Adoption Considerations

Getting Started with This Innovation

• Investigate the hospital’s current use, if any, of the tape for pediatric drug dosing.
• Appoint a quality improvement manager or designate the emergency medical services medical director to champion acquisition of Broselow® tapes and charts and coordinate training and future evaluation.
• Develop a timeline for the project, and identify a trainer for paramedics and ED staff who will serve as the ED contacts for paramedics in the field.
• Assign roles and responsibilities to team members and use check-back processes to verify communications and actions to reduce errors and clarify communications in high-stress, emergency situations.
• Integrate training on use of the tape into established training systems for new and existing employees. Coordinate training with the local hospital or hospitals that are capable of handling pediatric emergencies.
• Incorporate documentation of tape usage, dose identification, and ultimate dose accuracy into emergency medical services run reports and hospital reports. Identify who will monitor tape usage, track effectiveness, and identify potential opportunities for improvement.

Sustaining This Innovation

• Use dose accuracy and communication information gleaned from each emergency medical services call to continuously improve care delivery and fine-tune training.
• Hold regular meetings between emergency medical services and hospital staff to evaluate tape usage and efficacy.

Additional Considerations and Lessons

The current dosing error rate in Los Angeles County is still unacceptable, even with mandatory use of the tape and joint training and consultation with hospital ED personnel, suggesting that other measures should be taken to further improve medication dosing for children.

Researchers are finding that the tape, which measures height and the average weight associated with that height, may underestimate weight and appropriate doses for obese children. Given the obesity epidemic in U.S. children, this means that the potential for inaccurate dosing remains high for this significant, growing subset of the pediatric population.

Use By Other Organizations

Orange County, which is just south of Los Angeles County, recently mandated training and use of the Broselow® tape by its emergency medical services responders.

References

1. Selbst SM, Fein JA, Osterhoudt K, et al. Medication errors in a pediatric emergency department. Pediatr Emerg Care. 1999;15(1):1-4. [PubMed]
2. Kaji A, Gausche-Hill M, Conrad H, et al. Emergency medical services system changes reduce pediatric epinephrine dosing errors in the prehospital setting. Pediatrics. 2006;118(4):1493-1500. [PubMed] Available at: http://www.pediatrics.org/cgi/content/full/118/4/1493
3. Pediatric pharmacotherapy: a monthly newsletter for health care professionals, Children’s Medical Center at the University of Virginia. 1996 Dec;2(12). Available at: http://www.medicine.virginia.edu/clinical/departments/pediatrics/education/pharm-news/1995-2000/199612.pdf
4. Vilke GM, Marino A, Fisher R, et al. Estimation of pediatric patient weight by EMT-PS. J Emerg Med. 2001;21(2):125-8. [PubMed]