EpiPen:How its use in Pediatric Hospital Anaphylaxis May

Impact Efficiency and Patient Safety

Melinda Hamilton,Michael Rosen, Nnenna Chime, Elizabeth Hunt

Background

• Anaphylaxis fatalities1

– Fatal food reactions, arrest within 30-35 min– Insect stings, collapse from shock 10-15 min– Deaths after IV medications occur within 5 min

• Errors with epinephrine administration– Concentration of medication– Dose of Medication– Administration site

• Epinephrine Autoinjectors– Concentration and dose guaranteed– More timely– Ease of use ?? 1Pumphrey et al, Clin Exp Allerg 2000

PICO Question

• Population– Pediatric code teams managing a simulated pediatric

anaphylaxis scenario

• Intervention– Will the use of an epinephrine autoinjector device decrease

medication errors and decrease time to medication administration during pediatric anaphylaxis

• Comparison– compared with standard administration (med, syringe) of

epinephrine from a code cart

• Outcome– Decrease medication errors (dose, concentration, site) and

decrease time to medication administration

Approach

• Several levels1. Survey to children’s hospitals to understand their

anaphylaxis protocols

2. Simulation testing to define concerns (pilot)1. Standard epi administration vs autoinjector

1. Evaluate time, dose, concentration

2. Note errors

3. Randomized controlled trial of simulated anaphylaxis scenarios1. Measure time to administration

2. Dose, concentration

3. Errors

3 Questions

• What are children’s hospitals doing now?• Can we understand how big of an issue this is in

pediatric hospitals?• What portions should be conducted at multiple

centers ?

ALERT Presentation:Improving neonatal resuscitation using a

virtual interactive trainer

Judy LeFlore, JoDee Anderson, Myra Wyckoff, Taylor Sawyer, Lindsay Johnston, Susan

Niermeyer, Akira Nishisaki, Kathleen Ventre, Marge Zielke

Background

• Airway management continues to be the leading challenge to neonatal patient survival and safety because endotracheal intubation skills are not easily taught.

• Proficiency in safe and successful endotracheal tube placement improves with experience

• Inability to recognize key landmarks for successful endotracheal intubation is the most significant failure point.

• There is evidence that gaming and virtual reality in health care education increases knowledge acquisition and facilitates skill acquisition and transfer to clinical practice.

PICO Question

• Population– Healthcare providers that have newborn resuscitation

opportunities• NNPs• Pediatric residents• Respiratory therapists• Paramedics

• Intervention– Neonatal Interactive Virtual Airway Trainer (NIVAT)

• Comparison– Power point presentation

• Outcome– Intubation success in the clinical setting will be

greater for the NIVAT intervention group than for the PP intervention group

Approach• 3-Phase study (Design over 3 years)

1. Phase I: Development Phase1. Develop NIVAT, Proficiency assessment, PPT2. Rater reliability3. Recruit/randomize

1. Benchmark proficiency (#1)2. Orient to intervention, study protocol, introduce journals

4. Participants keep journals during remainder of Dev Phase2. Phase 2: Intervention Phase

1. Collect journals (#1)2. Proficiency assessment (#2)3. Intervention

3. Phase 3: Degradation Phase1. Collect journals (#2)2. Proficiency assessment (#3)3. Data analysis

Intervention Phase Begins 1. Collect journals (#1) 2. Proficiency assessment (#2) 3. NIVAT or PPT Group Intervention

Decay Phase 1. Collect journals (#2) 2. Proficiency assessment (#3)3. Data analysis

Develop Phase (1 year) 1. NIVAT2. PPT3. Proficiency assessment tool

4..Recruit5. Randomize6. Rater reliability7. Benchmark Proficiency (#1), 8.Orient to intervention, study protocol, and journal. 9 Study participants keep journals during Development Phase

3 Questions

• HOW DO WE:– To calculate adequately power for the study, what should be

used to calculate effect size?– 30second from AAP– Success on first or second try 80% of time?

– Where to recruit from now the GME no longer requires intubation as a competency. Will program directors think this study is important? How do we promote participants adherence to monthly NIVAT or PPT. Should we try different exposure times to assess “Dose effect”? Reliability of keeping accurate journals r/t intubation opportunities throughout the study?

– Recruit research assistants committed to completing proficiency assessments when indicated

The impact of tele-presence on pediatric acute care in the emergency department

Marc Auerbach, David Kessler, Adam Cheng, Betsy Hunt, Noelle Zuckerbraun, Bob Dudas,

Lisa McQueen, John Lin, Vinay Nadkarni

Background

• Pediatric Emergency Care is “uneven”– Pediatrics comprises 1/3 of ED visits– 80% GED, 20% PED

• Telemedicine can improve access to specialists– Radiology, cardiology, child abuse, trauma, stroke– Tele-presence: real time participation in process

• Reduced mortality in adult ICUs

• Goal: optimal care whenever and wherever children present

PICO Question

• Population– Simulated critically ill pediatric patient in a standard ED setting

• Confederate/scripted RN, parents, ancillary staff• Standard patient evolution

• Intervention– GED attending + Tele-present specialist (PED, PICU)

• Comparison– GED attending only, PED attending only

• Outcomes ?– Improve time to interventions, adherence to guidelines– Reduce errors

Project Aims

1. To characterize the differences in the process of care for a simulated critically ill infant by pediatric and general emergency medicine physicians

2. To evaluate the impact of real-time tele-presence of sub-specialty pediatric acute care providers on the process of care for a simulated critically ill infant

Approach

• Prospective simulation-based study

PED GED

GED

Tele

1 2 3

3 Questions

1. What is the “ideal” case for this study? 2. What is our outcome variables and statistical

plans for this study? (primary and secondary)– Time to interventions– Adherence to PALS– No flow fraction– Errors

3. How do we train confederates as team members to isolate provider cognitive processes?

Objectives for 2.5 hours

• Create timeline for study• Determine primary outcome, secondary

outcomes• Design case scenario(s)• Frame up an assessment instrument to pilot• Assign projects to collaborators

NIPPERS Presentation:National Inter Professional

Paediatric Education Research in Simulation network (UK)

C. Bennett, K. Claydon-Smith, J. Cusack, D, DeBeer, T. Everett, J.Fawke, S. Gough, D. Grant, S.Hancock, S.

Hanna, F. Horrox, A. Johnson, D. Kerr, R. MacKinnon, W. Marriage, S. Newell, K. Parkins, D. Rowney, A.

Stevenson & P. Weir

Background

• Collaborative simulation research scarcity in UK• ASPIH / IPSS

– Inter-professional UK network

– Vision: to answer local issues through well formulated research

– Inaugural research group meeting 5th Feb 2012

• Identifiable Patient Impact Knowledge Gaps– Trauma Team Outreach Educational Interventions– Paediatric Palliative Care Packages– In situ Paediatric Cardiac Arrest Team Performance– Inter-professional Undergraduate Education

PICO Question

• Population– In UK pediatric inter-professional teams

• Intervention– will the use of a multi-site targeted simulation educational

interventions

• Comparison– compared with no interventions

• Outcome– improve direct clinical impact, team performance & translational

learning

Approach

• Mixed Methods Analysis1. Development of standardised peer reviewed

educational interventions

2. Pilot studies of educational interventions

3. Assessment pre-introduction

4. Focus groups & targeted cohorts for educational interventions

5. Quantitative & Qualitative assessment of impact on patient care, team performance & translational learning

3 Questions

• Is there scope for international collaboration?

• What issues do we need to consider when standardizing the research across study sites?

• How will the INSPIRE model function to address the needs of national networks and single institution members of part of INSPIRE network?