Handtevy Minute - Pediatric Medication Safety in EMS (NAEMSP 2020 Position Statement)

Hey, everyone, this is Dr. Peter Entebbe for another edition of the Hentevi Minute. Today I want to talk about a paper that was just published in August of this year. It's a position paper by the NMSP on medication safety in pediatrics, specifically in EMS, something I've been passionate about for over 20 years. This position paper really pulls on data over the last 30 years to put in one document what we should all be doing in EMS to protect children when we're providing medications in the field. So let's take a look at how this position paper was put together. Subject matter experts from the fields of pediatrics, pediatric emergency medicine, and EMS all came together and they ended up screening 86 articles, 70 of which were actually used in the final evaluation. And from those 70 papers, they came up with some very important points on pediatric medication administration and safety in ems. And that's what I want to go through right now. Now, there are four main research topics that the authors sought to cover here. Number one, what are the greatest safety threats that result in significant dosing errors that potentially result in harm to patients? Number two, what practices or technologies are known to enhance dosing safety? Three, can data from other settings be extrapolated to the EMS environment to inform dosing safety? And lastly, what impact could standardization of medication formularies have on enhancing dosing safety? Okay, now we've all been there. We're responding to a 2 year old who's having a seizure or a 6 year old in cardiac arrest. It's 2 o' clock in the morning and we have to get to the scene prepared to treat that patient rapidly and effectively. So we know that only 10% of all EMS calls are pediatric in nature, and only a small percentage of those children even require medication. And that's why medication dosing in pediatrics is so difficult, but also so important. Studies have shown up to 37% of all children who receive a medication dose receive one in error. Now, those are called errors of commission. But we also know that there are many children who need a drug, let's say midazolam for seizure, fentanyl for pain, who don't get it. That's called an error of omission, maybe even more important than the errors of commission. Okay, so for those of you not in EMS or not in pediatrics, and you're wondering why is it so difficult to get pediatric patients the right dose of medication? Well, look at this graphic. Latent errors in dose calculation. You could see in that green box how difficult it is to get to the volume Dose in MLS for a pediatric medication, you have to take the units per kilo times the kilogram weight. And remember, in children you have to convert pounds to kilograms first, then divided by the concentration. You get what I'm saying? This is not easy to do. And so when you wonder why we should never be doing dose calculations at the scene or at the bedside, this is exactly why. And so this paper goes into detail, talking about how EMS systems need to have a tool that already converts that dosing using the calculation from the protocol, using the concentration that they carry on their ambulance to then provide them with the ML dose without ever having to do a calculation on scene. That's what we feel is a very, very important topic in this position paper. So these subject matter experts determined that there is strong evidence to support the use of pre printed dosing cards in ems. Kage, Bernius, Hoyle and Rapoport all have published in the literature talking about pre printed dosing in children. Pediatric dosing requires the volume dose. And let's get rid of all those mathematical equations that come before it. Now, the position paper also describes randomized control trials using mobile applications to improve the accuracy of pediatric dosing in the field. Okay, so the third big topic here in this position paper is what can we learn from other settings and extrapolate into EMS with respect to dosing and safety? Well, number one is the art of simulation. Now, I could tell you that even if you're a great EMS professional and you can dose up any adult, if I bring in that anxiety of a parent or a very sick child in front of you, well, where that skill and that anxiety intersect, that's where the dosing errors happen. And so the very, very important point of a medication administration cross check, which the position paper states that we need more research into, it's an important topic because all that is is a second person, a live human being, who's going to double check that you have the right vial, the right concentration, and that you're pulling up the right dose. Okay, and lastly, what about standardizing the medication formularies that we use? Now, we know that there are many EMS systems that have multiple concentrations of the same medication, and we do feel that that's an issue. But we also have to remember that because of the drug shortages that we experience in ems, oftentimes we have no choice but to insert multiple concentrations. What's very, very important, and the paper discusses this, is have the ability to have a tool, an electronic tool that modifies those concentrations in real time. So even though you're modifying concentrations because of drug shortages. Your providers in the field will never have a problem and will never be required to calculate that dose when they need it the most. Okay, so to wrap things up, I wanted to thank Mark Cicero, John Ling, Marianga Shahil and the entire pediatric committee from the NMSP. It's really important here that in 2020 we finally turn the corner in pediatric care and we're treating kids just like we would treat the adult. We're treating cardiac arrest on scene, we're treating seizures on scene. Let's treat and fix those kids where we find them instead of racing to the hospital where lo and behold, the same exact thing is being done. And the only way we can do that is by using the right tools that are customized to each individual agencies that could be nimble, that could be quick, that could be modified rapidly and safely. This has been Dr. Peter Hantevi. Thanks for joining me for another edition of the Hantevi Minute.