Study Finds Card Printed With Simple Dosing Information Can Cut Risk, Save Time
When paramedics are transporting a sick child to the hospital by ambulance, every moment counts and every treatment decision is crucial. A University of Maryland School of Medicine study has found that a simple card printed with basic pediatric medication dosage information can save precious time and reduce dangerous errors when children are being transported to the hospital.
While adults receive standard doses of medications to keep them alive before they reach the hospital, children receive doses specifically tailored to their individual weight. In the ambulance with a child, in the heat of an emergency, paramedics are left to work mathematical formulas in their heads in a matter of precious seconds. At the same time, the paramedics are managing the child’s airway, placing IV lines, and potentially performing CPR.
“It’s a recipe for disaster,” says Morgen Bernius, MD, assistant clinical instructor at the University of Maryland School of Medicine and lead investigator on the study published in the journal Prehospital Emergency Care.
“It’s an antiquated system that demands too much of paramedics,” adds Dr. Bernius, who completed her residency at the University of Maryland Hospital for Children. The study found that paramedics who were provided with a card listing weight-based drug doses and endotracheal tube sizes were able to answer medication calculation questions more quickly and accurately than those without the card.
Paramedics with access to the pediatric code card designed by Dr. Bernius correctly answered 94 percent of the medication calculation questions they were asked, on average, compared to 65 percent among paramedics without the cards. The group without the cards took an average of 11.4 minutes to complete the questionnaire. The group with the cards took just 7.1 minutes.
“This solution is so simple, but so clever. It can save lives. The card is a great example of the innovative spirit we try to foster in our residents,” says Steven Czinn, MD, professor and chair of the Department of Pediatrics at the University of Maryland School of Medicine and director of the University of Maryland Hospital for Children, part of the University of Maryland Medical Center. The hospital’s pediatric emergency department is one of just two emergency departments in the state of Maryland that are specifically tailored to the needs of children.
In an ambulance, paramedics don’t have access to computerized medication calculation, state-of-the-art technology and the advice or opinions of colleagues. They’re often left to calculate complicated dosages and tube sizes in their heads based on intricate formulas and assumptions about a child’s weight and size. The entire process takes place in the heat of the moment of an emergency situation.
Dr. Bernius realized the need for the cards in the prehospital setting while working as an EMS fellow with the Baltimore City Fire Department. Dr. Bernius had just completed her residency at the University of Maryland Medical Center’s departments of pediatrics and emergency medicine, caring for patients in the University of Maryland Hospital for Children and its pediatric emergency department. The study investigators included Dr. Bernius’ fellow residents Bryan Thibodeau, MD, Abby Jones, MD, and Brian Clothier, MD.
Dr. Bernius devised a pediatric code card first-responders could carry on their person or in the ambulance to use as a quick, on-the-spot reference guide. The card lists 13 common medications — including atropine, diazepam, epinephrine, lidocaine and morphine — and the appropriate dosages for children in 10 different weight categories, from 3.5 kilograms to 60 kilograms. The card also lists the appropriate size of endotracheal tube — used to keep the airway open — for children of various ages and weights, from newborn up to 12 years old. The card also includes a chart to assist paramedics in converting pounds to kilograms — an eight-pound baby makes for a 3.5 kg newborn; a child who weighs 100 lbs. also weighs 45 kg, and is likely about 13 years old.
Dr. Bernius and her colleagues distributed the cards to Advanced Life Support paramedics who took continuing education courses in Maryland and Washington between June and November 2006. The providers — paramedics or emergency medical technicians — then were asked to answer questionnaires requiring them to calculate medication doses and tube sizes. Of 523 providers, 246 used the pediatric code cards while answering the questions. The other 277 study participants did not use the cards.
In addition to answering correctly on average 94 percent of the calculation questions, the group with access to the cards also calculated endotracheal tube sizes more accurately. Ninety-eight percent of the group with access to the cards calculated the correct tube sizes, compared to just 23 percent of the unaided group. In the overall pool of questions — including the eight calculation questions and the three tube-size questions — 67 percent of the responses were correct in the group without the pediatric code cards. The group with the cards answered 93.4 percent of the questions correctly.
“The results of this study clearly demonstrate that the pediatric code cards in the prehospital setting are significantly more effective than relying on paramedics to simply do the math in their heads,” says Dr. Bernius. “The high rate of error among the unaided group is very sobering.”
After the study, the Baltimore County Fire Department adopted the pediatric code cards into its Emergency Medical Services, or EMS, system, according to Dr. Bernius, who now serves as the fire department’s associate medical director. The EMS system in Richmond, Virginia, also uses the cards, and other jurisdictions are evaluating the idea.
“I have confidence this study will have ongoing impact on the way children are cared for during the crucial time that passes before they reach the hospital,” says Dr. Czinn.
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