Comparison of Four Methods of Paramedic Continuing Education in the Management of Pediatric Emergencies.

Introduction: Finite resources limit the amount of time EMS agencies can dedicate to continuing education in pediatric emergencies. EMS instructors need effective, efficient, and affordable educational strategies for these high-risk, low frequency events.Objective: To compare the effectiveness of four training methods in management of pediatric emergencies for paramedics.Methods: A validated, performance-based, simulated clinical assessment module was used to provide a baseline measurement of paramedics' resuscitation skills during three simulated pediatric emergencies. Educational modules were developed that targeted deficiencies identified by the baseline assessment, including advanced pediatric life support skills, airway management, use of the Broselow-Luten Tape®, pediatric drug dose calculations and drug delivery, seizure management, and trauma assessment. Paramedics from five EMS agencies in Michigan were randomized to four education intervention groups. The control group used an existing, online, continuing education course. Three experimental groups were exposed to the same content during five, one-hour sessions conducted over 2.5 years. Instruction was delivered using high-fidelity, simulated case-based training, low-fidelity simulation training, or lecture with procedural skills lab, based on group assignment. After the training, all groups were tested within 4-6 months using methods identical to baseline testing.Results: One hundred forty-seven subjects completed the study. There were no differences in baseline skill levels among the four groups. Only the low fidelity simulation training group demonstrated improvement of combined scenario scores (p = 0.0008). Scores for targeted skills improved in one scenario in the high-fidelity group, two in the low-fidelity group, one in the lecture/lab group, and none in the control group.Conclusions: Although improvements in those skills included in the training were found in three groups, two hours of training in pediatric emergencies per year was insufficient to produce a substantial improvement overall. Expensive, high-fidelity simulators were not necessary for teaching pediatric resuscitation skills to paramedics; instructive scenarios using low-fidelity manikins and debriefings appear to be adequate. The content delivered by an online refresher course did not provide any improvement in performance as measured by simulated, case-based assessments.

Errors and error-producing conditions during a simulated, prehospital, pediatric cardiopulmonary arrest.

INTRODUCTION: Management of pediatric cardiac arrest challenges the skills of prehospital care providers. Errors and error-producing conditions are difficult to identify from retrospective records. The objective of this study was to identify errors committed by prehospital care providers and the underlying causes of those errors during a simulated pediatric cardiopulmonary arrest followed by a structured debriefing. METHODS: Performance criteria were defined prospectively by an advisory panel. Prehospital care providers from 6 emergency medical service agencies in Michigan participated in a simulation of an infant cardiopulmonary arrest using their own drugs, equipment, and protocols in a mobile trailer. Simulations were video recorded and played back during debriefings that were conducted immediately after the event to facilitate error analysis. Observed errors and subjects' explanations were analyzed by thematic qualitative assessment methods and descriptive statistics. RESULTS: One hundred ninety-four subjects, including paramedics, emergency medical technicians, and emergency medical responders in various crew configurations, participated in 60 simulation sessions during a 5-month period (April to August of 2010). Error types were classified into 4 clinically important themes as follows: failure to provide adequate ventilation, failure to provide effective circulation, failure to achieve vascular access rapidly, and medication errors. Multiple underlying causes of medication dosing and other errors were identified, including cognitive, procedural, communication, teamwork, and systems factors. CONCLUSIONS: We systematically observed many types of errors and identified some of the underlying causes during a simulated, prehospital, pediatric cardiopulmonary arrest. There were numerous, multifactorial, and sometimes, synergistic causes of medication dosing errors. Emergency medical service officials can use these findings to prevent future errors.

Medication errors in prehospital management of simulated pediatric anaphylaxis.

BACKGROUND: Systematic evaluation of the performances of prehospital providers during actual pediatric anaphylaxis cases has never been reported. Epinephrine medication errors in pediatric resuscitation are common, but the root causes of these errors are not fully understood. OBJECTIVE: The primary objective of this study was to identify underlying causes of prehospital medication errors that were observed during a simulated pediatric anaphylaxis reaction. METHODS: Two- and 4-person emergency medical services crews from eight geographically diverse agencies participated in a 20-minute simulation of a 5-year old child with progressive respiratory distress and hypotension from an anaphylactic reaction. Crews used their own equipment and drugs. A checklist-based scoring protocol was developed to help identify errors. A trained facilitator conducted a structured debriefing, supplemented by playback of video recordings, immediately after the simulated event to elicit underlying causes of errors. Errors were analyzed with mixed quantitative and qualitative methods. RESULTS: One hundred forty-two subjects participated in 62 simulation sessions. Ninety-five percent of crews (59/62) gave epinephrine, but 27 of those crews (46%) delivered the correct dose of epinephrine in an appropriate concentration and route. Twelve crews (20%) gave a dose that was ≥5 times the correct dose; 8 crews (14%) bolused epinephrine intravenously. Among the 55 crews who gave diphenhydramine, 4 delivered the protocol-based dose. Three crews provided an intravenous steroid, and 1 used the protocol-based dose. Underlying causes of errors were categorized into eight themes: faulty reasoning, weight estimation errors, faulty recall of medication dosages, problematic references, calculation errors, dose estimation, communication errors, and medication delivery errors. CONCLUSION: Simulation, followed by a structured debriefing, identified multiple, underlying causes of medication errors in the prehospital management of pediatric anaphylactic reactions. Sequential and synergistic errors were observed with epinephrine delivery.