Maa Tensing, Scherzer Daniel J, Harwayne-Gidansky Ilana, Capua Tali, Kessler David O, Trainor Jennifer L, Jani Priti, Damazo Becky, Abulebda Kamal, Diaz Maria Carmen G, Sharara-Chami Rana, Srinivasan Sushant, Zurca Adrian D, Deutsch Ellen S, Hunt Elizabeth A, Auerbach Marc
Division of Pediatric Critical Care Medicine, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, Ohio.
Division of Pediatric Emergency Medicine, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, Ohio.
J Allergy Clin Immunol Pract. 2020 Apr;8(4):1239-1246.e3. doi: 10.1016/j.jaip.2019.11.013. Epub 2019 Nov 23.
Multi-institutional, international practice variation of pediatric anaphylaxis management by health care providers has not been reported.
To characterize variability in epinephrine administration for pediatric anaphylaxis across institutions, including frequency and types of medication errors.
A prospective, observational, study using a standardized in situ simulated anaphylaxis scenario was performed across 28 health care institutions in 6 countries. The on-duty health care team was called for a child (patient simulator) in anaphylaxis. Real medications and supplies were obtained from their actual locations. Demographic data about team members, institutional protocols for anaphylaxis, timing of epinephrine delivery, medication errors, and systems safety issues discovered during the simulation were collected.
Thirty-seven in situ simulations were performed. Anaphylaxis guidelines existed in 41% (15 of 37) of institutions. Teams used a cognitive aid for medication dosing 41% (15 of 37) of the time and 32% (12 of 37) for preparation. Epinephrine autoinjectors were not available in 54% (20 of 37) of institutions and were used in only 14% (5 of 37) of simulations. Median time to epinephrine administration was 95 seconds (interquartile range, 77-252) for epinephrine autoinjector and 263 seconds (interquartile range, 146-407.5) for manually prepared epinephrine (P = .12). At least 1 medication error occurred in 68% (25 of 37) of simulations. Nursing experience with epinephrine administration for anaphylaxis was associated with fewer preparation (P = .04) and administration (P = .01) errors. Latent safety threats were reported by 30% (11 of 37) of institutions, and more than half of these (6 of 11) involved a cognitive aid.
A multicenter, international study of simulated pediatric anaphylaxis reveals (1) variation in management between institutions in the use of protocols, cognitive aids, and medication formularies, (2) frequent errors involving epinephrine, and (3) latent safety threats related to cognitive aids among multiple sites.
医疗服务提供者对儿童过敏反应管理的多机构、国际实践差异尚未见报道。
描述各机构间儿童过敏反应肾上腺素给药的差异，包括用药错误的频率和类型。
在6个国家的28个医疗机构中，采用标准化的现场模拟过敏反应场景进行了一项前瞻性观察研究。呼叫值班医疗团队处理一名处于过敏反应中的儿童（患者模拟器）。从实际存放地点获取真实的药品和用品。收集了关于团队成员的人口统计学数据、过敏反应的机构规程、肾上腺素给药时间、用药错误以及模拟过程中发现的系统安全问题。
进行了37次现场模拟。41%（37个中的15个）的机构存在过敏反应指南。团队在41%（37次中的15次）的模拟中使用了用药剂量辅助工具，在32%（37次中的12次）的模拟中用于准备工作。54%（37个中的20个）的机构没有肾上腺素自动注射器，仅在14%（37次中的5次）的模拟中使用。使用肾上腺素自动注射器时，肾上腺素给药的中位时间为95秒（四分位间距，77 - 252），手动配制肾上腺素时为263秒（四分位间距，146 - 407.5）（P = 0.12）。68%（37次中的25次）的模拟中至少发生了1次用药错误。护士进行过敏反应肾上腺素给药的经验与较少的准备（P = 0.04）和给药（P = 0.01）错误相关。30%（37个中的11个）的机构报告了潜在安全威胁，其中一半以上（11个中的6个）涉及用药剂量辅助工具。
一项多中心、国际性的模拟儿童过敏反应研究表明：（1）各机构在规程、用药剂量辅助工具和药物配方使用方面的管理存在差异；（2）涉及肾上腺素的错误频繁发生；（3）多个地点存在与用药剂量辅助工具相关的潜在安全威胁。
