Received June 9, 2021 from Los Angeles County Emergency Medical Services Agency, Santa Fe Springs, California (NM, MG-H); Department of Emergency Medicine, Harbor-UCLA Medical Center and, the Lundquist Institute, Torrance, California (NM, AHM); David Geffen School of Medicine at UCLA, Los Angeles, California (NM, AHM, MG-H). Revision received July 6, 2021; accepted for publication July 6, 2021.
Prehosp Emerg Care. 2022 Jul-Aug;26(4):492-502. doi: 10.1080/10903127.2021.1955058. Epub 2021 Aug 4.
We hypothesized that implementation of a Medical Control Guideline (MCG) with a standardized formulary (fixed medication concentrations) and pre-calculated medication dosages in a large emergency medical services (EMS) system would reduce pediatric dosing errors. To assess the effectiveness of the standardized formulary to reduce errors, we chose to evaluate midazolam administration for seizures, because it is the most frequently dosed medication by EMS for children, and seizures are a time-sensitive condition. The objective of this study was to compare: 1) frequency of midazolam dosing errors during the field treatment of pediatric seizures and 2) paramedic anxiety and confidence in dosing midazolam for pediatric seizures, before and after implementation of the MCG. In this mixed-methods study, we utilized the Los Angeles County EMS data registry to identify pediatric patients ≤14 years-old treated with midazolam for seizure. We defined a dosing error as outside the dose directed by the color code on the length-based resuscitation tape, or ±20% the weight-based midazolam dose when color code was absent. We compared dosing errors during a two-year period before and after implementation of the MCG with the standardized formulary in February 2017. We surveyed paramedics to assess their level of anxiety and confidence in dosing midazolam and conducted semi-structured interviews with 20 respondents to further explore its impact on paramedic practice. There were 80 dosing errors in 569 patients treated post-formulary (14.1%) compared with 92 dosing errors in 497 patients treated pre-formulary (18.5%), risk difference -4.5% (95% CI -8.9 to 0.0), p = 0.049. Among 304 paramedic survey respondents who had experience with the formulary, anxiety decreased (p < 0.001) and confidence increased (p < 0.001) post-formulary. Paramedics expressed the challenges of pediatric calls, the benefits of the MCG with the standardized formulary, and the ongoing challenges of pediatric medication dosing. Benefits included simplifying paramedic tasks, increasing paramedic self-efficacy, facilitating provider communication, and improving patient care. Implementation of a MCG with standardized formulary and pre-calculated medication dosing by weight reduced pediatric medication dosing errors and increased paramedic confidence in pediatric medication dosing. It may have the potential to facilitate patient care through improved communications and task simplification.
我们假设在大型紧急医疗服务（EMS）系统中实施医疗控制指南（MCG），并采用标准化配方（固定药物浓度）和预先计算的药物剂量，将减少儿科用药错误。为了评估标准化配方减少错误的效果，我们选择评估咪达唑仑治疗癫痫发作时的给药剂量，因为它是 EMS 为儿童最常使用的药物，而癫痫发作是一种时间敏感的病症。本研究的目的是比较：1）在现场治疗儿科癫痫发作期间咪达唑仑给药剂量错误的频率，以及 2）在 MCG 实施前后，护理人员在为儿科癫痫发作给药咪达唑仑时的焦虑程度和信心。在这项混合方法研究中，我们利用洛杉矶县 EMS 数据登记处，确定了 14 岁以下接受咪达唑仑治疗癫痫发作的儿科患者。我们将剂量错误定义为超出基于长度的复苏带颜色编码指导的剂量，或在颜色编码不存在时，偏离基于体重的咪达唑仑剂量的±20%。我们比较了 MCG 实施前后两年期间（2017 年 2 月）标准化配方实施前后的剂量错误。我们对护理人员进行了调查，以评估他们给药咪达唑仑的焦虑程度和信心，并对 20 名受访者进行了半结构化访谈，以进一步探讨其对护理人员实践的影响。在接受配方治疗的 569 名患者中有 80 次剂量错误（14.1%），而在接受配方治疗的 497 名患者中有 92 次剂量错误（18.5%），差异风险为-4.5%（95%CI：-8.9，0.0），p=0.049。在接受过配方调查的 304 名护理人员中，焦虑程度降低（p<0.001），信心增加（p<0.001）。护理人员表示儿科电话的挑战、MCG 与标准化配方的好处，以及儿科药物剂量的持续挑战。好处包括简化护理人员的任务、提高护理人员的自我效能、促进提供者之间的沟通和改善患者护理。实施 MCG 与标准化配方和按体重预先计算药物剂量减少了儿科药物剂量错误，并提高了护理人员对儿科药物剂量的信心。它有可能通过改善沟通和简化任务来促进患者护理。
