Paramedics' Adoption of Established Tool to Measure a Child's Weight Enhances Accuracy of Drug Dosing for Resuscitations

Problem Addressed

• Drug dosing critical in pediatric emergency cases: Epinephrine (adrenaline) is the most frequently used resuscitation medication in infants and children experiencing cardiac arrest or anaphylaxis (a severe, whole-body allergic reaction).³ Although there is little variation in epinephrine doses administered to adults in cardiac arrest, the appropriate pediatric dosage is based almost entirely on weight. If too little is administered, the drug is ineffective and the resuscitation effort fails, if too much is administered, there is a risk of intracranial hemorrhage and hypertension.³
• Lack of experience among paramedics: Because paramedics infrequently care for critically ill children, they lack experience in determining a child's weight and his or her appropriate dosage, which is compounded by the high-stress nature of emergency situations such as cardiac arrest. In one study, only 7 percent of all paramedic calls involved patients aged 14 years or younger.⁴
• Proven tool to help, but rarely used by paramedics: Since the 1980s, the Broselow^® tape has been used to help clinicians rapidly estimate body weight and correct drug doses in children, but it is rarely used by emergency medical services providers nationwide. However, when paramedics estimated pediatric weights using the tool in a classroom setting, they were able to determine epinephrine doses accurately 95 percent of the time.²

Description of the Innovative Activity

• Training: Paramedics and hospital ED personnel are trained to use the tape and to communicate about dosing decisions during pediatric resuscitations. (See the Planning and Development section for more information about training.)
• Communication and coordination: The paramedic in the field uses the tape to measure the child and determine which "color zone" applies. The paramedic then routinely confers with hospital ED personnel by radio. 
• Dosing decisions: The ED determines the correct epinephrine dose; each color zone corresponds to a color-coded drug-dosing and resuscitation equipment chart. References at each color bar on the tape indicate what emergency resuscitation equipment size to use, and references at each weight zone on the tape show correct, precalculated medication dosages. Designated resuscitation equipment and medications are often contained in corresponding, color-coded containers in each ambulance.
• Review: Emergency medical services and hospital officials regularly review dosages and use of the tape after pediatric medical emergencies to assess performance and improve delivery of care in the field.

References/Related Articles

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Results

• Dosing accuracy more than doubles: Before mandating use of the tape, only 28 percent of children (29 of 104 cases) who experienced cardiopulmonary arrest received the correct first dose of epinephrine from Los Angeles Emergency Medical Services Agency paramedics. After the mandate went into place, 57 percent (21 of 37 children) received the appropriate dose. Similar results are seen when comparing the frequency of dosing within 20 percent of the correct level. Before the mandate, 44 percent (46 of 104) of children received a dose that was within 20 percent of the correct dose. After the mandate, the corresponding figure was 65 percent (24 of 37 children).
• Accuracy expected to improve for use of other drugs and equipment in pediatric emergencies: While no hard data are available, mandated use of the tape should also lead to improvements in dosing of other emergency drugs administered to children, including antiseizure and sedation medication. The mandate should also improve selection of appropriately sized resuscitation equipment for children, such as tubes and ventilators.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Joint paramedic and hospital personnel training: Los Angeles County paramedics and ED hospital personnel (in Los Angeles County’s case, the hospital personnel were mobile intensive care nurses) were both trained in the use of the Broselow^® Tape and color zones for drug dose and resuscitation equipment determinations in the field. The training was conducted by a physician and nurse educators from the Department of Emergency Medicine at Harbor-UCLA Medical Center. As a part of this training, paramedics were taught to verbally report the color to hospital ED personnel, and hospital personnel were taught to repeat back the dosage to the paramedics as an extra step to confirm dose accuracy before administration of the first resuscitation dose. Once existing personnel received this initial training, ongoing instruction and reminders about use of the tape was made a part of the emergency medical services agency's regular training regimen.
• Purchase and deployment of equipment: Paramedics and hospital personnel were supplied with the tape and color-coded precalculated drug-dosing reference charts. Each of the county’s 200 ambulances was equipped with five tapes and reference charts.
• Quality improvement oversight: A quality improvement process was instituted to track the performance of paramedics and ED personnel in documenting the color zone for each child evaluated in the field. Emergency medical services data forms and original paramedic run reports were collected and reviewed. The correct first dose of epinephrine that should have been administered to each patient was calculated according to LA County prehospital care treatment guidelines and the weight determined with the Broselow^® Tape (if available), the parental weight estimate recorded in the field, or the weight recorded in the ED. How often conferencing actually occurred between paramedics and hospital ED personnel was not recorded.

Resources Used and Skills Needed

• Staffing: The program requires no new staff, as paramedics and hospital ED personnel participate as part of their regular duties.
• Costs: A Broselow^® Tape and accompanying chart costs about $80 each, which means that Los Angeles County spent approximately $80,000 on 1,000 tapes and charts (5 for each of 200 ambulances). The cost of training paramedics and hospital personnel in the use of the Broselow^® Tape is not known; training costs will vary by county or municipality, based on the size of the emergency medical services department.

Funding Sources

Agency for Healthcare Research and Quality; Health Resources and Services Administration; State of California - Emergency Medical Services; National Center for Research Resources

Tools and Other Resources

Getting Started with This Innovation

• Investigate the hospital's current use, if any, of the tape for pediatric drug dosing.
• Appoint a quality improvement manager or designate the emergency medical services medical director to champion acquisition of Broselow^® Tapes and charts, and coordinate training and future evaluation.
• Develop a timeline for the project, and identify a trainer for paramedics and ED staff who will serve as the ED contacts for paramedics in the field.
• Assign roles and responsibilities to team members and use check-back processes to verify communications and actions to reduce errors and clarify communications in high-stress, emergency situations.
• Integrate training on use of the tape into established training systems for new and existing employees. Coordinate training with the local hospital or hospitals that are capable of handling pediatric emergencies.
• Incorporate documentation of tape usage, dose identification, and ultimate dose accuracy into emergency medical services run reports and hospital reports. Identify who will monitor tape usage, track effectiveness, and identify potential opportunities for improvement.

Sustaining This Innovation

• Use dose accuracy and communication information gleaned from each emergency medical services call to continuously improve care delivery and fine-tune training.
• Hold regular meetings between emergency medical services and hospital staff to evaluate tape usage and efficacy.

Additional Considerations and Lessons

• The current dosing error rate in Los Angeles County is still unacceptable, even with mandatory use of the tape and joint training and consultation with hospital ED personnel, suggesting that other measures should be taken to further improve medication dosing for children.
• Researchers are finding that the tape, which measures height and the average weight associated with that height, may underestimate weight and appropriate doses for obese children. Given the obesity epidemic in U.S. children, this means that the potential for inaccurate dosing remains high for this significant, growing subset of the pediatric population. 

Use By Other Organizations

• Orange County, which is just south of Los Angeles County, recently mandated training and use of the Broselow^® Tape by its emergency medical services responders.