G234(P) The safe administration and availability of intramuscular adrenaline for paediatric anaphylaxis – quality improvement through simulation

Abstract

Introduction Intramuscular adrenaline is a time-critical emergency treatment in the acute management of paediatric anaphylaxis. A low fidelity simulation project was carried out to identify the relative safety of existing emergency kit adrenaline vials compared to pre-filled adrenaline autoinjectors in the management of a simulated anaphylaxis in a 5 year old male. Method A low fidelity simulation consisting of a paediatric registrar and a paediatric staff nurse familiar with their departments were carried out under timed conditions. 12 Paired trials were carried out across two centres in paediatric emergency departments, paediatric admission units, and paediatric inpatient wards. Each paired trial occurred during the same shift with the same staff. The time from the medical request for a defined dose of 0.15 ml of 1:1000 adrenaline to be provided at the bedside in a syringe with an IM needle attached was recorded. Errors in the initially provided dose were immediately identified and the time required for the provision of the correct dose measured. Results The mean time to completion of the simulation for the emergency kit arm was 138.3 seconds (range 96 – 223 seconds) compared to 33.6 seconds (range 17 – 54 seconds) for the adrenaline autoinjector arm. Incorrect doses of adrenaline were provided to the clinician in 2 of 6 emergency kit simulations. There were no dosing errors in the autoinjector arm. In all cases the nursing staff reported preferring the autoinjector method. Conclusion This study provides clear evidence for the improved safety of adrenaline autoinjectors over emergency kits in the hospital management of paediatric anaphylaxis. The increased time for the emergency kit arm may partly reflect the availability of various components (vials, syringes, filter and IM needles) in different clinical settings. The significant risk of errors as a consequence of human factors in emergency drug preparation is already well-known and reflected in this study. Following these results, paediatric adrenaline autoinjectors have been adopted universally across both sites. The cost consideration of autoinjectors over adrenaline vials, particularly variation in expiry rate, is important when considering departmental policy change. However, the safety concerns were considered to outweigh the increased cost in these centres.