The Evolution of Excellence in Pediatric Emergency Care—Part 3: What the Future Holds

In the first parts of this series, we examined the Broselow-Luten and Handevy systems for pediatric patient care. Both systems utilize a variety of approaches to providing crucial information in critical situations. Both aim to increase patient safety, enhance treatment speed and effectiveness, and heighten provider confidence by reducing stress, confusion, and uncertainty.

Pocket reminders, wall posters, and tapes for carts are great and have undoubtedly made a huge difference in the care we provide. But, as they say, what have you done for us lately? How do we keep up with the present, let alone prepare for the future?

You don’t need a crystal ball to see the future of prehospital and hospital-based pediatric emergency care—just point and click. The availability of electronic devices might seem overwhelming, but we need to recognize this simple fact: The answers are all there. And you don’t need much information (data) to start with—an age, a color code, a vial of medication. Whatever you have, just enter and click.

Fear not, the future is here.

There’s an App for That

Both the Broselow-Luten and Handtevy systems are actively addressing the move to a more digital world. Whether on a desktop or laptop computer, a smartphone or tablet device, an incredible amount of information is now available at your fingertips. And it’s available as quickly as you can enter some very basic data. (Making these applications even better is that they are being integrated into electronic medical record systems!)

As an added benefit, the electronic versions of the measuring tapes are customizable to a specific EMS system’s or hospital’s formulary. Most of the time you’re only working with a single concentration or preparation of a medication. If the electronic system already knows this, cumbersome calculations are made much easier. Instead of having to calculate the proper dilution or concentration, all you’ll need is the age or color range of your pediatric patient and their specific medication, and the system does all the math! 

Imagine this: Your ambulance service only stocks one concentration of Narcan (naloxone)—1 mg/mL. When you click on the app, that’s all you’ll see. The dose is calculated to that concentration and shows you not only the mg, but also the mL to push. This is a huge help, since mental math under stress is not your friend. And since change is inevitable, these electronic systems can be updated quickly and easily, with no need to print and replace guidebooks or handouts.

Medication safety is also improved because if a drug gets a new “black box” warning or the recommended dosing changes, adjustments can be distributed to all consumers immediately. If one concentration or medication becomes unavailable, alternatives can be chosen and programming adjusted as needed.

And there’s even more: eBroselow and its SafeDose mobile app (a specific EMS version is coming soon) have recently introduced barcode scanning of all medications. Using the camera on your mobile device, you can scan the label on the vial of medication, and the system will provide you with all the needed dosing and administration information, even if the medication is new in your formulary or supply system. And both pediatric systems are either currently integrated with or actively working on integration into common industry EMR systems.

Benefits

Consider the following situations:

Intubation—A 1-year-old needs to be intubated. We must figure out what size endotracheal tube to use. Now, what was that formula? Age plus something divided by something? Or was it age divided by something plus something? Even if you remember the formula, you still have to do the math.

And on top of that, what’s the deal with an uncuffed tube versus a cuffed tube? And if we figure out the tube size, where do we tape it? And then what size suction catheter, what size NG/OG tube, what size urinary catheter? Oh, and did we mention it’s 4 a.m. and toward the end of a hectic shift? Feeling the stress?

Or would you rather use a measuring device or select a color-coded age-specific card? Or maybe just open an app and enter the age (or color code) of the patient? In a second or two, you have everything you need right in front of you: ET tube sizes, taping points, and sizes for suction and urinary catheters as well as NG tubes, without having to make a single calculation.

Medications—A 1-year-old child has a femur fracture after falling down stairs. Pain relief is certainly appropriate, but what is the dose of fentanyl? It’s something per kg, because it almost always is something per kg. But how much, and is the nasal dosing more or less than the IV dosing? And what’s the weight of the child in kilograms when mom only knows the pounds and ounces? And you need to figure out how to dilute the drug based on the concentration. And don’t forget to convert the dose in milligrams to the proper volume in milliliters. And yes, it’s still 0400. Feeling the stress?

But wait—you have a smartphone or tablet! With a few simple clicks on the screen, you have all your answers. You can take care of your patient instead of stressing about the math.

And what about the dreaded drips? You have the same choice: lots of math and stress, or a few clicks and the information is at your fingertips. Dosing, mixing, pump rate—it’s all right there.

Real-life experiences—All too often we find that even though we think we know how to use the tools and toys, we really don’t. Even when we know what information is on the tapes or cards or computer screen, getting to that information isn’t as quick as it should be. We stumble with the equipment or technology.

The bottom line, now and in the future: The resources are out there, and most are incredibly easy to use as long as you take a few minutes to prepare and practice first. Take whatever cheat sheets, books, cards, tapes, or apps you have and regularly take a few minutes to actually play with them. Try to find the most common things you need (ETT size, epi dose, etc.) and then try to find those many other things you don’t need as often. That way you know where stuff is, what it’s called, and how to find it quickly and easily. 

Preparation plus practice produces proficiency. Your patients deserve nothing less!  

The authors wish to thank Peter Antevy, MD, James Broselow, MD, Bonnie Lundblom, RN, and Robert Luten, MD, for their invaluable insights in the preparation of these articles.

Scott DeBoer, RN, MSN, CPEN, CEN, CCRN, CFRN, EMT-P, is an international pediatric seminar leader and nurse consultant with more than 25 years of nursing experience. He retired from flight nursing in 2015 following more than 20 years with the University of Chicago Hospital UCAN flight team. He is the founder and primary seminar leader for Pedi-Ed-Trics Emergency Medical Solutions. 

Emily Dawson, MD, is a pediatric emergency medicine and critical care attending physician at Advocate Children’s Hospital, Oak Lawn, Ill.

Lisa DeBoer, CET, NREMT, PI, is president and cofounder of Pedi-Ed-Trics Emergency Medical Solutions. 

Julie Bacon, MSN-HCSM, RNC-LRN, NE-BC, CPN, CPEN, C-NPT, has more than 25 years of experience in emergency transport medicine, with expertise in pediatric and neonatal transport and critical care. She is program manager and chief flight nurse for Johns Hopkins All Children’s Life Line, St. Petersburg, Fla.

Michael Seaver, RN, BA, is a healthcare informatics consultant based in Chicago.