Treatment of a simulated child with anaphylaxis: an in situ two-arm study

Simulation based education in paediatric resuscitation

There is increasing use of clinical Simulation Based Education (SBE) in healthcare due to an increased focus on patient safety, the call for a new training model not based solely on apprenticeship, a desire for standardised educational opportunities that are available on-demand, and a need to practice and hone skills in a controlled environment. SBE programs should be evaluated against Kirkpatrick level 3 or 4 criteria to ensure they improve patient or staff outcomes in the real world. SBE programs have been shown to improve outcomes in neonatology - reductions in hypoxic ischaemic encephalopathy, in brachial plexus injury, rates of school age cerebral palsy, reductions in 24hr mortality and improvements in first pass intubation rates. In paediatrics SBE programs have shown improvements in paediatric cardiac arrest survival, PICU survival, reduced PICU admissions, reduced PICU length of stay and reduced time to critical operations. SBE can improve the non-technical tasks of teamwork, leadership and communication (within the team and with patients and carers). Simulation is a useful tool in Quality and Safety and is used to identify latent safety issues that can be addressed by future programs. In high stakes assessment simulation can be a mode of assessment, however, care needs to be taken to ensure the tool is validated carefully.

Immediate Adverse Events Following COVID-19 Vaccination in Australian Pharmacies: A Retrospective Review

BACKGROUND

Four COVID-19 vaccines are approved for use in Australia: Pfizer-BioNTech BNT162b2 (Comirnaty), AstraZeneca ChAdOx1 (Vaxzevria), Moderna mRNA-1273 (Spikevax), and Novavax NVX-CoV2373 (Nuvaxovid). We sought to examine the type and management of immediate adverse events following immunisation (I-AEFI) after COVID-19 vaccination.

METHODS

Retrospective review of I-AEFI recorded between July 2021 and June 2022 in 314 community pharmacies in Australia.

RESULTS

I-AEFI were recorded in 0.05% (n = 526/977,559) of all COVID-19 vaccinations (highest: AstraZeneca (n = 173/161,857; 0.11%); lowest: Pfizer (n = 50/258,606; 0.02%)). The most common reactions were: (1) syncope, after the first dose of AstraZeneca (n = 105/67,907; 0.15%), Moderna (n = 156/108,339; 0.14%), and Pfizer (n = 22/16,287; 0.14%); and (2) Nausea/vomiting after the first dose of Pfizer (n = 9/16,287; 0.06%), Moderna (n = 55/108,339; 0.05%), and AstraZeneca (n = 31/67,907; 0.05%) vaccines. A total of 23 anaphylactic reactions were recorded (n = 23/977,559; 0.002%), and 59 additional I-AEFI were identified using MedDRA^® terminology. Pharmacists primarily managed syncope by laying the patient down (n = 227/342; 66.4%); nausea/vomiting was managed primarily by laying the patient down (n = 62/126; 49.2%), giving water (n = 38/126; 30.2%), or monitoring in the pharmacy (n = 29/126; 23.0%); anaphylactic reaction was treated with adrenaline (n = 18/23; 78.3%) and n = 13/23 (56.5%) anaphylactic reactions were treated with the combination of: administered adrenaline, called ambulance, and laid patient down.

CONCLUSION

The most commonly recorded I-AEFI was syncope after COVID-19 vaccination in pharmacy; I-AEFI are similar to those previously reported. Pharmacists identified and managed serious and non-serious I-AEFI appropriately and comprehensively.

Is in situ simulation in emergency medicine safe? A scoping review

OBJECTIVES

To provide an overview of the available evidence regarding the safety of in situ simulation (ISS) in the emergency department (ED).

DESIGN

Scoping review.

METHODS

Original articles published before March 2021 were included if they investigated the use of ISS in the field of emergency medicine.

INFORMATION SOURCES

MEDLINE, EMBASE, Cochrane and Web of Science.

RESULTS

A total of 4077 records were identified by our search strategy and 2476 abstracts were screened. One hundred and thirty full articles were reviewed and 81 full articles were included. Only 33 studies (40%) assessed safety-related issues, among which 11 chose a safety-related primary outcome. Latent safety threats (LSTs) assessment was conducted in 24 studies (30%) and the cancellation rate was described in 9 studies (11%). The possible negative impact of ISS on real ED patients was assessed in two studies (2.5%), through a questionnaire and not through patient outcomes.

CONCLUSION

Most studies use ISS for systems-based or education-based applications. Patient safety during ISS is often evaluated in the context of identifying or mitigating LSTs and rarely on the potential impact and risks to patients simultaneously receiving care in the ED. Our scoping review identified knowledge gaps related to the safe conduct of ISS in the ED, which may warrant further investigation.

Emergency treatment of anaphylaxis: concise clinical guidance

Anaphylaxis is a serious systemic hypersensitivity reaction that is usually rapid in onset and may cause death. It is characterised by the rapid development of airway and/or breathing and/or circulation problems. Intramuscular adrenaline is the most important treatment, although, even in healthcare settings, many patients do not receive this intervention contrary to guidelines. The Resuscitation Council UK published an updated guideline in 2021 with some significant changes in recognition, management, observation and follow-up of patients with anaphylaxis. This is a concise version of the updated guideline.

Knowledge, Attitude, and Practice regarding Anaphylaxis among Pediatric Health Care Providers in a Teaching Hospital

Anaphylaxis is a severe, life threatening generalized or systemic hypersensitivity reaction which requires prompt, accurate diagnosis, and appropriate management. The objective of the study is to assess the extent of knowledge, management skills, and attitude on anaphylaxis among pediatric health care providers of a tertiary care teaching hospital. This was a cross-sectional study done in the department of pediatrics, which included faculty, residents, interns, and nurses. The knowledge, attitude, and practice were assessed using a standardized questionnaire comprised of 35 questions. The questionnaire was distributed and collected in person to all the participants. Informed consent was obtained from all participants and confidentiality was ensured at all stages. Collected data were analyzed using SPSS version 20. The mean of total knowledge score (TKS) was 7.36 ± 1.42. TKS of faculty was 8.36 ± 1.15, in residents 7.81 ± 1.25, in interns 7.46 ± 1.15, and in nurses 6.69 ± 1.57. Knowledge scores of faculty, residents, and interns were significantly higher than that of nurses while there was no significant difference between faculty, residents, and interns. The majority of participants have positive attitude toward anaphylaxis. Incorrect practice is followed by most of the participants. The extent of knowledge about anaphylaxis among pediatric health care providers is moderate but management skills remains suboptimal. Thus, proper training, through continued medical educations and programs to improve abilities to recognize and manage anaphylaxis are very crucial. Differential approach may be followed to different groups; nurses need extra training for optimal management of anaphylaxis.

Utilization of high-fidelity simulation for medical student and resident education of allergic-immunologic emergencies

BACKGROUND

The advantages of clinical simulation used in medical education include the acquisition of clinical skills in a controlled setting, promoting a multidisciplinary approach to patient care, and a high degree of learner satisfaction.

OBJECTIVE

We aimed to identify knowledge gaps among Internal Medicine residents and students in the diagnosis and treatment of anaphylaxis and angiotensin-converting enzyme (ACE)-inhibitor-induced angioedema through their participation in a simulation course.

METHODS

We conducted a cohort study involving clinical simulations with a high-fidelity, patient-simulator. The cases (antibiotic-induced anaphylaxis and ACE-inhibitor-induced angioedema) were standardized and algorithmic. Participants completed a pre- and post- simulation knowledge assessment and course evaluation. A follow-up knowledge survey was sent out 6 to 12 months after the course completion.

RESULTS

Twelve groups comprising 45 medical students and residents completed the anaphylaxis course. All groups diagnosed anaphylaxis after more than 2-organ-system involvement had manifested, and half of the groups made the diagnosis after the patient-simulator was in anaphylactic shock. Half gave an incorrect dose of epinephrine, and most of the participants were inexperienced in epinephrine auto-injector (EAI) administration. Eight groups comprising 27 participants completed the ACE-inhibitor-angioedema course. Six of the groups correctly diagnosed the patient-simulator, but multiple incorrect treatments were given, and only 1 group successfully intubated the patient-simulator. Knowledge improved immediately after the simulation, and knowledge specific to EAI treatment seemed to be retained long-term. All participants agreed that the simulation was practical to their education.

CONCLUSION

Clinical simulation improves knowledge on the diagnosis and treatment of anaphylaxis and ACE-inhibitor-induced angioedema. We advocate that clinical simulation be incorporated at institutions with appropriate capabilities.

Epidemiology of severe anaphylaxis: can we use population-based data to understand anaphylaxis?

PURPOSE OF REVIEW

The observed increase in incidence of allergic disease in many regions over the past 3 decades has intensified interest in understanding the epidemiology of severe allergic reactions. We discuss the issues in collecting and interpreting these data and highlight current deficiencies in the current methods of data gathering.

RECENT FINDINGS

Anaphylaxis, as measured by hospital admission rates, is not uncommon and has increased in the United Kingdom, the United States, Canada, and Australia over the last 10-20 years. All large datasets are hampered by a large proportion of uncoded, 'unspecified' causes of anaphylaxis. Fatal anaphylaxis remains a rare event, but appears to be increasing for medication in Australia, Canada, and the United States. The rate of fatal food anaphylaxis is stable in the United Kingdom and the United States, but has increased in Australia. The age distribution for fatal food anaphylaxis is different to other causes, with data suggesting an age-related predisposition to fatal outcomes in teenagers and adults to the fourth decade of life.

SUMMARY

The increasing rates of food and medication allergy (the latter exacerbated by an ageing population) has significant implications for future fatality trends. An improved ability to accurately gather and analyse population-level anaphylaxis data in a harmonized fashion is required, so as to ultimately minimize risk and improve management.

What are the measures that can be used to assess performance during in situ Paediatric Emergency Medicine Simulation?

Background

Paediatric in situ simulation within emergency departments is growing in popularity as an approach for improving multidisciplinary team working, enabling clinical skills development and exploring the importance of human factors in the clinical setting. However, measuring the success of such programmes is often through participant feedback of satisfaction and not measures of performance, which makes it difficult to assess whether such programmes lead to improvements in clinical behaviour.

Objective

To identify the measures that can be used to assess performance during in situ paediatric emergency medicine simulations.

Study selection

A literature search of EMBASE, ERIC and MEDLINE was performed using the key terms (Paediatrics and Emergency and Simulation.) MeSH and subheadings were used to ensure all possible variations of the key terms were included within the search.

Findings

The search revealed 607 articles, with 16 articles meeting inclusion criteria. Three themes of evaluation strategy were identified—the use of feedback forms (56% n=9/16), performance evaluation methods (63% n=10/16) or other strategies (25% n=4/16), which included provider comfort scores, latent safety threat identification and episodes of suboptimal care and their causation.

Conclusions

The most frequently used method of assessment in paediatric emergency department simulation are performance evaluation methods. None of the studies in this area have looked at patient level outcomes and this is therefore an area which should be explored in the future.

The diagnosis and management of children presenting with anaphylaxis to a metropolitan emergency department: A 2-year retrospective case series

AIM

To investigate the diagnosis and management of children with anaphylaxis presenting to an Emergency Department (ED). We compared the management with the Australasian Society of Clinical Immunology and Allergy (ASCIA) guidelines to gauge compliance.

METHODS

A retrospective case series was developed from children aged from birth to 16 years presenting to the ED at Sunshine Hospital (SH) in Melbourne, Australia over a 2-year period from 1 January 2012 to 31 December 2013. The demographic characteristics, causative agents, clinical features, treatment administered and discharge destination were recorded.

RESULTS

Fifty-five children diagnosed with anaphylaxis during the 2-year period were identified. Fifty-two children (95%) met the ASCIA diagnostic criteria, 49 (94%) children received adrenaline. The median age of presentation was five years, with males predominating (32 (62%)). The most common setting was home (35 (67%)), and food (39 (75%)) was the most common causative agent. Cutaneous symptoms (50 (96%)) were the most prevalent. Twenty-eight (54%) children received adrenaline prior to arrival in ED, whilst 22 (42%) received adrenaline in the ED. Thirty-three (63%) children were discharged home.

CONCLUSION

Childhood anaphylaxis commonly presents to the ED. More than half of children presenting with anaphylaxis were treated prior to attending the ED. The findings demonstrate that anaphylaxis diagnosis and management guidelines are being adhered to in the majority of cases. There were no adverse outcomes recorded.