Analysis of an Intervention for Emergency Medical Services Personnel to Reduce Epinephrine Dosing Errors in Infants

Several studies have documented epinephrine dosing errors in out-of-hospital cardiac arrest resuscitation of pediatric patients.^1,2 Currently, adults receive a 1-mg dose of epinephrine during a cardiac arrest.³ The pediatric dose is 0.01 mg/kg (0.1 mL/kg), which can be calculated using the patient’s actual weight or estimated based on age or length. The smallest children are at the greatest risk of epinephrine dosing errors, owing to the potential for decimal translation errors (resulting in 10-fold errors) and the inaccuracy in delivering smaller doses using commonly supplied (1 mg/10 mL) prefilled epinephrine syringes.⁴ Infants also account for approximately 40% of pediatric out-of-hospital cardiac arrests.⁵ Large overdoses of epinephrine are associated with poorer survival.⁴ Although incorrect epinephrine dosing is known to be a problem, there is currently little evidence regarding how to mitigate it. This study investigated whether a simulation-driven emergency medical services (EMS) protocol change using a 1-mL syringe to administer small epinephrine doses reduces dosing errors in infants.

In this quality improvement study, we conducted simulations in 2 different time periods and we collected data in real time during the simulation scenarios. All aspects of the study were approved by the Oregon Health & Science University Institutional Review Board. Informed consent was obtained from all participants. The study followed the SQUIRE reporting guidelines.

All simulations were conducted in situ using the same infant simulator and the same EMS agencies in a large regional EMS system in which advanced life support–capable public fire and private transfer units respond to all calls for service.

In 2016, we conducted a neonatal resuscitation simulation that included indications for intravenous administration of 1 mg/10 mL of epinephrine. Medication dosing was measured by clinical experts with a standardized tool using both real-time observation and video review. Simulations included real-time didactic debriefings. We communicated lessons learned to the EMS medical directors after the study. Specifically, to improve the accuracy of dosing and reduce the magnitude of potential overdoses, we recommended that agencies draw up epinephrine doses of 1 mL or less in a 1-mL syringe (eFigure in the Supplement) rather than use a (1 mg/10 mL) prefilled epinephrine syringe.

In 2020, we conducted additional simulation sessions including a 4-month-old infant in nonshockable cardiac arrest requiring epinephrine. EMS pediatric training hours were unchanged from normal during the study period.

The correct epinephrine dosage was defined as ±20% of the ideal dose calculated using the simulator length to estimate infant weight.⁶ The dose recommended by the local length-based guide was within this range. We performed a 2-tailed Fisher exact test to compare the 2016 and 2020 data; this test was selected because of our relatively small sample sizes. All statistical analyses were performed using Stata version 15.

A total of 432 EMS personnel participated in this study. In 2016, we conducted 47 neonatal cardiac arrest simulations (209 EMS personnel), which included approximately 15% of the area EMS workforce (1400 personnel). Two simulations were excluded because of audio/video problems and lack of participant consent. In 2020, we conducted 39 infant cardiac arrest simulations (223 EMS personnel). As shown in Table 1, the percentage of patients who received epinephrine increased significantly from 2016 (19 of 45 [42%]) to 2020 (36 of 39 [92%]) (P < .001). Among those who received epinephrine, the percentage who received an appropriate dose also increased significantly from 2016 (12 of 19 [63%]) to 2020 (35 of 36 [97%]) (P = .01; Table 2). Time to epinephrine delivery decreased from a mean (SD) of 395 (30) seconds in the 2016 simulations to 322 (18) seconds in the 2020 simulations using the 1-mL syringe (P < .001).

In this simulation-based quality improvement study, a simple EMS intervention using a 1-mL syringe for small epinephrine doses was associated with an improved rate of administering the correct epinephrine dose without slowing delivery speed. The limitations of this study include its observational design and single urban EMS system setting. These findings suggest that a similar intervention could reduce epinephrine dosing errors among infants.

Accepted for Publication: February 28, 2022.

Published: April 15, 2022. doi:10.1001/jamanetworkopen.2022.7645

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Hansen M et al. JAMA Network Open.

Corresponding Author: Matt Hansen, MD, MCR, Departments of Emergency Medicine and Pediatrics, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239 (hansemat@ohsu.edu).

Author Contributions: Drs Hansen and Guise had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Hansen, Eriksson, Meckler, Harrod, Guise.

Acquisition, analysis, or interpretation of data: Hansen, Walker-Stevenson, Eriksson, Harrod, Bahr, Guise.

Drafting of the manuscript: Hansen, Walker-Stevenson, Bahr, Guise.

Critical revision of the manuscript for important intellectual content: Hansen, Eriksson, Meckler, Harrod, Guise.

Statistical analysis: Walker-Stevenson, Bahr.

Obtained funding: Hansen, Guise.

Administrative, technical, or material support: Hansen, Meckler, Harrod, Guise.

Supervision: Hansen, Meckler, Bahr, Guise.

Conflict of Interest Disclosures: Dr Hansen reported receiving grants from the National Institutes of Health (NIH) National Heart, Lung, and Blood Institute during the conduct of the study. Dr Eriksson reported receiving grants from the NIH during the conduct of the study. Dr Guise reported receiving grants from the NIH during the conduct of the study. No other disclosures were reported.

Funding/Support: This work was supported by grant 5R01HL141429 from the NIH National Heart, Lung, and Blood Institute (all authors) and grant R01HD062478 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (Drs Hansen, Meckler, and Guise and Ms Harrod).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.