Article

A weighty matter: Obtaining and documenting pediatric weight in the emergency department

Correspondence / American Journal of Emergency Medicine 38 (2020) 681-689 685

Zhou X, Xu W, Xu Y, Qian Z. Iron supplementation improves cardiovascular out- comes in patients with heart failure. Am J Med 2019 [doi.org/10.1016 jamjmed 2019.02.018, Article in Press].
  • Lewis GD, Malhotra R, Hernandez AF, McNulty SE, Smith A, Felker M, et al. Effect of oral iron repletion on exercise capacity in patients with heart failure with reduced ejection fraction and iron deficiency. JAMA 2017;317:1958-66.
  • Kleber M., Kozhuharov N., Sabti Z., Glatz B., Isenreich R., Wussler D et al., Relative hypochromia and mortality in acute heart failure, Int J Cardiol, [doi 10.1016/j.ijcard 2019.02.060 Article in Press].
  • Simbaqueba C, Shrestha K, Patarroyo M, Troughton RW, Borowski AG, Klein AL, et al. prognostic implications of relative hypochromia in ambulatory patients with chronic systolic heart failure. Congest Heart Fail 2013;19:180-5.
  • Tkaczyszyn M, Cimin-Colet J, Voors AA, van Veldhuisen DJ, Enjuanes C, Moliner- Borja P, et al. Iron deficiency and red cell indices in patients with heart failure. Eur J Heart Fail 2018;20:114-22.
  • Beverborg NG, Klip IT, Meijers WC, Voors AA, vegter EL, H2 van der Wal, et al. Def- inition of iron deficiency based on the gold standard of bone marrow iron staining in heart failure patients. Circ Heart Fail 2018;11:e004519.
  • Phiri KS., Calis JCJ., Kachala D., Borgstein E., Waluza J., Bates Iet al, Improved method for assessing iron stores in the bone marrow, J Clin Pathol 2009;62:685-689.
  • Urrechaga E, Borque L, Escanero JF. clinical value of hypochromia markers in the de- tection of latent iron deficiency in nonanemic premenopausal women. J Clin Lab Anal 2016;30:623-7.
  • Malczewska-Lenczowska J, Orysiak J, Szczepanska B, Turowski D, Burkhard- Jagodzinska K, Gajewski J. Reticulocyte and erythrocyte hypochromia markers in de- tection of iron deficiency in adolescent female athletes. BiolSport 2017;34:111-8.
  • A weighty matter: Obtaining and documenting pediatric weight in the emergency department

    Pediatric patients in the emergency department (ED) are at in- creased risk of Medication errors compared to adult ED patients [1,2]. Children are particularly vulnerable to medication errors because pedi- atric dosing requires an accurate knowledge of a child’s weight in kilo- grams. Multiple studies have reported errors in pediatric medication dosing due to a misstep in either obtaining or documenting weight. This occurs when clinical staff confuse measurement of pounds with ki- lograms or errors during measurement conversion [2-6]. In 2009, “Guidelines for the Care of Children in the Emergency Department” was published by the American College of Emergency Physicians, Emer- gency Nurses Association and American Academy of Pediatrics, which included the specific recommendation to obtain and document weight exclusively in kilograms [7]. Despite creation and promotion of these recommendations, non-compliance has been reported [8,9]. The Na- tional Pediatric Readiness Project performed a survey of EDs in 2013 and reported inconsistent weighing practices in EDs nationwide; how- ever, it did not include details regarding state-by-state weighing prac- tices [9]. Additionally, there have been no further assessments on pediatric weighing practices or how pediatric weight is estimated in the ED. We aimed to assess current pediatric weighing practices in Mas- sachusetts EDs.

    From April-November 2018, we conducted a survey among pediat- ric emergency care coordinators (PECCs) in all 73 Massachusetts EDs [10]. We obtained 2018 ED characteristics (e.g., annual total and pediat- ric ED patient volumes, urban location, and presence of any designated area for children in the ED) using the National Emergency Department Inventory-USA database [10]. The Partners Human Research Committee reviewed the project and classified it as exempt. Each PECC was sent up to eight e-mail and/or telephone survey invitations. Through this sur- vey, we asked if pediatric weights are obtained and documented in pounds, kilograms, or both, and we asked about the methods used to measure or estimate pediatric weight. Data were analyzed using Wilcoxon-Mann-Whitney, chi-square, or Fisher’s exact tests, as appro- priate. All analyses were performed using Stata 14.2 (Stata Corp, College Station, TX). Two-tailed P b 0.05 was considered statistically significant. Of the 73 Massachusetts EDs, PECCs in 65 (89%) EDs responded to the survey. Of the PECCs that responded, 46 (71%) were physicians, 10

    were nurses (15%), 1 was a physician assistant (2%) and 8 (12%) had a physician/nurse team. Approximately half (n = 34, 52%) reported obtaining and documenting the weight of pediatric patients in kilo- grams only (Table 1). The others (n = 31, 48%) reported obtaining and/or documenting weight in diverse ways (Table 2). EDs with any pe- diatric area were more likely to perform recommended weighing and documenting practices compared to those that did not (P = 0.03).

    When asked about which methods are used to measure or estimate the weights of children, 63 (97%) reported using a scale. Furthermore, 10 (15%) EDs reported using a scale exclusively, and 12 EDs (18%) re- ported using a scale and Broselow tape exclusively. The others reported diverse combinations of methods for estimating pediatric weight (Table 3). Sixty-one (94%) EDs reported that measuring or estimating weight with a scale is the most commonly-used method. Three reported most-commonly asking a parent for the child’s most recent weight, and one ED reported not having a standard practice for measuring or es- timating weight in children.

    Our study shows that only half of Massachusetts EDs follow the rec- ommended practice of obtaining and documenting pediatric weight in exclusively kilograms. Potential obstacles to implementation of recom- mended weighing practices across all EDs include challenges with healthcare provider buy-in, medical record requirement for measure- ment in pounds, ED scale that measures in pounds, or patient and family frustration with metric measurements [8]. Additionally, we found that Massachusetts PECCs are reporting a variety of methods for measuring or estimating pediatric weight within the ED. Our data provide a base- line understanding of current practice of pediatric weight estimation. We also found that EDs with a pediatric area were more likely to follow recommended practice, perhaps indicating a departmental attention to pediatric emergency care.

    This study has several potential limitations. First, although there is a challenge in verifying if the survey response represents true practice within the ED, respondents are clinicians that are involved in direct pa- tient care and therefore should be familiar with their EDs’ current

    Table 1

    Characteristics of Massachusetts emergency departments by pediatric weighing practices in 2018, n = 65.

    ED characteristics

    Obtains weights only in kg, documents only in kg

    Other weighing practices

    P-value

    n = 34

    n = 31

    Annual total ED visits, median (IQR)

    43,567 (30,533-60,000)

    36,500 (23,362-53,000)

    0.26

    Annual ED visits by children, median (IQR)

    6107 (3000-11,891)

    4754 (2400-8395)

    0.26

    Percent of annual ED visits by children, median (IQR)

    14 (10-20)

    15 (12-19)

    0.96

    Urban location, n (%)

    31 (91)

    31 (100)

    0.24

    Pediatric areaa, n (%)

    0.03

    Yes

    14 (41)

    5 (16)

    No

    20 (59)

    26 (84)

    Abbreviations: ED, emergency department; kg, kilograms; IQR, interquartile range.

    a Separate area in the ED dedicated to the care of children.

    686 Correspondence / American Journal of Emergency Medicine 38 (2020) 681-689

    Table 2

    Pediatric weighing practices of Massachusetts emergency departments in 2018, n = 65.

    Obtains weight in:

    Documents weight in:

    n (%)

    kg

    kg

    34 (52%)

    both

    kg

    12 (18%)

    both

    both

    10 (15%)

    kg

    both

    4 (6%)

    lbs.

    kg

    4 (6%)

    No policy

    No policy

    1 (2%)

    Abbreviations: kg, kilograms; lbs., pounds; both, kilograms and pounds.

    practices. Additionally, there are no data for non-respondents. However, given the high response rate to the survey (89%), we believe our data provides an accurate estimate of current weighing practices in the state of Massachusetts.

    In conclusion, despite ten years of pediatric weighing recommenda- tions, a significant portion of Massachusetts EDs still do not obtain and document pediatric weights exclusively in kilograms [7]. Additionally, EDs with a pediatric area were more likely to follow recommended weighing guidelines. A better understanding of barriers to following the guidelines and the possible impact of changing current weighing practices is needed to create interventions that lead to safe and effective patient-centered care.

    Funding sources

    R Baby Foundation (New York, United States of America).

    Author contributions

    AAF, EP, KB, CC and JL all contributed to original concept and design of project. AAF and KB contributed to direct survey collection regarding weighing practices from pediatric emergency care coordinators and KB, AFS and CC were responsible for the National Emergency Department Inventory-USA database. AAF, KMB, and JL had full access to all of the data in the study and take responsibility for the integrity of the data and accuracy of the data analysis. AAF primarily wrote manuscript with all authors contributing to the editing and review of the manuscript.

    Declaration of competing interest

    None reported.

    Ashley A. Foster MD* Joyce Li MD, MPH

    Department of Emergency Medicine, Boston Childrens Hospital, 300 Longwood Ave, Boston, MA 02115, United States of America

    E-mail addresses: [email protected] (A.A. Foster)

    Table 3 Methods that Massachusetts emergency departments use to measure or estimate weights of children, n = 65.

    Obtains weights only in kg, documents only in kg

    n = 34

    Other weighing practices

    n = 31

    Weigh with a scale

    34

    29

    Ask parent

    21

    20

    Use Broselow tape

    24

    17

    Estimate weight based on visual

    4

    7

    inspection of child

    Other

    4

    0

    Abbreviations: kg, kilograms; lbs., pounds.

    Corresponding author at: Division of Emergency Medicine, Boston Children’s Hospital, 300 Longwood Ave BCH3066, Boston, MA 02115,

    United States of America.

    Emory M. Petrack, MD Department of Emergency Medicine, Floating Hospital for Children Tufts Medical Center, 800 Washington Street, Boston, MA 02111,

    United States of America E-mail addresses: [email protected] (E.M. Petrack)

    Krislyn M. Boggs, MPH Ashley F. Sullivan, MS MPH Carlos A. Camargo, Jr. MD DrPH

    Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114,

    United States of America E-mail addresses: KBoggs@partners. org (K.M. Boggs), [email protected] (A.F. Sullivan), [email protected] (C.A.

    Camargo), [email protected]. edu (J. Li)

    Received 3 June 2019

    https://doi.org/10.1016/j.ajem.2019.158424

    References

    1. Institute of Medicine. Emergency care for children: Growing pains. Washington, DC: The National Academies Press; 2007.
    2. Pennsylvania Patient Safety Authority. Medication errors: significance of accurate patient weights. Pennsylvania Patient Saf Advis 2009;6(1):10-5.
    3. Hirata KM, Kang AH, Ramirez GV, Kimata C, Yamamoto LG. Pediatric weight errors and resultant medication dosing errors in the emergency department. Pediatr Emerg Care 2017;00(00):1.
    4. Thomas DO, Henderson DP. Lessons learned: basic evidence-based advice for preventing medication errors in children. J Emerg Nurs 2005;31(5):490-3.
    5. Cadwell SM. Pediatric Medication Safety in the emergency department. J Emerg Nurs

      2008;34(4):375-7.

      Paparella SF. Adopt the 2014-2015 targeted best practices for medication safety. J Emerg Nurs 2014;40(3):263-5.

    6. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine; American College of Emergency Physicians PCENAPC. Joint policy statement–guide- lines for care in the emergency department. Ann Emerg Med 2009;54:543-52.
    7. Stone-Griffith S, Broekema J, Cody K, Fluta J, Halazon M, Luevano A. Unintended practice consequences of applying evidence-based change. J Emerg Nurs 2014;40 (2):190-2.
    8. Gausche-Hill M, Ely M, Schmuhl P, et al. A national assessment of pediatric readiness of emergency departments. JAMA Pediatr 2015;169(6):527-34.
    9. Camargo CAJ, Boggs KM, Sullivan AF, Gutierrez CE, Petrack EM. Grassroots interven- tion to increase appointment of pediatric emergency care coordinators in Massachu- setts emergency departments. Acad Emerg Med 2018;25(12):1442-6.

      Does a dose relationship exist with prothrombin complex and factor Xa inhibitor reversal? An alternate perspective

      We read with great enthusiasm the study by Yohe et al. entitled, “Four-factor prothrombin complex concentrate dose response relation- ships with INR for warfarin reversal.” We applaud the authors for exam- ining Four-factor prothrombin complex concentrate (4PCC) dosing strategies in a unique way given that dose finding studies were never completed for Kcentra(R) [1]. The authors observed that escalating doses of 4PCC were associated with increased in-hospital mortality, and that for every 500-unit incremental increase in dose above 1000 units, a reduction in INR by only 0.02 was appreciated. This is significant given that guideline-recommended and FDA approved dosing strate- gies utilize body weight and initial INR that require higher doses.

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