ª Springer Science+Business Media New York 2016
Abdominal Radiology
Abdom Radiol (2016) DOI: 10.1007/s00261-016-0660-8
Effect of available intravenous access on accuracy and timeliness of epinephrine administration William R. Masch,1,2 James H. Ellis,2,3 Carolyn L. Wang,2,4 Richard H. Cohan,2,3 Matthew S. Davenport2,3,5,6 1
Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, White 270, Boston, MA 02114, USA Division of Abdominal Imaging, Department of Radiology, University of Michigan Health System, 1500 E. Medical Center Dr. B1-D502H, Ann Arbor, MI 48109, USA 3 Department of Radiology, University of Michigan Health System, 1500 E. Medical Center Dr., B1-D502G, Ann Arbor, MI 48109, USA 4 Department of Radiology, University of Washington, 1959 NE Pacific St., Seattle, WA 98195, USA 5 Department of Radiology, University of Michigan Health System, 1500 E. Medical Center Dr., B2-A209P, Ann Arbor, MI 48108, USA 6 Michigan Radiology Quality Collaborative, Ann Arbor, USA 2
Abstract Purpose: To evaluate the effect of available intravenous (IV) access on the accuracy and timeliness of epinephrine administration during a surprise mock severe contrast reaction. Methods: Informed consent was waived for this prospective randomized IRB-approved study. Radiology trainees with previous annual hands-on contrast reaction training (n = 46) were randomized to one of two surprise mock contrast reactions over a 23-month period: Group 1—severe laryngeal edema with IV access present (n = 27) or Group 2—severe laryngeal edema without IV access present (n = 19). Both intramuscular (IM, Epi-PenÒ) and IV epinephrine were available in both scenarios. Time-to-treat and epinephrine administration error rates were compared by study group and by route of administration using two-tailed Student’s t test or v2 test. Epinephrine administration errors were correlated with training experience using Pearson’s correlation. Results: Mean time to epinephrine administration was significantly faster for scenarios without IV access (Group 2: 35 ± 16 s vs. Group 1: 62 ± 49 s, p = 0.03), and for intramuscular administrations overall (IM: 42 ± 34 s vs. IV: 98 ± 46 s, p < 0.001). Epinephrine administration errors were common: (63% [17/27, Group Correspondence to: Matthew S. Davenport; email: matdaven@med. umich.edu
1] vs. 61% [11/18, Group 2], p = 1.00), had no relationship with time to most recent hands-on training (r = 0.24, p = 0.11), and were not predicted by year of post-graduate training (r = 0.04, p = 0.79). Conclusions: Lack of IV access is associated with a faster epinephrine administration time but no improvement in epinephrine administration error rate among radiology trainees responding to a surprise mock severe contrast reaction. Annual hands-on training appears to have little effect on epinephrine administration accuracy. Key words: Contrast reaction—Simulation—Training— High-fidelity—Epinephrine
Epinephrine is the recommended treatment for severe acute allergic-like reactions to iodinated contrast media including laryngeal edema, severe bronchospasm, and anaphylactoid hypotension with tachycardia [1–3]. While such reactions are infrequent, occurring in approximately 4 in 10,000 administrations [4–6], appropriate and timely treatment is important because delayed epinephrine administration has been associated with poor patient outcomes [7–11]. Epinephrine may be administered by intravenous (IV) or intramuscular (IM) routes, and the ACR recommends contrast reaction kits at imaging centers contain at least one form of epinephrine [3]. Some institutions, including ours, stock both IV and IM forms
W. R. Masch et al.: Effect of available intravenous access on accuracy
in their kits because each form has unique advantages and disadvantages. Possible advantages of IV epinephrine are that it gains immediate access to the circulatory system resulting in quicker onset of action, and that its dose may be easily titrated over time [1, 12]. Possible advantages of IM epinephrine, particularly the IM epinephrine auto-injector, include rapid administration (fewer steps and no need for a running saline flush), and a lower risk of epinephrine overdose [2, 13, 14]. It remains unclear what is the optimal epinephrine form, or form combination, to stock in contrast reaction kits. Specifically, it has not been determined whether having the choice of two forms of epinephrine available might slow appropriate epinephrine administration during a severe contrast reaction. We hypothesized that having only the ability to use IM epinephrine (i.e., no available IV catheter) would improve the rapidity and accuracy of epinephrine injection. To test this hypothesis, we subjected radiology trainees to surprise mock severe contrast reactions necessitating epinephrine use and randomized them to either have IV access available (choice of treatment with IV or IM epinephrine) or IV access not available (forced treatment with IM epinephrine). The purpose of our study was to evaluate the effect of available IV access on the accuracy and timeliness of epinephrine administration during a surprise mock severe contrast reaction.
Methods Institutional review board approval was obtained for this prospective randomized quality improvement study. The requirement for informed consent was waived by the institutional review board (i.e., part of an educational curriculum), but subjects were allowed to decline participation.
Subjects The study population consisted of 45 radiology trainees (residents and fellows: 14 post-graduate year (PGY)-2, 10 PGY-3, 8 PGY-4, 2 PGY-5, and 11 PGY-6) who were prospectively enrolled over a 23-month period (July 1, 2013 to June 3, 2015) at a single academic university-based health system. All subjects had previous hands-on contrast reaction treatment training consisting of at least one two-week course of related lectures (e.g., contrast media basics and contrast reaction treatment algorithms) and hands-on high-fidelity simulation scenarios (e.g., oxygen management, contrast reaction management, drug delivery [including IV epinephrine syringes and IM epinephrine auto-injectors], and basic life support). This two-week course is an annual mandatory requirement of all radiology resident and fellow trainees at the study institution. Subjects were randomized by coin toss to one of the two study arms: Group 1—severe laryngeal edema with IV access present (n = 27) or Group 2—severe laryngeal
edema without IV access present (n = 19). One subject from Group 2 declined participation. The details of the study population are provided in Fig. 1.
Surprise mock contrast reactions Subjects were summoned by phone from one of the three radiology reading rooms on the same floor of the hospital (i.e., chest radiology, neuroradiology, and abdominal radiology) to a nearby CT gantry without warning during the course of a normal workday to treat unscheduled, unannounced mock contrast reactions. The level of trainee experience was similar across reading rooms. Subjects were not aware that the reaction to which they were responding was simulated until they arrived at the CT gantry, at which time they were greeted with a manikin on a CT table and two actors playing the role of technologist and patient. Subjects were instructed upon entry: ‘‘This is a mock contrast reaction. Treat this as if it was an actual contrast reaction.’’ Scripting then followed immediately as shown in Figs. 2 and 3. A contrast reaction kit was available in the room for all scenarios as is our institutional standard. The contents of the kit were in accord with the recommendations by the American College of Radiology Manual on Contrast Media v.10 [3] and were unchanged from the institutional standard. Both IM (i.e., Epi-PenÒ, Mylan Specialty L.P., Morgantown, WV) and IV epinephrine injection USP 1:10,000 (1 mg at 0.1 mg/mL, Abboject syringe, Hospira, Inc., Lake Forest, IL) were available in each contrast reaction kit in each scenario—only the availability of IV access varied between groups.
Scenario An adult MegaCode Kelly manikin (Laerdal, Wappingers Falls, NY) was placed supine on the CT gantry. In Group 1 scenarios (IV access present), the manikin was equipped with a simulated IV cannula and drainage receptacle such that subjects participating in the reaction could infuse intravenous fluids and/or administer live intravenous epinephrine without spillage. No connector tubing was pre-affixed for IV infusions—any IV infusions first required assembly of IV connector tubing that was contained in each contrast reaction kit. In Group 2 scenarios, the subjects were informed by the actor-technologist that the IV cannula was not functional (Fig. 3). The contrast reaction kits available in each scenario were identical between study groups, and nearly identical to the contrast reactions kits used routinely for clinical care; the sole exception was that the Epi-PenÒ auto-injectors (Epi-PenÒ, Epi-PenÒ Junior) were replaced with color coded Epi-PenÒ trainers to avoid auto-injection into study subjects. Other than availability of IV access, all scenarios were identical: severe laryngeal edema for which IV or IM
W. R. Masch et al.: Effect of available intravenous access on accuracy
46 parcipants that aended departmental contrast lecture within last year randomized
19 randomized into Group 2 (IV access not present)
27 randomized into Group 1 (IV access present)
1 withdrew from parcipaon
7 administered IV epinephrine (Group 1)
Fig. 1.
1 gave no epinephrine (Group 1)
19 administered IM epinephrine (Group 1)
18 administered IM epinephrine (Group 2)
Study population flow chart.
TIME STARTS WHEN RESPONDER ENTERS ROOM. Scenario: A 55 year-old male has just finished a CT scan for severe epigastric abdominal pain that began last night aer eang a burrito. Aer the scan he develops shortness of breath. Paent: -Speaks with a hoarse voice and exhibits stridor. -When responder enters room: “Help me! I feel as if my throat is closing up!” -Past medical history: -HTN: treated with diet and exercise -DM II: treated with diet and exercise -Seasonal allergies -Osteoarthris in bilateral knees -Past surgical history: -Right inguinal hernia repair 5 years prior -Tonsillectomy as a child -Allergies: no known drug allergies -Medicatons: -PRN motrin -PRN Allegra -Social history: Works as an electrical engineer for a local car company. Lives with wife and two children. No tobacco use. Four alcoholic drinks per week (usually on weekends). -Family History: Father with premature CAD. -To all other quesons not answered by the above informaon, the paent should respond: “Help me! I feel as if my throat is closing up!” THE PATIENT SHOULD OFFER NO OTHER HELP TO THE RESPONDER Follow up queson: 20 minutes aer you administer epinephrine, the paent’s symptoms return. What do you do next?
Fig. 2. Simulated patient mock reaction script.
W. R. Masch et al.: Effect of available intravenous access on accuracy
TIME STARTS WHEN RESPONDER ENTERS ROOM. Scenario: A 55 year-old male has just finished a CT scan for severe epigastric abdominal pain that began last night aer eang a burrito. Aer the scan he develops shortness of breath. Technologist: -If asked for informaon about the paent, the technologist should say: “This paent is a 55 year-old male who just had a CT scan for epigastric abdominal pain that began last night aer eang a burrito. Iodinated contrast was administered and aerwards the paent acutely developed shortness of breath. I think he is having a reacon!” -When asked for paent’s vitals, the technologist should read: “Oxygen saturaon 94% on room air, respiratory rate 25, pulse 110, blood pressure 165/90.” -When asked to help with Oxygen, the technologist should place a facemask on the paent and administer Oxygen. -If asked to call for help or to call a code: “Calling for help” or “code called,” and pantomime calling for help/calling a code. -If asked to hang saline and/or connect IV tubing to paent, the technologist should do so. -If asked where the contrast reacon kit is, technologist should point to it. (IN THE NO IV ACCESS SCENARIO ONLY): -If asked “Do we have IV access?”: “No, the vein blew during injecon.” -If asked: “Can you obtain IV access?”: “No, the paent has bad veins, it took us 45 minutes the first me around.” -IN THE NO IV ACCESS SCENARIO ONLY: if the responder aempts to obtain IV access the technologist should stop him or her and say: “I don’t think you’ll have much luck, the paent has bad veins and it took us 45 minutes to obtain access the first me around.” THE TECHNOLOGIST SHOULD OFFER NO OTHER HELP TO THE RESPONDER
epinephrine was indicated [1–3]. The actor-technologist was allowed to follow a narrow spectrum of pre-selected commands if issued by the treating trainee (e.g., administer oxygen by facemask, obtain vital signs, call code or rapid response team, identify location of contrast reaction kit). For Group 1 subjects, the technologist was permitted to attach IV catheter tubing and/or administer IV fluids if instructed to do so. For Group 2 subjects, IV access was not available and the technologist would respond to such requests as directed in Fig. 3. Neither the actor-technologist nor actor-patient was allowed to deviate from the script or offer advice.
Data collection The following data were recorded by two recorders for each study subject: (1) time when subject entered the CT room, (2) time when epinephrine was removed from the contrast reaction kit, (3) time at start of epinephrine administration, and (4) time at cessation of epinephrine administration. The average times between the two recorders were used. Using these data, the following were calculated: (1) Time-to-Treat: time from removal of epinephrine from the contrast reaction kit to time of the start of the epinephrine administration; (2) Door-to-Treat Time time from the subject entering the CT room to time of the start of epinephrine administration; (3) Epinephrine Administration Time time from the start of epinephrine
Fig. 3. Simulated radiology technologist (RT) mock reaction script.
administration to time at cessation of epinephrine administration. The same recorders also registered the following nontemporal data: (1) route and location of epinephrine administration, (2) type of epinephrine administered, if any (i.e., Epi-PenÒ, Epi-PenÒ Junior, IV epinephrine syringe, and no epinephrine), (3) use of an IV saline flush if IV epinephrine was utilized, (4) effective removal of the ‘‘safety’’ if Epi-PenÒ was utilized, (5) use of the correct end of the device (i.e., the ‘‘business end’’) if the EpiPenÒ was utilized, (6) whether the subject stopped to read the instructions if the Epi-PenÒ was utilized, (7) placement of the subject’s thumb or fingers over the needle end if the Epi-PenÒ was utilized, (8) dose (in mg) of epinephrine administered, (9) subjects’ level of postgraduate training, and (10) subject’s study group assignment.
Epinephrine administration errors The following were considered minor epinephrine administration errors: (1) administration of an Epi-PenÒ Jr. dose (0.15 mg) to the adult simulated patient, (2) administration of an Epi-PenÒ to the anterior (not anterolateral) thigh, (3) Epi-PenÒ administration time 5– 9 s [10 s is the recommended time; >10 s has no deleterious effect as all the drug is already delivered], and (4) IV epinephrine administration time 5–29 s [IV epinephrine should be administered slowly into a running
W. R. Masch et al.: Effect of available intravenous access on accuracy
IV infusion over a period of 30 s or more; however, a slightly more rapid infusion is unlikely to cause serious harm]. The following were considered severe epinephrine administration errors: (1) indicated epinephrine not administered, (2) failure to remove the ‘‘safety’’ if an EpiPenÒ was utilized, (3) administering IV epinephrine as a bolus without infusing through a running IV line [i.e., no or minimal drug delivery to the simulated patient], (4) Epi-PenÒ administration time
Abdominal Radiology
Abdom Radiol (2016) DOI: 10.1007/s00261-016-0660-8
Effect of available intravenous access on accuracy and timeliness of epinephrine administration William R. Masch,1,2 James H. Ellis,2,3 Carolyn L. Wang,2,4 Richard H. Cohan,2,3 Matthew S. Davenport2,3,5,6 1
Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, White 270, Boston, MA 02114, USA Division of Abdominal Imaging, Department of Radiology, University of Michigan Health System, 1500 E. Medical Center Dr. B1-D502H, Ann Arbor, MI 48109, USA 3 Department of Radiology, University of Michigan Health System, 1500 E. Medical Center Dr., B1-D502G, Ann Arbor, MI 48109, USA 4 Department of Radiology, University of Washington, 1959 NE Pacific St., Seattle, WA 98195, USA 5 Department of Radiology, University of Michigan Health System, 1500 E. Medical Center Dr., B2-A209P, Ann Arbor, MI 48108, USA 6 Michigan Radiology Quality Collaborative, Ann Arbor, USA 2
Abstract Purpose: To evaluate the effect of available intravenous (IV) access on the accuracy and timeliness of epinephrine administration during a surprise mock severe contrast reaction. Methods: Informed consent was waived for this prospective randomized IRB-approved study. Radiology trainees with previous annual hands-on contrast reaction training (n = 46) were randomized to one of two surprise mock contrast reactions over a 23-month period: Group 1—severe laryngeal edema with IV access present (n = 27) or Group 2—severe laryngeal edema without IV access present (n = 19). Both intramuscular (IM, Epi-PenÒ) and IV epinephrine were available in both scenarios. Time-to-treat and epinephrine administration error rates were compared by study group and by route of administration using two-tailed Student’s t test or v2 test. Epinephrine administration errors were correlated with training experience using Pearson’s correlation. Results: Mean time to epinephrine administration was significantly faster for scenarios without IV access (Group 2: 35 ± 16 s vs. Group 1: 62 ± 49 s, p = 0.03), and for intramuscular administrations overall (IM: 42 ± 34 s vs. IV: 98 ± 46 s, p < 0.001). Epinephrine administration errors were common: (63% [17/27, Group Correspondence to: Matthew S. Davenport; email: matdaven@med. umich.edu
1] vs. 61% [11/18, Group 2], p = 1.00), had no relationship with time to most recent hands-on training (r = 0.24, p = 0.11), and were not predicted by year of post-graduate training (r = 0.04, p = 0.79). Conclusions: Lack of IV access is associated with a faster epinephrine administration time but no improvement in epinephrine administration error rate among radiology trainees responding to a surprise mock severe contrast reaction. Annual hands-on training appears to have little effect on epinephrine administration accuracy. Key words: Contrast reaction—Simulation—Training— High-fidelity—Epinephrine
Epinephrine is the recommended treatment for severe acute allergic-like reactions to iodinated contrast media including laryngeal edema, severe bronchospasm, and anaphylactoid hypotension with tachycardia [1–3]. While such reactions are infrequent, occurring in approximately 4 in 10,000 administrations [4–6], appropriate and timely treatment is important because delayed epinephrine administration has been associated with poor patient outcomes [7–11]. Epinephrine may be administered by intravenous (IV) or intramuscular (IM) routes, and the ACR recommends contrast reaction kits at imaging centers contain at least one form of epinephrine [3]. Some institutions, including ours, stock both IV and IM forms
W. R. Masch et al.: Effect of available intravenous access on accuracy
in their kits because each form has unique advantages and disadvantages. Possible advantages of IV epinephrine are that it gains immediate access to the circulatory system resulting in quicker onset of action, and that its dose may be easily titrated over time [1, 12]. Possible advantages of IM epinephrine, particularly the IM epinephrine auto-injector, include rapid administration (fewer steps and no need for a running saline flush), and a lower risk of epinephrine overdose [2, 13, 14]. It remains unclear what is the optimal epinephrine form, or form combination, to stock in contrast reaction kits. Specifically, it has not been determined whether having the choice of two forms of epinephrine available might slow appropriate epinephrine administration during a severe contrast reaction. We hypothesized that having only the ability to use IM epinephrine (i.e., no available IV catheter) would improve the rapidity and accuracy of epinephrine injection. To test this hypothesis, we subjected radiology trainees to surprise mock severe contrast reactions necessitating epinephrine use and randomized them to either have IV access available (choice of treatment with IV or IM epinephrine) or IV access not available (forced treatment with IM epinephrine). The purpose of our study was to evaluate the effect of available IV access on the accuracy and timeliness of epinephrine administration during a surprise mock severe contrast reaction.
Methods Institutional review board approval was obtained for this prospective randomized quality improvement study. The requirement for informed consent was waived by the institutional review board (i.e., part of an educational curriculum), but subjects were allowed to decline participation.
Subjects The study population consisted of 45 radiology trainees (residents and fellows: 14 post-graduate year (PGY)-2, 10 PGY-3, 8 PGY-4, 2 PGY-5, and 11 PGY-6) who were prospectively enrolled over a 23-month period (July 1, 2013 to June 3, 2015) at a single academic university-based health system. All subjects had previous hands-on contrast reaction treatment training consisting of at least one two-week course of related lectures (e.g., contrast media basics and contrast reaction treatment algorithms) and hands-on high-fidelity simulation scenarios (e.g., oxygen management, contrast reaction management, drug delivery [including IV epinephrine syringes and IM epinephrine auto-injectors], and basic life support). This two-week course is an annual mandatory requirement of all radiology resident and fellow trainees at the study institution. Subjects were randomized by coin toss to one of the two study arms: Group 1—severe laryngeal edema with IV access present (n = 27) or Group 2—severe laryngeal
edema without IV access present (n = 19). One subject from Group 2 declined participation. The details of the study population are provided in Fig. 1.
Surprise mock contrast reactions Subjects were summoned by phone from one of the three radiology reading rooms on the same floor of the hospital (i.e., chest radiology, neuroradiology, and abdominal radiology) to a nearby CT gantry without warning during the course of a normal workday to treat unscheduled, unannounced mock contrast reactions. The level of trainee experience was similar across reading rooms. Subjects were not aware that the reaction to which they were responding was simulated until they arrived at the CT gantry, at which time they were greeted with a manikin on a CT table and two actors playing the role of technologist and patient. Subjects were instructed upon entry: ‘‘This is a mock contrast reaction. Treat this as if it was an actual contrast reaction.’’ Scripting then followed immediately as shown in Figs. 2 and 3. A contrast reaction kit was available in the room for all scenarios as is our institutional standard. The contents of the kit were in accord with the recommendations by the American College of Radiology Manual on Contrast Media v.10 [3] and were unchanged from the institutional standard. Both IM (i.e., Epi-PenÒ, Mylan Specialty L.P., Morgantown, WV) and IV epinephrine injection USP 1:10,000 (1 mg at 0.1 mg/mL, Abboject syringe, Hospira, Inc., Lake Forest, IL) were available in each contrast reaction kit in each scenario—only the availability of IV access varied between groups.
Scenario An adult MegaCode Kelly manikin (Laerdal, Wappingers Falls, NY) was placed supine on the CT gantry. In Group 1 scenarios (IV access present), the manikin was equipped with a simulated IV cannula and drainage receptacle such that subjects participating in the reaction could infuse intravenous fluids and/or administer live intravenous epinephrine without spillage. No connector tubing was pre-affixed for IV infusions—any IV infusions first required assembly of IV connector tubing that was contained in each contrast reaction kit. In Group 2 scenarios, the subjects were informed by the actor-technologist that the IV cannula was not functional (Fig. 3). The contrast reaction kits available in each scenario were identical between study groups, and nearly identical to the contrast reactions kits used routinely for clinical care; the sole exception was that the Epi-PenÒ auto-injectors (Epi-PenÒ, Epi-PenÒ Junior) were replaced with color coded Epi-PenÒ trainers to avoid auto-injection into study subjects. Other than availability of IV access, all scenarios were identical: severe laryngeal edema for which IV or IM
W. R. Masch et al.: Effect of available intravenous access on accuracy
46 parcipants that aended departmental contrast lecture within last year randomized
19 randomized into Group 2 (IV access not present)
27 randomized into Group 1 (IV access present)
1 withdrew from parcipaon
7 administered IV epinephrine (Group 1)
Fig. 1.
1 gave no epinephrine (Group 1)
19 administered IM epinephrine (Group 1)
18 administered IM epinephrine (Group 2)
Study population flow chart.
TIME STARTS WHEN RESPONDER ENTERS ROOM. Scenario: A 55 year-old male has just finished a CT scan for severe epigastric abdominal pain that began last night aer eang a burrito. Aer the scan he develops shortness of breath. Paent: -Speaks with a hoarse voice and exhibits stridor. -When responder enters room: “Help me! I feel as if my throat is closing up!” -Past medical history: -HTN: treated with diet and exercise -DM II: treated with diet and exercise -Seasonal allergies -Osteoarthris in bilateral knees -Past surgical history: -Right inguinal hernia repair 5 years prior -Tonsillectomy as a child -Allergies: no known drug allergies -Medicatons: -PRN motrin -PRN Allegra -Social history: Works as an electrical engineer for a local car company. Lives with wife and two children. No tobacco use. Four alcoholic drinks per week (usually on weekends). -Family History: Father with premature CAD. -To all other quesons not answered by the above informaon, the paent should respond: “Help me! I feel as if my throat is closing up!” THE PATIENT SHOULD OFFER NO OTHER HELP TO THE RESPONDER Follow up queson: 20 minutes aer you administer epinephrine, the paent’s symptoms return. What do you do next?
Fig. 2. Simulated patient mock reaction script.
W. R. Masch et al.: Effect of available intravenous access on accuracy
TIME STARTS WHEN RESPONDER ENTERS ROOM. Scenario: A 55 year-old male has just finished a CT scan for severe epigastric abdominal pain that began last night aer eang a burrito. Aer the scan he develops shortness of breath. Technologist: -If asked for informaon about the paent, the technologist should say: “This paent is a 55 year-old male who just had a CT scan for epigastric abdominal pain that began last night aer eang a burrito. Iodinated contrast was administered and aerwards the paent acutely developed shortness of breath. I think he is having a reacon!” -When asked for paent’s vitals, the technologist should read: “Oxygen saturaon 94% on room air, respiratory rate 25, pulse 110, blood pressure 165/90.” -When asked to help with Oxygen, the technologist should place a facemask on the paent and administer Oxygen. -If asked to call for help or to call a code: “Calling for help” or “code called,” and pantomime calling for help/calling a code. -If asked to hang saline and/or connect IV tubing to paent, the technologist should do so. -If asked where the contrast reacon kit is, technologist should point to it. (IN THE NO IV ACCESS SCENARIO ONLY): -If asked “Do we have IV access?”: “No, the vein blew during injecon.” -If asked: “Can you obtain IV access?”: “No, the paent has bad veins, it took us 45 minutes the first me around.” -IN THE NO IV ACCESS SCENARIO ONLY: if the responder aempts to obtain IV access the technologist should stop him or her and say: “I don’t think you’ll have much luck, the paent has bad veins and it took us 45 minutes to obtain access the first me around.” THE TECHNOLOGIST SHOULD OFFER NO OTHER HELP TO THE RESPONDER
epinephrine was indicated [1–3]. The actor-technologist was allowed to follow a narrow spectrum of pre-selected commands if issued by the treating trainee (e.g., administer oxygen by facemask, obtain vital signs, call code or rapid response team, identify location of contrast reaction kit). For Group 1 subjects, the technologist was permitted to attach IV catheter tubing and/or administer IV fluids if instructed to do so. For Group 2 subjects, IV access was not available and the technologist would respond to such requests as directed in Fig. 3. Neither the actor-technologist nor actor-patient was allowed to deviate from the script or offer advice.
Data collection The following data were recorded by two recorders for each study subject: (1) time when subject entered the CT room, (2) time when epinephrine was removed from the contrast reaction kit, (3) time at start of epinephrine administration, and (4) time at cessation of epinephrine administration. The average times between the two recorders were used. Using these data, the following were calculated: (1) Time-to-Treat: time from removal of epinephrine from the contrast reaction kit to time of the start of the epinephrine administration; (2) Door-to-Treat Time time from the subject entering the CT room to time of the start of epinephrine administration; (3) Epinephrine Administration Time time from the start of epinephrine
Fig. 3. Simulated radiology technologist (RT) mock reaction script.
administration to time at cessation of epinephrine administration. The same recorders also registered the following nontemporal data: (1) route and location of epinephrine administration, (2) type of epinephrine administered, if any (i.e., Epi-PenÒ, Epi-PenÒ Junior, IV epinephrine syringe, and no epinephrine), (3) use of an IV saline flush if IV epinephrine was utilized, (4) effective removal of the ‘‘safety’’ if Epi-PenÒ was utilized, (5) use of the correct end of the device (i.e., the ‘‘business end’’) if the EpiPenÒ was utilized, (6) whether the subject stopped to read the instructions if the Epi-PenÒ was utilized, (7) placement of the subject’s thumb or fingers over the needle end if the Epi-PenÒ was utilized, (8) dose (in mg) of epinephrine administered, (9) subjects’ level of postgraduate training, and (10) subject’s study group assignment.
Epinephrine administration errors The following were considered minor epinephrine administration errors: (1) administration of an Epi-PenÒ Jr. dose (0.15 mg) to the adult simulated patient, (2) administration of an Epi-PenÒ to the anterior (not anterolateral) thigh, (3) Epi-PenÒ administration time 5– 9 s [10 s is the recommended time; >10 s has no deleterious effect as all the drug is already delivered], and (4) IV epinephrine administration time 5–29 s [IV epinephrine should be administered slowly into a running
W. R. Masch et al.: Effect of available intravenous access on accuracy
IV infusion over a period of 30 s or more; however, a slightly more rapid infusion is unlikely to cause serious harm]. The following were considered severe epinephrine administration errors: (1) indicated epinephrine not administered, (2) failure to remove the ‘‘safety’’ if an EpiPenÒ was utilized, (3) administering IV epinephrine as a bolus without infusing through a running IV line [i.e., no or minimal drug delivery to the simulated patient], (4) Epi-PenÒ administration time
