When a child is picked up by paramedics or brought into an emergency department, we don’t know their weight.
Many research teams have been trying to find the best method to estimate a child’s weight, so medication can be dosed safely and equipment sized appropriately.
So what weight estimation guidelines are we supposed to use?
Traditionally, we’ve used age-based formulae, but these are inaccurate. More reliable methods are available. However, all require more information than age, whether that be height, mid-arm circumference, a parent estimate or a smartphone image.
At the moment, we still use age-based formulae in Australia, and although inaccurate, there are some advantages to using such formulae.
Why use age-based formulae?
They are very quick. Most prescribers use these formulae in conjunction with resuscitation aids, emergency manuals or clinical practice guidelines. This means they do not need to remember the formula or do the calculation themselves as they are given a table with corresponding weight to age.
Given age-to-weight conversions are often provided, staff do not need to be trained on how to gather the estimate.
They do not require any additional equipment, which may be hard to find if an ambulance or emergency department rarely sees paediatric critical cases.
You can predict the weight of the child that is about to arrive by ambulance if you have their age. This means you can draw up any critical medications in advance.
The impact of cognitive load on medication errors
Extrinsic cognitive load is a key risk factor for committing a human error in paediatric critical events. Mistakes include significant medication errors like ten-fold errors (where 10x the medication is prescribed or administered because the decimal point is moved or the concentration is incorrectly calculated). These cause significant patient morbidity and mortality.
Gathering more information in order to make the weight estimate more accurate (e.g. measuring the child, taking a sufficient quality image, or finding a parent) increase the complexity of the weight estimation phase. This increased complexity increases cognitive load and increases the risk of human error at all phases in the dosing process.
What is the ideal weight estimation tool?
We need to find something that can be used by anyone who might need to manage a critical paediatric event. This includes paramedics, junior medical staff and adult emergency department personnel that may need to manage patients before they reach a tertiary children’s hospital or paediatric emergency department.
We need clear, easy-to-follow guidelines and associated training that can be rolled out broadly. We need to keep the cognitive burden as low as possible, as many prescribers will be in an unfamiliar, stressful situation.
Future protocols may also differ based on the paediatric emergency expertise and training available in that setting, so this needs to be taken into consideration. For example, a paediatric emergency department may choose a more accurate method with a higher cognitive load than an ambulance service.
Another crucial factor to take into account is the time delay associated with each weight estimation strategy. When it comes to events that require weight estimation, time is of the essence. It is essential to consider not only the time required to obtain the estimate but also the time needed to locate the appropriate equipment, perform subsequent dose calculations, and prepare the medication for administration. There is a significant advantage if emergency departments have the ability to prepare medications in advance, even before the child arrives. By pre-calculating and pre-preparing doses, the time delay in administering the drugs would be significantly reduced, which is paramount in emergency situations.
In light of the increasing prevalence of childhood obesity, it is crucial to find a weight estimation strategy that can accommodate various body types and medication requirements. Different drugs necessitate dosing based on different factors, such as ideal body weight (IBW) or total body weight (TBW), depending on their pharmacokinetic characteristics. Dosing medication based on TBW in obese children can potentially result in overdosing.
Sydney Children’s Hospital has provided a comprehensive overview of the necessary adjustments for specific medications, which is highly valuable. However, when it comes to pediatric emergencies, making weight adjustments for each individual medication can further burden healthcare providers with additional cognitive load.
Regrettably, there is a scarcity of available data on patient outcomes to provide us with clear guidance. Existing studies examining the impact of weight errors focus on incorrectly recorded weights, such as instances where the wrong unit (e.g., pounds instead of kilograms) or decimal point placement was used. None of these studies specifically investigate the harms resulting from weight estimation errors.
There is no suggestion that using the original APLS formula in Australia is causing harm to patients. However, there is also a lack of evidence to definitively prove otherwise. Therefore, the overarching goal should always be to minimize errors.
Nonetheless, it is important to consider that increasing the complexity of weight estimation methods could heighten the cognitive load on healthcare providers, increasing the risk of more significant errors. Hence, it is crucial to strike a balance between accuracy and practicality.
Getting an accurately dosed drug into a critically ill or injured child is a complex process.
Unfortunately, there is a lack of high-quality evidence to guide our practice when it comes to weight estimation and drug dosing. We have limited knowledge about the consequences of dosing errors and the appropriate doses for many medications.
We can take two perspectives. One is to argue that accurate weight estimation doesn’t matter since there is no evidence showing its impact on outcomes. The other is to advocate for maximum accuracy to minimize potential drug dosing errors, which is the more ethical option.
Fortunately, recent evidence supports the idea that accurate weight estimation is crucial. A significant medication error is likely in at least one-third of clinically stable children. The situation becomes even more concerning for children needing resuscitation.
We should not only focus on weight estimation errors but also consider the cumulative impact of other errors in weight-based drug dosing. These are known as compounded errors. These can occur during medication preparation and administration. Errors in medication preparation and administration may match or surpass the weight estimation error. Moreover, drug concentration errors can contribute an additional 10 to 15% error. Therefore, a 20% weight estimation error, combined with a 20% administration error and a 10% concentration error, quickly becomes a potential 50% error.
Let’s use adrenaline as an example. The “low” indicates the maximum potential underdosing and the “high” the maximum potential overdosing at each step of the compounded error.
*An adrenaline/epinephrine solution must contain 90% to 115% of the labelled amount to meet United States Pharmacopeia standards (Epinephrine injection. The United States Pharmacopeia: The National Formulary. United States Pharmacopeial Convention, Rockville, MD; 2013).
So, what is the solution? We need to use accurate weight estimation systems and ensure appropriate, goal-directed training in the preparation and administration of emergency medications. Errors should be minimised at every step of the drug dosing-delivery process.
There are three important considerations when evaluating weight estimation systems: their accuracy, their usability and their ability to integrate with a drug dosing system.
Accuracy of weight estimation guidelines
When it comes to accuracy in weight estimation, our goal is straightforward: we want the most precise system available, as long as it’s not excessively costly. However, given the increasing prevalence of childhood obesity, we now face the challenge of needing a system that can estimate both total body weight and ideal body weight. This flexibility allows us to optimize drug dosing for each specific medication and each individual patient.
While there is limited data on the outcomes of incorrect dosing in obese children, there is enough evidence to raise concern. Therefore, it is crucial to establish a minimum accuracy target. 95% of weight estimates should lie within 20% of the actual weight for any system we choose to use. Currently, the PAWPER tape, the Mercy method, and potentially parental estimates are the approaches that come closest to meeting this standard.
Usability of weight estimation guidelines
In addition to accuracy, the usability of weight estimation systems plays a crucial role. This encompasses two important aspects: ease of use and vulnerability to human and patient factor errors. A system’s usability not only affects its accuracy but also impacts its practicality. Striking the balance between usability and accuracy is essential to minimize the stress already felt by healthcare providers during emergencies.
The ideal weight estimation system should not only be accurate but also help reduce cognitive burden. We have taken careful consideration of the usability factor in designing the PAWPER tape. This system is designed to be quick and easy to use without adding to the cognitive load of healthcare providers. On the other hand, the Mercy method is a bit more complex to use and is more vulnerable to human and patient factor errors.
Finding a weight estimation system that is both accurate and user-friendly is vital in ensuring effective and efficient weight estimation, especially in time-sensitive situations. By prioritizing usability, we can enhance the usability-accuracy balance and better support healthcare providers in delivering optimal care during pediatric emergencies.
The ability of a weight estimation system to contribute to the accuracy of downstream processes needs to be considered. This refers to how it can improve the accuracy of drug dosing by how well the system integrates with a drug dosing guide. The best example (in a good way) is an App that can generate an accurate estimate of weight which is automatically used for drug dosing calculations with limited further user input. The worst system is one in which there is no integration at all, such as parental estimates of weight or age-based formulas. Colour-coded systems and other length-based tapes with precalculated drug doses fall in the middle.
Having identified the most appropriate weight estimation system for your setting, the next step is to use it optimally. There are valid arguments about ensuring the system is maximally usable with a low cognitive load, but there is no system that is completely cognitively neutral. However, complexity during emergencies is the reason that emergency medicine specialists exist. Our training and learning need to prepare us to practise effectively during emergencies, and the fact that treatment takes place during an emergency should not excuse a diminished quality of care. These circumstances should not excuse potentially harmful practices.
Weight estimation systems must be evaluated according to their accuracy, usability and ability to be integrated with a drug dosing guide.
The cumulative medication errors resulting from weight estimation errors and drug preparation and administration can be significant and have a high potential to cause patient harm.
Appropriate training in the use of weight estimation systems and emergency drug preparation and administration is essential. The incorporation of this practice into simulation training is likewise essential.
Healthcare providers who specialise in providing care during emergencies must be competent at managing the cognitive loads experienced during emergency care. This can be achieved through appropriate teaching and training. The emergent nature of the presentation should not excuse a diminished quality of care or the use of inaccurate or inappropriate adjuncts (including weight estimation tools).
Some degree of complexity is inevitable in many aspects of emergency care and adds to the cognitive load. The answer is to limit the complexity as much as possible without negatively affecting patient care and ensure that training is adequate to reduce the effects of the cognitive load.
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Great to see the final report – well done ?