Staff rescue doctor using allergic reaction kit he helped design
Earlier this year, Dr. Ian Jones was working as a resident in Hamilton Health Sciences’ (HHS) Hamilton General Hospital’s intensive care unit. In the staff break room, he snacked on a piece of chocolate that, unbeknownst to him, contained peanuts. He started to have difficulty breathing and signaled for help. He knew he was experiencing serious allergic reaction.
Staff in the area immediately hurried to the Omnicell, a secure tower where drugs are stored on each unit, to get the anaphylaxis kit and administer a dose of Epinephrine, the recommended first-line treatment for life-threatening allergic reactions.
A full-circle moment
Amazingly, five years earlier when Jones was working as a medical student in HHS’ McMaster Children’s Hospital’s pediatric intensive care unit (PICU), he helped lead a Quality Improvement project to develop this very kit that would later save his life.
“The goal was to ensure timely administration of the correct dose, via the correct route, at the right time.”
He joined the PICU while they were exploring how to improve timely treatment with Epinephrine for patients experiencing acute anaphylaxis. Anaphylaxis is a severe and potentially life-threatening condition when the throat closes during an allergic reaction and can cause a person to stop breathing. When severe anaphylaxis is happening, treatment with Epinephrine is required immediately.
The project was part of HHS’ Continuous Quality Improvement (CQI) initiative, which empowers front-line staff to find solutions to everyday issues – a bottom-up approach to problem-solving. Since launching almost 10 years ago, CQI has expanded across HHS and has launched more than 6500 improvements.
Filomena Canci Tavares, clinical manager of the PICU
“Ian helped us develop, design, test, and implement a pediatric anaphylaxis kit,” says Filomena Canci Tavares, clinical manager of the PICU. “The goal was to create a kit that had all the necessary supplies as well as clear messaging on how to administer the correct dose. Since Ian has a peanut allergy, he was keen to help develop something that could help others who suffered from severe allergies. Never did he imagine one day he would urgently need Epinephrine from the same kit he helped to create as a quality improvement project.”
Motivated by a code blue
After a code blue event at MCH – which happens when a patient requires critical resuscitation support because they stop breathing or their heart stops beating – staff identified a CQI opportunity to improve how allergic reaction medication was administered during anaphylaxis. Having one kit with all the necessary supplies for anaphylaxis would help clinicians administer the correct Epinephrine dose as quickly and safely as possible to help immediately reverse the severe and potentially life-threatening throat swelling and trouble breathing that can happen during a severe anaphylactic reaction.
There was an existing pediatric anaphylaxis kit being used at MCH but it needed improvement. The kit contained three types of drugs, but did not the contain the necessary supplies to administer the medications, such as syringes and needles. This could cause critical delays in administration as staff would need to locate the right supplies. Epinephrine is a powerful medication that has different routes of administration and dosing ranges depending on the indication needed. Other improvements the team targeted is kit labelling to help ensure the correct dose, concentration, and route for anaphylaxis was delivered to a person in need, quickly.
“The goal was to ensure timely administration of the correct dose, via the correct route, at the right time,” says Tavares.
Continuous Quality Improvement process makes changes for the better
The CQI process involved assessing the problem (current state) and the desired outcome (target state), consulting with more than 20 stakeholders from different areas across the hospital, and undergoing simulation testing.
“It was cool to see what we put a lot of energy into came out successful in the end.”
Part of Jones’s role was to have nurses test the draft kits using different instruction labels and different supplies to see which options resulted in the quickest and most accurate dose. The team wanted to understand which labels were most clear, to ensure the contents of the kit were easy to use, and to time how long the process took.
The result was an improved kit with only one first-line medication, Epinephrine, along with the right supplies to give the drug, and a label with a clear visual representation of the appropriate dose and administration instructions.
Simulation testing of the new kit versus the old kit with nurses demonstrated quicker administration times when the new kit with all necessary supplies was used and that no errors in dosing or route were observed.
The kit has supplies and medication to support very small to adult-sized patients. Given its low cost, ease of use, and the ability to be used on all size patients, the kit was rolled out across all of HHS in multiple sites in 2020.
Professional becomes personal
While Jones never expected to have to use it, he’s grateful it was improved and easy to use.
“We spent a lot of time making sure the kit was optimized so it could be used quickly and easily when emotions were running high. When they ended up using it on me, it was very fast and efficient. It was cool to see what we put a lot of energy into came out successful in the end,” he says.
“From a clinical perspective, anaphylaxis is life-threatening, very fast developing and can be very significant. From a personal standpoint, I also have a severe peanut allergy so the project was near and dear to me.”
