P3.R350: When Treatment Algorithms are Not Enough: Using simulation to understand safety threats in anaphylaxis management.

Purpose/Objectives: Anaphylaxis is a severe and life-threatening hypersensitivity reaction to an allergen. Approximately one-fourth of anaphylactic reactions annually occur in children under the age of 17¹. While most of these severe reactions are seen in outpatient settings such as the emergency department, they may also occur in hospitalized patients. Despite the rarity of these events, patients who experience anaphylaxis during hospitalization exhibit elevated risk of morbidity and mortality². Managing a patient with anaphylaxis requires a high level of skill, as team members must emergently administer medication, manage the patient's airway, and prevent decompensation of the compromised patient.
These rare but high-acuity situations can be effectively recreated in the clinical environment using in situ simulation. In situ simulation can be used as a valuable tool to educate teams, evaluate the system's competence, and identify latent safety threats³. In situ simulation identified gaps in team and system-level factors in the treatment of anaphylaxis.

Design/Methods: Intradisciplinary healthcare teams on the general pediatric inpatient units responded to simulated patients having an anaphylactic emergency. These in situ simulations were limited to a 5-minute pre-briefing, a 10-minute simulation, and 15 minutes of de-briefing. The simulations were video-recorded for review, and data was extracted. The primary outcome measure was deficiencies in team behavior. A critical action

Results: 91 healthcare team members participated in 13 simulations between August 2020 and October 2023. Simulations were conducted on both night and day shifts. Errors were documented as critical action deficiencies and were categorized into three distinct areas: clinical, system, or process (Table 4). 26 documented critical action deficiencies were noted across the 13 simulations. Clear patterns among the deficiencies included a lack of adherence to anaphylaxis protocol or PALS guidelines, delays in monitoring or protecting the airway, and delays or errors in medication administration.

Conclusion/Discussion: Pediatric resuscitations are relatively rare, with only a subset due to anaphylactoid reactions. Simulations can provide insight into latent safety threats related to these rare clinical events. In situ simulation could identify and mitigate team and system performance gaps. Similar approaches could provide new insight into safety gaps related to other clinical events.

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