Journal Club (Critical appraisal of a research paper)

1. Smartphone Use For Paediatric
Calculations In Emergencies
(SPaCE)
Jordan Evans, Zoe Morrison, Rhian Thomas-turner, Omar Bouamra,
Stephen Mullen, Jeff Morgan
Journal
Club [09.02.24]
Ehab Zahran

2. Context
&
Background
Emergency drug and fluid volumes are calculated,
based on estimated weight, in preparation for the
arrival of a critically unwell or injured paediatric
patient using the commonly taught WETFLAG
acronym.

3. Context
&
Background
(Cont’d)
A survey of the paediatric emergency research in
the UK and Ireland network reported that APLS
WETFLAG calculation was the most-commonly
selected method of resuscitation aid to prepare
medication doses (79%), followed by hardcopy
reference charts (56%).
While smartphone applications are increasingly
used for these calculations in clinical practice,
limited studies have explored their accuracy and
safety.

4. Aim of study
The primary aim of this study was to explore the
difference in the rate of error for the completion of
paediatric emergency drug and fluid calculations
using three methods:
1. Smartphone app (specially designed).
2. Reference charts.
3. Traditional calculation (mental
arithmetic/calculator).

5. Aim of study
(Cont’d)
The secondary aims were to also compare both the
time taken and the level of task-related stress.

6. Clinical
Question
P - Healthcare professionals
I - Using smartphone app for fluid/drug
calculations
C - Using traditional methods for fluid/drug
calculations
O - Rate of error, time taken and stress
level
Is using a smartphone app superior to the traditional
methods for paediatric emergency drug and fluid
calculations?

7. Methods
A smartphone app was developed by a healthcare
technology company at the direct request of the
research team. The app consisted of a single page
with the functionality to input age in months or
years along with sex.
Based on the correct input of these variables with
one click, the app would display the ‘WETFLAG’
values on a single screen page, as determined from
the APLS weight calculations.
The method and case order were randomised
centrally.

8. Methods
(Cont’d)

9. This study took place between April 2021 and June
2022 across four sites within three health boards.
A convenience sample of 96 healthcare
professionals of fully qualified nurses and doctors
were invited to participate in the study when the
clinical workload in the department permitted.
Site
1
Site 2 Site
3
Site
4
Emergency department 12 12 12 12
Paediatric assessment
units
12 12 12 12
Methods
(Cont’d)

10. Participants were asked to calculate emergency
drug and fluid calculations using the WETFLAG
acronym for fictional paediatric patients using
three different methods:
1. Traditional calculation - mental arithmetic or
calculator (personal preference of participant).
2. Reference charts (APLS aide-memoire charts).
3. The smartphone app (on a phone provided by
the research team).
Methods
(Cont’d)

11. Methods
(Cont’d)

12. The fictional cases represented a range of ages:
Case one - 3 months (male).
Case two - 15 months (female).
Case three - 23 months (male).
Case four - 5 years (female).
Case five - 8 years (male).
Case six - 12 years (female).
Each participant performed one method of
calculation for each of the six cases.
Methods
(Cont’d)

13. The time taken to complete the calculations and
transcribe these was recorded using a hand-held
digital stopwatch. The same brand and model of
stopwatch was used across all four sites.
On completion of each scenario, participants were
asked to rate their stress levels on a Likert scale
(0=no stress, 10=maximum stress).
Methods
(Cont’d)

14. Results
Ninety-six participants calculated values for six
fictional cases, resulting in 576 calculations.
Traditional calculation methods showed a
statistically significant higher rate of error
compared with the use of a smartphone app or
reference charts (mean=1, 0, 0, respectively).
The smartphone app outperformed both traditional
calculation methods and reference charts for time
taken and user-reported stress levels.

15. Results
(Number of Errors)
Traditional calculation methods (mental arithmetic
or calculator) had the highest mean number of
errors and were significantly different from both
alternate methods.
Mean number of errors:
Traditional = 1.45
App = 0.44
Chart = 0.38

16. Results
(Number of Errors)

17. Results
(Time)
The mean times were significantly different for the
three methods (p<0.0001).
Mean time:
App = 27.8s
Chart = 45.5s
Traditional = 84.8

18. Results
(Time)

19. Results
(Stress)
Pairwise comparison confirmed that the use of the
app has a significantly lower level of stress with
respect to the other methods of calculation
(p<0.0001).
Mean level of stress.
App: 1.1
Chart: 3.3
Traditional: 4.9

20. Results
(Stress)

21. Discussion
This study compared different methods for
calculating paediatric emergency drug doses and
fluid volumes, and to the best of our knowledge is
the first multicentre study to do so.
Study found that using a dedicated app (for
WETFLAG) or reference charts resulted in a
statistically significant reduction in errors compared
with traditional APLS methods (mental arithmetic
or calculator).

22. Discussion
(Cont’d)
It is however worth noting that multiple errors
were more common with the app and traditional
calculation, potentially due to incorrect weight
calculation. Multiple errors were rare with charts.
Use of the app was associated with both a
statistically significant increased speed of
calculation and reduced stress level for the user
compared with either traditional calculation or
the use of aide-memoire charts.

23. Recommendatio
ns
Based on the findings, it’s recommended that
emergency and acute paediatrics departments
should adopt the use of a smartphone app or
reference charts over the more commonly used
traditional APLS calculations.
Further studies should assess the potential
benefits and disadvantages of medical apps
already widely adopted in clinical practice,
together with those in development.

24. Limitations
1. Researcher bias.
2. Measurement bias.
3. Questionable “real-life” accuracy.

25. Are the
results valid?

26. 1. Did the study address a clearly focused
research question?

27. 2. Was the assignments of participants to
interventions randomised?

28. 3. Were the participants who entered the
study accounted for at its conclusion?

29. 4. Were the participants and investigators
‘blind’ to intervention they were given?

30. 5. Were the study groups similar at the start
of the RCT?

31. 6. Apart from the experimental intervention,
did each study group receive the same level
of care (that is, were they treated equally)?

32. 7. Were the effects of intervention reported
comprehensively?

33. 8. Do the benefits of the experimental
intervention outweigh the harms and costs?

34. 9. Can the results be applied to your local
population/in your context?

35. 10. Would the experimental intervention
provide greater value to the people in your
care than any of the existing interventions?

36. Summary
&
Conclusion
This study found using traditional ‘WETFLAG’ value
calculations to have higher error rates than using
reference charts or a smartphone app.
Using a smartphone app significantly reduces
calculation time and lowers user stress levels.
Further research on apps in paediatric resuscitation
is needed to establish their utility and safety for
clinicians and patients.

37. References
• Advanced Life Support Group. Advanced paediatric life support. 6th ed. West Sussex,
UK: Wiley / BMJ, 2016.
• Mosa ASM, Yoo I, Sheets L. A systematic review of healthcare applications for
smartphones. BMC Med Inform Decis Mak 2012;12.
• Payne KFB, Wharrad H, Watts K. Smartphone and medical related app use among
medical students and junior doctors in the United Kingdom (UK): a regional survey. BMC
Med Inform Decis Mak 2012;12.
• Jyothi S, Halton F, Goodyear H. Use of smartphone apps by paediatric trainees. Br J Hosp
Med 2015;76:475–7.
• Jahn HK, Jahn IH, Roland D, et al. Mobile device and app use in paediatric emergency
care: a survey of departmental practice in the UK and Ireland. Arch Dis Child
2019;104:1203–7.
• Gálvez JA, Lockman JL, Schleelein LE, et al. Interactive pediatric emergency checklists to
the palm of your hand - how the pedi crisis app traveled around the world. Paediatr
Anaesth 2017;27:835–40.
• Siebert JN, Ehrler F, Combescure C, et al. A mobile device app to reduce time to drug
delivery and medication errors during simulated pediatric cardiopulmonary
resuscitation: a randomized controlled trial. J Med Internet Res 2017;19:e31.
• Flannigan C, McAloon J. Students prescribing emergency drug infusions utilising
smartphones outperform consultants using BNFCs. Resuscitation 2011;82:1424–7.
• Lauria MJ, Gallo IA, Rush S, et al. Psychological skills to improve emergency care
providers’ performance under stress. Ann Emerg Med 2017;70:884–90.

38. References
(Cont’d)
• Hunziker S, Laschinger L, Portmann-Schwarz S, et al. Perceived stress and team
performance during a simulated resuscitation. Intensive Care Med 2011;37:1473–9.
• LeBlanc VR. The effects of acute stress on performance: implications for health
professions education. Acad Med 2009;84:S25–33.
• Marlow RD, Lo D, Walton LJ. Accurate paediatric weight estimation by age: mission
impossible? Arch Dis Child 2011;96:A1–2.
• Carley S. APLS weight estimation – don’t do it (well almost never). St.Emlyn’s; 2013.
Available: http://stemlynsblog.org/apls-estimation-formulas-do-not-safely-predict-
weight-in-uk-children-st-emlyns/ [Accessed 07 Jul 2017].
• Black K, Barnett P, Wolfe R, et al. Are methods used to estimate weight in children
accurate. Emerg Med 2002;14:160–5.
• Graves L, Chayen G, Peat J, et al. A comparison of actual to estimated weights in
Australian children attending a tertiary children’s’ hospital, using the original and
updated APLS, Luscombe and Owens, best guess formulae and the broselow tape.
Resuscitation 2014;85:392–6.
• Marikar D, Varshneya K, Wahid A, et al. Just too many things to remember? A survey of
paediatric trainees’ recall of advanced paediatric life support (APLS) weight estimation
formulae. Arch Dis Child 2013;98:921.
• McVey L, Young D, Hulst J, et al. Development and validation of a novel paediatric
weight estimation equation in multinational cohorts of sick children. Resuscitation
2017;117:118–21.
• Jahn HK, Jahn IHJ, Roland D, et al. Prescribing in a paediatric emergency: a PERUKI
survey of prescribing and resuscitation AIDS. Acta Paediatr 2021;110:1038–45.

39. BNF
Top Medical
Apps for
Paediatricians
in the UK
MicroGuide TOXBASE
NeoMate
Induction Pediatric Oncall
iResus Paediatric Emergencies
MDCalc

40. Deapp 2