Aaron Donoghue

Effect of high-fidelity simulation on Pediatric Advanced Life Support training in pediatric house staff: a randomized trial.

Objectives: To assess the effect of high-fidelity simulation (SIM) on cognitive performance after a training session involving several mock resuscitations designed to teach and reinforce Pediatric Advanced Life Support (PALS) algorithms. Methods: Pediatric residents were randomized to high-fidelity simulation (SIM) or standard mannequin (MAN) groups. Each subject completed 3 study phases: (1) mock code exercises (asystole, tachydysrhythmia, respiratory arrest, and shock) to assess baseline performance (PRE phase), (2) a didactic session reviewing PALS algorithms, and (3) repeated mock code exercises requiring identical cognitive skills in a different clinical context to assess change in performance (POST phase). SIM subjects completed all 3 phases using a high-fidelity simulator (SimBaby, Laerdal Medical, Stavanger, Norway), and MAN subjects used SimBaby without simulated physical findings (ie, as a standard mannequin). Performance in PRE and POST was measured by a scoring instrument designed to measure cognitive performance; scores were scaled to a range of 0 to 100 points. Improvement in performance from PRE to POST phases was evaluated by mixed modeling using a random intercept to account for within-subject variability. Results: Fifty-one subjects (SIM, 25; MAN, 26) completed all phases. The PRE performance was similar between groups. Both groups demonstrated improvement in POST performance. The improvement in scores between PRE and POST phases was significantly better in the SIM group (mean [SD], 11.1 [4.8] vs. 4.8 [1.7], P = 0.007). Conclusions: The use of high-fidelity simulation in a PALS training session resulted in improved cognitive performance by pediatric house staff. Future studies should address skill and knowledge decays and team dynamics, and clearly defined and reproducible outcome measures should be sought.

Quantitative Analysis of CPR Quality During In-Hospital Resuscitation of Older Children and Adolescents

OBJECTIVE: Few data exist on pediatric cardiopulmonary resuscitation (CPR) quality. This study is the first to evaluate actual in-hospital pediatric CPR. We hypothesized that with bedside CPR training and corrective feedback, CPR quality can approach American Heart Association (AHA) targets. PATIENTS AND METHODS: Using CPR recording/feedback defibrillators, quality of CPR was assessed for patients ≥8 years of age who suffered a cardiac arrest in the PICU or emergency department (ED). Before and during the study, a bedside CPR training program was initiated. RESULTS: Between October 2006 and February 2008, twenty events in 18 patients met inclusion criteria and resulted in 36749 evaluable chest compressions (CCs) during 392.3 minutes of arrest. CCs were shallow (<38 mm or <1.5 in) in 27.2% (9998 of 36749), with excessive residual leaning force (≥2500 g) in 23.4% (8611 of 36749). Segmental analysis of the first 5 minutes of the events demonstrated that shallow CCs and excessive residual leaning force were less prevalent during the first 5 minutes. AHA targets were not achieved for CC rate in 62 (43.1%) of 144 segments, CC depth in 52 (36.1%) of 144 segments, and residual leaning force in 53 (36.8%) of 144 segments. CONCLUSIONS: This prospective, observational study demonstrates feasibility of monitoring in-hospital pediatric CPR. Even with bedside CPR retraining and corrective audiovisual feedback, CPR quality frequently did not meet AHA targets. Importantly, no flow fraction target of 10% was achieved. Future studies should investigate novel educational methods and targeted feedback technologies.

Part 13: Pediatric Basic Life Support

For best survival and quality of life, pediatric basic life support (BLS) should be part of a community effort that includes prevention, early cardiopulmonary resuscitation (CPR), prompt access to the emergency response system, and rapid pediatric advanced life support (PALS), followed by integrated post–cardiac arrest care. These 5 links form the American Heart Association (AHA) pediatric Chain of Survival (Figure 1), the first 3 links of which constitute pediatric BLS. Figure 1. Pediatric Chain of Survival. Rapid and effective bystander CPR can be associated with successful return of spontaneous circulation (ROSC) and neurologically intact survival in children following out-of-hospital cardiac arrest.1,–,3 Bystander resuscitation may have the greatest impact for out-of-hospital respiratory arrest,4 because survival rates >70% have been reported with good neurologic outcome.5,6 Bystander resuscitation may also have substantial impact on survival from primary ventricular fibrillation (VF), because survival rates of 20% to 30% have been documented in children with sudden out-of-hospital witnessed VF.7 Overall about 6%8 of children who suffer an out-of-hospital cardiac arrest and 8% of those who receive prehospital emergency response resuscitation survive, but many suffer serious permanent brain injury as a result of their arrest.7,9,–,14 Out-of-hospital survival rates and neurological outcome can be improved with prompt bystander CPR,3,6,15,–,17 but only about one third to one half of infants and children who suffer cardiac arrest receive bystander CPR.3,9,12,18 Infants are less likely to survive out-of-hospital cardiac arrest (4%) than children (10%) or adolescents (13%), presumably because many infants included in the arrest figure are found dead after a substantial period of time, most from sudden infant death syndrome (SIDS).8 As in adults, survival is …

Effect of Just-in-time Simulation Training on Tracheal Intubation Procedure Safety in the Pediatric Intensive Care Unit

Background:Tracheal intubation-associated events (TIAEs) are common (20%) and life threatening (4%) in pediatric intensive care units. Physician trainees are required to learn tracheal intubation during intensive care unit rotations. The authors hypothesized that “just-in-time” simulation-based intubation refresher training would improve resident participation, success, and decrease TIAEs. Methods:For 14 months, one of two on-call residents, nurses, and respiratory therapists received 20-min multidisciplinary simulation-based tracheal intubation training and 10-min resident skill refresher training at the beginning of their on-call period in addition to routine residency education. The rate of first attempt and overall success between refresher-trained and concurrent non–refresher-trained residents (controls) during the intervention phase was compared. The incidence of TIAEs between preintervention and intervention phase was also compared. Results:Four hundred one consecutive primary orotracheal intubations were evaluated: 220 preintervention and 181 intervention. During intervention phase, neither first-attempt success nor overall success rate differed between refresher-trained residents versus concurrent non–refresher-trained residents: 20 of 40 (50%) versus 15 of 24 (62.5%), P = 0.44 and 23 of 40 (57.5%) versus 18 of 24 (75.0%), P = 0.19, respectively. The residents first attempt and overall success rate did not differ between preintervention and intervention phases. The incidence of TIAE during preintervention and intervention phases was similar: 22.0% preintervention versus 19.9% intervention, P = 0.62, whereas resident participation increased from 20.9% preintervention to 35.4% intervention, P = 0.002. Resident participation continued to be associated with TIAE even after adjusting for the phase and difficult airway condition: odds ratio 2.22 (95% CI 1.28–3.87, P = 0.005). Conclusions:Brief just-in-time multidisciplinary simulation-based intubation refresher training did not improve the residents first attempt or overall tracheal intubation success.

Effect of mattress deflection on CPR quality assessment for older children and adolescents.

UNLABELLED Appropriate chest compression (CC) depth is associated with improved CPR outcome. CCs provided in hospital are often conducted on a compliant mattress. The objective was to quantify the effect of mattress compression on the assessment of CPR quality in children. METHODS A force and deflection sensor (FDS) was used during CPR in the Pediatric Intensive Care Unit and Emergency Department of a childrens hospital. The sensor was interposed between the chest of the patient and hands of the rescuer and measured CC depth. Following CPR event, each event was reconstructed with a manikin and an identical mattress/backboard/patient configuration. CCs were performed using FDS on the sternum and a reference accelerometer attached to the spine of the manikin, providing a means to calculate the mattress deflection. RESULTS Twelve CPR events with 14,487 CC (11 patients, median age 14.9 years) were recorded and reconstructed: 9 on ICU beds (9296 CC), 3 on stretchers (5191 CC). Measured mean CC depth during CPR was 47+/-8mm on ICU beds, and 45+/-7 mm on stretcher beds with overestimation of 13+/-4mm and 4+/-1mm, respectively, due to mattress compression. After adjusting for this, the proportion of CC that met the CPR guidelines decreased from 88.4 to 31.8% on ICU beds (p<0.001), and 86.3 to 64.7% on stretcher (p<0.001). The proportion of appropriate depth CC was significantly smaller on ICU beds (p<0.001). CONCLUSION CC conducted on a non-rigid surface may not be deep enough. FDS may overestimate CC depth by 28% on ICU beds, and 10% on stretcher beds.

Effect of Hospital Characteristics on Outcomes From Pediatric Cardiopulmonary Resuscitation: A Report From the National Registry of Cardiopulmonary Resuscitation

OBJECTIVE. Cardiac arrest is uncommon among pediatric patients. Prehospital data demonstrate differences in care processes between children and adults receiving cardiopulmonary resuscitation and advanced life support. We sought to evaluate whether children receiving in-hospital cardiopulmonary resuscitation would attain superior 24-hour survival in hospitals with a higher level of pediatric physician staffing, greater intensity of pediatric care services, and higher pediatric patient volume. METHODS. A retrospective cohort of 778 hospital inpatients aged <18 years receiving cardiopulmonary resuscitation was identified from the National Registry of Cardiopulmonary Resuscitation from January 2000 to December 2002. Data on hospital pediatric facilities were obtained via telephone survey. Univariate analyses comparing 24-hour survivors and nonsurvivors were conducted using Wilcoxon rank-sum testing for continuous variables and χ2 analysis for dichotomous variables. Multivariate regression analysis was done to examine hospital characteristics as independent predictors of 24-hour survival. RESULTS. Complete data were available for 677 patients. Univariate analyses showed an association between several pediatric-specific facility characteristics and 24-hour survival. After accounting for indicators of pre-event clinical condition and monitoring, multivariate analysis showed improved 24-hour survival in hospitals staffed by pediatric residents and surgeons and pediatric residents, surgeons, and fellows than for hospitals with no pediatric physician staffing or pediatric surgeons alone. Measures of available facilities and patient volume were not associated with improved outcome. CONCLUSIONS. Improved 24-hour survival for children receiving in-hospital cardiopulmonary resuscitation is associated with the presence of pediatric residents and fellows.

Examining Pediatric Resuscitation Education Using Simulation and Scripted Debriefing: A Multicenter Randomized Trial

IMPORTANCE Resuscitation training programs use simulation and debriefing as an educational modality with limited standardization of debriefing format and content. Our study attempted to address this issue by using a debriefing script to standardize debriefings. OBJECTIVE To determine whether use of a scripted debriefing by novice instructors and/or simulator physical realism affects knowledge and performance in simulated cardiopulmonary arrests. DESIGN Prospective, randomized, factorial study design. SETTING The study was conducted from 2008 to 2011 at 14 Examining Pediatric Resuscitation Education Using Simulation and Scripted Debriefing (EXPRESS) network simulation programs. Interprofessional health care teams participated in 2 simulated cardiopulmonary arrests, before and after debriefing. PARTICIPANTS We randomized 97 participants (23 teams) to nonscripted low-realism; 93 participants (22 teams) to scripted low-realism; 103 participants (23 teams) to nonscripted high-realism; and 94 participants (22 teams) to scripted high-realism groups. INTERVENTION Participants were randomized to 1 of 4 arms: permutations of scripted vs nonscripted debriefing and high-realism vs low-realism simulators. MAIN OUTCOMES AND MEASURES Percentage difference (0%-100%) in multiple choice question (MCQ) test (individual scores), Behavioral Assessment Tool (BAT) (team leader performance), and the Clinical Performance Tool (CPT) (team performance) scores postintervention vs preintervention comparison (PPC). RESULTS There was no significant difference at baseline in nonscripted vs scripted groups for MCQ (P = .87), BAT (P = .99), and CPT (P = .95) scores. Scripted debriefing showed greater improvement in knowledge (mean [95% CI] MCQ-PPC, 5.3% [4.1%-6.5%] vs 3.6% [2.3%-4.7%]; P = .04) and team leader behavioral performance (median [interquartile range (IQR)] BAT-PPC, 16% [7.4%-28.5%] vs 8% [0.2%-31.6%]; P = .03). Their improvement in clinical performance during simulated cardiopulmonary arrests was not significantly different (median [IQR] CPT-PPC, 7.9% [4.8%-15.1%] vs 6.7% [2.8%-12.7%], P = .18). Level of physical realism of the simulator had no independent effect on these outcomes. CONCLUSIONS AND RELEVANCE The use of a standardized script by novice instructors to facilitate team debriefings improves acquisition of knowledge and team leader behavioral performance during subsequent simulated cardiopulmonary arrests. Implementation of debriefing scripts in resuscitation courses may help to improve learning outcomes and standardize delivery of debriefing, particularly for novice instructors.

Part 14: Education 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Cardiac arrest is a major public health issue, with more than 500 000 deaths of children and adults per year in the United States.1–3 Despite significant scientific advances in the care of cardiac arrest victims, there remain striking disparities in survival rates for both out-of-hospital and in-hospital cardiac arrest. Survival can vary among geographic regions by as much as 6-fold for victims in the prehospital setting.4,5 Significant variability in survival outcomes also exists for cardiac arrest victims in the hospital setting, particularly when the time of day or the location of the cardiac arrest is considered.6 Inconsistencies in performance of both healthcare professionals and the systems in which they work likely contribute to these differences in outcome.7 For out-of-hospital cardiac arrest victims, the key determinants of survival are the timely performance of bystander cardiopulmonary resuscitation (CPR) and defibrillation for those in ventricular fibrillation or pulseless ventricular tachycardia. Only a minority of cardiac arrest victims receive potentially lifesaving bystander CPR, thus indicating room for improvement from a systems and educational point of view. For in-hospital cardiac arrest, the important provider-dependent determinants of survival are early defibrillation for shockable rhythms and high-quality CPR, along with recognition and response to deteriorating patients before an arrest. Defining the optimal means of delivering resuscitation education to address these critical determinants of survival may help to improve outcomes from cardiac arrest. Resuscitation education is primarily focused on ensuring widespread and uniform implementation of the science of resuscitation (eg, the Scientific Statements and Guidelines) into practice by lay and healthcare CPR providers. It aims to close the gap between actual and desired performance by providing lay providers with CPR skills and the self-efficacy to use them; supplementing training with in-the-moment support, such as dispatch-assisted CPR; improving healthcare professionals’ ability …

Factors Associated With Cervical Spine Injury in Children After Blunt Trauma

STUDY OBJECTIVE Cervical spine injuries in children are rare. However, immobilization and imaging for potential cervical spine injury after trauma are common and are associated with adverse effects. Risk factors for cervical spine injury have been developed to safely limit immobilization and radiography in adults, but not in children. The purpose of our study is to identify risk factors associated with cervical spine injury in children after blunt trauma. METHODS We conducted a case-control study of children younger than 16 years, presenting after blunt trauma, and who received cervical spine radiographs at 17 hospitals in the Pediatric Emergency Care Applied Research Network (PECARN) between January 2000 and December 2004. Cases were children with cervical spine injury. We created 3 control groups of children free of cervical spine injury: (1) random controls, (2) age and mechanism of injury-matched controls, and (3) for cases receiving out-of-hospital emergency medical services (EMS), age-matched controls who also received EMS care. We abstracted data from 3 sources: PECARN hospital, referring hospital, and out-of-hospital patient records. We performed multiple logistic regression analyses to identify predictors of cervical spine injury and calculated the models sensitivity and specificity. RESULTS We reviewed 540 records of children with cervical spine injury and 1,060, 1,012, and 702 random, mechanism of injury, and EMS controls, respectively. In the analysis using random controls, we identified 8 factors associated with cervical spine injury: altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, conditions predisposing to cervical spine injury, diving, and high-risk motor vehicle crash. Having 1 or more factors was 98% (95% confidence interval 96% to 99%) sensitive and 26% (95% confidence interval 23% to 29%) specific for cervical spine injury. We identified similar risk factors in the other analyses. CONCLUSION We identified an 8-variable model for cervical spine injury in children after blunt trauma that warrants prospective refinement and validation.

2010 American Heart Association recommended compression depths during pediatric in-hospital resuscitations are associated with survival

AIM Gaps exist in pediatric resuscitation knowledge due to limited data collected during cardiac arrest in real children. The objective of this study was to evaluate the relationship between the 2010 American Heart Association (AHA) recommended chest compression (CC) depth (≥51 mm) and survival following pediatric resuscitation attempts. METHODS Single-center prospectively collected and retrospectively analyzed observational study of children (>1 year) who received CCs between October 2006 and September 2013 in the intensive care unit (ICU) or emergency department (ED) at a tertiary care childrens hospital. Multivariate logistic regression models controlling for calendar year and known potential confounders were used to estimate the association between 2010 AHA depth compliance and survival outcomes. The primary outcome was 24-h survival. The primary predictor variable was event AHA depth compliance, prospectively defined as an event with ≥60% of 30-s epochs achieving an average CC depth ≥51 mm during the first 5 min of the resuscitation. RESULTS There were 89 CC events, 87 with quantitative CPR data collected (23 AHA depth compliant). AHA depth compliant events were associated with improved 24-h survival on both univariate analysis (70% vs. 16%, p<0.001) and after controlling for potential confounders (calendar year of arrest, gender, first documented rhythm; aOR 10.3; CI(95): 2.75-38.8; p<0.001). CONCLUSIONS 2010 AHA compliant chest compression depths (≥51 mm) are associated with higher 24-h survival compared to shallower chest compression depths, even after accounting for potentially confounding patient and event factors.