Akira Nishisaki

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.

Interdisciplinary ICU Cardiac Arrest Debriefing Improves Survival Outcomes

Objective:In-hospital cardiac arrest is an important public health problem. High-quality resuscitation improves survival but is difficult to achieve. Our objective is to evaluate the effectiveness of a novel, interdisciplinary, postevent quantitative debriefing program to improve survival outcomes after in-hospital pediatric chest compression events. Design, Setting, and Patients:Single-center prospective interventional study of children who received chest compressions between December 2008 and June 2012 in the ICU. Interventions:Structured, quantitative, audiovisual, interdisciplinary debriefing of chest compression events with front-line providers. Measurements and Main Results:Primary outcome was survival to hospital discharge. Secondary outcomes included survival of event (return of spontaneous circulation for ≥ 20 min) and favorable neurologic outcome. Primary resuscitation quality outcome was a composite variable, termed “excellent cardiopulmonary resuscitation,” prospectively defined as a chest compression depth ≥ 38 mm, rate ≥ 100/min, ⩽ 10% of chest compressions with leaning, and a chest compression fraction > 90% during a given 30-second epoch. Quantitative data were available only for patients who are 8 years old or older. There were 119 chest compression events (60 control and 59 interventional). The intervention was associated with a trend toward improved survival to hospital discharge on both univariate analysis (52% vs 33%, p = 0.054) and after controlling for confounders (adjusted odds ratio, 2.5; 95% CI, 0.91–6.8; p = 0.075), and it significantly increased survival with favorable neurologic outcome on both univariate (50% vs 29%, p = 0.036) and multivariable analyses (adjusted odds ratio, 2.75; 95% CI, 1.01–7.5; p = 0.047). Cardiopulmonary resuscitation epochs for patients who are 8 years old or older during the debriefing period were 5.6 times more likely to meet targets of excellent cardiopulmonary resuscitation (95% CI, 2.9–10.6; p < 0.01). Conclusion:Implementation of an interdisciplinary, postevent quantitative debriefing program was significantly associated with improved cardiopulmonary resuscitation quality and survival with favorable neurologic outcome.

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.

Leaning is common during in-hospital pediatric CPR, and decreased with automated corrective feedback

BACKGROUND Cardiopulmonary Resuscitation (CPR) guidelines recommend complete release between chest compressions (CC). No study has evaluated prevalence of leaning and the effect of real-time automated audiovisual feedback during in-hospital pediatric CPR. OBJECTIVES We hypothesize that leaning during in-hospital pediatric CPR will be common, and that real-time automated feedback will be associated with reduced leaning prevalence and force. METHODS A feedback-capable monitor/defibrillator equipped with force transducer and accelerometer recorded CC leaning force and depth during in-hospital cardiac arrests (>/=8 years) at a childrens hospital. Automated feedback was enabled at the resuscitation leaders discretion, and audiovisual prompts were given when leaning force exceeded 2.5 kg. Leaning force and depth CC with No Feedback (NoF) vs. with Feedback (F) were compared. RESULTS 20 pediatric (mean age 14.7+/-3.8 years) pulse less arrests generated 37,396 evaluable CC. Median leaning force was 1.6 kg [0.9-2.7 kg] and leaning depth 2.9 (1.6-4.7)mm. Leaning force was greater with NoF (2.5 kg, [1.6-3.5 kg]; n=1921) vs. F (1.6 kg [0.9-2.6 kg]; n=35,164, p<0.001). Leaning>2.5 kg (adult feedback threshold) occurred in 50% (n=969) of CC with NoF and 27% (n=9367) CC with F (p<0.001). CC without leaning, defined as a leaning force of<0.5 kg, occurred in 2.2% (n=43) CC with NoF vs. 10.5% (n=3681) CC with F (p<0.001). CONCLUSIONS Leaning (residual force>2.5 kg) was common during pediatric CPR. The prevalence and force of leaning were reduced with automated audiovisual feedback. Further study is necessary to determine the effect of the specific leaning threshold on CPR hemodynamics.

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.

A multi-institutional high-fidelity simulation "boot camp" orientation and training program for first year pediatric critical care fellows.

Objective: Simulation training has been used to integrate didactic knowledge, technical skills, and crisis resource management for effective orientation and patient safety. We hypothesize multi-institutional simulation-based training for first year pediatric critical care (PCC) fellows is feasible and effective. Design: Descriptive, educational intervention study. Setting: The simulation facility at the host institution. Interventions: A multicentered simulation-based orientation training “boot camp” for first year PCC fellows was held at a large simulation center. Immediate posttraining evaluation and 6-month follow-up surveys were distributed to participants. Measurements and Main Results: A novel simulation-based orientation training for first year PCC fellows was facilitated by volunteer faculty from seven institutions. The two and a half day course was organized to cover common PCC crises. High-fidelity simulation was integrated into each session (airway management, vascular access, resuscitation, sepsis, trauma/traumatic brain injury, delivering bad news). Twenty-two first year PCC fellows from nine fellowship programs attended, and 13 faculty facilitated, for a total of 15.5 hours (369 person-hours) of training. This consisted of 2.75 hours for whole group didactic sessions (17.7%), 1.08 hours for a small group interactive session (7.0%), 4.67 hours for task training (30.1%), and 7 hours for training (45.2%) with high-fidelity simulation and crisis resource management. A “train to success” approach with repetitive practice of critical assessment and interventional skills yielded higher scores in training effectiveness in the end-of-course evaluation. A follow-up survey revealed this training was highly effective in improving clinical performance and self-confidence. Conclusions: The first PCC orientation training integrated with simulation was effective and logistically feasible. The train to success concept with repetitive practice was highly valued by participants. Continuation and expansion of this novel multi-institutional training is planned.

Level of Trainee and Tracheal Intubation Outcomes

BACKGROUND: Tracheal intubation is an important intervention to stabilize critically ill and injured children. Provider training level has been associated with procedural safety and outcomes in the neonatal intensive care settings. We hypothesized that tracheal intubation success and adverse tracheal intubation–associated events are correlated with provider training level in the PICU. METHODS: A prospective multicenter observational cohort study was performed across 15 PICUs to evaluate tracheal intubation between July 2010 to December 2011. All data were collected by using a standard National Emergency Airway Registry for Children reporting system endorsed as a Quality Improvement project of the Pediatric Acute Lung Injury and Sepsis Investigator network. Outcome measures included first attempt success, overall success, and adverse tracheal intubation–associated events. RESULTS: Reported were 1265 primary oral intubation encounters by pediatric providers. First and overall attempt success were residents (37%, 51%), fellows (70%, 89%), and attending physicians (72%, 94%). After adjustment for relevant patient factors, fellow provider was associated with a higher rate of first attempt success (odds ratio [OR], 4.29; 95% confidence interval [CI], 3.24–5.68) and overall success (OR, 9.27; 95% CI, 6.56–13.1) compared with residents. Fellow (versus resident) as first airway provider was associated with fewer tracheal intubation associated events (OR, 0.42; 95% CI, 0.31–0.57). CONCLUSIONS: Across a broad spectrum of PICUs, resident provider tracheal intubation success is low and adverse associated events are high, compared with fellows. More intensive pediatric resident procedural training is necessary before “live” tracheal intubations in the intensive care setting.

A National Emergency Airway Registry for children: landscape of tracheal intubation in 15 PICUs.

Objectives:To characterize the landscape of process of care and safety outcomes for tracheal intubation across pediatric intensive care units Background:Procedural process of care and safety outcomes of tracheal intubation across pediatric intensive care units has not been described. We hypothesize that the novel National Emergency Airway Registry for Children registry is a feasible tool to capture tracheal intubation process of care and outcomes. Design:Prospective, descriptive. Setting:Fifteen academic PICUs in North America. Patients:Critically ill children requiring tracheal intubation in PICUs. Interventions:Tracheal intubation quality improvement data were prospectively collected for all initial tracheal intubation in 15 PICUs from July 2010 to December 2011 using the National Emergency Airway Registry for Children tool with explicit site-specific compliance plans and operational definitions including adverse tracheal intubation associated events. Measurement and Main Results:One thousand seven hundred fifteen tracheal intubation encounters were reported (averaging 1/3.4 days, or 1/86 bed days). Ninety-eight percent of primary tracheal intubation were successful; 86% were successful with less than or equal to two attempts. First attempt was by pediatric residents in 23%, pediatric critical care fellows in 41%, and critical care attending physicians in 13%: first attempt success rate was 62%, first provider success rate was 79%. The first method was oral intubation in 1,659 (98%) and nasal in 55 (2%). Direct laryngoscopy was used in 96%. Ninety percent of tracheal intubation were with cuffed tracheal tubes. Adverse tracheal intubation associated events were reported in 20% of intubations (n = 372), with severe tracheal intubation associated events in 6% (n = 115). Esophageal intubation with immediate recognition was the most common tracheal intubation associated events (n = 167, 9%). History of difficult airway, diagnostic category, unstable hemodynamics, and resident provider as first airway provider were associated with occurrence of tracheal intubation associated events. Severe tracheal intubation associated events were associated with diagnostic category and pre-existing unstable hemodynamics. Elective tracheal intubation status was associated with fewer severe tracheal intubation associated events. Conclusions:National Emergency Airway Registry for Children was feasible to characterize PICU tracheal intubation procedural process of care and safety outcomes. Self-reported adverse tracheal intubation associated events occurred frequently and were associated with patient, provider, and practice characteristics.

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.