Elizabeth A. Hunt

Rapid response systems: a systematic review.

Context:Rapid response systems have been advocated as a potential model to identify and intervene in patients who are experiencing deterioration on general hospital wards. Objective:To conduct a meta-analysis to evaluate the impact of rapid response systems on hospital mortality and cardiac arrest rates. Data Source:We searched MEDLINE, EMBASE, and the Cochrane Library from January 1, 1990, to June 30, 2005, for all studies relevant to rapid response systems. We restricted the search to the English language and by age category (all adults: ≥19 years). Study Selection:We selected observational and randomized trials of rapid response systems that provided empirical data on hospital mortality and cardiac arrest in control and intervention groups. We reviewed 10,228 abstracts and identified eight relevant studies meeting these criteria. Data Synthesis:Of the included studies, five used historical controls, one used concurrent controls, and two used a cluster-randomized design. The pooled relative risk for hospital mortality comparing rapid response teams to control was 0.76 (95% confidence interval, 0.39–1.48) between the two randomized studies and 0.87 (95% confidence interval, 0.73–1.04) among the five observational studies. The pooled relative risk for cardiac arrest comparing rapid response systems to control was 0.94 (95% confidence interval, 0.79–1.13) in the single randomized study and 0.70 (95% confidence interval, 0.56–0.92) in four observational studies. Conclusions:We found weak evidence that rapid response systems are associated with a reduction in hospital mortality and cardiac arrest rates, but limitations in the quality of the original studies, the wide confidence intervals, and the presence of heterogeneity limited our ability to conclude that rapid response systems are effective interventions. Large randomized controlled trials are needed to clarify the efficacy of rapid response systems before they should become standard of care.

Simulation of In-Hospital Pediatric Medical Emergencies and Cardiopulmonary Arrests: Highlighting the Importance of the First 5 Minutes

OBJECTIVES. Outcomes of in-hospital pediatric cardiopulmonary arrest are dismal. Recent data suggest that the quality of basic and advanced life support delivered to adults is low and contributes to poor outcomes, but few data regarding pediatric events have been reported. The objectives of this study were to (1) measure the median elapsed time to initiate important resuscitation maneuvers in simulated pediatric medical emergencies (ie, “mock codes”) and (2) identify the types and frequency of errors committed during pediatric mock codes. METHODS. A prospective, observational study was conducted of 34 consecutive hospital-based mock codes. A mannequin or computerized simulator was used to enact unannounced, simulated crisis situations involving children with respiratory distress or insufficiency, respiratory arrest, hemodynamic instability, and/or cardiopulmonary arrest. Assessment included time elapsed to initiation of specific resuscitation maneuvers and deviation from American Heart Association guidelines. RESULTS. Among the 34 mock codes, the median time to assessment of airway and breathing was 1.3 minutes, to administration of oxygen was 2.0 minutes, to assessment of circulation was 4.0 minutes, to arrival of any physician was 3.0 minutes, and to arrival of first member of code team was 6.0 minutes. Among cardiopulmonary arrest scenarios, elapsed time to initiation of compressions was 1.5 minutes and to request for defibrillator was 4.3 minutes. In 75% of mock codes, the team deviated from American Heart Association pediatric basic life support protocols, and in 100% of mock codes there was a communication error. CONCLUSIONS. Alarming delays and deviations occur in the major components of pediatric resuscitation. Future educational and organizational interventions should focus on improving the quality of care delivered during the first 5 minutes of resuscitation. Simulation of pediatric crises can identify targets for educational intervention to improve pediatric cardiopulmonary resuscitation and, ideally, outcomes.

Part 16: Education, Implementation, and Teams 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Optimizing the links in the Chain of Survival improves outcomes and saves lives. The use of evidence-based education and implementation strategies will allow organizations and communities to strengthen these links in the most effective and efficient manner.

Part 12: Education, Implementation, and Teams

Note From the Writing Group: Throughout this article, the reader will notice combinations of superscripted letters and numbers (eg, “Precourse Preparation”). These callouts are hyperlinked to evidence-based worksheets, which were used in the development of this article. An appendix of worksheets, applicable to this article, is located at the end of the text. The worksheets are available in PDF format and are open access.

Transition from a traditional code team to a medical emergency team and categorization of cardiopulmonary arrests in a children's center.

OBJECTIVES To study the effect of an intervention on prevention of respiratory arrest and cardiopulmonary arrest (CPA) and to characterize ward CPAs by preceding signs and symptoms and initial cardiac rhythm. DESIGN A before-and-after interventional trial (12 months preintervention and 12 months postintervention). SETTING A tertiary care, academic childrens hospital. PARTICIPANTS Admitted patients who subsequently had either the code team or pediatric medical emergency team (PMET) called or who had a respiratory arrest or CPA on the wards. Intervention Transition from a traditional code team to a PMET that responds to clinically deteriorating children in noncritical care areas. OUTCOME MEASURES Combined rate of respiratory arrests and CPAs, rate of CPAs, and rate of respiratory arrests on the wards and agreement between independent reviewers on categorization of CPAs. RESULTS There was no change in the rate of CPAs on the wards. However, there was a 73% decrease in the incidence of respiratory arrests (0.23 respiratory arrests/1000 patient-days pre-PMET vs 0.06 post-PMET, P = .03). There was 100% agreement between reviewers on categorization of CPAs. CONCLUSIONS Transition to a PMET was not associated with a change in CPAs but was associated with a significant decrease in the incidence of ward respiratory arrests. We also describe children who may have benefited from the PMET but whose data were not captured by current outcome measures. Finally, we present a new method for categorization of ward CPAs based on preceding signs and symptoms and initial cardiac rhythm.

Simulation of pediatric trauma stabilization in 35 north carolina emergency departments : Identification of targets for performance improvement

OBJECTIVE. Trauma is the leading cause of death in children. Most children present to community hospital emergency departments (EDs) for initial stabilization. Thus, all EDs must be prepared to care for injured children. The objectives of this study were to (1) characterize the quality of trauma stabilization efforts in EDs and (2) identify targets for educational interventions. METHODS. This was a prospective observational study of simulated trauma stabilizations, that is, “mock codes,” at 35 North Carolina EDs. An evaluation tool was created to score each mock code on 44 stabilization tasks. Primary outcomes were (1) interrater reliability of tool, (2) overall performance by each ED, and (3) performance per stabilization task. RESULTS. Evaluation-tool interrater reliability was excellent. The median number of stabilization tasks that needed improvement by the EDs was 25 (57%) of 44 tasks. Although problems were numerous and varied, many EDs need improvement in tasks uniquely important and/or complicated in pediatric resuscitations, including (1) estimating a childs weight (17 of 35 EDs [49%]), (2) preparing for intraosseous needle placement (24 of 35 [69%]), (3) ordering intravenous fluid boluses (31 of 35 [89%]), (4) applying warming measures (34 of 35 [97%]), and (5) ordering dextrose for hypoglycemia (34 of 35 [97%]). CONCLUSIONS. This study used simulation to identify deficiencies in stabilization of children presenting to EDs, revealing that mistakes are ubiquitous. ED personnel were universally receptive to feedback. Future research should investigate whether interventions aimed at improving identified deficiencies can improve trauma stabilization performance and, ultimately, the outcomes of children who present to EDs.

Part 6: Pediatric basic life support and pediatric advanced life support. 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

The Pediatric Task Force reviewed all questions submitted by the International Liaison Committee on Resuscitation (ILCOR) member councils in 2010, reviewed all council training materials and resuscitation guidelines and algorithms, and conferred on recent areas of interest and controversy. We identified a few areas where there were key differences in council-specific guidelines based on historical recommendations, such as the A-B-C (Airway, Breathing, Circulation) versus C-A-B (Circulation, Airway, Breathing) sequence of provision of cardiopulmonary resuscitation (CPR), initial back blows versus abdominal thrusts for foreign-body airway obstruction, an upper limit for recommended chest compression rate, and initial defibrillation dose for shockable rhythms (2 versus 4 J/kg). We produced a working list of prioritized questions and topics, which was adjusted with the advent of new research evidence. This led to a prioritized palate of 21 PICO (population, intervention, comparator, outcome) questions for ILCOR task force focus. The 2015 process was supported by information specialists who performed in-depth systematic searches, liaising with pediatric content experts so that the most appropriate terms and outcomes and the most relevant publications were identified. Relevant adult literature was considered (extrapolated) in those PICO questions that overlapped with other task forces, or when there were insufficient pediatric data. In rare circumstances (in the absence of sufficient human data), appropriate animal studies were incorporated into reviews of the literature. However, these data were considered only when higher levels of evidence were not available and the topic was deemed critical. When formulating the PICO questions, the task force felt it important to evaluate patient outcomes that extend beyond return of spontaneous circulation (ROSC) or discharge from the pediatric intensive care unit (PICU). In recognition that the measures must have meaning, not only to clinicians but also to parents and caregivers, longer-term outcomes at 30 …

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.

Outcomes After In-Hospital Cardiac Arrest in Children With Cardiac Disease A Report From Get With the Guidelines–Resuscitation

Background— Small studies suggest that children experiencing a cardiac arrest after undergoing cardiac surgery have better outcomes than other groups of patients, but the survival outcomes and periarrest variables of cardiac and noncardiac pediatric patients have not been compared. Methods and Results— All cardiac arrests in patients <18 years of age were identified from Get With the Guidelines–Resuscitation from 2000 to 2008. Cardiac arrests occurring in the neonatal intensive care unit were excluded. Of 3323 index cardiac arrests, 19% occurred in surgical-cardiac, 17% in medical-cardiac, and 64% in noncardiac (trauma, surgical-noncardiac, and medical-noncardiac) patients. Survival to hospital discharge was significantly higher in the surgical-cardiac group (37%) compared with the medical-cardiac group (28%; adjusted odds ratio, 1.8; 95% confidence interval, 1.3–2.5) and the noncardiac group (23%; adjusted odds ratio, 1.8; 95% confidence interval, 1.4–2.4). Those in the cardiac groups were younger and less likely to have preexisting noncardiac organ dysfunction, but were more likely to have ventricular arrhythmias as their first pulseless rhythm, to be monitored and hospitalized in the intensive care unit at the time of cardiac arrest, and to have extracorporeal cardiopulmonary resuscitation compared with those in the noncardiac group. There was no survival advantage for patients in the medical-cardiac group compared with those in the noncardiac group when adjusted for periarrest variables. Conclusion— Children with surgical-cardiac disease have significantly better survival to hospital discharge after an in-hospital cardiac arrest compared with children with medical-cardiac disease and noncardiac disease. # Clinical Perspective {#article-title-25}Background— Small studies suggest that children experiencing a cardiac arrest after undergoing cardiac surgery have better outcomes than other groups of patients, but the survival outcomes and periarrest variables of cardiac and noncardiac pediatric patients have not been compared. Methods and Results— All cardiac arrests in patients <18 years of age were identified from Get With the Guidelines–Resuscitation from 2000 to 2008. Cardiac arrests occurring in the neonatal intensive care unit were excluded. Of 3323 index cardiac arrests, 19% occurred in surgical-cardiac, 17% in medical-cardiac, and 64% in noncardiac (trauma, surgical-noncardiac, and medical-noncardiac) patients. Survival to hospital discharge was significantly higher in the surgical-cardiac group (37%) compared with the medical-cardiac group (28%; adjusted odds ratio, 1.8; 95% confidence interval, 1.3–2.5) and the noncardiac group (23%; adjusted odds ratio, 1.8; 95% confidence interval, 1.4–2.4). Those in the cardiac groups were younger and less likely to have preexisting noncardiac organ dysfunction, but were more likely to have ventricular arrhythmias as their first pulseless rhythm, to be monitored and hospitalized in the intensive care unit at the time of cardiac arrest, and to have extracorporeal cardiopulmonary resuscitation compared with those in the noncardiac group. There was no survival advantage for patients in the medical-cardiac group compared with those in the noncardiac group when adjusted for periarrest variables. Conclusion— Children with surgical-cardiac disease have significantly better survival to hospital discharge after an in-hospital cardiac arrest compared with children with medical-cardiac disease and noncardiac disease.