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OBJECTIVES Optimal cardiopulmonary resuscitation can improve pediatric outcomes but rarely is cardiopulmonary resuscitation performed perfectly despite numerous iterations of Basic and Pediatric Advanced Life Support. Cardiac arrests resuscitation events are complex, often chaotic environments with significant mental and physical workload for team members, especially team leaders. Our primary objective was to determine the impact of a cardiopulmonary resuscitation coach on cardiopulmonary resuscitation provider workload during simulated pediatric cardiac arrest. DESIGN Multicenter observational study. SETTING Four pediatric simulation centers. SUBJECTS Team leaders, cardiopulmonary resuscitation coach, and team members during an 18-minute pediatric resuscitation scenario. INTERVENTIONS National Aeronautics and Space Administration-Task Load Index. MEASUREMENTS AND MAIN RESULTS Forty-one teams (205 participants) were recruited with one team (five participants) excluded from analysis due to protocol violation. Demographic data revealed no significant differences between the groups in regard to age, experience, distribution of training (nurse, physician, and respiratory therapist). For most workload subscales, there were no significant differences between groups. However, cardiopulmonary resuscitation providers had a higher physical workload (89.3 vs 77.9; mean difference, -11.4; 95% CI, -17.6 to -5.1; p = 0.001) and a lower mental demand (40.6 vs 55.0; mean difference, 14.5; 95% CI, 4.0-24.9; p = 0.007) with a coach (intervention) than without (control). Both the team leader and coach had similarly high mental demand in the intervention group (75.0 vs 73.9; mean difference, 0.10; 95% CI, -0.88 to 1.09; p = 0.827). When comparing the cardiopulmonary resuscitation quality of providers with high workload (average score > 60) and low to medium workload (average score < 60), we found no significant difference between the two groups in percentage of guideline compliant cardiopulmonary resuscitation (42.5% vs 52.7%; mean difference, -10.2; 95% CI, -23.1 to 2.7; p = 0.118). CONCLUSIONS The addition of a cardiopulmonary resuscitation coach increases physical workload and decreases mental workload of cardiopulmonary resuscitation providers. There was no change in team leader workload.

Bystander cardiopulmonary resuscitation (CPR) is critical to increasing survival from out-of-hospital cardiac arrest. However, the percentage of cases in which an individual receives bystander CPR is actually low, at only 35% to 40% globally. Preparing lay responders to recognize the signs of sudden cardiac arrest, call 9-1-1, and perform CPR in public and private locations is crucial to increasing survival from this public health problem. The objective of this scientific statement is to summarize the most recent published evidence about the lay responder experience of training, responding, and dealing with the residual impact of witnessing an out-of-hospital cardiac arrest. The scientific statement focuses on the experience-based literature of actual responders, which includes barriers to responding, experiences of doing CPR, use of an automated external defibrillator, the impact of dispatcher-assisted CPR, and the potential for postevent psychological sequelae. The large body of qualitative and observational studies identifies several gaps in crucial knowledge that, if targeted, could increase the likelihood that those who are trained in CPR will act. We suggest using the experience of actual responders to inform more contextualized training, including the implications of performing CPR on a family member, dispelling myths about harm, training and litigation, and recognition of the potential for psychologic sequelae after the event.

Aim: To evaluate an algorithm that uses an end-tidal carbon dioxide (ETCO2) target of ≥ 30 torr to guide specific changes in chest compression rate and epinephrine administration during cardiopulmonary resuscitation (CPR) in paediatric swine. Methods: Swine underwent asphyxial cardiac arrest followed by resuscitation with either standard or ETCO2-guided algorithm CPR. The standard group received chest compressions at a rate of 100/min and epinephrine every 4 min during advanced life support consistent with the American Heart Association paediatric resuscitation guidelines. In the ETCO2-guided algorithm group, chest compression rate was increased by 10 compressions/min for every minute that the ETCO2 was < 30 torr, and the epinephrine administration interval was decreased to every 2 min if the ETCO2 remained < 30 torr. Short-term survival and physiologic data during active resuscitation were compared. Results: Short-term survival was significantly greater in the ETCO2-guided algorithm CPR group than in the standard CPR group (16/28 [57.1%] versus 4/28 [14.3%]; p = 0.002). Additionally, the algorithm group had higher predicted mean ETCO2, chest compression rate, diastolic and mean arterial pressure, and myocardial perfusion pressure throughout resuscitation. Swine in the algorithm group also exhibited significantly greater improvement in diastolic and mean arterial pressure and cerebral perfusion pressure after the first dose of epinephrine than did those in the standard group. Incidence of resuscitation-related injuries was similar in the two groups. Conclusions: Use of a resuscitation algorithm with stepwise guidance for changes in the chest compression rate and epinephrine administration interval based on a goal ETCO2 level improved survival and intra-arrest hemodynamics in this porcine cardiac arrest model.

AIM: To examine the relationship between survival and diastolic blood pressure (DBP) throughout resuscitation from paediatric asphyxial cardiac arrest. METHODS: Retrospective, secondary analysis of 200 swine resuscitations. Swine underwent asphyxial cardiac arrest and were resuscitated with predefined periods of basic and advanced life support (BLS and ALS, respectively). DBP was recorded every 30 s. Survival was defined as 20-min sustained return of spontaneous circulation (ROSC). RESULTS: During BLS, DBP peaked between 1–3 min and was greater in survivors (20.0 [11.3, 33.3] mmHg) than in non-survivors (5.0 [1.0, 10.0] mmHg; p

AIM To examine the associations between ETCO2, ROSC, and chest compression quality markers in paediatric patients during active resuscitation. METHODS This was a single-centre cohort study of data collected as part of an institutional prospective quality initiative improvement program that included all paediatric patients who received chest compressions of any duration from January 1, 2013, through July 10, 2018, in the Johns Hopkins Children's Center. Data was collected from Zoll R Series® defibrillators. Events were included if Zoll data files contained both chest compression and ETCO2 data. 2,746 minutes corresponding to 143 events were included in the analyses. RESULTS The median event ETCO2 for all 143 events was 16.8 [9.3-26.3] mmHg. There was a significant difference in median event ETCO2 between events that achieved ROSC and those that did not (ROSC: 19.3 [14.4-26.6] vs. NO ROSC: 13.9 [6.6-25.5] mmHg; p

OBJECTIVES Effective cardiopulmonary resuscitation (CPR) is critical to ensure optimal outcomes from cardiac arrest, yet trained health care providers consistently struggle to provide guideline-compliant CPR. Rescuer fatigue can impact chest compression (CC) quality during a cardiac arrest event, although it is unknown if visual feedback or just-in-time training influences change of CC quality over time. In this study, we attempt to describe the changes in CC quality over a 12-minute simulated resuscitation and examine the influence of just-in-time training and visual feedback on CC quality over time. METHODS We conducted secondary analysis of data collected from the CPRCARES study, a multicenter randomized trial in which CPR-certified health care providers from 10 different pediatric tertiary care centers were randomized to receive visual feedback, just-in-time CPR training, or no intervention. They participated in a simulated cardiac arrest scenario with 2 team members providing CCs. We compared the quality of CCs delivered (depth and rate) at the beginning (0-4 minutes), middle (4-8 minutes), and end (8-12 minutes) of the resuscitation. RESULTS There was no significant change in depth over the 3 time intervals in any of the arms. There was a significant increase in rate (128 to 133 CC/min) in the no intervention arm over the scenario duration (P < 0.05). CONCLUSIONS There was no significant drop in CC depth over a 12-minute cardiac arrest scenario with 2 team members providing compressions.

Objectives The American Heart Association recommends minimizing pauses of chest compressions and defines high performance resuscitation as achieving a chest compression fraction greater than 80%. We hypothesize that interruption times are excessively long, leading to an unnecessarily large impact on chest compression fraction. Design A retrospective study using video review of a convenience sample of clinically realistic in situ simulated pulseless electrical activity cardiopulmonary arrests. Setting Johns Hopkins Children's Center; September 2013 to June 2017. Patients Twenty-two simulated patients. Interventions A framework was developed to characterize interruptions. Two new metrics were defined as follows: interruption time excess (the difference between actual and guideline-indicated allowable duration of interruption from compressions), and chest compression fraction potential (chest compression fraction with all interruption time excess excluded). Measurements and main results Descriptive statistics were generated for interruption-level and event-level variables. Differences between median chest compression fraction and chest compression fraction potential were assessed using Wilcoxon rank-sum test. Comparisons of interruption proportion before and after the first 5 minutes were assessed using the X test statistic. Seven-hundred sixty-six interruptions occurred over 22 events. Median event duration was 463.0 seconds (interquartile range, 397.5-557.8 s), with a mean 34.8 interruptions per event. Auscultation and intubation had the longest median interruption time excess of 13.0 and 7.5 seconds, respectively. Median chest compression fraction was 76.0% (interquartile range, 67.7-80.7 s), and median chest compression fraction potential was 83.4% (interquartile range, 80.4-87.4%). Comparing median chest compression fraction to median chest compression fraction potential found an absolute percent difference of 7.6% (chest compression fraction: 76.0% vs chest compression fraction potential: 83.4%; p Conclusions This lays the groundwork for studying inefficiency during cardiopulmonary resuscitation associated with chest compression interruptions. The framework we created allows for the determination of significant avoidable interruption time. By further elucidating the nature of interruptions, we can design and implement targeted interventions to improve patient outcomes.

AIM: Recommendations for standardised communication to reduce chest compression (CC) pauses are lacking. We aimed to achieve consensus and evaluate feasibility and efficacy using standardised communication during cardiopulmonary resuscitation (CPR) events.METHODS: Modified Delphi consensus process to design standardised communication elements. Feasibility was pilot tested in 16 simulated CPR scenarios (8 scenarios with physician team leaders and 8 with chest compressors) randomized (1:1) to standardised [INTERVENTION] vs. closed-loop communication [CONTROL]. Adherence and efficacy (duration of CC pauses for defibrillation, intubation, rhythm check) was assessed by audiovisual recording. Mental demand and frustration were assessed by NASA task load index subscales.RESULTS: Consensus elements for standardised communication included: 1) team preparation 15-30 s before CC interruption, 2) pre-interruption countdown synchronized with last 5 CCs, 3) specific action words for defibrillation, intubation, and interrupting/resuming CCs. Median (Q1,Q3) adherence to standardised phrases was 98% (80%,100%). Efficacy analysis showed a median [Q1,Q3] peri-shock pause of 5.1 s. [4.4; 5.8] vs. 7.5 s. [6.3; 8.8] seconds, p CONCLUSION: This pilot study demonstrated feasibility of using consensus-based standardised communication that was associated with shorter CC pauses for defibrillation, intubation, and rhythm checks without increasing frustration index or mental demand compared to current best practice, closed loop communication.

To determine if integrating a trained CPR Coach into resuscitation teams can improve CPR quality during simulated pediatric cardiopulmonary arrest (CPA).We conducted a multicenter, prospective, randomized trial. An 18-minute simulated CPA scenario was run for resuscitation teams comprised of CPR-certified professionals from four International Network for Simulation-based Pediatric Innovation, ResearchEducation (INSPIRE) institutions. Forty teams (200 participants) were randomized to having a trained CPR Coach vs. no CPR Coach. CPR Coaches were responsible for providing real-time verbal feedback of CPR performance to compressors. All teams utilized CPR feedback technology. We report the proportion of overall excellent CPR, proportion of chest compressions (CC) with depth 50-60 mm, the proportion of CC with rate 100-120 per minute, CC fraction, and pre-, post-, and peri-shock pause duration.CPR coached teams compared with teams without a CPR Coach resulted in an absolute improvements in overall excellent CPR by 31.8% (95% CI, 17.7, 35.9; p 0.001), mean CC depth compliance by 31.5% (15.7, 47.4; p 0.001), mean CC depth by 4.6 mm (1.6, 7.5; p 0.001), mean CC fraction by 5.4% (0.2, 10.6; p = 0.04), and mean pre-, post- and peri-shock pause duration by -2.7 s (-5.1, -0.4; p = 0.02), -1.0 s (-1.8, -0.2; p = 0.01); and -3.8 (-6.6, -1.0; p = 0.008), respectively. Changes in mean CC rate compliance and mean CC rate were not statistically significant.In the presence of CPR feedback technology, the integration of a trained CPR coach into resuscitation teams enhances CPRquality metrics associated with improved survival outcomes from pediatric cardiac arrest.

OBJECTIVES Pediatric in-hospital cardiac arrest cardiopulmonary resuscitation quality metrics have been reported in few children less than 8 years. Our objective was to characterize chest compression fraction, rate, depth, and compliance with 2015 American Heart Association guidelines across multiple pediatric hospitals. DESIGN Retrospective observational study of data from a multicenter resuscitation quality collaborative from October 2015 to April 2017. SETTING Twelve pediatric hospitals across United States, Canada, and Europe. PATIENTS In-hospital cardiac arrest patients (age < 18 yr) with quantitative cardiopulmonary resuscitation data recordings. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 112 events yielding 2,046 evaluable 60-second epochs of cardiopulmonary resuscitation (196,669 chest compression). Event cardiopulmonary resuscitation metric summaries (median [interquartile range]) by age: less than 1 year (38/112): chest compression fraction 0.88 (0.61-0.98), chest compression rate 119/min (110-129), and chest compression depth 2.3 cm (1.9-3.0 cm); for 1 to less than 8 years (42/112): chest compression fraction 0.94 (0.79-1.00), chest compression rate 117/min (110-124), and chest compression depth 3.8 cm (2.9-4.6 cm); for 8 to less than 18 years (32/112): chest compression fraction 0.94 (0.85-1.00), chest compression rate 117/min (110-123), chest compression depth 5.5 cm (4.0-6.5 cm). "Compliance" with guideline targets for 60-second chest compression "epochs" was predefined: chest compression fraction greater than 0.80, chest compression rate 100-120/min, and chest compression depth: greater than or equal to 3.4 cm in less than 1 year, greater than or equal to 4.4 cm in 1 to less than 8 years, and 4.5 to less than 6.6 cm in 8 to less than 18 years. Proportion of less than 1 year, 1 to less than 8 years, and 8 to less than 18 years events with greater than or equal to 60% of 60-second epochs meeting compliance (respectively): chest compression fraction was 53%, 81%, and 78%; chest compression rate was 32%, 50%, and 63%; chest compression depth was 13%, 19%, and 44%. For all events combined, total compliance (meeting all three guideline targets) was 10% (11/112). CONCLUSIONS Across an international pediatric resuscitation collaborative, we characterized the landscape of pediatric in-hospital cardiac arrest chest compression quality metrics and found that they often do not meet 2015 American Heart Association guidelines. Guideline compliance for rate and depth in children less than 18 years is poor, with the greatest difficulty in achieving chest compression depth targets in younger children.

Background: Recommendations for “standardized” communication during cardiopulmonary resuscitation (CPR) events to reduce interruptions in chest compressions (CCs) are lacking. We aimed to achieve consensus on standardized communication during in-hospital CPR, evaluate feasibility and potential to decrease CC pauses, mental task load, and frustration. Methods: Modified Delphi consensus surveys of International Liaison Committee on Resuscitation taskforce members to identify preferred communication for in-hospital cardiac arrest teams. Consensus was reached after-survey teleconference resolution by a team of interdisciplinary experts in communication and CPR. Feasibility was tested in 8 simulated CPR scenarios with physician team leaders randomized (1:1) to ‘standardized’ communication vs. “usual best practice”, closed loop communication. Team leaders watched a 3-min video and received a 10-min training on the assigned intervention before the CPR scenario. NASA task load index questionnaires were used to assess mental task load and frustration (0=lowest to 100=highest). Results: Modified Delphi consensus on standardized communication included: 1) preparing the team 15-30 seconds before interrupting CCs, 2) countdown for interruption synchronized with 5 CCs, 3) action words for stopping and resuming CCs, 4) action words for intubation and defibrillation. Among 8 CPR teams (4 standardized, 4 usual communication), median (Q1; Q3) CC interruption duration for rhythm check was significantly shorter, 5.3 (4.8; 6.8) vs. 9.4 (6.4; 13.0) sec for standardized vs. closed loop communication [p=0.02]. Median (Q1; Q3) scores of mental task load were 63 (33; 70) vs 85 (70; 96), [p=0.10] and frustration 10 (5; 34) vs 40 (26; 50) [p=0.11] for standardized vs. closed loop communication. Trained team leaders adhered to standardized phrases 77% of the time. Conclusion: Expert consensus for standardized communication during in-hospital CPR was achieved. Pilot simulation implementation of standardized communication demonstrated feasibility of team leader adherence, significantly decreased duration of CC interruption during rhythm checks, and a tendency to reduce team leader task load and frustration.

Introduction: The American Heart Association (AHA) recommends the use of end-tidal CO 2 (ETCO 2 ) to evaluate the quality of chest compression delivery during CPR. In a pediatric model of asphyxial cardiac arrest, ETCO 2 -guided chest compression delivery improved survival over standard CPR. Since the most common cause of pediatric cardiac arrest is respiratory failure, we investigated whether this observed survival benefit persisted in a model of respiratory failure preceding cardiac arrest. Methods: Prior to a 17-min asphyxial cardiac arrest, peak inspiratory pressures were adjusted to a goal PaCO 2 of 80 torr to mimic pre-arrest respiratory failure. Male swine (3-4 kg) were randomized to receive either ETCO 2 -guided or standard CPR for 10 min of BLS followed by 10 min of ALS. In the ETCO 2 -guided group, chest compression rate and depth were adjusted to obtain a maximal ETCO 2 level. In the standard group, chest compressions were delivered per AHA guidelines. Hemodynamic parameters were recorded every 30 seconds, and resuscitation was continued for 20 min or until ROSC. Results: Twenty swine underwent asphyxial cardiac arrest. After adjustment of ventilation prior to asphyxia, pH and PaCO 2 were 7.15 and 79 torr in the ETCO 2 -guided group and 7.14 and 78 torr in the standard group. Survival was greater in the ETCO 2 -guided group than in the standard group (7/10 versus 1/10; p=0.02). During resuscitation, mean ETCO 2 and chest compression rate were higher in the ETCO 2 -guided group (38.6 ± 1.2 versus 22.9 ± 1.2, p=0.01; 154.4 ± 1.2 versus 100.5 ± 0.1, p2 -guided group ( Figure 1 ) Conclusions: ETCO 2 -guided chest compression delivery improves survival and resuscitation hemodynamics over standard CPR in a pediatric model of respiratory failure and cardiac arrest.

Normal 0 false false false EN-US X-NONE X-NONE /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:12.0pt; font-family:"Calibri",sans-serif; mso-ascii-font-family:Calibri; mso-ascii-theme-font:minor-latin; mso-hansi-font-family:Calibri; mso-hansi-theme-font:minor-latin;} Little evidence exists to guide end-tidal carbon dioxide (ETCO 2 ) use during cardiac arrest events in pediatric populations. Despite this, integrating physiologic feedback, including ETCO 2 , into resuscitation optimization is recognized as an important component to precision resuscitation. This was a prospective observational study of ETCO 2 , CPR quality and ROSC. The study population included any pediatric patient who received chest compressions from January 1, 2013 through July 10, 2018 in the Johns Hopkins Children’s Center. During this time, 457 arrest events of any length requiring chest compressions occurred. Of these events, 274 utilized ETCO 2 in some capacity and 198 recorded ETCO 2 on a Zoll R Series® defibrillator. Data files from 145 of these events that contained both chest compression and ETCO 2 data were successfully obtained. These 145 events contained 2200 minutes of ETCO 2 data and 2156 minutes of both chest compression and ETCO 2 data; values are reported as median [IQR]. The average ETCO 2 for all events was 21 mmHg [15-32]. ETCO 2 by age category was (0-1: 12 [0-29]; 1-8: 20 [2-35]; 8+: 10.15 [0-21]). When comparing patients who achieved ROSC > 20 minutes to those who did not, we observed a significant difference in ETCO 2 between those who survived and those who did not (ROSC: 25 [15-30] vs. NO ROSC: 15 [9-22]; p2 and resuscitation data, our findings suggest that a difference may exist in survival associated with an ETCO 2 difference between 15 and 20 mmHg.

BACKGROUND: Current pediatric resuscitation guidelines suggest that resuscitators using an advanced airway deliver 8–10 breaths per minute while carefully avoiding excessive ventilation. In the intraoperative setting, having a dedicated ventilation rescuer may be difficult because of limited personnel. Continuing pressure-controlled mechanical ventilation during resuscitation for intraoperative cardiac arrest reduces personnel needed and the risk of hyperventilation but might risk hypoventilation during chest compression delivery. AIMS: To determine if the use of pressure-controlled mechanical ventilation at pre-arrest settings provides normoxia and normocarbia during resuscitation from cardiac arrest. METHODS: We retrospectively analyzed combined data from preclinical randomized controlled trials. Two-week-old swine (3–4 kg) underwent asphyxia-induced cardiac arrest. Animals were resuscitated with periods of basic and advanced life support. During resuscitation, pressure-controlled mechanical ventilation was delivered at the pre-arrest respiratory rate, peak inspiratory pressure, and positive end-expiratory pressure. Arterial blood gases were measured pre-arrest, at 11 minutes of asphyxia, and at 8 and 20 minutes of cardiopulmonary resuscitation. RESULTS: Piglets (n=154) received pressure-controlled mechanical ventilation before and during cardiopulmonary resuscitation with a peak inspiratory pressure of 14–15 cm H(2)O, positive end-expiratory pressure of 4 cm H(2)O, 20 breaths/minute, and an inspiratory:expiratory ratio of 1:2. During asphyxia, the arterial blood gas showed the expected severe hypercarbia and hypoxia. Continuing pressure-controlled mechanical ventilation using pre-arrest parameters and increasing the FiO(2) to 1.0 returned the PaCO(2) to pre-arrest levels and slightly increased the partial pressure of arterial oxygen at 8 and 20 minutes of cardiopulmonary resuscitation. CONCLUSION: In this piglet model of resuscitation from asphyxial arrest, pressure-controlled mechanical ventilation during cardiopulmonary resuscitation at the pre-arrest ventilator settings with an FiO(2) of 1.0 provides adequate oxygenation and restores normocarbia. Clinical investigation is warranted to determine the benefits of continuing pressure-controlled mechanical ventilation at pre-arrest parameters during pediatric cardiopulmonary resuscitation.

OBJECTIVES We aimed to describe the impact of a cardiopulmonary resuscitation coach on healthcare provider perception of cardiopulmonary resuscitation quality during simulated pediatric cardiac arrest. DESIGN Prospective, observational study. SETTING We conducted secondary analysis of data collected from a multicenter, randomized trial of providers who participated in a simulated pediatric cardiac arrest. SUBJECTS Two-hundred pediatric acute care providers. INTERVENTIONS Participants were randomized to having a cardiopulmonary resuscitation coach versus no cardiopulmonary resuscitation coach. Cardiopulmonary resuscitation coaches provided feedback on cardiopulmonary resuscitation performance and helped to coordinate key tasks. All teams used cardiopulmonary resuscitation feedback technology. MEASUREMENTS AND MAIN RESULTS Cardiopulmonary resuscitation quality was collected by the defibrillator, and perceived cardiopulmonary resuscitation quality was collected by surveying participants after the scenario. We calculated the difference between perceived and measured quality of cardiopulmonary resuscitation and defined accurate perception as no more than 10% deviation from measured quality of cardiopulmonary resuscitation. Teams with a cardiopulmonary resuscitation coach were more likely to accurately estimate chest compressions depth in comparison to teams without a cardiopulmonary resuscitation coach (odds ratio, 2.97; 95% CI, 1.61-5.46; p < 0.001). There was no significant difference detected in accurate perception of chest compressions rate between groups (odds ratio, 1.33; 95% CI, 0.77-2.32; p = 0.32). Among teams with a cardiopulmonary resuscitation coach, the cardiopulmonary resuscitation coach had the best chest compressions depth perception (80%) compared with the rest of the team (team leader 40%, airway 55%, cardiopulmonary resuscitation provider 30%) (p = 0.003). No differences were found in perception of chest compressions rate between roles (p = 0.86). CONCLUSIONS Healthcare providers improved their perception of cardiopulmonary resuscitation depth with a cardiopulmonary resuscitation coach present. The cardiopulmonary resuscitation coach had the best perception of chest compressions depth.

OBJECTIVES: To describe the clinical characteristics and outcomes of a large, multicenter cohort of pediatric medical emergency team (MET) events occurring in US hospitals reported to the American Heart Association’s Get With the Guidelines-Resuscitation registry. METHODS: We analyzed consecutive pediatric ( RESULTS: We identified 3647 MET events from 151 US hospitals: 3080 (84%) ward and 567 (16%) telemetry/step-down unit events; median age 3.0 years (interquartile range: 0.0–11.0); 54% male; median duration 29 minutes (interquartile range: 18–49). Triggers included decreased oxygen saturation (32%), difficulty breathing (26%), and staff concern (24%). Thirty-seven percent (1137/3059) were admitted within 24 hours before MET event. Within 24 hours before the MET event, 16% were transferred from a PICU, 24% from an emergency department, and 7% from a pediatric anesthesia care unit. Fifty-three percent of MET events resulted in transfer to a PICU; 3251 (89%) received nonpharmacologic interventions, 2135 (59%) received pharmacologic interventions, 223 (6.1%) progressed to an acute respiratory compromise event, and 17 events (0.5%) escalated to cardiopulmonary arrest during the event. Survival to hospital discharge was 93.3% (n = 3299/3536). CONCLUSIONS: Few pediatric MET events progress to respiratory or cardiac arrest, but most require nonpharmacologic and pharmacologic intervention. Median duration of MET event was 29 minutes (interquartile range: 18–49), and 53% required transfer to a PICU. Events often occurred within 24 hours after hospital admission or transfer from the PICU, emergency department, or pediatric anesthesia care unit and may represent an opportunity to improve triage and other systems of care.

Over the past two decades survival from pediatric cardiac arrest has improved dramatically, particularly in the in-hospital setting, from 15% to nearly 50%. The reasons for this are multifactorial and include but are likely not limited to the use of ECPR, personalizing the care delivered to the child's age and also the child's underlying cardiac anatomy and physiology, and applying a multitude of approaches to improving the quality of care we deliver. Teams are now systematically addressing the quality of cardiopulmonary resuscitation (CPR) delivered during the event with real-time feedback with bedside devices and quality CPR coaches, postevent debriefing, and meticulously managing the post–cardiac arrest care period. Unfortunately, there is evidence of great variability between hospitals, suggesting there are still lives to be saved. In the upcoming decades we need to continue to explore physiologic targets to optimize coronary and cerebral perfusion while minimizing harm from compressions, use human factors to improve team dynamics and room ergonomics, refine approaches to post–cardiac arrest care, and improve our ability to prognosticate on outcomes. Although avoiding a cardiac arrest is always best, we now know that many lives can be saved with exquisite CPR, and we must continue to focus on optimizing outcomes for these most vulnerable of patients.

Background Over 6000 children have an in‐hospital cardiac arrest in the United States annually. Most will not survive to discharge, with significant variability in survival across hospitals suggesting improvement in resuscitation performance can save lives. Methods and Results A prospective observational study of quality of chest compressions (CC) during pediatric in‐hospital cardiac arrest associated with development and implementation of a resuscitation quality bundle. Objectives were to: 1) implement a debriefing program, 2) identify impediments to delivering high quality CC, 3) develop a resuscitation quality bundle, and 4) measure the impact of the resuscitation quality bundle on compliance with American Heart Association (AHA) Pediatric Advanced Life Support CC guidelines over time. Logistic regression was used to assess the relationship between compliance and year of event, adjusting for age and weight. Over 3 years, 317 consecutive cardiac arrests were debriefed, 38% (119/317) had CC data captured via defibrillator‐based accelerometer pads, data capture increasing over time: (2013:13% [12/92] versus 2014:43% [44/102] versus 2015:51% [63/123], P

Background Over 6000 children have an in‐hospital cardiac arrest in the United States annually. Most will not survive to discharge, with significant variability in survival across hospitals suggesting improvement in resuscitation performance can save lives. Methods and Results A prospective observational study of quality of chest compressions ( CC ) during pediatric in‐hospital cardiac arrest associated with development and implementation of a resuscitation quality bundle. Objectives were to: 1) implement a debriefing program, 2) identify impediments to delivering high quality CC , 3) develop a resuscitation quality bundle, and 4) measure the impact of the resuscitation quality bundle on compliance with American Heart Association ( AHA ) Pediatric Advanced Life Support CC guidelines over time. Logistic regression was used to assess the relationship between compliance and year of event, adjusting for age and weight. Over 3 years, 317 consecutive cardiac arrests were debriefed, 38% (119/317) had CC data captured via defibrillator‐based accelerometer pads, data capture increasing over time: (2013:13% [12/92] versus 2014:43% [44/102] versus 2015:51% [63/123], P P CPR Coaching, Objective‐Data Evaluation, Action‐linked‐phrases, Choreography, Ergonomics, Structured debriefing and Simulation (CODE ACES 2 ). The adjusted marginal probability of a CC epoch meeting the criteria for excellent CPR (compliant for rate, depth, and chest compression fraction) in 2015, after CPR Coaching, Objective‐Data Evaluation, Action‐linked‐phrases, Choreography, Ergonomics, Structured debriefing and Simulation was developed and implemented, was 44.3% (35.3–53.3) versus 19.9%(6.9–32.9) in 2013; (odds ratio 3.2 [95% confidence interval:1.3–8.1], P =0.01). Conclusions CODE ACES 2 was associated with progressively increased compliance with AHA CPR guidelines during in‐hospital cardiac arrest.

OBJECTIVES To describe the U.S. experience with interhospital transport of children in cardiac arrest undergoing cardiopulmonary resuscitation. DESIGN Self-administered electronic survey. SETTING Pediatric transport teams listed with the American Academy of Pediatrics Section on Transport Medicine. SUBJECTS Leaders of U.S. pediatric transport teams. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Sixty of the 88 teams surveyed (68%) responded. Nineteen teams (32%) from 13 states transport children undergoing cardiopulmonary resuscitation between hospitals. The most common reasons for transfer of children in cardiac arrest are higher level-of-care (70%), extracorporeal life support (60%), and advanced trauma resuscitation (35%). Eligibility is typically decided on a case-by-case basis (85%) and sometimes involves a short interhospital distance (35%), or prompt institution of high-quality cardiopulmonary resuscitation (20%). Of the 19 teams that transport with ongoing cardiopulmonary resuscitation, 42% report no special staff safety features, 42% have guidelines or protocols, 37% train staff on resuscitation during transport, 11% brace with another provider, and 5% use mechanical cardiopulmonary resuscitation devices for patients less than 18 years. In the past 5 years, 18 teams report having done such cardiopulmonary resuscitation transports: 22% did greater than five transports, 44% did two to five transports, 6% did one transport, and the remaining 28% did not recall the number of transports. Seventy-eight percent recall having transported by ambulance, 44% by helicopter, and 22% by fixed-wing. Although patient outcomes were varied, eight teams (44%) reported survivors to ICU and/or hospital discharge. CONCLUSIONS A minority of U.S. teams perform interhospital transport of children in cardiac arrest undergoing cardiopulmonary resuscitation. Eligibility criteria, transport logistics, and patient outcomes are heterogeneous. Importantly, there is a paucity of established safety protocols for the staff performing cardiopulmonary resuscitation in transport.

The formula for survival in resuscitation describes educational efficiency and local implementation as key determinants in survival after cardiac arrest. Current educational offerings in the form of standardized online and face-to-face courses are falling short, with providers demonstrating a decay of skills over time. This translates to suboptimal clinical care and poor survival outcomes from cardiac arrest. In many institutions, guidelines taught in courses are not thoughtfully implemented in the clinical environment. A current synthesis of the evidence supporting best educational and knowledge translation strategies in resuscitation is lacking. In this American Heart Association scientific statement, we provide a review of the literature describing key elements of educational efficiency and local implementation, including mastery learning and deliberate practice, spaced practice, contextual learning, feedback and debriefing, assessment, innovative educational strategies, faculty development, and knowledge translation and implementation. For each topic, we provide suggestions for improving provider performance that may ultimately optimize patient outcomes from cardiac arrest.

Introduction Although American Heart Association guidelines exist for proper management of cardiopulmonary arrest (CPA), in-hospital cardiopulmonary resuscitation (CPR) may be of poor quality and is not performed in all indicated situations. Cognitive aids have been created to assist in rapid, accurate recall of guidelines for pediatric CPA management. Methods Pediatric residents participated in individual mock codes for two years. Using a high-fidelity simulator, each resident participated in a standardized scenario that required management of both pulseless ventricular tachycardia and pulseless electrical activity. The primary study objective was to calculate the proportion of residents (a) who were not performing CPR on a simulated "pulseless" patient when cognitive aid use was first initiated and (b) who subsequently initiated CPR after cognitive aid use. Results One hundred thirty-two (83.5%) of 158 pediatric residents participated, and of 125 videos available for review, 107 residents (85.6%) used a cognitive aid. Mean (SD) time to cognitive aid use was 106 (100) seconds after the mannequin became pulseless. Most common immediate actions prompted by cognitive aid use were the following: defibrillation, 43 (40%) of 107; and adrenaline (epinephrine) administration, 28 (26%) of 107. Most alarmingly, 58 (54%) of 107 were not performing CPR on the pulseless patient when cognitive aid use was initiated and only two (3.4%) of 58 were subsequently prompted to initiate chest compressions. Discussion Cognitive aids in use during this study did not prompt timely initiation of CPR, potentially contributing to delays and errors in CPA management. Failure of these aids to prompt CPR initiation represents a "missed opportunity" to enhance performance of this vital skill.

The variability in quality of CPR provided during cardiac arrest across pediatric institutions is unknown. We aimed to describe the degree of variability in the quality of CPR across 9 pediatric institutions, and determine if variability across sites would be affected by Just-in-Time CPR training and/or visual feedback during simulated cardiac arrest.We conducted secondary analyses of data collected from a prospective, multi-center trial. Participants were equally randomized to either: (1) No intervention; (2) Real-time CPR visual feedback during cardiac arrest or (3) Just-in-Time CPR training. We report the variability in median chest compression depth and rate across institutions, and the variability in the proportion of 30-s epochs of CPR meeting 2010 American Heart Association guidelines for depth and rate.We analyzed data from 528 epochs in the no intervention group, 552 epochs in the visual feedback group, and 525 epochs in the JIT training group. In the no intervention group, compression depth (median range 22.2-39.2mm) and rate (median range 116.0-147.6 min(-1)) demonstrated significant variability between study sites (p0.001). The proportion of compressions with adequate depth (0-11.5%) and rate (0-60.5%) also varied significantly across sites (p0.001). The variability in compression depth and rate persisted despite use of real-time visual feedback or JIT training (p0.001).The quality of CPR across multiple pediatric institutions is variable. Variability in CPR quality across institutions persists even with the implementation of a Just-in-Time training session and visual feedback for CPR quality during simulated cardiac arrest.

This article illustrates the use of simulation as a collaborative problem-solving and design tool using resuscitation as an exemplar. To address the issue of poor-quality in-hospital resuscitation efforts, a research study was designed to assess methods of improving nurses' retention of cardiopulmonary resuscitation priorities. Central to this project was developing choreography to help nurses' work synergistically to achieve the American Heart Association goals for resuscitation. The study team used simulation to develop and refine the ideal steps for the first few minutes of a cardiac arrest. The resultant video of this choreography was used as a core component of the training in the research study.

Reprint: The American Heart Association requests that this document be cited as follows: Atkins DL, Berger S, Duff JP, Gonzales JC, Hunt EA, Joyner BL, Meaney PA, Niles DE, Samson RA, Schexnayder SM. Part 11: pediatric basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation . 2015;132(suppl 2):S519–S525. Reprinted with permission of the American Heart Association, Inc. This article has been published in Circulation . This 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) section on pediatric basic life support (BLS) differs substantially from previous versions of the AHA Guidelines.1 This publication updates the 2010 AHA Guidelines on pediatric BLS for several key questions related to pediatric CPR. The Pediatric ILCOR Task Force reviewed the topics covered in the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations and the 2010 council-specific guidelines for CPR and ECC (including those published by the AHA) and formulated 3 priority questions to address for the 2015 systematic reviews. In the online version of this document, live links are provided so the reader can connect directly to those systematic reviews on the International Liaison Committee on Resuscitation (ILCOR) Scientific Evidence Evaluation and Review System (SEERS) website. These links are indicated by a superscript combination of letters and numbers (eg, Peds 709). We encourage readers to use the links and review the evidence and appendices. A rigorous systematic review process was undertaken to review the relevant literature to answer those questions, resulting in the 2015 International Consensus on CPR and ECC Science With Treatment Recommendations, “Part 6: Pediatric Basic Life Support and Pediatric Advanced Life Support.”2,3 This 2015 Guidelines Update covers only those topics reviewed as …

Many healthcare providers rely on visual perception to guide cardiopulmonary resuscitation (CPR), but little is known about the accuracy of provider perceptions of CPR quality. We aimed to describe the difference between perceived versus measured CPR quality, and to determine the impact of provider role, real-time visual CPR feedback and Just-in-Time (JIT) CPR training on provider perceptions.We conducted secondary analyses of data collected from a prospective, multicenter, randomized trial of 324 healthcare providers who participated in a simulated cardiac arrest scenario between July 2012 and April 2014. Participants were randomized to one of four permutations of: JIT CPR training and real-time visual CPR feedback. We calculated the difference between perceived and measured quality of CPR and reported the proportion of subjects accurately estimating the quality of CPR within each study arm.Participants overestimated achieving adequate chest compression depth (mean difference range: 16.1-60.6%) and rate (range: 0.2-51%), and underestimated chest compression fraction (0.2-2.9%) across all arms. Compared to no intervention, the use of real-time feedback and JIT CPR training (alone or in combination) improved perception of depth (p0.001). Accurate estimation of CPR quality was poor for chest compression depth (0-13%), rate (5-46%) and chest compression fraction (60-63%). Perception of depth is more accurate in CPR providers versus team leaders (27.8% vs. 7.4%; p=0.043) when using real-time feedback.Healthcare providers' visual perception of CPR quality is poor. Perceptions of CPR depth are improved by using real-time visual feedback and with prior JIT CPR training.

Traditional American Heart Association (AHA) cardiopulmonary resuscitation (CPR) curriculum focuses on teams of two performing quality chest compressions with rescuers on their knees but does not include training specific to In-Hospital Cardiac Arrests (IHCA), i.e. patient in hospital bed with large resuscitation teams and sophisticated technology available.A randomized controlled trial was conducted with the primary goal of evaluating the effectiveness and ideal frequency of in-situ training on time elapsed from call for help to; (1) initiation of chest compressions and (2) successful defibrillation in IHCA.Non-intensive care unit nurses were randomized into four groups: standard AHA training (C) and three groups that participated in 15 min in-situ IHCA training sessions every two (2M), three (3M) or six months (6M). Curriculum included specific choreography for teams to achieve immediate chest compressions, high chest compression fractions and rapid defibrillation while incorporating use of a backboard, stepstool.More frequent training was associated with decreased median (IQR) seconds to: starting compressions: [C: 33(25-40) vs. 6M: 21(15-26) vs. 3M: 14(10-20) vs. 2M: 13(9-20); p0.001]; and defibrillation: [C: 157(140-254) vs. 6M: 138(107-158) vs. 3M: 115(101-119) vs. 2M: 109(98-129); p0.001]. A composite outcome of key priorities, compressions within 20s, defibrillation within 180 s and use of a backboard, revealed improvement with more frequent training sessions: [C:5%(1/18) vs. 6M: 23%(4/17) vs. 3M: 56%(9/16) vs. 2M: 73%(11/15); p0.001].Results revealed short in-situ training sessions conducted every 3 months are effective in improving timely initiation of chest compressions and defibrillation in IHCA.

Background Observations of cardiopulmonary arrests (CPAs) reveal concerning patterns when clinicians identify a problem, (e.g. loss of pulse) but do not immediately initiate appropriate therapy (e.g. compressions) resulting in delays in life saving therapy. Methods We hypothesized that when individuals utilized specific, short, easy-to-state action phrases stating an observation followed by an associated intervention, there would be a higher likelihood that appropriate action would immediately occur. Phase I: A retrospective analysis of residents in simulated CPAs measured what proportion verbalized “There's no pulse”, statements and/or actions that followed and whether “Action-Linked Phrases” were associated with faster initiation of compressions. Phase II: Two prospective, quasi-experimental studies evaluated if teaching three Action-Linked Phrases for Basic Life Support (BLS) courses or six Action-Linked Phrases for Advanced Cardiovascular Life Support (ACLS) courses was associated with increased use of these phrases. Results Phase I: 62% (42/68) of residents verbalized “there's no pulse” during initial assessment of a pulseless patient, and only 16/42 (38%) followed that by stating “start compressions”. Residents verbalizing this Action-Linked Phrase started compressions sooner than others: (30 s [IQR:19–42] vs. 150 [IQR:51-242], p

This focused update to the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care follows the Pediatric Task Force of the International Liaison Committee on Resuscitation evidence review. It aligns with the International Liaison Committee on Resuscitation’s continuous evidence review process, and updates are published when the International Liaison Committee on Resuscitation completes a literature review based on new science. This update provides the evidence review and treatment recommendation for chest compression–only CPR versus CPR using chest compressions with rescue breaths for children

OBJECTIVES To determine whether end-tidal CO2-guided chest compression delivery improves survival over standard cardiopulmonary resuscitation after prolonged asphyxial arrest. DESIGN Preclinical randomized controlled study. SETTING University animal research laboratory. SUBJECTS 1-2-week-old swine. INTERVENTIONS After undergoing a 20-minute asphyxial arrest, animals received either standard or end-tidal CO2-guided cardiopulmonary resuscitation. In the standard group, chest compression delivery was optimized by video and verbal feedback to maintain the rate, depth, and release within published guidelines. In the end-tidal CO2-guided group, chest compression rate and depth were adjusted to obtain a maximal end-tidal CO2 level without other feedback. Cardiopulmonary resuscitation included 10 minutes of basic life support followed by advanced life support for 10 minutes or until return of spontaneous circulation. MEASUREMENTS AND MAIN RESULTS Mean end-tidal CO2 at 10 minutes of cardiopulmonary resuscitation was 34 ± 8 torr in the end-tidal CO2 group (n = 14) and 19 ± 9 torr in the standard group (n = 14; p = 0.0001). The return of spontaneous circulation rate was 7 of 14 (50%) in the end-tidal CO2 group and 2 of 14 (14%) in the standard group (p = 0.04). The chest compression rate averaged 143 ± 10/min in the end-tidal CO2 group and 102 ± 2/min in the standard group (p < 0.0001). Neither asphyxia-related hypercarbia nor epinephrine administration confounded the use of end-tidal CO2-guided chest compression delivery. The response of the relaxation arterial pressure and cerebral perfusion pressure to the initial epinephrine administration was greater in the end-tidal CO2 group than in the standard group (p = 0.01 and p = 0.03, respectively). The prevalence of resuscitation-related injuries was similar between groups. CONCLUSIONS End-tidal CO2-guided chest compression delivery is an effective resuscitation method that improves early survival after prolonged asphyxial arrest in this neonatal piglet model. Optimizing end-tidal CO2 levels during cardiopulmonary resuscitation required that chest compression delivery rate exceed current guidelines. The use of physiologic feedback during cardiopulmonary resuscitation has the potential to provide optimized and individualized resuscitative efforts.

To discuss risks and benefits of interhospital transport of children in cardiac arrest undergoing cardiopulmonary resuscitation.Narrative review.Not applicable.Transporting children in cardiac arrest with ongoing cardiopulmonary resuscitation between hospitals is potentially lifesaving if it enables access to resources such as extracorporeal support, but may risk transport personnel safety. Research is needed to optimize outcomes of patients transported with ongoing cardiopulmonary resuscitation and reduce risks to the staff caring for them.

ObjectivesWe aimed to explore whether a) step stool use is associated with improved cardiopulmonary resuscitation (CPR) quality; b) provider adjusted height is associated with improved CPR quality; and if associations exist, c) determine whether just-in-time (JIT) CPR training and/or CPR visual feedback attenuates the effect of height and/or step stool use on CPR quality.MethodsWe analysed data from a trial of simulated cardiac arrests with three study arms: No intervention; CPR visual feedback; and JIT CPR training. Step stool use was voluntary. We explored the association between 1) step stool use and CPR quality, and 2) provider adjusted height and CPR quality. Adjusted height was defined as provider height + 23 cm (if step stool was used). Below-average height participants were ≤ gender-specific average height; the remainder were above average height. We assessed for interaction between study arm and both adjusted height and step stool use.ResultsOne hundred twenty-four subjects participated; 1,230 30-second epochs of CPR were analysed. Step stool use was associated with improved compression depth in below-average (female, p=0.007; male, pp=0.001; male, ppp=0.025) on compression depth; JIT training did not (p=0.918). Visual feedback and JIT training attenuated the effect of step stool use (pConclusionsStep stool use is associated with improved compression depth regardless of height. Increased provider height is associated with improved compression depth, with visual feedback attenuating the effects of height and step stool use.

Previous studies reveal pediatric resident resuscitation skills are inadequate, with little improvement during residency. The Accreditation Council for Graduate Medical Education highlights the need for documenting incremental acquisition of skills, i.e., "Milestones". We developed a simulation-based teaching approach "Rapid Cycle Deliberate Practice" (RCDP) focused on rapid acquisition of procedural and teamwork skills (i.e., "first-five minutes" (FFM) resuscitation skills). This novel method utilizes direct feedback and prioritizes opportunities for learners to "try again" over lengthy debriefing.Pediatric residents from an academic medical center.Prospective pre-post interventional study of residents managing a simulated cardiopulmonary arrest. Main outcome measures include: (1) interval between onset of pulseless ventricular tachycardia to initiation of compressions and (2) defibrillation.Seventy pediatric residents participated in the pre-intervention and fifty-one in the post-intervention period. Baseline characteristics were similar. The RCDP-FFM intervention was associated with a decrease in: no-flow fraction: [pre: 74% (5-100%) vs. post: 34% (26-53%); p0.001)], no-blow fraction: [pre: 39% (22-64%) median (IQR) vs. post: 30% (22-41%); p=0.01], and pre-shock pause: [pre: 84 s (26-162) vs. post: 8s (4-18); p0.001]. Survival analysis revealed RCDP-FFM was associated with starting compressions within 1 min of loss of pulse: [Adjusted Hazard Ratio (HR): 3.8 (95% CI: 2.0-7.2)] and defibrillating within 2 min: [HR: 1.7 (95% CI: 1.03-2.65)]. Third year residents were significantly more likely than first years to defibrillate within 2 min: [HR: 2.8 (95% CI: 1.5-5.1)].Implementation of the RCDP-FFM was associated with improvement in performance of key measures of quality life support and progressive acquisition of resuscitation skills during pediatric residency.

BACKGROUND In-hospital cardiac arrest (IHCA) outcomes vary widely between hospitals, even after adjusting for patient characteristics, suggesting variations in practice as a potential etiology. However, little is known about the standards of IHCA resuscitation practice among US hospitals. OBJECTIVE To describe current US hospital practices with regard to resuscitation care. DESIGN A nationally representative mail survey. SETTING A random sample of 1000 hospitals from the American Hospital Association database, stratified into 9 categories by hospital volume tertile and teaching status (major teaching, minor teaching, and nonteaching). SUBJECTS Surveys were addressed to each hospital's cardiopulmonary resuscitation (CPR) committee chair or chief medical/quality officer. MEASUREMENTS A 27-item questionnaire. RESULTS Responses were received from 439 hospitals with a similar distribution of admission volume and teaching status as the sample population (P = 0.50). Of the 270 (66%) hospitals with a CPR committee, 23 (10%) were chaired by a hospitalist. High frequency practices included having a rapid response team (91%) and standardizing defibrillators (88%). Low frequency practices included therapeutic hypothermia and use of CPR assist technology. Other practices such as debriefing (34%) and simulation training (62%) were more variable and correlated with the presence of a CPR committee and/or dedicated personnel for resuscitation quality improvement. The majority of hospitals (79%) reported at least 1 barrier to quality improvement, of which the lack of a resuscitation champion and inadequate training were the most common. CONCLUSIONS There is wide variability among hospitals and within practices for resuscitation care in the United States with opportunities for improvement. Journal of Hospital Medicine 2014;9:353–357. © 2014 Society of Hospital Medicine

A recent report by the National Registry of Cardiopulmonary Resuscitation (NRCPR) of 207 hospitals within the U.S. revealed that the majority (86%) has an organized team to respond to in-hospital cardiac arrests.1 Despite the existence of these teams, there is mounting evidence that errors in the management of care for patients with in-hospital cardiac arrests and other medical crises may contribute to poor outcomes.2 – 8 Currently, no standards exist in terms of how such “code teams” are dispatched, how many members are on the team, or the team’s composition. There are even fewer reports regarding the make-up of Medical Emergency Teams (METs). Training to enhance the quality of care delivered by crisis teams in hospitals is essential. Although the composition of these two types of hospital teams varies from place to place, the principles of team training remain the same, and are reviewed in this chapter.

The objective was to compare resuscitation performance on simulated in-hospital cardiac arrests after traditional American Heart Association (AHA) Healthcare Provider Basic Life Support course (TradBLS) versus revised course including in-hospital skills (HospBLS).This study is a prospective, randomized, controlled curriculum evaluation.Johns Hopkins Medicine Simulation Center.One hundred twenty-two first year medical students were divided into fifty-nine teams.HospBLS course of identical length, containing additional content contextual to hospital environments, taught utilizing Rapid Cycle Deliberate Practice (RCDP).The primary outcome measure during simulated cardiac arrest scenarios was chest compression fraction (CCF) and secondary outcome measures included metrics of high quality resuscitation.Out-of-hospital cardiac arrest HospBLS teams had larger CCF: [69% (65-74) vs. 58% (53-62), p0.001] and were faster than TradBLS at initiating compressions: [median (IQR): 9s (7-12) vs. 22s (17.5-30.5), p0.001]. In-hospital cardiac arrest HospBLS teams had larger CCF: [73% (68-75) vs. 50% (43-54), p0.001] and were faster to initiate compressions: [10s (6-11) vs. 36s (27-63), p0.001]. All teams utilized the hospital AED to defibrillate within 180s per AHA guidelines [HospBLS: 122s (103-149) vs. TradBLS: 139s (117-172), p=0.09]. HospBLS teams performed more hospital-specific maneuvers to optimize compressions, i.e. utilized: CPR button to flatten bed: [7/30 (23%) vs. 0/29 (0%), p=0.006], backboard: [21/30 (70%) vs. 5/29 (17%), p0.001], stepstool: [28/30 (93%) vs. 8/29 (28%), p0.001], lowered bedrails: [28/30 (93%) vs. 10/29 (34%), p0.001], connected oxygen appropriately: [26/30 (87%) vs. 1/29 (3%), p0.001] and used oral airway and/or two-person bagging when traditional bag-mask-ventilation unsuccessful: [30/30 (100%) vs. 0/29 (0%), p0.001].A hospital focused BLS course utilizing RCDP was associated with improved performance on hospital-specific quality measures compared with the traditional AHA course.

Background In‐hospital cardiac arrest ( IHCA ) is a major public health problem with significant mortality. A better understanding of where IHCA occurs in hospitals (intensive care unit [ ICU ] versus monitored ward [telemetry] versus unmonitored ward) could inform strategies for reducing preventable deaths. Methods and Results This is a retrospective study of adult IHCA events in the Get with the Guidelines—Resuscitation database from January 2003 to September 2010. Unadjusted analyses were used to characterize patient, arrest, and hospital‐level characteristics by hospital location of arrest ( ICU versus inpatient ward). IHCA event rates and outcomes were plotted over time by arrest location. Among 85 201 IHCA events at 445 hospitals, 59% (50 514) occurred in the ICU compared to 41% (34 687) on the inpatient wards. Compared to ward patients, ICU patients were younger (64±16 years versus 69±14; P P ICU , mean event rate/1000 bed‐days was 0.337 (±0.215) compared with 0.109 (±0.079) for telemetry wards and 0.134 (±0.098) for unmonitored wards. Of patients with an arrest in the ICU , the adjusted mean survival to discharge was 0.140 (0.037) compared with the unmonitored wards 0.106 (0.037) and telemetry wards 0.193 (0.074). More IHCA events occurred in the ICU compared to the inpatient wards and there was a slight increase in events/1000 patient bed‐days in both locations. Conclusions Survival rates vary based on location of IHCA . Optimizing patient assignment to unmonitored wards versus telemetry wards may contribute to improved survival after IHCA .

Children transferred from community hospitals lacking specialized pediatric care are more seriously ill than those presenting to pediatric centers. Pediatric consultation and adherence to management guidelines improve outcomes. The aims of the study were (1) to assess whether telemedicine consultation in critical situations is feasible and (2) to compare the impact of pediatric critical care medicine (PCCM) consultation via telemedicine versus telephone on community hospital adherence to resuscitation guidelines through a randomized controlled telemedicine trial. In situ, high-fidelity simulation scenarios of critically ill children presenting to a community hospital and progressing to cardiopulmonary arrest were performed. Scenarios were randomized to PCCM consultation via telephone (control) or telemedicine (intervention). Primary outcome measure was proportion of teams who successfully defibrillated in 180 seconds or less from presentation of pulseless ventricular tachycardia. The following 30 scenarios were completed: 15 control and 15 intervention. Only 11 (37%) of 30 teams, defibrillated in 180 seconds or less from presentation of pulseless ventricular tachycardia; control: 6 (40%) of 15 versus intervention: 5 (33%) of 15, P = 0.7. Request for or use of backboard during cardiopulmonary resuscitation occurred in 24 (80%) of 30 scenarios; control: 9 (60%) of 15 versus intervention: 15 (100%) of 15, P = 0.006. Request for or use of stepstool during cardiopulmonary resuscitation occurred in 6 (20%) of 30 scenarios; control: 1 (7%) of 15 versus intervention: 5 (33%) of 15, P = 0.07. This study demonstrates the feasibility of using telemedicine to support acute management of children who present to community hospitals. Neither study arm adhered to current resuscitation guidelines and telemedicine consultation with PCCM experts was not associated with improvement. However, further research on optimizing telemedicine impact on the quality of pediatric care at community hospitals is warranted.

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 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.

Over the past decade, medical simulation has evolved into an essential component of pediatric resuscitation education and team training. Evidence to support its value as an adjunct to traditional methods of education is expanding; however, large multicenter studies are very rare. Simulation-based researchers currently face many challenges related to small sample sizes, poor generalizability, and paucity of clinically proven and relevant outcome measures. The Examining Pediatric Resuscitation Education Using Simulation and Scripting (EXPRESS) pediatric simulation research collaborative was formed in an attempt to directly address and overcome these challenges. The primary mission of the EXPRESS collaborative is to improve the delivery of medical care to critically ill children by answering important research questions pertaining to pediatric resuscitation and education and is focused on using simulation either as a key intervention of interest or as the outcome measurement tool. Going forward, the collaborative aims to expand its membership internationally and collectively identify pediatric resuscitation and simulation-based research priorities and use these to guide future projects. Ultimately, we hope that with innovative and high-quality research, the EXPRESS pediatric simulation research collaborative will help to build momentum for simulation-based research on an international level.

Article-at-a-Glance Background Data suggest that the overall quality of inhospital resuscitation is suboptimal and contributes to poor patient outcomes. In 2000 the American Heart Association created the National Registry of Cardiopulmonary Resuscitation (NRCPR) as an evidence-based hospital safety program. Participating hospitals voluntarily join the registry and pay an annual fee that includes data support and report generation. The primary purpose of NRCPR is to support local facility efforts in practice management and performance improvement (PI). Chain of Survival The Chain of Survival illustrates the series of critical, interdependent actions necessary to maximize patient outcome from sudden cardiac arrest—early access to the emergency response system, early cardiopulmonary resuscitation (CPR), early defibrillation, and early advanced cardiovascular care. NRCPR specifically addresses each link and helps hospitals develop, implement, and monitor their resuscitation processes in a manner that builds on available evidence. Participation in NRCPR On enrollment into NRCPR, each hospital identifies an onsite coordinator who is instructed on a standardized method for abstracting data from patient charts and how to enter data into the NRCPR database. The NRCPR database is managed centrally and provides participating organizations with ongoing, quarterly, and annual reports related to their resuscitation events. Discussion NRCPR is used as both a local PI tool as well as a source of data that scientists are analyzing to further the understanding of inhospital resuscitation processes and outcomes. Over time, researchers have recognized the need to refine the Chain of Survival to reflect the unique aspects of inhospital resuscitation. A rapid response system provides a new link at the beginning, and postresuscitation care provides a new link at the end of the Chain of Survival.

Recent data from in- and out-of-hospital cardiopulmonary arrests reveal that health care teams frequently deviate from American Heart Association guidelines during resuscitation efforts. These discrepancies between the current state of evidence-based resuscitation guidelines and the quality of basic and advanced life support actually delivered represent a missed opportunity and provide a significant target for optimizing patient outcomes through improved educational effectiveness. This article presents discussion of the quality of resuscitation delivered to patients, a brief history of the development of cardiopulmonary resuscitation and attempts to translate the science of resuscitation to the bedside through effective educational strategies, a review of educational best practices that relate to resuscitation education, and discussion of the role of medical simulation in resuscitation training.

Background: Management of pediatric cardiopulmonary arrest (CPA) is challenging because of the low volume of experience of most pediatric health care providers. Use of cognitive aids may assist in making rapid decisions in these crises; however, there are no known published reports on whether these aids are actually used during arrest management and whether they impact quality of care. Methods: Sixty pediatric residents participated in individual simulated CPA scenarios, which involved pulseless ventricular tachycardia and pulseless electrical activity. Our primary outcome measure was the proportion of pediatric residents who used cognitive aids during simulated CPAs. Secondary outcome measures were to quantify 1) type of aids used, 2) category of use, and 3) human errors made during resuscitation efforts. Results: Eighty-five percent of residents voluntarily used a cognitive aid to assist in managing simulated pediatric CPAs. The most commonly used aids were an American Heart Association Pediatric Advanced Life Support aid and an institutionally created aid. Forty-three of 51 (84.3%) and 23 of 46 (60.5%) residents used these aids for assistance with the pulseless ventricular tachycardia and pulseless electrical activity algorithm, respectively. Unfortunately, 13 of 51 (25.5%) residents chose the incorrect treatment algorithm, resulting in inappropriate management. Conclusion and Application: Although the majority of residents chose to use cognitive aids for assistance, errors in management were common. Further study is required to determine whether these errors are associated with cognitive aid design flaws and whether improving their design through human factors research can help minimize errors in Basic and Advanced Life Support, ultimately improving patient outcomes.

Summary This is a report of an 11-year-old boy who had sudden cardiac death after a lightning strike while playing lacrosse at summer camp. The camp staff had performed weekly drills to prepare for various medical emergencies and quickly activated their "Emergency Activation System". The child received immediate cardiopulmonary resuscitation (CPR) and was defibrillated with an automated defibrillator (AED) within 3min of becoming pulseless and was ultimately resuscitated after being defibrillated three times. A community ambulance with a defibrillator on board did not arrive until several minutes after the on-site team had achieved return of spontaneous circulation. In this report, we describe the clinical course of this patient; briefly review lightning injuries, other causes of sudden cardiac death in children and use of AEDs. Finally, we review how simulation has been used in this case and others as a mechanism to ensure preparedness for medical emergencies. This child is alive and well today because of these well-trained camp counselors. Their system of using simulation to maintain emergency readiness serves as an example for lay and professional medical providers alike.

This 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) section on pediatric basic life support (BLS) differs substantially from previous versions of the AHA Guidelines.1 This publication updates the 2010 AHA Guidelines on pediatric BLS for several key questions related to pediatric CPR. The Pediatric ILCOR Task Force reviewed the topics covered in the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations and the 2010 council-specific guidelines for CPR and ECC (including those published by the AHA) and formulated 3 priority questions to address for the 2015 systematic reviews. In the online version of this document, live links are provided so the reader can connect directly to those systematic reviews on the International Liaison Committee on Resuscitation (ILCOR) Scientific Evidence Evaluation and Review System (SEERS) website. These links are indicated by a superscript combination of letters and numbers (eg, Peds 709). We encourage readers to use the links and review the evidence and appendices. A rigorous systematic review process was undertaken to review the relevant literature to answer those questions, resulting in the 2015 International Consensus on CPR and ECC Science With Treatment Recommendations , “Part 6: Pediatric Basic Life Support and Pediatric Advanced Life Support.”2,3 This 2015 Guidelines Update covers only those topics reviewed as part of the 2015 systematic review process. Other recommendations published in the 2010 AHA Guidelines remain the official recommendations of the AHA ECC scientists (see Appendix). When making AHA treatment recommendations, we used the AHA Class of Recommendation and Level of Evidence (LOE) systems. This update uses the newest AHA Class of Recommendation and LOE classification system, which contains modifications of the Class III recommendation and introduces LOE B-R (randomized studies) and B-NR (nonrandomized studies) as …

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 …