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To assess whether access to a voice activated decision support system (VADSS) containing video clips demonstrating resuscitation manoeuvres was associated with increased compliance with American Heart Association Basic Life Support (AHA BLS) guidelines.This was a prospective, randomised controlled trial. Subjects with no recent clinical experience were randomised to the VADSS or control group and participated in a 5-min simulated out-of-hospital cardiopulmonary arrest with another 'bystander'. Data on performance for predefined outcome measures based on the AHA BLS guidelines were abstracted from videos and the simulator log.31 subjects were enrolled (VADSS 16 vs control 15), with no significant differences in baseline characteristics. Study subjects in the VADSS were more likely to direct the bystander to: (1) perform compressions to ventilations at the correct ratio of 30:2 (VADSS 15/16 (94%) vs control 4/15 (27%), p=0.001) and (2) insist the bystander switch compressor versus ventilator roles after 2 min (VADSS 12/16 (75%) vs control 2/15 (13%), p=0.001). The VADSS group took longer to initiate chest compressions than the control group: VADSS 159.5 (±53) s versus control 78.2 (±20) s, p0.001. Mean no-flow fractions were very high in both groups: VADSS 72.2% (±0.1) versus control 75.4 (±8.0), p=0.35.The use of an audio and video assisted decision support system during a simulated out-of-hospital cardiopulmonary arrest prompted lay rescuers to follow cardiopulmonary resuscitation (CPR) guidelines but was also associated with an unacceptable delay to starting chest compressions. Future studies should explore: (1) if video is synergistic to audio prompts, (2) how mobile technologies may be leveraged to spread CPR decision support and (3) usability testing to avoid unintended consequences.

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.To describe current US hospital practices with regard to resuscitation care.A nationally representative mail survey.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).Surveys were addressed to each hospital's cardiopulmonary resuscitation (CPR) committee chair or chief medical/quality officer.A 27-item questionnaire.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.There is wide variability among hospitals and within practices for resuscitation care in the United States with opportunities for improvement.

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.

Importance Nearly 6000 hospitalized children in the United States receive cardiopulmonary resuscitation (CPR) annually. Little is known about whether the survival of these children is influenced by the time of the event (eg, nighttime or weekends). Differences in survival could have important implications for hospital staffing, training, and resource allocation. Objective To determine whether outcomes after pediatric in-hospital cardiac arrests differ during nights and weekends compared with days/evenings and weekdays. Design, Setting, and Participants This study included a total of 354 hospitals participating in the American Heart Association’s Get With the Guidelines–Resuscitation registry from January 1, 2000, to December 12, 2012. Index cases (12 404 children) from all children younger than 18 years of age receiving CPR for at least 2 minutes were included. Data analysis was performed in December 2014 and June 2016. We aggregated hourly blocks of time, using previously defined time intervals of day/evening and night, as well as weekend. Multivariable logistic regression models were used to examine the effect of independent variables on survival to hospital discharge. We used a combination of a priori variables based on previous literature (including age, first documented rhythm, location of event in hospital, extracorporeal CPR, and hypotension as the cause of arrest), as well as variables that were identified in bivariate generalized estimating equation models, and maintained significance of P ≤ .15 in the final multivariable models. Main Outcomes and Measures The primary outcome measure was survival to hospital discharge, and secondary outcomes included return of circulation lasting more than 20 minutes and 24-hour survival. Results Of 12 404 children (56.0% were male), 8731 (70.4%) experienced a return of circulation lasting more than 20 minutes, 7248 (58.4%) survived for 24 hours, and 4488 (36.2%) survived to hospital discharge. After adjusting for potential confounders, we found that the rate of survival to hospital discharge was lower during nights than during days/evenings (adjusted odds ratio, 0.88 [95% CI, 0.80-0.97]; P = .007) but was not different between weekends and weekdays (adjusted odds ratio, 0.92 [95% CI, 0.84-1.01]; P = .09). Conclusions and Relevance The rate of survival to hospital discharge was lower for pediatric CPR events occurring at night than for CPR events occurring during daytime and evening hours, even after adjusting for many potentially confounding patient-, event-, and hospital-related factors.

Introduction: Education in the health sciences increasingly relies on simulation-based training strategies to provide safe, structured, engaging, and effective practice opportunities. While this frequently occurs within a simulation center, in situ simulations occur within an actual clinical environment. This blending of learning and work environments may provide a powerful method for continuing education. However, as this is a relatively new strategy, best practices for the design and delivery of in situ learning experiences have yet to be established. This article provides a systematic review of the in situ simulation literature and compares the state of the science and practice against principles of effective education and training design, delivery, and evaluation. Methods: A total of 3190 articles were identified using academic databases and screened for descriptive accounts or studies of in situ simulation programs. Of these, 29 full articles were retrieved and coded using a standard data extraction protocol (kappa = 0.90). Results: In situ simulations have been applied to foster individual, team, unit, and organizational learning across several clinical and nonclinical areas. Approaches to design, delivery, and evaluation of the simulations were highly variable across studies. The overall quality of in situ simulation studies is low. A positive impact of in situ simulation on learning and organizational performance has been demonstrated in a small number of studies. Discussion: The evidence surrounding in situ simulation efficacy is still emerging, but the existing research is promising. Practical program planning strategies are evolving to meet the complexity of a novel learning activity that engages providers in their actual work environment.

OBJECTIVES To determine the type and frequency of and indications for medications used during pediatric medical emergency team (PMET) events and to describe a PMET pharmacist training model, creation of a standardized “pharmacist PMET supply,” and the pharmacist's role in implementation and ongoing improvement of a PMET. METHODS This is a retrospective observational cohort study of 210 PMET events in 172 patients in a tertiary care, academic pediatric hospital, from September 15, 2005, to September 15, 2007. We focused on the types and sources of medications used during PMET events. RESULTS The medications most commonly used were lorazepam (11%), neuromuscular blockers (10.5%), atropine (9.5%), epinephrine bolus (9%), and albuterol or levalbuterol (9%). However, 49 distinct medications were used in 53.8% of all PMET events. Of all medications requested during a PMET event, only 40% originated from an institutionally standardized emergency medication box, while an additional 35% were readily available at the patient's bedside as part of the “pharmacist PMET supply.” CONCLUSIONS A wide variety of medications are required to care for children who suffer acute in-hospital deterioration. The pharmacist's medication supply and expertise ensured immediate availability of therapies for clinical entities ranging from seizures and anaphylaxis to rapid sequence intubation, regardless of the PMET event location.

In earlier empirical research and policies, fathering was often reduced to 2 aspects of father involvement, focused financial support and residence in the child's home, with these most often measured as simply absent or present. More recent theory and study suggest fathering should be considered multidimensionally, with the 2 broad constructs of involvement and parenting skills as major components. In this chapter we review the research on fathering, with a particular focus on minority men living in urban neighborhoods. We discuss data collected from a sample of approximately 300 young adult men who had taken part in the Chicago Youth Development Study (CYDS) beginning when these young men were between the ages of 11 and 13. Initial and descriptive results of this study are presented, along with findings from the larger body of research in this area.

Our previous studies in Parkinson's disease have shown that both levodopa and expectancy of receiving levodopa reduce cortical excitability. We designed this study to evaluate how degree of expectancy and other individual factors modulate placebo response in Parkinson's patients. Twenty-six Parkinson's patients were randomized to 1 of 3 groups: 0%, 50%, and 100% expectancy of receiving levodopa. All subjects received placebo regardless of expectancy group. Subjects completed the NEO-Five Factor Inventory, General Perceived Self-Efficacy Scale, and Perceived Stress Scale. Cortical excitability was measured by the amplitude of motor-evoked potential (MEP) evoked by transcranial magnetic stimulation. Objective physical fatigue of extensor carpi radialis before and after placebo levodopa was also measured. Responders were defined as subjects who responded to the placebo levodopa with a decrease in MEP. Degree of expectancy had a significant effect on MEP response (P .05). Subjects in the 50% and 100% expectancy groups responded with a decrease in MEP, whereas those in the 0% expectancy group responded with an increase in MEP (P .05). Responders tended to be more open to experience than nonresponders. There were no significant changes in objective physical fatigue between the expectancy groups or between responders and nonresponders. Expectancy is associated with changes in cortical excitability. Further studies are needed to examine the relationship between personality and placebo effect in Parkinson's patients. © 2013 Movement Disorder Society.

This study was done to assess whether a modified "ABC-SBAR" mnemonic (airway, breathing, circulation followed by situation, background, assessment, and recommendation) improves hand-offs by pediatric interns in a simulated critical patient scenario.Each of 26 interns reviewed a scenario involving a decompensating pediatric patient and gave a simulated hand-off to a responder. They received a didactic session on ABC-SBAR, then performed a second hand-off using another scenario. Two blinded reviewers assessed 52 video-recorded hand-offs for inclusion, order, and elapsed time to essential hand-off information using a scoring tool.Mean score of hand-offs increased after ABC-SBAR training (preintervention: 3.1/10 vs postintervention: 7.8/10, P0.001). In hand-offs after ABC-SBAR training, the reason for the emergency call was more often prioritized before background information (preintervention: 4% vs postintervention: 81%, P0.001) and stated earlier (elapsed time preintervention: 19 seconds vs postintervention: 7 seconds, P0.001). Hand-offs including an airway or breathing assessment increased after training (preintervention: 35% vs postintervention: 85%, P = 0.001), and this information was also stated earlier (preintervention: 25 seconds vs postintervention: 5 seconds, P0.001). Total hand-off duration was increased (preintervention: 29 seconds vs postintervention: 36 seconds, P = 0.004).Unstructured hand-off by interns in a simulated patient emergency emphasizes background information, leaving essential information (such as reason for the call and ABCs) delayed or omitted. ABC-SBAR was associated with improved inclusion and timeliness of essential information in simulated critical patient hand-offs by pediatric interns; however, hand-off duration was increased. Further studies are needed to elucidate optimal hand-off in an emergency situation.

It has been a decade since the Institute of Medicine raised the call to action for patient safety in their landmark report, To Err Is Human, which brought to the public’s attention the significant problems with patient safety in our healthcare system. This call to action has been heeded by many healthcare leaders, who are actively and vigorously addressing patient safety issues. The healthcare community has worked to educate themselves on methods to improve safety, and strived to execute interventions toward the goal of improving patient safety. We still have much to do and the science of safety needs to mature rapidly to meet the needs of patients. We especially need to develop effective methods for evaluating the impact of our interventions so that we know what works and where to best invest our resources and answer the question, “Are patients safer?”

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.

Compared with adults, cardiac emergencies are infrequent in children and clinical presentation is often quite variable. In adults, cardiac emergencies are most commonly related to complications of coronary artery disease; however, in pediatric cases, the coronaries are only rarely the underlying problem. Pediatric cardiac emergencies comprise a range of pathology including but not limited to undiagnosed congenital heart disease in the infant; complications of palliated congenital heart disease in children; arrhythmias related to underlying cardiac pathology in the teenager and acquired heart disease. The emergency room physician and pediatric intensivist will usually be the first and second lines of care for pediatric cardiac emergencies and thus it is imperative that they have knowledge of the diverse presentations of cardiac disease in order to increase the likelihood of delivering early appropriate therapy and referral. The objective of this review is to outline cardiac emergencies in the pediatric population and contrast the presentation with adults.

To describe the prevalence of postarrest hyperthermia among children during the first 24 hrs after inhospital cardiac arrest and to determine the association of persistent postarrest hyperthermia with neurologic outcome and death before hospital discharge.Multicenter, national registry of inhospital cardiopulmonary resuscitation.A total of 196 hospitals reporting to the American Heart Association's National Registry of Cardiopulmonary Resuscitation from January 1, 2005 to December 31, 2007.A total of 547 pediatric patients who suffered inhospital pulseless cardiac arrests reported to the National Registry of Cardiopulmonary Resuscitation, who survived resuscitative efforts and who had the maximum and the minimum temperature in the first 24 hrs postresuscitation reported to the National Registry of Cardiopulmonary Resuscitation.None.Among 547 children with pulseless cardiac arrests, 238 (43.5%) had at least one temperature of ≥38°C, and 30 (5.5%) had "persistent hyperthermia" (i.e., both the minimum and the maximum temperature of ≥38°C) during the first 24 hrs postarrest. After adjusting for potential confounders by multivariate logistic regression, persistent hyperthermia in the first 24 hrs postarrest was associated with unfavorable neurologic outcome (adjusted odds ratio, 2.7; 95% confidence interval, 1.1-6.7), but not with death before hospital discharge (adjusted odds ratio, 1.2; 95% confidence interval, 0.4-3.4).Despite current guidelines to avoid postarrest hyperthermia, a temperature of ≥38°C occurred commonly among children in the first 24 hrs postarrest. Persistent postarrest hyperthermia was associated with unfavorable neurologic outcomes, even after controlling for potential confounding factors.

Disseminated intravascular coagulation (DIC) as a complication of surgery for ventriculoperitoneal (VP) shunts is extremely rare, and only one case has been documented in the literature. The authors present the case of a 9-year-old girl with shunted hydrocephalus who presented with a 3-day history of headaches and vomiting. A head CT showed enlarged ventricles compared with baseline. An emergent VP shunt revision was performed, during which an obstructed proximal catheter was found. Immediately after extubation, the patient became apneic and progressed to cardiopulmonary arrest. A breathing tube was reinserted followed by resuscitation attempts that led to extracorporeal membrane oxygenation. Soon after reintubation, bloody drainage was noted in the endotracheal tube, and subsequent laboratory studies were consistent with DIC. The patient died on postoperative Day 1, and autopsy findings confirmed DIC. Note that DIC is a recognized complication of trauma, particularly with brain injury, but it is rare with neurosurgical procedures. Disseminated intravascular coagulation should be considered if excessive bleeding occurs after any brain insult.

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.Descriptive, educational intervention study.The simulation facility at the host institution.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.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.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.

Supraventricular tachycardia (SVT) is the most frequent tachydysrhythmia in children. SVT with hemodynamic compromise should be terminated by immediate electrical cardioversion. Study objectives were to: (1) establish time to recognition and cardioversion of simulated unstable SVT; and (2) document delays and mistakes made during cardioversion.Ten teams of pediatric residents were presented with an unresponsive "patient" (Laerdal SimMan) in unstable SVT. Actions of team members and simulator timestamps of key events were recorded. A retrospective review of events and time logs was performed with primary outcome measure of time to successful cardioversion.Median time to cardioversion was 8.9 minutes (range, 5.3 minutes to unsuccessful scenario terminated at 15 minutes). In 20% of scenarios, the patient was never cardioverted. Ninety percent of teams administered adenosine, but 44% of attempts demonstrated incorrect administration technique. Other maneuvers before cardioversion: 70% administered fluid, 60% attempted vagal maneuvers, 30% requested electrocardiogram, 30% requested antiarrhythmics. In 20% of scenarios, the rhythm was misidentified. When cardioversion was performed, 25% failed to use gel, 37.5% failed to synchronize, 25% used inappropriate energy doses. In 60% of scenarios, no oxygen was administered. In 90% there was no assignment of Glasgow Coma Scale, and no assessment of mental status in 30%. In 60% perfusion was not assessed.Median time to cardioversion of 8.9 minutes is inconsistent with AHA recommendations for treatment of unstable SVT with "immediate cardioversion." Delays were secondary to lack of recognition of "unstable" SVT, due to failure to assess perfusion and mental status. Errors encountered during simulation identify curriculum reform targets.

OBJECTIVE The literature suggests pediatric residents are inadequately prepared to perform resuscitation maneuvers when a child suffers a cardiopulmonary arrest (CPA). Our objective was to characterize the resuscitation training and CPA resuscitation experience of residents, including hands on experience with discharging a defibrillator. DESIGN : Cross-sectional survey. SETTING Tertiary care, academic pediatric residency program. SUBJECTS Pediatric residents. MEASUREMENTS AND MAIN RESULTS Seventy-six of 80 (95%) pediatric residents responded. The median (interquartile range) number of CPAs attended increased significantly by level of training, with some attending as many as 20 CPAs during residency (postgraduate year [PGY]1: 2.0 [1.0-3.0] vs. PGY2: 5.0 [3.0-8.0] vs. PGY3: 10.0 [5.0-12.0], p < 0.001). Nine of 25 (36%) senior residents had led a resuscitation. The proportion of third-year residents who had attended at least 1 CPA in the following locations was: general ward 20 of 25 (80%), Emergency Department 18 of 25 (72%), Neonatal intensive care unit 24 of 25 (96%), pediatric intensive care unit 23 of 25 (92%), and secondary training hospital 19 of 25 (76%). Twelve of 76 (16%) residents had discharged a defibrillator on an actual patient; however, 25 of 76 (33%) had never discharged a defibrillator, either on a patient or during training exercises. Although most residents had received required training in American Heart Association Basic Life Support and Pediatric Advance Life Support (i.e., BLS and PALS), 6 of 76 (8%) residents had never taken basic life support and 4 of 48 (8%) of upper level residents had never taken pediatric advanced life support. Multivariate analysis revealed that level of training, pediatric advanced life support training, and attendance at a mock code in the past year were not independently associated with having discharged a defibrillator (i.e., patient, mannequin, etc.), whereas attendance at an institutional Code Team training course was. CONCLUSIONS Almost every pediatric resident was involved in attempting to resuscitate a child suffering a CPA, yet many were inadequately trained to respond. Formal mechanisms are needed to guarantee adequate resuscitation training for pediatric residents, especially regarding participation in basic life support and hands on defibrillator training.

This tool directs the health care team to discuss specific goals of care and best-practice safety measures daily for each patient and to ensure goal understanding and implementation.

Background The quality of life support delivered during cardiopulmonary resuscitation affects outcomes. However, little data exist regarding the quality of resuscitation delivered to children and factors associated with adherence to American Heart Association (AHA) resuscitation guidelines. Participants Pediatric residents from an academic, tertiary care hospital. Design Prospective, observational cohort study of residents trained in the AHA PALS 2000 guidelines managing a high-fidelity mannequin simulator programmed to develop pulseless ventricular tachycardia (PVT). Main outcome measures Proportion of residents who: (1) started compressions in ≤1min from onset of PVT, (2) defibrillated in ≤3min and (3) factors associated with time to defibrillation. Results Seventy of eighty (88%) residents participated. Forty-six of seventy (66%) failed to start compressions within 1min of pulselessness and 23/70 (33%) never started compressions. Only 38/70 (54%) residents defibrillated the mannequin in ≤3min of onset of PVT. There was no significant difference in time elapsed between onset of PVT and defibrillation by level of post-graduate training. However, residents who had previously discharged a defibrillator on either a patient or a simulator compared to those who had not were 87% more likely to successfully defibrillate the mannequin at any point in time (hazard ratio 1.87, 95% CI: 1.08–3.21, p =0.02). Conclusions Pediatric residents do not meet performance standards set by the AHA. Future curricula should focus training on identified defects including: (1) equal emphasis on "airway and breathing" and "circulation" and (2) hands-on training with using and discharging a defibrillator in order to improve safety and outcomes.

The field of team training is quickly evolving and data are emerging to support the close relationship between effective teamwork and patient safety in medicine. This paper provides a review of the literature on team training with specific emphasis on the perspectives of emergency and critical care pediatricians.Errors in medicine are most frequently due to an interaction of human factors like poor teamwork and poor communication rather than individual mistakes. Critical care settings and those in which patients are at the extremes of age are particularly high-risk, making emergency and critical care pediatrics a special area of concern. Team training is one approach for reducing error and enhancing patient safety. Currently, there is no single standard for team training in medicine, but multiple disciplines, including anesthesiology, emergency medicine and neonatology, have adapted key principles from other high-reliability industries such as aviation into crisis resource management training.Team training holds promise to improve patient safety in pediatric emergency departments and critical care settings. We must carefully delineate the optimal instructional strategies to improve team behaviors and combine these with rigorous outcomes assessment to diagnose team problems and prescribe targeted solutions, and determine their long-term impact on patient safety.

Determine anesthesiologists' knowledge of the 2005 American Heart Association (AHA) Pediatric Advanced Life Support (PALS) recommendations.After obtaining institutional review board approval, a survey was sent in February 2007 to members of the Society for Pediatric Anesthesia via a web-based survey tool, and re-sent to nonresponders five times over the following 7 months.Overall response rate was 51% (389/768 members). Eighty-five percent of respondents had pediatric anesthesia fellowships, 71% provided anesthesia primarily to children, 71% had been in practice10 years, 29% had PALS or APLS training during the previous year, and 37% had a patient requiring chest compressions in the previous year. Overall, 89% of respondents knew the correct initial dose of epinephrine (adrenaline) for asystole, 44% knew subsequent management for asystole if initial epinephrine dose was ineffective, 49% knew defibrillation sequence to treat pulseless ventricular tachycardia (VT), and 73% knew the medication sequence to treat pulseless VT. Only those respondents who reported to be in practice for10 years scored significantly (p0.0001) better on all resuscitation treatment questions. Respondents who had PALS or APLS training in the previous year or previous 2 years scored significantly better on the defibrillation sequence for pulseless VT (p=0.001 and p=0.045, respectively), and the medication sequence for pulseless VT (p=0.0005 and p=0.011, respectively) when compared with those who had no previous training.Deficiencies exist in the knowledge of current AHA PALS guidelines among anesthesiologists. Formal resuscitation training programs should be considered in ongoing continuing medical education.

OBJECTIVE. The objective of this study was to document the frequency of pediatric resident experiences with end-of-life care for children and the educational context for these experiences, as well as to determine whether residents deem their preparatory training adequate. METHODS. An Internet-based survey was distributed to all categorical pediatric residents at the Johns Hopkins Children's Center. Survey items asked residents to (1) quantify their experiences with specific responsibilities associated with the death of a pediatric patient, (2) identify their educational experiences, and (3) respond to Likert scale statements of, “I feel adequately trained to… .” The responsibilities were discussion of withdrawal/limitation of life-sustaining therapy, symptom management, declaration of death, discussion of autopsy, completion of a death certificate, seeking self-support, and follow-up with families. RESULTS. Forty (50%) of 80 residents completed the survey. Residents had been present for a mean (± SD) of 4.7 (± 3.0) patient deaths. More than 50% of residents had participated in discussions of withdrawal/limitation of life-sustaining therapy, symptom management, completing a death certificate, and seeking personal support; however, CONCLUSION. Pediatric residents have limited experience with pediatric end-of-life care and highly varied educational experiences and do not feel adequately trained to fulfill the responsibilities associated with providing end-of-life care for children. Overall, this perception does not improve with increased level of training. This study identifies several target areas for curricular intervention that may ultimately improve the end-of-life experience for our pediatric patients and their families and the young physicians who care for them.

Background: As cardiopulmonary arrest (CPA) can occur anywhere, laypersons may need to initiate CPR. However, recent literature reveals the quality of basic life support (BLS) provided during CPA is poor. There is increasing interest in whether devices can support laypeople, as well as others, to manage medical emergencies. Methods: We performed a prospective, randomized, controlled trial of simulated out of hospital CPA in which each subject was asked to manage a standardized event using the Laerdal Resusci-Anne simulator. A study member played a second rescuer to help as directed. The intervention was a device with audiovisual prompts designed to assist with decision making. Study subjects included laypeople and nursing and medical students. The primary outcome measure was the proportion of subjects who performed compressions and ventilations at a 30:2 ratio. Secondary outcome measures were proportion of subjects who insisted on switching roles with the second rescuer after 2 minutes and other measures of quality BLS. Results: Thirty-one subjects were enrolled, 16 in the intervention arm and 15 in the control arm, with similar baseline characteristics. Subjects in the intervention arm were more likely to perform compressions to ventilations at a ratio of 30:2 than controls, [15/16 (94%) vs. 4/15 (27%), p Conclusions: The device resulted in a behavior change as intervention subjects were more likely to perform 30:2 and switch providers. Unfortunately, the device slowed the initial response time. These results are promising, but future studies should concentrate on decreasing latency time, periods without compressions and possible incorporation into automated external defibrillators.

As demonstrated in this case report, parental concern can serve as an important and effective call trigger.

Importance The quality of cardiopulmonary resuscitation (CPR) affects hemodynamics, survival, and neurological outcomes following pediatric cardiopulmonary arrest (CPA). Most health care professionals fail to perform CPR within established American Heart Association guidelines. Objective To determine whether “just-in-time” (JIT) CPR training with visual feedback (VisF) before CPA or real-time VisF during CPA improves the quality of chest compressions (CCs) during simulated CPA. Design, Setting, and Participants Prospective, randomized, 2 × 2 factorial-design trial with explicit methods (July 1, 2012, to April 15, 2014) at 10 International Network for Simulation-Based Pediatric Innovation, Research, & Education (INSPIRE) institutions running a standardized simulated CPA scenario, including 324 CPR-certified health care professionals assigned to 3-person resuscitation teams (108 teams). Interventions Each team was randomized to 1 of 4 permutations, including JIT training vs no JIT training before CPA and real-time VisF vs no real-time VisF during simulated CPA. Main Outcomes and Measures The proportion of CCs with depth exceeding 50 mm, the proportion of CPR time with a CC rate of 100 to 120 per minute, and CC fraction (percentage CPR time) during simulated CPA. Results The quality of CPR was poor in the control group, with 12.7% (95% CI, 5.2%-20.1%) mean depth compliance and 27.1% (95% CI, 14.2%-40.1%) mean rate compliance. JIT training compared with no JIT training improved depth compliance by 19.9% (95% CI, 11.1%-28.7%; P P = .037). Visual feedback compared with no VisF improved depth compliance by 15.4% (95% CI, 6.6%-24.2%; P = .001) and rate compliance by 40.1% (95% CI, 28.8%-51.3%; P 89.0%) in all groups. Combining both interventions showed the highest compliance with American Heart Association guidelines but was not significantly better than either intervention in isolation. Conclusions and Relevance The quality of CPR provided by health care professionals is poor. Using novel and practical technology, JIT training before CPA or real-time VisF during CPA, alone or in combination, improves compliance with American Heart Association guidelines for CPR that are associated with better outcomes. Trial Registration clinicaltrials.gov Identifier:NCT02075450

In the years 1999 and 2001, landmark reports from the Institute of Medicine (IOM) made deficiencies in quality of care and patient safety inescapably visible to health care professionals and the public (Institute of Medicine 1999, 2001). What have we accomplished since these reports? Are we safer; and if so, how do we know? Many say we lack empiric evidence to demonstrate improved safety (Wachter 2004; Brennan et al. 2005; Leape and Berwick 2005), with few measures to broadly evaluate our progress with improvements. Current publicly reported performance measures are likely insufficient for providers to evaluate safety. In many hospitals, these performance measures apply to

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 child's 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.

One of the unresolved issues in reserves evaluations is the continuing practice of assessing probable reserves for projects where no proved reserves have been claimed. The practice typically arises in the early delineation stage. The initial assessment of best estimate recoverable quantities (proved plus probable ("2P")) meets internal criteria sufficiently to justify development. While the project is potentially commercial, it may not meet all the criteria for disclosure of proved reserves under regulatory guidelines. In this paper, it is assumed that governing agency is the U.S. Securities and Exchange Commission (SEC). The issue is an interesting exercise in logic. Is probable a discrete entity or is it merely the incremental volume beyond proved in a 2P estimate? If no part of the accumulation meets the proved reserves criteria, then can the total 2P estimate be classified as probable reserves? The resolution may lie in more careful application of the full resource classification published by the Society of Petroleum Engineers (SPE) in 2000. The SPE recognized that ambiguity may exist between their definitions of uproven reserves and contingent resources. While reserves are accumulations that are recoverable under current conditions, this same distribution of volumes would be classified as contingent resources if technical and/or commercial risks prevent development commitment. The separation of risk and uncertainty in the assessment process is critical. One solution is to initially classify volumes associated with all new discoveries as contingent resources with its internal certainty categories (low/best/high estimates) until such time as the SEC proved reserves criteria are satisfied. As contingencies are removed, volumes would then be transferred to reserves subdivided into parallel certainty categories of proved (1P), proved plus probable (2P) and proved plus probable plus possible (3P). It may or may not be that simple; this paper critically examines associated issues with examples.

Abstract Exploration and Production firms implementing corporate-wide portfolio management require a rigorous volume classification system and a consistent technique for volume aggregation and category transfers that incorporate associated risk and uncertainty. The SPE approved classification of Reserves, Contingent Resources, and Prospective Resources is the basis of volume accounting. Integrating stochastic and deterministic estimates generate average confidence factors for Proved, Probable, and Possible volumes to be used in aggregation. Estimated Ultimate Recoverable (EUR) interpretations are the expected mean volume that will be recovered from a property by a specified development program with an associated investment and production schedule. Volumes are transferred from "risked or confidence-discounted" Probable and Possible to Proved according to a drilling schedule and results of re-interpretation from new technical data. Transfers from Proved Undeveloped to Proved Developed reserves require facility installations. Contingent Resource estimates utilize a Chance of Commerciality (Pct) to comparatively quantify commercial risk. Prospective Resources in untested prospects have an associated Chance of Geological Success (Pg). Potential future acquisitions of both production and exploration assets are modified by a Probability of Capture (Pcp). Thus for a given capital investment schedule, the system can compute annual projections of production, remaining reserves and resources by certainty class, and a total remaining EUR that aggregates volumes discounted for technical certainty, commercial certainty, discovery risk, and acquisition probability. Moreover, the aggregated volumes have an associated production profile that can be combined with product price and operating expense forecasts to generate cash flows for financial performance and asset value assessment. Introduction Oil and gas companies are increasingly adopting portfolio management applications to support their decision making process with the goal of improving financial performance. These companies are also re-developing their resource database and reporting systems to better track historical performance and fully define their current hydrocarbon asset base. Ultimately the two systems will merge into a single suite of databases and applications. In such a merged system, estimates of remaining recoverable for each project would have an associated production profile and cash flow schedule. Analysis of these future cash flows yield financial metrics such as Net Present Value (NPV). The merged system can then be interrogated in three reporting modes:- report current asset volumes with associated value assuming full funding- project current asset value under specific funding scenarios- project portfolio results under alternative scenarios including acquisitions and dispositions. If approached from the resource database perspective, reports would be generated for the current and each future year listing volume and value estimates by resource class. In addition, analysis would include the typical reconciliation reports of annual revisions and additions. In order to facilitate this type of system, a consistent logical process model of hydrocarbon resource evaluation is required. This paper examines several underlying issues around resource classification, the treatment of chance, risk and uncertainty, and the synchronization of volume and value analyses that may impact the logical model. Both deterministic and probabilistic approaches are considered.

Abstract As reported in SPE 28329, Mobil Corporation utilizes a unique methodology for reserve and resource evaluation. The approach integrates both deterministic and probabilistic methods to evaluate reserves and establish the full hydrocarbon potential of fields/prospects. We believe both methods have valid justification for utilization, but when used jointly provide greater insight into the recoverable hydrocarbon volumes and the probability of recovering those volumes. Continuing dialog, within the international industry, which Mobil strongly supports, has resulted in several proposals to develop "accepted industry practices," such as the SPE/WPC Approved Reserves Definitions. Mobil is also continually testing new methodologies that provide further clarity to determining the quantity of hydrocarbon volumes and the associated value. This paper provides an update on new insights into Mobil's methodology utilizing actual examples and hopes to serve as a catalyst in the continuing dialog to develop "accepted industry practices." Introduction The changing landscape in the petroleum industry calls for innovative practices. These "practices" were generally not recognized as essential requirements just a few years ago. Each "stakeholder", whether it be the host country, operating company, service contractor, financial institution (and others), require a common "language" for business dialog. We can lend body to this language through "definitions", "guidelines", and "industry accepted practices"; and several international bodies have participated in this endeavor. But, in the end, the industry must have an accepted set of "norms", which evolve with time (and need) to form the foundation. Since recoverable hydrocarbon volumes are the "base" asset for each of the "stakeholders", an understanding of the magnitude, the risks, and the value from their own and each other's perspective is essential. This need for understanding, combined with the evolution of technology, has focused greater effort towards improved nomenclature to achieve consistency. Industry organizations, professional societies, and governmental agencies continue to address these issues. Of particular note, are the recently published SPE/WPC Definitions. These efforts are laudable, and need to be progressed. As mentioned earlier, the changing business environment where the industry undertakes new and technically challenging projects, requires sophisticated classification systems and evaluation methodologies. Many of these projects have non-traditional financial and political risk, which test the limits of current classification of hydrocarbon volumes. Many companies, facing these challenges, continue to review their internal procedures and systems to enhance the system's utility for external reporting while providing a strong link to business plans. This process is accelerating with a realization that not all barrels have equal value, when looking at them in tandem with the associated risks and uncertainties. A strong dialog is ongoing, within the industry, to promote a better understanding of the salient issues and thereby support further evolution. We strongly support the continuing efforts to develop "standards" and "industry accepted practices." Mobil is continually testing new methodologies that provide further clarity to determining and representing the quantity of hydrocarbon volumes and the associated values. The purpose of this paper is to provide a discussion of current practices being used within Mobil, in keeping with our desire to further support the ongoing exchange of ideas. P. 535^

Introduction: Recent evidence suggests debriefing teams after cardiopulmonary arrests (CPA) is associated with improved performance. Strong quality assurance programs depend on reliable capture of events and robust data driven debriefing. In 2012, our Children's Hospital moved into a new building wi