Simulation and educationDelays and errors in cardiopulmonary resuscitation and defibrillation by pediatric residents during simulated cardiopulmonary arrests☆
Introduction
Most pediatric cardiopulmonary arrests (CPAs) are secondary to respiratory events, thus pediatricians are commonly instructed to focus on airway management when resuscitating children.1 As a result, pediatric life support curricula place less emphasis on compressions and defibrillation than those for adults. However, respiratory arrest may progress to cardiac arrest. Performing airway management without compressions to circulate the oxygenated blood in a pulseless, non-newly born patient virtually guarantees a poor outcome. In addition, 14% of pediatric in-hospital CPAs will actually begin with an arrhythmia that requires defibrillation, i.e. pulseless ventricular tachycardia (PVT) or ventricular fibrillation (VF), and 27% of children will develop one of these rhythms during a CPA.2 Errors in performing basic (chest compressions) and advanced (defibrillation) life support (BLS/ALS) are common and poor quality of resuscitation can affect outcome.3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 To improve outcomes, researchers need to identify and eliminate errors in providing BLS and ALS.
The American Heart Associations (AHA) recommends that pulseless patients of any age should receive chest compressions immediately and defibrillation in ≤3 min of onset of a shockable rhythm, i.e. PVT/VF.15, 16 Residents, especially third year residents, should be able to direct a team to comply with these standards. Thus our objectives were to measure during a simulated CPA (sCPA): (1) the proportion of residents who directed a team to initiate compressions in ≤1 min of pulselessness, (2) the proportion of residents who successfully defibrillated in ≤3 min of onset of PVT, and (3) factors associated with time to defibrillation, including whether there was a significant improvement between first and third year pediatric residents. The overall goals were to identify targets to improve the quality of care delivered to children suffering a CPA and ultimately improve patient outcomes.
Section snippets
Study design
We conducted a prospective observational cohort study of sCPAs. This protocol was deemed to be exempt by the Johns Hopkins University Institutional Review Board.
Primary outcome measure
The primary outcome measure was time elapsed between onset of PVT in a high fidelity mannequin simulator until successful delivery of the first shock.
Secondary outcome measures
Secondary outcome measures included markers of quality and compliance with AHA BLS and the 2000 Pediatric ALS (PALS) guidelines, as well as an assessment of errors made while operating the
Results
Seventy of eighty (88%) pediatric residents participated in the survey and sCPA. There was no statistically significant difference in the proportion of residents responding by post-graduate year of training (PGY) class: [PGY1: 27/28 (96%) vs. PGY2: 22/26 (85%) vs. PGY3: 21/26 (81%), p = 0.19]. Baseline characteristics stratified by PGY are reported in Table 1. While third year residents were the most likely to have led a team during a CPA, 50% had never led a resuscitation team. Four of
Discussion
During our study, we were unable to identify any clear improvement in resuscitation performance between first and third year residents. In fact, the majority of pediatric residents did not deliver timely compressions or defibrillation per AHA recommendations.15, 16 Indeed, 33% failed to start compressions and 7% never defibrillated, virtually guaranteeing a fatal outcome for those patients. These data are consistent with recent literature and guidelines that call for attention to improving the
Conclusions
In our study, few pediatric residents met performance standards set by the AHA and there was no clear incremental improvement with each year of training. Our current training programs are not adequately preparing residents to manage in-hospital CPAs. Future curricula should focus training on known defects, including those identified in this study with: (1) equal emphasis for children on “airway and breathing” and “circulation” and (2) hands-on training with using and discharging a
Role of funding source
Dr. Hunt had a NIH loan repayment grant based on this project. However, the NIH LRP program had no involvement in the study design, in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication.
Conflict of interest
The authors have no conflicts of interest to disclose.
Acknowledgements
We would like to thank the pediatric residents and chief residents of Johns Hopkins for their dedication to learning how to care for sick children and for helping us in our efforts to determine the best manner in which to train them.
References (37)
- et al.
Simulated cardiac arrests for monitoring quality of in-hospital resuscitation
Lancet
(1986) - et al.
Quality of out-of-hospital cardiopulmonary resuscitation with real time automated feedback: prospective interventional study
Resuscitation
(2006) - et al.
Effects of compression depth and pre-shock pauses predict defibrillation during cardiac arrest
Resuscitation
(2006) - et al.
Uniform reporting of measured quality of cardiopulmonary resuscitation (CPR)
Resuscitation
(2007) - et al.
The challenge of CPR quality: improvement in the real world
Resuscitation
(2008) - et al.
Poor interface design and lack of usability testing facilitate medical error
Jt Comm J Qual Saf
(2004) Who left the defibrillator on?
Jt Comm J Qual Saf
(2004)- et al.
Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest
Resuscitation
(2006) - et al.
Automated external defibrillation versus manual defibrillation for prolonged ventricular fibrillation: lethal delays of chest compressions before and after countershocks
Ann Emerg Med
(2003) - et al.
The impact of manual defibrillation technique on no-flow time during simulated cardiopulmonary resuscitation
Resuscitation
(2007)
General considerations in the care of sick children: pediatric critical care—cardiopulmonary resuscitation
First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults
JAMA
Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest
JAMA
Quality of cardiopulmonary resuscitation among highly trained staff in an emergency department setting
Arch Intern Med
Teaching hospital physicians’ skills and knowledge of resuscitation algorithms are deficient
Acta Anaesthesiol Scand
Simulated pediatric cardiopulmonary resuscitation: initial events and response times of a hospital arrest team
Respir Care
Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes
Pediatrics
Chest compression rates during cardiopulmonary resuscitation are suboptimal: a prospective study during in-hospital cardiac arrest
Circulation
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A Spanish translated version of the summary of this article appears as Appendix in the online version at doi:10.1016/j.resuscitation.2009.03.020.