Elsevier

Resuscitation

Volume 80, Issue 7, July 2009, Pages 819-825
Resuscitation

Simulation and education
Delays and errors in cardiopulmonary resuscitation and defibrillation by pediatric residents during simulated cardiopulmonary arrests

https://doi.org/10.1016/j.resuscitation.2009.03.020Get rights and content

Abstract

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 ≤1 min from onset of PVT, (2) defibrillated in ≤3 min 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 1 min of pulselessness and 23/70 (33%) never started compressions. Only 38/70 (54%) residents defibrillated the mannequin in ≤3 min 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.

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.

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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.

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