Cerebral Oximetry During Pediatric In-Hospital Cardiac Arrest: A Multicenter Study of Survival and Neurologic Outcome.

OBJECTIVES: To determine if near-infrared spectroscopy measuring cerebral regional oxygen saturation (crS o2 ) during cardiopulmonary resuscitation is associated with return of spontaneous circulation (ROSC) and survival to hospital discharge (SHD) in children. DESIGN: Multicenter, observational study. SETTING: Three hospitals in the pediatric Resuscitation Quality (pediRES-Q) collaborative from 2015 to 2022. PATIENTS: Children younger than 18 years, gestational age 37 weeks old or older with in-hospital cardiac arrest (IHCA) receiving cardiopulmonary resuscitation greater than or equal to 1 minute and intra-arrest crS o2 monitoring. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcome was ROSC greater than or equal to 20 minutes without extracorporeal membrane oxygenation. Secondary outcomes included SHD and favorable neurologic outcome (FNO) (Pediatric Cerebral Performance Category 1-2 or no change from prearrest). Among 3212 IHCA events (index and nonindex), 123 met inclusion criteria in 93 patients. Median age was 0.3 years (0.1-1.4 yr) and 31% (38/123) of the cardiopulmonary resuscitation events occurred in patients with cyanotic heart disease. Median cardiopulmonary resuscitation duration was 8 minutes (3-28 min) and ROSC was achieved in 65% (80/123). For index events, SHD was achieved in 59% (54/91) and FNO in 41% (37/91). We determined the association of median intra-arrest crS o2 and percent of crS o2 values above a priori thresholds during the: 1) entire cardiopulmonary resuscitation event, 2) first 5 minutes, and 3) last 5 minutes with ROSC, SHD, and FNO. Higher crS o2 for the entire cardiopulmonary resuscitation event, first 5 minutes, and last 5 minutes were associated with higher likelihood of ROSC, SHD, and FNO. In multivariable analysis of the infant group (age < 1 yr), higher crS o2 was associated with ROSC (odds ratio [OR], 1.06; 95% CI, 1.03-1.10), SHD (OR, 1.04; 95% CI, 1.01-1.07), and FNO (OR, 1.05; 95% CI, 1.02-1.08) after adjusting for presence of cyanotic heart disease. CONCLUSIONS: Higher crS o2 during pediatric IHCA was associated with increased rate of ROSC, SHD, and FNO. Intra-arrest crS o2 may have a role as a real-time, noninvasive predictor of ROSC.

The effect of peer-group size on the delivery of feedback in basic life support refresher training: a cluster randomized controlled trial.

BACKGROUND: Students are largely providing feedback to one another when instructor facilitates peer feedback rather than teaching in group training. The number of students in a group affect the learning of students in the group training. We aimed to investigate whether a larger group size increases students' test scores on a post-training test with peer feedback facilitated by instructor after video-guided basic life support (BLS) refresher training. Students' one-rescuer adult BLS skills were assessed by a 2-min checklist-based test 1 year after the initial training. METHODS: A cluster randomized controlled trial was conducted to evaluate the effect of student number in a group on BLS refresher training. Participants included 115 final-year medical students undergoing their emergency medicine clerkship. The median number of students was 8 in the large groups and 4 in the standard group. The primary outcome was to examine group differences in post-training test scores after video-guided BLS training. Secondary outcomes included the feedback time, number of feedback topics, and results of end-of-training evaluation questionnaires. RESULTS: Scores on the post-training test increased over three consecutive tests with instructor-led peer feedback, but not differ between large and standard groups. The feedback time was longer and number of feedback topics generated by students were higher in standard groups compared to large groups on the first and second tests. The end-of-training questionnaire revealed that the students in large groups preferred the smaller group size compared to their actual group size. CONCLUSIONS: In this BLS refresher training, the instructor-led group feedback increased the test score after tutorial video-guided BLS learning, irrespective of the group size. A smaller group size allowed more participations in peer feedback.

An application of the learning curve-cumulative summation test to evaluate training for endotracheal intubation in emergency medicine.

OBJECTIVE: The learning curve-cumulative summation (LC-CUSUM) test allows for quantitative and individual assessments of the learning process. In this study, we evaluated the process of skill acquisition for performing endotracheal intubation (ETI) in three emergency medicine (EM) residents over a 2 year period in their first 2 years of their EM residency. METHODS: We evaluated 342 ETI cases performed by three EM residents using the LC-CUSUM test according to their rate of success or failure of ETI. A 90% success rate (SR) was chosen to define adequate performance and an SR of 80% was considered inadequate. After the learning phase, the standard CUSUM test was applied to ensure that performance was maintained. RESULTS: The mean number of ETI cases required to reach the predefined level of performance was 74.7 (95% CI 62.0 to 87.3). CUSUM tests confirmed that performance was maintained after the learning phase. CONCLUSIONS: By using the LC-CUSUM test, we were able to quantitatively monitor the acquisition of the skill of ETI by EM residents. The LC-CUSUM could be useful for monitoring the learning process for the training of airway management in the practice of EM.

Validation of a Novel Mobile Application for Assessing Pediatric Tracheostomy Emergency Simulations.

Objective: Pediatric tracheostomy is associated with high morbidity and mortality, yet clinician knowledge and quality of tracheostomy care may vary widely. In situ simulation is effective at detecting and mitigating related latent safety threats, but evaluation via retrospective video review has disadvantages (eg, delayed analysis, and potential data loss). We evaluated whether a novel mobile application is accurate and reliable for assessment of in situ tracheostomy emergency simulations. Methods: A novel mobile application was developed for assessment of tracheostomy emergency in situ simulation team performance. After 1.25 hours of training, 6 raters scored 10 tracheostomy emergency simulation videos for the occurrence and timing of 12 critical steps. To assess accuracy, rater scores were compared to a reference standard to determine agreement for occurrence or absence of critical steps and a timestamp within ±5 seconds. Interrater reliability was determined through Cohen's and Fleiss' kappa and intraclass correlation coefficient. Results: Raters had 86.0% agreement with the reference standard when considering step occurrence and timing, and 92.8% agreement when considering only occurrence. The average timestamp difference from the reference standard was 1.3 ± 18.5 seconds. Overall interrater reliability was almost perfect for both step occurrence (Fleiss' kappa of 0.81) and timing of step (intraclass correlation coefficient of 0.99). Discussion: Using our novel mobile application, raters with minimal training accurately and reliably assessed videos of tracheostomy emergency simulations and identified areas for future refinement. Implications for Practice: With refinements, this innovative mobile application is an effective tool for real-time data capture of time-critical steps in in situ tracheostomy emergency simulations.

Use of backboard and deflation improve quality of chest compression when cardiopulmonary resuscitation is performed on a typical air inflated mattress configuration.

No study has examined the effectiveness of backboards and air deflation for achieving adequate chest compression (CC) depth on air mattresses with the typical configurations seen in intensive care units. To determine this efficacy, we measured mattress compression depth (MCD, mm) on these surfaces using dual accelerometers. Eight cardiopulmonary resuscitation providers performed CCs on manikins lying on 4 different surfaces using a visual feedback system. The surfaces were as follows: A, a bed frame; B, a deflated air mattress placed on top of a foam mattress laid on a bed frame; C, a typical air mattress configuration with an inflated air mattress placed on a foam mattress laid on a bed frame; and D, C with a backboard. Deflation of the air mattress decreased MCD significantly (B; 14.74 ± 1.36 vs C; 30.16 ± 3.96, P < 0.001). The use of a backboard also decreased MCD (C; 30.16 ± 3.96 vs D; 25.46 ± 2.89, P = 0.002). However, deflation of the air mattress decreased MCD more than use of a backboard (B; 14.74 ± 1.36 vs D; 25.46 ± 2.89, P = 0.002). The use of a both a backboard and a deflated air mattress in this configuration reduces MCD and thus helps achieve accurate CC depth during cardiopulmonary resuscitation.

Longitudinal effect of high frequency training on CPR performance during simulated and actual pediatric cardiac arrest.

STUDY AIM: To determine the impact of high-frequency CPR training on performance during simulated and real pediatric CPR events in a pediatric emergency department (ED). METHODS: Prospective observational study. A high-frequency CPR training program (Resuscitation Quality Improvement (RQI)) was implemented among ED providers in a children's hospital. Data on CPR performance was collected longitundinally during quarterly retraining sessions; scores were analyzed between quarter 1 and quarter 4 by nonparametric methods. Data on CPR performance during actual patient events was collected by simultaneous combination of video review and compression monitor devices to allow measurement of CPR quality by individual providers; linear mixed effects models were used to analyze the association between RQI components and CPR quality. RESULTS: 159 providers completed four consecutive RQI sessions. Scores for all CPR tasks during retraining sessions significantly improved during the study period. 28 actual CPR events were captured during the study period; 49 observations of RQI trained providers performing CPR on children were analyzed. A significant association was found between the number of prior RQI sessions and the percent of compressions meeting guidelines for rate (ß coefficient -0.08; standard error 0.04; p = 0.03). CONCLUSIONS: Over a 15 month period, RQI resulted in improved performance during training sessions for all skills. A significant association was found between number of sessions and adherence to compression rate guidelines during real patient events. Fewer than 30% of providers performed CPR on a patient during the study period. Multicenter studies over longer time periods should be undertaken to overcome the limitation of these rare events.