Improving Pediatric Readiness in General Emergency Departments: A Prospective Interventional Study.

OBJECTIVE: To describe the impact of a national interventional collaborative on pediatric readiness within general emergency departments (EDs). STUDY DESIGN: A prospective, multicenter, interventional study measured pediatric readiness in general EDs before and after participation in a pediatric readiness improvement intervention. Pediatric readiness was assessed using the weighted pediatric readiness score (WPRS) on a 100-point scale. The study protocol extended over 6 months and involved 3 phases: (1) a baseline on-site assessment of pediatric readiness and simulated quality of care; (2) pediatric readiness interventions; and (3) a follow-up on-site assessment of WPRS. The intervention phase included a benchmarking performance report, resources toolkits, and ongoing interactions between general EDs and academic medical centers. RESULTS: Thirty-six general EDs were enrolled, and 34 (94%) completed the study. Four EDs (11%) were located in Canada, and the rest were in the US. The mean improvement in WPRS was 16.3 (P < .001) from a baseline of 62.4 (SEM = 2.2) to 78.7 (SEM = 2.1), with significant improvement in the domains of administration/coordination of care; policies, protocol, and procedures; and quality improvement. Six EDs (17%) were fully adherent to the protocol timeline. CONCLUSIONS: Implementing a collaborative intervention model including simulation and quality improvement initiatives is associated with improvement in WPRS when disseminated to a diverse group of general EDs partnering with their regional pediatric academic medical centers. This work provides evidence that innovative collaboration facilitated by academic medical centers can serve as an effective strategy to improve pediatric readiness and processes of care.

Code Team Structure and Training in the Pediatric Resuscitation Quality International Collaborative.

OBJECTIVES: Code team structure and training for pediatric in-hospital cardiac arrest are variable. There are no data on the optimal structure of a resuscitation team. The objective of this study is to characterize the structure and training of pediatric code teams in sites participating in the Pediatric Resuscitation Quality Collaborative. METHODS: From May to July 2017, an anonymous voluntary survey was distributed to 18 sites in the international Pediatric Resuscitation Quality Collaborative. The survey content was developed by the study investigators and iteratively adapted by consensus. Descriptive statistics were calculated. RESULTS: All sites have a designated code team and hospital-wide code team activation system. Code team composition varies greatly across sites, with teams consisting of 3 to 17 members. Preassigned roles for code team members before the event occur at 78% of sites. A step stool and backboard are used during resuscitations in 89% of surveyed sites. Cardiopulmonary resuscitation (CPR) feedback is used by 72% of the sites. Of those sites that use CPR feedback, all use an audiovisual feedback device incorporated into the defibrillator and 54% use a CPR coach. Multidisciplinary and simulation-based code team training is conducted by 67% of institutions. CONCLUSIONS: Code team structure, equipment, and training vary widely in a survey of international children's hospitals. The variations in team composition, role assignments, equipment, and training described in this article will be used to facilitate future studies regarding the impact of structure and training of code teams on team performance and patient outcomes.

Improving code team performance and survival outcomes: implementation of pediatric resuscitation team training.

OBJECTIVE: To determine whether implementation of Composite Resuscitation Team Training is associated with improvement in survival to discharge and code team performance after pediatric in-hospital cardiopulmonary arrest. DESIGN, SETTING, AND SUBJECTS: We conducted a prospective observational study with historical controls at a 302-bed, quaternary care, academic children's hospital. Inpatients who experienced cardiopulmonary arrest between January 1, 2006, and December 31, 2009, were included in the control group (123 patients experienced 183 cardiopulmonary arrests) and between July 1, 2010, and June 30, 2011, were included in the intervention group (46 patients experienced 65 cardiopulmonary arrests). INTERVENTION: Code team members were introduced to Composite Resuscitation Team Training and continued training throughout the intervention period (January 1, 2010-June 30, 2011). Training was integrated via in situ code blue simulations (n = 16). Simulations were videotaped and participants were debriefed for education and process improvement. Primary outcome was survival to discharge after cardiopulmonary arrest. Secondary outcome measures were 1) change in neurologic morbidity from admission to discharge, measured by Pediatric Cerebral Performance Category, and 2) code team adherence to resuscitation Standard Operating Performance variables. MEASUREMENTS AND MAIN RESULTS: The intervention group was more likely to survive than the control group (60.9% vs 40.3%) (unadjusted odds ratio, 2.3 [95% CI, 1.15-4.60]) and had no significant change in neurologic morbidity (mean change in Pediatric Cerebral Performance Category 0.11 vs 0.27; p = 0.37). Code teams exposed to Composite Resuscitation Team Training were more likely than control group to adhere to resuscitation Standard Operating Performance (35.9% vs 20.8%) (unadjusted odds ratio, 2.14 [95% CI, 1.15-3.99]). After adjusting for adherence to Standard Operating Performance, survival remained improved in the intervention period (odds ratio, 2.13 [95% CI, 1.06-4.36]). CONCLUSION: With implementation of Composite Resuscitation Team Training, survival to discharge after pediatric cardiopulmonary arrest improved, as did code team performance. Demonstration of improved survival after adjusting for code team adherence to resuscitation standards suggests that this may be a valuable resuscitation training program. Further studies are needed to determine causality and generalizability.

Operating Room Codes Redefined: A Highly Reliable Model Integrating the Core Hospital Code Team.

INTRODUCTION: Typically, multidisciplinary teams manage cardiac arrests occurring outside of the operating room (OR). This approach results in reduced morbidity. However, arrests that occur in the OR are usually managed by OR personnel alone, missing the benefits of out-of-OR hospital code teams. At our institution, there were multiple pathways to activate codes, each having different respondents, depending on time and day of the week. This improvement initiative aimed to create a reliable intraoperative emergency response system with standardized respondents and predefined roles. METHODS: A multidisciplinary improvement team led this project at an academic pediatric hospital in California. After simulations performed in the OR (in situ), the team identified a valuable key driver-a consistent activation process that initiated standard respondents, 24 hours a day, 7 days a week. By utilizing core hospital code members routinely available outside of the OR during days, nights, and weekends, respondents were identified to augment OR personnel. Code roles were preassigned. After education, we conducted in situ simulations that included the perioperative and out-of-OR code team members. We administered a knowledge assessment to perioperative staff. RESULTS: The knowledge assessment for perioperative staff (n = 52) had an average score of 96%. Review of subsequent OR codes reflects an improved initiation process and management. CONCLUSIONS: The process for activating the emergency response system and roles for intraoperative code respondents were standardized to ensure a predictable code response, regardless of time or day of the week. Ongoing simulations with perioperative personnel continue to optimize the process.

Near Miss in Intraoperative Magnetic Resonance Imaging: A Case for In Situ Simulation.

Pediatric patients in intraoperative magnetic resonance imaging (iMRI) settings are at high risk for morbidity should an adverse event occur. We describe an experience in the iMRI scanner where no harm occurred, yet revealed an opportunity to improve the safety of patients utilizing the iMRI. The perioperative quality improvement team, resuscitation team, and radiology nurse leadership collaborated to understand the process better through in situ simulation. METHODS: After a problem analysis, the team planned an in situ, high-fidelity simulation with predefined learning objectives to identify previously overlooked opportunities for improvement. The iMRI simulation had unique considerations, including the use of a magnetic resonance imaging (MRI)-compatible mannequin and ensuring participants' safety. Audiovisual equipment was placed in strategic locations to record the MRI and operating room (OR) segments of the simulation, and trained health-care simulation experts provided debriefing. RESULTS: After completion of the iMRI simulation, the quality improvement team solicited feedback from participants and reviewed the video-recorded simulation. Several opportunities for improvement surrounding staff responsibilities and unique aspects of the iMRI environment were identified. CONCLUSIONS: iMRI in situ simulation has not been previously described. It presents unique challenges given the integration of personnel from OR and radiology environments, anesthetized patients, and risks from the high-powered MRI magnet. Other institutions utilizing hybrid ORs with iMRI may consider conducting in situ simulations using the described methods.

Saving a life after discharge: CPR training for parents of high-risk children.

Pediatric patients with chronic disease are at risk for cardiopulmonary arrest (CPA). Outcomes of CPA are improved if prompt quality cardiopulmonary resuscitation (CPR) is performed. This study examined the efficacy of the CPR Anytime™ Kit as a standardized method of CPR discharge training to families of high-risk children. The kit was provided to parents of 117 high-risk pediatric patients prior to hospital discharge. A telephone survey was used at 1, 3, and 6 months to assess retention of CPR knowledge and skills, parental comfort levels with CPR, and kit dissemination to family members. A second survey was used 1 year after implementation of program to assess nursing satisfaction. CPR comfort levels were reported as confident, knowledge and skills were reported as moderate on follow-up telephone surveys. A total of 82% of subjects reviewed the video at least once after discharge, and 79% of subjects shared the kit with at least two other family members or friends. A total of 72 of 74 nurses (97% ) surveyed were either "satisfied" or "very satisfied" with the program. Provision of the CPR Anytime Kit™ to families of high-risk pediatric patients prior to discharge leads to sustained levels of CPR knowledge and confidence.