Understanding the Importance of the Lay Responder Experience in Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association.

Bystander cardiopulmonary resuscitation (CPR) is critical to increasing survival from out-of-hospital cardiac arrest. However, the percentage of cases in which an individual receives bystander CPR is actually low, at only 35% to 40% globally. Preparing lay responders to recognize the signs of sudden cardiac arrest, call 9-1-1, and perform CPR in public and private locations is crucial to increasing survival from this public health problem. The objective of this scientific statement is to summarize the most recent published evidence about the lay responder experience of training, responding, and dealing with the residual impact of witnessing an out-of-hospital cardiac arrest. The scientific statement focuses on the experience-based literature of actual responders, which includes barriers to responding, experiences of doing CPR, use of an automated external defibrillator, the impact of dispatcher-assisted CPR, and the potential for postevent psychological sequelae. The large body of qualitative and observational studies identifies several gaps in crucial knowledge that, if targeted, could increase the likelihood that those who are trained in CPR will act. We suggest using the experience of actual responders to inform more contextualized training, including the implications of performing CPR on a family member, dispelling myths about harm, training and litigation, and recognition of the potential for psychologic sequelae after the event.

Change in Cardiopulmonary Resuscitation Performance Over Time During Simulated Pediatric Cardiac Arrest and the Effect of Just-in-Time Training and Feedback.

OBJECTIVES: Effective cardiopulmonary resuscitation (CPR) is critical to ensure optimal outcomes from cardiac arrest, yet trained health care providers consistently struggle to provide guideline-compliant CPR. Rescuer fatigue can impact chest compression (CC) quality during a cardiac arrest event, although it is unknown if visual feedback or just-in-time training influences change of CC quality over time. In this study, we attempt to describe the changes in CC quality over a 12-minute simulated resuscitation and examine the influence of just-in-time training and visual feedback on CC quality over time. METHODS: We conducted secondary analysis of data collected from the CPRCARES study, a multicenter randomized trial in which CPR-certified health care providers from 10 different pediatric tertiary care centers were randomized to receive visual feedback, just-in-time CPR training, or no intervention. They participated in a simulated cardiac arrest scenario with 2 team members providing CCs. We compared the quality of CCs delivered (depth and rate) at the beginning (0-4 minutes), middle (4-8 minutes), and end (8-12 minutes) of the resuscitation. RESULTS: There was no significant change in depth over the 3 time intervals in any of the arms. There was a significant increase in rate (128 to 133 CC/min) in the no intervention arm over the scenario duration (P < 0.05). CONCLUSIONS: There was no significant drop in CC depth over a 12-minute cardiac arrest scenario with 2 team members providing compressions.

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.

Effects of changes in adult erythropoietin dosing guidelines on erythropoietin dosing practices, anemia, and blood transfusion in children on hemodialysis: findings from North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS).

BACKGROUND: While adult hemodialysis (HD) patients have increased morbidity with higher target hemoglobin levels, similar findings have not been demonstrated in pediatric patients. We evaluated changes in transfusions, anemia frequency, and erythropoietin (epo) dosing among pediatric HD patients before, during, and after implementation of federal dialysis payment policies regarding epo dosing for adult HD patients. METHODS: This is a retrospective cohort study of pediatric HD patients enrolled in NAPRTCS. We evaluated need for transfusion, anemia, median hemoglobin, and median epo dose 6 months after starting HD in 3 eras: baseline (2003-2007), implementation (2008-2011), and post implementation (2012-2016). We used multivariate logistic regression models to evaluate potential differences in transfusion across the eras. RESULTS: Six months after dialysis initiation, 12.6% of patients required transfusion pre-implementation, 17.9% during implementation, and 15.5% post implementation. Anemia occurred in 17.4% of patients pre, 23.5% during, and 23.8% post implementation, with median hemoglobin levels of 11.9 g/dL pre, 11 g/dL during, and 11 g/dL post implementation. Epo use was high across all 3 eras, but epo dosing decreased during and post implementation, despite more anemia during these periods. Odds of transfusion in implementation era compared with pre-implementation was 1.75 (95% CI 1.11-2.77) and odds of transfusion in post implementation era compared with pre was 1.19 (95% CI 0.71-1.98), controlling for age, race, gender, and prior transplant status. CONCLUSIONS: During and following implementation of adult epo dosing guidelines, transfusion and anemia frequency increased in pediatric HD patients. Ideal target hemoglobin levels for pediatric dialysis patients warrant further study.

Effect of a Cardiopulmonary Resuscitation Coach on Workload During Pediatric Cardiopulmonary Arrest: A Multicenter, Simulation-Based Study.

OBJECTIVES: Optimal cardiopulmonary resuscitation can improve pediatric outcomes but rarely is cardiopulmonary resuscitation performed perfectly despite numerous iterations of Basic and Pediatric Advanced Life Support. Cardiac arrests resuscitation events are complex, often chaotic environments with significant mental and physical workload for team members, especially team leaders. Our primary objective was to determine the impact of a cardiopulmonary resuscitation coach on cardiopulmonary resuscitation provider workload during simulated pediatric cardiac arrest. DESIGN: Multicenter observational study. SETTING: Four pediatric simulation centers. SUBJECTS: Team leaders, cardiopulmonary resuscitation coach, and team members during an 18-minute pediatric resuscitation scenario. INTERVENTIONS: National Aeronautics and Space Administration-Task Load Index. MEASUREMENTS AND MAIN RESULTS: Forty-one teams (205 participants) were recruited with one team (five participants) excluded from analysis due to protocol violation. Demographic data revealed no significant differences between the groups in regard to age, experience, distribution of training (nurse, physician, and respiratory therapist). For most workload subscales, there were no significant differences between groups. However, cardiopulmonary resuscitation providers had a higher physical workload (89.3 vs 77.9; mean difference, -11.4; 95% CI, -17.6 to -5.1; p = 0.001) and a lower mental demand (40.6 vs 55.0; mean difference, 14.5; 95% CI, 4.0-24.9; p = 0.007) with a coach (intervention) than without (control). Both the team leader and coach had similarly high mental demand in the intervention group (75.0 vs 73.9; mean difference, 0.10; 95% CI, -0.88 to 1.09; p = 0.827). When comparing the cardiopulmonary resuscitation quality of providers with high workload (average score > 60) and low to medium workload (average score < 60), we found no significant difference between the two groups in percentage of guideline compliant cardiopulmonary resuscitation (42.5% vs 52.7%; mean difference, -10.2; 95% CI, -23.1 to 2.7; p = 0.118). CONCLUSIONS: The addition of a cardiopulmonary resuscitation coach increases physical workload and decreases mental workload of cardiopulmonary resuscitation providers. There was no change in team leader workload.

Closing the Gap: Optimizing Performance to Reduce Interruptions in Cardiopulmonary Resuscitation.

OBJECTIVES: The American Heart Association recommends minimizing pauses of chest compressions and defines high performance resuscitation as achieving a chest compression fraction greater than 80%. We hypothesize that interruption times are excessively long, leading to an unnecessarily large impact on chest compression fraction. DESIGN: A retrospective study using video review of a convenience sample of clinically realistic in situ simulated pulseless electrical activity cardiopulmonary arrests. SETTING: Johns Hopkins Children's Center; September 2013 to June 2017. PATIENTS: Twenty-two simulated patients. INTERVENTIONS: A framework was developed to characterize interruptions. Two new metrics were defined as follows: interruption time excess (the difference between actual and guideline-indicated allowable duration of interruption from compressions), and chest compression fraction potential (chest compression fraction with all interruption time excess excluded). MEASUREMENTS AND MAIN RESULTS: Descriptive statistics were generated for interruption-level and event-level variables. Differences between median chest compression fraction and chest compression fraction potential were assessed using Wilcoxon rank-sum test. Comparisons of interruption proportion before and after the first 5 minutes were assessed using the X test statistic. Seven-hundred sixty-six interruptions occurred over 22 events. Median event duration was 463.0 seconds (interquartile range, 397.5-557.8 s), with a mean 34.8 interruptions per event. Auscultation and intubation had the longest median interruption time excess of 13.0 and 7.5 seconds, respectively. Median chest compression fraction was 76.0% (interquartile range, 67.7-80.7 s), and median chest compression fraction potential was 83.4% (interquartile range, 80.4-87.4%). Comparing median chest compression fraction to median chest compression fraction potential found an absolute percent difference of 7.6% (chest compression fraction: 76.0% vs chest compression fraction potential: 83.4%; p < 0.001). CONCLUSIONS: This lays the groundwork for studying inefficiency during cardiopulmonary resuscitation associated with chest compression interruptions. The framework we created allows for the determination of significant avoidable interruption time. By further elucidating the nature of interruptions, we can design and implement targeted interventions to improve patient outcomes.

The use of pressure-controlled mechanical ventilation in a swine model of intraoperative pediatric cardiac arrest.

BACKGROUND: Current pediatric resuscitation guidelines suggest that resuscitators using an advanced airway deliver 8-10 breaths per minute while carefully avoiding excessive ventilation. In the intraoperative setting, having a dedicated ventilation rescuer may be difficult because of limited personnel. Continuing pressure-controlled mechanical ventilation during resuscitation for intraoperative cardiac arrest reduces personnel needed and the risk of hyperventilation but might risk hypoventilation during chest compression delivery. AIMS: To determine whether the use of pressure-controlled mechanical ventilation at prearrest settings provides normoxia and normocarbia during resuscitation from cardiac arrest. METHODS: We retrospectively analyzed combined data from preclinical randomized controlled trials. Two-week-old swine (3-4 kg) underwent asphyxia-induced cardiac arrest. Animals were resuscitated with periods of basic and advanced life support. During resuscitation, pressure-controlled mechanical ventilation was delivered at the prearrest respiratory rate, peak inspiratory pressure, and positive end-expiratory pressure. Arterial blood gases were measured prearrest, at 11 minutes of asphyxia, and at 8 and 20 minutes of cardiopulmonary resuscitation. RESULTS: Piglets (n = 154) received pressure-controlled mechanical ventilation before and during cardiopulmonary resuscitation with a peak inspiratory pressure of 14-15 cm H2 O, positive end-expiratory pressure of 4 cm H2 O, 20 breaths/minute, and an inspiratory:expiratory ratio of 1:2. During asphyxia, the arterial blood gas showed the expected severe hypercarbia and hypoxia. Continuing pressure-controlled mechanical ventilation using prearrest parameters and increasing the FiO2 to 1.0 returned the PaCO2 to prearrest levels and slightly increased the partial pressure of arterial oxygen at 8 and 20 minutes of cardiopulmonary resuscitation. CONCLUSION: In this piglet model of resuscitation from asphyxial arrest, pressure-controlled mechanical ventilation during cardiopulmonary resuscitation at the prearrest ventilator settings with an FiO2 of 1.0 provides adequate oxygenation and restores normocarbia. Clinical investigation is warranted to determine the benefits of continuing pressure-controlled mechanical ventilation at prearrest parameters during pediatric cardiopulmonary resuscitation.

Pediatric Transport Triage: Development and Assessment of an Objective Tool to Guide Transport Planning.

OBJECTIVES: We developed a Pediatric Transport Triage Tool (PT3) to objectively guide selection of team composition and transport mode, thereby standardizing transport planning. Previously, modified Pediatric Early Warning Score for transport has been used to assess illness severity but not to guide transport decision making. METHODS: The PT3 was created for pediatric transport by combining objective evaluations of neurologic, cardiovascular, and respiratory systems with a systems-based medical condition list to identify diagnoses requiring expedited transport and/or advanced team composition not captured by neurologic, cardiovascular, and respiratory systems alone. A scoring algorithm was developed to guide transport planning. Transport data (mode, team composition, time to dispatch, patient disposition, and complications) were collected before and after PT3 implementation at a single tertiary care center over an 18-month period. RESULTS: We reviewed 2237 inbound pediatric transports. Transport mode, patient disposition, and dispatch time were unchanged over the study period. Fewer calls using a transport nurse were noted after PT3 implementation (33.9% vs 30%, P = 0.05), with a trend toward fewer rotor-wing transports and transports requiring physicians. The majority of users, regardless of experience level, reported improved transport standardization with the tool. Need to upgrade team composition or mode during transport was not different during the study period. No adverse patient safety events occurred with PT3 use. CONCLUSIONS: The PT3 represents an objective triage tool to reduce variability in transport planning. The PT3 decreased resource utilization and was not associated with adverse outcomes. Teams with dynamic staffing models, various experience levels, and multiple transport modes may benefit from this standardized assessment tool.

2017 American Heart Association Focused Update on Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

This focused update to the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care follows the Pediatric Task Force of the International Liaison Committee on Resuscitation evidence review. It aligns with the International Liaison Committee on Resuscitation's continuous evidence review process, and updates are published when the International Liaison Committee on Resuscitation completes a literature review based on new science. This update provides the evidence review and treatment recommendation for chest compression-only CPR versus CPR using chest compressions with rescue breaths for children <18 years of age. Four large database studies were available for review, including 2 published after the "2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care." Two demonstrated worse 30-day outcomes with chest compression-only CPR for children 1 through 18 years of age, whereas 2 studies documented no difference between chest compression-only CPR and CPR using chest compressions with rescue breaths. When the results were analyzed for infants <1 year of age, CPR using chest compressions with rescue breaths was better than no CPR but was no different from chest compression-only CPR in 1 study, whereas another study observed no differences among chest compression-only CPR, CPR using chest compressions with rescue breaths, and no CPR. CPR using chest compressions with rescue breaths should be provided for infants and children in cardiac arrest. If bystanders are unwilling or unable to deliver rescue breaths, we recommend that rescuers provide chest compressions for infants and children.

Resuscitation Education Science: Educational Strategies to Improve Outcomes From Cardiac Arrest: A Scientific Statement From the American Heart Association.

The formula for survival in resuscitation describes educational efficiency and local implementation as key determinants in survival after cardiac arrest. Current educational offerings in the form of standardized online and face-to-face courses are falling short, with providers demonstrating a decay of skills over time. This translates to suboptimal clinical care and poor survival outcomes from cardiac arrest. In many institutions, guidelines taught in courses are not thoughtfully implemented in the clinical environment. A current synthesis of the evidence supporting best educational and knowledge translation strategies in resuscitation is lacking. In this American Heart Association scientific statement, we provide a review of the literature describing key elements of educational efficiency and local implementation, including mastery learning and deliberate practice, spaced practice, contextual learning, feedback and debriefing, assessment, innovative educational strategies, faculty development, and knowledge translation and implementation. For each topic, we provide suggestions for improving provider performance that may ultimately optimize patient outcomes from cardiac arrest.

Outcomes After Extracorporeal Cardiopulmonary Resuscitation of Pediatric In-Hospital Cardiac Arrest: A Report From the Get With the Guidelines-Resuscitation and the Extracorporeal Life Support Organization Registries.

OBJECTIVES: The aim of this study was to determine cardiac arrest- and extracorporeal membrane oxygenation-related risk factors associated with unfavorable outcomes after extracorporeal cardiopulmonary resuscitation. DESIGN: We performed an analysis of merged data from the Extracorporeal Life Support Organization and the American Heart Association Get With the Guidelines-Resuscitation registries. SETTING: A total of 32 hospitals reporting to both registries between 2000 and 2014. PATIENTS: Children younger than 18 years old who suffered in-hospital cardiac arrest and underwent extracorporeal cardiopulmonary resuscitation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 593 children included in the final cohort, 240 (40.5%) died prior to decannulation from extracorporeal membrane oxygenation and 352 (59.4%) died prior to hospital discharge. A noncardiac diagnosis and preexisting renal insufficiency were associated with increased odds of death (adjusted odds ratio, 1.85 [95% CI, 1.19-2.89] and 4.74 [95% CI, 2.06-10.9], respectively). The median time from onset of the cardiopulmonary resuscitation event to extracorporeal membrane oxygenation initiation was 48 minutes (interquartile range, 28-70 min). Longer time from onset of the cardiopulmonary resuscitation event to extracorporeal membrane oxygenation initiation was associated with higher odds of death prior to hospital discharge (adjusted odds ratio for each 5 additional minutes of cardiopulmonary resuscitation prior to extracorporeal membrane oxygenation initiation, 1.04 [95% CI, 1.01-1.07]). Each individual adverse event documented during the extracorporeal membrane oxygenation course, including neurologic, pulmonary, renal, metabolic, cardiovascular and hemorrhagic, was associated with higher odds of death, with higher odds as the cumulative number of documented adverse events during the extracorporeal membrane oxygenation course increased. CONCLUSIONS: Outcomes after extracorporeal cardiopulmonary resuscitation reported by linking two national registries are encouraging. Noncardiac diagnoses, preexisting renal insufficiency, longer time from onset of the cardiopulmonary resuscitation event to extracorporeal membrane oxygenation initiation, and adverse events during the extracorporeal membrane oxygenation course are associated with worse outcomes.

Influence of Cardiopulmonary Resuscitation Coaching and Provider Role on Perception of Cardiopulmonary Resuscitation Quality During Simulated Pediatric Cardiac Arrest.

OBJECTIVES: We aimed to describe the impact of a cardiopulmonary resuscitation coach on healthcare provider perception of cardiopulmonary resuscitation quality during simulated pediatric cardiac arrest. DESIGN: Prospective, observational study. SETTING: We conducted secondary analysis of data collected from a multicenter, randomized trial of providers who participated in a simulated pediatric cardiac arrest. SUBJECTS: Two-hundred pediatric acute care providers. INTERVENTIONS: Participants were randomized to having a cardiopulmonary resuscitation coach versus no cardiopulmonary resuscitation coach. Cardiopulmonary resuscitation coaches provided feedback on cardiopulmonary resuscitation performance and helped to coordinate key tasks. All teams used cardiopulmonary resuscitation feedback technology. MEASUREMENTS AND MAIN RESULTS: Cardiopulmonary resuscitation quality was collected by the defibrillator, and perceived cardiopulmonary resuscitation quality was collected by surveying participants after the scenario. We calculated the difference between perceived and measured quality of cardiopulmonary resuscitation and defined accurate perception as no more than 10% deviation from measured quality of cardiopulmonary resuscitation. Teams with a cardiopulmonary resuscitation coach were more likely to accurately estimate chest compressions depth in comparison to teams without a cardiopulmonary resuscitation coach (odds ratio, 2.97; 95% CI, 1.61-5.46; p < 0.001). There was no significant difference detected in accurate perception of chest compressions rate between groups (odds ratio, 1.33; 95% CI, 0.77-2.32; p = 0.32). Among teams with a cardiopulmonary resuscitation coach, the cardiopulmonary resuscitation coach had the best chest compressions depth perception (80%) compared with the rest of the team (team leader 40%, airway 55%, cardiopulmonary resuscitation provider 30%) (p = 0.003). No differences were found in perception of chest compressions rate between roles (p = 0.86). CONCLUSIONS: Healthcare providers improved their perception of cardiopulmonary resuscitation depth with a cardiopulmonary resuscitation coach present. The cardiopulmonary resuscitation coach had the best perception of chest compressions depth.

A National Survey on Interhospital Transport of Children in Cardiac Arrest.

OBJECTIVES: To describe the U.S. experience with interhospital transport of children in cardiac arrest undergoing cardiopulmonary resuscitation. DESIGN: Self-administered electronic survey. SETTING: Pediatric transport teams listed with the American Academy of Pediatrics Section on Transport Medicine. SUBJECTS: Leaders of U.S. pediatric transport teams. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Sixty of the 88 teams surveyed (68%) responded. Nineteen teams (32%) from 13 states transport children undergoing cardiopulmonary resuscitation between hospitals. The most common reasons for transfer of children in cardiac arrest are higher level-of-care (70%), extracorporeal life support (60%), and advanced trauma resuscitation (35%). Eligibility is typically decided on a case-by-case basis (85%) and sometimes involves a short interhospital distance (35%), or prompt institution of high-quality cardiopulmonary resuscitation (20%). Of the 19 teams that transport with ongoing cardiopulmonary resuscitation, 42% report no special staff safety features, 42% have guidelines or protocols, 37% train staff on resuscitation during transport, 11% brace with another provider, and 5% use mechanical cardiopulmonary resuscitation devices for patients less than 18 years. In the past 5 years, 18 teams report having done such cardiopulmonary resuscitation transports: 22% did greater than five transports, 44% did two to five transports, 6% did one transport, and the remaining 28% did not recall the number of transports. Seventy-eight percent recall having transported by ambulance, 44% by helicopter, and 22% by fixed-wing. Although patient outcomes were varied, eight teams (44%) reported survivors to ICU and/or hospital discharge. CONCLUSIONS: A minority of U.S. teams perform interhospital transport of children in cardiac arrest undergoing cardiopulmonary resuscitation. Eligibility criteria, transport logistics, and patient outcomes are heterogeneous. Importantly, there is a paucity of established safety protocols for the staff performing cardiopulmonary resuscitation in transport.

The Effect of Asphyxia Arrest Duration on a Pediatric End-Tidal CO2-Guided Chest Compression Delivery Model.

OBJECTIVES: To determine the effect of the duration of asphyxial arrest on the survival benefit previously seen with end-tidal CO2-guided chest compression delivery. DESIGN: Preclinical randomized controlled study. SETTING: University animal research laboratory. SUBJECTS: Two-week-old swine. INTERVENTIONS: After either 17 or 23 minutes of asphyxial arrest, animals were randomized to standard cardiopulmonary resuscitation or end-tidal CO2-guided chest compression delivery. Standard cardiopulmonary resuscitation was optimized by marker, monitor, and verbal feedback about compression rate, depth, and release. End-tidal CO2-guided delivery used adjustments to chest compression rate and depth to maximize end-tidal CO2 level without other feedback. Cardiopulmonary resuscitation for both groups proceeded from 10 minutes of basic life support to 10 minutes of advanced life support or return of spontaneous circulation. MEASUREMENTS AND MAIN RESULTS: After 17 minutes of asphyxial arrest, mean end-tidal CO2 during 10 minutes of cardiopulmonary resuscitation was 18 ± 9 torr in the standard group and 33 ± 15 torr in the end-tidal CO2 group (p = 0.004). The rate of return of spontaneous circulation was three of 14 (21%) in the standard group rate and nine of 14 (64%) in the end-tidal CO2 group (p = 0.05). After a 23-minute asphyxial arrest, neither end-tidal CO2 values (20 vs 26) nor return of spontaneous circulation rate (3/14 vs 1/14) differed between the standard and end-tidal CO2-guided groups. CONCLUSIONS: Our previously observed survival benefit of end-tidal CO2-guided chest compression delivery after 20 minutes of asphyxial arrest was confirmed after 17 minutes of asphyxial arrest. The poor survival after 23 minutes of asphyxia shows that the benefit of end-tidal CO2-guided chest compression delivery is limited by severe asphyxia duration.

HeartWare Ventricular Assist Device Implantation for Pediatric Heart Failure-A Single Center Approach.

While pediatric HeartWare HVAD application has increased, determining candidacy and timing for initiation of pediatric VAD support has remained a challenge. We present our experience with a systematic approach to HVAD implantation as a bridge to pediatric heart transplantation. We performed a retrospective, single center review of pediatric patients (n = 11) who underwent HVAD implantation between September 2014 and January 2018. Primary endpoints evaluated were survival to heart transplantation, need for right ventricular assist device (RVAD) at any point, ongoing HVAD support, or death. Median patient age was 11 years (range: 3-16). Median BSA was 1.25 m2 (range: 0.56-2.1). Heart failure etiologies requiring support were dilated cardiomyopathy (n = 8), myocarditis (n = 1), congenital mitral valve disease (n = 1), and single ventricle heart failure (n = 1). Median time from cardiac ICU admission for heart failure to HVAD placement was 15 days (range 3-55), based on standardized VAD implantation criteria involving imaging assessment and noncardiac organ evaluation. The majority of patients (91%) were INTERMACS Level 2 at time of implant. Three patients (27%) had CentriMag RVAD placement at time of HVAD implantation. Two of these three patients had successful RVAD explanation within 2 weeks. Median length of HVAD support was 60 days (range 6-405 days). Among the 11 patients, survival during HVAD therapy to date is 91% (10/11) with 9 (82%) bridged to heart transplantation and one (9%) continuing to receive support. Posttransplant survival has been 100%, with median follow-up of 573 days (range 152-1126). A systematic approach to HVAD implantation can provide excellent results in pediatric heart failure management for a variety of etiologies and broad BSA range.

Improving the handover and transport of critically ill pediatric patients.

AIMS AND OBJECTIVES: The aims of this project were to (a) determine barriers to current handover and transport process, (b) develop a new protocol and process for team-to-team handover, and (c) evaluate staff satisfaction with the new process. BACKGROUND: The handover and transport of critically ill patients from the paediatric emergency department to the paediatric intensive care unit is a period of vulnerability associated with adverse events. DESIGN: A mixed-methods study using a quasi-experimental design and qualitative approach. METHODS: Focus groups were conducted to determine the barriers and facilitators of the current handover and transport process. Using these themes, a multidisciplinary team developed and implemented a new process including establishment of eight patient criteria for specialised transport and a standardised, interdisciplinary handover tool for team-to-team handover. Staff satisfaction was examined pre- and postintervention. RESULTS: Content analysis of focus groups revealed five categories: need for improved communication, cultural dissonance among units, defects in system and processes, need for standardisation and ambiguity between providers regarding acuity. Staff members reported improvements in their perceptions of satisfaction, safety, communication and role understanding associated with the new process. CONCLUSIONS: Standardisation through the establishment of severity of illness criteria and communication tools creates shared mental models and decreases risks to safety. A paradigm shift of team-to-team handover and transport is recommended. RELEVANCE TO CLINICAL PRACTICE: This paper suggests the importance of improving communication during the handover and transport process through establishing standardised patient severity of illness criteria, use of standardised tools and team-to-team handover processes.

A Multi-Institutional Simulation Boot Camp for Pediatric Cardiac Critical Care Nurse Practitioners.

OBJECTIVES: Assess the effect of a simulation "boot camp" on the ability of pediatric nurse practitioners to identify and treat a low cardiac output state in postoperative patients with congenital heart disease. Additionally, assess the pediatric nurse practitioners' confidence and satisfaction with simulation training. DESIGN: Prospective pre/post interventional pilot study. SETTING: University simulation center. SUBJECTS: Thirty acute care pediatric nurse practitioners from 13 academic medical centers in North America. INTERVENTIONS: We conducted an expert opinion survey to guide curriculum development. The curriculum included didactic sessions, case studies, and high-fidelity simulation, based on high-complexity cases, congenital heart disease benchmark procedures, and a mix of lesion-specific postoperative complications. To cover multiple, high-complexity cases, we implemented Rapid Cycle Deliberate Practice method of teaching for selected simulation scenarios using an expert driven checklist. MEASUREMENTS AND MAIN RESULTS: Knowledge was assessed with a pre-/posttest format (maximum score, 100%). A paired-sample t test showed a statistically significant increase in the posttest scores (mean [SD], pre test, 36.8% [14.3%] vs post test, 56.0% [15.8%]; p < 0.001). Time to recognize and treat an acute deterioration was evaluated through the use of selected high-fidelity simulation. Median time improved overall "time to task" across these scenarios. There was a significant increase in the proportion of clinically time-sensitive tasks completed within 5 minutes (pre, 60% [30/50] vs post, 86% [43/50]; p = 0.003] Confidence and satisfaction were evaluated with a validated tool ("Student Satisfaction and Self-Confidence in Learning"). Using a five-point Likert scale, the participants reported a high level of satisfaction (4.7 ± 0.30) and performance confidence (4.8 ± 0.31) with the simulation experience. CONCLUSIONS: Although simulation boot camps have been used effectively for training physicians and educating critical care providers, this was a novel approach to educating pediatric nurse practitioners from multiple academic centers. The course improved overall knowledge, and the pediatric nurse practitioners reported satisfaction and confidence in the simulation experience.

Characterization of Pediatric In-Hospital Cardiopulmonary Resuscitation Quality Metrics Across an International Resuscitation Collaborative.

OBJECTIVES: Pediatric in-hospital cardiac arrest cardiopulmonary resuscitation quality metrics have been reported in few children less than 8 years. Our objective was to characterize chest compression fraction, rate, depth, and compliance with 2015 American Heart Association guidelines across multiple pediatric hospitals. DESIGN: Retrospective observational study of data from a multicenter resuscitation quality collaborative from October 2015 to April 2017. SETTING: Twelve pediatric hospitals across United States, Canada, and Europe. PATIENTS: In-hospital cardiac arrest patients (age < 18 yr) with quantitative cardiopulmonary resuscitation data recordings. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 112 events yielding 2,046 evaluable 60-second epochs of cardiopulmonary resuscitation (196,669 chest compression). Event cardiopulmonary resuscitation metric summaries (median [interquartile range]) by age: less than 1 year (38/112): chest compression fraction 0.88 (0.61-0.98), chest compression rate 119/min (110-129), and chest compression depth 2.3 cm (1.9-3.0 cm); for 1 to less than 8 years (42/112): chest compression fraction 0.94 (0.79-1.00), chest compression rate 117/min (110-124), and chest compression depth 3.8 cm (2.9-4.6 cm); for 8 to less than 18 years (32/112): chest compression fraction 0.94 (0.85-1.00), chest compression rate 117/min (110-123), chest compression depth 5.5 cm (4.0-6.5 cm). "Compliance" with guideline targets for 60-second chest compression "epochs" was predefined: chest compression fraction greater than 0.80, chest compression rate 100-120/min, and chest compression depth: greater than or equal to 3.4 cm in less than 1 year, greater than or equal to 4.4 cm in 1 to less than 8 years, and 4.5 to less than 6.6 cm in 8 to less than 18 years. Proportion of less than 1 year, 1 to less than 8 years, and 8 to less than 18 years events with greater than or equal to 60% of 60-second epochs meeting compliance (respectively): chest compression fraction was 53%, 81%, and 78%; chest compression rate was 32%, 50%, and 63%; chest compression depth was 13%, 19%, and 44%. For all events combined, total compliance (meeting all three guideline targets) was 10% (11/112). CONCLUSIONS: Across an international pediatric resuscitation collaborative, we characterized the landscape of pediatric in-hospital cardiac arrest chest compression quality metrics and found that they often do not meet 2015 American Heart Association guidelines. Guideline compliance for rate and depth in children less than 18 years is poor, with the greatest difficulty in achieving chest compression depth targets in younger children.

Effect of a Pediatric Early Warning System on All-Cause Mortality in Hospitalized Pediatric Patients: The EPOCH Randomized Clinical Trial.

Importance: There is limited evidence that the use of severity of illness scores in pediatric patients can facilitate timely admission to the intensive care unit or improve patient outcomes. Objective: To determine the effect of the Bedside Paediatric Early Warning System (BedsidePEWS) on all-cause hospital mortality and late admission to the intensive care unit (ICU), cardiac arrest, and ICU resource use. Design, Setting, and Participants: A multicenter cluster randomized trial of 21 hospitals located in 7 countries (Belgium, Canada, England, Ireland, Italy, New Zealand, and the Netherlands) that provided inpatient pediatric care for infants (gestational age ≥37 weeks) to teenagers (aged ≤18 years). Participating hospitals had continuous physician staffing and subspecialized pediatric services. Patient enrollment began on February 28, 2011, and ended on June 21, 2015. Follow-up ended on July 19, 2015. Interventions: The BedsidePEWS intervention (10 hospitals) was compared with usual care (no severity of illness score; 11 hospitals). Main Outcomes and Measures: The primary outcome was all-cause hospital mortality. The secondary outcome was a significant clinical deterioration event, which was defined as a composite outcome reflecting late ICU admission. Regression analyses accounted for hospital-level clustering and baseline rates. Results: Among 144 539 patient discharges at 21 randomized hospitals, there were 559 443 patient-days and 144 539 patients (100%) completed the trial. All-cause hospital mortality was 1.93 per 1000 patient discharges at hospitals with BedsidePEWS and 1.56 per 1000 patient discharges at hospitals with usual care (adjusted between-group rate difference, 0.01 [95% CI, -0.80 to 0.81 per 1000 patient discharges]; adjusted odds ratio, 1.01 [95% CI, 0.61 to 1.69]; P = .96). Significant clinical deterioration events occurred during 0.50 per 1000 patient-days at hospitals with BedsidePEWS vs 0.84 per 1000 patient-days at hospitals with usual care (adjusted between-group rate difference, -0.34 [95% CI, -0.73 to 0.05 per 1000 patient-days]; adjusted rate ratio, 0.77 [95% CI, 0.61 to 0.97]; P = .03). Conclusions and Relevance: Implementation of the Bedside Paediatric Early Warning System compared with usual care did not significantly decrease all-cause mortality among hospitalized pediatric patients. These findings do not support the use of this system to reduce mortality. Trial Registration: clinicaltrials.gov Identifier: NCT01260831.

Interhospital Transport of Children Undergoing Cardiopulmonary Resuscitation: A Practical and Ethical Dilemma.

OBJECTIVES: To discuss risks and benefits of interhospital transport of children in cardiac arrest undergoing cardiopulmonary resuscitation. DESIGN: Narrative review. RESULTS: Not applicable. CONCLUSIONS: Transporting children in cardiac arrest with ongoing cardiopulmonary resuscitation between hospitals is potentially lifesaving if it enables access to resources such as extracorporeal support, but may risk transport personnel safety. Research is needed to optimize outcomes of patients transported with ongoing cardiopulmonary resuscitation and reduce risks to the staff caring for them.