Use of Initial Endotracheal Versus Intravenous Epinephrine During Neonatal Cardiopulmonary Resuscitation in the Delivery Room: Review of a National Database.

OBJECTIVE: To assess whether initial epinephrine administration by endotracheal tube (ET) in newly born infants receiving chest compressions and epinephrine in the delivery room (DR) is associated with lower rates of return of spontaneous circulation (ROSC) than newborns receiving initial intravenous (IV) epinephrine. STUDY DESIGN: We conducted a retrospective review of neonates receiving chest compressions and epinephrine in the DR from the AHA Get With The Guidelines-Resuscitation registry from October 2013 through July 2020. Neonates were classified according to initial route of epinephrine (ET vs IV). The primary outcome of interest was ROSC in the DR. RESULTS: In total, 408 infants met inclusion criteria; of these, 281 (68.9%) received initial ET epinephrine and 127 (31.1%) received initial IV epinephrine. The initial ET epinephrine group included those infants who also received subsequent IV epinephrine when ET epinephrine failed to achieve ROSC. Comparing initial ET with initial IV epinephrine, ROSC was achieved in 70.1% vs 58.3% (adjusted risk difference 10.02; 95% CI 0.05-19.99). ROSC was achieved in 58.3% with IV epinephrine alone, and 47.0% with ET epinephrine alone, with 40.0% receiving subsequent IV epinephrine. CONCLUSIONS: This study suggests that initial use of ET epinephrine is reasonable during DR resuscitation, as there were greater rates of ROSC compared with initial IV epinephrine administration. However, administration of IV epinephrine should not be delayed in those infants not responding to initial ET epinephrine, as almost one-half of infants who received initial ET epinephrine subsequently received IV epinephrine before achieving ROSC.

Multiple Hospital In-Situ Mass Casualty Incident Training Simulation for Emergency Medicine Residents: A Sarin Bomb Scenario.

INTRODUCTION: We simulated an on-site, multi-hospital mass casualty incident (MCI) to educate emergency medicine providers in the principles of trauma resuscitation and collaboration with administration and staff during an MCI. METHODS: We implemented high-fidelity manikins, inflatable manikins, and actors to simulate a sarin gas bombing. Learners triaged patients at a decontamination tent using the simple triage and rapid treatment (START) tool, or they participated in a simulation in a resuscitation bay. RESULTS: Forty participants anonymously rated the learning impact of the exercise, the clinical relevance to emergency medicine, and the effectiveness of the faculty facilitation and debriefing on a 1-5 Likert scale. The average responses to all questions were 4.45 or greater, and 98% of respondents recommended adding the scenario to the standard curriculum. DISCUSSION: We successfully executed a novel, multi- hospital, MCI drill that was rated to be a better alternative to sequential simulation in a simulation center.

Factors Associated With Improved Pediatric Resuscitative Care in General Emergency Departments.

OBJECTIVES: To describe the quality of pediatric resuscitative care in general emergency departments (GEDs) and to determine hospital-level factors associated with higher quality. METHODS: Prospective observational study of resuscitative care provided to 3 in situ simulated patients (infant seizure, infant sepsis, and child cardiac arrest) by interprofessional GED teams. A composite quality score (CQS) was measured and the association of this score with modifiable and nonmodifiable hospital-level factors was explored. RESULTS: A median CQS of 62.8 of 100 (interquartile range 50.5-71.1) was noted for 287 resuscitation teams from 175 emergency departments. In the unadjusted analyses, a higher score was associated with the modifiable factor of an affiliation with a pediatric academic medical center (PAMC) and the nonmodifiable factors of higher pediatric volume and location in the Northeast and Midwest. In the adjusted analyses, a higher CQS was associated with modifiable factors of an affiliation with a PAMC and the designation of both a nurse and physician pediatric emergency care coordinator, and nonmodifiable factors of higher pediatric volume and location in the Northeast and Midwest. A weak correlation was noted between quality and pediatric readiness scores. CONCLUSIONS: A low quality of pediatric resuscitative care, measured using simulation, was noted across a cohort of GEDs. Hospital factors associated with higher quality included: an affiliation with a PAMC, designation of a pediatric emergency care coordinator, higher pediatric volume, and geographic location. A weak correlation was noted between quality and pediatric readiness scores.

Faculty support bundle for simulation education.

BACKGROUND: Postgraduate training programmes rely on faculty to meet core educational needs, including simulation. Time is arguably the most valuable resource for academic physicians, which presents a challenge for recruiting faculty to provide extra-clinical teaching. To increase faculty engagement in simulation-based education (SBE), we first identified barriers to participation. Next, we sought to overcome barriers using a self-determination theory (SDT) framework to increase motivation using strategies that addressed faculty autonomy, competence and relatedness. METHODS: Faculty from a single department of emergency medicine were surveyed about factors influencing participation in SBE. Responses were grouped into themes and used to develop the intervention-a faculty support bundle-to overcome common barriers and promote participation. Supports focused on course materials, organisational consistency and peer recognition. Faculty participation in SBE pre- and post-implementation of the support bundle was analysed via chi-squared analysis. Faculty who delivered SBE were resurveyed after the implementation phase to explore how the support bundle affected their experience. RESULTS: Initial survey response was 41%. Reported barriers to participation in SBE included scheduling issues, preparation time, competing responsibilities, lack of confidence with simulation and lack of interest. Twenty-four faculty participated in SBE during the pre-implementation phase, compared to 39 post implementation (p = 0.03). DISCUSSION: The faculty support bundle increases faculty participation in SBE. Strategies focused on internal motivators identified using an SDT framework. In contrast to traditional external motivators, these were no cost interventions. Those seeking to increase faculty participation in SBE should consider implementing similar strategies.

Preparedness for Pediatric Office Emergencies: A Multicenter, Simulation-Based Study.

OBJECTIVES: Pediatric emergencies can occur in pediatric primary care offices. However, few studies have measured emergency preparedness, or the processes of emergency care, provided in the pediatric office setting. In this study, we aimed to measure emergency preparedness and care in a national cohort of pediatric offices. METHODS: This was a multicenter study conducted over 15 months. Emergency preparedness scores were calculated as a percentage adherence to 2 checklists on the basis of the American Academy of Pediatrics guidelines (essential equipment and supplies and policies and protocols checklists). To measure the quality of emergency care, we recruited office teams for simulation sessions consisting of 2 patients: a child with respiratory distress and a child with a seizure. An unweighted percentage of adherence to checklists for each case was calculated. RESULTS: Forty-eight teams from 42 offices across 9 states participated. The mean emergency preparedness score was 74.7% (SD: 12.9). The mean essential equipment and supplies subscore was 82.2% (SD: 15.1), and the mean policies and protocols subscore was 57.1% (SD: 25.6). Multivariable analyses revealed that independent practices and smaller total staff size were associated with lower preparedness. The median asthma case performance score was 63.6% (interquartile range: 43.2-81.2), whereas the median seizure case score was 69.2% (interquartile range: 46.2-80.8). Offices that had a standardized process of contacting emergency medical services (EMS) had a higher rate of activating EMS during the simulations. CONCLUSIONS: Pediatric office preparedness remains suboptimal in a multicenter cohort, especially in smaller, independent practices. Academic and community partnerships using simulation can help address gaps and implement important processes like contacting EMS.

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.

When Parents Hit: Providing Education to Physician Trainees About Corporal Punishment Through a Pilot Simulation and Debriefing.

OBJECTIVES: No studies have evaluated how training physicians intervene when corporal punishment (CP) is observed in a simulated hospital setting. The pilot study examined physician trainee performance in a simulation where hitting is observed between caregiver and child during a medical visit and to assess physician self-reported experiences, opinions, and comfort when observing CP in a simulation. METHODS: We ran 7 simulations where one pediatric resident, emergency medicine resident, or pediatric emergency medicine fellow participated in the simulation while a group of similar trainees observed. All participants were given a postsurvey, followed by a semistructured debriefing led by a child abuse pediatrician. RESULTS: Thirty-seven physician trainees participated; 7 engaged in the simulation while 30 observed. The majority (6/7) did not de-escalate the increasingly aggravated parent prior to hitting, 4 of 7 did not recommend that the caregiver refrain from CP, and most (5/7) did not provide education to the parent about more appropriate discipline. The majority (91.4%) believe that a physician should intervene when a parent hits or spanks his/her child in the hospital setting, highlighting the incongruity between this belief and their performance in/knowledge of intervening. All participants stated they would benefit from additional education and training on CP. CONCLUSIONS: The educational experience provided physicians in training with the opportunity to participate in or observe a situation in which CP occurs in the medical setting. The simulation and debriefing were an innovative approach to providing an educational opportunity for physicians to learn from difficult situations and discussions surrounding CP with caregivers.

Excellence in Communication and Emergency Leadership (ExCEL): Pediatric First 5 Minutes Workshop for Residents.

Introduction: In-hospital pediatric cardiopulmonary arrest is associated with high morbidity and mortality, and appropriate initial management has been associated with improved clinical outcomes. Despite current training, pediatric residents often do not feel confident in their ability to deliver this initial management. This workshop focused on the initial management of critically ill pediatric patients and performance of high-quality CPR. Methods: This hands-on workshop utilized skill stations with low- and medium-fidelity simulators to instruct learners on initial management during the first 5 minutes of a code, including high-quality CPR. It was designed for residents across all levels of training who care for pediatric patients (including pediatrics, medicine-pediatrics, pediatrics, psychiatry, and child psychiatry, family medicine, and emergency medicine residents) and can be adapted for different session durations and group sizes. Results: This workshop was conducted at two separate institutions with a total of 18 resident participants. Participants strongly agreed that this workshop was relevant and effective in teaching the initial assessment and management of the critical pediatric patient, including how to best perform high-quality CPR. Residents further reported high levels of confidence in initially assessing and managing a critically ill patient, describing the markers of high-quality CPR, and performing high-quality CPR. Discussion: This workshop provided residents with additional instruction and practice in the initial management of critically ill pediatric patients in cardiopulmonary arrest. The structure and timeline of this curriculum can be adapted to the needs of the individual institution's program and the number of workshop participants.

Substance use screening, brief intervention, and referral to treatment training for emergency medicine trainees.

INTRODUCTION: Emergency medicine (EM) providers are in an opportunistic position to identify and intervene with patients at risk for alcohol misuse and related problems. However, alcohol screening, brief intervention, and referral to treatment (SBIRT) services are underutilized within the emergency department. Providing SBIRT training to trainees may help to increase utilization of these valuable services in the future. An SBIRT training program for EM faculty and trainees was developed and delivered to increase trainees' skills and practice of SBIRT services. METHODS: The SBIRT training program included unique tracks for medical students, physician assistant (PA) students, EM residents and faculty preceptors. Faculty and trainees completed performance measures at the end of each training session, 30 days post-training and 12 months later. RESULTS: SBIRT training was provided to 238 trainees and 65 faculty members. At all follow-up time points, satisfaction of training and usefulness varied by trainee type with PA students rating constructs higher than both medical students and EM residents. At the 12-month follow-up survey, there was no significant difference in ratings of sharing the information (χ2 (2)=0.38, P=0.33) between these trainees, with the majority of all trainees (96% of PA students, 83% of residents and 68% of medical students) responding that they had applied what they learned in the training to their work. CONCLUSION: An SBIRT training curriculum for EM trainees was delivered successfully and utilized 12 months after implementation.

Community-based in situ simulation: bringing simulation to the masses.

Simulation-based methods are regularly used to train inter-professional groups of healthcare providers at academic medical centers (AMC). These techniques are used less frequently in community hospitals. Bringing in-situ simulation (ISS) from AMCs to community sites is an approach that holds promise for addressing this disparity. This type of programming allows academic center faculty to freely share their expertise with community site providers. By creating meaningful partnerships community-based ISS facilitates the communication of best practices, distribution of up to date policies, and education/training. It also provides an opportunity for system testing at the community sites. In this article, we illustrate the process of implementing an outreach ISS program at community sites by presenting four exemplar programs. Using these exemplars as a springboard for discussion, we outline key lessons learned discuss barriers we encountered, and provide a framework that can be used to create similar simulation programs and partnerships. It is our hope that this discussion will serve as a foundation for those wishing to implement community-based, outreach ISS.

Optimizing CPR performance with CPR coaching for pediatric cardiac arrest: A randomized simulation-based clinical trial.

AIM: To determine if integrating a trained CPR Coach into resuscitation teams can improve CPR quality during simulated pediatric cardiopulmonary arrest (CPA). METHODS: We conducted a multicenter, prospective, randomized trial. An 18-minute simulated CPA scenario was run for resuscitation teams comprised of CPR-certified professionals from four International Network for Simulation-based Pediatric Innovation, Research & Education (INSPIRE) institutions. Forty teams (200 participants) were randomized to having a trained CPR Coach vs. no CPR Coach. CPR Coaches were responsible for providing real-time verbal feedback of CPR performance to compressors. All teams utilized CPR feedback technology. We report the proportion of overall excellent CPR, proportion of chest compressions (CC) with depth 50-60 mm, the proportion of CC with rate 100-120 per minute, CC fraction, and pre-, post-, and peri-shock pause duration. RESULTS: CPR coached teams compared with teams without a CPR Coach resulted in an absolute improvements in overall excellent CPR by 31.8% (95% CI, 17.7, 35.9; p < 0.001), mean CC depth compliance by 31.5% (15.7, 47.4; p < 0.001), mean CC depth by 4.6 mm (1.6, 7.5; p < 0.001), mean CC fraction by 5.4% (0.2, 10.6; p = 0.04), and mean pre-, post- and peri-shock pause duration by -2.7 s (-5.1, -0.4; p = 0.02), -1.0 s (-1.8, -0.2; p = 0.01); and -3.8 (-6.6, -1.0; p = 0.008), respectively. Changes in mean CC rate compliance and mean CC rate were not statistically significant. CONCLUSIONS: In the presence of CPR feedback technology, the integration of a trained CPR coach into resuscitation teams enhances CPRquality metrics associated with improved survival outcomes from pediatric cardiac arrest.

Impact of a CPR feedback device on healthcare provider workload during simulated cardiac arrest.

OBJECTIVE: We aimed to describe the differences in workload between team leaders and CPR providers during a simulated pediatric cardiac arrest, to evaluate the impact of a CPR feedback device on provider workload, and to describe the association between provider workload and the quality of CPR. METHODS: We conducted secondary analysis of data from a randomized trial comparing CPR quality in teams with and without use of a real-time visual CPR feedback device [1]. Healthcare providers (team leaders and CPR providers) completed the NASA Task Load Index survey after participating in a simulated cardiac arrest scenario. The effect of provider roles and real-time feedback on workload were compared with independent t-tests. RESULTS: Team leaders reported higher levels of mental demand, temporal demand, performance-related workload and frustration, while CPR providers reported comparatively higher physical workload. CPR providers reported significantly higher average workload (control 58.5 vs. feedback 62.3; p = 0.035) with real-time feedback provided compared to the group without feedback. Providers with high workloads (average score >60) had an increased percentage of time with guideline-compliant CPR depth versus those with low workloads (average score <60) (p = 0.034). CONCLUSIONS: Healthcare providers reported high workloads during a simulated pediatric cardiac arrest. Physical and mental workloads differed based on provider role. CPR providers using a CPR feedback device reported increased average workloads. The quality of CPR improved with higher reported physical workloads.

Providers' Perceptions of Caring for Pediatric Patients in Community Hospital Emergency Departments: A Mixed-methods Analysis.

BACKGROUND: Approximately 90% of pediatric emergency care is provided in community emergency departments (CEDs) that care for both adults and children. Paradoxically, the majority of pediatric emergency medicine knowledge generation, quality improvement work, and clinical training occurs in children's hospitals. There is a paucity of information of perceptions on pediatric care from CED providers. This information is needed to guide the development of strategies to improve CED pediatric readiness. OBJECTIVE: The objective was to explore interprofessional CED providers' perceptions of caring for pediatric patients. METHODS: A preparticipation survey collected data on demographics, experience, and comfort in caring for children. Emergency pediatric simulations were then utilized to prime interprofessional teams for debriefings. These discussions underwent qualitative analysis by three blinded authors who coded transcripts into themes through an inductive method derived from grounded theory. The other authors participated in confirmability and dependability checks. RESULTS: A total of 171 community hospital providers from six CEDs completed surveys (49% nurses, 22% physicians, 23% technicians). The majority were PALS trained (70%) and experienced fewer than five pediatric resuscitations in their careers (61%). Most self-reported comfort in caring for acutely ill and injured children. From the debriefings, three major challenge themes emerged: 1) knowledge and skill limitations attributed to infrequency of training and actual clinical events, 2) the emotional toll of caring for a sick child, and 3) acknowledgment of pediatric specific quality and safety deficits. Subthemes focused on causes and potential mitigating factors contributing to these challenges. A solution theme highlighted novel partnering opportunities with local children's hospitals. CONCLUSION: Interprofessional CED providers perceive that caring for pediatric patients is challenging due to case infrequency, the emotional toll of caring for sick children, and pediatric quality and safety deficits in their systems. These areas of focus can be used to generate specific strategies for improving CED pediatric readiness.

Electronic Medical Record in the ED: A Cross-Sectional Survey of Resuscitation Documentation Practices and Perceptions Among Emergency Department Clinicians.

OBJECTIVES: The aims of this study were to describe current practices in nursing documentation of trauma and medical resuscitations across emergency departments (EDs) and explore physicians' and nurses' perceptions of electronic medical record (EMR) use for nursing documentation of resuscitations. METHODS: An anonymous Web-based survey was developed and distributed to a convenience sample of ED physicians and nurses in the United States. RESULTS: Of 438 respondents, 154 were nurses; 97.2% of respondents reported that their EDs use EMR generally. Of those, 51.2% use EMR to document resuscitations. When describing documentation processes, 19% (95% confidence interval [CI], 15%-23%) reported direct documentation on EMR, 18% (95% CI, 14%-21%) reported documenting on paper before transferring to EMR, and 22% (95% CI, 18%-26%) reported simultaneously documenting on EMR and paper. Thirty-seven percent of respondents reported that the "documentor" frequently performs other tasks during resuscitations. Few nurses (39.6%) and physicians (26.4%) perceived EMR as more efficient than paper. Nurses (66.2%) and physicians (51.8%) perceived paper as more complete than EMR. Few nurses (31.6%) and physicians (25.6%) agreed that paper would facilitate continuity of care better than EMR. No associations between nurses' perceptions of EMR, professional experience, or technology use were found. CONCLUSIONS: Although EMR adoption was common among respondents, only half reported using EMR to document resuscitations. Even fewer reported documenting directly on EMR, whereas a significant proportion reported processes that may be inefficient, redundant, or prone to errors. Respondents endorsed mostly negative perceptions of EMR. Our findings suggest that there may be factors inherent to resuscitations and the existing EMR interfaces that render documenting resuscitations on EMR uniquely challenging.

A Grounded Theory Qualitative Analysis of Interprofessional Providers' Perceptions on Caring for Critically Ill Infants and Children in Pediatric and General Emergency Departments.

OBJECTIVE: The objective of this study was to explore pediatric emergency department (PED) and general emergency department (GED) providers' perceptions on caring for critically ill infants and children. METHODS: This study utilized qualitative methods to examine the perceptions of emergency department providers caring for critically ill infants and children. Teams of providers participated in 4 in situ simulation cases followed by facilitated debriefings. Debriefings were recorded and professionally transcribed. The transcripts were reviewed independently and followed by group coding discussions to identify emerging themes. Consistent with grounded theory, the team iteratively revised the debriefing script as new understanding was gained. A total of 188 simulation debriefings were recorded in 24 departments, with 15 teams participating from 8 PEDs and 32 teams from 16 GEDs. RESULTS: Twenty-four debriefings were audiotaped and professionally transcribed verbatim. Thematic saturation was achieved after 20 transcripts. In our iterative qualitative analysis of these transcripts, we observed 4 themes: (1) GED provider comfort with algorithm-based pediatric care and overall comfort with pediatric care in PED, (2) GED provider reliance on cognitive aids versus experience-based recall by PED providers, (3) GED provider discomfort with locating and determining size or dose of pediatric-specific equipment and medications, and (4) PED provider reliance on larger team size and challenges with multitasking during resuscitation. CONCLUSIONS: Our qualitative analysis produced several themes that help us to understand providers' perceptions in caring for critically ill children in GEDs and PEDs. These data could guide the development of targeted educational and improvement interventions.

Safety Threats During the Care of Infants with Hypoglycemic Seizures in the Emergency Department: A Multicenter, Simulation-Based Prospective Cohort Study.

BACKGROUND: Errors in the timely diagnosis and treatment of infants with hypoglycemic seizures can lead to significant patient harm. It is challenging to precisely measure medical errors that occur during high-stakes/low-frequency events. Simulation can be used to assess risk and identify errors. OBJECTIVE: We hypothesized that general emergency departments (GEDs) would have higher rates of deviations from best practices (errors) compared to pediatric emergency departments (PEDs) when managing an infant with hypoglycemic seizures. METHODS: This multicenter simulation-based prospective cohort study was conducted in GEDs and PEDs. In situ simulation was used to measure deviations from best practices during management of an infant with hypoglycemic seizures by inter-professional teams. Seven variables were measured: five nonpharmacologic (i.e., delays in airway assessment, checking dextrose, starting infusion, verbalizing disposition) and two pharmacologic (incorrect dextrose dose and incorrect dextrose concentration). The primary aim was to describe and compare the frequency and types of errors between GEDs and PEDs. RESULTS: Fifty-eight teams from 30 hospitals (22 GEDs, 8 PEDs) were enrolled. Pharmacologic errors occurred more often in GEDs compared to PEDs (p = 0.043), while nonpharmacologic errors were uncommon in both groups. Errors more frequent in GEDs related to incorrect dextrose concentration (60% vs. 88%; p = 0.025), incorrect dose (20% vs. 56%; p = 0.033), and failure to start maintenance dextrose (33% vs. 65%; p = 0.040). CONCLUSIONS: During the simulated care of an infant with hypoglycemic seizures, errors were more frequent in GEDs compared to PEDs. Decreasing annual pediatric patient volume was the best predictor of errors on regression analysis.

Perception of CPR quality: Influence of CPR feedback, Just-in-Time CPR training and provider role.

AIM: Many healthcare providers rely on visual perception to guide cardiopulmonary resuscitation (CPR), but little is known about the accuracy of provider perceptions of CPR quality. We aimed to describe the difference between perceived versus measured CPR quality, and to determine the impact of provider role, real-time visual CPR feedback and Just-in-Time (JIT) CPR training on provider perceptions. METHODS: We conducted secondary analyses of data collected from a prospective, multicenter, randomized trial of 324 healthcare providers who participated in a simulated cardiac arrest scenario between July 2012 and April 2014. Participants were randomized to one of four permutations of: JIT CPR training and real-time visual CPR feedback. We calculated the difference between perceived and measured quality of CPR and reported the proportion of subjects accurately estimating the quality of CPR within each study arm. RESULTS: Participants overestimated achieving adequate chest compression depth (mean difference range: 16.1-60.6%) and rate (range: 0.2-51%), and underestimated chest compression fraction (0.2-2.9%) across all arms. Compared to no intervention, the use of real-time feedback and JIT CPR training (alone or in combination) improved perception of depth (p<0.001). Accurate estimation of CPR quality was poor for chest compression depth (0-13%), rate (5-46%) and chest compression fraction (60-63%). Perception of depth is more accurate in CPR providers versus team leaders (27.8% vs. 7.4%; p=0.043) when using real-time feedback. CONCLUSION: Healthcare providers' visual perception of CPR quality is poor. Perceptions of CPR depth are improved by using real-time visual feedback and with prior JIT CPR training.

Improving cardiopulmonary resuscitation with a CPR feedback device and refresher simulations (CPR CARES Study): a randomized clinical trial.

IMPORTANCE: The quality of cardiopulmonary resuscitation (CPR) affects hemodynamics, survival, and neurological outcomes following pediatric cardiopulmonary arrest (CPA). Most health care professionals fail to perform CPR within established American Heart Association guidelines. OBJECTIVE: To determine whether "just-in-time" (JIT) CPR training with visual feedback (VisF) before CPA or real-time VisF during CPA improves the quality of chest compressions (CCs) during simulated CPA. DESIGN, SETTING, AND PARTICIPANTS: Prospective, randomized, 2 × 2 factorial-design trial with explicit methods (July 1, 2012, to April 15, 2014) at 10 International Network for Simulation-Based Pediatric Innovation, Research, & Education (INSPIRE) institutions running a standardized simulated CPA scenario, including 324 CPR-certified health care professionals assigned to 3-person resuscitation teams (108 teams). INTERVENTIONS: Each team was randomized to 1 of 4 permutations, including JIT training vs no JIT training before CPA and real-time VisF vs no real-time VisF during simulated CPA. MAIN OUTCOMES AND MEASURES: The proportion of CCs with depth exceeding 50 mm, the proportion of CPR time with a CC rate of 100 to 120 per minute, and CC fraction (percentage CPR time) during simulated CPA. RESULTS: The quality of CPR was poor in the control group, with 12.7% (95% CI, 5.2%-20.1%) mean depth compliance and 27.1% (95% CI, 14.2%-40.1%) mean rate compliance. JIT training compared with no JIT training improved depth compliance by 19.9% (95% CI, 11.1%-28.7%; P < .001) and rate compliance by 12.0% (95% CI, 0.8%-23.2%; P = .037). Visual feedback compared with no VisF improved depth compliance by 15.4% (95% CI, 6.6%-24.2%; P = .001) and rate compliance by 40.1% (95% CI, 28.8%-51.3%; P < .001). Neither intervention had a statistically significant effect on CC fraction, which was excellent (>89.0%) in all groups. Combining both interventions showed the highest compliance with American Heart Association guidelines but was not significantly better than either intervention in isolation. CONCLUSIONS AND RELEVANCE: The quality of CPR provided by health care professionals is poor. Using novel and practical technology, JIT training before CPA or real-time VisF during CPA, alone or in combination, improves compliance with American Heart Association guidelines for CPR that are associated with better outcomes. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02075450.

Development of a survey of teamwork and task load among medical providers: a measure of provider perceptions of teamwork when caring for critical pediatric patients.

INTRODUCTION: Teamwork training focuses on improving patient outcomes through better communication. Scales exist to assess providers' perceptions of teamwork; however, they are not designed for use immediately after the care of critically ill patients. OBJECTIVES: This study aimed to develop a survey to quantify providers' perceptions of teamwork and task load during critical care resuscitations in a PED and to use the tool to compare physician and nonphysician ratings of resuscitations. METHODS: Survey items were adapted from validated tools. The resulting survey contained 15 Likert scale items completed by providers immediately after resuscitations. An exploratory factor analysis was conducted. Mixed models, accounting for clustering of providers within resuscitations, tested for systematic differences in responses between physicians and nonphysicians and explored how well the factor scores predicted the overall "smoothness" of the resuscitation. RESULTS: Six hundred fifty-four surveys from 169 resuscitations were conducted. The exploratory factor analysis identified 2 factors with 13 items explaining 47% of the overall variance of "teamwork and communication" (Cronbach α = 0.80) and "task load" (Cronbach α = 0.77). There were no differences in factors predicting smoothness between physicians and nonphysicians (P = 0.27). Both were significant positive predictors of the outcome "the resuscitation went smoothly." CONCLUSIONS: The Survey of Teamwork and Task Load among Medical Providers was developed to evaluate providers' perceptions of teamwork immediately after care of critically ill patients in a pediatric emergency department. Items reflect 2 constructs, with good internal consistency. Responses did not vary by professional training, suggesting that it is useful for all providers. Both factors predicted the overall smoothness. Each was useful in predicting the perception that the resuscitation went smoothly.

Pediatric resuscitation: lessons learned and future directions.

The science of resuscitation has had significant and meaningful advances over the past fifty years, with resultant improvements in outcomes for both adult and pediatric populations. This article aims to describe some of the recent advances in pediatric resuscitation, including aspects of care affecting the management of cardiac arrest and sepsis, and to give a glimpse into technologies and methodologies that may be utilized to improve outcomes for children in the near future.