Implications of pediatric extracorporeal cardiopulmonary resuscitation simulation for intensive care team confidence and coordination: A pilot study.

INTRODUCTION: Extracorporeal cardiopulmonary resuscitation (ECPR) is associated with improved outcomes in select populations, however, crisis resource management (CRM) in this setting is logistically challenging. This study evaluates the impact of ECPR simulation on self-perceived confidence and collaboration of intensive care unit team members. METHODS: This is a prospective observational study analyzing data obtained between July 2018-December 2019. This study focused on non-surgical members of critical care team consisting of pediatric intensivists, resident physicians, registered nurses, respiratory therapists. Participants were expected to perform cardiopulmonary resuscitation (CPR) during the ECPR event, participate in code-team responsibilities and provide ancillary support during cannulation. Pre- and post-simulation surveys employed the Likert scale (1 = not at all confident, 5 = highly confident) to assess self-perceived scores in specified clinical competencies. RESULTS: Twenty-nine providers participated in the simulation; 38% had prior ECPR experience. Compared to mean pre-study Likert scores (2.4, 2.4, 2.5), post-simulation scores increased (4.2, 4.4, 4.3) when self-evaluating: confidence in assessing patients needing ECPR, confidence in participating in ECPR workflow and confidence in performing high-quality CPR, respectively. Post-simulation values of >3 were reported by 100% of participants in all domains (p < .0001). All participants indicated the clinical scenario and procedural environment to be realistic and appropriately reflective of situational stress. Additionally, 100% of participants reported the simulation to improve perceived team communication and teamwork skills. CONCLUSION: This study demonstrated preliminary feasibility of pediatric ECPR simulation in enhancing independent provider confidence and team communication. This self-perceived improvement may establish a foundation for cohesive CRM, in preparation for a real life ECPR encounter.

Simulation-Based Training in High-Quality Cardiopulmonary Resuscitation Among Neonatal Intensive Care Unit Providers.

Introduction: American Heart Association guidelines recommend the use of feedback devices for CPR provider resuscitation training. There is paucity of published literature regarding the utility of these devices especially in neonates and infants. We sought to evaluate if simulation-based education and debriefing using a CPR feedback device would improve CPR performance on an infant manikin in a cohort of NICU nurses as evaluated by CPR feedback device. Methods: We conducted a prospective, observational simulation study to assess the quality of chest compressions by NICU nurses before and after debriefing using CPR quality data captured by an accelerometer-based device. Chest compression (CC) depth, rate, recoil, CC fraction and nursing confidence level related to performing a high-quality CPR were compared before and after debriefing using paired t-test and Wilcoxon rank sum test. Results: A total of 62 NICU nurses participated in the study and all of them were Neonatal Resuscitation Program (NRP) certified. There was a significant improvement in CC depth and CC fraction [mean + SD values = 0.79 in + 0.17 (pre-debrief), 0.86 in + 0.21 (post-debrief) (p = 0.034) and 56.8% + 17.7 (pre-debrief), 70.8% + 18.4 (post-debrief) (0.0014), respectively]. There was no difference in CC rate (p = 0.36) and recoil (p = 0.25) between pre and post structured debriefing. The confidence level of nurses in all CPR dynamics (appropriate CC rate, CC depth, team communication, minimizing interruption in CC and coordinating CC with ventilation) was significantly higher after simulation and structured debriefing. All the nurses used 3:1 compression: ventilation ratio of NRP despite the patient being a 4 month old premature baby in the NICU. Conclusions: Simulation training and debriefing of NICU nurses using CPR feedback device improved their chest compression quality on an infant mannequin and their confidence level for performing high-quality CPR. NICU providers tend to use NRP protocol of 3:1 compression: ventilation ratio during CPR in the NICU irrespective of age of the infant.

Operation continued care: A large mass-casualty, full-scale exercise as a test of regional preparedness.

BACKGROUND: Our regional trauma organization, which comprises 7 trauma centers, 30 acute care hospitals and free-standing emergency departments, and 42 emergency medical services agencies, conducted possibly the largest mass-casualty drill to date, totaling 445 victims at 3 sites involving 11 hospitals and 25 agencies and organizations. METHODS: The drill was preceded by a tabletop exercise 4 months beforehand called Operation Continued Care Full-Scale Exercise, which consisted of simulated terrorist events at 3 sites to wound 445 moulaged patients. Four law enforcement and 5 fire and emergency medical services departments and 16 supporting organizations and agencies were involved in transporting patients to 11 different hospitals. The 7 objectives for the event addressed coordinating emergency operations, sustaining adequate communications, updating regional bed status, processing resource requests, triaging patients, tracking patients, and patient identification. RESULTS: Of the 445 transported patients, 270 (60%) were entered correctly into the state patient tracking system; 68 (25.2%) upgrades and 34 (12.6%) downgrades from scene triage categories were noted. Multiple opportunities for improvement were identified, with major weaknesses noted in communication and coordination from event sites to the regional trauma organizations and hospitals. CONCLUSION: The size and complexity of the drill provided experience and knowledge to facilitate future disaster preparedness and highlighted weaknesses in communication and coordination. Large, multijurisdictional, multiagency exercises provide opportunities to stress, evaluate, and improve regional disaster preparedness.

Ambulance staging for potentially dangerous scenes: another hidden component of response time.

BACKGROUND: Emergency medical services (EMS) responses to some scenes are potentially more dangerous than others, requiring EMS systems to develop policies that stage medical responders away from the scene until law enforcement has the area secured. OBJECTIVES: We sought to characterize the calls that are staged and to demonstrate the effect of staging on the response time interval and differences in red lights and sirens (RLS) transport to the hospital between staged calls (SC) and nonstaged calls (NSC). METHODS: This was a retrospective cohort study of all 9-1-1 calls received during calendar year 2006 in a midwestern, high-performance system. Descriptive statistics, Mann-Whitney U test, and chi-square analysis were used as appropriate; p < 0.05 was considered significant. RESULTS: There were 62,157 emergency calls for which responders arrived on scene during the study period; 4,414 (7.1%) were SC and 57,743 (92.9%) were NSC. By protocol, dispatchers ordered EMS to stage on five categories: 924 for assault/rape (20.9%), 393 for unknown problem/man down (8.9%), 918 for overdose (20.8%), 734 for psychiatric/suicide attempt (16.6%), and 413 for stab/gunshot wound (9.4%). Dispatchers ordered staging using their own discretion for 1,032 (23.4%) calls. The median response time interval (call received until ambulance arrived at the scene) was 10 minutes 55 seconds (i.e., 10:55 minutes) (interquartile range [IQR]: 8:00-14:27) for SC and 6:16 minutes (IQR: 4:42-8:28) for NSC (p < 0.0001). Patients were transported to the hospital for 3,104 (70.3%) of SC, 223 (7.2%) with RLS; patients were transported to the hospital for 41,716 (72.2%) of NSC, 2,802 (6.7%) with RLS. There was no difference in the rate of RLS return between SC and NSC (p = 0.314). CONCLUSION: The practice of staging ambulances while police secure potentially dangerous scenes added approximately 4.5 minutes to the response time. We were unable to demonstrate a difference in RLS return to the hospital (our proxy for patient acuity) between SC and NSC.

Improved patient survival using a modified resuscitation protocol for out-of-hospital cardiac arrest.

BACKGROUND: Cardiac arrest continues to have poor survival in the United States. Recent studies have questioned current practice in resuscitation. Our emergency medical services system made significant changes to the adult cardiac arrest resuscitation protocol, including minimizing chest compression interruptions, increasing the ratio of compressions to ventilation, deemphasizing or delaying intubation, and advocating chest compressions before initial countershock. METHODS AND RESULTS: This retrospective observational cohort study reviewed all adult primary ventricular fibrillation and pulseless ventricular tachycardia cardiac arrests 36 months before and 12 months after the protocol change. Primary outcome was survival to discharge; secondary outcomes were return of spontaneous circulation and cerebral performance category. Survival of out-of-hospital arrest of presumed primary cardiac origin improved from 7.5% (82 of 1097) in the historical cohort to 13.9% (47 of 339) in the revised protocol cohort (odds ratio, 1.80; 95% confidence interval, 1.19 to 2.70). Similar increases in return of spontaneous circulation were achieved for the subset of witnessed cardiac arrest patients with initial rhythm of ventricular fibrillation from 37.8% (54 of 143) to 59.6% (34 of 57) (odds ratio, 2.44; 95% confidence interval, 1.24 to 4.80). Survival to hospital discharge also improved from an unadjusted survival rate of 22.4% (32 of 143) to 43.9% (25 of 57) (odds ratio, 2.71; 95% confidence interval, 1.34 to 1.59) with the protocol. Of the 25 survivors, 88% (n=22) had favorable cerebral performance categories on discharge. CONCLUSIONS: The changes to our prehospital protocol for adult cardiac arrest that optimized chest compressions and reduced disruptions increased the return of spontaneous circulation and survival to discharge in our patient population. These changes should be further evaluated for improving survival of out-of-hospital cardiac arrest patients.

Handicapping: the effects of its source and frequency.

Using a sample of 246 working adults, the authors created a 2 x 2 x 2 experimental design to isolate the influence of performance outcome, source of handicapping, and frequency of handicapping on reactions to handicapping in organizations. Dependent measures were observers' allocations of credit/blame, interpersonal affect, and the perceived credibility of the explanation. Results showed direct effects on observer impressions for all 3 independent variables, along with a significant Source x Frequency interaction. Handicapping information presented by others yielded more favorable observer impressions than did self-handicapping, and frequent handicapping decreased observer impressions. The least credible handicapping strategy was multiple self-handicaps. A significant 3-way interaction showed that source and frequency affected perceived credibility differently, depending upon whether actual performance was a success or a failure.

Environmental factors encountered during out-of-hospital intubation attempts.

OBJECTIVES: Emergency medical services (EMS) literature has studied paramedic performance with endotracheal intubation; however, there are few data describing environmental differences between out-of-hospital and in-hospital providers during intubation attempts. The purpose of this study was to describe the environmental factors encountered by paramedics. SETTING: Midwest, urban, public utility model, all-advanced life support (ALS) ambulance service with 85,000 calls and 55,000 transports per year. DESIGN: Prospective, observational study using a standardized data-collection tool completed on all adult cardiac arrest patients for whom intubation was attempted during the period from September 1, 2000, through September 1, 2004. Descriptive data including count and frequency statistics of environmental factors were calculated. RESULTS: There were 1,894 attempts on 1,396 patients during the study period; 236 (12.5%) attempts on 161 patients (11.5%) were removed from the analysis because of incomplete data, leaving 1,658 attempts on 1,235 patients. The intubation success rate was 85% (95% confidence interval [CI] 83, 97). Paramedics most frequently attempt intubation indoors (1,239, 75%), prefer to kneel at the patient's head (899, 54%), encounter significant scene distractions (340, 20%), have optimal lighting (1,271, 77%), but frequently have suboptimal space (655, 40%). Patients are most often supine (1,653, 99%). CONCLUSIONS: The out-of-hospital intubation environment is significantly different from that of in-hospital providers. Paramedics frequently have a poor physical operating environment and encounter significant distractions while trying to perform endotracheal intubation. Future studies should analyze the association of these factors with intubation success.

The association of dispatch prioritization and patient acuity.

INTRODUCTION: EMS systems use call prioritization to distinguish between high and low acuity patients, better use resources, and set system response times. Previous research focused on patient condition; however, recent research has reviewed patient acuity as an important maker for system response. Our objective was to analyze any trend between priority dispatch determinant codes and using a red lights and siren (RLS) transport from the scene. METHODS: Retrospective cohort observational study of 9-1-1 calls received in CY 2003. Chi-square analysis for trend and odds ratios with 95% CI were calculated to evaluate the differences in proportions of patients being transported RLS from the scene according to determinant level, p < 0.05 was considered significant. RESULTS: There was significant heterogeneity among the determinant cohorts (chi-square = 204.477, p < 0.001, 5 df). Further analysis showed absolute and proportional increases in RLS transport from the scene with increasing determinant level. The three lowest determinant levels were low risk (OR 0.13, 0.49, and 0.58), and the two highest determinant levels had significant risk for RLS transport (OR 1.63, 32.11). CONCLUSIONS: Patients had increasing likelihood of being transported by RLS from the scene with increasing determinant level. Calls with the two highest determinant levels were at significant risk of being transported RLS from the scene.