Improved Cardiopulmonary Resuscitation Performance With CODE ACES2: A Resuscitation Quality Bundle.

Background Over 6000 children have an in-hospital cardiac arrest in the United States annually. Most will not survive to discharge, with significant variability in survival across hospitals suggesting improvement in resuscitation performance can save lives. Methods and Results A prospective observational study of quality of chest compressions ( CC ) during pediatric in-hospital cardiac arrest associated with development and implementation of a resuscitation quality bundle. Objectives were to: 1) implement a debriefing program, 2) identify impediments to delivering high quality CC , 3) develop a resuscitation quality bundle, and 4) measure the impact of the resuscitation quality bundle on compliance with American Heart Association ( AHA ) Pediatric Advanced Life Support CC guidelines over time. Logistic regression was used to assess the relationship between compliance and year of event, adjusting for age and weight. Over 3 years, 317 consecutive cardiac arrests were debriefed, 38% (119/317) had CC data captured via defibrillator-based accelerometer pads, data capture increasing over time: (2013:13% [12/92] versus 2014:43% [44/102] versus 2015:51% [63/123], P<0.001). There were 2135 1-minute cardiopulmonary resuscitation (CPR) epoch data available for analysis, (2013:152 versus 2014:922 versus 2015:1061, P<0.001). Performance mitigating themes were identified and evolved into the resuscitation quality bundle entitled CPR Coaching, Objective-Data Evaluation, Action-linked-phrases, Choreography, Ergonomics, Structured debriefing and Simulation (CODE ACES2). The adjusted marginal probability of a CC epoch meeting the criteria for excellent CPR (compliant for rate, depth, and chest compression fraction) in 2015, after CPR Coaching, Objective-Data Evaluation, Action-linked-phrases, Choreography, Ergonomics, Structured debriefing and Simulation was developed and implemented, was 44.3% (35.3-53.3) versus 19.9%(6.9-32.9) in 2013; (odds ratio 3.2 [95% confidence interval:1.3-8.1], P=0.01). Conclusions CODE ACES2 was associated with progressively increased compliance with AHA CPR guidelines during in-hospital cardiac arrest.

Design and Deployment of a Pediatric Cardiac Arrest Surveillance System.

OBJECTIVE: We aimed to increase detection of pediatric cardiopulmonary resuscitation (CPR) events and collection of physiologic and performance data for use in quality improvement (QI) efforts. MATERIALS AND METHODS: We developed a workflow-driven surveillance system that leveraged organizational information technology systems to trigger CPR detection and analysis processes. We characterized detection by notification source, type, location, and year, and compared it to previous methods of detection. RESULTS: From 1/1/2013 through 12/31/2015, there were 2,986 unique notifications associated with 2,145 events, 317 requiring CPR. PICU and PEDS-ED accounted for 65% of CPR events, whereas floor care areas were responsible for only 3% of events. 100% of PEDS-OR and >70% of PICU CPR events would not have been included in QI efforts. Performance data from both defibrillator and bedside monitor increased annually. (2013: 1%; 2014: 18%; 2015: 27%). DISCUSSION: After deployment of this system, detection has increased ∼9-fold and performance data collection increased annually. Had the system not been deployed, 100% of PEDS-OR and 50-70% of PICU, NICU, and PEDS-ED events would have been missed. CONCLUSION: By leveraging hospital information technology and medical device data, identification of pediatric cardiac arrest with an associated increased capture in the proportion of objective performance data is possible.

Integration of in-hospital cardiac arrest contextual curriculum into a basic life support course: a randomized, controlled simulation study.

OBJECTIVE: The objective was to compare resuscitation performance on simulated in-hospital cardiac arrests after traditional American Heart Association (AHA) Healthcare Provider Basic Life Support course (TradBLS) versus revised course including in-hospital skills (HospBLS). DESIGN: This study is a prospective, randomized, controlled curriculum evaluation. SETTING: Johns Hopkins Medicine Simulation Center. SUBJECTS: One hundred twenty-two first year medical students were divided into fifty-nine teams. INTERVENTION: HospBLS course of identical length, containing additional content contextual to hospital environments, taught utilizing Rapid Cycle Deliberate Practice (RCDP). MEASUREMENTS: The primary outcome measure during simulated cardiac arrest scenarios was chest compression fraction (CCF) and secondary outcome measures included metrics of high quality resuscitation. MAIN RESULTS: Out-of-hospital cardiac arrest HospBLS teams had larger CCF: [69% (65-74) vs. 58% (53-62), p<0.001] and were faster than TradBLS at initiating compressions: [median (IQR): 9s (7-12) vs. 22s (17.5-30.5), p<0.001]. In-hospital cardiac arrest HospBLS teams had larger CCF: [73% (68-75) vs. 50% (43-54), p<0.001] and were faster to initiate compressions: [10s (6-11) vs. 36s (27-63), p<0.001]. All teams utilized the hospital AED to defibrillate within 180s per AHA guidelines [HospBLS: 122s (103-149) vs. TradBLS: 139s (117-172), p=0.09]. HospBLS teams performed more hospital-specific maneuvers to optimize compressions, i.e. utilized: CPR button to flatten bed: [7/30 (23%) vs. 0/29 (0%), p=0.006], backboard: [21/30 (70%) vs. 5/29 (17%), p<0.001], stepstool: [28/30 (93%) vs. 8/29 (28%), p<0.001], lowered bedrails: [28/30 (93%) vs. 10/29 (34%), p<0.001], connected oxygen appropriately: [26/30 (87%) vs. 1/29 (3%), p<0.001] and used oral airway and/or two-person bagging when traditional bag-mask-ventilation unsuccessful: [30/30 (100%) vs. 0/29 (0%), p<0.001]. CONCLUSION: A hospital focused BLS course utilizing RCDP was associated with improved performance on hospital-specific quality measures compared with the traditional AHA course.

Elevated prothrombin time on routine preoperative laboratory results in a healthy infant undergoing craniosynostosis repair: Diagnosis and perioperative management of congenital factor VII deficiency.

INTRODUCTION: Congenital factor VII deficiency is a rare bleeding disorder with high phenotypic variability. It is critical that children with congenital Factor VII deficiency be identified early when high-risk surgery is planned. Cranial vault surgery is common for children with craniosynostosis, and these surgeries are associated with significant morbidity mostly secondary to the risk of massive blood loss. PRESENTATION OF CASE: A two-month old infant who presented for elective craniosynostosis repair was noted to have an elevated prothrombin time (PT) with a normal activated partial thromboplastin time (aPTT) on preoperative labs. The infant had no clinical history or reported family history of bleeding disorders, therefore a multidisciplinary decision was made to repeat the labs under general anesthesia and await the results prior to incision. The results confirmed the abnormal PT and the case was canceled. Hematologic workup during admission revealed factor VII deficiency. The patient underwent an uneventful endoscopic strip craniectomy with perioperative administration of recombinant Factor VIIa. DISCUSSION: Important considerations for perioperative laboratory evaluation and management in children with factor VII deficiency are discussed. Anesthetic and surgical management of the child with factor VII deficiency necessitates meticulous planning to prevent life threatening bleeding during the perioperative period. CONCLUSION: A thorough history and physical examination with a high clinical suspicion are vital in preventing hemorrhage during surgeries in children with coagulopathies. Abnormal preoperative lab values should always be confirmed and addressed before proceeding with high-risk surgery. A multidisciplinary discussion is essential to optimize the risk-benefit ratio during the perioperative period.

Diagnostic Errors in a PICU: Insights From the Morbidity and Mortality Conference.

OBJECTIVES: To describe diagnostic errors identified among patients discussed at a PICU morbidity and mortality conference in terms of Goldman classification, medical category, severity, preventability, contributing factors, and occurrence in the diagnostic process. DESIGN: Retrospective record review of morbidity and mortality conference agendas, patient charts, and autopsy reports. SETTING: Single tertiary referral PICU in Baltimore, MD. PATIENTS: Ninety-six patients discussed at the PICU morbidity and mortality conference from November 2011 to December 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Eighty-nine of 96 patients (93%) discussed at the PICU morbidity and mortality conference had at least one identified safety event. A total of 377 safety events were identified. Twenty patients (21%) had identified misdiagnoses, comprising 5.3% of all safety events. Out of 20 total diagnostic errors identified, 35% were discovered at autopsy while 55% were reported primarily through the morbidity and mortality conference. Almost all diagnostic errors (95%) could have had an impact on patient survival or safety. Forty percent of errors did not cause actual patient harm, but 25% were severe enough to have potentially contributed to death (40% no harm vs 35% some harm vs 25% possibly contributed to death). Half of the diagnostic errors (50%) were rated as preventable. There were slightly more system-related factors (40%) solely contributing to diagnostic errors compared with cognitive factors (20%); however, 35% had both system and cognitive factors playing a role. Most errors involved vascular (35%) followed by neurologic (30%) events. CONCLUSIONS: Diagnostic errors in the PICU are not uncommon and potentially cause patient harm. Most appear to be preventable by targeting both cognitive- and system-related contributing factors. Prospective studies are needed to further determine how and why diagnostic errors occur in the PICU and what interventions would likely be effective for prevention.

A novel approach to life support training using "action-linked phrases".

BACKGROUND: Observations of cardiopulmonary arrests (CPAs) reveal concerning patterns when clinicians identify a problem, (e.g. loss of pulse) but do not immediately initiate appropriate therapy (e.g. compressions) resulting in delays in life saving therapy. METHODS: We hypothesized that when individuals utilized specific, short, easy-to-state action phrases stating an observation followed by an associated intervention, there would be a higher likelihood that appropriate action would immediately occur. Phase I: A retrospective analysis of residents in simulated CPAs measured what proportion verbalized "There's no pulse", statements and/or actions that followed and whether "Action-Linked Phrases" were associated with faster initiation of compressions. Phase II: Two prospective, quasi-experimental studies evaluated if teaching three Action-Linked Phrases for Basic Life Support (BLS) courses or six Action-Linked Phrases for Advanced Cardiovascular Life Support (ACLS) courses was associated with increased use of these phrases. RESULTS: Phase I: 62% (42/68) of residents verbalized "there's no pulse" during initial assessment of a pulseless patient, and only 16/42 (38%) followed that by stating "start compressions". Residents verbalizing this Action-Linked Phrase started compressions sooner than others: (30s [IQR:19-42] vs. 150 [IQR:51-242], p < 0.001). Phase II: In BLS courses, the three Action-Linked Phrases were used more frequently in the intervention group: (226/270 [84%] vs. 14/195 [7%]; p < 0.001). In ACLS courses, the six Action-Linked Phrases were uttered more often in the intervention group: (43% [157/368] vs. 23% [46/201], p < 0.001). CONCLUSIONS: Action-Linked Phrases innately used by residents in simulated CPAs were associated with faster initiation of compressions. Action-Linked Phrases were verbalized more frequently if taught as part of a regular BLS or ACLS course. This simple, easy to teach, and easy to implement technique holds promise for impacting cardiac arrest teams' performance of key actions.

The morbidity and mortality conference as an adverse event surveillance tool in a paediatric intensive care unit.

OBJECTIVE: To determine if standardised chart review applied to records of patients discussed at a paediatric intensive care unit (PICU) morbidity and mortality conference (MMC) yields additional or different information regarding safety event occurrence and characteristics. DESIGN: Retrospective record review. SETTING: Single tertiary referral PICU in Baltimore, Maryland, USA. PARTICIPANTS: 96 patients discussed at the PICU MMC over 14 months (November 2011-December 2012). MAIN OUTCOME MEASURES: Safety events and their characteristics (medical error category, severity and preventability). RESULTS: A total of 275 safety events were identified through the MMC and/or chart review. The MMC identified 131 (48%) events, 53 (19%) of which were identified through the MMC alone. After chart review was performed, an additional 144 (52%) events were identified. 78 (28%) events were identified through both. High severity adverse events potentially contributing to permanent harm or death were more likely to be identified through both the MMC and chart review (47%) compared with either alone. The MMC alone identified more near-misses (21%) and preventable events (96%) compared with chart review alone or both MMC and chart review. Although chart review alone helped to identify many healthcare-associated infections, medication errors and sedation/pain control issues not elicited through the MMC, the MMC alone identified more communication errors and workflow problems. The MMC alone also identified 40% of all diagnostic errors, which would not have been discovered otherwise despite chart review by itself identifying 50% of such misdiagnoses. CONCLUSIONS: Standardised chart review applied to records of patients discussed at a PICU MMC identified significantly more safety events not initially discovered through the MMC. However, the MMC was superior to chart review in identifying broader problems such as communication errors, workflow issues and certain diagnostic errors not captured by chart review, which can potentially affect many aspects of care.

The resident decision-making process in global health education: appraising factors influencing participation.

The globalization of pediatric graduate medical education is ongoing; thus, this study was conducted to begin to explore the nature of resident interest in global health (GH) training and to further identify potentially modifiable factors influencing participation in away rotations. The authors surveyed all residents at Cincinnati Children's Hospital Medical Center to identify factors influencing participation in education efforts and away rotations. With a participation rate of 79.4% (n = 143), 5 key factors emerged as most significant in the decision-making process amid all participants. Among residents who had previous experience, 82.1% were interested in participating in an away elective compared with 58.3% of those without experience (P = .002). Residents with previous experience abroad were also more likely to plan to integrate GH into their careers (61.7% vs 26.7%, P < .0001). This article describes specific obstacles to resident participation in GH education and documents the association between previous experience and significant interest in long-term involvement.