Pediatric Respiratory Therapists Lack a Standard Mental Model for Managing the Patient Who Is Difficult to Ventilate: A Video Review.

BACKGROUND: All health-care providers who care for infants and children should be able to effectively provide ventilation with a bag and a mask. Respiratory therapists (RTs'), as part of rapid response teams, need to quickly identify the need for airway support and use adjunct airway interventions when subjects are difficult to mask ventilate. Before implementation of an educational curriculum for airway management, we assessed whether pediatric RTs' who enter the room of a simulated infant mannequin in severe respiratory distress are able to apply bag-mask ventilation within 60 s and implement 2 adjunct airway maneuvers in a patient who is difficult to ventilate. METHODS: All pediatric RTs' were required to attend one high-fidelity simulation at the Johns Hopkins Medicine Simulation Center. The sessions were reviewed to evaluate whether the therapists would implement adjunct maneuvers to a patient who was in respiratory distress and was difficult to ventilate. RESULTS: Twenty-eight therapists participated in the baseline skills assessment session, and 26 (72% of eligible therapists) were evaluable with video clips. Only 3 of 26 (12%) attempted bag-mask ventilation within 60 s. Although all the therapists attempted one airway maneuver, only 65% were able to implement ≥2 airway maneuvers and achieve effective ventilation, with a wide range of time (98-298 s). There was no pattern regarding which intervention was implemented first, second, and so forth. CONCLUSIONS: Our team of pediatric RTs' did not share a standard mental model for initiating bag-mask ventilation during impending respiratory failure or implementing airway adjuncts. This may place children who are critically ill at risk of suboptimal management and threaten clinical outcomes. Therapist performance indicated that no established care algorithm had been effectively implemented or that skill retention was poor. A change in the content and delivery method of bag-mask ventilation training is warranted to improve the time to performance of key interventions and to establish a clear cognitive framework of difficult mask ventilation management.

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.