Outcomes of Extracorporeal Cardiopulmonary Resuscitation for In-Hospital Cardiac Arrest Among Children With Noncardiac Illness Categories.

OBJECTIVES: The objective of this study was to determine the association of the use of extracorporeal cardiopulmonary resuscitation (ECPR) with survival to hospital discharge in pediatric patients with a noncardiac illness category. A secondary objective was to report on trends in ECPR usage in this population for 20 years. DESIGN: Retrospective multicenter cohort study. SETTING: Hospitals contributing data to the American Heart Association's Get With The Guidelines-Resuscitation registry between 2000 and 2021. PATIENTS: Children (<18 yr) with noncardiac illness category who received greater than or equal to 30 minutes of cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Propensity score weighting balanced ECPR and conventional CPR (CCPR) groups on hospital and patient characteristics. Multivariable logistic regression incorporating these scores tested the association of ECPR with survival to discharge. A Bayesian logistic regression model estimated the probability of a positive effect from ECPR. A secondary analysis explored temporal trends in ECPR utilization. Of 875 patients, 159 received ECPR and 716 received CCPR. The median age was 1.0 [interquartile range: 0.2-7.0] year. Most patients (597/875; 68%) had a primary diagnosis of respiratory insufficiency. Median CPR duration was 45 [35-63] minutes. ECPR use increased over time ( p < 0.001). We did not identify differences in survival to discharge between the ECPR group (21.4%) and the CCPR group (16.2%) in univariable analysis ( p = 0.13) or propensity-weighted multivariable logistic regression (adjusted odds ratio 1.42 [95% CI, 0.84-2.40; p = 0.19]). The Bayesian model estimated an 85.1% posterior probability of a positive effect of ECPR on survival to discharge. CONCLUSIONS: ECPR usage increased substantially for the last 20 years. We failed to identify a significant association between ECPR and survival to hospital discharge, although a post hoc Bayesian analysis suggested a survival benefit (85% posterior probability).

Hacking teamwork in health care: Addressing adverse effects of ad hoc team composition in critical care medicine.

BACKGROUND: The continued need for improved teamwork in all areas of health care is widely recognized. The present article reports on the application of a hackathon to the teamwork problems specifically associated with ad hoc team formation in rapid response teams. PURPOSES: Hackathons-problem-solving events pioneered in computer science-are on the rise in health care management. The focus of these events tends to be on medical technologies, however, with calls for improvements in management practices as general recommendations. The hackathon reported here contributes to health care management practice by addressing improvements in teamwork as the focal problem. METHODOLOGY: The hackathon event took place over 2.5 days in conjunction with an academic conference focused on group research. Three teams comprised of practicing healthcare professionals, academic researchers and students developed solutions to problems of ad hoc team formation in rapid response teams. FINDINGS: The event fulfilled several goals. The teams produced three distinct, yet complementary solutions that were backed by both field-based experience and solid research evidence. The event provided the opportunity for two-way translation of research and practice through direct collaboration among key stakeholders. The hackathon produced long term effects through establishing or strengthening collaborations, dissemination of the ideas through presentations, workshops, and publications, and changes in participantsâ work practices. PRACTICE IMPLICATION: The event demonstrated that hackathons, classically focused on technology, can also offer a spur to innovation around organizational processes. The article provides advice for organizing other hackathons focused on similar topics. The solutions offered by the participants in the event yields the clear insight that multipronged solutions for emergency-oriented teamwork are needed. The hackathon highlighted the scaled of collaboration and effort needed to tackle the many complexities in health care that impact outcomes for providers, patients, and health organizations.

Perioperative complications and outcome after surgery for treatment of gastric carcinoma in dogs: A Veterinary Society of Surgical Oncology retrospective study of 40 cases (2004-2018).

OBJECTIVE: To describe the clinical characteristics, perioperative complications, and outcomes in dogs surgically treated for gastric carcinoma. STUDY DESIGN: Multi-institutional retrospective case series. ANIMALS: Forty client-owned dogs with histologically confirmed gastric carcinoma. METHODS: Medical records were reviewed for preoperative diagnostics, surgery, histopathology, postoperative complications, adjuvant chemotherapy, disease progression, and survival. Variables were assessed for associations with outcome by using Cox proportional hazards regression analysis. RESULTS: Surgical treatment included partial gastrectomy (28 dogs), Billroth I (9 dogs), subtotal gastrectomy (2 dogs), and submucosal resection (1 dog). Major postoperative complications occurred in 8 of 40 dogs, including septic peritonitis secondary to dehiscence in 4 dogs. The median progression free interval was 54 days, and the median survival time (MST) was 178 days (range, 1-1902). According to multivariable analysis results, experiencing an intraoperative complication was associated with an increased risk of death (hazard ratio [HR] 3.5, 95% CI 1.1-9.8, P = .005), and administration of adjuvant chemotherapy correlated with an improved survival (HR 0.4, 95% CI 0.2-0.9, P = .03). CONCLUSION: In this population of dogs, MST exceeded historically reported data, major postoperative complication rates were comparable to established literature, and administration of adjuvant chemotherapy was associated with improved survival. CLINICAL SIGNIFICANCE: Results from this study may be used to counsel owners more accurately regarding prognosis for dogs undergoing surgical excision for gastric carcinoma.

Evaluation of a Single Intra-Articular Injection of Autologous Protein Solution for Treatment of Osteoarthritis in a Canine Population.

OBJECTIVE: To evaluate the safety and efficacy of an intra-articular injection of autologous protein solution (APS) for treatment of canine osteoarthritis (OA). STUDY DESIGN: Prospective, randomized, blinded, placebo-controlled pilot clinical trial. ANIMALS: Client-owned dogs with single limb lameness because of OA in a stifle or elbow joint (n=21). METHODS: Lame dogs, confirmed with OA by physical and lameness examination and imaging, were randomly assigned to control or treatment groups. Owners, blinded to treatment, scored pain (University of Pennsylvania Canine Brief Pain Inventory) and lameness severity (Hudson Visual Analogue Scale [HVAS]). Weight-bearing was assessed by kinetic gait analysis. Dogs were injected intra-articularly with APS (treatment group) or saline solution (control group). Evaluations were performed before injection, and 2 and 12 weeks post-injection. RESULTS: Compared to pretreatment values, APS treatment data showed a significant improvement in week 12 pain scores (improved 25.6% over baseline), lameness scores (improved 15% over baseline) and peak vertical force (PVF; N/kg; increased 14.9% of baseline), as well as vertical impulse (Ns/kg) and PVF normalized to stance time (N/kg/s). Control group dogs improved at week 2 in owner assigned indices, but not force plate values and had no significant improvement in scores or force plate values from pretreatment values at 12 weeks. CONCLUSION: APS injection reduced pain and lameness scores and increased weight-bearing associated with the OA-affected joint in dogs at 12 weeks providing preliminary evidence that APS therapy may be beneficial in the treatment of OA in dogs and supporting pursuit of additional studies.

COMPARISON OF COMPUTED TOMOGRAPHY AND ABDOMINAL RADIOGRAPHY FOR DETECTION OF CANINE MECHANICAL INTESTINAL OBSTRUCTION.

Vomiting, often caused by mechanical intestinal obstruction, is common in dogs. Equivocal radiographic signs often necessitate repeat radiographs or additional imaging procedures. For our prospective, case-controlled, accuracy study, we hypothesized the following: (1) using computed tomography (CT), radiologists will be more sensitive and specific for detecting mechanical intestinal obstruction and recommending surgery compared to using radiographs; and (2) using measurements, radiologists will be more sensitive and specific using radiographs or CT for detecting mechanical intestinal obstruction and recommending surgery. Twenty dogs had abdominal radiographs and abdominal CT. Seventeen dogs had abdominal surgery and three dogs were not obstructed based on clinical follow-up. Confidence levels (five-point scale) of three experienced radiologists for mechanical intestinal obstruction and recommending surgery were recorded before and after making selected measurements. Eight dogs had surgically confirmed mechanical intestinal obstruction, and 12 dogs did not have obstruction. For detecting mechanical intestinal obstruction, CT was more sensitive (95.8% vs. 79.2%) and specific (80.6% vs. 69.4%) compared to radiographs, but the difference was not statistically significant. For recommending surgery, radiography was more sensitive (91.7% vs. 83.3%) and specific (83.3% vs. 72.2%) than using CT, but differences were not statistically significant. We reported objective CT measurements for predicting small mechanical intestinal obstruction. By incorporating these objective data, the diagnosis of mechanical intestinal obstruction changed in five of 120 instances (radiographs and CT). In no instance (0/120), did the objective data change the recommendation for surgery. Using CT or abdominal radiographs for the detection of canine mechanical intestinal obstruction is sensitive and specific when evaluated by experienced veterinary radiologists.

Cardiac resuscitation events: one eyewitness is not enough.

OBJECTIVE: To determine the accuracy of paper cardiopulmonary resuscitation records. DESIGN: Case series. SETTING: Twenty-six-bed video-monitored pediatric cardiac ICU. PATIENTS: All patients who had a resuscitation event with available video and electronically stored vital sign and waveform data from May 2012 to February 2013. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 41 cardiopulmonary resuscitation events during the study period. Fifteen had complete and valid data from the paper cardiopulmonary resuscitation forms, the retrieved monitor data, and the continuous bedside video monitoring. These 15 events occurred in 12 individual patients, and there was 100% agreement of data in the documentation of interventions in place (ventilation, arterial catheter, pulse oximetry, and vascular access) and in the presence of a witness at the onset of the arrest. All events were witnessed. Of the 15 events, video and monitor review revealed that 14 used waveform and numeric capnometry to confirm endotracheal tube/tracheostomy placement, but this section was only completed on the paper cardiopulmonary resuscitation record in three of the 14 cases. All records showed no discrepancies in the time of return of spontaneous circulation. The video and monitor review revealed delay in initiating cardiopulmonary resuscitation (mode, 2 min; two cases ≥ 7 min) and shockable rhythms (ventricular arrhythmia) in two cases. A sign of pulseless state was discovered in seven cases classified on the paper record as "always with a pulse." Those include sudden loss of consciousness, flat arterial line tracing, and abrupt drop in the partial pressure of exhaled carbon dioxide tracing (< 10 mm Hg). CONCLUSIONS: Eyewitness accounts of cardiopulmonary resuscitation are often inaccurate and incomplete. Review of information from video and electronically stored vital sign and waveform data provides more accurate information than review of paper-based cardiopulmonary resuscitation records and may provide the insight necessary to improving cardiopulmonary resuscitation.

Comparison of tibial plateau angles in small and large breed dogs.

Cranial cruciate ligament (CCL) disease can affect dogs of all sizes. The literature describing tibial plateau angle (TPA) in small breed dogs is limited. A retrospective study was conducted in unselected dogs presented for stifle or tibial examination to compare TPA in small breed dogs (n = 146 dogs, 185 stifles) versus large breed dogs (n = 200 dogs, 265 stifles). Small breed dogs had a mean TPA 3.1° ± 0.6° higher than large breed dogs. There were higher TPAs in spayed females and castrated males for all dogs compared with intact males (3.6° ± 1.0° and 2.7° ± 1.0°, respectively). Dogs with unilateral and bilateral CCL disease had higher TPAs compared to dogs with intact CCLs (2.0° ± 0.7° and 2.5° ± 0.8°, respectively). Tibial morphology differs between large and small breed dogs; however, the significance of the impact of TPA on CCL disease in small breed dogs is unknown.

Comparaison des angles du plateau tibial chez les chiens de petite et de grande races. La maladie du ligament cruciforme crânien (LCC) peut affecter les chiens de toutes les tailles. La littérature décrivant l'angle du plateau tibial (APT) chez les chiens de petites races est limitée. Une étude rétrospective a été réalisée chez des chiens non sélectionnés présentés pour un examen du grasset ou du tibia pour comparer l'APT chez les chiens de petite race (n = 146 chiens, 185 grassets) par rapport aux chiens de grande race (n = 200 chiens, 265 grassets). Les chiens de petite race présentait un APT moyen de 3,1° ± 0,6° de plus que les chiens de grande race. Il y avait des APT supérieurs chez les femelles stérilisées et les mâles castrés pour tous les chiens comparativement aux mâles intacts (3,6° ± 1,0° et 2,7° ± 1,0°, respectivement). Les chiens atteints d'une maladie LCC unilatérale et bilatérale présentaient des APT supérieurs comparativement aux chiens avec des LCC intacts (2,0° ± 0,7° et 2,5° ± 0,8°, respectivement). La morphologie tibiale diffère entre les chiens de grande et de petite race. Cependant, l'importance de l'impact de l'APT sur la maladie LCC chez les chiens de petite race est inconnue.(Traduit par Isabelle Vallières).

Implementation of an extracorporeal cardiopulmonary resuscitation simulation program reduces extracorporeal cardiopulmonary resuscitation times in real patients.

OBJECTIVE: To determine if development of an extracorporeal cardiopulmonary resuscitation simulation program reduced extracorporeal cardiopulmonary resuscitation times in real patients DESIGN: : Before-after study. SETTING: Twenty-six bed pediatric cardiac ICU in a tertiary urban hospital. PATIENTS: Forty-three cardiac patients (aged 1 d to 16 yr) who received extracorporeal cardiopulmonary resuscitation. INTERVENTIONS: An interdisciplinary team collaborated to define the roles and clarify responsibilities of each individual involved in extracorporeal cardiopulmonary resuscitation. An "ideal rapid deployment" was defined and tested using simulation sessions. This included a task analysis, role creation, and multidisciplinary simulations, including structured debriefings and video review and the creation of a master checklist. MEASUREMENTS AND MAIN RESULTS: There were a total of 43 episodes of extracorporeal cardiopulmonary resuscitation during the study period, 16 (37%) of which occurred during the preintervention time period (from February 2009 to March 2010) and 27 (63%) during the postintervention time period (April 2010 to March 2013). The median deployment time in the preintervention time period was 51 minutes (interquartile range, 43-62 min), whereas the median deployment time in the postintervention time period was 40 minutes (interquartile range, 23-52 min) (p = 0.018). CONCLUSIONS: There are no standard guidelines of how a team should coordinate the efforts of nursing, physicians, extracorporeal membrane oxygenation specialists, surgeons, respiratory therapists, patient care technicians, and unit clerks to emergently execute this complex procedure. Because time is of the essence, it is essential to develop a highly functioning and well-coordinated team with a standardized method of the procedure, its documentation, and communication. Simulation accomplished this for our program. Following these simulation exercises, not only was there a subjectively observed improved coordination and smoother deployment of extracorporeal membrane oxygenation in real-life extracorporeal cardiopulmonary resuscitation, but we have also demonstrated a significantly faster deployment of extracorporeal membrane oxygenation as compared with the presimulation era.

Developing and validating the Unhurried Conversations Assessment Tool (UCAT).

OBJECTIVE: Given the importance of unhurried conversations for providing careful and kind care, we sought to create, test, and validate the Unhurried Conversations Assessment Tool (UCAT) for assessing the unhurriedness of patient-clinician consultations. METHODS: In the first two phases, the unhurried conversation dimensions were identified and transformed into an assessment tool. In the third phase, two independent raters used UCAT to evaluate the unhurriedness of 100 randomly selected consultations from 184 videos recorded for a large research trial. UCAT's psychometric properties were evaluated using this data. RESULTS: UCAT demonstrates content validity based on the literature and expert review. EFA and reliability analyses confirm its construct validity and internal consistency. The seven formative dimensions account for 89.93% of the variance in unhurriedness, each displaying excellent internal consistency (α > 0.90). Inter-rater agreement for the overall assessment item was fair (ICC = 0.59), with individual dimension ICCs ranging from 0.26 (poor) to 0.95 (excellent). CONCLUSION: UCAT components comprehensively assess the unhurriedness of consultations. The tool exhibits content and construct validity and can be used reliably. PRACTICE IMPLICATIONS: UCAT's design and psychometric properties make it a practical and efficient tool. Clinicians can use it for self-evaluations and training to foster unhurried conversations.

Outcomes of pediatric patients with COVID-19 and in-hospital cardiopulmonary resuscitation.

BACKGROUND: Early studies found low survival rates for adults with COVID-19 infection and in-hospital cardiac arrest (IHCA). We evaluated the association of COVID-19 infection on survival outcomes in pediatric patients undergoing cardiopulmonary resuscitation (CPR). METHODS: Within Get-With-The-Guidelines®-Resuscitation, we identified pediatric patients who underwent CPR for an IHCA or bradycardia with poor perfusion between March and December, 2020. We compared survival outcomes (survival to discharge and return of spontaneous circulation for ≥20 minutes [ROSC]) between patients with suspected/confirmed COVID-19 infection and non-COVID-19 patients using multivariable hierarchical regression, with hospital site as a random effect and patient and cardiac arrest variables with a significant (p < 0.05) bivariate association as fixed effects. RESULTS: Overall, 1328 pediatric in-hospital CPR events were identified (590 IHCA, 738 bradycardia with poor perfusion), of which 46 (32 IHCA, 14 bradycardia) had suspected/confirmed COVID-19 infection. Rates of survival to discharge were similar between those with and without COVID-19 infection (39.1% vs. 44.9%; adjusted RR, 1.14 [95% CI: 0.55-2.36]), and these estimates were similar for those with IHCA and bradycardia with poor perfusion (adjusted RRs of 1.03 and 1.05; interaction p = 0.96). Rates of ROSC were also similar between pediatric patients with and without COVID-19 overall (67.4% vs. 76.9%; adjusted RR, 0.87 [0.43, 1.77]), and for the subgroups with IHCA or bradycardia requiring CPR (adjusted RRs of 0.95 and 0.86, interaction p = 0.26). CONCLUSIONS: In a large multicenter national registry of CPR events, COVID-19 infection was not associated with lower rates of ROSC or survival to hospital discharge in pediatric patients undergoing CPR.

Distraction osteogenesis-induced muscle fibrosis may not be associated with TGF-ß1.

BACKGROUND: Transforming growth factor-ß 1 (TGF-ß1) participates in the synthesis and deposition of collagen. It has been implicated in fibrosis of tendons in wound-healing models but has never been studied in muscles with respect to distraction osteogenesis. METHODS: Using a rabbit model of distraction osteogenesis, we distracted the left tibias of 36 New Zealand white rabbits at 0.75 mm/d for 20 days. To determine whether suramin, an antagonist of TGF-ß, could aid in the prevention of fibrosis, we injected it into the anterior tibialis muscle [12 rabbits received low-dose suramin (50 mg), 12 received high-dose suramin (100 mg), and 12 received sham injections]. Half of each group was killed at the end of distraction (day 24) and the other half at day 60. At the time of killing the rabbits, joint range of motion was measured, and strength and morphometric measures of the muscle were taken. Muscle was harvested and immunolabeled for TGF-ß1. All findings were compared between study limbs and control (right) limbs. RESULTS: The comparison failed to demonstrate improvements in the range of motion, and in strength or morphometric muscle development. Immunolabeling for TGF-ß1 failed to show any staining in the intramuscular fibrosis. Paradoxically, muscle injected with high-dose suramin had the highest degree of fibrosis. CONCLUSIONS: We conclude that TGF-ß1 may not be the primary mediator of muscle fibrosis in distraction osteogenesis. CLINICAL RELEVANCE: Injection of suramin may not prevent contracture formation after distraction osteogenesis.

Influence of Simulation-based Training on Reflective Practice.

BACKGROUND: Simulation-based training (SBT) is often evaluated based on the transfer of specific knowledge and skills. In contrast, the degree to which reflective practice is inculcated by SBT is rarely considered. Because reflection is a pillar of adult learning theories, we sought to examine the degree to which participation in SBT was associated with increased reflective practice. METHOD: Eighty one healthcare professionals completed a survey which included the number of SBTs they participated in during the past two years, content- and administrative-related features of those SBTs, and a key aspect of reflective practice (i.e., self-appraisal). RESULTS: The number of SBTs healthcare professionals participated in during the past two years was positively associated with reflective self-appraisal. This relationship was not moderated by the inclusion of reflection components in SBTs nor by the voluntary/mandatory nature of participation in SBTs. Furthermore, the facilitator was ranked as the most important feature of the overall learning experience in SBTs. Also, no significant differences were found between the number of technical skills-based and non-technical skills-based SBTs. CONCLUSION: These findings demonstrate the importance (of evaluating) SBTs for facilitating reflective learning mindsets that healthcare practitioners can apply beyond the specific skills trained by SBTs.

Applying Educational Theory to Interdisciplinary Education in Pediatric Cardiac Critical Care.

At the 14th Annual International Meeting for the Pediatric Cardiac Intensive Care Society, the authors presented a simulation workshop for junior multidisciplinary providers focused on cardiopulmonary interactions. We provide an overview of educational theories of particular relevance to curricular design for simulation-based or enhanced activities. We then demonstrate how these theories are applied to curriculum development for individuals to teams and for novice to experts. We review the role of simulation in cardiac intensive care education and the education theories that support its use. Finally, we demonstrate how a conceptual framework, SIMZones, can be applied to design effective simulation-based teaching.

Extracorporeal membrane oxygenation in congenital heart disease.

This review article will discuss the indications for and outcomes of neonates with congenital heart disease who receive extracorporeal membrane oxygenation (ECMO) support. Most commonly, ECMO is used as a perioperative bridge to recovery or temporary support for those after cardiac arrest or near arrest in patients with congenital or acquired heart disease. What had historically been considered a contraindication to ECMO, is evolving and more of the sickest and most complicated babies are cared for on ECMO. Given that, it is imperative for aggressive survellience for long-term morbidity in survivors, particularly neurodevelopmental outcomes.

Effects of designated leadership and team-size on cardiopulmonary resuscitation: The Basel-Washington SIMulation (BaWaSim) trial.

OBJECTIVE: During cardiopulmonary resuscitation (CPR), it remains unclear whether designating an individual person as team leader compared with emergent leadership results in better team performance. Also, the effect of CPR team size on team performance remains understudied. METHODS: This randomized-controlled trial compared designated versus emergent leadership and size of rescue team (3 vs 6 rescuers) on resuscitation performance. RESULTS: We included 90 teams with a total of 408 students. No difference in mean (±SD) hands-on time (seconds) were observed between emergent leadership (106 ±â€¯30) compared to designated leadership (103 ±â€¯27) groups (adjusted difference - 2.97 (95%CI -15.75 to 9.80, p = 0.645), or between smaller (103 ±â€¯30) and larger teams (106 ±â€¯26, adjusted difference 3.53, 95%CI -8.47 to 15.53, p = 0.56). Emergent leadership groups had a shorter time to circulation check and first defibrillation, but the quality of CPR based on arm and shoulder position was lower. No differences in CPR quality measures were observed between smaller and larger teams. CONCLUSIONS: Within this international US/Swiss trial, leadership designation and larger team size did not improve hands-on time, but emergent leadership teams initiated defibrillation earlier. Improvements in performance may be more likely to be achieved by optimization of emergent leadership than increasing the size of cardiac arrest teams.

Novel, 3D Display of Heart Models in the Postoperative Care Setting Improves CICU Caregiver Confidence.

BACKGROUND: Postoperative care delivered in the pediatric cardiac intensive care unit (CICU) relies on providers' understanding of patients' congenital heart defects (CHDs) and procedure performed. Novel, bedside use of virtual, three-dimensional (3D) heart models creates access to patients' CHD to improve understanding. This study evaluates the impact of patient-specific virtual 3D heart models on CICU provider attitudes and care delivery. METHODS: Virtual 3D heart models were created from standard preoperative cardiac imaging of ten patients with CHD undergoing repair and displayed on a bedside tablet in the CICU. Providers completed a Likert questionnaire evaluating the models' value in understanding anatomy and improving care delivery. Responses were compared using two-tailed t test and Mann-Whitney U test and were also compared to previously collected CICU provider responses regarding use of printed 3D heart models. RESULTS: Fifty-three clinicians (19 physicians, 34 nurses/trainees) participated; 49 (92%) of 53 and 44 (83%) of 53 reported at least moderate to high satisfaction with the virtual 3D heart's ability to enhance understanding of anatomy and surgical repair, respectively. Seventy-one percent of participants felt strongly that virtual 3D models improved their ability to manage postoperative problems. The majority of both groups (63% physicians, 53% nurses) felt that virtual 3D heart models improved CICU handoffs. Virtual 3D heart models were as effective as printed models in improving understanding and care delivery, with a noted provider preference for printed 3D heart models. CONCLUSIONS: Virtual 3D heart models depicting patient-specific CHDs are perceived to improve understanding and postoperative care delivery in the CICU.

Improving quality in measuring time to initiation of CPR during in-hospital resuscitation.

OBJECTIVE: Time from the onset of "low or no flow" indicators of cardiac failure to initiation of cardiopulmonary resuscitation is an important quality metric thought to improve the likelihood of survival and preservation of end organ function. We hypothesized that delays in initiation of chest compressions were under recognized during in-hospital resuscitation and aimed to develop a system which identifies the actual time of deterioration during cardiac events. METHODS: Retrospective review on prospectively identified resuscitation records and monitor data were compared. Return of spontaneous circulation, survival, and changes in functional status of patients pre- and post-events with chest compressions were collected as outcome measures. RESULTS: Between October 2012 and April 2015, 59 events which met eligibility criteria occurred in either our pediatric cardiac or general pediatric intensive care units. The median time from event onset to initiation of chest compressions was 47s(s) (interquartile range (IQR) 28-80s) as assessed using monitor data, while the resuscitation record reported a median time of 0s (IQR 0-60s), reflecting the time from recognition to initiation of chest compressions. According to the resuscitation record, 81% vs. 63% of events achieved the quality standard of less than one minute depending on which review method was used (p=0.04). CONCLUSIONS: There is a significant difference between time of deterioration to initiation of chest compressions and the time of recognition to initiation of chest compressions. Resuscitation records should be modified to include more information about the actual timing of patient deterioration.

Trauma resuscitation: can team behaviours in the prearrival period predict resuscitation performance?

Background: Optimising team performance is critical in paediatric trauma resuscitation. Previous studies in aviation and surgery link performance to behaviours in the prearrival period. Objective: To determine if patterns of human behaviour in the prearrival period of a simulated trauma resuscitation is predictive of resuscitation performance. Design: Twelve volunteer trauma teams performed in four simulation scenarios in a paediatric hospital. The scenarios were video recorded, transcribed and analysed in 10-second intervals. Variation in the amount of utterances per team member in the prearrival period was compared with team performance and implicit coordination during the resuscitation. Key results: Coders analysed 18 962 s of video. They coded 5204 team member utterances into one of eight communication behaviour categories. Inter-rater reliability was excellent (an average of 83.1% across all four scenarios). The average number of communications occurring during the prearrival period was 18.84 utterances, with a range of 2-42 and a SD of 9.55. The average length of this period was almost 2 minutes (mean =117.30 s, SD=39.20). Lower variance in team member communication during the prearrival better was associated with better implicit coordination (p=0.011) but not team performance (p=0.054) during the resuscitation. Conclusion: Patterns of communication in the prearrival trauma resuscitation period predicted implicit coordination and a trend towards significance for team performance which suggests further studies in such patterns are warranted.