To investigate the effectiveness of brief bedside cardiopulmonary resuscitation (CPR) training to improve the skill retention of hospital-based pediatric providers. We hypothesized that a low-dose, ...high-frequency training program (booster training) would improve CPR skill retention.
CPR recording/feedback defibrillators were used to evaluate CPR quality during simulated arrest. Basic life support-certified, hospital-based providers were randomly assigned to 1 of 4 study arms: (1) instructor-only training; (2) automated defibrillator feedback only; (3) instructor training combined with automated feedback; and (4) control (no structured training). Each session (time: 0, 1, 3, and 6 months after training) consisted of a pretraining evaluation (60 seconds), booster training (120 seconds), and a posttraining evaluation (60 seconds). Excellent CPR was defined as chest compression (CC) depth ≥ one-third anterior-posterior chest depth, rate ≥90 and ≤120 CC per minute, ≤20% of CCs with incomplete release (>2500 g), and no flow fraction ≤ 0.30.
Eighty-nine providers were randomly assigned; 74 (83%) completed all sessions. Retention of CPR skills was 2.3 times (95% confidence interval CI: 1.1-4.5; P=.02) more likely after 2 trainings and 2.9 times (95% CI: 1.4-6.2; P=.005) more likely after 3 trainings. The automated defibrillator feedback only group had lower retention rates compared with the instructor-only training group (odds ratio: 0.41 95% CI: 0.17-0.97; P = .043).
Brief bedside booster CPR training improves CPR skill retention. Our data reveal that instructor-led training improves retention compared with automated feedback training alone. Future studies should investigate whether bedside training improves CPR quality during actual pediatric arrests.
Our objectives were to determine the impact of family presence during PICU rounds on family satisfaction, resident teaching, and length of rounds and to assess factors associated with family ...satisfaction.
This was an observational study of a convenience sample of morning work rounds in a PICU, followed by surveys of family members of patients in the unit and residents who had been present for rounds.
A total of 411 patient encounters were observed, 98 family questionnaires were fully completed, and 33 resident questionnaires were completed. Ninety-eight percent of family members liked to be present for rounds. On the first day of admission, family members were less likely to understand the plan (P=.03), to feel comfortable asking questions (P = .007), or to want bad news during rounds (P = .009). They were more likely to have privacy concerns (P = .02) and to want 1 individual to convey the plan after rounds (P=.01). Higher education level was associated with decreased privacy concerns (P = .002) but did not affect understanding of the plan. Fifty-two percent of residents perceived that teaching was decreased with families present. Time spent with individual patients was not increased by family member presence (P = .12).
Family satisfaction is high, but families of patients on the first day of admission may need special attention. The medical team should conduct rounds in a manner that addresses the privacy concerns of families. Residents often think that teaching is decreased when families are present.
OBJECTIVE:Attending physicians are only required to provide in-hospital coverage during daytime hours in many pediatric intensive care units. An in-hospital 24-hr pediatric intensive care unit ...attending coverage model has been increasingly popular, but the impact of 24-hr, in-hospital attending coverage on care processes and outcomes has not been reported. We compared processes of care and outcomes before and after the implementation of a 24-hr in-hospital pediatric intensive care unit attending physician model.
DESIGN:Retrospective comparison of before and after cohorts.
SETTING:A single large, academic tertiary medical/surgical pediatric intensive care unit.
PATIENTS:Pediatric intensive care unit admissions in 2000–2006.
INTERVENTION:Transition to 24-hr from 12-hr in-hospital pediatric critical care attending physician coverage model in January 2004.
MEASUREMENTS AND MAIN RESULTS:A total of 18,702 patients were admitted to intensive care unit8,520 in 24 hrs; 10,182 in 12 hrs. Duration of mechanical ventilation was lower (median 33 hrs interquartile range 12–88 vs. 48 hrs interquartile range 16–133, adjusted reduction of 35% 95% confidence interval 25%–44%, p < .001) and intensive care unit length of stay was shorter (median 2 days interquartile range 1–4 vs. 2 days interquartile range 1–5, adjusted p < .001) for 24 hr vs. 12 hr coverage. The reduction in mechanical ventilation hours was similar when noninvasive, mechanical ventilation was included in ventilation hours (median 42 hrs vs. 56 hrs, adjusted reduction in ventilation hours33% 95% confidence interval 20–45, p < .001). Intensive care unit mortality was not significantly different (2.2% vs. 2.5%, adjusted p =.23). These associations were consistent across daytime and nighttime admissions, weekend and weekday admissions, and among subgroups with higher Pediatric Risk of Mortality III scores, postsurgical patients, and histories of previous intensive care unit admission.
CONCLUSIONS:Implementation of 24-hr in-hospital pediatric critical care attending coverage was associated with shorter duration of mechanical ventilation and shorter length of intensive care unit stay. After accounting for potential confounders, this finding was consistent across a broad spectrum of critically ill children.
To characterize tracheal intubation process of care and safety outcomes in a large tertiary pediatric intensive care unit using a pediatric adaptation of the National Emergency Airway Registry. ...Variances in process of care and safety outcome of intubation in the pediatric intensive care unit have not been described. We hypothesize that tracheal intubation is a common but high-risk procedure and that the novel pediatric adaptation of the National Emergency Airway Registry is a feasible tool to capture variances in process of care and outcomes.
Prospective descriptive study.
A single 45-bed tertiary noncardiac pediatric intensive care unit in a large university-affiliated children's hospital.
Critically ill children who required intubation in the pediatric intensive care unit.
Airway management data were prospectively collected for all initial airway management from July 2007 through September 2008 using the National Emergency Airway Registry tool tailored for pediatric application with explicit operational definitions.
One hundred ninety-seven initial intubation encounters were reported (averaging one every 2.3 days). The first course intubation method was oral intubation in 181 (91.9%) and nasal in 16 (9.1%). Unwanted tracheal intubation-associated events were frequently reported (n = 38 19.3%), but severe tracheal intubation-associated events were rare (n = 6 3.0%). Esophageal intubation with immediate recognition was the most common tracheal intubation-associated event (n = 22). Desaturation <80% was reported in 51 of 183 (27.7%) and more than two intubation attempts in 30 of 196 (15.3%), both associated with occurrence of a tracheal intubation-associated event (p < .001, p = .001, respectively). Interestingly, patient age, history of difficult airway, and first attempt by resident were not associated with tracheal intubation-associated events.
Unwanted tracheal intubation-associated events occurred frequently, but severe tracheal intubation-associated events were rare. Our novel registry can be used to describe the pediatric intensive care unit tracheal intubation procedural process of care and safety outcomes.
Tracheal intubation-associated events (TIAEs) are common (20%) and life threatening (4%) in pediatric intensive care units. Physician trainees are required to learn tracheal intubation during ...intensive care unit rotations. The authors hypothesized that "just-in-time" simulation-based intubation refresher training would improve resident participation, success, and decrease TIAEs.
For 14 months, one of two on-call residents, nurses, and respiratory therapists received 20-min multidisciplinary simulation-based tracheal intubation training and 10-min resident skill refresher training at the beginning of their on-call period in addition to routine residency education. The rate of first attempt and overall success between refresher-trained and concurrent non-refresher-trained residents (controls) during the intervention phase was compared. The incidence of TIAEs between preintervention and intervention phase was also compared.
Four hundred one consecutive primary orotracheal intubations were evaluated: 220 preintervention and 181 intervention. During intervention phase, neither first-attempt success nor overall success rate differed between refresher-trained residents versus concurrent non-refresher-trained residents: 20 of 40 (50%) versus 15 of 24 (62.5%), P = 0.44 and 23 of 40 (57.5%) versus 18 of 24 (75.0%), P = 0.19, respectively. The resident's first attempt and overall success rate did not differ between preintervention and intervention phases. The incidence of TIAE during preintervention and intervention phases was similar: 22.0% preintervention versus 19.9% intervention, P = 0.62, whereas resident participation increased from 20.9% preintervention to 35.4% intervention, P = 0.002. Resident participation continued to be associated with TIAE even after adjusting for the phase and difficult airway condition: odds ratio 2.22 (95% CI 1.28-3.87, P = 0.005).
Brief just-in-time multidisciplinary simulation-based intubation refresher training did not improve the resident's first attempt or overall tracheal intubation success.
Few data exist on pediatric cardiopulmonary resuscitation (CPR) quality. This study is the first to evaluate actual in-hospital pediatric CPR. We hypothesized that with bedside CPR training and ...corrective feedback, CPR quality can approach American Heart Association (AHA) targets.
Using CPR recording/feedback defibrillators, quality of CPR was assessed for patients >or=8 years of age who suffered a cardiac arrest in the PICU or emergency department (ED). Before and during the study, a bedside CPR training program was initiated.
Between October 2006 and February 2008, twenty events in 18 patients met inclusion criteria and resulted in 36749 evaluable chest compressions (CCs) during 392.3 minutes of arrest. CCs were shallow (<38 mm or <1.5 in) in 27.2% (9998 of 36749), with excessive residual leaning force (>or=2500 g) in 23.4% (8611 of 36749). Segmental analysis of the first 5 minutes of the events demonstrated that shallow CCs and excessive residual leaning force were less prevalent during the first 5 minutes. AHA targets were not achieved for CC rate in 62 (43.1%) of 144 segments, CC depth in 52 (36.1%) of 144 segments, and residual leaning force in 53 (36.8%) of 144 segments.
This prospective, observational study demonstrates feasibility of monitoring in-hospital pediatric CPR. Even with bedside CPR retraining and corrective audiovisual feedback, CPR quality frequently did not meet AHA targets. Importantly, no flow fraction target of 10% was achieved. Future studies should investigate novel educational methods and targeted feedback technologies.
The purpose of this multicenter study was to confirm the validity and reliability of the Pediatric Cardiac Quality of Life Inventory (PCQLI).
Seven centers recruited pediatric patients (8-18 years of ...age) with heart disease (HD) and their parents to complete the PCQLI and generic health-related quality of life (Pediatric Quality of Life Inventory PedsQL) and non-quality of life (Self-Perception Profile for Children SPPC/Self-Perception Profile for Adolescents SPPA and Youth Self-Report YSR/Child Behavior Checklist CBCL) tools. PCQLI construct validity was assessed through correlations of PCQLI scores between patients and parents and with severity of congenital HD, medical care utilization, and PedsQL, SPPC/SPPA, and YSR/CBCL scores. PCQLI test-retest reliability was evaluated.
The study enrolled 1605 patient-parent pairs. Construct validity was substantiated by the association of lower PCQLI scores with Fontan palliation and increased numbers of cardiac operations, hospital admissions, and physician visits (P<.001); moderate to good correlations between patient and parent PCQLI scores (r=0.41-0.61; P<.001); and fair to good correlations between PCQLI total scores and PedsQL total (r=0.70-0.76), SPPC/SPPA global self-worth (r=0.43-0.46), YSR/CBCL total competency (r=0.28-0.37), and syndrome and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-oriented scale (r=-0.58 to -0.30; P<.001) scores. Test-retest reliability correlations were excellent (r=0.78-0.90; P<.001).
PCQLI scores are valid and reliable for children and adolescents with congenital and acquired HD and may be useful for future research and clinical management.
Cumulative effects of repetitive mild head injury in the pediatric population are unknown. We have developed a cognitive composite dysfunction score that correlates white matter injury severity in ...neonatal piglets with neurobehavioral assessments of executive function, memory, learning, and problem solving. Anesthetized 3- to 5-day-old piglets were subjected to single (n = 7), double one day apart (n = 7), and double one week apart (n = 7) moderate (190 rad/s) rapid non-impact axial rotations of the head and compared to instrumented shams (n = 7). Animals experiencing two head rotations one day apart had a significantly higher mortality rate (43%) compared to the other groups and had higher failures rates in visual-based problem solving compared to instrumented shams. White matter injury, assessed by beta-APP staining, was significantly higher in the double one week apart group compared to that with single injury and sham. Worsening performance on cognitive composite score correlated well with increasing severity of white matter axonal injury. In our immature large animal model of TBI, two head rotations produced poorer outcome as assessed by neuropathology and neurobehavioral functional outcomes compared to that with single rotations. More importantly, we have observed an increase in injury severity and mortality when the head rotations occur 24 h apart compared to 7 days apart. These observations have important clinical translation to infants subjected to repeated inflicted head trauma.
Abstract Aim To quantitatively describe pauses in chest compression (CC) delivery during resuscitation from in-hospital pediatric and adolescent cardiac arrest. We hypothesized that CPR error will be ...more likely after a chest compression provider change compared to other causes for pauses. Methods CPR recording/feedback defibrillators were used to evaluate CPR quality for victims ≥8 years who received CPR in the PICU/ED. Audiovisual feedback was supplied in accordance with AHA targets. Etiology of CC pauses identified by post-event debriefing/reviews of stored CPR quality data. Results Analysis yielded 205 pauses during 304.8 min of CPR from 20 consecutive cardiac arrests. Etiologies were: 57.1% for provider switch; 23.9% for pulse/rhythm analysis; 4.4% for defibrillation; and 14.6% “other.” Provider switch accounted for 41.2% of no-flow duration. Compared to other causes, CPR epochs following pauses due to provider switch were more likely to have measurable residual leaning (OR: 5.52; CI95 : 2.94, 10.32; p < 0.001) and were shallower (43 ± 8 vs. 46 ± 7 mm; mean difference: −2.42 mm; CI95 : −4.71, −0.13; p = 0.04). Individuals performing continuous CPR ≥ 120 s as compared to those switching earlier performed deeper chest compressions (42 ± 6 vs. 38 ± 7 mm; mean difference: 4.44 mm; CI95 : 2.39, 6.49; p < 0.001) and were more compliant with guideline depth recommendations (OR: 5.11; CI95 : 1.67, 15.66; p = 0.004). Conclusions Provider switches account for a significant portion of no-flow time. Measurable residual leaning is more likely after provider switch. Feedback systems may allow some providers to continue high quality CPR past the recommended switch time of 2 min during in-hospital resuscitation attempts.
Tracheal intubation in the pediatric intensive care unit is often performed in emergency situations with high risks. Simulation has been recognized as an effective methodology to train both technical ...and teamwork skills. Our objectives were to develop a feasible tool to evaluate team performance during tracheal intubation in the pediatric intensive care unit and to apply the tool in the clinical setting to determine whether multidisciplinary teams with a higher number of simulation-trained providers exhibit more proficient performance.
Prospective, observational pilot study.
Single tertiary children's hospital pediatric intensive care unit.
Pediatric and emergency medicine residents, pediatric intensive care unit nurses, and respiratory therapists from October 2007 to June 2008.
A pediatric intensive care unit on-call resident, a pediatric intensive care unit nurse, and a respiratory therapist received simulation-based multidisciplinary airway management training every morning. An assessment tool for team technical and behavioral skills was developed. Independent trained observers rated actual intubations in the pediatric intensive care unit by using this tool.
For observer training, two independent raters (research assistants 1 and 2) evaluated a total of 53 training sessions (research assistant 1, 16; research assistant 2, 37). The correlation coefficient with the facilitator expert (surrogate standard) was .73 for research assistant 1 and .88 for research assistant 2 (p ≤ .001 for both) in the total score, .84 for research assistant 1 and .77 for research assistant 2 (p < .001 for both) in the technical domain, and .63 for research assistant 1 (p = .009) and .84 for research assistant 2 (p < .001) in the behavioral domain. The correlation coefficient was lower in video-based observation (.62 vs. .88, on-site). For clinical observation, 15 intubations were observed in real time by raters. The performance by a team with two or more simulation-trained members was rated higher compared with the team with fewer than two trained members (total score: 127 ± 6 vs. 116 ± 9, p = .012, mean ± sd).
It is feasible to rate the technical and behavioral performance of multidisciplinary airway management teams during real intensive care unit intubation events by using our assessment tool. The presence of two or more multidisciplinary simulation-trained providers is associated with improved performance during real events.
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