OBJECTIVE:In-hospital cardiac arrest is an important public health problem. High-quality resuscitation improves survival but is difficult to achieve. Our objective is to evaluate the effectiveness of ...a novel, interdisciplinary, postevent quantitative debriefing program to improve survival outcomes after in-hospital pediatric chest compression events.
DESIGN, SETTING, AND PATIENTS:Single-center prospective interventional study of children who received chest compressions between December 2008 and June 2012 in the ICU.
INTERVENTIONS:Structured, quantitative, audiovisual, interdisciplinary debriefing of chest compression events with front-line providers.
MEASUREMENTS AND MAIN RESULTS:Primary outcome was survival to hospital discharge. Secondary outcomes included survival of event (return of spontaneous circulation for ≥ 20 min) and favorable neurologic outcome. Primary resuscitation quality outcome was a composite variable, termed “excellent cardiopulmonary resuscitation,” prospectively defined as a chest compression depth ≥ 38 mm, rate ≥ 100/min, ≤ 10% of chest compressions with leaning, and a chest compression fraction > 90% during a given 30-second epoch. Quantitative data were available only for patients who are 8 years old or older. There were 119 chest compression events (60 control and 59 interventional). The intervention was associated with a trend toward improved survival to hospital discharge on both univariate analysis (52% vs 33%, p = 0.054) and after controlling for confounders (adjusted odds ratio, 2.5; 95% CI, 0.91–6.8; p = 0.075), and it significantly increased survival with favorable neurologic outcome on both univariate (50% vs 29%, p = 0.036) and multivariable analyses (adjusted odds ratio, 2.75; 95% CI, 1.01–7.5; p = 0.047). Cardiopulmonary resuscitation epochs for patients who are 8 years old or older during the debriefing period were 5.6 times more likely to meet targets of excellent cardiopulmonary resuscitation (95% CI, 2.9–10.6; p < 0.01).
CONCLUSION:Implementation of an interdisciplinary, postevent quantitative debriefing program was significantly associated with improved cardiopulmonary resuscitation quality and survival with favorable neurologic outcome.
The American Heart Association recommends debriefing after attempted resuscitation from in-hospital cardiac arrest (IHCA) to improve resuscitation quality and outcomes. This is the first published ...study detailing the utilization, process and content of hot debriefings after pediatric IHCA.
Using prospective data from the Pediatric Resuscitation Quality Collaborative (pediRES-Q), we analyzed data from 227 arrests occurring between February 1, 2016, and August 31, 2017. Hot debriefings, defined as occurring within minutes to hours of IHCA, were evaluated using a modified Team Emergency Assessment Measure framework for qualitative content analysis of debriefing comments.
Hot debriefings were performed following 108 of 227 IHCAs (47%). The median interval to debriefing was 130 min (Interquartile range IQR 45, 270). Median debriefing duration was 15 min (IQR 10, 20). Physicians facilitated 95% of debriefings, with a median of 9 participants (IQR 7, 11). After multivariate analysis, accounting for hospital site, debriefing frequency was not associated with patient age, gender, race, illness category or unit type. The most frequent positive (plus) comments involved cooperation/coordination (60%), communication (47%) and clinical standards (41%). The most frequent negative (delta) comments involved equipment (46%), cooperation/coordination (45%), and clinical standards (36%).
Approximately half of pediatric IHCAs were followed by hot debriefings. Hot debriefings were multi-disciplinary, timely, and often addressed issues of team cooperation/coordination, communication, clinical standards, and equipment. Additional studies are warranted to identify barriers to hot debriefings and to evaluate the impact of these debriefings on patient outcomes.
This focused update to the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care follows the Pediatric Task Force of the International ...Liaison Committee on Resuscitation evidence review. It aligns with the International Liaison Committee on Resuscitation’s continuous evidence review process, and updates are published when the International Liaison Committee on Resuscitation completes a literature review based on new science. This update provides the evidence review and treatment recommendation for chest compression–only CPR versus CPR using chest compressions with rescue breaths for children <18 years of age. Four large database studies were available for review, including 2 published after the “2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.” Two demonstrated worse 30-day outcomes with chest compression–only CPR for children 1 through 18 years of age, whereas 2 studies documented no difference between chest compression–only CPR and CPR using chest compressions with rescue breaths. When the results were analyzed for infants <1 year of age, CPR using chest compressions with rescue breaths was better than no CPR but was no different from chest compression–only CPR in 1 study, whereas another study observed no differences among chest compression–only CPR, CPR using chest compressions with rescue breaths, and no CPR. CPR using chest compressions with rescue breaths should be provided for infants and children in cardiac arrest. If bystanders are unwilling or unable to deliver rescue breaths, we recommend that rescuers provide chest compressions for infants and children.
Background Current pediatric cardiac arrest guidelines recommend depressing the chest by one-third anterior-posterior diameter (APD), which is presumed to equate to absolute age-specific chest ...compression depth targets (4 cm for infants and 5 cm for children). However, no clinical studies during pediatric cardiac arrest have validated this presumption. We aimed to study the concordance of measured one-third APD with absolute age-specific chest compression depth targets in a cohort of pediatric patients with cardiac arrest. Methods and Results This was a retrospective observational study from a multicenter, pediatric resuscitation quality collaborative (pediRES-Q Pediatric Resuscitation Quality Collaborative) from October 2015 to March 2022. In-hospital patients with cardiac arrest ≤12 years old with APD measurements recorded were included for analysis. One hundred eighty-two patients (118 infants >28 days old to <1 year old, and 64 children 1 to 12 years old) were analyzed. The mean one-third APD of infants was 3.2 cm (SD, 0.7 cm), which was significantly smaller than the 4 cm target depth (
<0.001). Seventeen percent of the infants had one-third APD measurements within the 4 cm ±10% target range. For children, the mean one-third APD was 4.3 cm (SD, 1.1 cm). Thirty-nine percent of children had one-third APD within the 5 cm ±10% range. Except for children 8 to 12 years old and overweight children, the measured mean one-third APD of the majority of the children was significantly smaller than the 5 cm depth target (
<0.05). Conclusions There was poor concordance between measured one-third APD and absolute age-specific chest compression depth targets, particularly for infants. Further study is needed to validate current pediatric chest compression depth targets and evaluate the optimal chest compression depth to improve cardiac arrest outcomes. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02708134.
Abstract Aim Gaps exist in pediatric resuscitation knowledge due to limited data collected during cardiac arrest in real children. The objective of this study was to evaluate the relationship between ...the 2010 American Heart Association (AHA) recommended chest compression (CC) depth (≥51 mm) and survival following pediatric resuscitation attempts. Methods Single-center prospectively collected and retrospectively analyzed observational study of children (>1 year) who received CCs between October 2006 and September 2013 in the intensive care unit (ICU) or emergency department (ED) at a tertiary care children's hospital. Multivariate logistic regression models controlling for calendar year and known potential confounders were used to estimate the association between 2010 AHA depth compliance and survival outcomes. The primary outcome was 24-h survival. The primary predictor variable was event AHA depth compliance, prospectively defined as an event with ≥60% of 30-s epochs achieving an average CC depth ≥51 mm during the first 5 min of the resuscitation. Results There were 89 CC events, 87 with quantitative CPR data collected (23 AHA depth compliant). AHA depth compliant events were associated with improved 24-h survival on both univariate analysis (70% vs. 16%, p < 0.001) and after controlling for potential confounders (calendar year of arrest, gender, first documented rhythm; aOR 10.3; CI95 : 2.75–38.8; p < 0.001). Conclusions 2010 AHA compliant chest compression depths (≥51 mm) are associated with higher 24-h survival compared to shallower chest compression depths, even after accounting for potentially confounding patient and event factors.
The association between chest compression (CC) pause duration and pediatric in-hospital cardiac arrest survival outcomes is unknown. The American Heart Association has recommended minimizing pauses ...in CC in children to <10 seconds, without supportive evidence. We hypothesized that longer maximum CC pause durations are associated with worse survival and neurological outcomes.
In this cohort study of index pediatric in-hospital cardiac arrests reported in pediRES-Q (Quality of Pediatric Resuscitation in a Multicenter Collaborative) from July of 2015 through December of 2021, we analyzed the association in 5-second increments of the longest CC pause duration for each event with survival and favorable neurological outcome (Pediatric Cerebral Performance Category ≤3 or no change from baseline). Secondary exposures included having any pause >10 seconds or >20 seconds and number of pauses >10 seconds and >20 seconds per 2 minutes.
We identified 562 index in-hospital cardiac arrests (median Q1, Q3 age 2.9 years 0.6, 10.0, 43% female, 13% shockable rhythm). Median length of the longest CC pause for each event was 29.8 seconds (11.5, 63.1). After adjustment for confounders, each 5-second increment in the longest CC pause duration was associated with a 3% lower relative risk of survival with favorable neurological outcome (adjusted risk ratio, 0.97 95% CI, 0.95-0.99;
=0.02). Longest CC pause duration was also associated with survival to hospital discharge (adjusted risk ratio, 0.98 95% CI, 0.96-0.99;
=0.01) and return of spontaneous circulation (adjusted risk ratio, 0.93 95% CI, 0.91-0.94;
<0.001). Secondary outcomes of any pause >10 seconds or >20 seconds and number of CC pauses >10 seconds and >20 seconds were each significantly associated with adjusted risk ratio of return of spontaneous circulation, but not survival or neurological outcomes.
Each 5-second increment in longest CC pause duration during pediatric in-hospital cardiac arrest was associated with lower chance of survival with favorable neurological outcome, survival to hospital discharge, and return of spontaneous circulation. Any CC pause >10 seconds or >20 seconds and number of pauses >10 seconds and >20 seconds were significantly associated with lower adjusted probability of return of spontaneous circulation, but not survival or neurological outcomes.
Abstract INTRODUCTION The Neonatal Resuscitation Program (NRP) guidelines recommend positive pressure ventilation (PPV) in the first 60 seconds of life to support perinatal transition in ...non-breathing newborns. Our aim was to describe the incidence and characteristics of newborn PPV using real-time observation in the delivery unit. METHODS Prospective, observational, quality improvement study conducted at a tertiary academic hospital. Deliveries during randomized weekday/evening 8-hour shifts were attended by a trained observer. Intervention data were recorded for all newborns with gestational age (GA) ≥34wks that received PPV. Descriptive summaries and Kruskal-Wallis test for continuous variables and Fisher’s exact test for categorical variables were used to compare characteristics. RESULTS Of 1,135 live deliveries directly observed over 18mos, 64 (6%) newborns with a mean GA 39 ± 2wks received PPV: Median time from birth to warmer was 20 sec (IQR 15–22 sec); PPV was initiated within 60 sec of life in 29 (45%) and between 60–90 sec of life in 17 (27%). PPV duration was <120 sec in 38 (60%). Seven/21 (33%) newborns that received PPV after vaginal delivery were not pre-identified and resuscitation team was alerted after delivery. We found no association between PPV start time and duration of PPV (p = 0.86). CONCLUSION We observed that most (94%) term newborns spontaneously initiate respirations. In over half observed deliveries receiving PPV, time to initiation of PPV was greater than 60 sec (longer than recommended). Compliance with current NRP guidelines is difficult, and it’s not clear whether it is the recommendations or the training to achieve PPV recommendations that should be modified.
Providers caring for newly born infants require skills and knowledge to initiate prompt and effective positive pressure ventilation (PPV) if the newborn does not breathe spontaneously after birth. We ...hypothesized implementation of high frequency/short duration deliberate practice training and post event video-based debriefings would improve process of care and decreases time to effective spontaneous respiration.
Pre- and post-interventional quality study performed at two Norwegian university hospitals. All newborns receiving PPV were prospectively video-recorded, and initial performance data guided the development of educational interventions. A priori primary outcome was changed from process of care using the Neonatal Resuscitation Performance Evaluation (NRPE) score to time to effective spontaneous respiration as the NRPE score could only be obtained from one site due to lack of staff resources.
Over 12 months, 297 PPV-Refreshers and 52 performance debriefings were completed with 227 unique providers attending a PPV-Refresher and 93 unique providers completed a debriefing. We compared 102 PPV-events pre- to 160 PPV-events post-bundle implementation. The time to effective spontaneous respiration decreased from median (95% confidence interval) 196 (140–237) to 144 (120–163) s, p = 0.010. The NRPE-score increased significantly from median 77% (75–81) pre- to 89% (86–92) post-implementation, p < 0.001. There were no significant differences in time to heart rate >100 beats/min or number of newborns transferred to intensive care.
High frequency/short duration deliberate practice PPV psychomotor training combined with performance-focused team debriefings using video recordings of actual resuscitations may improve time to effective spontaneous breathing and adherence to guidelines during real neonatal resuscitations.
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