The Association of Hospital Rate of Delayed Epinephrine Administration With Survival to Discharge for Pediatric Nonshockable In-Hospital Cardiac Arrest

Evaluation of hospital management of paediatric out-of-hospital cardiac arrest

INTRODUCTION

Pediatric out of hospital cardiac arrest (POHCA) is rare, with high mortality and neurological morbidity. Adherence to Pediatric Advanced Life Support guidelines standardizes in-hospital care and improves outcomes. We hypothesized that in-hospital care of POHCA patients was variable and deviations from guidelines were associated with higher mortality.

METHODS

POHCA patients in the London-Middlesex region between January 2012 and June 2020 were included. The care of children with ongoing arrest (intra-arrest) and post-arrest outcomes were reviewed using the Children's Hospital, London Health Sciences Centre (LHSC) patient database and the Adverse Event Management System.

RESULTS

50 POHCA patients arrived to hospital, with 15 (30%) patients admitted and 2 (4.0%) surviving to discharge, both with poor neurological outcomes and no improvement at 90 days. Deviations occurred at every event with intra-arrest care deviations occurring mostly in medication delivery and defibrillation (98%). Post-arrest deviations occurred mostly in temperature monitoring (60%). Data missingness was 15.9% in the intra-arrest and 1.7% in the post-arrest group.

DISCUSSION

Deviations commonly occurred in both in-hospital arrest and post-arrest care. The study was under-powered to identify associations between DEVs and outcomes. Future work includes addressing specific deviations in intra-arrest and post-arrest care of POHCA patients and standardizing electronic documentation.

Video Review of Simulated Pediatric Cardiac Arrest to Identify Errors/Latent Safety Threats: A Mixed Methods Study

INTRODUCTION

Outcomes from pediatric in-hospital cardiac arrest depend on the treatment provided as well as resuscitation team performance. Our study aimed to identify errors occurring in this clinical context and develop an analytical framework to classify them. This analytical framework provided a better understanding of team performance, leading to improved patient outcomes.

METHODS

We analyzed 25 video recordings of pediatric cardiac arrest simulations from the pediatric intensive care unit at the Alberta Children's Hospital. We conducted a qualitative-dominant crossover mixed method analysis to produce a broad understanding of the etiology of errors. Using qualitative framework analysis, we identified and qualitatively described errors and transformed the data coded into quantitative data to determine the frequency of errors.

RESULTS

We identified 546 errors/error-related actions and behaviors and 25 near misses. The errors were coded into 21 codes that were organized into 5 main themes. Clinical task-related errors accounted for most errors (41.9%), followed by planning, and executing task-related errors (22.3%), distraction-related errors (18.7%), communication-related errors (10.1%), and knowledge/training-related errors (7%).

CONCLUSIONS

This novel analytical framework can robustly identify, classify, and describe the root causes of errors within this complex clinical context. Future validation of this classification of errors and error-related actions and behaviors on larger samples of resuscitations from various contexts will allow for a better understanding of how errors can be mitigated to improve patient outcomes.

Gamification educational intervention improves pediatric nurses' comfort and speed drawing up code-dose epinephrine

PURPOSE

Drawing up weight-based doses of epinephrine is a vital skill for pediatric nurses; however, non-intensive care unit (ICU) nurses may not routinely perform this skill and may not be as efficient or comfortable doing so during pediatric resuscitations. This study aimed to evaluate the impact of a gamification program on non-ICU pediatric nurses' knowledge and skills regarding epinephrine for pediatric cardiac arrest.

DESIGN AND METHODS

Comfort and time to draw up three doses of epinephrine during out-of-ICU in-hospital pediatric cardiac arrest were measured pre- and post- a gamification-centered educational intervention.

RESULTS

Nursing comfort improved from 2.93 ± 1.90 to 6.68 ± 1.46 out of 10 (mean difference 3.6 +/- 2.1, p < 0.001). Overall time to draw up three doses of epinephrine decreased after the intervention by an average of 27.1 s (p = 0.019). The number of nurses who could complete the task in under 2 min improved from 23% to 59% (p = 0.031).

CONCLUSIONS

At baseline few non-ICU nurses could draw up multiple weight-based doses of epinephrine in under two minutes. A gamification simulation-based educational intervention improved pediatric non-ICU nurses' comfort and speed drawing up epinephrine.

PRACTICE IMPLICATIONS

Wide-spread implementation of gamification-centered educational initiatives could result in faster epinephrine administration and improved mortality rates from in-hospital pediatric cardiac arrest.

Pulseless electrical activity and asystolic cardiac arrest in infants: identifying factors that influence outcomes

BACKGROUND

There is limited information on pulseless electrical activity (PEA)/asystolic cardiac arrest (CA) in the infant population. The aim is to describe the incidence and factors associated with outcomes in infants with PEA/asystolic CA.

METHODS

Single-center retrospective chart review study of infants less than one year of age who suffer in-hospital PEA/asystolic CA from January 1 2011 to June 30 2019. The primary outcome was the return of spontaneous circulation. The secondary outcome was survival to discharge.

RESULTS

CA occurred in 148 infants and PEA/asystolic was found in 38 (26%). Of those 29 (76%) achieved ROSC, and 12 (32%) survived to discharge. Infants on inotrope support or receiving longer duration of chest compressions and epinephrine had increase mortality. All infants with respiratory etiology of arrest survived to hospital discharge.

CONCLUSION

PEA/asystolic CAs are uncommon. Poor prognostic indicators include the need for pre-arrest inotrope support and increased duration of chest compressions.

Time-to-Task Validation in Sequential Simulations as a Component of Nursing Student Competency

BACKGROUND

Time goals have not been tested as a component of nursing competence.

METHODS

Using a known-groups approach, a multisite study was performed on prelicensure nursing students (novices) and experienced nurses (experts) who participated in 2 simulations of patient deterioration with time goals. Video capture was achieved with an eye tracker.

RESULTS

While all novices did not achieve the time goals in both simulations, there was a significant improvement between the 2 simulations (P = .04). Experts were more successful in achieving the time-to-task goals in both simulations (44% and 95%, respectively). Statistical significance was found between the novice and expert groups in achieving the time goal for both simulations (P < .01).

CONCLUSIONS

This study was able to differentiate the expert group as being more proficient in a timed assessment, although the novices showed improvement between 2 simulations. This illustrates an opportunity for skill development among novices in managing patient deterioration amenable to time as an objective assessment.

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

Early On-Scene Management of Pediatric Out-of-Hospital Cardiac Arrest Can Result in Improved Likelihood for Neurologically-Intact Survival

AIM

To evaluate the frequency of neurologically-intact survival (SURV) following pediatric out-of-hospital cardiac arrest (POHCA) when comparing traditional early evacuation strategies to those emphasizing resuscitation efforts being performed immediately on-scene.

METHODS

Before 2014, emergency medical services (EMS) crews in a county-wide EMS agency provided limited treatment for POHCA on-scene and rapidly transported patients to appropriate hospitals. After 2014, training strongly concentrated upon EMS provider comfort levels with on-scene resuscitation efforts including methods to expedite protocols on-site and control positive-pressure ventilation. Frequency of SURV (hospital discharge) was compared for the two years prior to initiating the immediate on-scene care strategy to the ensuing two years following implementation.

RESULTS

Between 01/01/2012 and 12/31/2015, 94 children experienced POHCA. There were no significant differences before and after the on-scene focus in terms of age, sex, etiology, presenting electrocardiograph, drug infusions or bystander-performed cardiopulmonary resuscitation and total scene times actually remained similar (14.3 vs. 17.67 minutes). SURV increased significantly upon implementation of the immediate on-scene management strategy and was sustained over the next two years (0.0% to 23%; p = 0.0013). Though statistically-indeterminate in this analysis, the improvement was associated with a shorter mean time to epinephrine administration among resuscitated patients (16.6 vs. 7.65 minutes).

CONCLUSION

Facilitating immediate on-scene management of POHCA can result in improvements in life-saving. Although a historically-controlled evaluation, the compelling appearance of neurologically-intact survivors was immediate and sustained. Targeted training, more efficient, physiologically-driven procedures, and trusted encouragement from supervisors, likely played the most significant roles and not necessarily extended scene times.