Adherence to Pediatric Cardiac Arrest Guidelines Across a Spectrum of Fifty Emergency Departments: A Prospective, In Situ, Simulation-based Study

Marc Auerbach, Linda Brown, Travis Whitfill, Janette Baird, Kamal Abulebda, Ambika Bhatnagar, Riad Lutfi, Marcie Gawel, Barbara Walsh, Khoon Yen Tay, Megan Lavoie, Vinay Nadkarni, Robert A Dudas, David Kessler, Jessica Katznelson, Sandeep Ganghadaran, Melinda Fiedor Hamilton

Research output: Contribution to journalArticle

Abstract

Background and Objectives: Pediatric out-of-hospital cardiac arrest survival outcomes are dismal (<10%). Care that is provided in adherence to established guidelines has been associated with improved survival. Lower mortality rates have been reported in higher-volume hospitals, teaching hospitals, and trauma centers. The primary objective of this article was to explore the relationship of hospital characteristics, such as annual pediatric patient volume, to adherence to pediatric cardiac arrest guidelines during an in situ simulation. Secondary objectives included comparing adherence to other team, provider, and system factors. Methods: This prospective, multicenter, observational study evaluated interprofessional teams in their native emergency department (ED) resuscitation bays caring for a simulated 5-year-old child presenting in cardiac arrest. The primary outcome, adherence to the American Heart Association pediatric guidelines, was assessed using a 14-item tool including three component domains: basic life support (BLS), pulseless electrical activity (PEA), and ventricular fibrillation (VF). Provider, team, and hospital-level data were collected as independent data. EDs were evaluated in four pediatric volume groups (low < 1,800/year; medium 1,800–4,999; medium-high 5,000–9,999; high > 10,000). Cardiac arrest adherence and domains were evaluated by pediatric patient volume and other team and hospital-level characteristics, and path analyses were performed to evaluate the contribution of patient volume, systems readiness, and teamwork on BLS, PEA, and VF adherence. Results: A total of 101 teams from a spectrum of 50 EDs participated including nine low pediatric volume (<1,800/year), 36 medium volume (1,800–4,999/year), 24 medium-high (5,000–9,999/year), and 32 high volume (≥10000/year). The median total adherence score was 57.1 (interquartile range = 50.0–78.6). This was not significantly different across the four volume groups. The highest level of adherence for BLS and PEA domains was noted in the medium-high–volume sites, while no difference was noted for the VF domain. The lowest level of BLS adherence was noted in the lowest-volume EDs. Improved adherence was not directly associated with higher pediatric readiness survey (PRS) score provider experience, simulation teamwork performance, or more providers with Pediatric Advanced Life Support (PALS) training. EDs in teaching hospitals with a trauma center designation that served only children demonstrated higher adherence compared to nonteaching hospitals (64.3 vs 57.1), nontrauma centers (64.3 vs. 57.1), and mixed pediatric and adult departments (67.9 vs. 57.1), respectively. The overall effect sizes for total cardiac adherence score are ED type γ = 0.47 and pediatric volume (low and medium vs. medium-high and high) γ = 0.41. A series of path analyses models was conducted that indicated that overall pediatric ED volume predicted significantly better guideline adherence, but the effect of volume on performance was only mediated by the PRS for the VF domain. Conclusions: This study demonstrated variable adherence to pediatric cardiac arrest guidelines across a spectrum of EDs. Overall adherence was not associated with ED pediatric volume. Medium-high–volume EDs demonstrated the highest levels of adherence for BLS and PEA. Lower-volume EDs were noted to have lower adherence to BLS guidelines. Improved adherence was not directly associated with higher PRS score provider experience, simulation teamwork performance, or more providers with PALS training. This study demonstrates that current approaches optimizing the care of children in cardiac arrest in the ED (provider training, teamwork training, environmental preparation) are insufficient.

Original languageEnglish (US)
JournalAcademic Emergency Medicine
DOIs
StateAccepted/In press - Jan 1 2018

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Heart Arrest
Hospital Emergency Service
Guidelines
Pediatrics
Training Support
Out-of-Hospital Cardiac Arrest
Guideline Adherence
Pediatric Hospitals
Trauma Centers
Only Child
Child Care
Teaching Hospitals

ASJC Scopus subject areas

  • Emergency Medicine

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Adherence to Pediatric Cardiac Arrest Guidelines Across a Spectrum of Fifty Emergency Departments : A Prospective, In Situ, Simulation-based Study. / Auerbach, Marc; Brown, Linda; Whitfill, Travis; Baird, Janette; Abulebda, Kamal; Bhatnagar, Ambika; Lutfi, Riad; Gawel, Marcie; Walsh, Barbara; Tay, Khoon Yen; Lavoie, Megan; Nadkarni, Vinay; Dudas, Robert A; Kessler, David; Katznelson, Jessica; Ganghadaran, Sandeep; Hamilton, Melinda Fiedor.

In: Academic Emergency Medicine, 01.01.2018.

Research output: Contribution to journalArticle

Auerbach, M, Brown, L, Whitfill, T, Baird, J, Abulebda, K, Bhatnagar, A, Lutfi, R, Gawel, M, Walsh, B, Tay, KY, Lavoie, M, Nadkarni, V, Dudas, RA, Kessler, D, Katznelson, J, Ganghadaran, S & Hamilton, MF 2018, 'Adherence to Pediatric Cardiac Arrest Guidelines Across a Spectrum of Fifty Emergency Departments: A Prospective, In Situ, Simulation-based Study', Academic Emergency Medicine. https://doi.org/10.1111/acem.13564
Auerbach, Marc ; Brown, Linda ; Whitfill, Travis ; Baird, Janette ; Abulebda, Kamal ; Bhatnagar, Ambika ; Lutfi, Riad ; Gawel, Marcie ; Walsh, Barbara ; Tay, Khoon Yen ; Lavoie, Megan ; Nadkarni, Vinay ; Dudas, Robert A ; Kessler, David ; Katznelson, Jessica ; Ganghadaran, Sandeep ; Hamilton, Melinda Fiedor. / Adherence to Pediatric Cardiac Arrest Guidelines Across a Spectrum of Fifty Emergency Departments : A Prospective, In Situ, Simulation-based Study. In: Academic Emergency Medicine. 2018.
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abstract = "Background and Objectives: Pediatric out-of-hospital cardiac arrest survival outcomes are dismal (<10{\%}). Care that is provided in adherence to established guidelines has been associated with improved survival. Lower mortality rates have been reported in higher-volume hospitals, teaching hospitals, and trauma centers. The primary objective of this article was to explore the relationship of hospital characteristics, such as annual pediatric patient volume, to adherence to pediatric cardiac arrest guidelines during an in situ simulation. Secondary objectives included comparing adherence to other team, provider, and system factors. Methods: This prospective, multicenter, observational study evaluated interprofessional teams in their native emergency department (ED) resuscitation bays caring for a simulated 5-year-old child presenting in cardiac arrest. The primary outcome, adherence to the American Heart Association pediatric guidelines, was assessed using a 14-item tool including three component domains: basic life support (BLS), pulseless electrical activity (PEA), and ventricular fibrillation (VF). Provider, team, and hospital-level data were collected as independent data. EDs were evaluated in four pediatric volume groups (low < 1,800/year; medium 1,800–4,999; medium-high 5,000–9,999; high > 10,000). Cardiac arrest adherence and domains were evaluated by pediatric patient volume and other team and hospital-level characteristics, and path analyses were performed to evaluate the contribution of patient volume, systems readiness, and teamwork on BLS, PEA, and VF adherence. Results: A total of 101 teams from a spectrum of 50 EDs participated including nine low pediatric volume (<1,800/year), 36 medium volume (1,800–4,999/year), 24 medium-high (5,000–9,999/year), and 32 high volume (≥10000/year). The median total adherence score was 57.1 (interquartile range = 50.0–78.6). This was not significantly different across the four volume groups. The highest level of adherence for BLS and PEA domains was noted in the medium-high–volume sites, while no difference was noted for the VF domain. The lowest level of BLS adherence was noted in the lowest-volume EDs. Improved adherence was not directly associated with higher pediatric readiness survey (PRS) score provider experience, simulation teamwork performance, or more providers with Pediatric Advanced Life Support (PALS) training. EDs in teaching hospitals with a trauma center designation that served only children demonstrated higher adherence compared to nonteaching hospitals (64.3 vs 57.1), nontrauma centers (64.3 vs. 57.1), and mixed pediatric and adult departments (67.9 vs. 57.1), respectively. The overall effect sizes for total cardiac adherence score are ED type γ = 0.47 and pediatric volume (low and medium vs. medium-high and high) γ = 0.41. A series of path analyses models was conducted that indicated that overall pediatric ED volume predicted significantly better guideline adherence, but the effect of volume on performance was only mediated by the PRS for the VF domain. Conclusions: This study demonstrated variable adherence to pediatric cardiac arrest guidelines across a spectrum of EDs. Overall adherence was not associated with ED pediatric volume. Medium-high–volume EDs demonstrated the highest levels of adherence for BLS and PEA. Lower-volume EDs were noted to have lower adherence to BLS guidelines. Improved adherence was not directly associated with higher PRS score provider experience, simulation teamwork performance, or more providers with PALS training. This study demonstrates that current approaches optimizing the care of children in cardiac arrest in the ED (provider training, teamwork training, environmental preparation) are insufficient.",
author = "Marc Auerbach and Linda Brown and Travis Whitfill and Janette Baird and Kamal Abulebda and Ambika Bhatnagar and Riad Lutfi and Marcie Gawel and Barbara Walsh and Tay, {Khoon Yen} and Megan Lavoie and Vinay Nadkarni and Dudas, {Robert A} and David Kessler and Jessica Katznelson and Sandeep Ganghadaran and Hamilton, {Melinda Fiedor}",
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TY - JOUR

T1 - Adherence to Pediatric Cardiac Arrest Guidelines Across a Spectrum of Fifty Emergency Departments

T2 - A Prospective, In Situ, Simulation-based Study

AU - Auerbach, Marc

AU - Brown, Linda

AU - Whitfill, Travis

AU - Baird, Janette

AU - Abulebda, Kamal

AU - Bhatnagar, Ambika

AU - Lutfi, Riad

AU - Gawel, Marcie

AU - Walsh, Barbara

AU - Tay, Khoon Yen

AU - Lavoie, Megan

AU - Nadkarni, Vinay

AU - Dudas, Robert A

AU - Kessler, David

AU - Katznelson, Jessica

AU - Ganghadaran, Sandeep

AU - Hamilton, Melinda Fiedor

PY - 2018/1/1

Y1 - 2018/1/1

N2 - Background and Objectives: Pediatric out-of-hospital cardiac arrest survival outcomes are dismal (<10%). Care that is provided in adherence to established guidelines has been associated with improved survival. Lower mortality rates have been reported in higher-volume hospitals, teaching hospitals, and trauma centers. The primary objective of this article was to explore the relationship of hospital characteristics, such as annual pediatric patient volume, to adherence to pediatric cardiac arrest guidelines during an in situ simulation. Secondary objectives included comparing adherence to other team, provider, and system factors. Methods: This prospective, multicenter, observational study evaluated interprofessional teams in their native emergency department (ED) resuscitation bays caring for a simulated 5-year-old child presenting in cardiac arrest. The primary outcome, adherence to the American Heart Association pediatric guidelines, was assessed using a 14-item tool including three component domains: basic life support (BLS), pulseless electrical activity (PEA), and ventricular fibrillation (VF). Provider, team, and hospital-level data were collected as independent data. EDs were evaluated in four pediatric volume groups (low < 1,800/year; medium 1,800–4,999; medium-high 5,000–9,999; high > 10,000). Cardiac arrest adherence and domains were evaluated by pediatric patient volume and other team and hospital-level characteristics, and path analyses were performed to evaluate the contribution of patient volume, systems readiness, and teamwork on BLS, PEA, and VF adherence. Results: A total of 101 teams from a spectrum of 50 EDs participated including nine low pediatric volume (<1,800/year), 36 medium volume (1,800–4,999/year), 24 medium-high (5,000–9,999/year), and 32 high volume (≥10000/year). The median total adherence score was 57.1 (interquartile range = 50.0–78.6). This was not significantly different across the four volume groups. The highest level of adherence for BLS and PEA domains was noted in the medium-high–volume sites, while no difference was noted for the VF domain. The lowest level of BLS adherence was noted in the lowest-volume EDs. Improved adherence was not directly associated with higher pediatric readiness survey (PRS) score provider experience, simulation teamwork performance, or more providers with Pediatric Advanced Life Support (PALS) training. EDs in teaching hospitals with a trauma center designation that served only children demonstrated higher adherence compared to nonteaching hospitals (64.3 vs 57.1), nontrauma centers (64.3 vs. 57.1), and mixed pediatric and adult departments (67.9 vs. 57.1), respectively. The overall effect sizes for total cardiac adherence score are ED type γ = 0.47 and pediatric volume (low and medium vs. medium-high and high) γ = 0.41. A series of path analyses models was conducted that indicated that overall pediatric ED volume predicted significantly better guideline adherence, but the effect of volume on performance was only mediated by the PRS for the VF domain. Conclusions: This study demonstrated variable adherence to pediatric cardiac arrest guidelines across a spectrum of EDs. Overall adherence was not associated with ED pediatric volume. Medium-high–volume EDs demonstrated the highest levels of adherence for BLS and PEA. Lower-volume EDs were noted to have lower adherence to BLS guidelines. Improved adherence was not directly associated with higher PRS score provider experience, simulation teamwork performance, or more providers with PALS training. This study demonstrates that current approaches optimizing the care of children in cardiac arrest in the ED (provider training, teamwork training, environmental preparation) are insufficient.

AB - Background and Objectives: Pediatric out-of-hospital cardiac arrest survival outcomes are dismal (<10%). Care that is provided in adherence to established guidelines has been associated with improved survival. Lower mortality rates have been reported in higher-volume hospitals, teaching hospitals, and trauma centers. The primary objective of this article was to explore the relationship of hospital characteristics, such as annual pediatric patient volume, to adherence to pediatric cardiac arrest guidelines during an in situ simulation. Secondary objectives included comparing adherence to other team, provider, and system factors. Methods: This prospective, multicenter, observational study evaluated interprofessional teams in their native emergency department (ED) resuscitation bays caring for a simulated 5-year-old child presenting in cardiac arrest. The primary outcome, adherence to the American Heart Association pediatric guidelines, was assessed using a 14-item tool including three component domains: basic life support (BLS), pulseless electrical activity (PEA), and ventricular fibrillation (VF). Provider, team, and hospital-level data were collected as independent data. EDs were evaluated in four pediatric volume groups (low < 1,800/year; medium 1,800–4,999; medium-high 5,000–9,999; high > 10,000). Cardiac arrest adherence and domains were evaluated by pediatric patient volume and other team and hospital-level characteristics, and path analyses were performed to evaluate the contribution of patient volume, systems readiness, and teamwork on BLS, PEA, and VF adherence. Results: A total of 101 teams from a spectrum of 50 EDs participated including nine low pediatric volume (<1,800/year), 36 medium volume (1,800–4,999/year), 24 medium-high (5,000–9,999/year), and 32 high volume (≥10000/year). The median total adherence score was 57.1 (interquartile range = 50.0–78.6). This was not significantly different across the four volume groups. The highest level of adherence for BLS and PEA domains was noted in the medium-high–volume sites, while no difference was noted for the VF domain. The lowest level of BLS adherence was noted in the lowest-volume EDs. Improved adherence was not directly associated with higher pediatric readiness survey (PRS) score provider experience, simulation teamwork performance, or more providers with Pediatric Advanced Life Support (PALS) training. EDs in teaching hospitals with a trauma center designation that served only children demonstrated higher adherence compared to nonteaching hospitals (64.3 vs 57.1), nontrauma centers (64.3 vs. 57.1), and mixed pediatric and adult departments (67.9 vs. 57.1), respectively. The overall effect sizes for total cardiac adherence score are ED type γ = 0.47 and pediatric volume (low and medium vs. medium-high and high) γ = 0.41. A series of path analyses models was conducted that indicated that overall pediatric ED volume predicted significantly better guideline adherence, but the effect of volume on performance was only mediated by the PRS for the VF domain. Conclusions: This study demonstrated variable adherence to pediatric cardiac arrest guidelines across a spectrum of EDs. Overall adherence was not associated with ED pediatric volume. Medium-high–volume EDs demonstrated the highest levels of adherence for BLS and PEA. Lower-volume EDs were noted to have lower adherence to BLS guidelines. Improved adherence was not directly associated with higher PRS score provider experience, simulation teamwork performance, or more providers with PALS training. This study demonstrates that current approaches optimizing the care of children in cardiac arrest in the ED (provider training, teamwork training, environmental preparation) are insufficient.

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