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OBJECTIVE: To characterize chest compression (CC) pause duration during the last 5 minutes of pediatric cardiopulmonary resuscitation (CPR) prior to extracorporeal-CPR (E-CPR) cannulation and the association with survival outcomes.METHODS: Cohort study from a resuscitation quality collaborative including pediatric E-CPR cardiac arrest events ≥10 min with CPR quality data. We characterized CC interruptions during the last 5 min of defibrillator-electrode recorded CPR (prior to cannulation) and assessed the association between the longest CC pause duration and survival outcomes using multivariable logistic regression.RESULTS: Of 49 E-CPR events, median age was 2.0 [Q1, Q3: 0.6, 6.6] years, 55% (27/49) survived to hospital discharge and 18/49 (37%) with favorable neurological outcome. Median duration of CPR was 51 [43, 69] min. During the last 5 min of recorded CPR prior to cannulation, median duration of the longest CC pause was 14.0 [6.3, 29.4] sec: 66% >10 sec, 25% >29 sec, 14% >60 sec, and longest pause 168 sec. Following planned adjustment for known confounders of age and CPR duration, each 5-sec increase in longest CC pause duration was associated with lower odds of survival to hospital discharge [adjusted OR 0.89, 95%CI: 0.79-0.99] and lower odds of survival with favorable neurological outcome [adjusted OR 0.77, 95%CI: 0.60-0.98].CONCLUSIONS: Long CC pauses were common during the last 5 min of recorded CPR prior to E-CPR cannulation. Following adjustment for age and CPR duration, each 5-second incremental increase in longest CC pause duration was associated with significantly decreased rates of survival and favorable neurological outcome.

Aim of study: Recurrent in-hospital cardiac arrest (IHCA) is associated with morbidity and mortality in adults. We aimed to describe the risk factors and outcomes for paediatric recurrent IHCA. Methods: Retrospective cohort study of patients ≤18 years old with single or recurrent IHCA. Recurrent IHCA was defined as ≥2 IHCA within the same hospitalization. Categorical variables expressed as percentages and compared via Chi square test. Continuous variables expressed as medians with interquartile ranges and compared via rank sum test. Outcomes assessed in a propensity match cohort. Results: From July 1, 2015 to January 26, 2021, 139/894 (15.5%) patients experienced recurrent IHCA. Compared to patients with a single IHCA, recurrent IHCA patients were more likely to be trauma and less likely to be surgical cardiac patients. Median duration of cardiopulmonary resuscitation (CPR) was shorter in the recurrent IHCA (5 vs. 11 min; p < 0.001) with no difference in IHCA location or immediate cause of CPR. Patients with recurrent IHCA had worse survival to intensive care unit (ICU) discharge (31% vs. 52%; p < 0.001), and worse survival to hospital discharge (30% vs. 48%; p < 0.001) in unadjusted analyses and after propensity matching, patients with recurrent IHCA still had worse survival to ICU (34% vs. 67%; p < 0.001) and hospital (31% vs. 64%; p < 0.001) discharge. Conclusion: When examining those with a single vs. a recurrent IHCA, event and patient factors including more pre-existing conditions and shorter duration of CPR were associated with risk for recurrent IHCA. Recurrent IHCA is associated with worse survival outcomes following propensity matching.

Background:Personal protective equipment (PPE) is worn by prehospital providers (PHPs) for protection from hazardous exposures. Evidence regarding the ability of PHPs to perform resuscitation procedures has been described in adult but not pediatric models. This study examined the effects of PPE on the ability of PHPs to perform resuscitation procedures on pediatric patients.Methods:This prospective study was conducted at a US simulation center. Paramedics wore normal attire at the baseline session and donned full Level B PPE for the second session. During each session, they performed timed sets of psychomotor tasks simulating clinical care of a critically ill pediatric patient. The difference in time to completion between baseline and PPE sessions per task was examined using Wilcoxon signed-rank tests.Results:A total of 50 paramedics completed both sessions. Median times for task completion at the PPE sessions increased significantly from baseline for several procedures: tracheal intubation (+4.5 s; P = 0.01), automated external defibrillator (AED) placement (+9.5 s; P = 0.01), intraosseous line insertion (+7 s; P < 0.0001), tourniquet (+8.5 s; P < 0.0001), intramuscular injection (+21-23 s, P < 0.0001), and pulse oximetry (+4 s; P < 0.0001). There was no significant increase in completion time for bag-mask ventilation or autoinjector use.Conclusions:PPE did not have a significant impact on PHPs performing critical tasks while caring for a pediatric patient with a highly infectious or chemical exposure. This information may guide PHPs faced with the situation of resuscitating children while wearing Level B PPE.

OBJECTIVES Personal protective equipment (PPE) is worn by health care providers (HCPs) to protect against hazardous exposures. Studies of HCPs performing critical resuscitation tasks in PPE have yielded mixed results and have not evaluated performance in care of children. We evaluated the impacts of PPE on timeliness or success of emergency procedures performed by pediatric HCPs. METHODS This prospective study was conducted at 2 tertiary children's hospitals. For session 1, HCPs (medical doctors and registered nurses) wore normal attire; for session 2, they wore full-shroud PPE garb with 2 glove types: Ebola level or chemical. During each session, they performed clinical tasks on a patient simulator: intubation, bag-valve mask ventilation, venous catheter (IV) placement, push-pull fluid bolus, and defibrillation. Differences in completion time per task were compared. RESULTS There were no significant differences in medical doctor completion time across sessions. For registered nurses, there was a significant difference between baseline and PPE sessions for both defibrillation and IV placement tasks. Registered nurses were faster to defibrillate in Ebola PPE and slower when wearing chemical PPE (median difference, -3.5 vs 2 seconds, respectively; P < 0.01). Registered nurse IV placement took longer in Ebola and chemical PPE (5.5 vs 42 seconds, respectively; P < 0.01). After the PPE session, participants were significantly less likely to indicate that full-body PPE interfered with procedures, was claustrophobic, or slowed them down. CONCLUSIONS Personal protective equipment did not affect procedure timeliness or success on a simulated child, with the exception of IV placement. Further study is needed to investigate PPE's impact on procedures performed in a clinical care context.

Tracheal intubation (TI) practice across pediatric emergency departments (EDs) has not been comprehensively reported. We aim to describe TI practice and outcomes in pediatric EDs in contrast to those in intensive are units (ICUs) and use the data to identify quality improvement targets.Consecutive TI encounters from pediatric EDs and ICUs in the National Emergency Airway Registry for Children (NEAR4KIDS) database from 2015 to 2018 were analyzed for patient, provider, and practice characteristics and outcomes: adverse TI-associated events (TIAEs), oxygen desaturation (SpOA total of 756 TIs in 13 pediatric EDs and 12,512 TIs in 51 pediatric/cardiac ICUs were reported. Median (interquartile range [IQR]) patient age for ED TIs was higher (32 [7-108] months) than that for ICU TIs (15 [3-91] months; p 0.001). Proportion of TIs for respiratory decompensation (52% of ED vs. 64% ICU), shock (26% vs. 14%), and neurologic deterioration (30% vs. 11%) also differed by location. Limited neck mobility was reported more often in the ED (16% vs. 6%). TIs in the ED were performed more often via video laryngoscopy (64% vs. 29%). Adverse TIAE rates (15.6% ED, 14% ICU; absolute difference = 1.6%, 95% confidence interval [CI] = -1.1 to 4.2; p = 0.23) and severe TIAE rates (5.4% ED, 5.8% ICU; absolute difference = -0.3%, 95% CI = -2.0 to 1.3; p = 0.68) were not different. Oxygen desaturation was less commonly reported in ED TIs (13.6%) than ICU TIs (17%, absolute difference = -3.4%, 95% CI = -5.9 to -0.8; p = 0.016). Among ED TIs, shock as an indication (adjusted odds ratio [aOR] = 2.15, 95% CI = 1.26 to 3.65) and limited mouth opening (aOR = 1.74, 95% CI = 1.04 to 2.93) were independently associated with TIAEs.While TI characteristics vary between pediatric EDs and ICUs, outcomes are similar. Shock and limited mouth opening were independently associated with adverse TI events in the ED.

Minimizing pauses in chest compressions during cardiopulmonary resuscitation (CPR) is recommended by the American Heart Association (AHA) and is associated with improved patient outcomes. We studied the quality of pediatric CPR performed in a tertiary pediatric emergency department (ED) with a focus on pauses in chest compressions.We conducted an observational study of CPR quality in two pediatric EDs using video review during pediatric cardiac arrest. Events were reviewed for AHA guideline adherence. Parameters of CPR performance were described according to individual compressor segment. Pauses in compressions were analyzed for duration and pause activities.From a 30-month period, 81 cardiac arrests were analyzed, including 1003 individual compressor segments and 900 pauses. Median chest compression fraction was 91%, with a median pause duration of 4 s (IQR 2, 10); 22% of pauses were prolonged (10 s). Pulse checks occurred in 23% of pauses; 62% were prolonged. Checking a single pulse site (p 0.001) and having fingers ready pre-pause (p = 0. 001) were associated with significantly shorter pause duration. Pause duration was correlated with the number of pause tasks (r = 0.559, p 0.001). "Coordinated pauses" (pulse check, rhythm check and compressor change) were rare (6%) and long in duration (19 s; IQR 11, 30).Prolonged pauses in chest compressions occurred frequently during CPR and were associated with pulse checks and multiple simultaneous tasks. Checking a single pulse site with fingers ready on the pulse site pre-pause could decrease pause duration and improve CPR quality.

Study aim To determine the impact of high-frequency CPR training on performance during simulated and real pediatric CPR events in a pediatric emergency department (ED). Methods Prospective observational study. A high-frequency CPR training program (Resuscitation Quality Improvement (RQI)) was implemented among ED providers in a children’s hospital. Data on CPR performance was collected longitundinally during quarterly retraining sessions; scores were analyzed between quarter 1 and quarter 4 by nonparametric methods. Data on CPR performance during actual patient events was collected by simultaneous combination of video review and compression monitor devices to allow measurement of CPR quality by individual providers; linear mixed effects models were used to analyze the association between RQI components and CPR quality. Results 159 providers completed four consecutive RQI sessions. Scores for all CPR tasks during retraining sessions significantly improved during the study period. 28 actual CPR events were captured during the study period; 49 observations of RQI trained providers performing CPR on children were analyzed. A significant association was found between the number of prior RQI sessions and the percent of compressions meeting guidelines for rate (β coefficient -0.08; standard error 0.04; p = 0.03). Conclusions Over a 15 month period, RQI resulted in improved performance during training sessions for all skills. A significant association was found between number of sessions and adherence to compression rate guidelines during real patient events. Fewer than 30% of providers performed CPR on a patient during the study period. Multicenter studies over longer time periods should be undertaken to overcome the limitation of these rare events.

Introduction: Endotracheal intubation (ETI) of critically ill children is a high acuity, low frequency procedure in the pediatric emergency department that presents unique challenges to both pediatric and general acute care providers. COVID-19 and the associated requirements for PPE use, limitations of in-room personnel, communication difficulties, and reorganization of equipment have created new complexities. Objective: To use video review to compare intubator training level, first-attempt ETI success and presence of hypoxia during ETI attempts in the pediatric emergency department in the pre-COVID and COVID era. Methods: This is a retrospective multi-center case series of videorecordings of endotracheal intubations at the four tertiary care pediatric emergency departments comprising the VIPER Collaborative. All children undergoing emergent ETI between 1/1/2019-6/1/2020 in whom videorecordings were available were included for analysis. Data on patient age and intubator background was collected. Outcomes were first-attempt intubation success and hypoxia, defined as SpO2 Results: Between 1/1/2019 and 6/1/2020, a total of 272 patients underwent ETI (239 PRE, 33 POST). Overall first attempt success was 155/239 (65%) in PRE and 28/33 (85%) in POST (p=0.02). Hypoxia was noted in 15% of PRE patients and in 12% of POST patients. Analysis of the training level of the intubator was notable for a significant increase in the number of intubations performed by anesthesiologists (55% POST vs. 13% PRE, p Conclusion: Pediatric ETI in the COVID-19 era is associated with increased first attempt success when compared to the pre-COVID era.

Background: Hyperventilation is common during pediatric CPR and has known deleterious hemodynamic consequences. It is not known whether the presence of an advanced airway (AA) is independently associated with hyperventilation. Objective: To determine the independent association between the presence of an AA and hyperventilation during pediatric CPR in a collaborative of pediatric emergency departments using video review during resuscitations. Methods/Design: We present a report from the Videography in Pediatric Emergency Resuscitation (VIPER) Collaborative, a prospective review database. All events where CPR was performed and manual ventilations could be counted for at least 30 seconds were eligible for inclusion. Ventilation rates were counted and expressed in segments corresponding to individual CPR providers (‘compressor segments') and extrapolated to breaths per minute (bpm) where applicable. Hyperventilation was defined as a rate greater than 12 bpm, in accordance with American Heart Association recommendations. Ventilation rates were compared between CPR segments with a natural airway (bag-valve mask device; NA) versus an advanced airway (endotracheal tube or supraglottic airway; AA). Univariate analysis was done by two sided t-testing. Repeated measures logistic regression with random effects modeling (patient as intercept) was performed to determine the independent association of the presence of an AA with hyperventilation. Results/Discussion: 595 compressor segments in 67 CPR events were analyzed. Twenty-six patients underwent intubation and had segments with both NA and AA analyzed. Across all patients, 402/595 (68%) of segments occurred with an AA. Ventilation rates were significantly higher in patients with an AA compared with NA (14 + 10 bpm vs. 24 + 17 bpm, p < 0.001). By multivariate analysis, the presence of an advanced airway was independently associated with hyperventilation (AOR 12.2, 95% CI 5.0 - 30.3) during pediatric CPR. Future studies should examine methods of limiting manual hyperventilation during pediatric CPR, as well as the impact of ventilation rates on patient outcomes.

For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.

The 2020 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care is based on the extensive evidence evaluation performed in conjunction with the International Liaison Committee on Resuscitation. The Adult Basic and Advanced Life Support, Pediatric Basic and Advanced Life Support, Neonatal Life Support, Resuscitation Education Science, and Systems of Care Writing Groups drafted, reviewed, and approved recommendations, assigning to each recommendation a Class of Recommendation (ie, strength) and Level of Evidence (ie, quality). The 2020 Guidelines are organized in knowledge chunks that are grouped into discrete modules of information on specific topics or management issues. The 2020 Guidelines underwent blinded peer review by subject matter experts and were also reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. The AHA has rigorous conflict-of-interest policies and procedures to minimize the risk of bias or improper influence during development of the guidelines. Anyone involved in any part of the guideline development process disclosed all commercial relationships and other potential conflicts of interest.

Objectives This study aimed to determine whether personal protective equipment (PPE) results in deterioration in chest compression (CC) quality and greater fatigue for administering health care providers (HCPs). Methods In this multicenter study, HCPs completed 2 sessions. In session 1 (baseline), HCPs wore normal attire; in session 2, HCPs donned full PPE. During each session, they performed 5 minutes of uninterrupted CCs on a child manikin. Chest compression rate, depth, and release velocity were reported in ten 30-second epochs. Change in CC parameters and self-reported fatigue were measured between the start and 2- and 5-minute epochs. Results We enrolled 108 HCPs (prehospital and in-hospital providers). The median CC rate did not change significantly between epochs 1 and 10 during baseline sessions. Median CC depth and release velocity decreased for 5 minutes with PPE. There were no significant differences in CC parameters between baseline and PPE sessions in any provider group. Median fatigue scores during baseline sessions were 2 (at start), 4 (at 2 minutes), and 6 (at 5 minutes). There was a significantly higher median fatigue score between 0 and 5 minutes in both study sessions and in all groups. Fatigue scores were significantly higher for providers wearing PPE compared with baseline specifically among prehospital providers. Conclusions During a clinically appropriate 2-minute period, neither CC quality nor self-reported fatigue worsened to a significant degree in providers wearing PPE. Our data suggest that Pediatric Basic Life Support recommendations for CC providers to switch every 2 minutes need not be altered with PPE use.

Aim To use video review to compare CC quality between 2-thumb encircling (2T) and one-hand anterior (1H) hand position in infants receiving CPR. Methods Events where an infant received >2 min of CC using a CPR monitor device while videorecorded were included. CC were measured in segments provided by a single compressor; segment duration, identity of the compressor, and hand position (2T vs 1H) was determined from video review. CC rate and depth were measured by the monitor device. Results Seven infants received 111 min of CCs from a total of 28 providers. 12/28 providers were assessed using both 2T and 1H; 6 providers used 2T and 1H in the same patient. 80 CC segments were analyzed; the median duration of CC segments was 74 s (IQR 50–95 s). Median CC rate across all segments was 127/min (IQR 115–142/min); median CC depth was 3.0 cm (IQR 2.4–3.4 cm). 2T position was used in 33/80 (41%) of segments. There was no significant difference in CC depth between 2T and 1H position (3.0 ± 0.8 vs 3.0 ± 0.6 cm, p = 0.81). 1H position was significantly associated with faster CC rate than 2T position (134 ± 18 vs. 118 ± 15 CC/min, p Conclusions During CC in infants, 1H position was associated with a greater prevalence of inappropriately fast CC rate compared to 2T. There was no significant difference in depth between 2T and 1H. Future studies should evaluate the effect of hand position on clinical outcomes.

Over the last 30 years there has been a rapid rise in publications related to capnography, or continuous end-tidal carbon dioxide (ETCO2) monitoring, with a parallel increase in the number of patient applications for this device.1 Importantly, capnography has been studied in the setting of intubation and cardiopulmonary resuscitation (CPR) and shown to provide benefits to both patients and providers.2 In the setting of intubation, capnography is the ‘gold-standard’ method for confirmation of endotracheal tube (ETT) placement in the trachea; it also accurately detects ETT dislodgement and may decrease the frequency of inadvertent hypo- and hyperventilation.3-7 During CPR, capnography may correlate with pulmonary blood flow as a measure of the effectiveness of chest compressions, can be an early indicator of the return of spontaneous circulation (ROSC), and may be useful in predicting mortality.8-10 With this growing body of evidence, the International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science as well as the American Heart Association (AHA) updated their guidelines for both Adult and Pediatric Advanced Life Support in 2010 to include recommendations for capnography use during these critical events.11-13 The new guidelines recommended the routine use of quantitative waveform capnography for both intubation and during CPR.11-13 Since capnography is the most reliable method to confirm placement of the ETT, this method was given a class I recommendation for all hospital settings.12 In the event of CPR, capnography can improve the quality of chest compressions by serving as a guide to effective compressions and reduce interruptions by identifying ROSC without frequent pauses for pulse checks (Class IIa). Since these recommendations have been released, it is unclear if they are being adhered to for children. Overall, there is little data documenting how capnography is being used in children, particularly in the emergency department (ED). Our primary objectives were to determine how often capnography is being used during critical events and if publication of the updated AHA guidelines resulted in an increase in use of capnography. Our secondary objective was to examine associations between patient characteristics and capnography use among these patients in the pediatric acute care setting.

To describe chest compression (CC) quality by individual providers in two pediatric emergency departments (EDs) using video review and compression monitor output during pediatric cardiac arrests.Prospective observational study. Patients18 yo receiving CC for1 min were eligible. Data was collected from video review and CC monitor device in a synchronized fashion and reported in 'segments' by individual providers. Univariate comparison by age (1 yo, 1-8 yo,8 yo) was performed by chi-square testing for dichotomous variables ('high-quality' CPR) and nonparametric testing for continuous variables (CC rate and depth). Univariate comparison of ventilation rate (V) was made between segments with an advanced airway versus without.524 segments had data available; 42/524 (8%) met criteria for 'high-quality CC'. Patients8 yo had more segments meeting criteria (18% vs. 2% and 0.5%; p 0.001). Segments compliant for rate were less frequent in1 yo (17% vs. 24% vs. 27%; p = 0.03). Segments compliant for depth were less frequent in1 year olds and 1-8 year olds (5% and 9% vs. 20%, p 0.001.) Mean V for segments with an advanced airway was higher than with a natural airway (24 ± 18 vs. 14 ± 10 bpm, p 0.001). Hyperventilation was more prevalent in CPR segments with an advanced airway (66% vs. 32%, p 0.001).CC depth is rarely guideline compliant in infants. Hyperventilation is more prevalent during CPR periods with an advanced airway in place. Measuring individual provider CPR quality is feasible, allowing future studies to evaluate the impact of CPR training.

The Resuscitation Quality Improvement Program is a low-dose high-frequency training method for CPR skills. Evidence linking high-frequency training to improved performance during actual CPR is lacking. We have previously reported on the simultaneous use of video review and chest compression (CC) monitoring devices to describe CC quality at the level of individual providers. We sought to evaluate CC quality in pediatric CPR over a one year period following RQI implementation. Methods: Observational study in a pediatric ED where codes are videorecorded and where all providers were enrolled in RQI in October 2017. Video review is used to identify CPR providers and measure the duration of CC segments they perform. A monitor device is used to record CC depth and rate, allowing summarization of CC parameters for those individual time segments (i.e. CC performance by individual providers). CCs were analyzed by ‘compressor segment’, defined as the period of time where a single provider performed chest compressions until replaced by another. Data was summarized by quarter; change over time was analyzed by mixed effect logistic regression modeling adjusting for quarter and segment duration as fixed effects. Results: 159 providers enrolled in RQI. Data for 18 events totaling 206 CC segments were analyzed. 52 providers performed CC at some point during the study period. CC segments are graphed per quarter in Figure 1. There were no significant differences in proportion of CC segments meeting guidelines during the study period. Conclusions: CPR events in our ED are infrequent and a minority of providers perform CPR in routine clinical practice. Over a 15 month period following the implementation of RQI in a pediatric ED, CC quality during CPR events in children did not improve with time, although our analysis was limited by sample size constraints. Future research should expand this method to examine the impact of varied retraining intervals and varied participant groups on CC quality.

Introduction and Objective: The optimal retraining interval in CPR for healthcare providers is unknown. The Resuscitation Quality Improvement Program (RQI ® ) is a competency based, low-dose high-frequency quality improvement solution CPR psychomotor skills. We sought to describe the longitudinal change in skill performance during simulated CPR over a one year period following the implementation of RQI in a tertiary pediatric ED. Methods: Observational study in a single pediatric ED. All healthcare providers involved in resuscitative care in the ED were enrolled in RQI in October 2017. Once per 3-month period, each provider completed a feedback-guided skills session for 4 basic BLS skills (Infant compressions, infant ventilation, adult compressions, adult ventilation). A weighted scoring algorithm (range 0-100%) was used to score each subject’s performance. In the event of a score of less than 75%, repeated attempt(s) were required until a passing score was achieved. Q4 2017 median overall scores and first daily scores were compared to Q3 2018 median overall scores and first daily scores using a Wilcoxon Signed-Rank Test. Results: 159 providers completed all four quarterly training sessions in the 12-month study period. Median scores stratified by quarter and difference scores between the first and last quarter for each task are shown in Table 1. Overall scores and first daily scores for all four psychomotor CPR skills improved significantly for all tasks between Q4 2017 and Q3 2018. Conclusions: Pediatric ED providers enrolled in RQI showed improved CPR skill performance over a one year period. Future research should link RQI training and skill performance with CPR performance during actual patient care.

Introduction: Classical teaching in pediatric laryngoscopy advocates the use of straight blades to be placed underneath the epiglottis, whereas curved blades are placed in the vallecula. Anesthesia studies suggest that straight blade positioning in the vallecula may be a satisfactory technique for small children. We sought to assess laryngoscope blade tip position during pediatric tracheal intubation (TI) and its association with intubation success. Methods: Observational single center study. Children undergoing TI from November 2017 until December 2018 in a pediatric emergency department (ED) and pediatric intensive care unit (PICU) using a CMAC video laryngoscope with recorded images available for review were eligible for inclusion. Patient and provider characteristics were obtained from quality improvement database. Each video was independently reviewed, and the blade tip position was determined by study personnel as ‘in vallecula’ or ‘under epiglottis’. TI success was defined as observation of the tube entering the trachea on video. Univariate analysis between blade tip position and success, as well as potential confounders, was performed by chi 2 testing. Multivariable logistic regression to determine the independent association between blade tip position and success while controlling for relevant confounders. Results: 95 TI attempts were analysed. 58% of attempts were successful (14/35 in infants, 8/15 in 1-7 yr old, 33/45 in 8+ yr, p=0.01). Blade tip position was in the vallecula for 20/31 (65%) attempts with curved blades and 23/64 (36%) with straight blades. In univariate analysis, TI attempts with blade tip position ‘in vallecula’ were significantly more successful than attempts with ‘under epiglottis’ (37% vs. 84%, p Conclusion: During pediatric TI, laryngoscope blade tip position in the vallecula was independently associated with success when compared with placement under the epiglottis.

Background: Pediatric resuscitation events are infrequent but resource-intensive events which pull staff, leaving higher patient:provider ratios and less access to the resources in the emergency department (ED). There is a paucity of literature on the impact of these events on overall ED flow. Objective: Use novel, prospective, comprehensive data collection to evaluate the impact of resuscitation events on the time to physician evaluation (eval) for patients arriving to the ED after a resuscitation event. Methods: Data from all resuscitation events occurring in the ED are logged prospectively. Resuscitation dates were matched to 2 control dates by census within 2 weeks and with no resuscitation events within 3 hours of time zero. A difference-in-differences evaluation compared median time to physician eval for all ED patients arriving pre and post time zero between cases and controls. Multivariate linear mixed-effects models were used to compare time to physician eval post-resuscitation between cases and controls. Results: 459 resuscitation dates were matched to 812 control dates. A higher median time to physician eval was found for cases, as compared to controls, which lasted for 2 hours after the time of the event (see Figure). A significant difference in time to physician eval post-resuscitation was found for cases (p=0.003) in multivariate models (see Table). Conclusions: Pediatric resuscitation events occurring in a large, high-resource, pediatric ED impact overall flow of the ED. Initiatives to redistribute care during resuscitation events, and evaluation of the impact of these interventions, could help ensure timely and appropriate care delivery to all ED patients.

Purpose of review The pediatric resuscitation environment is a high-stakes, environment in which a multidisciplinary team must work together with patient outcomes dependent, at least in part, on the performance of that team. Given constraints of the environment and the nature of these events, quality improvement work in pediatric resuscitation can be challenging. Ongoing collection of accurate and reliable data on team performance is necessary to inform and evaluate change. Recent findings Despite the relative difficulty of quality improvement analysis and intervention implementation in the resuscitation environment, these efforts can have significant impact on patient outcomes. Although there are barriers to accurate data collection in real-life resuscitation, team performance of both technical and nontechnical skills can be reliably measured in video-based quality improvement programs. Training of nontechnical skills, using crisis resource management principles, can improve care delivery in resuscitation. Summary Striving toward a learning healthcare system model in resuscitation care delivery can allow for efficient performance improvement. Given the possible impacts on mortality and quality of life of care delivered in the resuscitation environment, all providers who could possibly face a resuscitation event - no matter how rare - should consider how they are evaluating the quality of their care delivery in this arena.

Simulation-based research (SBR) is the term used to describe research in clinical care, education, or health care systems where simulation is incorporated into the study design. Simulation-based research has increased in prevalence and scope in the past decade, including a growing number of investigations in pediatric emergency medicine (PEM). The conduct of high-quality SBR is faced with a variety of challenges related to study design, sample size, analytic considerations, and the interpretation and/or extrapolation of experimental results to actual clinical care. This article will review the application of SBR to PEM, including a review of these methodological challenges; examples of published SBE studies in PEM will illustrate successful approaches to dealing with such challenges. In addition, future directions and recommendations for optimizing quality of ongoing SBE in PEM will be discussed.

Quality cardiopulmonary resuscitation (CPR) is associated with improved outcomes during cardiac arrest. Duty cycle (DC) represents an understudied element of CPR quality. Our objective was to quantitatively analyze DC during actual pediatric and adolescent in-hospital cardiac arrest (IHCA).Prospective observational study of IHCA at a large academic children's hospital. CPR variables included DC (%) up to the first 10min of recorded chest compressions (CCs). American Heart Association (AHA) DC compliance was prospectively defined as an average event DC of 50±5%. Percentage of events compliant with AHA DC was compared to a priori hypothesized compliance percentage of 25% using chi-square. Association between DC quartiles and categories of depth (38, 38-49, ≥50mm) and rate (100, 100-120,120min(-1)) were analyzed by chi-square test for trend.Between October 2006 and June 2015, 97 events in 87 patients were analyzed. Mean DC for events was 40±2.8%. DC quartiles: Q1 (DC ≤38.3%), Q2 (38.3-40.1%), Q3 (40.1-42.1%), Q4 (42.1%). Only 5 (5.2%) events met AHA DC compliance, significantly less than the a priori hypothesis of 25% (p0.001). Average CC rates trended higher across DC quartiles: (Q1) 105±9; (Q2) 106±9; (Q3) 112±8; and (Q4) 118±14min(-1); p0.001. Other CPR quality variables were not associated with DC. There was no association between DC and survival.Compression DC during resuscitation of actual child and adolescent IHCA met AHA recommendations in only 5% of events. In this series we found no association of DC with CC depth or survival.

Introduction: Classical teaching in laryngoscopy advocates the use of Miller (Straight) blades to be placed underneath the epiglottis and lift it, whereas for Macintosh (Curved) blades the tip is positioned in the vallecula. Published studies in anesthesia suggest that straight blade positioning in the vallecula may be a satisfactory technique for small children. However, there is no clear evidence of consistent implementation of this methodology in practice and associated intubation success. Objectives: To assess laryngoscope blade tip position during pediatric tracheal intubation in the emergency department (ED) and its association with intubation success and time of laryngoscopy. Methods: Single center retrospective observational cohort study. Children undergoing tracheal intubation in a tertiary pediatric ED under video-recorded conditions were eligible for inclusion. A CMAC video laryngoscope was used as first line device with the video feed recorded for review. Videos were reviewed and the blade tip position during intubation recorded by study personnel. Blade tip position was categorized as ‘Correct’ if the curved blade was in the vallecula or straight blade was lifting the epiglottis; otherwise the position was categorized as ‘Incorrect’. Time of laryngoscopy was defined as time from blade insertion to removal. Univariate analysis between covariates was done by Fisher’s exact testing for intubation success and by nonparametric methods for laryngoscopy time. Results: A total of 17 complete videos were included in the study. Mac blade was used correctly in 8/10 cases (80%); Miller was used correctly in 1/7 cases (14%). Among infants (≤ 12 months), the Miller was used incorrectly in 3/4 cases (75%). Intubation was successful in 9/9 cases (100%) with correct blade position and in 5/8 cases (63%) with incorrect position (p=0.04). There was no significant difference in mean calculated laryngoscopy time for correct versus incorrect blade tip position (37.90 ± 26.80 sec vs. 44.33± 15.22 sec, p=0.12) Conclusion: Correct position of the laryngoscope blade tip is associated with higher intubation success. There was no significant difference in the laryngoscopy time for both correct and incorrect blade position.

Introduction: The quality of chest compressions (CC) is crucial for good outcomes for pediatric cardiac arrest. Verbal prompts from resuscitation leader or CPR coach may help to optimize it. The objective of this study is to describe the frequency of appropriate verbal prompts during pediatric CPR. We hypothesized that verbal prompts for CC would be given less frequently to infants compared to children. Methods: A report from the Videography In Pediatric Emergency Resuscitation (VIPER) Collaborative, a prospective observational database from three tertiary PEDs from December 2016 to April 2018. All study sites videorecord and review resuscitations and use a pressure sensor/monitor device during CPR. All events where chest compressions (CC) were performed under videorecorded conditions with the monitor device in use were eligible for inclusion. Events where real-time feedback from monitoring devices for CC was available were excluded (ages > 8). Data on CPR performance was collected by a combination of video review and monitor device; CC rate and depth and ventilation rate were extracted in time periods corresponding to individual CPR providers. Data on verbal prompts (time, who gave prompts, what prompt consisted of) were identified during video review. Results: There were 21 cases with total 182 providers included in database during study periods (infants: n=15, children: n=6). Verbal prompts for compression rate and depth were given in 14/21 (67%) of cases. 19/80 (24%) came from the resuscitation leader; 32/80 (40%) and from a CPR coach. 7 (3.9%) providers doing CC watched ZOLL monitor for feedback. Appropriate verbal prompts for CC rate were given to 4.2 % of providers in infants and 8.8 % in children (p=0.024). And 9.2% in infants and 10.5 % in children (p=0.064) were given to providers for CC depth. After adjusting by confounders, there weren’t any significant differences between age groups for both CC rate: OR1.22 (95%CI 0.49-3.05, P=0.670) and depth: OR 2.82 (95%CI 0.73-10.9, P=0.134). Conclusions: Verbal prompts frequency for CC rate and depth during pediatric CPR was described. There weren’t any significant differences between infants and children under 8 years old.

Background: American Heart Association (AHA) recommends high quality CPR to promote optimal patient outcomes. Few reports compare team members’ perceptions of CPR quality with quantitative CPR data during actual pediatric CPR. Hypothesis: Self-reported team perception of CPR performance will not meet quantitative CPR metrics using AHA BLS guideline criteria. Methods: Prospective data from an international pediatric (pediRES-Q) resuscitation collaborative from February 2016 to August 2017. A modified Team Emergency Assessment Measure framework for qualitative content analysis was used to assess data from “hot” debriefings (held soon after arrest) by language processing experts blinded to CPR data. Events without reported perception of CPR and quantitative CPR data were excluded. Comments regarding CPR perception were grouped as either Plus perceptions of performance (PPP) or Delta perceptions of performance (DPP). Grouped events were matched and compared to quantitative CPR data of chest compression (CC) fraction (CCF), rate, and depth as collected by CPR-recording defibrillators. Compliance with AHA BLS guidelines were defined as events with mean: CCF >60%, CC rate 100-120/min; and CC depth for infants Results: Of 227 arrests, 108 (48%) hot debriefings were reported. Reported CPR perceptions with paired quantitative CPR data were available for 53/108 (49%) events; 32/53 (60%) PPP and 21/53 (39%) DPP. Event CPR metric summaries (median [IQR]) for PPP - CCF 0.87 [0.77, 0.93]; CC rate 116/min [108.5, 120]; CC depth age 1yr 4.2 [3.3, 5.05] cm. DPP - CCF 0.79 [0.69, 0.92]; CC rate 118/min [109,129]; CC depth < 1 yo 2.03 [1.95, 2.2] cm; >1yo 3.93 [3.3, 5.06] cm. PPP events, 28/32 (87%) met guideline criteria for CCF, 25/32 (78%) for CC rate; 6/32 (19%) for CC depth; and 4/32 (12%) met criteria for all 3 categories. For DPP events, 17/21 (80%) met guideline criteria for CCF; 15/21 (71%) for CC rate; and 3/21 (15%) for CC depth, and 2/21 (9%) met criteria for all 3 categories. Conclusions: Self-reported team perception of CPR quality does not match quantitative CPR metrics using AHA guideline criteria whether CPR was positively perceived or not, depth being main reason for non-compliance.

Background: Team dynamics have been a learning objective of AHA courses since 2005. Cardiopulmonary resuscitation (CPR) in a hospital setting involves a multidisciplinary team with multiple specific roles occurring simultaneously. Though evaluation of team performance in simulated resuscitation events has been studied, little information exists on the performance of teams in real CPR events. The development of a video-based resuscitation quality improvement (QI) program has allowed a route for the analysis of team performance during actual patient care. Objective: Demonstrate feasibility of team performance rating of real pediatric CPR events using video review. Methods: All pediatric resuscitations requiring cardiopulmonary resuscitation (CPR) in the emergency department of a tertiary children’s hospital are video-recorded for QI purposes. Following video review, team performance was rated by study personnel using the validated Behavioral Assessment Tool (BAT). The BAT scores 10 domains of team performance, each on a 0-4 Likert Scale (score range 0 – 40). Univariate comparison of BAT scores was done between patient age categories, event duration, location of arrest (in- vs. out-of-hospital), and chest compression fraction (CCF) below or above 80% using nonparametric methods. Results: 13 events requiring CPR occurred during the study period. Mean BAT scores were 32 (+/- 6) points. Lowest rated domains were Attention allocation , Distribution of workload, and Utilization of information. Highest rated domains across all events were Recognition of Limitations and Professional behavior. BAT scores were significantly higher in infant CPR events than older children (39 vs. 28, p=0.005) and out-of-hospital events compared with in-hospital (37 vs 27, p=0.04). There were no significant differences in BAT scores based on event duration or CCF. Conclusions: Video-based review of pediatric CPR events is a feasible method for efficient evaluation of team performance using validated tools. Quantitative assessment of team performance allows for needs assessments to determine areas in which intervention should be focused for maximum impact on CPR quality. Future work should focus on interventions to address areas of suboptimal performance.

OBJECTIVES We aimed to quantify time performing chest compressions (CCs) per year of individual providers in a pediatric ED and to project a rate of opportunity for CC based on median clinical hours per provider category. METHODS This was an observational study of video-recorded resuscitations in a pediatric ED over 1 year. Events where CCs were performed for more than 2 minutes were included. Identification of providers and duration of CCs per provider were determined by video review. Time of CCs was totaled per provider over the study period. Data were expressed as median and interquartile range (IQR). Rate of opportunity for providing CC to a child was calculated by dividing the median clinical hours per year per provider type by the number of CC events per year. RESULTS Twenty-three CC events totaling 340 minutes of CCs were analyzed. Chest compressions were performed by 6 (13%) of 45 attending physicians, 3 (25%) of 12 fellows, 32 (22%) of 143 nurses, and 19 (59%) of 32 technicians. The median amount of time performing CC was 182 seconds (IQR, 91-396 seconds); by provider category, median amount of time was as follows: attending physicians, 83 seconds (IQR, 64-103 seconds); fellows, 45 seconds (IQR, 6-83 seconds); nurses, 128 seconds (IQR, 93-271 seconds); and technicians, 534 seconds (IQR, 217-793 seconds). The projected hours needed for an opportunity to perform CCs was 730 hours (91 shifts) for attending physicians, 243 hours (30 shifts) for fellows, and 1460 hours (121 shifts) for nurses and technicians. CONCLUSIONS Performing CCs on children in the ED is a rare event, with a median of 3 minutes per provider per year. Future studies should determine training methods to optimize readiness for these rare occurrences.

Objectives High-quality clinical research of resuscitations in a pediatric emergency department is challenging because of the limitations of traditional methods of data collection (chart review, self-report) and the low frequency of cases in a single center. To facilitate valid and reliable research for resuscitations in the pediatric emergency department, investigators from 3 pediatric centers, each with experience completing successful single-center, video-based studies, formed the Videography In Pediatric Emergency Research (VIPER) collaborative. Methods Our initial effort was the development of a multicenter, video-based registry and simulation-based testing of the feasibility and reliability of the VIPER registry. Feasibility of data collection was assessed by the frequency of an indeterminate response for all data elements in the registry. Reliability was assessed by the calculation of Cohen κ for dichotomous data elements and intraclass correlation coefficients for continuous data elements. Results Video-based data collection was completed for 8 simulated pediatric resuscitations, with at least 2 reviewers per case. Data were labeled as indeterminate by at least 1 reviewer for 18 (3%) of 524 relevant data fields. The Cohen κ for all dichotomous data fields together was 0.81 (95% confidence interval, 0.61-1.0). For all continuous (time-based) variables combined, the intraclass correlation coefficient was 0.88 (95% confidence interval, 0.70-0.96). Conclusions Initial simulation-based testing suggests video-based data collection using the VIPER registry is feasible and reliable. Our next step is to assess feasibility and reliability for actual pediatric resuscitations and to complete several prospective, hypothesis-based studies of specific aspects of resuscitative care, including of cardiopulmonary resuscitation, tracheal intubation, and teamwork and communication.

The formula for survival in resuscitation describes educational efficiency and local implementation as key determinants in survival after cardiac arrest. Current educational offerings in the form of standardized online and face-to-face courses are falling short, with providers demonstrating a decay of skills over time. This translates to suboptimal clinical care and poor survival outcomes from cardiac arrest. In many institutions, guidelines taught in courses are not thoughtfully implemented in the clinical environment. A current synthesis of the evidence supporting best educational and knowledge translation strategies in resuscitation is lacking. In this American Heart Association scientific statement, we provide a review of the literature describing key elements of educational efficiency and local implementation, including mastery learning and deliberate practice, spaced practice, contextual learning, feedback and debriefing, assessment, innovative educational strategies, faculty development, and knowledge translation and implementation. For each topic, we provide suggestions for improving provider performance that may ultimately optimize patient outcomes from cardiac arrest.

Objectives To describe procedural characteristics of tracheal intubation (TI) during cardiopulmonary resuscitation (CPR) in a pediatric emergency department, and to characterize interruptions in CPR associated with TI performance. Methods Retrospective single center case series. Resuscitations in a pediatric ED are videorecorded for quality improvement. Children who underwent TI while receiving chest compressions were eligible for inclusion. Intubations done by methods other than direct laryngoscopy were excluded. Background data included patient age and training background of intubator. Data on intubation attempts (success, laryngoscopy time) and chest compressions (interruptions, duration of pauses) were collected. Results Between December 2012 and February 2014, 32 patients had 59 TI attempts performed during CPR. Overall first attempt success at TI was 15/32 (47%); a median of 2 attempts were made per patient (range 1 to 4). Median laryngoscopy time was 47s (range 8–115s). 32/59 (54%) TI attempts had an associated interruption in CPR; the median interruption duration was 25s (range 3–64s). TI attempts without interruption in CPR were successful in 20/32 (63%) compared to 11/27 (41%) when CPR was paused ( p =0.09). Laryngoscopy time was not significantly different between TI attempts with (47±21s) and without (47±26s; p =0.2) interruptions in compressions. 25/32 (78%) of pauses exceeded 10s in duration. Conclusions TI during pediatric CPR results in significant interruptions in chest compressions. Procedural outcomes were not significantly different between attempts with and without compressions paused. In children receiving CPR, TI should be performed without pausing chest compressions.

The variability in quality of CPR provided during cardiac arrest across pediatric institutions is unknown. We aimed to describe the degree of variability in the quality of CPR across 9 pediatric institutions, and determine if variability across sites would be affected by Just-in-Time CPR training and/or visual feedback during simulated cardiac arrest.We conducted secondary analyses of data collected from a prospective, multi-center trial. Participants were equally randomized to either: (1) No intervention; (2) Real-time CPR visual feedback during cardiac arrest or (3) Just-in-Time CPR training. We report the variability in median chest compression depth and rate across institutions, and the variability in the proportion of 30-s epochs of CPR meeting 2010 American Heart Association guidelines for depth and rate.We analyzed data from 528 epochs in the no intervention group, 552 epochs in the visual feedback group, and 525 epochs in the JIT training group. In the no intervention group, compression depth (median range 22.2-39.2mm) and rate (median range 116.0-147.6 min(-1)) demonstrated significant variability between study sites (p0.001). The proportion of compressions with adequate depth (0-11.5%) and rate (0-60.5%) also varied significantly across sites (p0.001). The variability in compression depth and rate persisted despite use of real-time visual feedback or JIT training (p0.001).The quality of CPR across multiple pediatric institutions is variable. Variability in CPR quality across institutions persists even with the implementation of a Just-in-Time training session and visual feedback for CPR quality during simulated cardiac arrest.

To describe chest compression (CC) rate, depth, and leaning during pediatric cardiopulmonary resuscitation (CPR) as measured by two simultaneous methods, and to assess the accuracy and reliability of video review in measuring CC quality.Resuscitations in a pediatric emergency department are videorecorded for quality improvement. Patients aged 8-18 years receiving CPR under videorecording were eligible for inclusion. CPR was recorded by a pressure/accelerometer feedback device and tabulated in 30-s epochs of uninterrupted CC. Investigators reviewed videorecorded CPR and measured rate, depth, and release by observation. Raters categorized epochs as 'meeting criteria' if 80% of CCs in an epoch were done with appropriate depth (45 mm) and/or release (2.5 kg leaning). Comparison between device measurement and video was made by Spearman's ρ for rate and by κ statistic for depth and release. Interrater reliability for depth and release was measured by κ statistic.Five patients underwent videorecorded CPR using the feedback device. 97 30-s epochs of CCs were analyzed. CCs met criteria for rate in 74/97 (76%) of epochs; depth in 38/97 (39%); release in 82/97 (84%). Agreement between video and feedback device for rate was good (ρ = 0.77); agreement was poor for depth and release (κ 0.04-0.41). Interrater reliability for depth and release measured by video was poor (κ 0.04-0.49).Video review measured CC rate accurately; depth and release were not reliably or accurately assessed by video. Future research should focus on the optimal combination of methods for measuring CPR quality.

To describe the adherence to guidelines for CPR in a tertiary pediatric emergency department (ED) where resuscitations are reviewed by videorecording.Resuscitations in a tertiary pediatric ED are videorecorded as part of a quality improvement project. Patients receiving CPR under videorecorded conditions were eligible for inclusion. CPR parameters were quantified by retrospective review. Data were described by 30-s epoch (compression rate, ventilation rate, compression:ventilation ratio), by segment (duration of single providers' compressions) and by overall event (compression fraction). Duration of interruptions in compressions was measured; tasks completed during pauses were tabulated.33 children received CPR under videorecorded conditions. A total of 650 min of CPR were analyzed. Chest compressions were performed at100/min in 90/714 (13%) of epochs; 100-120/min in 309/714 (43%);120/min in 315/714 (44%). Ventilations were 6-12 breaths/min in 201/708 (23%) of epochs and12/min in 489/708 (70%). During CPR without an artificial airway, compression:ventilation coordination (15:2) was done in 93/234 (40%) of epochs. 178 pauses in CPR occurred; 120 (67%) were10s in duration. Of 370 segments of compressions by individual providers, 282/370 (76%) were2 min in duration. Median compression fraction was 91% (range 88-100%).CPR in a tertiary pediatric ED frequently met recommended parameters for compression rate, pause duration, and compression fraction. Hyperventilation and failure of C:V coordination were very common. Future studies should focus on the impact of training methods on CPR performance as documented by videorecording.