Published online December 31, 2007
PEDIATRICS Vol. 121 No. 1 January 2008, pp. e34-e43 (doi:10.1542/peds.2007-0029)
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ARTICLE

Simulation of In-Hospital Pediatric Medical Emergencies and Cardiopulmonary Arrests: Highlighting the Importance of the First 5 Minutes

Elizabeth A. Hunt, MD, MPHa,b,c,d, Allen R. Walker, MD, MBAc,d, Donald H. Shaffner, MDa,d, Marlene R. Miller, MDc,d and Peter J. Pronovost, MD, PhDa,d

a Department of Anesthesiology and Critical Care Medicine
b Johns Hopkins Simulation Center
c Department of Pediatrics
d Johns Hopkins University School of Medicine, Baltimore, Maryland

OBJECTIVES. Outcomes of in-hospital pediatric cardiopulmonary arrest are dismal. Recent data suggest that the quality of basic and advanced life support delivered to adults is low and contributes to poor outcomes, but few data regarding pediatric events have been reported. The objectives of this study were to (1) measure the median elapsed time to initiate important resuscitation maneuvers in simulated pediatric medical emergencies (ie, "mock codes") and (2) identify the types and frequency of errors committed during pediatric mock codes.

METHODS. A prospective, observational study was conducted of 34 consecutive hospital-based mock codes. A mannequin or computerized simulator was used to enact unannounced, simulated crisis situations involving children with respiratory distress or insufficiency, respiratory arrest, hemodynamic instability, and/or cardiopulmonary arrest. Assessment included time elapsed to initiation of specific resuscitation maneuvers and deviation from American Heart Association guidelines.

RESULTS. Among the 34 mock codes, the median time to assessment of airway and breathing was 1.3 minutes, to administration of oxygen was 2.0 minutes, to assessment of circulation was 4.0 minutes, to arrival of any physician was 3.0 minutes, and to arrival of first member of code team was 6.0 minutes. Among cardiopulmonary arrest scenarios, elapsed time to initiation of compressions was 1.5 minutes and to request for defibrillator was 4.3 minutes. In 75% of mock codes, the team deviated from American Heart Association pediatric basic life support protocols, and in 100% of mock codes there was a communication error.

CONCLUSIONS. Alarming delays and deviations occur in the major components of pediatric resuscitation. Future educational and organizational interventions should focus on improving the quality of care delivered during the first 5 minutes of resuscitation. Simulation of pediatric crises can identify targets for educational intervention to improve pediatric cardiopulmonary resuscitation and, ideally, outcomes.

Key Words: cardiopulmonary arrest • cardiopulmonary resuscitation • simulation • basic life support • pediatric advanced life support

Abbreviations: CPA—cardiopulmonary arrest • BVM—bag-valve-mask • AHA—American Heart Association • BLS—basic life support • ACLS—advanced cardiac life support • PALS—pediatric advanced life support • PBLS—pediatric basic life support • ABCs—airway, breathing, and circulation • CPR—cardiopulmonary resuscitation

Accepted Jun 11, 2007.




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P3Rs:

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Very important study--repeat it with adult scenarios?
John A Stewart
Pediatrics Online, 18 Jan 2008 [Full text]