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


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 APPENDIX: CATEGORIES AND...
 REFERENCES
 
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

The outcome for children who sustain an in-hospital cardiopulmonary arrest (CPA) is dismal. Reports of survival to discharge range from 14% to 36% and are even worse for adults.1–6 Despite efforts to prevent arrest or enhance resuscitation care before, during, and after CPA, survival rates have not improved in the past 4 decades.7

Increased knowledge of resuscitation guidelines improves performance of resuscitation skills.8 Unfortunately, recall of both guidelines and skills such as bag-valve-mask (BVM) ventilation, chest compressions, and defibrillation decays quickly8–14; therefore, despite the fact that hospital nurses and physicians have usually received training in resuscitation, there is no guarantee that they have retained the skills necessary to deliver high-quality resuscitation efforts. Observations of the management of simulated adult CPAs (ie, "mock codes") and a small number of actual adult CPAs suggested that the quality of resuscitative efforts is poor.15–17 A recent report of 67 actual in-hospital adult CPAs confirmed this, which suggests that improving the quality of care that is delivered during adult in-hospital CPAs may improve patient outcomes.18 Partially in response to these data, the 2005 American Heart Association (AHA) basic and advanced life support guidelines for both adults and children (basic life support [BLS], advanced cardiac life support [ACLS], and pediatric advance life support [PALS]) reflect a new emphasis on delivering quality life support.19,20

In the pediatric literature, there are reports of how to introduce a mock-code program into a children's center and on the use of mock codes to identify deficiencies in resuscitation skills13,14,21; however, we are unaware of any reports that systematically measure the quality of pediatric resuscitation that is delivered during actual pediatric medical emergencies and CPAs and only 1 that systematically analyzed performance during multidisciplinary in-hospital pediatric mock codes.22 Thus, there are still significant gaps in our understanding of the quality of care delivered by health care teams during pediatric in-hospital medical emergencies and CPAs.

In this study, our primary goal was to characterize the quality of actions by first responders during simulated in-hospital pediatric medical emergencies and CPAs. This was our focus because early appropriate therapy has the potential to improve a child's clinical status before it irreversibly deteriorates. We were also interested in assessing the performance of pediatric resident members of the code team, who, on completion of their residency programs, could soon be hospitalists or PICU or emergency medicine fellows in charge of caring for critically ill children. Our specific objectives were (1) to examine critical delays by measuring the median duration of the interval between when a resuscitation maneuver was indicated and when it was initiated by first responders and/or pediatric resident trainees and (2) to describe the type and frequency of resuscitation errors identified as deviations from AHA guidelines during pediatric mock codes in noncritical care areas of the hospital.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 APPENDIX: CATEGORIES AND...
 REFERENCES
 
This was a prospective, observational study to evaluate the response to simulated pediatric medical crises by actual health care teams. During a 40-month period, 34 consecutive mock codes were performed in 1 of 3 urban academic medical centers with pediatric residents. The institutional review board considered this study to be exempt from review. Data regarding performance of the team were collected by pediatric chief residents in 5 (15%) of 34 mock codes or by 1 of the authors (Dr Hunt) in 29 (85%) of 34. The mock codes occurred in locations to which the pediatric code team might have to respond, including ward rooms, procedure rooms, and radiology suites, but not in operating rooms, emergency departments, or ICUs that have dedicated teams to manage emergencies at all times. All scenarios were unique to avoid pattern recognition by caregivers who might attend multiple mock codes and consisted of an unannounced, simulated crisis situation involving 1 of the following: (1) respiratory distress or insufficiency; (2) respiratory arrest; (3) hemodynamic instability, and/or (4) cardiopulmonary arrest (Table 1).


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  		TABLE 1 Description of 34 Pediatric Mock Codes: Etiology and Categories of Cases (N = 34 Mock Codes)

 
Each patient room in our children's hospital has a button on the wall that parents are shown and told to press, in case of emergency. Staff members use this button in emergencies to get help into the room and refer to this as the "code button." The button triggers a loud overhead alarm, and a light outside the room and connects the person to the front desk so that he or she can describe the problem. The mock code started when the code button in a chosen room was activated, indicating that help was needed (ie, time 0). The first person to enter the room in response to the code button was defined as the first responder, given a short vignette, and told to proceed as though it were a real code. We also marked the time when the vignette had been fully communicated so that we could perform analyses with and without the additional time that it would take to be briefly oriented to the exercise and hear the vignette. Age-appropriate mannequins with arrhythmia generators were used initially; the Laerdal (Wappingers Falls, NY) simulator SimMan was available and used for the last few scenarios.

All scenarios were pre-scripted by the pediatric chief residents and reviewed by pediatric emergency medicine or critical care physicians before use. Scripts included the initial clinical vignette; vital signs; patient weight; laboratory values; planned changes in clinical status, including what and when decompensations should occur (eg, ~4 minutes into scenario, the patient will progress to asystole); and planned responses to actions by participants (eg, the patient will return to sinus rhythm if epinephrine is administered). For maintaining realism, little interaction occurred between participants and evaluators.

If no one remembered to call the operator or ask the front desk clerk to request that the code team be paged, then the emergency was managed with only ward staff. When they were called, the operators paged the entire code team and gave no indication that this was not a true emergency. The usual members of the code team at the time of this study included the PICU fellow, PICU nurse, PICU respiratory therapist, shift coordinator (senior nurse coordinating beds for the day), senior and junior pediatric residents, and a pediatric intern. In this study, all staff who would normally respond to a pediatric medical emergency on that particular day were involved in the mock codes except the PICU fellows and nurses, who were asked not to respond; therefore, the only physicians who responded were the resident members of the team. Although the primary focus of this study was to assess the quality of resuscitation delivered by first responders before the code team's arrival, the mock-code exercises also allowed us to assess the resuscitation skills of pediatric resident trainees.

At our hospital, all nursing staff are required to pass a BLS course every 2 years, and PALS training is optional. The pediatric residents receive BLS training during their intern orientation and PALS training immediately before starting their second year of residency. Those who provide conscious sedation must pass a hospital sedation course and maintain BLS training. Appropriately sized, single-use, self-inflating bags are kept in their original plastic bags at the bedside of each patient; they are readily accessible but need to be removed from the plastic bag and attached to oxygen before use. Standardized pediatric code carts, pediatric emergency drug boxes, and defibrillators are maintained on each ward, in radiology suites, and at strategic nonclinical locations throughout the hospital.

During each mock code, data were collected regarding the quality of resuscitation efforts. Measurements included time to specific resuscitation maneuvers, deviations from AHA pediatric basic life support (PBLS) and PALS guidelines, and documentation of type and frequency of resuscitation errors identified during pediatric mock codes. The evaluators used a stopwatch to document the time at which each event occurred. Before analysis of study data, a group of physicians who specialize in pediatric critical care medicine, anesthesiology, cardiology, and emergency medicine and are involved in resuscitation research and/or education created time goals for when each particular resuscitation maneuver should be completed by a consensus process. In the case of defibrillation, we noted when the need for defibrillation was verbalized as opposed to completion of the multistep process required to actually deliver a shock because not all of the mannequins could be defibrillated.

Data Collection
Personnel
Data were collected and reported with the focus based on the group, rather than on individual performance (ie, nurse, pediatric resident, ward clerk, or respiratory therapist).

Time Intervals
The times to perform important resuscitation maneuvers were documented, including the variables listed in Tables 2 and 3. Time 0 was defined as the moment the code button was triggered to capture system problems that resulted in delays in delivery of care to the patient and to be consistent with the Utstein guidelines’ "time of patient collapse."23 Thus, actions that should be taken as soon as possible for every critically ill patient, such as assessment of airway, breathing, and circulation (ABCs), were captured by measuring the time elapsed from time 0 until any person initiated the action. Actions that need to be done only when a patient meets certain criteria were measured in relation to when the patient needed the action. For example, the time to "initiation of chest compressions" was measured as the time elapsed between when the patient developed a pulseless rhythm or severe bradycardia that required chest compressions and when compressions were initiated.


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  		TABLE 2 Median Time Elapsed Until Performance of Important Resuscitation Maneuvers in Simulated Pediatric Medical Emergencies

 

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  		TABLE 3 Categorization, Frequency, and Examples of Errors Made During Simulated Pediatric Medical Emergencies

 
The time to "arrival of the first physician" was the time elapsed between time 0 and when any physician entered the room, capturing the period during which the nursing staff were the sole providers of care for the patient. Alternatively, time to "arrival of the first member of the code team" provided a measurement of the multistep process required to activate and respond to a code pager.

The time to "decision to defibrillate" was used rather than the actual defibrillation time because many of our mannequins could not be truly defibrillated, which made measuring the time that it took actually to deliver shocks in most mock codes impossible. In mock codes in which the entire process of defibrillation could be observed, data were collected for future study.

Resuscitation Errors
A taxonomy of errors was created to report on resuscitation efforts that had the potential to have an impact on the quality of resuscitation and patient outcomes. A review of the literature and observation of both mock and real resuscitations were used to develop a taxonomy of resuscitation errors that is useful for clinicians or researchers.

Each observed error was placed in the most appropriate category and counted only once (Table 3). Codes could have >1 type of error (see Appendix for definitions of errors for each category and Table 3 for examples of each category). Errors that occurred as part of airway management could fall under several categories, such as a time delay error or an error in PBLS or PALS, so a separate analysis of airway-related errors was conducted as well (Fig 1).


Figure 1
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  		FIGURE 1 Proportion of 34 simulated pediatric medical emergencies in which essential airway maneuvers were not performed. a Mock codes that required either bag-valve-mask ventilation and/or intubation of the simulated patient (N = 28); b mock-code scenarios in which the team attempted to intubate (n = 28). A & B indicates assessment of airway and breathing; oxygen, administration of oxygen to the patient; breath sounds, auscultates breath sounds bilaterally; ETCO2, end-tidal carbon dixoide.

 
Data Management and Statistical Analysis
Data were entered into Microsoft Excel (Redmond, WA) and analyzed with Stata 8 (Stata Corp, College Station, TX). Because elapsed-time measurements were not normally distributed, median times and interquartile ranges (25%–75%) were reported. The proportion of resuscitation maneuvers that were completed within the time period that had been preestablished as a goal was calculated. Frequencies for types of errors were reported as percentages of the total number of mock codes eligible for that type of error. The unit of analysis was the mock code. Time intervals and types of errors were determined at the time of the mock code.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 APPENDIX: CATEGORIES AND...
 REFERENCES
 
We performed 34 mock codes during a 40-month period. Pediatric residents from each training level (postgraduate years 1, 2, and 3) and ward nurses were involved in 100% of the mock codes; ward clerks and telephone operators were involved in 88%.

The first responders were universally nurses. The time to enter the room, be oriented to the exercise, and have the vignette explained was always within 15 seconds of time 0. The median time to arrival of any physician was 3 minutes and to arrival of the first member of the code team was 6 minutes.

Table 1 describes the underlying diagnoses and categories of PBLS and PALS maneuvers required in each of the 34 mock codes. Table 2 describes the time intervals for resuscitation maneuvers. Analysis of the interquartile range shows that in 25% of scenarios, the first responders took >1.5 minutes to initiate assessment of airway and breathing, >5 minutes to initiate BVM ventilation, and >7 minutes to initiate assessment of circulation by pulse check.

The frequencies of errors related to airway management are described in Fig 1. Only 9 (26%) of 34 teams assessed airway and breathing within 30 seconds, and only 10 (29%) of 34 teams administered oxygen in <1 minute. In the 28 scenarios that required airway management with BVM ventilation and/or intubation, 13 (46%) of teams set up suction and only 2 (7%) of the teams applied cricoid pressure. In the 27 scenarios in which the teams attempted to intubate, 100% of teams listened for bilateral breath sounds to confirm appropriate endotracheal tube placement, but only 15 (56%) used an end-tidal carbon dioxide detector, per AHA recommendations and hospital protocol.

In 17 of the mock codes, the patient either developed a pulseless rhythm or developed severe bradycardia that required compressions (per PALS guidelines). In 2 of those, the team moved directly to requesting defibrillation, rather than starting compressions. In 11 (73%) of the remaining 15, the interval from loss of pulses to initiation of chest compressions was >1 minute; in 6 (40%) of the 15, it was ≥3 minutes; and in 2 (13%) of the 15, it was >12 minutes (Fig 2).


Figure 2
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  		FIGURE 2 Time elapsed from loss of pulse or severe bradycardia until initiation of chest compressions in a simulation of pediatric cardiopulmonary arrest (n = 15). The gray bar indicates that only 27% of teams initiated compressions in ≤1 minute.

 
In 4 (67%) of the 6 mock codes in which the patient developed a pulseless rhythm that required defibrillation, ≥3 minutes elapsed between when the patient developed a rhythm that required defibrillation and the time when a pediatric resident requested defibrillation (indicating recognition of the need for defibrillation). In 1 mock code, the team took 14 minutes to request the defibrillator.

Data were also analyzed in relation to our preestablished goals for times by which resuscitation maneuvers should be performed. The proportions of teams who met our goals were as follows: assessment of airway, 26%; assessment of circulation, 3%; initiation of BVM ventilation, 19%; initiation of chest compressions, 27%; and verbalizing the need to establish intraosseous access, 40% (Table 2).

All of the codes had at least 1 resuscitation error. The frequencies of the different error types are described in Table 3. In 12 (71%) of 17 mock codes that called for chest compressions, the care team failed to adhere to AHA PBLS guidelines; and in 31 (100%) of 31 mock codes that required PALS, the care team failed to adhere to the AHA guidelines. In all of the 6 patients who became apneic as a result of onset of pulseless ventricular tachycardia/fibrillation, physicians attempted to intubate rather than initiate cardiopulmonary resuscitation (CPR) and defibrillate as soon as possible.

Participants in 11 (33%) of 33 mock codes failed to identify a leader (data not collected in 1 mock code). Leaders commonly performed procedures rather than choosing to supervise and delegate, rendering them at least temporarily unable to monitor for changes in status or give additional direction. Most leaders failed to assign tasks, to ensure quality of compressions and ventilations, and had difficulty giving orders effectively. In fact, at least 1 communication error occurred in all cases, resulting in delays or errors in the delivery of PBLS or PALS.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 APPENDIX: CATEGORIES AND...
 REFERENCES
 
Little is known about the types of errors that occur in the management of pediatric medical emergencies and CPAs. We found that mistakes are ubiquitous in simulated pediatric codes and include problems with adherence to AHA guidelines for PBLS and PALS, communication, leadership, and misdiagnoses. Specifically, we observed a lack of timely initiation of resuscitation maneuvers that are integral to achieving good patient outcomes.

Our study identifies the need and opportunities to improve performance in pediatric resuscitation. Several studies of adult in-hospital CPAs support that it is essential to improve timeliness of interventions. Brenner et al24 demonstrated that initiation of assisted ventilation at <1 minute, 1 to 3 minutes, or >3 minutes from respiratory arrest or CPA was associated with a declining likelihood of a "good outcome": 21%, 12%, and 0%, respectively. Only 19% of our teams initiated BVM ventilation within 1 minute of when it was indicated. In addition, most teams made other airway management errors that are likely to contribute to a poor expected outcome. Additional research is essential to identify mechanisms of improving basic airway management and to show that they will reduce reaction times and management errors.

Herlitz et al25 reported that patients who received start of CPR within 1 minute of collapse were twice as likely to survive as those who did not. Cooper et al26 demonstrated that initiation of BLS within 3 minutes of cardiac arrest was associated with a 25% increase in survival, when compared with initiation of CPR at >3 minutes. In our study, chest compressions were initiated in ≤1 minute in only 27% of mock codes and were not initiated for ≥3 minutes in 40% of mock codes (Fig 1). In addition, we observed similar PBLS errors to that of Abella et al,18 including compressions that were too slow with frequent prolonged interruptions. Again, these data highlight the need to improve both the timeliness and the quality of compressions for pediatric CPA to optimize outcomes.

In our study hospitals, as in most, the first responder is likely to be a nurse, making her or him the first link in the "chain of survival."27,28 Because the median time to arrival for the first physician in our study was 3 minutes and that for the code team was 6 minutes, the actions of the ward nurses will be an important determinant of outcome. The 6-minute delay reflects the multistep process that is required to activate the team, which in our institution involves the first responder's performing an initial assessment of the patient and asking someone to call the code team, someone's calling the operator, the operator's activating the pagers, the page's being transmitted to the pagers, and then team members’ responding to the pagers. Our team members actually did respond within 2 minutes of the pagers’ being activated. If our hospital used an overhead paging system, then it may have been able to save the amount of time that it took for the page to be transmitted to the pager (<1 minute), but the other steps would still have been necessary.

The prolonged time to arrival for the first physician and for the code team in this study highlights the importance of the quality and the timeliness of initial actions of the ward staff. Soar et al28 found that all of the adult in-patients who had CPR and survived to discharge in their study had return of spontaneous circulation as a result of actions by the first responders. Despite the importance of the first responder's interventions at an in-hospital cardiac arrest, several other publications have shown that their response is often inadequate.24,29–34 This study helped us to identify that our ward nurses were being asked to do too many things at once and that the application of the PBLS ABCs was delayed while they prepared the room to be able to deliver advanced life support (eg, drawing up resuscitation drugs, getting the code cart and defibrillator). One of the most important implications of this study is the realization that the ward staff members have lost their "first responder instincts," and rather than doing their ABC's, they were instead preparing for the arrival of the code team.

Since our study was completed, we have rewritten the job descriptions in our CPR policy so that ward nurses are clearly expected to perform as first responders. In addition, the Johns Hopkins Children's Center nurse educators have developed a curriculum called "The First 5 Minutes," which highlights the importance of nursing staff actions during those minutes before the arrival of the code team on a child's outcome. Finally, while debriefing the mock-code exercises, we emphasize that the ward staff must function as a team before the code team arrival, with the charge nurse acting as their team leader. Subsequent analysis of both mock codes and actual ward CPAs has suggested a dramatic improvement in the quality of PBLS that our ward staff provide before the arrival of our code team but will require formal analysis.

Leadership is an important component of successful teamwork. Analysis of actual adult cardiac arrest management revealed that codes in which leaders participated in a "hands-on" manner had a higher likelihood of errors, delays, and poor team function that are likely to affect outcomes.35 Marsch et al36 used simulated CPAs to demonstrate that lack of specific leadership characteristics was associated with delays in performing BLS and/or defibrillation. Although our study did not focus on leadership, we observed a similar problem. In addition, we noted subjectively that successful resident leaders (1) identified themselves as the leader, (2) assigned tasks, (3) confirmed the quality of procedures (eg, ventilations, compressions), (4) communicated effectively, and (5) followed up to ensure that ordered therapies had been administered. Although additional research is needed, resident education should include education on leadership skills in critical situations.

As a result of the data from this study, we have also initiated a curriculum for pediatric residents focused on improving their resuscitation knowledge, skills, and teamwork, including annual individual simulated CPAs to assess competency and effectiveness of the new curriculum. Finally, our children's center transitioned from a code team to a rapid response team to encourage the ward staff to call us before a patient had progressed to full CPA.

We recognize several limitations to our study. First, the study is an analysis of simulated resuscitations and may not represent responses during a real CPA. We are unaware of data that correlate performance during simulated to that of real cardiac arrests; however, the low incidence of pediatric CPAs and the inability to predict where they will occur make it difficult to observe a high volume of true arrests to assess resuscitation performance, particularly during the first few minutes. Second, a rigorously validated tool to measure errors during resuscitation is not available. To begin the development of such a tool, we evaluated performance on interventions that are commonly accepted as standard (PBLS/PALS), as have other authors.13,37–39 We provide definitions of delays on the basis of available outcome studies and guidelines and include key intervals outlined by the Pediatric Utstein Task Force.24–26,37,40 One might argue that by using the "time of collapse" as our time 0 (as suggested in the Utstein style of reporting), we are unfairly biasing our results toward identifying delays in treatment by the first responders and code team members; therefore, we also analyzed the times after subtracting the time that it took for first responders to enter the room and hear the vignette (10–15 seconds). This did not significantly alter any of our results.

Third, we did not include the PICU members of the code team, which may have skewed our data to overestimate PALS errors and does not allow us to extrapolate our results to the quality of advanced life support that a patient in our hospitals would receive. Despite this, we believe that it is important to highlight that despite being PALS certified, our pediatric residents uniformly made mistakes, which suggests that pediatric residents in our hospitals and perhaps others require additional resuscitation training to care adequately for critically ill children. Of note, the first responders did represent the actual members of the team who would respond to events in our hospital and highlights the need for additional education, which we have since implemented.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
APPENDIX: CATEGORIES AND...
 REFERENCES
 
Resuscitation errors were more frequent than anticipated and occurred in every mock code in our study, and delays in performing life-saving interventions were the norm rather than the exception. First responders generally did not adhere to AHA PBLS guidelines despite being the sole providers of care for several minutes. They seemed to have lost their "first responder instinct" and instead were believing that the highest priority was to prepare the room for the code team. Pediatric residents consistently made mistakes in the delivery of BLS and advanced life support. These results suggest that had real patients been involved in this study, poor outcomes for them would have been expected. Fortunately, the use of simulation allowed us to evaluate and train providers without endangering patients. Future educational and organizational interventions should focus on improving the quality of care that is delivered during the first 5 minutes of resuscitation and emphasize BLS and early defibrillation. Additional research is required to determine whether such educational and evaluation methods can be used to improve performance and whether improved performance in simulation leads to improved clinical performance and, ultimately, improved patient outcomes.


   APPENDIX: CATEGORIES AND DEFINITIONS OF ERRORS USED TO EVALUATE MOCK CODES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 APPENDIX: CATEGORIES AND...
REFERENCES
 
PBLS: A PBLS error was defined as deviance from AHA BLS guidelines.37 Delays to initiation of PBLS were placed in the "time delays" category (category 3). Depth of compressions could not be evaluated.

PALS: A PALS error was defined as a deviance from AHA PALS guidelines.37

Time delays: The time intervals that were chosen to define an error were selected by first reviewing AHA recommendations and outcome data related to delays in resuscitation maneuvers from the literature. This review of the literature was then discussed by a group of specialists in pediatric critical care, anesthesiology, emergency medicine, and cardiology until consensus was achieved.24–26,37,40

Communication: A communication error was defined as a communication problem that resulted in delays or errors in the delivery of care. The debriefing period was used to clarify and/or identify additional communication problems. Team leaders were asked which medications they ordered and what they believed had been administered. Nurses were asked which orders they had heard and what they had actually administered to the patient. Discrepancies were attributed to a communication error when a misunderstanding was identified and the doctors and nurses confirmed our assessment that an error in communication had been made.

Leadership: A leadership error was defined as a failure to identify a team leader at any point in the mock code. The lack of effective leadership also contributed to communication errors, delays, PBLS errors, PALS errors, misuse of equipment, or misdiagnoses. The authors placed errors that were caused by the lack of leadership into the category that was the most direct cause of the error, as opposed to the leadership category.

Diagnosis: A diagnostic error was defined as an error in medical diagnosis that affected delivery of care. The most obvious and potentially lethal diagnostic errors involved dysrhythmia recognition, which resulted in use of the wrong PALS algorithm. Also identified were cases in which the team failed to recognize or treat the underlying medical problem, which led to deterioration into CPA.

Airway: The consensus panel created the time goals for airway management. AHA PALS and pediatric critical care textbooks instruct those who treat patients who have not been fasting (ie, emergency airways) to consider application of cricoid pressure when performing BVM ventilation when a third provider is available, to have suction ready when preparing to intubate, and to auscultate for breath sounds bilaterally and perform secondary confirmation of appropriate placement of an endotracheal tube through use of end-tidal carbon dioxide.37,41,42 We teach all of these components as part of standard emergency airway management.


   ACKNOWLEDGMENTS
 
This project was supported by a Pearl M. Stetler Grant for Women Researchers (to Dr Hunt).

We thank David G. Nichols, MD, MBA, for guidance and critical revision of the manuscript and Tzipora Sofare, MA, for fine editorial contribution to this manuscript.


   FOOTNOTES
 
Accepted Jun 11, 2007.

Address correspondence to Elizabeth A. Hunt, MD, MPH, 600 N Wolfe St, Blalock 904, Baltimore, MD 21287. E-mail: ehunt{at}jhmi.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 APPENDIX: CATEGORIES AND...
 REFERENCES
 

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P. Sharek and S. J. Roth
Cardiorespiratory Arrests and Rapid Response Teams in Pediatrics--Reply
JAMA, March 26, 2008; 299(12): 1424 - 1424.
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Very important study--repeat it with adult scenarios?
John A Stewart
Pediatrics Online, 18 Jan 2008 [Full text]
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