Cardiac arrest & CPR quality in a tertiary PICU: Recognition, challenges & opportunities
CCCF ePoster library. Gilfoyle E. 11/13/19; 283368; EP105
Dr. Elaine Gilfoyle
Dr. Elaine Gilfoyle
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Topic: Quality Assurance & Improvement

Garcia-Jorda, Dailys1; Nikitovic, Dejana2; Martin, Dori-Ann2; Camphaug, Jenna2; Bissett, Wendy2; Spence, Tanya2; Mahoney, Meagan2,3; Cheng, Adam4; Lin, Yiqun4; Gilfoyle, Elaine2,3
1 W21C, Cumming School of Medicine, University of Calgary, Calgary, Canada
2 Pediatric Intensive Care Unit, Alberta Children’s Hospital, Calgary, Canada
3 Section of Critical Care, Department of Pediatrics, University of Calgary, Calgary, Canada
4 Section of Emergency Medicine, University of Calgary, Calgary, Canada

Introduction: Delaying cardiopulmonary resuscitation (CPR) and first defibrillation to patients in cardiac arrest decreases survival by 10%/minute (1). American Heart Association recommends starting compressions immediately in a pulseless patient (2); The Clinical Performance Tool (CPT), a pediatric resuscitation guideline-adherence tool with published evidence of validity (3) gives 30 seconds as a timeframe for this task. Skill decay, lack of training and uncertainty within nurses and resident physicians in recognizing cardiac arrest and properly initiating management have been reported (4-6).
Objectives: To describe time elapsed and behaviours of bedside providers during the initial phase of resuscitation during simulated cardiac arrest events.
Methods: Prospective, mixed methods observational study at Alberta Children's Hospital PICU in Calgary, Alberta, from Sept 2015 to Sept 2016. Video-recorded simulated cardiac arrests using 9 clinical scenarios, where the patients were stable and arrested in front of bedside healthcare providers, were analyzed by two researchers. Descriptive statistics were determined for time elapsed and qualitative inductive analysis of the videos captured behaviours, skills, and interactions among the team.
Results: Nurses, respiratory therapists, resident physician, and attending physicians participated in 19 simulations. Compliance with recommended time to start CPR was low, with 9 of 19 teams (47.4%) starting CPR after 30 seconds, and 7 of those taking longer than 1 minute. Median time to start CPR was 29 seconds (IQR: 14, 63s) after recognizing cardiac arrest. Qualitative findings described how unnecessary delays in starting CPR also happened in most of the resuscitations where compressions started in 30 seconds or less.  Hesitation, lack of urgency, and miscommunication were observed among bedside staff. They recognized the cardiac arrest (or at least an unusual rhythm) as they asked for the crash cart and the presence of a resident or doctor in the room, yet most of them did not attempt to start CPR until the physician gave the order.
Conclusion: Significant delays in starting CPR were observed in our study. These delays seem to be due to bedside staff failing to recognize cardiac arrest, calling for help, and starting compressions.  Considering the impact that delays have on patient survival, we have identified multiple important targets for improvement. Contextual factors that limit nurses and other bedside providers ability to provide high quality resuscitative care in early stages of cardiac arrest must be further studied and addressed. Qualitative inquiry may elucidate in the decision-making process of first responders to enact CPR in a timely manner.

1. Valenzuela TD RD, Cretin S, et al. Estimating effectiveness of cardiac arrest interventions: a logistic regression survival model. Circulation. 1997;96(10):3308-13.
2. Atkins DL, Berger S, Duff JP, Gonzales JC, Hunt EA, Joyner BL, et al. Part 11: Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(18 Suppl 2):S519-25.
3. Donoghue A, Ventre K, Boulet J, Brett-Fleegler M, Nishisaki A, Overly F, et al. Design, implementation, and psychometric analysis of a scoring instrument for simulated pediatric resuscitation: a report from the EXPRESS pediatric investigators. Simul Healthc. 2011;6(2):71-7.
4. Hebert RL. Initiation of In-hospital CPR: An Examination of Nursing Behaviour within their Scope of Practice. Ottawa: University of Ottawa; 2017.
5. Panesar SS, Ignatowicz AM, Donaldson LJ. Errors in the management of cardiac arrests: an observational study of patient safety incidents in England. Resuscitation. 2014;85(12):1759-63.
6. Hunt EA, Vera K, Diener-West M, Haggerty JA, Nelson KL, Shaffner DH, et al. Delays and errors in cardiopulmonary resuscitation and defibrillation by pediatric residents during simulated cardiopulmonary arrests. Resuscitation. 2009;80(7):819-25.

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