Cognitive Aids Do Not Prompt Initiation of Cardiopulmonary Resuscitation in Simulated Pediatric Cardiopulmonary Arrest.

Abstract

BACKGROUND: While American Heart Association (AHA) guidelines exist for proper management of cardiopulmonary arrest (CPA), in-hospital cardiopulmonary resuscitation (CPR) is often of poor quality and is not performed in all indicated situations. Pediatric CPA is additionally challenging due to complexity associated with weight-based medication dosing and low volume of health care provider experience. Code cards have been created to assist in rapid, accurate recall of the guidelines for pediatric CPA management and serve as an example of a cognitive aid, a device to supplement clinical decision-making. Such aids are now routinely used in other industries in high stress situations which are more prone to error. However, no published study to date has evaluated whether cognitive aid use prompts CPR initiation during pediatric CPA. OBJECTIVES: Primary outcome: 1) Calculate proportion of pediatric residents a) who are not performing CPR on the simulated ’pulseless’ patient when cognitive aid use is initiated and b) who then initiate CPR after cognitive aid use. Secondary outcomes: 1) Calculate a) proportion of residents who use a cognitive aid during simulated CPA and b) mean time to initial cognitive aid use. 2) Document action immediately following cognitive aid use. METHODS: Observational, descriptive study. Residents participated in individual mock codes over 2 years during competency assessments. Utilizing a high fidelity simulator, each resident participated in a standardized scenario that involved pulseless ventricular tachycardia and pulseless electrical activity. Residents were permitted to utilize items normally available in code situations, such as stethoscopes and cognitive aids. Cognitive aid use was documented if a resident referred to it to make a medical decision. Data was objectively assessed using videotapes and time-stamped computer logs. RESULTS: 132/158 (83.5%) of pediatric residents participated. 125/132 (95%) of videotapes were available for review. 107/125 (85.6%) of residents used a cognitive aid. Mean time to cognitive aid use was 106 seconds (+/-100) after the patient became pulseless. Most common immediate actions prompted by cognitive aid use were: defibrillation 43/107 (40%) and epinephrine administration 27/107 (25%). Of those residents who used the AHA Pediatric Advanced Life Support (PALS) aid, 11/41 (27%) inappropriately chose ’tachycardia with poor perfusion’ algorithm instead of ’pulseless’ algorithm. Using this algorithm resulted in cardioversion and adenosine administration, delaying appropriate actions of defibrillation and epinephrine administration. Most alarming, 58/107 (54%) were not performing CPR on the pulseless patient when cognitive aid use was initiated. Furthermore, despite actively using a cognitive aid, only 2/58 (3.4%) were prompted to initiate chest compressions. CONCLUSION: Initiation of timely CPR is a vital link in the chain of survival. This study demonstrates that current cognitive aids do not prompt initiation of these critical basic life support skills, likely contributing to delays and errors in cardiopulmonary arrest management. Pediatric residents appear to use cognitive aids early and often in cardiopulmonary arrests in an effort to effectively manage highly stressful events with high morbidity and mortality. Failure to prompt CPR initiation by these aids represents a ’missed opportunity’ to enhance performance of these vital skills. Future studies will objectively evaluate impact of cognitive aid design on CPR performance.