Initiation Of Chest Compressions Research Articles

Barriers to dispatcher-assisted cardiopulmonary resuscitation in Thailand

Background: Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) has proven effective in boosting bystander CPR rates in out-of-hospital cardiac arrests (OHCA). Recently, Thailand has implemented a DA-CPR program. Our objective was to delineate the obstacles to initiating chest compressions by callers. Methods: We reviewed dispatch recordings of OHCA cases received by the ambulance call center from July 2012 to March 2015. Excluding audio recordings of subpar quality, trained evaluators documented the successive stages of the dispatcher's CPR recognition, delivery of CPR instructions, and the caller's execution of CPR. The time required to achieve these milestones was recorded, while barriers hindering chest compressions were identified. Results: Throughout the study period, researchers identified 280 cases of OHCA. Among these cases, it was observed that 134 bystanders declined to administer CPR. Reasons for refusal varied: 25.4% cited difficulty in controlling their emotions, 21.65% encountered challenges accessing the scene, 20.9% refused to perform CPR, 14.9% dropped out of the call, 9.7% did not approach the emergency patient, 5.9% were unable to perform CPR due to physical limitations, and 2.9% faced difficulty moving the emergency patient to the ground floor. Conclusions: Barriers were present in 47.85% correlating with a reduced proportion of CPR initiation and longer delays in CPR initiation.

Is dispatcher-assisted cardiopulmonary resuscitation affected by a bystander’s emotional stress state in out-of-hospital cardiac arrest?

AimThe study aimed to investigate whether a bystander’s emotional stress state affects dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) in out-of-hospital cardiac arrest (OHCA). The primary outcome was initiation of chest compressions (Yes/No). Secondarily we analysed time until chest compressions were initiated and assessed how dispatchers instructed CPR.MethodThe study was a retrospective, observational study of OHCA emergency calls from the Capital Region of Denmark. Recorded calls were evaluated by five observers using a pre-defined code catalogue regarding the variables wished investigated.ResultsIncluded were 655 OHCA emergency calls, of which 211 callers were defined as emotionally stressed. When cardiac arrest was recognized, chest compressions were initiated in, respectively, 76.8% of cases with an emotionally stressed caller and 73.9% in cases with a not emotionally stressed caller (2.18 (0.80–7.64)). Cases with an emotionally stressed caller had a longer time until chest compressions were initiated compared to cases with a not emotionally stressed caller, however non-significant (164 s. vs. 146 s.; P = 0.145). The dispatchers were significantly more likely to be encouraging and motivating, and to instruct on speed and depth of chest compressions in cases with an emotionally stressed caller compared to cases with a not emotionally stressed caller (1.64 (1.07–2.56); 1.78 (1.13–2.88)). Barriers to CPR were significantly more often reported in cases with an emotionally stressed caller compared to cases with a not emotionally stressed caller (1.83 (1.32–2.56)).ConclusionThere was no significant difference in initiation of chest compressions or in time until initiation of chest compressions in the two groups. However, the dispatchers were overall more encouraging and motivating, and likely to instruct on speed and depth of chest compressions when the caller was emotionally stressed. Furthermore, barriers to CPR were more often reported in cases with an emotionally stressed caller compared to cases with a not emotionally stressed caller.Trial registrationWe applied for ethical approval from The Danish National Committee on Health Research Ethics, but formal approval was waived. We received permission for storage of data and to use these for research of OHCAs in the Capital Region of Denmark by Danish Data Protection Agency (P-2021-670) and Danish Health Authorities (R-2,005,114). The study is registered at ClinicalTrials (NTC05113706).

School children brief training to save foreign body airway obstruction

Foreign body airway obstruction (FBAO) is a relatively common emergency and a potential cause of sudden death both in children and older people; bystander immediate action will determine the victim’s outcome. Although many school children’s basic life support (BLS) training programs have been implemented in recent years, references to specific training on FBAO are lacking. Therefore, the aim was to assess FBAO-solving knowledge acquisition in 10–13-year-old school children. A quasi-experimental non-controlled simulation study was carried out on 564 ten-to-thirteen-year-old children from 5 schools in Galicia (Spain). Participants received a 60-min training led by their physical education teachers (5 min theory, 15 min demonstration by the teacher, and 30 min hands-on training) on how to help to solve an FBAO event. After the training session, the school children’s skills were assessed in a standardized adult’s progressive FBAO simulation scenario. The assessment was carried out by proficient researchers utilizing a comprehensive checklist specifically designed to address the variables involved in resolving a FBAO event according with current international guidelines. The assessment of school children’s acquired knowledge during the simulated mild FBAO revealed that 62.2% of participants successfully identified the event and promptly encouraged the simulated patient to cough actively. When the obstruction progressed, its severity was recognized by 86.2% and back blows were administered, followed by abdominal thrusts by 90.4%. When the simulated victim became unconscious, 77.1% of children identified the situation and immediately called the emergency medical service and 81.1% initiated chest compressions. No significant differences in performance were detected according to participants’ age. Conclusion: A brief focused training contributes to prepare 10–13-year-old school children to perform the recommended FBAO steps in a standardized simulated patient. We consider that FBAO should be included in BLS training programs for school children.What is Known:• Kids Save Lives strategy states that school children should learn basic life support (BLS) skills because of their potential role as first responders.• This BLS training does not include content for resolving a foreign body airway obstruction (FBAO).What is New:• Following a 60-min theoretical-practical training led by physical education teachers, 10–13-year-old school children are able to solve a simulated FBAO situation.• The inclusion of FBAO content in BLS training in schools should be considered.

Enhancing the detection of out-of-hospital cardiac arrest: a study of emergency medical system in Thailand

Background: Globally, survival rates for out-of-hospital cardiac arrest remain low. Implementing a dispatch-assisted cardiopulmonary resuscitation protocol in evolving emergency medical services systems has shown potential for improving OHCA detection and reducing the time to initiate chest compressions. Methods: In this study, audio recordings of OHCA emergency calls from different regions of Thailand were analyzed from January 2021 to December 2021. The study aimed to assess OHCA detection efficiency and provide CPR recommendations, including OHCA discrimination rates, time from call initiation to OHCA identification, and time to start CPR following dispatcher guidance. Results: There were 280 OHCA cases, with 170 (60.7%) successfully identified and excluded by dispatchers. OHCA detection took an average of 39 seconds (compared to a benchmark of 60 seconds), while the mean time from notification to chest compression initiation was 298 seconds (compared to a benchmark of 220 seconds). However, OHCA discrimination and phone-based resuscitation advice were highly sensitive (81.18%), accurate (85.72%), and specific (92.73%). Conclusions: OHCA presents challenges, with the need for faster CPR initiation. Improving reporting processes, enhancing caller understanding, and refining dispatcher skills are crucial to enhance OHCA detection and DA-CPR, ultimately improving survival rates.

Assessing the weak links – Necessity and impact of regional cardiac arrest awareness campaigns for laypersons

IntroductionPublic knowledge of out-of-hospital cardiac arrest (OHCA), and initiation of basic life support (BLS) is crucial to increase survival in OHCA. MethodsThe study analysed the knowledge and willingness to perform BLS of laypersons passing an AED at a public train station. Interviewees were recruited at two time points before and after a four year-long structured regional awareness campaign, which focused on call, compress, shock in a mid-size European city (270,000 inhabitants). Complete BLS was defined as multiple responses for call for help; initiation of chest compressions; and usage of an AED, without mentioning recovery position. Minimal BLS was defined as call for help and initiation of chest compressions. ResultsA total of 784 persons were interviewed, 257 at baseline and 527 post-campaign. Confronted with a fictional OHCA, at baseline 8.5% of the interviewees spontaneously mentioned actions for complete BLS and 17.9% post-campaign (p = 0.009). An even larger increase in knowledge was seen in minimal BLS (34.6% vs 60.6%, p < 0.001). ConclusionAfter a regional cardiac arrest awareness campaign, we found an increase in knowledge of BLS actions in the lay public. However, our investigation revealed severe gaps in BLS knowledge, possibly resulting in weak first links of the chain of survival.

Cardiac arrest in a 14-year-old at an overnight camp.

KEY POINTS A previously healthy 14-year-old girl on no medications, with recent history of resolved coryza and cough, suddenly became unresponsive while sitting in her cabin at camp. A fellow camper did not feel a radial pulse and immediately initiated chest compressions while others called for help

Abstract 14198: Implementing an Effective Standardized Bystander Cardiopulmonary Resuscitation Protocol for Golf Courses

Introduction: A golf course is the fifth most common public place for cardiac arrest (CA). Currently, no standardized protocol exists for bystander CPR in the event of full CA on a golf course. Informal interviews with golfers and golf course personnel strongly suggest incomplete and variable knowledge about what to do in accordance with most current guidelines. Hypothesis: We hypothesize that development and use of a standardized protocol for the three most critical first steps to assure a person’s survival of an on-golf course CA, including calling 911, initiating high quality bystander CPR with guideline based chest compressions and early defibrillation with a standardized automated external defibrillator (AED) will improve chances of surviving if playing partners, caddies and club staff are well prepared to respond urgently to such an emergency. Methods: We created a four-panel laminated infographic designed to fit easily into every golfer’s bag, assuring a readily available “911-CPR-AED” guide for lay bystanders to initiate chest compressions, notifying the Golf Shop Personnel for getting an AED and any BLS certified persons out to arrest site as fast as possible to deliver defibrillation, and simultaneously readying the golf course grounds crew to meet the arriving rescue ambulance at the front entrance to the course and escorting them quickly and safely out to the CA site. All aspects of this process were shared and approved by leaders of the closest Emergency Medical System (EMS) and hospital emergency department (ED). Results: We simulated with all key stakeholders a full on-course cardiac arrest and 911 call to EMS in accordance with the infographic protocol, including victim resuscitation of a standard CPR mannikin and onsite rescue by paramedics. Bystander CPR was immediately initiated, AED delivered at 3 minutes, ambulance arrival at 6 minutes and full advanced cardiac life support delivered at this time with return of blood pressure. EMS loaded the victim into the ambulance at 12 minutes and was escorted back to the front entrance of the course and then to the local ED. The 911-CPR-AED infographic has now been distributed to all golfers, caddies and staff. Conclusion: An effective, standard bystander CPR protocol now exists for use at any US golf course.

Prone cardiopulmonary resuscitation: an intensive care unit case series

Background: Critically ill patients frequently receive mechanical ventilation in the prone position. If hypoxic respiratory failure progresses, pulseless events requiring emergent cardiopulmonary resuscitation may occur. Administering cardiopulmonary resuscitation in the prone position provides an opportunity to initiate chest compressions quickly, eliminating delays in resuscitative efforts.

Inhospital cardiac arrest — the crucial first 5 min: a simulation study

BackgroundEarly recognition and call for help, fast initiation of chest compressions, and early defibrillation are key elements to improve survival after cardiac arrest but are often not achieved. We aimed to investigate what occurs during the initial treatment of unannounced in situ simulated inhospital cardiac arrests and reasons for successful or inadequate initial resuscitation efforts.MethodsWe conducted unannounced full-scale in situ simulated inhospital cardiac arrest followed by a debriefing. Simulations and debriefings were video recorded for subsequent analysis. We analyzed quantitative data on actions performed and time measurements to key actions from simulations and qualitative data from transcribed debriefings.ResultsWe conducted 36 simulations. Time to diagnosis of cardiac arrest was 37 (27; 55) s. Time to first chest compression from diagnosis of cardiac arrest was 37 (18; 74) s, time to calling the cardiac arrest team was 144 (71; 180) s, and time to first shock was 221 (181; 301) s. We observed participants perform several actions after diagnosing the cardiac arrest and before initiating chest compressions. Domains emerging from the debriefings were teaming and resources. Teaming included the themes communication, role allocation, leadership, and shared knowledge, which all included facilitators and barriers. Resources included the themes knowledge, technical issues, and organizational resources, of which all included barriers, and knowledge also included facilitators.ConclusionUsing unannounced in situ simulated cardiac arrests, we found that key elements such as chest compressions, calling the cardiac arrest team, and defibrillation were delayed. Perceived barriers to resuscitation performance were leadership and teaming, whereas experience, clear leadership, and recent training were perceived as important facilitators for treatment progress.

Quality of chest compressions during prehospital resuscitation phase from scene arrival to ambulance transport in out-of-hospital cardiac arrest

AimPrehospital cardiopulmonary resuscitation is performed from scene arrival to hospital arrival. The diverse prehospital resuscitation phases can affect the quality of chest compressions. This study aimed to evaluate the dynamic changes in chest compression quality during prehospital resuscitation. MethodsAdult out-of-hospital cardiac arrest patients treated without prehospital return of spontaneous circulation were included in Seoul between July 2020 and September 2021. The chest compressions quality was assessed using a real-time chest compression feedback device. The prehospital phase was divided by key events during the prehospital resuscitation timeline (phase 1: first 2 min after initiation of chest compression, phase 2: from the end of phase 1 to 1 min prior to ambulance departure; phase 3: from 1 min before to 1 min after ambulance departure; phase 4: from the end of phase 3 to hospital arrival). The main outcome was no-flow fraction. The no-flow fraction between prehospital phases was compared using repeated-measure analysis of variance. ResultsIn total, 788 patients were included. Mean no-flow fraction was the highest in phase 3 (phase 1: 11.3% ± 13.8, phase 2: 19.3% ± 12.3, phase 3: 33.0% ± 34.9, phase 4: 18.7% ± 23.7, p < 0.001). The mean number of total no-flow events per minute was also the highest in phase 3. The minute-by-minute analysis showed that the no-flow fraction rapidly increased before ambulance departure and decreased during ambulance transport. ConclusionDynamic changes in chest compression quality were observed during prehospital resuscitation phase. The no-flow fraction was the highest from 1 min before to 1 min after ambulance departure.

An observational study of peripheral intravenous and intraosseous device insertion reported in the United States of America National Emergency Medical Services Information System in 2016

ObjectiveTo investigate the prevalence of intravenous and interosseous device insertion in the prehospital setting by prehospital clinicians, and the characteristics of patients receiving these devices as reported to the United States of America National Emergency Medical Services Information System. MethodsA retrospective analysis of the United States of America National Emergency Medical Services Information System public release dataset for the 2016 calendar year. ResultsA total of 20,454,975 events involving 40,438,959 procedures were analysed. One or more peripheral intravenous catheters were inserted during 27.4 % of events, and one or more intraosseous devices in 0.4 % of events. Insertion was completed with one attempt in 71.6 % of peripheral intravenous catheter insertions and 86.9 % of intraosseous devices insertions. Insertion was successful for 74.7 % of peripheral intravenous catheter insertions and 85.4 % of intraosseous device insertions. High rates of peripheral intravenous catheter insertion were found with: being female (51.6 %), aged 40–90 years (80.2 %), having a cardiac rhythm disturbance (70.3 %), having a primary symptom of change in responsiveness (58.7 %), or when there was initiation of chest compressions (50.4 %). There were high rates of intraosseous device insertion if the patient was male (57.8 %), aged 40–90 years (77.2 %), experienced a cardiac arrest (29.2 %), had chest compressions initiated (33.6 %), or died (16.4 %). Scene time was longest for events with intraosseous devices inserted (19.7 min, IQR 13.2–28.6) but transport time shortest (9.0 min, IQR 5.0–15.0). ConclusionsThe distribution of patient factors and the insertion of peripheral intravenous catheters and intraosseous devices is described at a national level for the first time. The results provide prehospital clinicians and Emergency Medical Services rigorous data to compare, and possibly improve, practice.

Prehospital interventions and neurological outcomes in marathon-related sudden cardiac arrest using a rapid mobile automated external defibrillator system in Japan: a prospective observational study

ObjectiveTo describe neurological outcomes after sudden cardiac arrests (SCAs) in road and long-distance races using a rapid mobile automated external defibrillator system (RMAEDS) intervention.MethodsA total of 42 SCAs from 3...

2022 Interim Guidance to Health Care Providers for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration With the American Academy of Pediatrics, American Association for Respiratory Care, the Society

2022 Interim Guidance to Health Care Providers for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration With the American Academy of Pediatrics, American Association for Respiratory Care, the Society

Learning to resuscitate at school. Study in 8-12 year-old schoolchildren

ObjectiveTo quantitatively assess the learning capacity of school children aged between 8-12 years in basic life support (theory and practice) after a feasible school training programme. Material and methodsQuasi-experimental study with a convenience sample of 567 pupils in 3rd and 5th year of Primary Education, and first year of Compulsory Secondary Education, from 3 public schools in Galicia. They received 2h (one theoretical and another practical) of basic life support training by their Physical Education teachers, as part of the school program. The children were evaluated by a theoretical test and a practical skill test that measured the quality of chest compressions, and assessed the performance of the basic life support sequence. ResultsThe level of knowledge increased with respect to the baseline, and was higher in the higher grades (P < .001). The complete basic life support sequence was carried out by 16.5% of pupils in the 3rd year of Primary Education, 54.4% of pupils in the 5th year of Primary Education, and 28.5% of pupils in the 1st year of Secondary Education (P = .030). The following compression quality parameters improved significantly with age: continuity of compressions (P < .001), percentage of compressions performed at correct depth (P = .002), and median depth (P < .001), while the percentage of compressions with correct decompression decreased significantly (P < .001). ConclusionsAlthough their anthropometric characteristics may not allow them to achieve the ideal quality of this manoeuvre, a 2h theoretical and practical training programme, taught by Physical Education teachers, helps to improve the ability of children younger than 13 years old to recognise the emergency, start the chain of survival, and initiate chest compressions.

Abstract 11939: Can Live Video Streaming From Bystander's Smartphone Improve the Quality of Chest Compressions in Real Out-of-Hospital Cardiac Arrest?

Introduction: Good quality of cardiopulmonary resuscitation (CPR) provided by bystanders is important for the outcome in out-of-hospital cardiac arrest (OHCA). A live video stream from the bystander’s smartphone to the medical dispatcher might improve the quality of chest compressions performed during CPR. Methods: At the Copenhagen Emergency Medical Services in Denmark, the medical dispatcher can add a live video to the emergency call. In case of OHCA, the medical dispatcher guides bystanders in dispatcher-assisted CPR (DA-CPR). After initiating chest compressions, the medical dispatcher can add live video streaming. A cohort study was conducted with an evaluation of performed chest compressions from the video footage before and after the dispatcher used the video to instruct CPR (video-instructed DA-CPR). Correct chest compressions were defined according to European Resuscitation Council Guidelines. Results: CPR was provided with a live video stream in 52 OHCA calls, in which 90 bystanders performed chest compressions. Thirty OHCA occurred at a public location, and more than four bystanders were present in 32 (62%) cases. In 26 cases, chest compressions were performed by more than one bystander. Eight (9%) bystanders performed correct chest compressions before video-instructed DA-CPR. For the bystanders first initiating insufficient CPR improvements were observed for: hand placement 58% (n=17/29), compressions rate 73% (n=17/21), and compressions depth 62% (n=19/31) following video-instructed DA-CPR. For the second bystander providing CPR (n=26) improvements were still observed for: hand placement 57% (n=4/7), compressions rate 73% (N=8/11), and compressions depth 53% (n=11/21) following video-instructed DA-CPR. For the third and fourth bystander (n=10), providing CPR improvements were seen for: hand placement 100% (n=2/2), compressions rate 50 % (n=2/4), and compressions depth 60% (n=3/5). Eighteen bystanders had a chest compressions performance measurement that could not be observed. Conclusions: A live video from the bystander`s smartphone to the medical dispatcher could improve the quality of chest compressions in CPR, and guidance seems important not just for the first bystander but for all bystanders performing CPR.

Effectiveness of a Dispatcher-Assisted Cardiopulmonary Resuscitation Program Developed by the Thailand National Institute of Emergency Medicine (NIEMS).

Out-of-hospital cardiac arrest (OHCA) is a life-threatening condition with an overall survival rate that generally does not exceed 10%. Several factors play essential roles in increasing survival among patients experiencing cardiac arrest outside the hospital. Previous studies have reported that implementing a dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) program increases bystander CPR, quality of chest compressions, and patient survival. This study aimed to assess the effectiveness of a DA-CPR program developed by the Thailand National Institute for Emergency Medicine (NIEMS). This was an experimental study using a manikin model. The participants comprised both health care providers and non-health care providers aged 18 to 60 years. They were randomly assigned to either the DA-CPR group or the uninstructed CPR (U-CPR) group and performed chest compressions on a manikin model for two minutes. The sequentially numbered, opaque, sealed envelope method was used for randomization in blocks of four with a ratio of 1:1. There were 100 participants in this study (49 in the DA-CPR group and 51 in the U-CPR group). Time to initiate chest compressions was statistically significantly longer in the DA-CPR group than in the U-CPR group (85.82 [SD = 32.54] seconds versus 23.94 [SD = 16.70] seconds; P <.001). However, the CPR instruction did not translate into better performance or quality of chest compressions for the overall sample or for health care or non-health care providers. Those in the CPR-trained group applied chest compressions (initiated CPR) more quickly than those who initiated CPR based upon dispatch-based CPR instructions.

Singapore Basic Cardiac Life Support and Automated External Defibrillation Guidelines 2021.

Basic Cardiac Life Support and Automated External Defibrillation (BCLS+AED) refers to the skills required in resuscitating cardiac arrest casualties. On recognising cardiac arrest, the rescuer should call for '995' for Emergency Ambulance and immediately initiate chest compressions. Good-quality chest compressions are performed with arms extended, elbows locked, shoulders directly perpendicular over the casualty's chest, and the heel of the palm placed on the lower half of the sternum. The rescuer compresses hard and fast at 4-6 cm depth for adults at a compression rate of 100-120 per minute, with complete chest recoil after each compression. Two quick ventilations of 400-600 mL each can be delivered via a bag-valve-mask after every 30 chest compressions. Alternatively, a trained, able and willing rescuer can provide mouth-to-mouth ventilation. Cardiopulmonary resuscitation should be stopped only when the casualty wakes up, the emergency team takes over care, or when an automated external defibrillator prompts for heart rhythm analysis or delivery of a shock.

Interim Guidance for Emergency Medical Services Management of Out-of-Hospital Cardiac Arrest During the COVID-19 Pandemic.

Interim Guidance for Emergency Medical Services Management of Out-of-Hospital Cardiac Arrest During the COVID-19 Pandemic.

General practice and cardiac arrest community first response in Ireland

BackgroundIn Ireland, the MERIT 3 scheme enables doctors to volunteer as cardiac arrest community first responders and receive text message alerts from emergency medical services (EMS) to facilitate early care. AimTo establish the sustainability, systems and clinical outcomes of a novel, general practice based, cardiac arrest first response initiative over a four-year period. MethodsData on alerts, responses, incidents and outcomes were gathered prospectively using EMS control data, incident data reported by responders and corroborative data from the national Out-of-Hospital Cardiac Arrest Registry. ResultsOver the period 2016–2019, 196 doctors joined MERIT 3 and 163 (83.2%) were alerted on one or more occasions; 61.3% of those alerted responded to at least one alert. Volunteer doctors attended 300 patients of which 184 (61.3%) had suffered OHCA and had a resuscitation attempt. Responders arrived to OHCA before EMS on 75 occasions (40.8%), initiated chest compressions on seven occasions (3.8%), and brought the first defibrillator on 42 occasions (22.8%). Information on the first monitored rhythm was available for 149/184 (81.0%) patients and was shockable in 30/149 (20.1%); in 9/30 cases, shocks were administered by responders. The overall survival rate was 11.0% (national survival rate 7.3%). Doctors also provided advanced life support and were closely involved in decision making on ceasing resuscitation. ConclusionThe MERIT 3 initiative in Ireland has been sustained over a four-year period and has demonstrated the ability of volunteer doctors to provide early care for OHCA patients as well as more complex interventions including end-of-life care. Further development of this strategy is warranted.

1161: Physiologic Support to Initiate Chest Compressions for Nonpulseless Organized Rhythms

Zinna, Shairbanu1; Morgan, Ryan2; Landis, William2; Reeder, Ron3; Graham, Kathryn4; Wolfe, Heather5; Nadkarni, Vinay6; Berg, Robert7; Sutton, Robert4; ICU-RESUScitation Project Investigators (ICU-RESUS) , Eunice Kennedy Shriver Collaborative Pediatric Critical Care Research Network Investigators Author Information