Pediatric Advanced Life Support Research Articles

Characteristics of Paediatric Patients Transported by Emergency Care Personnel in a Government Tertiary Care Centre, Mysuru, India: A Cross-sectional Study

Introduction: Emergency Medical Service (EMS) systems have been well established and designed largely to cater to the needs of the cardiac and trauma related emergencies in adult patients. Paediatric emergencies are different; the benefits and outcomes of paediatric EMS have been assumed but without much evidence. With the emergence of paediatric and neonatal Advanced Life Support (ALS); it is imperative to have data that define the problems encountered in the prehospital care setting and also their outcome. This analysis may also provide insights into any modifications that may be required in the EMS system that exists to transport sick children. Aim: To characterise the paediatric prehospital care with emphasis on demography, presenting symptoms, treatment given, prehospital times, vitals monitoring and interventions done during EMS transport affiliated to Emergency Medical Service Agency. Materials and Methods: This descriptive cross-sectional study was conducted from July 2018 to June 2019 in Cheluvamba Hospital, a tertiary care referral teaching hospital attached to Mysore Medical College and Research Institute, Mysuru, India. The study included 147 children who were provided EMS by the 108 ambulance affiliated to the state/central government. Data pertaining to demography, presenting symptoms, vital sign monitoring, treatment given, various prehospital times, and interventions done during transport was obtained and analysed. Inpatient diagnosis with the duration of hospital stay and outcome in these childrens were also described. Results: Among the 147 children included; 3 were brought dead, hence the studied population comprised of 144 children. Amongst them, 42 were neonates and the remaining 102 belonged to the general paediatric population (older children). Overall, 61.8% were males and 57.64% hailed from a rural background. Mean ‘on- scene’ time was 12.12±2.34 minutes and 5.50±5.01 minutes, and ‘transport time’ was 33.79±16.78 minutes, and 26.11±14.2 minutes for neonates and older children, respectively. Respiratory distress was the most common presenting symptom. The mean Heart Rate (HR, beats/min), Respiratory Rate (RR, cycles/min) and temperature (°C) in neonates was 129.86±27.91, 59.90±15.40 and 36.14±0.84 whereas in older children it was 112.81±28.39, 34.87±14.86, and 37.40±0.96, respectively. Mean systolic blood pressure (SBP mmHg) in children aged more than 10 years was 116.67±8.61. Of the 39 children aged more than 6 years, 36 (92.30%) had a Glasgow Coma Scale (GCS) between 13-15. The most common intervention done was administering oxygen in 84.02% (121/144) of children; 34.02% (49/144) of children were unstable at admission; 127 (88.2%) were discharged; remaining 17 (11.8%) succumbed to their illness. On- scene time of more than 15 minutes, transport time of more than 30 minutes and factors such as hypoxia, respiratory failure and shock at admission were significantly associated with mortality (p<0.001). Conclusion: Majority of the EMS transports were related to medical conditions. Basic Life Support (BLS) interventions were done albeit mostly in older children. Emergency Medical Technicians (EMT)/paramedics delivering EMS need special training to orient themselves to the special needs of critically ill children and to improve their outcome.

A case of SVT: response to the third dose of Adenosine

Background: Supraventricular tachycardia (SVT), manifested as rapid and regular heartbeat, is the most frequent symptomatic tachyarrhythmia requiring medical intervention in children. SVT occurs in 1 in every 250-1,000 children. The heart rate can be as high as 180 beats/minute in children and 220 beats/minute in Infants. Evidence suggests that the primary dose of adenosine should be given as 0.1 mg/kg, administered in an intravenous bolus with a dose up to 6 mg. If the primary dose is insufficient, then the amount is increased by 0.1 mg/kg-0.2 mg/kg to a maximum of 12 mg. Our case demonstrates the response to adenosine after the third dose. Case presentation: A 12-year-old boy, previously diagnosed with recurrent SVT, presented with a complaint of palpitation for the last 30 minutes. There was no obvious trigger for his palpitation on history and examination. He was conscious, well looking with normal blood pressure, and good perfusion. We started the management in accordance with pediatric advanced life support guidelines, in which we noted a partial response after the administration of the second dose of adenosine. Subsequently, a third dose of adenosine of 0.2 mg/kg was administered, terminating SVT and regaining a normal sinus rhythm in the patient. Conclusion: After reviewing recent evidence regarding stable SVT management and adenosine side effects, we found that there is no evidence limiting the use of adenosine to only two doses, especially in a case of short or minimal response following the second dose.

198 A Novel ‘Virtual Simulation’ for The Advanced Life Support Group, Making a Dream a Reality: A Beginner’s Guide

In the UK, it is a requirement for staff involved in paediatric critical care to remain up to date with advanced paediatric life support (APLS). To do so there is an expectation to participate in face-to-face courses on a four-yearly basis. The Advanced Life Support Group (ALSG), an organization dedicated to supporting professional education, sought to add to their resources in line with advances in online capabilities. With stakeholder input, the goal emerged to develop an engaging, interactive and entirely novel educational product. Here we present the pilot stages of our project.The aim of this project was to produce an educationally effective and novel product that learners of APLS would engage with and enjoy.Stage 1 involved determining clearly defined learning objectives mapped to the APLS curriculum. At a round table with stakeholders, educationalists, and a technologist an outline of the project was formed and the scenario of a sick baby with bronchiolitis chosen for a pilot. Informed by literature on serious game design, a branching narrative was created. Stage 2 involved collating resources. A photoshoot at Leicester Royal Infirmary A&E (Accident and Emergency) created a set of images. A video shoot at the Royal London Hospital A&E generated a series of videos. These were then edited and used to create a Microsoft PowerPoint slide set. Voiceovers to text, sound effects to add a hospital atmosphere and questions were then added. Stage 3 involved taking this draft and translating it into an interactive final product utilizing Articulate Software. This enabled its usage across smartphone, desktop, and laptop devices. Testing followed with anonymous online feedback informed by the 7Is framework We launched the pilot version at the RCPCH (Royal College of Paediatrics and Child Health) Conference 2021. Feedback was collected from delegates and continues to be collected via online participants. It is hoped that ongoing quality improvement cycles will assist in assuring a finished fully functional online virtual advanced paediatric life support simulation for release in 2022. Further stakeholder review is pending. Thus far it has been met with universal approval, i.e. all learners questioned expressed that they would like to utilize this novel style of education again. The average duration to complete the virtual simulation was 15 minutes. All learners rated their knowledge and skills in APLS to be either unchanged/revised or improved. Finally, interactivity online was felt to need improvement by most participants. Interactivity is key if high levels of engagement are to be achieved. Future testing will determine whether any educational impact is maintained across time. The current pilot version can be accessed at the following webpage

Pediatric Hospitalist Resuscitation Skills Refresher Training With Pauses for Deliberate Practice.

IntroductionPediatric hospitalists are expected to lead resuscitative efforts for cardiopulmonary arrests, but the infrequency of these events and pediatric advanced life support (PALS) re-certifications are insufficient to maintain skill proficiency.We created a novel resuscitation refresher curriculum for pediatric hospitalists with strategic pauses during simulations for expert and peer coaching of procedural skills.MethodsIn a tertiary care academic pediatric hospital between September 2018 to June 2019, pediatric hospitalists and fellows voluntarily participated in a series of three quarterly two-hour training sessions taught by expert peer facilitators. Sessions focused on the thirty-second rapid cardiopulmonary assessment and each of the pediatric advanced life support (PALS) algorithms. Scenarios were strategically paused to practice critical hands-on skills. Cases centered on the themes of shock, respiratory, and cardiac emergencies and took place in a high-fidelity simulation lab requiring a technician and expert peer facilitator. Participants anonymously completed Likert scale-based evaluations after each session and again at the end of the year that focused on participants’ own perceived change in their comfort levels in performing various resuscitation skills and in knowing basic resuscitation steps. As part of our institutional and personal assessment of the curriculum, an end-of-year survey additionally asked participants to reflect on the overall simulation curriculum and resultant changes in their clinical practice.ResultsComfort in all skills practiced across the three sessions increased. The end-of-year survey showed a significant rise in comfort above baseline but some decrements when compared to that immediately post-training. Ninety-six percent of pediatric hospitalists rated the overall quality of the training “better” or “much better” than other resuscitation training (including PALS classes and traditional simulations with skills training after the scenario). The overall effect of the curriculum on perceived knowledge, skills, and confidence levels was significant (p <0.0001).ConclusionSerial resuscitation skills refreshers with expert peer coaching and strategic pauses for hands-on skills practice can result in significant improvements in perceived knowledge and comfort with skill performance as well as the leadership role among pediatric hospitalists.

NRP Versus PALS for Infants Outside the Delivery Room: Not If, but When?

Both the Neonatal Resuscitation Program and Pediatric Advanced Life Support guidelines can be used for infants requiring cardiopulmonary resuscitation outside the delivery room. Each set of guidelines has supporting algorithms for resuscitation; however, there are no current recommendations for transitioning older infants outside the delivery room. To provide background information on the algorithms in the Neonatal Resuscitation Program and Pediatric Advanced Life Support guidelines and to discuss the role that nurses and advanced practice nurses play in advancing scientific research on resuscitation. Summaries of both sets of guidelines, differences in practices, and recommendations for practice changes will be discussed. Provider preference and unit practice determine which guidelines are used for infants outside the delivery room. Providers in pediatric intensive care units and pediatric cardiac intensive care units often use the Pediatric Advanced Life Support guidelines, whereas providers in neonatal intensive care units use the Neonatal Resuscitation Program guidelines for infants of the same age. The variation in resuscitation practices for infants outside the delivery room can negatively affect resuscitation outcomes.

How to Maintain Safety and Maximize the Efficacy of Cardiopulmonary Resuscitation in COVID-19 Patients: Insights from the Recent Guidelines

Since December 2019, the novel coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has remained a challenge for governments and healthcare systems all around the globe. SARS-CoV-2 infection is associated with increased rates of hospital admissions and significant mortality. The pandemic increased the rate of cardiac arrest and the need for cardiopulmonary resuscitation (CPR). COVID-19, with its pathophysiology and detrimental effects on healthcare, influenced the profile of patients suffering from cardiac arrest, as well as the conditions of performing CPR. To ensure both the safety of medical personnel and the CPR efficacy for patients, resuscitation societies have published modified guidelines addressing the specific reality of the COVID-19 pandemic. In this review, we briefly describe the transmission and pathophysiology of COVID-19, present the challenges of CPR in SARS-CoV-2-infected patients, summarize the current recommendations regarding the algorithms of basic life support (BLS), advanced life support (ALS) and pediatric life support, and discuss other aspects of CPR in COVID-19 patients, which potentially affect the risk-to-benefit ratio of medical procedures and therefore should be considered while formulating further recommendations.

Abstract 13839: Knowledge, Attitude &amp; Practice of Health Care Workers Regarding Pediatric Early Warning System - A Cross Sectional Study in Karachi, Pakistan

Introduction: The Pediatrics Early Warning Scoring (PEWS) system is a quantitative instrument that measures the severity of the clinical situation of children aged 1 month to 18 years. Hypothesis: To assess the knowledge, attitude, and practices among nurses and doctors regarding the Pediatric Early Warning Signs (PEWS) system, in a pediatric ward at a tertiary care hospital in Karachi, Pakistan. Methods: A cross-sectional study design was used to address the study question. The universal sampling technique was used to recruit a total of 142 eligible nurses and doctors to explore the knowledge and attitude regarding the PEWS system. Medical records of patients who had a Pediatric Rapid Response Team (PRRT) request raised was reviewed for practice assessment of PEWS. The relationship between the study participants’ demographic characteristics and their knowledge and attitude regarding PEWS was assessed through Chi-square for categorical variables and one-way ANOVA for continuous variables. Results: The findings of the study revealed that out of 142 study participants, 50% participants had a low level of knowledge yet positive attitude towards the PEWS system. Professional qualification and age of participants were significantly associated with knowledge regarding the PEWS system. Profession, professional qualification, current position of the study participants and specialized training on PEWS had a significant association with attitude regarding the PEWS system. Medical records of 30 patients were eligible for practice assessment which revealed that 56.7% of the PEWS observations were documented in patient records which were either incomplete or inappropriate. About 50% showed a poor level of practice regarding PEWS. Conclusions: Our study revealed a knowledge and practice gap among the nurses and doctors while utilizing the PEWS system. Despite having a low level of knowledge, the participants had a positive attitude towards PEWS to enhance their PEWS knowledge and practices. PEWS should be incorporated in the Pediatric Advanced Life Support (PALS) certification course. Moreover, simulation-based teaching strategies should be planned to improve practice and knowledge regarding the system.

Utilizing High-fidelity Simulators in Improving Trainee Confidence and Competency in Code Management.

Introduction:Simulation training is central in preparing practitioners for code management that is free from patient harm.1 The purpose of this study was to determine if using a high-fidelity simulator in pediatric code education would improve trainee confidence and competency compared with the use of a traditional mannequin in the same setting.Methods:Fifty-third-year medical students participated in Pediatric Advanced Life Support code training, including a mock code scenario. Students were randomized into two groups and assigned to a simulator group: high-fidelity simulator (Group 1) or traditional mannequin (Group 2). To assess competency, trainees were evaluated using a checklist of required verbalized items or performed during the mock code scenario. To assess confidence, trainees completed pre- and postintervention confidence surveys, which were collected and compared.Results:Both Group 1 and Group 2 reported increased overall confidence in code management upon completion of their training. Although confidence increased universally, Group 1 reported increased confidence over that of Group 2 in three specific areas: ability to treat respiratory arrest, ability to run a code, and knowledge of the Pediatric Advanced Life Support algorithm. Group 1 also demonstrated increased competency in code management compared with Group 2 in four key code components: checking airway, checking breathing, checking pulses, and checking capillary refill.Conclusions:Trainee confidence increases after completion of Pediatric Advanced Life Support code training, regardless of simulator type utilized. However, trainees were more competent in code management when trained using a high-fidelity simulator compared with a traditional mannequin.

An Abnormal Echocardiogram and Telemetry Tracing in a Late Preterm Infant.

An Abnormal Echocardiogram and Telemetry Tracing in a Late Preterm Infant.

A Novel Code Team Leader Card to Improve Leader Identification.

Prompt and clear code team leader identification is vital in effective cardiopulmonary resuscitation (CPR), and pediatric trainees often have limited experience in these scenarios. This project sought to develop a tangible object that provided clear leader identification and assisted in code team management and simulated team training. A Code Team Leader Card (CTLC) was designed to provide clear leader identification while simultaneously providing a cognitive aid via integration of pediatric advanced life support (PALS) algorithms. Additionally, CTLC served to occupy the leader's hands to limit their ability to intervene on procedural tasks. The CTLC was incorporated into pediatric resident simulation training, and pre- and postintervention survey data were analyzed. Analysis particularly focused on whether "a leader was clearly identified by all team members." The relationship between CTLC implementation and consistent leader recognition was evaluated using chi-squared test, and secondary qualitative data were obtained via debriefing sessions. Pediatric residents completed 131 surveys prior to CTLC implementation and 41 surveys after implementation. Consistent code team leader recognition increased significantly from 61.8% (81 of 131) pre-CTLC to 80.5% (33 of 41) after introduction of CTLC (P=0.027). Participants commented on the benefits of CTLC during debriefing sessions. Use of a CTLC significantly improved leader recognition during simulated CPR. Inclusion of PALS algorithms led to normalization and increased utilization of these adjunct materials. The CTLC provided a secondary benefit of occupying the leader's hands, thereby allowing that person to focus on overseeing the team rather than assisting with procedural tasks.

FACTORS ASSOCIATED WITH ENDOTRACHEAL TUBE MALPOSITION AMONG PEDIATRIC PATIENTS WITH HEART DISEASE: A CROSS-SECTIONAL ANALYTICAL STUDY

TOPIC: Respiratory Care TYPE: Original Investigations PURPOSE: Several guidelines and formula for endotracheal tube depth insertion are being studied and used. These suggested formulas in computation for the endotracheal tube (ETT) size and depth are based on age, weight and height of those with normal growth and mostly of the Western population. These may not be applicable for those children with growth impairment in patients with cardiac diseases. Investigation of the incidence of inappropriate ETT size and ETT malposition is important to lessen pulmonary complications in these population. METHODS: This is a cross-sectional analytical study approved by the Institutional Review Board of the Philippine Heart Center. Review of charts of pediatric patients, neonates up to 18 years of age with heart disease, who has undergone endotracheal intubation between April 1, 2017 and December 31, 2019 was done. Age, gender, nutritional status, type of heart disease, setting of intubation, formula in computing for the ETT depth, and complications were all obtained from the charts of the patient. The actual ETT placement was compared with the computed ETT depth to identify which guideline specific formula was used. ETT placement, measured in centimeters, seen in chest radiograph taken in neutral position right after intubation was also obtained from the record of the patients. The chest radiographs were evaluated by a single identified radiologist to prevent inter-reader variation. RESULTS: A total of 99 patients with heart disease who underwent endotracheal intubation were included with age ranging from 4 days to 18 years and mean age of 87.71 months (±14.04). There is male preponderance (60.6%). From the review of the post-intubation chest radiographs, 51.52% endotracheal tubes were in place and 48.48% were misplaced. The presence of malnutrition was not a significant factor (p=0.52). However, from the different types of malnutrition, severe stunting (p=0.021) was a factor in the occurrence of malpositioned ETT. Patients with severe stunting, were 3.23 times more likely to have malpositioned ETT as compared to those with normal growth and to those with stunting. In the multivariate analysis, the use of guideline-specified formula was noted to be a significant factor in decreasing the likelihood of malpositioned ETT. Neonates intubated using the Neonatal Resuscitation Program (NRP) formula were 96.87% less likely to have malpositioned endotracheal tube. Furthermore, the NRP guideline was also utilized in infants up to 2 months old who weighed less than 4 kilograms. For those belonging to older age group, Internal Diameter (ID) estimation and Pediatric Advanced Life Support (PALS) formula were 75.33% and 70.88% less likely to have malpositioned ETT, respectively. Wheezing or bronchospasm was the most common complication followed by atelectasis of the left lung. CONCLUSIONS: There are several guidelines and recommendations in proper endotracheal tube insertion a mediical provider may choose and use; however, important factors and characteristics of the individual patient, such as his or her nutritional status should be taken into consideration. CLINICAL IMPLICATIONS: This important and life-saving emergency procedure should be further studied in the pediatric population with different growth patterns to decrease incidence of malpositoning and further pulmonary complications. DISCLOSURES: No relevant relationships by Karenne Somera, source=Web Response

389 Atropine Pretreatment and Adverse Events in Emergency Pediatric Intubation

Atropine may blunt the vagal response to laryngoscopy and endotracheal intubation in children, though its role in emergency pediatric intubation remains unclear. Pediatric Advanced Life Support (PALS) guidelines recommend against the routine use of prophylactic atropine when intubating critically-ill children and infants, but state it “may be reasonable” in specific situations with high risk of bradycardia (eg, when using succinylcholine for paralysis). Our goal was to describe the use of atropine for pediatric intubation in the emergency department (ED) and estimate its association with peri-intubation adverse events (AE). We performed a secondary analysis of prospectively-collected data from the National Emergency Airway Registry (NEAR), a multicenter registry of academic and community EDs in the United States requiring reporting of ≥90% of intubations for participation. Patients ≤15 years of age were included from 2016 through 2018. We report proportions with associated 95% CIs and multivariable logistic regression estimating the association between atropine pretreatment and AEs including bradycardia, hypotension, cardiac arrest, and hypoxia while adjusting for age, pre-intubation blood pressure and oxygen saturation, sedative and paralytic choice, type of laryngoscopy, intubator level of training, number of attempts and clustering within hospitals. 25 EDs provided data for 612 pediatric intubations: 139 <1 year of age; 129 ages 1 year to <3 years; 144 ages 3 years to <8 years; and 200 ages 8 years to ≤15 years. While all intubations were ultimately successful, first pass success rate was 78%. Atropine pretreatment was given in 7% of intubations, of which, 51% were <1 year and 23% received succinylcholine. AEs occurred in 16% of intubation attempts with hypoxia being the most common AE; cardiopulmonary AEs occurred in 4%; bradycardia in 2%. Of the 9 patients who did not receive atropine pretreatment and experienced bradycardia, 6 received rocuronium for paralysis and 3 received succinylcholine. After adjusting for confounding, atropine pretreatment was associated with an increased occurrence of cardiopulmonary AEs (OR 2.60, 95% CI 1.02-6.61). In this multicenter prospective cohort of pediatric intubations, atropine pretreatment was uncommon and associated with increased adverse cardiopulmonary events. This finding challenges the use of atropine to prevent bradycardia in emergency pediatric intubation and further research is required to explore the unexpected association with cardiopulmonary adverse events.

Evaluating pediatric advanced life support in emergency medical services with a performance and safety scoring tool.

Pediatric out-of-hospital cardiac arrests (P-OHCA) are infrequent, have low survival rates, and often have poor neurologic outcomes. Recent evidence indicates that high-performance emergency medical service (EMS) care can improve outcomes. To evaluate Pediatric Advanced Life Support (PALS) guideline performance in the out of hospital setting and introduce an easy-to-use tool that scores guideline compliance and patient safety. We observed EMS teams responding to standardized pediatric resuscitation simulations. Teams were dispatched to a mock assisted living home for a choking 6-year-old with a complex medical history. The child manikin was presented as unconscious and apneic, with bradycardic pulse. Teams were expected to monitor vitals; initiate airway management and cardiopulmonary resuscitation (CPR); and establish vascular access and administer epinephrine based on PALS guidelines. We developed a tool to score the quality of care for critical tasks and had a clinical expert evaluate technical performance using blinded video review. We observed 34 EMS teams providing care in P-OHCA simulations. Teams were proficient at assessing vitals, using correct-sized equipment, intubation, and confirmation of tube placement. Teams were delayed in initiating positive pressure ventilation (PPV) and chest compressions. Many teams (53%) deviated from guidelines in chest compressions with 17 (50%) performing continuous compressions before establishing an advanced airway and one (3%) not performing compressions. Similarly, 20 (59%) teams deviated from medication guidelines with 12 (35%) failing to administer epinephrine, six (18%) underdosing, and two (6%) overdosing by more than 20%. EMS teams were successful in selecting the appropriate equipment but delayed initiating ventilations in a child with severe bradycardia. We also noted frequent use of continuous chest CC rather than the AHA recommended 15:2 ratio. We developed a scoring tool with time-based criteria that can be used to assess guideline compliance, individual performance, and/or educational effectiveness.

Rapid-cycle deliberate practice improves time to defibrillation and reduces workload: A randomized controlled trial of simulation-based education.

The optimal structure of simulation to train teams to perform pediatric advanced life support (PALS) requires further research. Most simulation is structured with an uninterrupted scenario with postsimulation debriefing (PSD). Rapid-cycle deliberate practice (RCDP) is structured with a series of simulations with microdebriefing quickly switching within action targeting specific performance goals. The objective was to compare team performance immediately after training, as well as learner workload, for teams trained using either PSD or RCDP. In 2018-2019, a total of 41 interprofessional teams of 210 residents and nurses were recruited from 250 eligible participants (84%) and randomized into either arm (RCDP or PSD) teaching the same objectives of resuscitation of a patient in PEA arrest, in the same time frame. The structure of the simulation varied. Demographic surveys were collected before training, the National Aeronautics and Space Administration-Task Load Index (NASA-TLX) was administered immediately after training to assess workload during training and performance was assessed immediately after training using a pulseless ventricular tachycardia arrest with the primary outcome being time to defibrillation. Thirty-nine teams participated over a 16-month time span. Performance of teams randomized to RCDP showed significantly better time to defibrillation, 100s (95% confidence interval [CI]=90-111), compared to PSD groups, 163s (95% CI=120-201). The workload of the groups also showed a lower total NASA-TLX score for the RCDP groups. For team-based time-sensitive training of PALS, RCDP outperformed PSD. This may be due to a reduction in the workload faced by teams during training.

Impact of a multifaceted intervention to improve emergency care on newborn and child health outcomes in Rwanda.

Implementing context-appropriate neonatal and paediatric advanced life support management interventions has increasingly been recommended as one of the approaches to reduce under-five mortality in resource-constrained settings like Rwanda. One such intervention is ETAT+, which stands for Emergency Triage, Assessment and Treatment plus Admission care for severely ill newborns and children. In 2013, ETAT+ was implemented in Rwandan district hospitals. We evaluated the impact of the ETAT+ intervention on newborn and child health outcomes. We used monthly time-series data from the DHIS2-enabled Rwanda Health Management Information System from 2012 to 2016 to examine neonatal and paediatric hospital mortality rates. Each hospital contributed data for 12 and 36 months before and after ETAT+ implementation, respectively. Using controlled interrupted time-series analysis and segmented regression model, we estimated longitudinal changes in neonatal and paediatric hospital mortality rates in intervention hospitals relative to matched concurrent control hospitals. We also studied changes in case fatality rate specifically for ETAT+-targeted conditions. Our study cohort consisted of 7 intervention hospitals and 14 matched control hospitals contributing 142 424 neonatal and paediatric hospital admissions. After controlling for secular trends and autocorrelations, we found that the ETAT+ implementation had no statistically significant impact on the rate of all-cause neonatal and paediatric hospital mortality in intervention hospitals relative to control hospitals. However, the case fatality rate for ETAT+-targeted neonatal conditions decreased immediately following implementation by 5% (95% confidence interval: -9.25, -0.77) and over time by 0.8% monthly (95% confidence interval: -1.36, -0.25) in intervention hospitals compared with control hospitals. Case fatality rate for ETAT+-targeted paediatric conditions did not decrease following the ETAT+ implementation. While ETAT+ focuses on improving the quality of hospital care for both newborns and children, we only found an impact on neonatal hospital mortality for ETAT+-targeted conditions that should be interpreted with caution given the relatively short pre-intervention period and potential regression to the mean.

Neonatal resuscitation in the NICU; Challenges beyond NRP.

Resuscitation of neonates in the newborn period requires attention to cardiopulmonary health with a focus on ventilation and return of spontaneous circulation.1 Newborn resuscitation at delivery is performed according to the Neonatal Resuscitation Program (NRP) algorithm. Infants and children are resuscitated by Pediatric Advanced Life Support (PALS) guidelines from The American Heart Association (AHA). Resuscitation of infants beyond the 24 hours of age represents a challenge in selecting the most suitable algorithm. In general, both the AHA and NRP recommend using NRP guidelines during the immediate newborn period and through their initial hospitalization.1,2 However, questions remain whether all aspects of NRP are appropriate for infants who have long hospitalization times, well beyond the transition period, especially preterm infants.

The relationship between simulated milrinone exposure and hypotension in children.

Hypotension is an adverse event that may be related to systemic exposure of milrinone; however, the true exposure-safety relationship is unknown. Using the Pediatric Trials Network multicentre repository, we identified children ≤17 years treated with milrinone. Hypotension was defined according to age, using the Pediatric Advanced Life Support guidelines. Clinically significant hypotension was defined as hypotension with concomitant lactate >3mg/dl. A prior population pharmacokinetic model was used to simulate milrinone exposures to evaluate exposure-safety relationships. We included 399 children with a median (quarter 1, quarter 3) age of 1 year (0,5) who received 428 intravenous doses of milrinone (median infusion rate 0.31mcg/kg/min [0.29,0.5]). Median maximum plasma milrinone concentration was 110.7ng/ml (48.4,206.2). Median lowest systolic and diastolic blood pressures were 74mmHg (60,85) and 35mmHg (25,42), respectively. At least 1 episode of hypotension occurred in 178 (45%) subjects; clinically significant hypotension occurred in 10 (2%). The maximum simulated milrinone plasma concentrations were higher in subjects with clinically significant hypotension (251ng/ml [129,329]) versus with hypotension alone (86ng/ml [44, 173]) versus without hypotension (122ng/ml [57, 208], p = 0.002); however, this relationship was not retained on multivariable analysis (odds ratio 1.01; 95% confidence interval 0.998, 1.01). We successfully leveraged a population pharmacokinetic model and electronic health record data to evaluate the relationship between simulated plasma concentration of milrinone and systemic hypotension occurrence, respectively, supporting the broader applicability of our novel, efficient, and cost-effective study design for examining drug exposure-response and -safety relationships.

Implementing a Medical Emergency and Rapid Intervention Team

<h3>Background Information</h3> Failure to rescue accounts for approximately 60,000 deaths each year in Medicare patients under the age of 75. In a large outpatient oncology facility that encompasses an infusion center, multimodality procedure unit, radiation treatment center & multidisciplinary clinic, the need to implement a rapid rescue team was identified to mitigate the risk of failure to rescue. <h3>Objectives of Project</h3> The goal of this initiative was to implement a Medical Emergency and Rapid Intervention Team (MERIT) service to care for patients undergoing chemotherapy, blood transfusions, procedures, radiation and other oncology treatments. A standardized process was developed for MERIT activation by healthcare providers within the facility. In-Service all employees in the facility and empower them to activate MERIT for identified patients. <h3>Process of Implementation</h3> The current MERIT policy for inpatients was reviewed and collaboration was formed with institutional leaders to revise it for an ambulatory center. A needs assessment was conducted and knowledge deficits were identified. The skill mix of PACU nurses was reviewed to identify those with a high acuity background to be a core member of the MERIT team. An orientation and competency check-off was developed, which included requiring members to have Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS) and High Acuity Training. A post-implementation survey was conducted to assess needs and knowledge gaps. <h3>Statement of Successful Practice</h3> The assessment survey indicated 83% of staff were able to identify all the correct situations to call MERIT, 9% of staff were not sure what situations require MERIT and 25% of staff did not know the correct extension to request MERIT. Post implementation of MERIT service, the building team members indicated 84.4% of the staff were able to identify correct situations to call MERIT, and 98% of the staff knew the correct extension to request MERIT. Post education survey was done 2 weeks after go live and showed improvement in knowledge and comfort level in calling MERIT. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> Providing a MERIT service in an outpatient facility could mitigate the risk of failure to rescue, and improve patient outcomes.

Observational Study on the Effect of Duration from Pediatric Advanced Life Support (PALS) Certification on PALS Performance in Pediatric Interns in Simulated Cardiopulmonary Arrest.

Pediatric advanced life support (PALS) training is critical for pediatric residents. It is unclear how well PALS skills are developed during this course or maintained overtime. This study evaluated PALS skills of pediatric interns using a validated PALS performance score following their initial PALS certification. All pediatric interns were invited to a 45-minute rapid cycle deliberate practice (RCDP) training session following their initial PALS certification from July 2017 to June 2019. The PALS score and times for key events were recorded for participants prior to RCDP training. We then compared performance scores for those who took PALS ≥3 months, between 3 days to 3 months and 3 days after PALS. There were 72 participants, 30 (of 30) in 3 days, 18 in 3 days to 3 months, and 24 in ≥3 months groups (42 total of 52 residents, 81%). The average PALS performance score was 53 ± 20%. There was no significant difference between the groups (3 days, 53 ± 15%; 3 days-3 months, 51 ± 19%; ≥3 months, 54 ± 26%, p = 0.922). Chest compressions started later in the ≥3 months groups compared with the 3 days or ≤3 months groups ( p = 0.036). Time to defibrillation was longer in the 3 days group than the other groups ( p = 0.008). Defibrillation was asked for in 3 days group at 97%, 73% in 3 days to 3 months and 68% in ≥3 months groups. PALS performance skills were poor in pediatric interns after PALS certification and was unchanged regardless of when training occurred. Our study supports the importance of supplemental resuscitation training in addition to the traditional PALS course.

Incidence of Bradycardia and the Use of Atropine in Pediatric Rapid Sequence Intubation in the Emergency Department.

Bradycardia during rapid sequence intubation (RSI) is an uncommon but serious adverse effect encountered in pediatric intubations. Atropine has historically been used in the pediatric population as RSI premedication to prevent bradycardia, especially when using succinylcholine as an induction agent. The objective of this analysis was to identify the incidence of bradycardia with or without atropine use. This single-center, retrospective, observational case series reviewed pediatric patients up to 18 years old requiring intubation from January 1, 2015, to December 31, 2018. Bradycardia was determined by analyzing heart rates associated with time during and up to 5 minutes after intubation. A total of 62 patients were included. Three (4.8%) patients experienced a bradycardic event during intubation. A total of 15 (24.2%) patients received atropine for pretreatment of RSI. Incidence of bradycardia was similar between those who received atropine and those who did not. An increasing trend in atropine use was shown throughout the assessment period, yet only 18 (29%) patients met criteria for atropine pretreatment based on the 2015 Pediatric Advanced Life Support guideline recommendations for RSI. Bradycardia incidence was low in pediatric patients undergoing RSI in our emergency department. Use of atropine or succinylcholine did not affect the incidence of bradycardia during pediatric intubation over this study period. Our results show a low incidence of bradycardia and support the 2015 Pediatric Advanced Life Support Guideline recommendation of limiting the use of atropine premedication in pediatric intubations.