Resuscitation Events Research Articles

Pediatric Extracorporeal Cardiopulmonary Resuscitation ELSO Guidelines.

Pediatric Extracorporeal Cardiopulmonary Resuscitation ELSO Guidelines.

Cardiopulmonary resuscitation in quaternary neonatal intensive care units: a multicenter study

BackgroundThe reported incidence of cardiopulmonary resuscitation (CPR) in quaternary NICU is approximately 10-times higher than in the delivery room. However, the etiologies and outcomes of CPR in quaternary NICUs are poorly understood. We hypothesized that demographic characteristics, diagnoses, interventions, and arrest etiologies would be associated with survival to discharge after CPR. MethodsMulticenter retrospective cohort study of four quaternary NICUs over six years (2011–2016). Demographics, resuscitation event data, and post-arrest outcomes were analyzed. The primary outcome was survival to discharge. ResultsOf 17,358 patients admitted to four NICUs, 200 (1.1%) experienced a CPR event, and 45.5% of those survived to discharge. Acute respiratory compromise leading to cardiopulmonary arrest occurred in 182 (91%) of the CPR events. Most neonates requiring CPR were on mechanical ventilation (79%) and had central venous access (90%) at the time of arrest. Treatments at the time of the arrest associated with decreased survival to discharge included mechanical ventilation, antibiotics, or vasopressor therapy (p < 0.01). Etiologies of arrest associated with decreased survival to discharge included multisystem organ failure, septic shock, and pneumothorax (p < 0.05). Longer duration of CPR was associated with decreased survival to discharge. The odds of surviving to discharge decreased for infants who had a primarily cardiac arrest and for infants who received epinephrine during the arrest. ConclusionApproximately 1% of neonates admitted to quaternary NICUs require CPR. The most common etiology of arrest is acute respiratory compromise on a ventilator. CPR events with respiratory etiology have a favorable outcome as compared to non-respiratory causes.

Assessment of Healthcare Provider Workload in Neonatal Resuscitation.

Objective: Human errors or protocol deviations during neonatal resuscitation are common. Excess workload has been proposed as a contributor to human error during medical tasks. We aim to characterize healthcare providers' perceived workload during neonatal resuscitation.Design: Perceived workload was measured using a multi-dimensional retrospective National Aeronautics and Space Administration Task Load Index (NASA TLX) survey. The NASA TLX collects data on mental, physical, and temporal demand, performance, effort, and frustration. Each section is rated independently by participants on a scale of 0–20 (0 being lowest and 20 being highest). The Raw-TLX score is a composite score of all dimensions and presented on a scale of 0–100. Healthcare providers complete a paper and pencil survey after attending delivery room resuscitations within 3 months.Setting: Level three neonatal intensive care unit at the Royal Alexandra Hospital, Edmonton, AB, Canada.Participants: All neonatal healthcare providers who attended deliveries.Exposure: Participation in the delivery room care of newborns.Measurement: Raw TLX scores as a measure of overall workload and scores for each dimension of workload.Main Results: During the study period, ~880 neonatal resuscitation events occurred, and a total of 204 surveys were completed. Healthcare providers completed one survey for 179 deliveries, two surveys for 20 deliveries, and three surveys for 5 deliveries. The mean (standard deviation) gestational age was 35 (5) weeks, and the median (interquartile range) birth weight was 2,690 (1,830–3,440) g. Interventions at delivery were (i) stimulation 149 (73%), suction 130 (64%), continuous positive airway pressure 120 (59%), positive pressure ventilation 105 (52%), intubation 33 (16%), chest compression 10 (5%), and epinephrine 4 (2%). The overall median (interquartile range) Raw-TLX was 34 (18–49). The scores varied by dimension with mental demand 10 (5–14), physical demand 4 (1–6), temporal demand 8 (3–14), performance 4 (2–6), effort 8 (4–13), and frustration 4 (1–10). Raw-TLX scores were higher when healthcare providers performed any intervention compared to no intervention [35 (22–49) vs. 8 (6–18), p = 0.0011]; intubation and no intubation was [55 (46–62) vs. 30 (17–46), p = 0.0001], and between performing chest compression vs. no chest compression [55 (49–64) vs. 33 (18–47), p = 0.001].Conclusion: Perceived workload of neonatal healthcare providers increases during higher acuity deliveries. Healthcare providers' workload during neonatal resuscitation can be measured using NASATLX and was inversely associated with 5-min Apgar score. Future studies assessing healthcare providers' perceived workload during neonatal resuscitation in different settings are warranted.

Documentation during neonatal resuscitation: a systematic review

ObjectiveAccurate documentation in healthcare is necessary for ethical, legal, research and quality improvement purposes. In this review, we aimed to evaluate the accuracy of methods of documentation of delivery room...

Abstract 227: Cover Up- It's a Code Blue: Protecting Staff without Compromising Patient Outcomes

Introduction: During the COVID-19 pandemic, hospitals across the globe have been challenged with following the chain of survival with Get With The Guidelines (GWTG) metrics of time to epinephrine, CPR and early defibrillation while ensuring resuscitation teams are protected with recommended PPE. Healthcare organizations are seeking innovative processes to implement PPE during resuscitation events (codes) while maintaining a timely response. Hypothesis: Utilization of for PPE for Airborne Precautions for all resuscitation events can be achieved without compromising patient outcomes or GWTG metrics. Methods: In collaboration with Infection Prevention and Control (IPAC), the Resuscitation Subcommittee at an academic medical center developed a modified airborne PPE workflow for both inpatient and outpatient resuscitation events. For staff safety, all patients are considered as COVID-19 positive during a code response. Identifying timely donning and doffing techniques of PPE as paramount for maintaining GWTG metrics, a Safety Officer was implemented as an additional member of the code team. The role of the Safety Officer is to assist with the PPE process and to monitor code team compliance. Other measures implemented included attaching PPE supply bags to all code carts for easy access, adding viral filters on the bag valve masks, conducting educational mock code events, and providing online resources for staff. To measure process outcomes, pre COVID-19 pandemic GWTG metrics, mortality, and survival to discharge rates were compared with COVID-19 metrics utilizing the modified airborne PPE workflow. Conclusions: Despite additional use of PPE, the hospital has maintained patient outcomes and adhered to the GWTG resuscitation measures of time to epinephrine, CPR and defibrillation while ensuring the utmost safety of the code team during the COVID-19 pandemic. Table 1: GWTG-Award Measures *Preliminary Results

Abstract 252: Resuscitation in Prehospital Stage: Effectiveness and Influencing Factors

Background: Sudden cardiac arrest or sudden cardiac death is one of the leading causes of death all over the world. Of particular importance is out-of-hospital cardiac arrest (OHCA) - an important overworld public health issue. In order to help these people and improve their chances of survival, it is necessary to provide assistance as soon as possible. Bystanders are usually non-medical persons why it is more complicated to implement. The objectives of the study were to research effectiveness and influencing factors of resuscitation in prehospital stage and create suggestions and methodical recommendations as possible. Materials and Methods: A retrospective study was developed, which summarizes and analyzes the electronic call cards (IEK) of the Emergency Medical service of Latvia (EMS) for 2018 and 2019. IEK were selected that identified “successful resuscitation” and “unsuccessful resuscitation” as a complication of diagnosis (classification developed and validated by EMS of Latvia). Results: Overall 2538 resuscitations were performed, of which 27,6% were successful resuscitation. About a quarter (24,2%) of all resuscitations happened in a public place. The increase in the number of successful resuscitations is observed for resuscitation events that happened in public places. In most of cardiac arrest cases, bystanders did not perform CPR (60,3%). Arrival time of EMS in 2018 was 7,52 - 8,44 minutes and in 2019 was 7,75 - 8,23 minutes. The research shows that approximately 23% of cases the first monitored rhythm by EMS were VF/pVT. There is a significant difference in the increase in successful resuscitations if EMS performed defibrillation during the call. Conclusions: The most important influencing factors in the outcome of resuscitation are the patient’s age, the location, the first aid provided by bystanders, the time until the arrival of EMS and the first observed heart rhythm in a patient with cardiac arrest. It is necessary to create a register of AED (automated external defibrillator) devices in Latvia and their locations, to ensure the availability of data to the EMS service and the public.

Neonatal delivery room CPR: An analysis of the Get with the Guidelines®—Resuscitation Registry

BackgroundCardiopulmonary resuscitation (CPR) in the delivery room (DR) after birth is rare. We hypothesized that factors related to maternal, delivery, infant and resuscitation event characteristics associated with outcomes could be identified. We also hypothesized there would be substantial variation from the Neonatal Resuscitation Program (NRP) algorithm. MethodsRetrospective review of all neonates receiving chest compressions in the DR from the AHA Get With The Guidelines—Resuscitation registry from 2001 to 2014. The primary outcome was return of spontaneous circulation (ROSC) in the DR. Secondary outcome was survival to hospital discharge. Descriptive statistics were used to characterize data. Odds ratios with confidence intervals were calculated as appropriate to compare survivors and non-survivors. ResultsThere were 1153 neonates who received chest compressions in the DR. ROSC was achieved in 968 (84%) newborns and 761 (66%) survived to hospital discharge. Fifty-one percent of the cohort received chest compressions without medications. Cardiac compressions were initiated within the first minute of life in 76% of the events, and prior to endotracheal intubation in 79% of the events. In univariate analysis, factors such as prematurity, number of endotracheal intubation attempts, increased time to first adrenaline dose, and CPR duration were associated with decreased odds of ROSC in the DR. Longer CPR duration was associated with decreased odds of ROSC in multivariate analysis. ConclusionIn this cohort of infants receiving chest compressions following delivery, recognizable pre-birth risk factors as well as resuscitation interventions associated with increased and decreased odds of achieving ROSC were identified. Chest compressions were frequently initiated in the first minute of the event and often prior to endotracheal intubation. Further investigations should focus on methods to decrease time to critical resuscitation interventions, such as successful endotracheal intubation and administration of the first dose of adrenaline, in order to improve DR-CPR outcomes.

Timing and Cause of Death in Children Following Return of Circulation After Out-of-Hospital Cardiac Arrest: A Single-Center Retrospective Cohort Study.

To determine timing and cause of death in children admitted to the PICU following return of circulation after out-of-hospital cardiac arrest. Retrospective observational study. Single-center observational cohort study at the PICU of a tertiary-care hospital (Erasmus MC-Sophia, Rotterdam, The Netherlands) between 2012 and 2017. Children younger than 18 years old with out-of-hospital cardiac arrest and return of circulation admitted to the PICU. Data included general, cardiopulmonary resuscitation and postreturn of circulation characteristics. The primary outcome was defined as survival to hospital discharge. Modes of death were classified as brain death, withdrawal of life-sustaining therapies due to poor neurologic prognosis, withdrawal of life-sustaining therapies due to refractory circulatory and/or respiratory failure, and recurrent cardiac arrest without return of circulation. One hundred thirteen children with out-of-hospital cardiac arrest were admitted to the PICU following return of circulation (median age 53 months, 64% male, most common cause of out-of-hospital cardiac arrest drowning [21%]). In these 113 children, there was 44% survival to hospital discharge and 56% nonsurvival to hospital discharge (brain death 29%, withdrawal of life-sustaining therapies due to poor neurologic prognosis 67%, withdrawal of life-sustaining therapies due to refractory circulatory and/or respiratory failure 2%, and recurrent cardiac arrest 2%). Compared with nonsurvivors, more survivors had witnessed arrest (p = 0.007), initial shockable rhythm (p < 0.001), shorter cardiopulmonary resuscitation duration (p < 0.001), and more favorable clinical neurologic examination within 24 hours after admission. Basic cardiopulmonary resuscitation event and postreturn of circulation (except for the number of extracorporeal membrane oxygenation) characteristics did not significantly differ between the withdrawal of life-sustaining therapies due to poor neurologic prognosis and brain death patients. Timing of decision-making to withdrawal of life-sustaining therapies due to poor neurologic prognosis ranged from 0 to 18 days (median: 0 d; interquartile range, 0-3) after cardiopulmonary resuscitation. The decision to withdrawal of life-sustaining therapies was based on neurologic examination (100%), electroencephalography (44%), and/or brain imaging (35%). More than half of children who achieve return of circulation after out-of-hospital cardiac arrest died after PICU admission. Of these deaths, two thirds (67%) underwent withdrawal of life-sustaining therapies based on an expected poor neurologic prognosis and did so early after return of circulation. There is a need for international guidelines for accurate neuroprognostication in children after cardiac arrest.

The impact of a multidisciplinary debriefing protocol after in-hospital cardiac arrest on healthcare provider perspectives

Introduction: The American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care from 2015 recommend the implementation of performance-focused debriefing after in-hospital cardiac arrest events (class IIa). However, debriefing sessions are under-utilized and few studies have assessed their impact on healthcare providers’ perception of in-hospital resuscitation events.

Balancing Life and Death During the Golden Minute - Midwives' Experiences of Performing Newborn Resuscitation.

PurposeTo explore midwives’ experiences in performing newborn resuscitation on maternity wards.Patients and MethodsIt was a qualitative study, using a phenomenological hermeneutic approach. Individual interviews with 16 clinical midwives working in Norwegian maternity wards were conducted from August 2018 to January 2019.ResultsThe complexity underlying how midwives balance responsibility and vulnerability when performing newborn resuscitation during the Golden Minute was revealed. Midwives described the stress they experienced during resuscitation events and their need for support and confirmation after performing newborn resuscitation.ConclusionThe vulnerability and responsibility that midwives bear for mothers and newborns simultaneously affected midwives in several ways. We saw that midwives need support and confirmation to be prepared for newborn resuscitation. We also found that a lack of knowledge, skills and experience were barriers to midwives feeling prepared. Simulation training, including tailored programs, are suggested to improve midwives’ skills and help them feel prepared for real-life resuscitations. The importance of midwives’ assessment during the Golden Minute and further investigation from other perspectives are needed to understand fully this clinical complexity.

Pediatric Resuscitation Practices During the Coronavirus Disease 2019 Pandemic.

While most pediatric coronavirus disease 2019 cases are not life threatening, some children have severe disease requiring emergent resuscitative interventions. Resuscitation events present risks to healthcare provider safety and the potential for compromised patient care. Current resuscitation practices and policies for children with suspected/confirmed coronavirus disease 2019 are unknown. Multi-institutional survey regarding inpatient resuscitation practices during the coronavirus disease 2019 pandemic. Internet-based survey. U.S. PICU representatives (one per institution) involved in resuscitation system planning and oversight. None. Of 130 institutions surveyed, 78 (60%) responded. Forty-eight centers (62%) had admitted coronavirus disease 2019 patients; 26 (33%) reported code team activation for patients with suspected/confirmed coronavirus disease 2019. Sixty-seven respondents (86%) implemented changes to inpatient emergency response systems. The most common changes were as follows: limited number of personnel entering patient rooms (75; 96%), limited resident involvement (71; 91%), and new or refined team roles (74; 95%). New or adapted technology is being used for coronavirus disease 2019 resuscitations in 58 centers (74%). Most institutions (57; 73%) are using enhanced personal protective equipment for all coronavirus disease 2019 resuscitation events; 18 (23%) have personal protective equipment policies dependent on the performance of aerosol generating procedures. Due to coronavirus disease 2019, most respondents are intubating earlier during cardiopulmonary resuscitation (56; 72%), utilizing video laryngoscopy (67; 86%), pausing chest compressions during laryngoscopy (56; 72%), and leaving patients connected to the ventilator during cardiopulmonary resuscitation (56; 72%). Responses were varied regarding airway personnel, prone cardiopulmonary resuscitation, ventilation strategy during cardiopulmonary resuscitation without an airway in place, and extracorporeal cardiopulmonary resuscitation. Most institutions (46; 59%) do not have policies regarding limitations of resuscitation efforts in coronavirus disease 2019 patients. Most U.S. pediatric institutions rapidly adapted their resuscitation systems and practices in response to the coronavirus disease 2019 pandemic. Changes were commonly related to team members and roles, personal protective equipment, and airway and breathing management, reflecting attempts to balance quality resuscitation with healthcare provider safety.

Pediatric Cardiopulmonary Resuscitation Tasks and Hands-Off Time: A Descriptive Analysis Using Video Review.

To characterize tasks performed during cardiopulmonary resuscitation in association with hands-off time, using video recordings of resuscitation events. Single-center, prospective, observational trial. Twenty-six bed cardiac ICU in a quaternary care free standing pediatric academic hospital. Patients admitted to the cardiac ICU with cardiopulmonary resuscitation events lasting greater than 2 minutes captured on video. None. Videos of 17 cardiopulmonary resuscitation episodes comprising 264.5 minutes of cardiopulmonary resuscitation were reviewed: 11 classic cardiopulmonary resuscitation (87.5 min) and six extracorporeal cardiopulmonary resuscitations (177 min). A total of 209 tasks occurred in 178 discrete time periods including compressor change (36%), rhythm/pulse check (18%), surgical pause (18%), extracorporeal membrane oxygenation preparation/draping (9%), repositioning (7.5%), defibrillation (6%), backboard placement (3%), bagging (<1%), pacing (<1%), intubation (<1%). In 31 time periods, 62 tasks were clustered with 18 (58%) as compressor changes and pulse/rhythm check. In the 178 discrete time periods, 135 occurred with a pause in compressions for greater than or equal to 1 second; 43 tasks occurred without pause. After accounting for repeated measures from individual patients, providers were less likely to perform rhythm or pulse checks (p < 0.0001) or change compressors regularly (p = 0.02) during extracorporeal cardiopulmonary resuscitation as compared to classic cardiopulmonary resuscitation. The frequency of tasks occurring during cardiopulmonary resuscitation interruptions in the classic cardiopulmonary resuscitation group was constant over the resuscitation but variable in extracorporeal cardiopulmonary resuscitation, peaking during activities required for cannulation. On video review of cardiopulmonary resuscitation, we found that resuscitation guidelines were not strictly followed in either cardiopulmonary resuscitation or extracorporeal cardiopulmonary resuscitation patients, but adherence was worse in extracorporeal cardiopulmonary resuscitation. Clustering of resuscitation tasks occurred 23% of the time during chest compression pauses suggesting attempts at minimizing cardiopulmonary resuscitation interruptions. The frequency of cardiopulmonary resuscitation interruptions task events was relatively constant during classic cardiopulmonary resuscitation but variable in extracorporeal cardiopulmonary resuscitation. Characterization of resuscitation tasks by video review may inform better cardiopulmonary resuscitation orchestration and efficiency.

Survival and Mid-Term Neurologic Outcome After Extracorporeal Cardiopulmonary Resuscitation in Children.

Extracorporeal cardiopulmonary resuscitation in children with refractory cardiac arrest has been shown to improve survival, however, risk factors associated with mortality and neurologic impairments are not well defined. We analyzed our recent institutional experience with pediatric extracorporeal cardiopulmonary resuscitation to identify variables associated with survival and neurocognitive outcome. Retrospective observational study. Pediatric cardiology and congenital heart surgery departments of a tertiary referral heart center. Seventy-two consecutive children (median age, 0.3 yr [0.0-1.9 yr]) who underwent extracorporeal cardiopulmonary resuscitation at our institution during the study period from 2005 to 2016. Not applicable. Median duration of resuscitation was 60 minutes (42-80 min) and median extracorporeal support duration was 5.4 days (2.2-7.9 d). Forty-three (59.7%) extracorporeal cardiopulmonary resuscitation events occurred during off-hours, however, neither duration of resuscitation (65 min [49-89 min] vs 51 min [35-80 min]; p = 0.16) nor survival (34.9% vs 37.9%; p = 0.81) differed significantly compared to working hours. Congenital heart disease was present in 84.7% of the patients. Survival to hospital discharge was 36.1%; younger age, higher lactate levels after resuscitation, acute kidney injury, renal replacement therapy, hepatic injury, and complexity of prior cardiothoracic surgical procedures were significantly associated with mortality. At mid-term follow-up (median, 4.1 yr [3.7-6.1 yr]), 22 patients (84.6% of discharge survivors) were still alive with 77.3% having a favorable neurologic outcome. High lactate levels, arrest location other than ICU, and requirement for renal replacement therapy were associated with unfavorable neurologic outcome. Interestingly, longer duration of resuscitation did not negatively impact survival or neurologic outcome. Extracorporeal cardiopulmonary resuscitation is a valuable tool for the treatment of children with refractory cardiac arrest and a favorable neurologic outcome can be achieved in the majority of survivors even after prolonged resuscitation. Mortality after extracorporeal cardiopulmonary resuscitation in postcardiac surgery children is associated with procedural complexity.

Effect of a Cardiopulmonary Resuscitation Coach on Workload During Pediatric Cardiopulmonary Arrest: A Multicenter, Simulation-Based Study.

Optimal cardiopulmonary resuscitation can improve pediatric outcomes but rarely is cardiopulmonary resuscitation performed perfectly despite numerous iterations of Basic and Pediatric Advanced Life Support. Cardiac arrests resuscitation events are complex, often chaotic environments with significant mental and physical workload for team members, especially team leaders. Our primary objective was to determine the impact of a cardiopulmonary resuscitation coach on cardiopulmonary resuscitation provider workload during simulated pediatric cardiac arrest. Multicenter observational study. Four pediatric simulation centers. Team leaders, cardiopulmonary resuscitation coach, and team members during an 18-minute pediatric resuscitation scenario. National Aeronautics and Space Administration-Task Load Index. Forty-one teams (205 participants) were recruited with one team (five participants) excluded from analysis due to protocol violation. Demographic data revealed no significant differences between the groups in regard to age, experience, distribution of training (nurse, physician, and respiratory therapist). For most workload subscales, there were no significant differences between groups. However, cardiopulmonary resuscitation providers had a higher physical workload (89.3 vs 77.9; mean difference, -11.4; 95% CI, -17.6 to -5.1; p = 0.001) and a lower mental demand (40.6 vs 55.0; mean difference, 14.5; 95% CI, 4.0-24.9; p = 0.007) with a coach (intervention) than without (control). Both the team leader and coach had similarly high mental demand in the intervention group (75.0 vs 73.9; mean difference, 0.10; 95% CI, -0.88 to 1.09; p = 0.827). When comparing the cardiopulmonary resuscitation quality of providers with high workload (average score > 60) and low to medium workload (average score < 60), we found no significant difference between the two groups in percentage of guideline compliant cardiopulmonary resuscitation (42.5% vs 52.7%; mean difference, -10.2; 95% CI, -23.1 to 2.7; p = 0.118). The addition of a cardiopulmonary resuscitation coach increases physical workload and decreases mental workload of cardiopulmonary resuscitation providers. There was no change in team leader workload.

Quality of clinical care provided during simulated pediatric cardiac arrest: a simulation-based study.

We sought to assess compliance to resuscitation guidelines during pediatric simulated cardiac arrests in a pediatric intensive care unit (PICU) and to identify performance gaps to target with future training. In a prospective observational study in a PICU, ten cardiac arrest scenarios were developed for resuscitation training and video recorded. The video recordings were examined for times to start cardiopulmonary resuscitation (CPR), delivery of first shock, CPR quality (rate, depth), length of pauses, chest compression fraction (CCF), ventilation, pulse/rhythm assessment, compressors' rotation, and leader's behaviours. The primary outcome was percentage of events compliant to Pediatric Advance Life Support guidelines. Compliance to guidelines was poor in the 23 simulation events studied. The median [interquartile range] time to start CPR was 29 [16-76] sec and 320 [245-421] sec to deliver the first shock. A total of 306 30-sec epochs of CPR were analyzed; excellent CPR (≥ 90% compressions in target for rate and depth) was achieved in 22 (7%) epochs. More than a quarter of the CPR pauses lasted > 10 seconds (33/127, 26%) with just one task performed in most of them; CCF was ≥ 80% in 19/23 (82.6%) events. Ventilation rate for intubated patients was greater than 10 breaths·min-1 in 15/27 (56%) of one-minute epochs observed. Review of simulated resuscitation events found suboptimal compliance with resuscitation guidelines, particularly the times to starting CPR and delivering the first shock, as well as compression rate and depth.

Survival and Hemodynamics During Pediatric Cardiopulmonary Resuscitation for Bradycardia and Poor Perfusion Versus Pulseless Cardiac Arrest.

The objective of this study was to compare survival outcomes and intra-arrest arterial blood pressures between children receiving cardiopulmonary resuscitation for bradycardia and poor perfusion and those with pulseless cardiac arrests. Prospective, multicenter observational study. PICUs and cardiac ICUs of the Collaborative Pediatric Critical Care Research Network. Children (< 19 yr old) who received greater than or equal to 1 minute of cardiopulmonary resuscitation with invasive arterial blood pressure monitoring in place. None. Of 164 patients, 96 (59%) had bradycardia and poor perfusion as the initial cardiopulmonary resuscitation rhythm. Compared to those with initial pulseless rhythms, these children were younger (0.4 vs 1.4 yr; p = 0.005) and more likely to have a respiratory etiology of arrest (p < 0.001). Children with bradycardia and poor perfusion were more likely to survive to hospital discharge (adjusted odds ratio, 2.31; 95% CI, 1.10-4.83; p = 0.025) and survive with favorable neurologic outcome (adjusted odds ratio, 2.21; 95% CI, 1.04-4.67; p = 0.036). There were no differences in diastolic or systolic blood pressures or event survival (return of spontaneous circulation or return of circulation via extracorporeal cardiopulmonary resuscitation). Among patients with bradycardia and poor perfusion, 49 of 96 (51%) had subsequent pulselessness during the cardiopulmonary resuscitation event. During cardiopulmonary resuscitation, these patients had lower diastolic blood pressure (point estimate, -6.68 mm Hg [-10.92 to -2.44 mm Hg]; p = 0.003) and systolic blood pressure (point estimate, -12.36 mm Hg [-23.52 to -1.21 mm Hg]; p = 0.032) and lower rates of return of spontaneous circulation (26/49 vs 42/47; p < 0.001) than those who were never pulseless. Most children receiving cardiopulmonary resuscitation in ICUs had an initial rhythm of bradycardia and poor perfusion. They were more likely to survive to hospital discharge and survive with favorable neurologic outcomes than patients with pulseless arrests, although there were no differences in immediate event outcomes or intra-arrest hemodynamics. Patients who progressed to pulselessness after cardiopulmonary resuscitation initiation had lower intra-arrest hemodynamics and worse event outcomes than those who were never pulseless.

Standardising communication to improve in-hospital cardiopulmonary resuscitation

AimRecommendations for standardised communication to reduce chest compression (CC) pauses are lacking. We aimed to achieve consensus and evaluate feasibility and efficacy using standardised communication during cardiopulmonary resuscitation (CPR) events. MethodsModified Delphi consensus process to design standardised communication elements. Feasibility was pilot tested in 16 simulated CPR scenarios (8 scenarios with physician team leaders and 8 with chest compressors) randomized (1:1) to standardised [INTERVENTION] vs. closed-loop communication [CONTROL]. Adherence and efficacy (duration of CC pauses for defibrillation, intubation, rhythm check) was assessed by audiovisual recording. Mental demand and frustration were assessed by NASA task load index subscales. ResultsConsensus elements for standardised communication included: 1) team preparation 15−30 s before CC interruption, 2) pre-interruption countdown synchronized with last 5 CCs, 3) specific action words for defibrillation, intubation, and interrupting/resuming CCs. Median (Q1,Q3) adherence to standardised phrases was 98% (80%,100%). Efficacy analysis showed a median [Q1,Q3] peri-shock pause of 5.1 s. [4.4; 5.8] vs. 7.5 s. [6.3; 8.8] seconds, p < 0.001, intubation pause of 3.8 s. [3.6; 5.0] vs. 6.9 s. [4.8; 10.1] seconds, p = 0.03, rhythm check pause of 4.2 [3.2,5.7] vs. 8.6 [5.0,10.5] seconds, p < 0.001, median frustration index of 10/100 [5,20] vs. 35/100 [25,50], p < 0.001, and median mental demand load of 55/100 [30,70] vs. 65/100 [50,85], p = 0.41 for standardised vs. closed loop communication. ConclusionThis pilot study demonstrated feasibility of using consensus-based standardised communication that was associated with shorter CC pauses for defibrillation, intubation, and rhythm checks without increasing frustration index or mental demand compared to current best practice, closed loop communication.

Early patient deaths after transfer to a regional burn center

IntroductionPatients who sustain burn injuries are frequently transferred to regional burn centers. Severely injured patients, unlikely to survive, may be transported far from home and family to die shortly after arrival. An examination of early deaths, those that happen within a week of transfer, may offer an opportunity to revise the way we think about critical burns and consider the best way to provide regional care. MethodsThis is a focused review of burn patients who survived ≤1 week after transfer to a regional center from 2013–2017. Originating location data such as city, state, population at origin were obtained. Transfer data, including mode of transport and distance traveled, as well as patient characteristics, Total Body Surface Area (TBSA) burned, inhalation injury, medical history with calculation of revised-Baux (r-Baux) score were analyzed. Results25 patients (1.2%) met inclusion criteria. Patients were transferred from a wide geographic area with population ranges of 1000 to 279,000. 21 patients met criteria for burn resuscitation by TBSA; 4 (19%) were placed on comfort care upon arrival, 7 (33%) were placed on comfort care after discussion with the patient's family, and 10 (48%) received full resuscitation efforts. Of these 10 patients, 2 died as “full code”, 8 were transitioned to comfort care after failed resuscitation or other events. Code status was not always addressed prior to the decision to transfer. Two patients were transferred after cardiac arrest in the field both of which had significant medical comorbidities in addition to their burn. ConclusionsRegional burn centers support a variety of populations. Transferring patients for which care is futile may have a profound impact on resource utilization from a variety of perspectives including transferring centers, receiving centers, regional Emergency Medical Services and families. Referring providers need to be supported in identifying these severely injured, potentially expectant patients. Transfer of patients may negatively impact families as a loved one may die far from home, before family can arrive. With our increasing ability to utilize telemedicine, transfer may not always provide the best support we can offer for providers, patients, and families. Applicability of research to practiceEarly deaths after transfer to a regional burn center, especially those that do not undergo a full resuscitation, should be critically examined to determine the appropriateness of transfer in a palliative, patient and family centered approach.

Abstract 303: The Impact of Pediatric Resuscitation Events on Overall Emergency Department Flow

Background: Pediatric resuscitation events are infrequent but resource-intensive events which pull staff, leaving higher patient:provider ratios and less access to the resources in the emergency department (ED). There is a paucity of literature on the impact of these events on overall ED flow. Objective: Use novel, prospective, comprehensive data collection to evaluate the impact of resuscitation events on the time to physician evaluation (eval) for patients arriving to the ED after a resuscitation event. Methods: Data from all resuscitation events occurring in the ED are logged prospectively. Resuscitation dates were matched to 2 control dates by census within 2 weeks and with no resuscitation events within 3 hours of time zero. A difference-in-differences evaluation compared median time to physician eval for all ED patients arriving pre and post time zero between cases and controls. Multivariate linear mixed-effects models were used to compare time to physician eval post-resuscitation between cases and controls. Results: 459 resuscitation dates were matched to 812 control dates. A higher median time to physician eval was found for cases, as compared to controls, which lasted for 2 hours after the time of the event (see Figure). A significant difference in time to physician eval post-resuscitation was found for cases (p=0.003) in multivariate models (see Table). Conclusions: Pediatric resuscitation events occurring in a large, high-resource, pediatric ED impact overall flow of the ED. Initiatives to redistribute care during resuscitation events, and evaluation of the impact of these interventions, could help ensure timely and appropriate care delivery to all ED patients.

Abstract 247: Development and Evaluation of Standardized Communication for In-Hospital Resuscitation

Background: Recommendations for “standardized” communication during cardiopulmonary resuscitation (CPR) events to reduce interruptions in chest compressions (CCs) are lacking. We aimed to achieve consensus on standardized communication during in-hospital CPR, evaluate feasibility and potential to decrease CC pauses, mental task load, and frustration. Methods: Modified Delphi consensus surveys of International Liaison Committee on Resuscitation taskforce members to identify preferred communication for in-hospital cardiac arrest teams. Consensus was reached after-survey teleconference resolution by a team of interdisciplinary experts in communication and CPR. Feasibility was tested in 8 simulated CPR scenarios with physician team leaders randomized (1:1) to ‘standardized’ communication vs. “usual best practice”, closed loop communication. Team leaders watched a 3-min video and received a 10-min training on the assigned intervention before the CPR scenario. NASA task load index questionnaires were used to assess mental task load and frustration (0=lowest to 100=highest). Results: Modified Delphi consensus on standardized communication included: 1) preparing the team 15-30 seconds before interrupting CCs, 2) countdown for interruption synchronized with 5 CCs, 3) action words for stopping and resuming CCs, 4) action words for intubation and defibrillation. Among 8 CPR teams (4 standardized, 4 usual communication), median (Q1; Q3) CC interruption duration for rhythm check was significantly shorter, 5.3 (4.8; 6.8) vs. 9.4 (6.4; 13.0) sec for standardized vs. closed loop communication [p=0.02]. Median (Q1; Q3) scores of mental task load were 63 (33; 70) vs 85 (70; 96), [p=0.10] and frustration 10 (5; 34) vs 40 (26; 50) [p=0.11] for standardized vs. closed loop communication. Trained team leaders adhered to standardized phrases 77% of the time. Conclusion: Expert consensus for standardized communication during in-hospital CPR was achieved. Pilot simulation implementation of standardized communication demonstrated feasibility of team leader adherence, significantly decreased duration of CC interruption during rhythm checks, and a tendency to reduce team leader task load and frustration.