OBJECTIVE: To determine the effect of hand position on chest compression (CC) quality during CPR in young children.

METHODS: Prospective observational exploratory study. Patients < 8 years receiving CC for > 2 minutes were enrolled. Data was collected from video review and CC monitor device and analyzed in 'CC segments' (periods of CC by individual providers). Four techniques were compared: two thumbs (2 T), hands encircling the chest; two fingers (2F) on the sternum; one hand on sternum (1H); two hands on sternum (2H). Univariate analysis of CC rate and depth between hand positions was performed through nonparametric testing, stratified by age category.

RESULTS: 47 patients received 824 minutes of CC. Among 270 CC segments in infants < 1 yo, 2 T was used in 27%; 2F 3%; 1H 18%; 2H 26%. Among 189 CC segments in children aged 1 to 8 yo, 1H was used in 26%; 2H 74%. Across all segments, median CC rate was 117 cpm (IQR 110-125). Median depth was 2.92 cm (IQR 2.44 - 4.04) in infants < 1 yo, 3.56 cm (IQR 2.92 - 4.14) in children 1 to 8 yo. 1H achieved greater depth than 2 T in infants (p < 0.01), and 2H achieved greater depth than 1H in children > 1 (p < 0.001).

CONCLUSIONS: In infants, 1H resulted in greater CC depth than 2 T. In children 1 to 8 yo, 2H resulted in greater depth than 1H.. These data suggest that different hand position during CPR in young children from what is currently recommended may result in better CPR quality.

<p><strong>Study aim: </strong>To determine the impact of high-frequency CPR training on performance during simulated and real pediatric CPR events in a pediatric emergency department (ED).</p>

<p><strong>Methods: </strong>Prospective observational study. A high-frequency CPR training program (Resuscitation Quality Improvement (RQI)) was implemented among ED providers in a children's hospital. Data on CPR performance was collected longitundinally during quarterly retraining sessions; scores were analyzed between quarter 1 and quarter 4 by nonparametric methods. Data on CPR performance during actual patient events was collected by simultaneous combination of video review and compression monitor devices to allow measurement of CPR quality by individual providers; linear mixed effects models were used to analyze the association between RQI components and CPR quality.</p>

<p><strong>Results: </strong>159 providers completed four consecutive RQI sessions. Scores for all CPR tasks during retraining sessions significantly improved during the study period. 28 actual CPR events were captured during the study period; 49 observations of RQI trained providers performing CPR on children were analyzed. A significant association was found between the number of prior RQI sessions and the percent of compressions meeting guidelines for rate (β coefficient -0.08; standard error 0.04; p = 0.03).</p>

<p><strong>Conclusions: </strong>Over a 15 month period, RQI resulted in improved performance during training sessions for all skills. A significant association was found between number of sessions and adherence to compression rate guidelines during real patient events. Fewer than 30% of providers performed CPR on a patient during the study period. Multicenter studies over longer time periods should be undertaken to overcome the limitation of these rare events.</p>

<p><strong>OBJECTIVES: </strong>To describe chest compression (CC) quality by individual providers in two pediatric emergency departments (EDs) using video review and compression monitor output during pediatric cardiac arrests.</p>

<p><strong>METHODS: </strong>Prospective observational study. Patients &lt;18 yo receiving CC for &gt;1 min were eligible. Data was collected from video review and CC monitor device in a synchronized fashion and reported in 'segments' by individual providers. Univariate comparison by age (&lt;1 yo, 1-8 yo, &gt;8 yo) was performed by chi-square testing for dichotomous variables ('high-quality' CPR) and nonparametric testing for continuous variables (CC rate and depth). Univariate comparison of ventilation rate (V) was made between segments with an advanced airway versus without.</p>

<p><strong>RESULTS: </strong>524 segments had data available; 42/524 (8%) met criteria for 'high-quality CC'. Patients &gt;8 yo had more segments meeting criteria (18% vs. 2% and 0.5%; p &lt; 0.001). Segments compliant for rate were less frequent in &lt;1 yo (17% vs. 24% vs. 27%; p = 0.03). Segments compliant for depth were less frequent in &lt;1 year olds and 1-8 year olds (5% and 9% vs. 20%, p &lt; 0.001.) Mean V for segments with an advanced airway was higher than with a natural airway (24 ± 18 vs. 14 ± 10 bpm, p &lt; 0.001). Hyperventilation was more prevalent in CPR segments with an advanced airway (66% vs. 32%, p &lt; 0.001).</p>

<p><strong>CONCLUSIONS: </strong>CC depth is rarely guideline compliant in infants. Hyperventilation is more prevalent during CPR periods with an advanced airway in place. Measuring individual provider CPR quality is feasible, allowing future studies to evaluate the impact of CPR training.</p>

<p>Within the context of the coronavirus disease 2019 (COVID-19) pandemic, minimizing health care worker exposure to the novel coronavirus has become a paramount part of the provision of health care in all settings across the world. Limited supply of personal protective equipment, personnel shortages as a result of exposure, and ensuring the safety and health of workers have all dictated the need to minimize the number of health care workers with direct patient contact. In resuscitation events, there is high likelihood of multiple aerosol-generating procedures and increased risk of viral transmission; therefore, limiting personnel is of particular importance. The development of creative solutions to allow vital team contributions to occur outside of the direct patient care space whenever possible is critical.</p>

<p><strong>OBJECTIVES: </strong>High-quality clinical research of resuscitations in a pediatric emergency department is challenging because of the limitations of traditional methods of data collection (chart review, self-report) and the low frequency of cases in a single center. To facilitate valid and reliable research for resuscitations in the pediatric emergency department, investigators from 3 pediatric centers, each with experience completing successful single-center, video-based studies, formed the Videography In Pediatric Emergency Research (VIPER) collaborative.</p>

<p><strong>METHODS: </strong>Our initial effort was the development of a multicenter, video-based registry and simulation-based testing of the feasibility and reliability of the VIPER registry. Feasibility of data collection was assessed by the frequency of an indeterminate response for all data elements in the registry. Reliability was assessed by the calculation of Cohen κ for dichotomous data elements and intraclass correlation coefficients for continuous data elements.</p>

<p><strong>RESULTS: </strong>Video-based data collection was completed for 8 simulated pediatric resuscitations, with at least 2 reviewers per case. Data were labeled as indeterminate by at least 1 reviewer for 18 (3%) of 524 relevant data fields. The Cohen κ for all dichotomous data fields together was 0.81 (95% confidence interval, 0.61-1.0). For all continuous (time-based) variables combined, the intraclass correlation coefficient was 0.88 (95% confidence interval, 0.70-0.96).</p>

<p><strong>CONCLUSIONS: </strong>Initial simulation-based testing suggests video-based data collection using the VIPER registry is feasible and reliable. Our next step is to assess feasibility and reliability for actual pediatric resuscitations and to complete several prospective, hypothesis-based studies of specific aspects of resuscitative care, including of cardiopulmonary resuscitation, tracheal intubation, and teamwork and communication.</p>

<p><strong>OBJECTIVE: </strong>Minimizing pauses in chest compressions during cardiopulmonary resuscitation (CPR) is recommended by the American Heart Association (AHA) and is associated with improved patient outcomes. We studied the quality of pediatric CPR performed in a tertiary pediatric emergency department (ED) with a focus on pauses in chest compressions.</p>

<p><strong>METHODS: </strong>We conducted an observational study of CPR quality in two pediatric EDs using video review during pediatric cardiac arrest. Events were reviewed for AHA guideline adherence. Parameters of CPR performance were described according to individual compressor segment. Pauses in compressions were analyzed for duration and pause activities.</p>

<p><strong>RESULTS: </strong>From a 30-month period, 81 cardiac arrests were analyzed, including 1003 individual compressor segments and 900 pauses. Median chest compression fraction was 91%, with a median pause duration of 4 s (IQR 2, 10); 22% of pauses were prolonged (&gt;10 s). Pulse checks occurred in 23% of pauses; 62% were prolonged. Checking a single pulse site (p &lt; 0.001) and having fingers ready pre-pause (p = 0. 001) were associated with significantly shorter pause duration. Pause duration was correlated with the number of pause tasks (r = 0.559, p &lt; 0.001). "Coordinated pauses" (pulse check, rhythm check and compressor change) were rare (6%) and long in duration (19 s; IQR 11, 30).</p>

<p><strong>CONCLUSIONS: </strong>Prolonged pauses in chest compressions occurred frequently during CPR and were associated with pulse checks and multiple simultaneous tasks. Checking a single pulse site with fingers ready on the pulse site pre-pause could decrease pause duration and improve CPR quality.</p>

PURPOSE OF REVIEW: The pediatric resuscitation environment is a high-stakes, environment in which a multidisciplinary team must work together with patient outcomes dependent, at least in part, on the performance of that team. Given constraints of the environment and the nature of these events, quality improvement work in pediatric resuscitation can be challenging. Ongoing collection of accurate and reliable data on team performance is necessary to inform and evaluate change.

RECENT FINDINGS: Despite the relative difficulty of quality improvement analysis and intervention implementation in the resuscitation environment, these efforts can have significant impact on patient outcomes. Although there are barriers to accurate data collection in real-life resuscitation, team performance of both technical and nontechnical skills can be reliably measured in video-based quality improvement programs. Training of nontechnical skills, using crisis resource management principles, can improve care delivery in resuscitation.

SUMMARY: Striving toward a learning healthcare system model in resuscitation care delivery can allow for efficient performance improvement. Given the possible impacts on mortality and quality of life of care delivered in the resuscitation environment, all providers who could possibly face a resuscitation event - no matter how rare - should consider how they are evaluating the quality of their care delivery in this arena.

<p><strong>PURPOSE OF REVIEW: </strong>The pediatric resuscitation environment is a high-stakes, environment in which a multidisciplinary team must work together with patient outcomes dependent, at least in part, on the performance of that team. Given constraints of the environment and the nature of these events, quality improvement work in pediatric resuscitation can be challenging. Ongoing collection of accurate and reliable data on team performance is necessary to inform and evaluate change.</p>

<p><strong>RECENT FINDINGS: </strong>Despite the relative difficulty of quality improvement analysis and intervention implementation in the resuscitation environment, these efforts can have significant impact on patient outcomes. Although there are barriers to accurate data collection in real-life resuscitation, team performance of both technical and nontechnical skills can be reliably measured in video-based quality improvement programs. Training of nontechnical skills, using crisis resource management principles, can improve care delivery in resuscitation.</p>

<p><strong>SUMMARY: </strong>Striving toward a learning healthcare system model in resuscitation care delivery can allow for efficient performance improvement. Given the possible impacts on mortality and quality of life of care delivered in the resuscitation environment, all providers who could possibly face a resuscitation event - no matter how rare - should consider how they are evaluating the quality of their care delivery in this arena.</p>

<p><strong>OBJECTIVES: </strong>To describe the frequency, characteristics, and outcomes of heart failure-related emergency department (ED) visits in pediatric patients. We aimed to test the hypothesis that these visits are associated with higher admission rates, mortality, and resource utilization.</p>

<p><strong>STUDY DESIGN: </strong>A retrospective analysis of the Nationwide Emergency Department Sample for 2010 of patients ≤18 years of age was performed to describe ED visits with and without heart failure. Cases were identified using International Classification of Disease, Ninth Revision, Clinical Modification codes and assessed for factors associated with admission, mortality, and resource utilization.</p>

<p><strong>RESULTS: </strong>Among 28.6 million pediatric visits to the ED, there were 5971 (0.02%) heart failure-related cases. Heart failure-related ED patients were significantly more likely to be admitted (59.8% vs 4.01%; OR 35.3, 95% CI 31.5-39.7). Among heart failure-related visits, admission was more common in patients with congenital heart disease (OR 5.0, 95% CI 3.3-7.4) and in those with comorbidities including respiratory failure (OR 78.3, 95% CI 10.4-591) and renal failure (OR 7.9, 95% CI 1.7-36.3). Heart failure-related cases admitted to the hospital had a higher likelihood of death than nonheart failure-related cases (5.9% vs 0.32%, P &lt; .001). Factors associated with mortality included respiratory failure (OR 4.5, 95% CI 2.2-9.2) and renal failure (OR 7.8, 95% CI 2.9-20.7). Heart failure-related ED visits were more expensive than nonheart failure-related ED visits ($1460 [IQR $861-2038] vs $778 [IQR $442-1375] [P &lt; .01].)</p>

<p><strong>CONCLUSIONS</strong>: Heart failure-related visits represent a minority of pediatric ED visits but are associated with increased hospital admission and resource utilization.</p>