<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><strong>BACKGROUND: </strong>The coronavirus disease 2019 pandemic has challenged hospitals and pediatric emergency department (PED) providers to rapidly adjust numerous facets of the care of critically ill or injured children to minimize health care worker (HCW) exposure to severe acute respiratory syndrome coronavirus 2.</p>

<p><strong>OBJECTIVE: </strong>We aimed to iteratively devise protocols and processes that minimized HCW exposure while safely and effectively caring for children who may require unanticipated aerosol-generating procedures.</p>

<p><strong>METHODS: </strong>As part of our PED's initiative to optimize clinical care and HCW safety during the coronavirus disease 2019 pandemic, regular multidisciplinary systems and process simulation sessions were conducted. These sessions allowed us to evaluate and reorganize patient flow, test and improve communication modalities, alter the process for consultation in resuscitations, and teach and reinforce the appropriate donning and use of personal protective equipment.</p>

<p><strong>RESULTS: </strong>Simulation was a highly effective method to disseminate new practices to PED staff. Numerous workflow modifications were implemented as a result of our in situ systems and process simulations. Total number of persons in the resuscitation room was minimized, use of a "command post" with remote providers was initiated, communication devices and strategies were trialed and adopted, and personal protective equipment standards that optimized HCW safety and communication were enacted.</p>

<p><strong>CONCLUSIONS: </strong>Simulation can be an effective and agile tool in restructuring patient workflow and care of the most critically ill or injured patients in a PED during a novel pandemic.</p>

<p><strong>OBJECTIVE: </strong>To characterize the cohort of missed sepsis patients since implementation of an electronic sepsis alert in a pediatric emergency department (ED).</p>

<p><strong>METHODS: </strong>Retrospective cohort study in a tertiary care children's hospital ED from July 1, 2014, to June 30, 2017. Missed patients met international consensus criteria for severe sepsis requiring intensive care unit admission within 24 hours of ED stay but were not treated with the sepsis pathway/order set in the ED. We evaluated characteristics of missed patients compared with sepsis pathway patients including alert positivity, prior intensive care unit admission, and laboratory testing via medical record review. Outcomes included timeliness of antibiotic therapy and need for vasoactive medications.</p>

<p><strong>RESULTS: </strong>There were 919 sepsis pathway patients and 53 (5%) missed patients during the study period. Of the missed patients, 41 (77%) had vital signs that flagged the sepsis alert. Of these 41 patients, 13 (32%) had a documented sepsis huddle where the team determined that the sepsis pathway was not indicated and 28 (68%) had no sepsis alert-related documentation. Missed patients were less likely to receive timely antibiotics (relative risk, 0.4; 95% confidence interval, 0.3-0.7) and more likely to require vasoactive medications (relative risk, 4.3; 95% confidence interval, 2.9-6.5) compared with sepsis patients.</p>

<p><strong>CONCLUSIONS: </strong>In an ED with an electronic sepsis alert, missed patients often had positive sepsis alerts but were not treated for sepsis. Missed patients were more likely than sepsis pathway patients to require escalation of care after admission and less likely to receive timely antibiotics.</p>

<p><strong>OBJECTIVES: </strong>To compare timeliness of sepsis recognition and initial treatment in patients with and without high-risk comorbid conditions.</p>

<p><strong>METHODS: </strong>This was a retrospective cohort study of patients presenting to a pediatric emergency department (ED) who triggered a vital sign-based electronic sepsis alert resulting in bedside "huddle" assessment per institutional practice. A positive sepsis alert was defined as age-specific tachycardia or hypotension, concern for infection, and at least 1 of the following: abnormal capillary refill, abnormal mental status, or a high-risk condition. High-risk conditions were derived from the American Academy of Pediatrics sepsis alert tool. Patients with a positive alert underwent bedside huddle resulting in a decision regarding initiation of sepsis protocol. Placement on the protocol and time to initiation of protocol and individual therapies were compared for patients with and without high-risk conditions.</p>

<p><strong>RESULTS: </strong>During the 1-year study period, there were 1107 sepsis huddle alerts out of 96,427 ED visits. Of these, 713 (65%) had identified high-risk conditions, and 394 (35%) did not. Among patients with sepsis huddles, there was no difference in sepsis protocol initiation for patients with high-risk conditions compared with those without (24.8% vs 22.0%, P = 0.305). Between patients with high-risk conditions and those without, there were no differences in median time from triage to sepsis protocol activation, triage to initial intravenous antibiotic, triage to initial intravenous fluid therapy, or ED length of stay.</p>

<p><strong>CONCLUSIONS: </strong>Timeliness of care initiation was no different in high-risk patients with sepsis when using an electronic sepsis alert and protocolized sepsis care.</p>