A Simulation for Pediatric Cardiac Arrest

It’s tough to assess the absolute risk of SARS-CoV-2 transmission during cardiac resuscitation, but the evidence suggests it’s wise to consider it an aerosol-generating procedure – and to take appropriate precautions. But those precautions also risk throwing already chaotic procedures even deeper into confusion. At Children’s Hospital Colorado, thanks to a simple measure implemented long before the pandemic, the Emergency Department’s cardiac resuscitation team was able to adapt to the COVID-19 paradigm without missing a beat.

Cardiopulmonary resuscitation, or CPR, is pretty simple in theory: open the airway, chest compressions, rescue breaths. In practice, it’s well known that the actual effectiveness of CPR declines almost immediately after training.

It takes practice. A lot of it.

In pediatrics, even in the Emergency Department, practice is hard to get. Pediatric cardiac arrest just doesn’t happen that often, and children’s rates of return to spontaneous circulation (or ROSC rates) trail those of adults by statistically significant margins.

“In 2016, we started doing high-frequency, low-fidelity cardiac arrest simulations,” says pediatric emergency medicine specialist Tara Neubrand, MD. “For the last 30 months we’ve been able to maintain ROSC rates of greater than 97%.”

Effective team training for CPR events

It happens four times a week, twice for day shift and twice for night shift. The CPR team assembles around a low-fidelity manikin and a defibrillator and spends five minutes running a simulation of cardiac arrest. They’ve done it a thousand times. Which is exactly why it works.

CPR is a low-frequency, high-stress procedure that requires several people working together. Everyone needs to know their role. A quick simulation, actively practiced, means everyone in their room knows exactly where to stand, what to do and how to communicate with each other in advance.

“This project is really focused on effective team training, and the first step was recruiting a dynamic multidisciplinary team to help effect and implement change,” says Dr. Neubrand. “The result has been not only a vast improvement in outcomes, but improvements in emergency medical tech and nurse satisfaction, resiliency, ability to understand codes, all sorts of things.”

A model of team CPR simulation

One of the first recruits was pediatric nurse Stacey Coss, RN, MSN, who helped to build communication practices into the simulations. They’ve since expanded the model from Anschutz Medical Campus to all four emergency rooms within Children’s Colorado’s System of Care.

Of course, the model works best for in-hospital cardiac arrest, where the team can immediately take their positions and jump into action. When a patient shows up with no known medical history and may have been in cardiac arrest for 20 minutes beforehand, good outcomes are exponentially more difficult to achieve.

Even then the team posts comparatively stellar ROSC rates. Nationally it’s around 10%. Children’s Colorado’s rate is 23%.

Adapting CPR simulation to the COVID-19 paradigm

The COVID-19 pandemic changed the way hospitals operate, and emergency departments were no exception. In fact, in many ways, nowhere have the effects been more pronounced.

“We not only had to reorganize the physical structure of our trauma rooms,” says Dr. Neubrand. “We had to reorganize the personnel structures required to care for critically ill patients. How do we don and doff, limit people in the room, communicate with people outside the room?”

Nevertheless, from the initial spike in early 2020 through the many spikes, plateaus and dips since, the pandemic has failed to make a dent in the team’s ROSC rates.

Cardiac resuscitation as team sport

Resuscitation is a team sport,” Dr. Neubrand notes. “We’ve worked hard to make sure our teams have the tools to perform consistently at a high level, and that’s been incredibly important for our morale as we’ve weathered multiple rounds of COVID surges.”

The work continues. Even with rehearsal, cardiac events are chaotic and difficult to review objectively, Dr. Neubrand and her team are part of the Videography in Pediatric Emergency Research (or VIPER) Collective, dedicated to establishing a validated model of video review for resuscitation events in pediatric emergency departments. So far, that collective includes Cincinnati Children’s Hospital, Children’s National Medical Center and Children’s Hospital of Philadelphia. Over time, that work may yield insights that could improve outcomes even more.

“The innovative thing is the simplicity of it,” says Dr. Neubrand. “It took a lot of work and buy-in from staff, and it’s something we need to do consistently, but it’s given us a built-in platform to take those needed process changes and implement them quickly, and that makes us nimble and responsive to change.”