June 8, 2009

Mock CPR drills in kids show many residents fail in key skills

Research from the Johns Hopkins Children’s Center exposes alarming gaps in training hospital residents in “first response” emergency treatment of staged cardiorespiratory arrests in children, while at the same time offering a potent recipe for fixing the problem.

The research was conducted just before the release of the 2005 American Heart Association’s practice guidelines focusing on strengthening first-response skills, timing that suggests that at least some of the findings in the study may paint a grimmer picture than current reality, researchers say. Changes already made to the Johns Hopkins resident training program beginning in 2005 have resulted in significant improvement, they add.

The Johns Hopkins study, now available online and to be published in the July print issue of the journal Resuscitation, revealed critical mistakes during lifesaving maneuvers like chest compressions and defibrillations in children undergoing arrests, or “codes” as they are medically known.

Staging mock cardiopulmonary arrests with life-size dummies, researchers observed that of the 70 residents participating in the drills, one-third (24) never started chest compressions, while two- thirds (46) did so with a delay of more than one minute, the critical cutoff time to initiate compressions in a child without a pulse. Nearly half the residents (46 percent) failed to restore heart rhythm using a defibrillator within the recommended three minutes. Timely resuscitation of a child whose breathing or heartbeat has stopped is, of course, critical to prevent permanent brain damage and death.

Because most arrests in children are caused by respiratory rather than cardiac problems, pediatric life-support training in most teaching hospitals traditionally has emphasized airway rather than heart maneuvers to resuscitate a lifeless child. But in a patient without a pulse, airway maneuvers will work only if used together with chest compressions to circulate the blood, investigators say. Therefore, the Johns Hopkins team calls for a shift in focus that would equally emphasize cardiac maneuvers along with airway ventilation.

The findings, even though not necessarily applicable to other teaching hospitals, suggest the need for an honest examination of the way academic programs across the country train pediatric residents to deliver life support during cardiopulmonary arrests.

“We’re firm believers in the idea that only by identifying our weaknesses can we know exactly how and when we can improve care,” said lead investigator Elizabeth Hunt, a critical-care specialist at Hopkins Children’s.

“This has been a sobering experience,” she said, noting that no one likes to have problems exposed, but without the courage to gather evidence about what really is working and what is not, change won’t happen.

Hunt said the solution to the problem has so far proved relatively simple: Practice, practice, practice with simulated arrests, and strict measurement of results to increase skills and speed of response.

Hands-on training including monthly mock drills on pediatric units and simulations with child manikins–like those staged by the Johns Hopkins researchers–appear to dramatically improve fledgling doctors’ performance, according to preliminary and not-yet-published reports.

While length of residency training (first, second or third year) did not make much difference in performance in the study, experience in performing resuscitation did. The results show that residents who had even once used a defibrillator–either during a drill or in a real patient–were 87 percent more likely to successfully restore heartbeat during the exercise than those who had never used the lifesaving device. Making the residents practice all the steps required to defibrillate, rather than just watching a training video of someone else doing so, was the key to success. “There’s no substitute for practice,” said Hunt, who is also the director of the Johns Hopkins Medicine Simulation Center.

The study also demonstrates the importance of monitoring performance, the researchers say.

Senior investigator Peter Pronovost, a critical care specialist at Johns Hopkins and an internationally renowned expert on patient safety, said, “Simply taking a course is likely not enough to ensure adequate performance. We must couple hands-on training with monitoring. After all, patients’ lives depend on it.”

Past research shows that 14 percent of all arrests in hospitalized children are cardiac in origin, and many respiratory arrests quickly evolve into cardiac arrests. More than one-quarter of all arrests in children involve heart rhythm abnormalities that require use of a defibrillator to shock the heart into normal rhythm.

“The prevailing wisdom of focusing on ventilation rather than circulation during pediatric arrests is well-founded, but it may have caused the pendulum to swing too far,” Pronovost said. “We must restore the balance and start paying attention to circulation and heart rhythm maneuvers and teach future pediatricians [that] these are equally important.”

The Johns Hopkins curriculum has already augmented its basic life-support courses, and advanced life-support courses are required for all residents, with monthly mock codes on pediatric units and monthly resuscitation sessions using simulator life-size dummies, training that provides hands-on experience and helps residents learn how to communicate during a crisis.

Previous studies have shown that only 14 percent to 36 percent of children who suffer an arrest in the hospital survive. Even though the absolute number of deaths is quite small, the few deaths that do occur can be averted by strengthening first-responder instincts in residents, as well as in other hospital staff.

Co-investigators in the study are Kimberly Vera, Marie Diener-West, Jamie Haggerty, Kristen Nelson and Donald Shaffner, all of Johns Hopkins.