Evaluation of the Neonatal Resuscitation Program\u27s Recommended Chest Compression Depth Using Computerized Tomography Imaging.

BACKGROUND: Neonatal Resuscitation Program (NRP) guidelines recommend chest compression depths of 1/3 the anterior-posterior (AP) chest depth. Appropriateness of this recommendation has not been rigorously assessed. OBJECTIVE: To compare the efficacy and safety of neonatal chest compression depths of 1/4, 1/3, and 1/2 AP chest depth during cardiopulmonary resuscitation. DESIGN/METHODS: Anterior-posterior internal and external chest depth, heart dimensions, and non-cardiac thoracic tissue depth were measured from neonatal chest CTs. Using these measurements, residual internal chest depth, the remaining depth of the chest between the sternum and spine after external compression, was calculated for compression depths of 1/4, 1/3 and 1/2 anterior-posterior chest depth. Compression sufficient to compress the chest tomodel, an estimated ejection fraction (EF) was calculated for each chest compression depth. Compression inadequate to obtain a predicted 50% EF was defined as under-compression. Descriptive statistics, Fisher\u27s exact test and Student\u27s t-test were used to analyze data, where appropriate. RESULTS: Fifty-four neonatal chest CT scans were evaluated. Estimated chest compression induced EF increased incrementally with increasing chest compression depth (EF was 51+/-3% with 1/4 AP chest depth vs 69+/-3% with 1/3 AP chest depth, and 106% with 1/2 AP chest depth, p CONCLUSIONS: Mathematical modeling based upon neonatal chest CT scan dimensions suggests that current NRP chest compression recommendations of 1/3 AP chest depth should be more effective than 1/4 compression depth, and safer than 1/2 AP compression depth

Effect of mattress deflection on CPR quality assessment for older children and adolescents

Appropriate chest compression (CC) depth is associated with improved CPR outcome. CCs provided in hospital are often conducted on a compliant mattress. The objective was to quantify the effect of mattress compression on the assessment of CPR quality in children. Methods: A force and deflection sensor (FDS) was used during CPR in the Pediatric Intensive Care Unit and Emergency Department of a children's hospital. The sensor was interposed between the chest of the patient and hands of the rescuer and measured CC depth. Following CPR event, each event was reconstructed with a manikin and an identical mattress/backboard/patient configuration. CCs were performed using FDS on the sternum and a reference accelerometer attached to the spine of the manikin, providing a means to Calculate the mattress deflection. Results: Twelve CPR events with 14,487 CC (11 patients, median age 14.9 years) were recorded and reconstructed: 9 on ICU beds (9296 CC), 3 on stretchers (5191 CC). Measured mean CC depth during CPR was 47 +/- 8 mm on ICU beds, and 45 +/- 7 mm on stretcher beds with overestimation of 13 +/- 4 mm and 4 +/- 1 mm, respectively, due to mattress compression. After adjusting for this, the proportion of CC that met the CPR guidelines decreased from 88.4 to 31.8% on ICU beds (p < 0.001), and 86.3 to 64.7% on stretcher (p < 0.001 The proportion of appropriate depth CC was significantly smaller on ICU beds (p < 0.001). Conclusion: CC conducted on a non-rigid surface may not be deep enough. FDS may overestimate CC depth by 28% on ICU beds, and 10% on stretcher beds

Community-based in situ simulation: bringing simulation to the masses

Simulation-based methods are regularly used to train inter-professional groups of healthcare providers at academic medical centers (AMC). These techniques are used less frequently in community hospitals. Bringing in-situ simulation (ISS) from AMCs to community sites is an approach that holds promise for addressing this disparity. This type of programming allows academic center faculty to freely share their expertise with community site providers. By creating meaningful partnerships community-based ISS facilitates the communication of best practices, distribution of up to date policies, and education/training. It also provides an opportunity for system testing at the community sites. In this article, we illustrate the process of implementing an outreach ISS program at community sites by presenting four exemplar programs. Using these exemplars as a springboard for discussion, we outline key lessons learned discuss barriers we encountered, and provide a framework that can be used to create similar simulation programs and partnerships. It is our hope that this discussion will serve as a foundation for those wishing to implement community-based, outreach ISS

Differences in the Quality of Pediatric Resuscitative Care Across a Spectrum of Emergency Departments

Importance: The quality of pediatric resuscitative care delivered across the spectrum of emergency departments (EDs) in the United States is poorly described. In a recent study, more than 4000 EDs completed the Pediatric Readiness Survey (PRS); however, the correlation of PRS scores with the quality of simulated or real patient care has not been described. Objective: To measure and compare the quality of resuscitative care delivered to simulated pediatric patients across a spectrum of EDs and to examine the correlation of PRS scores with quality measures. Design, Setting, and Participants: This prospective multicenter cohort study evaluated 58 interprofessional teams in their native pediatric or general ED resuscitation bays caring for a series of 3 simulated critically ill patients (sepsis, seizure, and cardiac arrest). Main Outcomes and Measures: A composite quality score (CQS) was measured as the sum of 4 domains: (1) adherence to sepsis guidelines, (2) adherence to cardiac arrest guidelines, (3) performance on seizure resuscitation, and (4) teamwork. Pediatric Readiness Survey scores and health care professional demographics were collected as independent data. Correlations were explored between CQS and individual domain scores with PRS. Results: Overall, 58 teams from 30 hospitals participated (8 pediatric EDs [PEDs], 22 general EDs [GEDs]). The mean CQS was 71 (95% CI, 68-75); PEDs had a higher mean CQS (82; 95% CI, 79-85) vs GEDs (66; 95% CI, 63-69) and outperformed GEDs in all domains. However, when using generalized estimating equations to estimate CQS controlling for clustering of the data, PED status did not explain a higher CQS (beta = 4.28; 95% CI, -4.58 to 13.13) while the log of pediatric patient volume did explain a higher CQS (beta = 9.57; 95% CI, 2.64-16.49). The correlation of CQS to PRS was moderate (r = 0.51; P \u3c .001). The correlation was weak for cardiac arrest (r = 0.24; P = .07), weak for sepsis (rho = 0.45; P \u3c .001) and seizure (rho = 0.43; P = .001), and strong for teamwork (rho = 0.71; P \u3c .001). Conclusions and Relevance: This multicenter study noted significant differences in the quality of simulated pediatric resuscitative care across a spectrum of EDs. The CQS was higher in PEDs compared with GEDs. However, when controlling for pediatric patient volume and other variables in a multivariable model, PED status does not explain a higher CQS while pediatric patient volume does. The correlation of the PRS was moderate for simulation-based measures of quality

International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC).

BACKGROUND: Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children. METHODS: Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document. RESULTS: Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C). CONCLUSIONS: Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available

International consensus conference recommendations on ultrasound education for undergraduate medical students

Objectives: The purpose of this study is to provide expert consensus recommendations to establish a global ultrasound curriculum for undergraduate medical students. Methods: 64 multi-disciplinary ultrasound experts from 16 countries, 50 multi-disciplinary ultrasound consultants, and 21 medical students and residents contributed to these recommendations. A modified Delphi consensus method was used that included a systematic literature search, evaluation of the quality of literature by the GRADE system, and the RAND appropriateness method for panel judgment and consensus decisions. The process included four in-person international discussion sessions and two rounds of online voting. Results: A total of 332 consensus conference statements in four curricular domains were considered: (1) curricular scope (4 statements), (2) curricular rationale (10 statements), (3) curricular characteristics (14 statements), and (4) curricular content (304 statements). Of these 332 statements, 145 were recommended, 126 were strongly recommended, and 61 were not recommended. Important aspects of an undergraduate ultrasound curriculum identified include curricular integration across the basic and clinical sciences and a competency and entrustable professional activity-based model. The curriculum should form the foundation of a life-long continuum of ultrasound education that prepares students for advanced training and patient care. In addition, the curriculum should complement and support the medical school curriculum as a whole with enhanced understanding of anatomy, physiology, pathophysiological processes and clinical practice without displacing other important undergraduate learning. The content of the curriculum should be appropriate for the medical student level of training, evidence and expert opinion based, and include ongoing collaborative research and development to ensure optimum educational value and patient care. Conclusions: The international consensus conference has provided the first comprehensive document of recommendations for a basic ultrasound curriculum. The document reflects the opinion of a diverse and representative group of international expert ultrasound practitioners, educators, and learners. These recommendations can standardize undergraduate medical student ultrasound education while serving as a basis for additional research in medical education and the application of ultrasound in clinical practice

Effect of mattress deflection on CPR quality assessment for older children and adolescents

Appropriate chest compression (CC) depth is associated with improved CPR outcome. CCs provided in hospital are often conducted on a compliant mattress. The objective was to quantify the effect of mattress compression on the assessment of CPR quality in children. Methods: A force and deflection sensor (FDS) was used during CPR in the Pediatric Intensive Care Unit and Emergency Department of a children's hospital. The sensor was interposed between the chest of the patient and hands of the rescuer and measured CC depth. Following CPR event, each event was reconstructed with a manikin and an identical mattress/backboard/patient configuration. CCs were performed using FDS on the sternum and a reference accelerometer attached to the spine of the manikin, providing a means to Calculate the mattress deflection. Results: Twelve CPR events with 14,487 CC (11 patients, median age 14.9 years) were recorded and reconstructed: 9 on ICU beds (9296 CC), 3 on stretchers (5191 CC). Measured mean CC depth during CPR was 47 +/- 8 mm on ICU beds, and 45 +/- 7 mm on stretcher beds with overestimation of 13 +/- 4 mm and 4 +/- 1 mm, respectively, due to mattress compression. After adjusting for this, the proportion of CC that met the CPR guidelines decreased from 88.4 to 31.8% on ICU beds (p < 0.001), and 86.3 to 64.7% on stretcher (p < 0.001 The proportion of appropriate depth CC was significantly smaller on ICU beds (p < 0.001). Conclusion: CC conducted on a non-rigid surface may not be deep enough. FDS may overestimate CC depth by 28% on ICU beds, and 10% on stretcher beds