Article
Reference
CPR coaching during cardiac arrest improves adherence to PALS guidelines: a prospective, simulation-based trial
BUYCK, Michael, et al.
Abstract
Recent studies have shown that the integration of a trained cardiopulmonary resuscitation (CPR) Coach during resuscitation enhances the quality of CPR during simulated paediatric cardiac arrest. The objective of our study was to evaluate the effect of a CPR Coach on adherence to Paediatric Advanced Life Support (PALS) guidelines during simulated paediatric cardiac arrest.
BUYCK, Michael, et al . CPR coaching during cardiac arrest improves adherence to PALS guidelines: a prospective, simulation-based trial. Resuscitation plus , 2021, vol. 5, p. 100058
DOI : 10.1016/j.resplu.2020.100058 PMID : 34223330
PMCID : PMC8244489
Available at:
http://archive-ouverte.unige.ch/unige:155049
Disclaimer: layout of this document may differ from the published version.
1 / 1
Simulation and education
CPR coaching during cardiac arrest improves adherence to PALS guidelines: a prospective, simulation-based trial
Michael Buyck
a,b,*, Yasaman Shayan
a,b, Jocelyn Gravel
a,b, Elizabeth A. Hunt
c, Adam Cheng
d, Arielle Levy
a,baDepartmentofPediatricEmergencyMedicine,Sainte-JustineHospitalUniversityCentre,3175ChemindelaCoˆte-Sainte-Catherine,Montreal, Que´bec,H3T1C5,Canada
bUniversite´ deMontreal,Montreal,Que´bec,Canada
cDepartmentsofAnesthesiologyandCriticalCareMedicine,PediatricsandHealthInformatics,JohnsHopkinsUniversitySchoolofMedicine, Baltimore,Maryland,UnitedStates
dDepartmentsofPediatricsandEmergencyMedicine,UniversityofCalgary,Calgary,Canada
Abstract
Aim:Recentstudieshaveshownthattheintegrationofatrainedcardiopulmonaryresuscitation(CPR)Coachduringresuscitationenhancesthequality ofCPRduringsimulatedpaediatriccardiacarrest.TheobjectiveofourstudywastoevaluatetheeffectofaCPRCoachonadherencetoPaediatric AdvancedLifeSupport(PALS)guidelinesduringsimulatedpaediatriccardiacarrest.
Methods:ThiswasasecondaryanalysisofdatacollectedfromamulticentrerandomizedcontrolledtrialassessingthequalityofCPRinteamswithand withoutaCPRCoach.Fortypaediatricresuscitationteamswereequallyrandomizedinto2groups(withorwithoutaCPRCoach).Theprimaryoutcome wasadherencetoPALSguidelinesduringasimulatedpaediatriccardiacarrestcaseasmeasuredbytheClinicalPerformanceTool(CPT).Video recordingswereassignedto2pairsofexpertraters.Ratersweretrainedtoindependentlyscoreperformancesusingthetool.
Results:ThereliabilityoftheratingwasadequatefortheClinicalPerformanceToolwithanintraclasscoefficientsof0.67(95%CI:0.22to0.84).
Performancescoresofthedifferentteamsvariedbetween51and84pointsontheClinicalPerformanceToolwithameanscoreof70.TeamswithaCPR CoachdemonstratedbetteradherencetoPALSguidelines(i.e.CPTscore73points)comparedtoteamswithoutaCPRCoach(68points,difference5 points;95%CI:1.0 9.3,p =0.016).
Conclusion:InadditiontoimprovingCPRquality,thepresenceofaCPRCoachimprovesadherencetoPALSguidelinesduringsimulatedpaediatric cardiacarrestswhencomparedwithteamswithoutaCPRCoach.
Keywords:Pediatric,Emergency,Simulation,PALS,Resuscitation,CPR,CPRcoach
Introduction
PaediatricteamsstruggleprovidingguidelinecompliantCardiopul- monary resuscitation (CPR) during cardiac arrest.1,2 Strategies
implemented to enhance CPR quality, include simulation-based training,3CPRfeedbackdevices,4andintegrationofaCPRCoach.5,6 TheCPRCoachisarolecreatedatTheJohnsHopkinsHospitalin 2007anditerativelyrefinedoverthepastdecadeasreportedbyHunt etal.5TheprimaryobjectivesoftheCPRCoacharetoensurehigh
* Correspondingauthor.
E-mailaddresses:[email protected](M.Buyck),[email protected](Y.Shayan),[email protected](J.Gravel), [email protected](E.A. Hunt),[email protected](A.Cheng),[email protected](A.Levy).
http://dx.doi.org/10.1016/j.resplu.2020.100058
Received14September2020;Receivedinrevisedform12November2020;Accepted20November2020
2666-5204/©2020TheAuthors.PublishedbyElsevierB.V.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/
licenses/by-nc-nd/4.0/).
Availableonlineatwww.sciencedirect.com
Resuscitation Plus
journalhomepage:www.journals.elsevier.com/resuscitation-plus
qualityBasic Life Support orCPR and to cognitively unload the resuscitationleadersotheycanconcentrateonthemorecomplex components of a resuscitation, such as: rhythm recognition, identifying and following the advanced life support algorithm, diagnosingandtreatingreversiblecauses,andcommunicatingwith thefamily.
In additionto optimizingCPR delivery,adhering toPaediatric Advanced Life Support (PALS) guidelines is essential. Critical interventionsin paediatricresuscitation such asadvancedairway ventilation, cardiac rhythm recognition and adequate treatment (defibrillation and/or epinephrine) have shown to add substantial survivalbenefitin theadultpopulation.7Inaddition,adherence to PALSguidelinesisassociatedwithimprovedneurologicaloutcomes and survivalin children,8 though simulationstudies reveal major deviationsinadherencetoPALS.9Thebroadrangeofpatientsizes require variations in equipment size and medication doses that createsacognitiveloaduniquetomanagingchildren.10Foryears, cognitiveaidshavebeenrecommended11butshowedpoorefficacy12 supportingtheneedfora“humancognitiveaid”.ACPRCoachmight beconsideredahumancognitiveaid,astheteamleaderisrelievedof tasks, leaving more cognitive space for advanced clinical performance.5,13
CPRcoachingisassociatedwithimprovedCPRquality,butits’ effectongeneralclinicalperformanceinpaediatriccardiacarresthas notbeenevaluated.
Objective
TheobjectiveofthisstudywastoassessifthepresenceofaCPR CoachwouldimproveadherencetoPALSguidelinesduringsimulated paediatricresuscitations.
Methods
ThiswasasecondaryanalysisofdatafromamulticentreRandomized ControlledTrial(RCT)assessingtheimpactofaCPRCoachonCPR qualityduringsimulatedpaediatriccardiacarrests.6Thestudywas approvedbyresearchethicsboardsfromallstudysites.Informed consent was obtained from participants. The initial study was registered at clincaltrials.gov (Id: NCT03204162). The research questionofthecurrentstudywasdevelopedaftercompletingtheinitial study.
Setting
ThestudywasconductedatfourSimulationCentresacrossNorth AmericabetweenMarch2017andFebruary2018.6Participantswere video-recordedduringstandardized18-minutepaediatricresuscita- tion scenarios (cardiopulmonary arrest from hyperkalemia with progression from pulseless ventricular tachycardia to ventricular fibrillation,thenpulselesselectricalactivity)withidenticalequipment acrosssites(manikinLaerdal1SimJuniorandaZoll1CPRfeedback defibrillator).DebriefingsusedthePEARLSmethod,andoccurredat theendofsimulations.14
Studypopulation
Participantswereseniorresidents,fellowsornurseswithgreaterthan fiveyearsofpracticeandPALScertified.6Theyweredividedinto40
teamscomprisedoffivepeople:CPRproviders,ateamleader,an airway provider, and either a CPR Coach or bedside provider dependingonrandomization.
Intervention
Teamswererandomizedtooneoftwostudyarms:intervention(with CPR Coach)orcontrol.Randomizationwas conductedto ensure equalallocationofteamsacrossstudyarmsandineachcentre.The CPRCoachstoodclosetothedefibrillatorandactivelycoachedCPR providers.CPRCoachesweretrainedtocoordinatefourkeytasks:
initiationofCPR,providerswitchandpulse/rhythmcheck,defibrilla- tion,and intubation.A one-hourtrainingsessionwas providedto designated coaches.6CPR Coachtrainingwas notaccessiblefor otherparticipants,butparticipantsfromtheinterventionarmreceived adescriptionoftheCPRCoachrole.
Outcome
The primary outcome was adherence to PALS guidelines as measured by atailored versionof theClinical Performance Tool (CPT).Thetoolisatask-basedscoringinstrument,developedand validatedbyDonoghueetal.15andfurthervalidatedbyLevyetal.to evaluateclinicalperformanceduringpaediatricresuscitationsimulat- ed scenarios.16 The score is highly reliable with an intra-class coefficientof0.95.16Itassessescriticaltaskseveryfewminutesusing ascalefrom0to2points(exceptdefibrillationduringnon-shockable rhythmwhichwerescored0 1point).Wetailoredthetoolforthe standardized 18-minute scenario giving a minimum of 0 and a maximumof87points.
All 40 videos were evaluated in duplicate, by two sets of independentraters.Theeightraterswerepaediatriccriticalcareor paediatricemergencyphysicianswithexperienceinsimulation.Afirst setoffourraterswasblindedtoourstudyhypothesisandtheidentityof participants,butnottothestudyarm.Thesecondsetwasnotblinded tothestudyhypothesisandratedthesamescenariosasthefirstset,to beusedforinter-raterreliability.Eachblindedraterwaspairedwitha non-blindedrater,andIRRwerecalculatedseparatelyforeachvideo.
Results from non-blinded raters were not included in the main analysis.Ratersweretrainedtoscorescenariosandtogatherdataon performancesbytheprincipalinvestigator.Standardized,individual trainingsessionsinitiallyclearlydefinedeachitemofthescoreand addressedhowtoevaluatethevideos.Thiswasfollowedbyascoring sessionoftwovideos,differentfromthosetheywereexpectedtorate.
Eachpairofratersindependentlyratedtenvideos(fivewithandfive withoutaCPRCoach,durationofthreehours).
Samplesize
Thesamplesizewas40teams(20withand20withoutacoach), identicaltotheoriginalstudy.6
Analysis
Interrater reliability was initially assessed using the intra-class coefficient for the absolute scores assigned in duplicate usinga two-waymixedmodel.Apriori,itwasdecidedtoincludeonlyitems withanaveragecoefficienthigherthan0.6.
Theprimaryanalysiswasthedifferenceinmeanscoresforthetwo groupswith95%Confidenceinterval(95%CI)ontheCPTassuming
2
RESUSCITATIONPLUS 5(2021)100058normaldistributionforthescores.ThiswasusedbecauseaShapiro- Wilk test failed to reject normal distribution (P: 0.282). As an exploratoryanalysis,thedifferenceinmeanscoresforeachitemofthe toolwerecomparedforeachgroup.
Results
Intheoriginalstudy,oneteamwasexcludedbecauseofatechnical issue. The remaining 40 teams (200 participants) were equally randomizedbetweeninterventionandcontrolgroups.Demographic data revealedno significant differences betweenstudygroupsat baseline.6ThereliabilityoftheratingwasadequatefortheCPTwith intraclasscoefficientsof0.67(95%CI:0.22to0.84).17,18
Performancescoresofthedifferentteamsvariedbetween51and 84pointsontheCPT,withameanscoreof70.Scenariosinvolvingthe presenceofaCoachdemonstratedbetterperformancesthan the groupwithoutaCoachasshowninFig.1(difference:5.2points;95%
CI:1.0 9.3;p=0.016).ThisrepresentalargedifferencewithaCohen- Deffectsizeof0.797.Ofthe45itemsofthescore,8demonstrateda statisticallysignificantdifferencebetweenthetwogroups.Thelargest difference was asignificantly higherproportion ofCPR providers changewithinthefirst2mininteamswithaCPRCoach(1.85vs.0.95 points;p=0.001).OthermajorimprovementsforteamswithaCPR Coach included better diagnosis of the first rhythm (0.4 point;
p=0.027)andadequateventilationinitiation(0.2point;p=0.04)as showninTable1.
Discussion
OurstudydemonstratespresenceofaCPRCoachisassociatedwith improvedclinicalperformanceandadherence toPALSguidelines duringsimulatedpaediatriccardiacarrests.Previousstudieshave demonstratedimprovementinCPRmetricssuchaschestcompres- siondepth,rate,fractionandpauseswhenusingaCPRCoachin adult13andpaediatriccardiacarrests.5,6Toourknowledge,thisisthe firststudytoshowhavingaCPRCoachontheteamisassociatedwith
betterrecognitionofthefirstrhythm,acrucialsteptodeterminingthe correctPALSalgorithm.
PreviousstudiesshowedmajordeviationsinPALSadherence19,20 evenaftersimulationtraining.9,21Ourresultsmightbeexplainedby usingtheconceptof“divideandconquer”toprovidereliefincognitive overload.5,13Forexample,teamswithaCPRCoachhadabetter initiationofventilationandfirstCPRproviderchange(i.e.attentionto BLS)presumablybecausetheCPRCoachmadesurekeyelementsof CPR(compressionsandventilations)occurred.Simultaneously,the ResuscitationLeaderquicklyassessedtheinitialrhythm.
Animprovementof5.2outof87pointsonCPTscoremightbe consideredslight.However,2pointsrepresentatimelydefibrillationin a 2-minute interval (vs no defibrillation) or a correct rhythm identification. Hunt et al. showed that these elements are often delayedandmayworsenoutcomes.Therefore,differencesof5points inCPTscoresmightindeedhaveanimportantclinicalimpact.8
Ourresultssupport theprogressiveimplementationofCPR CoachinpaediatriccodeteamsofNorthAmerica.22In-hospital paediatricresuscitationsareusuallyovercrowded,sothiscould be re-allocation of roles. Provider confidence, satisfaction or stress23maybeimpactedbycommunicationandteamwork.CPR Coach training must include communication tips for the CPR team and Resuscitation Leader, such that the leader truly empowers the CPRCoach to bean excellent manager of the Airway and Compressor roles and then concentrates on advancedcomponentsoftheresuscitation.Thisshouldleadto fasterrecognitionofshockablerhythmsanddefibrillation,faster recognitionandtreatmentofobstructedendotrachealtubes,and diagnosisandtreatmentofotherreversiblecauses.Iftheleader doesnotdelegate,empowerortrusttheirCPRCoachthenthe resuscitationwillnotimprove.ThisrequirestrainingoftheCPR CoachesaswellastheResuscitationLeaders.
Limitations
Our studyhas limitations. Itwas impossible toblindraterstothe intervention. However, primary raters were blinded to the study question and hypothesis and there was an adequate inter-rater agreementbetweenbothsetofassessors.Thesimulatedsettingmay have influenced behaviours, but both groups had the same standardizedscenariowithidenticalresources.Insomevideos,the ventilationfrequencyornumberofjoulesusedinthedefibrillationwere notvisible.Assessors mayhavegivenscores despiteinsufficient information,causingbiasesinresultstowardsasmallerdifference betweengroups.Nostudyhasdefinedwhatisaclinicallysignificant differenceusingtheCPTscoreorifallitemsofthescorehavethe sameclinicalimpact.Theinformationfromthisstudycanbeusedto designfuturestudiesonhowtooptimizetheimpactoftheCPRCoach onPALS.
Conclusion
In conclusion, thepresence of a CPR Coachcorrelated with an improvement in adherence to PALS guidelines during simulated paediatric resuscitations. Emergency settings should consider adopting and implementing this new role during paediatric resuscitations.
Fig. 1– Score ofPALS adherence withcoach and no coach.
Author contribution
MichaelBuyckandArielleLevyinitiatedthestudyandtheyhadfull accessto allthedatain thestudyand takeresponsibility forthe integrityofthedataandtheaccuracyofthedataanalysis.
MichaelBuyck,YasamanShayan,JocelynGravel,ElizabethA.
Hunt,AdamCheng,andArielleLevycontributedtothestudydesign, organizationofdataacquisitionandtointerpretationoftheresults.
ThefirstdraftofthemanuscriptwaswrittenbyMichaelBuyck.
Allauthorscontributedtoamenditandapprovedthefinalversion.
Conflicts of interest
Dr.AdamChengisavolunteerfortheAmericanHeartAssociation (ResuscitationEducationSummitandEducationWritingGroup)and theInternationalLiaisonCommitteeforResuscitation(DomainLead, Education).
Dr. Elizabeth A. Hunt is a volunteer for the American Heart Association(ResuscitationEducationSummitandEducationWriting GroupandECCScienceSubcommittee).Sheisaconsultantforthe ZollMedicalCorporationandhasreceivedreimbursementfortravel and honoraria for speaking. She and research colleagues have patentsoneducationaltechnologythattheydevelopedandhavenon- exclusive licenses with Zoll Medical Corporation to use that technology.
Dr.ArielleLevyisavolunteerfortheAmericanHeartAssociation (2020AHAPaediatricGuidelinesEducationWritingGroup).
Theotherauthors(MichaelBuyck,YasamanShayan,andJocelyn Gravel)havenootherrelevantdisclosures.
Acknowledgement
Weacknowledgethefourblindedraterswhodedicatedtheirfreetime to analysethe videorecordings: Dre.LydiaDiLiddo, Dr.Michael Arsenault,Dr.AntonioD’Angelo,Dr.BaruchToledano.
Appendix A. Supplementary data
Supplementarymaterialrelatedtothisarticlecanbefound,inthe onlineversion,atdoi:https://doi.org/10.1016/j.resplu.2020.100058.
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