February 8, 2008 - Injury Free Coalition for Kids of Baltimore
Staging mock cardiac and respiratory arrests – “code” situations in hospital parlance – easily expose common failures in rapid response with CPR and other life-saving care for children and also set up powerful incentives to sharpen emergency skills and move fast to use them, suggests a study from the Johns Hopkins Children’s Center.
Results of the study, conducted in part at Hopkins Children’s, and published in the January issue of Pediatrics, found sometimes alarming delays and lapses in emergency care among first-responders during the critical five minutes after a child’s heart or breathing stops.
Although cardiopulmonary arrest deaths or permanent brain damage are relatively rare among hospitalized children, the mock drills, the researchers say, could help hospitals nationwide improve such dismal outcomes by focusing attention on fast action and the highly detectable events that lead up to such failures before they occur in real patients. Past research estimates that only 14 percent to 36 percent of children who suffer an arrest in the hospital survive, although the absolute number of deaths is quite small.
“An honest look at what goes wrong is uncomfortable but worth it if it means preventing harm to patients,” says lead investigator Elizabeth Hunt, M.D., M.P.H., a critical-care specialist at Hopkins Children’s. “Our hope is that other hospitals will use our model to test their own performance.”
Using a child-size dummy, researchers staged a series of pretend codes between 2000 and 2003 at Hopkins Children’s and another local hospital, simulating cardiac or pulmonary distress. In 75 percent of the 34 mock codes, nurses and residents failed to immediately check the ABCs (airway, breathing, circulation) and perform basic cardiopulmonary resuscitation (CPR) maneuvers such as opening the airway, checking the pulse and starting chest compressions. Virtually all mock codes revealed at least one resuscitation error, and there was miscommunication among caregivers in all drills.
While the codes were staged in general pediatric wards rather than the intensive care unit or the emergency room, where children are most likely to arrest and receive aggressive treatment from special code teams, arrests also happen on general wards, and delays in stabilizing children can have disastrous consequences.
Nurses, who are typically the first-responders on general wards, seemed to focus first on preparing the room for the arrival of the critical-care team rather than responding directly with ABCs and CPR, investigators observed.
“We see a lot of people who’ve lost their first-responder instincts because we’re asking them to do too much,” says Hunt. “The drills have a way of getting them back to the basics—open the airway, assess breathing and restore circulation. It’s really as simple as that.”
Since 2003, when the study ended, Hopkins Children’s now: • Clearly states in nurse job descriptions that they are required to act as first responders • Stages monthly mock codes for pediatric residents at all locations within Hopkins Children’s • Holds monthly classes on pediatric resuscitation and advanced life support
Hopkins Children’s also uses special rapid-response teams that can be called to a general ward anytime a nurse or a resident notices subtle changes in a child’s status that might signal an impending crisis, such as heavy breathing, fast heart rate and irritability, an often-ignored red flag that might mean the brain isn’t getting enough oxygen. “Our mantra to the nurses has been ‘call early even if it means a false alarm,’” Hunt says. Co-investigators in the study were Allen Walker, M.D., Donald Shaffner, M.D., Marlene Miller, M.D., M.Sc., and Peter Pronovost, M.D., Ph.D., all of Hopkins.
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