Using real-time acquisition of quantitative CPR quality data combined with a code leader post-event interview and questionnaire process, this investigation establishes that in-hospital code leaders frequently fail to recall CPR quality errors during the resuscitation of pediatric victims of cardiac arrest. Despite the availability of real-time continuous quantitative measures of CPR quality and a clinical environment primed to deliver high quality CPR, pediatric code leaders often failed to recall CPR quality errors in CC rate, CC depth, and CPR interruptions >10 s. Code leaders were more likely to recall ventilation rates exceeding the AHA recommended 10 bpm, but sometimes over-estimated ventilation errors.
While there were statistical differences between actual CPR quality errors and our a priori hypothesis of 75% recollection by code leaders, the clinical significance of these errors, particularly for rate and depth, is questionable. The “missed” errors for these two quality variables were not egregious (rate median was 94 (IQR 93–95)); depth median was 36 (IQR 35.5–36.5), and the clinical significance of these minor deviations is likely small. However, we have demonstrated significant non-recall of interruptions (median was 18 s (IQR 14.4–28.9)), with the lower quartile being nearly 5 s greater than that recommended by the AHA. In accordance with several previous adult studies, this magnitude of deviation from AHA recommendations (i.e., interruptions of these lengths) has been associated with worse outcomes during resuscitation.19–21
In the chaotic environment of a cardiac arrest resuscitation, identification of CPR quality error is an important challenge. Out-of-hospital studies demonstrate that front line rescuers and first responders often have distortion in their retrospective assessment of time spent in the field on paramedic runs.22
Moreover, in scenario-based CPR training sessions, physician and nurse rescuers both over- and under-estimate duration of resuscitative efforts.23
Previous observations of pediatric resident physicians have also demonstrated the gap between provider perception and performance.24
In a cohort study of pediatric residents, Nadel et al. noted that only 18% of residents properly performed airway positioning, bag-valve-mask ventilation, and naso-pharyngeal airway placement; however, 100% of these pediatric residents were confident in their ability to provide bag-valve-mask ventilation.24
These studies are consistent with our in-hospital findings, even in a pediatric ICU environment that is highly trained and primed to recognize and avoid CPR quality errors.
In a previous publication our investigator group reported on the quality of CPR delivered to a smaller cohort (20 events) of pediatric victims of cardiac arrest.2
In this smaller cohort, we documented approximately 30% non-compliance with existing AHA recommendations for CC rate, CC depth, and CPR interruption. Similar findings are reported during adult CPR.4,8
Despite these reports, code leaders continue to under appreciate the occurrence of CPR quality errors. While speculative, we can offer two possible explanations for our results. First, code leaders may be hesitant to disclose their awareness of CPR quality errors for fear that they will be criticized. Second, the use of quantitative monitors of CPR quality that provide real-time feedback may lead to complacency among code leaders. Code leaders did not report any concern with their ability to see or hear the CPR monitor, making this an unlikely source of CPR error. Code leaders must be informed that despite the presence of CPR quality monitors, CPR quality errors can, and do still occur. It should be reinforced that resuscitation team members determine CPR quality, not the CPR quality monitor. In order to reduce the occurrence of CPR quality errors, resuscitation educators must develop methods for front line clinicians to review their CPR performance.25,26
The use of resuscitation debriefing programs can significantly improve provider confidence, compliance, process of care, and patient outcomes.7,13
In fact, we hypothesize that our institutional debriefing program may in part be responsible for the reduction in CPR error that seems to have occurred since the time of our prior publication.
Excessive ventilation during CPR has been documented in both pediatric and adult victims of cardiac arrest. Animal models of cardiac arrest suggest that excessive ventilation during CPR leads to decreased survival.9,27,28
It is somewhat reassuring that code leaders were able to appreciate almost all instances of excessive ventilation, but unfortunately falsely identified CPR quality errors of ventilation that were not confirmed by quantitative analysis. It remains unclear why code leaders were able to recall the occurrence of excessive ventilation more sensitively, yet less specifically, than CC quality errors. It is possible that current code leader focus during a pediatric resuscitation of presumed respiratory etiology continues to prioritize rescue breathing. This approach persists despite the recent national guideline recommendations that prioritize early high quality CCs over ventilations, even for pediatric arrest victims (i.e., CAB over ABC).29
This study has several limitations. First, due to practical constraints and clinical responsibilities, code leaders were not interviewed and did not complete questionnaires immediately after the resuscitation event. Instead interviews and questionnaires were completed within 24 h of each resuscitation event, introducing the possibility of recall bias.
However, since many interviews were conducted immediately after the event, and most within 12 h, this bias is likely small. Second, at the time of data collection, clinical providers requested no link, de-identified or otherwise, to the actual resuscitation quality. Surveys were therefore completed anonymously. While it is possible that a single code leader may have completed more than one survey, the pool of possible code leaders is comprised of nearly 80 providers, making it unlikely that a single code leader completed more than three questionnaires. Third, we analyzed average CPR quality measures over the duration of an entire resuscitation event. While it is possible that this measure may not capture variation of CPR quality within an individual event, it is consistent with previous publications on CPR quality.3–5,7,8,11
Fourth, we lack detailed (audio or video recorded) information on the precise clinical circumstances that led to the CPR quality errors. In a typical code response, the screen displaying real time CPR quality would be directed toward the code leader. However, it is conceivable that in the crowded environment of a cardiac arrest event, this screen may be out of view of the code leader. Similarly, in the noisy environment of a code, the audio feedback prompts may not have been heard by the code leader. Code leaders may have been tailoring resuscitation therapy to more direct measures of CPR quality (e.g., invasive arterial blood pressure and end-tidal CO2
) that were not captured by the quantitative analysis on the monitor defibrillator, which may have appropriately superseded and guided the code leader to over-ride the generic standard AHA recommended rate, depth, interruption, and ventilation targets. Finally and importantly, this investigation was underpowered to assess whether code leader perception of CPR quality errors was affected by other possible confounding variables (e.g., length of resuscitation, time during resuscitation, location of event) or related to short and long-term clinical outcomes.