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The newspaper of The Johns Hopkins University February 18, 2008 | Vol. 37 No. 22
Drills Boost Child-Resuscitation Skills in 'Failing' Adult ERs

By Katerina Pesheva
Johns Hopkins Medicine

Following up on its 2005 study that found widespread failures in simulated child resuscitation among emergency room staff, a research team from the Johns Hopkins Children's Center and Duke University Medical Center reports that it doesn't take much more than a mock-trauma drill to diagnose shortcomings and a brief refresher to get ER workers' performance sharp again. The report appears in the November issue of Pediatric Emergency Care.

The investigators note that both studies involved adult ERs in community hospitals or adult trauma centers, not pediatric ER teams that specialize in child resuscitation. Of the 20 million children injured in the United States each year, only 20 percent end up in specialized pediatric ERs or pediatric trauma centers.

Trauma is the No. 1 cause of death in children under 14 years of age.

The lesson learned is that improvements can be seen in ER trauma resuscitation and other critical care given to children after brief performance tests and refresher programs, the researchers say.

"The bad news is that failures are widespread, but the good news is that fairly simple refreshers based on quick analysis of what isn't working could be really helpful," said lead investigator Elizabeth Hunt, a critical-care specialist at Johns Hopkins. "It's encouraging to see that, in most cases, merely raising a red flag and telling the staff, 'Here's what you did wrong, and here's how it should be done' helped them see their own shortcomings and do better the next time."

In its report, the research team recalled its 2005 study that found that one-third of North Carolina's 106 ERs failed in crucial areas while stabilizing a critically injured child during a mock emergency drill. Armed with an analysis of what went wrong, the team had returned to 18 of the 35 ERs and refreshed the staff's knowledge on 44 "tasks," including ones specific to child resuscitation, such as weight-based dosing of drug treatments, blood sugar assessments and placement of IVs through the bone, a critical route for delivering fluids to children whose veins have constricted due to blood loss or other injury.

In the current study, the team made surprise visits six months later to the 18 ERs and found that scores on 37 of the 44 tasks improved, and scores on 11 of the most important ones, such as accessing circulation through the bone or performing head examinations, improved significantly.

For example, following the refresher, the number of ERs properly estimating a child's weight nearly doubled, the number of ERs correctly assessing consciousness in a child nearly quadrupled, twice as many ER teams properly started an IV through the bone, more than twice as many ordered the correct anti-seizure medications, and more than twice as many correctly prepared a child for transport to CT scanners or operating rooms, a critical time when many problems can occur.

"Our findings would seem to offer a practical recipe for running a quick diagnostic test of ER skills related to resuscitating children from catastrophe, and improving them," Hunt said. In situ disaster simulations are already a monthly happening at the Johns Hopkins Children's Center, where trauma teams rate their own performance and diagnose problems in each other.

Researchers note that some tasks on their list of 44 still need improvement by workers, including assessing for neurological and spine injuries, delivering proper weight-based and timely doses of dextrose to stop life-threatening drops in blood sugar, and correctly administering IV fluids. Failures on these tasks can have catastrophic results, the investigators say, and more research is needed to understand why staff continued to perform poorly. The researchers caution that failures during drills do not necessarily reflect performance during a genuine emergency, when trauma teams experience "adrenaline surge" and ultra-sharp focus on the patient, and actual patients provide constant feedback to the team's actions, prompting more appropriate responses. "You can't exactly duplicate an actual trauma," Hunt said.

Margaret Heine of Johns Hopkins also participated in the study. Co-investigators from Duke University are Susan Hohenhaus, Xuemei Luo and Karen Frush.


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