Following up on its 2005 study that found widespread
failures in simulated child resuscitation
among emergency room staff, a research team from the
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
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
"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.