Staging mock cardiac and respiratory arrests —
"code" situations in hospital parlance — easily
exposes common failures in rapid response with CPR and
other life-saving care for children and also
sets 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 the center
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," said lead investigator Elizabeth Hunt, a
critical-care specialist at Johns Hopkins. "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 Johns Hopkins Children's Center 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 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," Hunt said. "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, Johns Hopkins
Children's now clearly states in job
descriptions that nurses are required to act as first
responders, stages monthly mock codes for
pediatric residents at all locations within the hospital
and holds monthly classes on pediatric
resuscitation and advanced life support.
The Johns Hopkins Children's Center 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 said.
Co-investigators in the study were Allen Walker,
Donald Shaffner, Marlene Miller and Peter
Pronovost, all of Johns Hopkins.
GO TO