BackgroundThe American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) are nowadays recognized as the world’s most authoritative resuscitation guidelines. Adherence to these guidelines optimizes the management of critically ill patients and increases their chances of survival after cardiac arrest. Despite their availability, suboptimal quality of CPR is still common. Currently, the median hospital survival rate after pediatric in-hospital cardiac arrest is 36%, whereas it falls below 10% for out-of-hospital cardiac arrest. Among emerging information technologies and devices able to support caregivers during resuscitation and increase adherence to AHA guidelines, augmented reality (AR) glasses have not yet been assessed. In order to assess their potential, we adapted AHA Pediatric Advanced Life Support (PALS) guidelines for AR glasses.ObjectiveThe study aimed to determine whether adapting AHA guidelines for AR glasses increased adherence by reducing deviation and time to initiation of critical life-saving maneuvers during pediatric CPR when compared with the use of PALS pocket reference cards.MethodsWe conducted a randomized controlled trial with two parallel groups of voluntary pediatric residents, comparing AR glasses to PALS pocket reference cards during a simulation-based pediatric cardiac arrest scenario—pulseless ventricular tachycardia (pVT). The primary outcome was the elapsed time in seconds in each allocation group, from onset of pVT to the first defibrillation attempt. Secondary outcomes were time elapsed to (1) initiation of chest compression, (2) subsequent defibrillation attempts, and (3) administration of drugs, as well as the time intervals between defibrillation attempts and drug doses, shock doses, and number of shocks. All these outcomes were assessed for deviation from AHA guidelines.ResultsTwenty residents were randomized into 2 groups. Time to first defibrillation attempt (mean: 146 s) and adherence to AHA guidelines in terms of time to other critical resuscitation endpoints and drug dose delivery were not improved using AR glasses. However, errors and deviations were significantly reduced in terms of defibrillation doses when compared with the use of the PALS pocket reference cards. In a total of 40 defibrillation attempts, residents not wearing AR glasses used wrong doses in 65% (26/40) of cases, including 21 shock overdoses >100 J, for a cumulative defibrillation dose of 18.7 Joules per kg. These errors were reduced by 53% (21/40, P<.001) and cumulative defibrillation dose by 37% (5.14/14, P=.001) with AR glasses.ConclusionsAR glasses did not decrease time to first defibrillation attempt and other critical resuscitation endpoints when compared with PALS pocket cards. However, they improved adherence and performance among residents in terms of administering the defibrillation doses set by AHA.
BackgroundDuring pediatric cardiopulmonary resuscitation (CPR), vasoactive drug preparation for continuous infusion is both complex and time-consuming, placing children at higher risk than adults for medication errors. Following an evidence-based ergonomic-driven approach, we developed a mobile device app called Pediatric Accurate Medication in Emergency Situations (PedAMINES), intended to guide caregivers step-by-step from preparation to delivery of drugs requiring continuous infusion.ObjectiveThe aim of our study was to determine whether the use of PedAMINES reduces drug preparation time (TDP) and time to delivery (TDD; primary outcome), as well as medication errors (secondary outcomes) when compared with conventional preparation methods.MethodsThe study was a randomized controlled crossover trial with 2 parallel groups comparing PedAMINES with a conventional and internationally used drugs infusion rate table in the preparation of continuous drug infusion. We used a simulation-based pediatric CPR cardiac arrest scenario with a high-fidelity manikin in the shock room of a tertiary care pediatric emergency department. After epinephrine-induced return of spontaneous circulation, pediatric emergency nurses were first asked to prepare a continuous infusion of dopamine, using either PedAMINES (intervention group) or the infusion table (control group), and second, a continuous infusion of norepinephrine by crossing the procedure. The primary outcome was the elapsed time in seconds, in each allocation group, from the oral prescription by the physician to TDD by the nurse. TDD included TDP. The secondary outcome was the medication dosage error rate during the sequence from drug preparation to drug injection.ResultsA total of 20 nurses were randomized into 2 groups. During the first study period, mean TDP while using PedAMINES and conventional preparation methods was 128.1 s (95% CI 102-154) and 308.1 s (95% CI 216-400), respectively (180 s reduction, P=.002). Mean TDD was 214 s (95% CI 171-256) and 391 s (95% CI 298-483), respectively (177.3 s reduction, P=.002). Medication errors were reduced from 70% to 0% (P<.001) by using PedAMINES when compared with conventional methods.ConclusionsIn this simulation-based study, PedAMINES dramatically reduced TDP, to delivery and the rate of medication errors.
IMPORTANCE Medication errors are a leading cause of injury and avoidable harm, affecting millions of people worldwide each year. Children are particularly susceptible to medication errors, but innovative interventions for the prevention of these errors in prehospital emergency care are lacking. OBJECTIVE To assess the efficacy of an evidence-based mobile app in reducing the occurrence of medication errors compared with conventional preparation methods during simulated pediatric out-of-hospital cardiac arrest scenarios. DESIGN, SETTING, AND PARTICIPANTS This nationwide, open-label, multicenter, randomized clinical trial was conducted at 14 emergency medical services centers in Switzerland from September 3, 2019, to January 21, 2020. The participants were 150 advanced paramedics with drug preparation autonomy. Each participant was exposed to a 20-minute, standardized, fully video-recorded, realistic pediatric out-of-hospital cardiac arrest cardiopulmonary resuscitation scenario concerning an 18-month-old child. Participants were tested on sequential preparations of 4 intravenous emergency drugs of varying degrees of preparation difficulty (epinephrine, midazolam, 10% dextrose, and sodium bicarbonate). INTERVENTION Participants were randomized (1:1 ratio) to the support of an app designed to assist with pediatric drug preparation (intervention; n = 74) or to follow conventional drug preparation methods without assistance (control; n = 76). MAIN OUTCOMES AND MEASURESThe primary outcome was the rate of medication errors, defined as a failure in drug preparation according to predefined, expert consensus-based criteria.Logistic regression models with mixed effects were used to assess the effect of the app on binary outcomes. Secondary outcomes included times to drug preparation and delivery, assessed with linear regression models with mixed effects. RESULTSIn total, 150 advanced paramedics (mean [SD] age, 35.6 [7.2] years; 101 men [67.3%];mean [SD] time since paramedic certification, 8.0 [6.2] years) participated in the study and completed 600 drug preparations. Of 304 preparations delivered using the conventional method, 191 (62.8%; 95% CI, 57.1%-68.3%) were associated with medication errors compared with 17 of 296 preparations delivered using the app (5.7%; 95% CI, 3.4%-9.0%). When accounting for repeated measures, with the app, the proportion of medication errors decreased in absolute terms by 66.5% (95% CI, 32.6%-83.8%; P < .001), the mean time to drug preparation decreased by 40 seconds (95% CI, 23-57 seconds; P < .001), and the mean time to drug delivery decreased by 47 seconds (95% CI, (continued) Key Points Question Does the use of an evidencebased, custom-designed, mobile app result in decreased rates of pediatric medication errors compared with conventional preparation methods in prehospital emergency care? Findings In this multicenter, simulationbased, randomized clinical trial including 150 advanced paramedics in 14 emergency medical services centers and 600 drug preparations, the proportion of medication er...
Background Coronavirus disease 2019 (COVID-19) has forced dramatic changes to the healthcare systems throughout the world. Time-sensitive management of cardiovascular emergencies such as ST-elevation myocardial infarction (STEMI) has yet to be evaluated in the context of these new policies, particularly in so-called “hot spot” cities. Methods We evaluated the early impact of the pandemic on STEMI performance in the Greater Montreal Area. A total of 167 patients from 3 different study periods were included. Patients presenting in the lockdown period from mid-March to mid-May 2020 (Group C, 53 patients) were compared to those from mid-March to mid-May 2019 (Group A, 60 patients) and the 2020 pre-COVID-19 period (Group B, 54 patients). Results The number of STEMI admissions was unaffected during the lockdown. However, significantly longer delays between symptom onset and first medical contact (FMC) were noted (Group C 189.0 IQR [70.0, 840.0] min vs. Group A 103.0 IQR [42.5, 263.0] min vs. Group B 91.0 IQR [38.0, 235.5 min], P= 0.007). In contrast, additional safety protocols do not appear to have significantly affected delays between FMC and first intracoronary device activation (Group C 102 IQR [73.0, 133.0] min vs. Group A 104 IQR [87.0, 146.0] min vs. Group B 99.5 IQR [80.0, 150.0] min, P=0.37). Patients that presented during the outbreak were more likely to be unstable with a higher incidence of Killip classes II-IV compared to groups A and B (28.3% vs. 18.3% vs. 5.6% respectively, P=0.008). Worse in-hospital outcomes were also noted with a significantly higher rate of major adverse cardiac events (Group A 5.0% vs. Group B 11.1% vs. Group C 22.6%, P=0.007). Conclusion During the lockdown period, many patients appear to have been reluctant to present to hospitals. This was associated with more unstable STEMI presentations and worse in-hospital course. Importantly, the health care system appears able to ensure timely acute cardiac care while ensuring that COVID-19 protocols are respected.
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