Literature Review: Simulated Codes and Pediatric CPA Survival

Andreatta P, Saxton E, Thompson M, Annich G. Simulation-based mock codes significantly correlate with improved pediatric patient cardiopulmonary arrest survival rates. Pediatr Crit Care Med, Jun 24, 2010 [e-pub ahead of print].

Abstract

   The objective was to evaluate the viability and effectiveness of a simulation-based pediatric mock code program on patient outcomes, as well as residents' confidence in performing resuscitations. A resident's leadership ability is integral to accurate and efficient clinical response in the successful management of cardiopulmonary arrest (CPA). Direct experience is a contributing factor to a resident's code team leadership ability; however, opportunities to gain experience are limited by relative infrequency of pediatric arrests and code occurrences.

   Methods--Clinicians responded to mock codes randomly called at increasing rates over a 48-month period just as they would actual CPA events. Events were recorded and used for immediate debriefing facilitated by clinical faculty to provide feedback about their performance. Self-assessment data were collected from all team members. Hospital records for pediatric CPA survival rates were examined for the study duration.  

Results--Survival rates increased to approximately 50% (p = .000), correlating with the increased number of mock codes (r = .87). These results are significantly above the average national pediatric CPA survival rates and held steady for three consecutive years, demonstrating the stability of the program's outcomes.

Conclusions--This study suggests that a simulation-based mock code program may significantly benefit pediatric patient CPA outcomes--not simply learner perceived value, increased confidence, or simulation-based outcomes. The use of mock codes as an integral part of residency programs could provide residents with the resuscitation training they require to become proficient in their practice. Future programs that incorporate transport scenarios, ambulatory care and other outpatient settings could further benefit pediatric patients in prehospital contexts.

Comment

    Although this study focuses on physicians in training, EMS systems, emergency departments, hospital inpatient services and outpatient care centers all face the same fundamental challenges. Pediatric cardiopulmonary arrests are uncommon, and correct treatment is critically important--the classic high-risk, low-frequency event. The traditional learning method of teaching the basics and expecting a certain amount of proficiency to be obtained from observation and clinical experience is not adequate.    

Many EMS systems have responded to this by requiring standardized courses, such as PALS or PEPP, usually completed every two years. But studies have documented that errors in pediatric care are common and continue, and most of us will agree that improvement is needed. The solution presented here--using mock codes that are recorded with immediate feedback--is reasonable for EMS programs. In fact, we also know (and I've discussed in previous columns) that adult resuscitation skills can be improved upon, and these structured mock codes would likely help there as well.

    EMS systems should, as part of their ongoing QI efforts, evaluate the quality of resuscitation events and consider incorporating regular, structured mock codes as part of their primary training and skills proficiency programs.

   Angelo Salvucci, Jr., MD, FACEP, is medical director for the Santa Barbara County and Ventura County (CA) EMS agencies.