Arrest team management of pediatric cardiopulmonary arrest

Therapeutics

Arrest Team Management of Pediatric CardiopulmonaryArrest M. DOUGLAS BAKER, MD In both the adult and the pediatric settings, successful cardiopulmonary resuscitation (CPR) requires an organized approach by highly trained personnel delivering specialized care according to specific protocols.’ Several reports of pediatric CPR (PCPR) outcome have mentioned the use of specific teams whose function it is to manage such events in the hospital setting. 2-4 Ehrlich and coworkers’ have detailed the structure of their arrest team. This article summarizes the systems of CPR management currently used by pediatric residency training programs in the United States. METHODS Questionnaires were mailed to 226 pediatric residency program directors listed in the Directory of Residency Training Progrums.5 Information regarding program size (number of residents trained), number of PCPRs managed per year, personnel responsible for managing both medical and trauma-associated CPRs, and method of notification of these individuals was gathered. Return-address stamped envelopes were enclosed, and feedback of survey results was offered to those requesting it. Statistical analysis was performed using Chi-square analysis.6 Statistical significance was defined as P < 0.05. RESULTS Of the 226 surveys mailed, 163 (72%) were returned and 155 (69%) completed (Table 1). Larger programs completed proportionately more questionnaires than did smaller programs (P < 0.01). There were no differences between participating and nonparticipating institutions with regard to either geographic location or university affiliation. Seventyeight (50%) programs responding indicated that they use specific pediatric arrest teams to manage medical PCPRs, From the Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland. Manuscript received June 2, 1986; accepted July 10, 1986. Address reprint requests to Dr. Baker: Children’s Hospital of Philadelphia, Emergency Department, 34th Street and Civic Center Blvd., Philadelphia, PA 19104.

Key Worcfs:Arrest team, cardiopulmonary resuscitation, pediatrics.

whereas 14 (9%) use combined adult and pediatric arrest teams, and 63 (41%) rely on first responders to the scene (i.e., nurses and physicians nearby at the time of the arrest). Tables 2 and 3 detail the number of training programs using medical arrest teams according to program size (total number of residents trained yearly) and frequency of occurrence of PCPRs, respectively. Although the smallest training programs use separate pediatric medical arrest teams less often than do larger programs, program size does not distinguish those not using organized arrest teams. Separate pediatric medical arrest teams are present in hospitals with fewer than 26 pediatric CPRs per year less often than in busier hospitals. However, this difference does not reach statistical significance. Hospitals managing the greatest number of arrests per year are as likely to have no organized arrest team as are those managing the fewest. A detailed description of the personnel included in existing pediatric medical arrest teams is presented in Table 4. Although all teams include medical residents, fewer than two thirds (62%) use nurses other than those immediately available at the scene. Respiratory therapists (49%), attending pediatricians (29%), surgery (28%) and anesthesiology (23%) residents, and pediatric fellows (16%) are also frequent members. Of the 155 programs surveyed, 86 (55%) are identified as regional trauma referral centers. Twenty-six (30%) of these, and 12 nonreferral centers have separate trauma resuscitation teams. Medical arrest teams also manage trauma arrests in 35 (41%) other trauma centers. The exact structure of existing trauma arrest teams is listed in Table 5. Nineteen of these teams are composed of the medical arrest teams plus a surgery resident. The remaining 19 teams include personnel distinct from the medical arrest team such as senior surgery residents, neurosurgery residents, attending surgeons, and trauma fellows. Notably, eight of these 19 teams include no pediatric medical residents and four include no pediatric medical physicians at all. The mean number of members of both the medical arrest teams (range, two to 12) and trauma arrest teams (range, three to 10) is six. An average of two nurses are present in both medical and trauma arrest teams that use them.

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TABLE1. Survey of Pediatric Training Programs

5, Number

2 n March

1987

TABLE3. Medical Arrest Team Utilization According to Frequency of Arrests

Number of Residents Trained per Year

Number of surveys distributed Number of sutveys returned Number of surveys completed

Arrest Team

~16

1630

31-E

>45

TOTAL

N(%)

N(%)

N(%)

N(%)

N(%)

79

63

52

32

226

47 (59)’

44 (70)

43 (83)

29 (91)’

163 (72)

41 (52)t

43

(68)

42 (81)

29 (91)t

15.5(69)

“P < 0.01. tP < 0.005.

Arrest teams are notified as indicated in Table 6. Only 9% of medical and 11% of trauma teams employ no beeper notification system. Sixty-nine percent of medical teams using beepers use specific arrest team units as opposed to 41% of trauma teams. Multiple notification systems are used by 56% of medical arrest teams and by 37% of trauma arrest teams. The status of duty preassignment for arrest team members is outlined in Table 7. Fifty percent of all teams preassign specific roles for all team members, whereas approximately one third do not preassign duties to any team physicians. There were no statistically significant differences between medical and trauma arrest teams in any of these aspects.

DISCUSSION The concept of using a designated medical team to manage PCPRs is not a new one.’ The theoretic and real advantages in quality and efficiency of PCPR management using the team approach have been previously noted.’ However, the current data indicate that significant portions of pediatric residency training hospitals do not currently use

Combined

Number of Arrests Per

Adult and

Pediatric

Pediatnc

Team

N(%)

N(%)

N(%)

Year

(N = 39)

O-25 26-50 51-100 101-150 151-200 >200 Unknown

(N (N (N (N (N (N

TOTAL

(N = 155)

= = = = = =

41) 26) 11) 13) 12) 13)

15 25 15 6 7 6 4

(36.5) (61 .O) (57.7) (54.5) (53.8) (50.0) (30.8)

78 (50.3)

6 (15.4) 3 (7.3) 2 (7.7) 3 (23.1)

18 13 9 5 6 6 6

14 (9.0)

63 (40.7)

Program Size Arrest Team Total Number of

Separate

Residents Trained

Pediatric

Adult and Pediatric

N(%)

NW)

per Year 1-15 16-30 31-45 >45

(N (A’ (N (A’

TOTAL

(N = 155)

lf < 0.05. tf < 0.01.

150

= = = =

41) 43) 42) 29)

12 24 26 16

(29)’ (56) (62) (55)

76 (50)

Combned

9 3 2 0

Gwt (7) (5) (0)

14 (9)

No Arrest Team N(%)

20 16 14 13

(49) (37) (33) (45)

63 (41)

(46.1) (31.7) (34.6) (45.5) (46.2) (50.0) (46.1)

such teams to manage either medical arrests (4 1%) or traumaassociated arrests (29%). Analysis of the distribution of arrest teams provides some interesting observations. One could easily rationalize finding significant differences in arrest team use on the basis of program size or volume. For example. smaller programs might find greater needs for such teams due to the overall lesser availability of qualified personnel, whereas larger programs might find similar needs due to the higher number of PCPRs that they are required to manage. The present data, however, indicate no such trends. Although the smallest training programs use separate pediatric medical arrest teams less often than do larger programs, program size does not affect the likelihood of using some form of arrest team for PCPR management. Similarly, both the highest and lowest volume (number of arrests managed per year) hospitals use arrest teams with the same frequency. Thus, arrest teams TABLE4. Medical Arrest Team Structure (N = 78) Number of

TABLE2. Medical Arrest Team Utilization According to

No Arrest

Separate

Number of

Type of

Teams Using

Type of

Teams Using

Personnel

N(%)

Personnel

N(%)

Nurse(s) Residents Pediatric PLl Pediatric PL2 Pediatric PL3

48 (62)

Pediatric PL4 Surgery Anesthesiology Fellows

21 (27) 22 (28) 18 (23)

Attending physicians PICU Cardiology Medical Respiratory therapist Pharmacist Chaplain Clerk Laboratory technician IV technician ECG technician Social services

PICU Other

54 (69) 53 (68) 76 (97)

9 (12) 3 14)

16 (21) 4 (5) 2 (3) 38 (49) 5 4 2 2

(6) (5) (3) (3)

1 111 1 (1)

1 (1)

BAKER n CARDIOPULMONARY ARREST TEAMS

TABLE6. Method of Notification of Arrest Teams

TABLE5. Trauma Arrest Team Structure (N = 38) Number of Teams Using N(%)

Type of Personnel

28 (74)

Nurse(s) Residents Surgery PLl Surgery PL2 Surgery PL3 Surgery PL4 Surgery PL5 Pediatric PLl

9 12 27 8 12 13

Pediatric PL2 Pediatric PL3 Anesthesiology Neurosurgery

(24) (32) (71) (21) (32) (34)

16 (42) 26 (68) 13 (34) 4 (11)

Type of Personnel Fellows PICU Trauma Cardiology Attendings Surgery Medicine Respiratory therapist Pharmacist Chaplain

Number of Teams Using N(%)

7 (18) 3 (8) 2 (5) 15 (39) 6 (16) 16 (42) 2 (5) 1 (3)

Number of Teams Using Notification System Overhead page Individuals’ names Arrest code Beeper page Personal units Arrest team units

Medical

Traumat

N(%)*

NW)*

7 (9) 39 (50)

4 (11) 15 (39)

31 (40) 50 (64)

22 (58) 15 (39)

*Total, N = 78. TTotal, N = 38. *Total exceeds 100% because the multiplicity of systems used by 44 (58%) medical arrest teams and 14 (37%) trauma arrest teams.

SYSTEMPROPOSAL

seem to be fairly randomly distributed among pediatric residency training hospitals. It is possible that the present data could be biased by the proportionately fewer number of surveys completed by smaller training programs. However, unless more academically oriented or more highly organized smaller programs selectively declined participation, it seems unlikely that additional information from this group would significantly alter the trends established by the current data. While the majority of programs surveyed have some form of organized arrest team, the structures of these teams are quite heterogeneous. With the exception of third-year residents, an individual from each category of personnel is present on fewer than 75% of all medical or trauma arrest teams. Among the least-well-represented groups are physicians with training beyond residency (i.e., emergency care, intensive care, or trauma surgery fellows or attending physicians). Although there are no data to suggest that the presence of these individuals improves patient outcome, perhaps the often dismally low survival rates’ of these victims of arrest could be improved by adding fellow or attending input. Further research is needed to address this issue properly. In addition to team structure, delineation of resuscitation responsibilities among team members is of prime importance. Surprisingly, only 40 to 50% of all arrest teams designate specific functions for members other than the team leader; and approximately one third preassign no duties. Again, no data exist that specifically address this issue; however, it would seem that the lack of predesignated responsibilities for arrest team members would only serve to compound the confusion that often surrounds arrests. The effectiveness of duty preassignment on patient outcome is another topic that merits further study.

At the Johns Hopkins Children’s Center, the pediatric medical arrest team has evolved to include seven medical personnel with preassigned duties who, with the exception of the pediatric intensive care fellow, are present in-house at all times. The team is headed by a third-year pediatric resident whose responsibility it is to run the arrest. A secondyear pediatric resident (duty: vascular access) and first year resident (duty: cardiac massage) are also present. Throughout the year, residents take turns being team members, periodically rotating arrest team beepers and responsibilities. Although most programs surveyed also captain their teams with third-year residents, one third do not include first- and second year residents. We feel that junior residents gain valuable experience as they advance year to year within the team system. Thus, all levels of pediatric residents are represented on our arrest team. Other arrest team members at our institution include the pediatric intensive care fellow (duty: airway stabilization and medical consultation), respiratory therapist (duty: airway management), pediatric nurse coordinator (duty: nursing coordination, crowd control, special unit communication), and pediatric intensive care nurse (duty: drug TABLE7. Preassignment of Duties for Arrest Team Members PCPR Duties Preassigned For

Medical arrest teams (N = 78) Trauma arrest teams (N = 38)

Team

Respiratory

All

Leader

Therapist

Members

Only

Only

None

N(%)

N(%)

N(%)

N(%)

39(50)

16(20)

3(4)

20(26)

16(42)

8(21)

l(3)

13(34)

.

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preparation). Ward or outpatient department nursing staff augment the team and perform other important duties such as recordkeeping, measurement of vital signs, preparation of intravenous lines, and application of equipment. Although the number of nonteam nurses at the scene is generally adequate to manage the arrest, assigning experienced nurses as permanent team members assures their presence when arrests occur in more sparsely staffed units or in nonpatient areas and aids in the accuracy and efficiency of dispensing cardioactive drugs. Trauma-associated arrests at our institution are managed by an expanded arrest team composed of the medical arrest team plus three pediatric surgery residents. Included is the chief surgical resident, who assumes command of the resuscitation. The additional surgical residents perform procedures at the direction of the team leader, whereas the third-year pediatric medical resident continues to provide expertise in the management of cardiac arrhythmias. Fifty percent of the pediatric trauma centers surveyed use similarly structured teams to manage trauma-associated arrests. The others use various combinations of surgeons and other medical professionals, but often lack adequate numbers of pediatricians. By including the members of the medical arrest team in the management of trauma-associated arrests, basic and advanced CPR continues to be managed by personnel experienced in medical resuscitation. An effective notification system is essential to optimal team function. The Hopkins arrest teams uses individual

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arrest team beepers that simultaneously inform team members of the location of the arrest. This eliminates any confusion with personal beeper pages and the uncertainty of notification by overhead systems. Personal beepers and overhead pages serve as back-ups. in summary, although the majority of pediatric residency training programs use arrest teams, a significant portion have yet to organize such units. This group includes many large programs as well as smaller ones. The structures and functions of these teams are quite variable. Further patient outcome oriented research addressing the issues of optimal team composition, organization, and implementation of resuscitative efforts is warranted.

REFERENCES 1. American Heart Association. Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA 1980;244:453-508 2. Ehrlich R, Emmett S, Rodriquez-Torres R. Pediatric cardiac resuscitation team: A 6-year study. J Pediatr 1974$4:152-l 55 3. Lewis JK, Minter MG, Shelman SJ, et al. Outcome of pediatric resuscitation. Ann Emer Med 1983;12:297-299 4. Ludwig S, Kettrick RG, Parker M. Pediatric cardiopulmonary resuscitation. Clin Pediatr 1984;23:71-75 5. American Medical Association. Directory of Residency Training Programs, 1985-l 986. 1986, pp 258-270 6. Zai J. Biostatistical Analysis. Englewood Cliffs, New Jersey, Prentice-Hail, 1974, pp 60+8 7. Ludwig S, Fleisher G. Pediatric cardiopulmonary resuscitation: A review and a proposal. Pediatr Emerg Care 1985;1:4044