Paediatric resuscitation is, thankfully, a rare event. When it happens we want to take every advantage of the training afforded to us and so we often turn to simulation. Any resuscitation can create a feeling of overwhelm, of cognitive overload, and so it makes some sense to offload some of the tasks of the team leader to someone else – a coach.
Cheng A, Duff JP, Kessler D, Tofil NM, Davidson J, Lin Y, Chatfield J, Brown LL, Hunt EA, Nye M, Gaither S. Optimizing CPR Performance with CPR Coaching for Pediatric Cardiac Arrest: A Randomized Simulation-based Clinical Trial. Resuscitation. 2018 Aug 24.
Population
Paediatric health care providers from either the ICU or the Emergency Department from one of the four hospitals involved. They were recruited into teams of five. These were made up of a team leader, an airway person, 2 CPR providers and either a coach or extra provider depending on study arm.
Intervention
Each group watched a standard orientation video then completed a scenario that included two confederates. They then ran through a standard simulated arrest scenario. The group was made up of leader, airway, 2 providers and a coach.
What is a CPR coach?
The role of coach is an interesting one. Dr. Betsy Hunt and her team at Johns Hopkins Children’s Centre introduced the concept of a CPR Coach. They stand by the defibrillator and focus on the quality of CPR providing positive reinforcement and encouragement using a number of techniques.
- Alert team members to CPR feedback device output
- Provide verbal corrective feedback based on data provided. e.g. press faster, deeper, slower.
- Reinforce positive performance
- Coordinate the correct ratio of ventilations to compressions
- Help reduce peri-procedural pauses in compressions
Comparitor
This was the standard group set up comprised of a team leader, airway person, and 3 bedside CPR providers.
Outcomes
Both groups were run through a complex 18 minute paediatric arrest scenario that progressed from hyperkalemia to pulseless VT then VF and finally to PEA. A CPR feedback device attached to the mannequin and the defibrillator recorded a number of data points.
The primary outcome measure was percentage of overall excellent CPR – defined as appropriate depth AND rate of chest compressions as recommended by the AHA.
The secondary outcome measures included percentage of compressions at the correct depth OR correct rate, the chest compression fraction, the duration of pre-, peri- and post-shock pauses and the mean rate and depth of compressions during each event.
Before we get carried away let’s take a sceptical look at the methodology. This was a prospective, multicentre, randomized control trial and so I’ll use the BEEM RCT critical appraisal device.
1.The study population included or focused on those in the ED.
It certainly did as participants were drawn from both ICU and ED.
2.The participants were adequately randomized.
Participants were randomized by team rather than by individual and was stratified by site. The authors do not mention how this randomization took place.
3.The randomization process was concealed.
Unsure
4. The teams were analyzed in the groups to which they were randomized.
Yes
5. The study groups were recruited consecutively (i.e. no selection bias).
How individuals were actually recruited is not mentioned in the paper. Perhaps these willing volunteers were already pretty confident of their skillset in one institution due to a robust training program and were less confident at an alternate site?
6. The members of both groups were similar with respect to prognostic factors.
Demographic data is provided in table 1. Statistical significance is not reported for any of the variance between groups so I wondered if this might have an impact on outcome measures. What interested me most was the number of female participants in the coaching group (83%) vs the control group (75%) and the number of instructors in each group (18% in the coached group vs 8% in the controls). At first glance these may look like significant differences but they are not.
7. All participants (patients, clinicians, outcome assessors) were unaware of group allocation.
Clearly all of the participants knew if there was a coach in the group. Given that outcome assessment was performed by a machine it is unlikely that it knew.
8. Both groups were treated equally except for the intervention.
CPR coaches received an hour of individual extra training. Given that the focus of this training – on the quality of CPR – was not provided to the control groups then it is possible that they would be less focussed on outcomes. There is also the potential that coaches could have spoken to their teams regarding the training they received given that it was provided up to 48 hours prior to the assessment session.
9. Follow-up was complete (i.e. at least 80% for both groups).
Yes.
10. All patient-important outcomes were considered.
This is a simulation study and, as such, can only really tell us how good the team is at trying to bring a piece of plastic back to life. The group have previously looked at translation of simulated practice into real life scenarios.
11. The treatment effect was large enough and precise enough to be clinically significant.
With regard to the primary outcome measure the coached team performed much better than the control group – 63.3% (53.3 – 73.3) excellent CPR compared with 31.5% (21.5-41.5). Breaking down individual elements by looking at the secondary outcome measures there was also a marked improvement across all groups.
My thoughts
All in all this was a well done study that makes me think about how I can utilize the role of CPR coach in both my paediatric and adult practice. The coach in this study used a proprietary feedback device that relayed information to the defib/monitor about both rate and depth of compressions. Is the role still a valid one if such information is not available? Running a paediatric arrest can be very confronting for all involved and the opportunity to cognitively offload even some of the burden seems tempting. We know that the key tenet of effective resuscitation is performing quality CPR and reducing the time off the chest by minimising pauses in compressions. The data suggests that the coach can reduce these pauses and so might be a valuable role even without the feedback device.
In my experience, whenever there is a paediatric arrest staff miraculously appear from out of the woodwork. Nurses, doctors and social workers appear from all over the hospital to help out and perhaps some of these folk could be trained in the coaching role?
COI declaration: I had a wonderful morning with Betsy Hunt on here recent Australian tour when she took a small group of us through the technique.
