September 30, 2016
Pediatric anesthesiologist Rahul Koka recalls the cardiac arrest and resuscitation of a good friend in the operating room at a community hospital. What impressed him was the speed at which anesthesiologists began chest compressions and defibrillation, so much so that the experience spurred him to develop ways to improve resuscitation in the pediatric OR, including a new quality improvement initiative at the Johns Hopkins Children’s Center.
“This project is personal for me,” says Koka. “Despite some tremendous odds working against my friend, he was successfully resuscitated due to a very good protocol for cardiopulmonary resuscitation.”
Johns Hopkins has very good arrest protocols for both adults and children, Koka says, but for an intervention where seconds can make the difference between life and death, there’s always room for improvement. It’s well-documented in the literature, Koka explains, that for every minute without chest compression or defibrillation after cardiac arrest, there is a 10 percent drop in survival. “You need good chest compressions quickly.”
In that regard, Koka’s “rapid-cycle deliberate practice” simulation stresses repetition, repetition and more repetition. Under Pediatric Advanced Life Support, or PALS, protocols, Koka notes, current CPR practice recommends didactics and simulation every two years. In his mind, that’s not often nor repetitive enough.
“The argument I would make is that’s not how violinists or pianists practice—they do it over and over and over again,” says Koka. “That’s how we’re aiming to practice.”
Importing in part the CPR protocol pioneered in the Johns Hopkins pediatric intensive care unit, Koka increased the frequency, length and depth of the simulations, adding pre-training simulations and debriefing surveys to assess the team’s confidence and performance in conducting the code. Simulation training sessions that took 30 minutes in the past now last an hour or more.
“We’d simulate an arrest, do compressions, then talk about what we did, and that was it,” says Koka. “But for this quality improvement protocol, that’s just the beginning, the first third of a simulation training. We go in, do the simulation, debrief, and then we do it again and again until we get it right.”
Getting it right means nuancing the protocol to chip seconds off of the time to chest compression and defibrillation. The simulations are also highly individualized to the anesthesiologist leading the code, who may believe, for example, that resuscitation can go quicker with the code cart on his right side rather than his left.
The results? Koka’s goal was chest compression within 10 seconds—and defibrillation within 30 seconds—of arrest. Anesthesiologists participating in the initiative were able to reduce the average time to compressions from 150 seconds to 2 seconds and the average time to defibrillation from 232 seconds to 31 seconds.
An added value of the QI initiative is its potential for influencing CPR simulations at other children’s hospitals. Greater frequency and intensity of simulations, says Koka, will help fight the learning decay that typically occurs six to eight months after a training simulation.
“Ideally, you want to be repeating this about every six months using different techniques and expanding it beyond attending physicians,” says Koka. “I would like to include nurse anesthetists as well.”