The Impact of a Tablet App on Adherence to American Heart Association Guidelines During Simulated Pediatric Cardiopulmonary Resuscitation: Randomized Controlled Trial

Johan N Siebert, Laurence Lacroix, Aymeric Cantais, Sergio Manzano, Frederic Ehrler, Johan N Siebert, Laurence Lacroix, Aymeric Cantais, Sergio Manzano, Frederic Ehrler

Abstract

Background: Evidence-based best practices are the cornerstone to guide optimal cardiopulmonary arrest resuscitation care. Adherence to the American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) optimizes the management of critically ill patients and increases their chances of survival after cardiac arrest. Despite advances in resuscitation science and survival improvement over the last decades, only approximately 38% of children survive to hospital discharge after in-hospital cardiac arrest and only 6%-20% after out-of-hospital cardiac arrest.

Objective: We investigated whether a mobile app developed as a guide to support and drive CPR providers in real time through interactive pediatric advanced life support (PALS) algorithms would increase adherence to AHA guidelines and reduce the time to initiation of critical life-saving maneuvers compared to the use of PALS pocket reference cards.

Methods: This study was a randomized controlled trial conducted during a simulation-based pediatric cardiac arrest scenario caused by pulseless ventricular tachycardia (pVT). A total of 26 pediatric residents were randomized into two groups. The primary outcome was the elapsed time in seconds in each allocation group from the 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, including the time intervals between defibrillation attempts and drug doses, shock doses, and the number of shocks. All outcomes were assessed for deviation from AHA guidelines.

Results: Mean time to the first defibrillation attempt (121.4 sec, 95% CI 105.3-137.5) was significantly reduced among residents using the app compared to those using PALS pocket cards (211.5 sec, 95% CI 162.5-260.6, P<.001). With the app, 11 out of 13 (85%) residents initiated chest compressions within 60 seconds from the onset of pVT and 12 out of 13 (92%) successfully defibrillated within 180 seconds. Time to all other defibrillation attempts was reduced with the app. Adherence to the 2018 AHA pVT algorithm improved by approximately 70% (P=.001) when using the app following all CPR sequences of action in a stepwise fashion until return of spontaneous circulation. The pVT rhythm was recognized correctly in 51 out of 52 (98%) opportunities among residents using the app compared to only 19 out of 52 (37%) among those using PALS cards (P<.001). Time to epinephrine injection was similar. Among a total of 78 opportunities, incorrect shock or drug doses occurred in 14% (11/78) of cases among those using the cards. These errors were reduced to 1% (1/78, P=.005) when using the app.

Conclusions: Use of the mobile app was associated with a shorter time to first and subsequent defibrillation attempts, fewer medication and defibrillation dose errors, and improved adherence to AHA recommendations compared with the use of PALS pocket cards.

Keywords: biomedical technologies; emergency medicine; guideline adherence; mobile apps; pediatrics; resuscitation.

Conflict of interest statement

Conflicts of Interest: None declared.

©Johan N Siebert, Laurence Lacroix, Aymeric Cantais, Sergio Manzano, Frederic Ehrler. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 27.05.2020.

Figures

Figure 1
Figure 1
A screenshot of the Guiding Pad app. The left-hand side of the screen displays the American Heart Association (AHA) pediatric advanced life support (PALS) ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT) cardiac arrest algorithm. The current step (eg, determining the shockable status of the arrhythmia) of the resuscitation process is surrounded by a blinking red line. Past actions already accomplished are shown as shaded. At the top right-hand side of the screen, a color-coded title depicts the current step in progress. Below, four pulseless dysrhythmias are displayed; the provider selects the right one under consideration. At the bottom right-hand side, a footer helps to anticipate the next cardiopulmonary resuscitation (CPR) step. IO: intraosseous; IV: intravenous.
Figure 2
Figure 2
Screenshot of the Guiding Pad app. The left-hand side of the screen displays the American Heart Association (AHA) pediatric advanced life support (PALS) ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT) cardiac arrest algorithm. The current step (eg, defibrillation) of the resuscitation process is displayed with a red lightning bolt. Past actions already accomplished are shown as shaded. On the right-hand side of the screen, the weight-based shock dose to deliver is displayed with a picture of a manual defibrillator (Philips HeartStart MRx Biphasic Defibrillator). Once delivered, clicking the “Shock delivered” button validates the action and allows the user to proceed to the next step. At the bottom right-hand side, a footer helps to anticipate the next compression:ventilation step. CPR: cardiopulmonary resuscitation; IO: intraosseous; IV: intravenous; PEA: pulseless electrical activity.
Figure 3
Figure 3
Screenshot of the Guiding Pad app. The left-hand side of the screen displays the American Heart Association (AHA) pediatric advanced life support (PALS) ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT) cardiac arrest algorithm. On the right-hand side of the screen, the sequence of actions to be taken are displayed in a stepwise manner to facilitate accurate progression along the algorithm. The current action (eg, to resume compression and ventilation) is brought to the attention of the provider by a red-box warning and requires validation by a simple click. Once completed, the next action will be to deliver the weight-based epinephrine dose automatically calculated by the app and then to prepare amiodarone. The next step shown at the bottom right-hand side will be to check the pulse. CPR: cardiopulmonary resuscitation; IO: intraosseous; IV: intravenous; PEA: pulseless electrical activity.
Figure 4
Figure 4
American Heart Association (AHA) pediatric cardiac arrest algorithm: 2018 update (Duff et al, 2018). CPR: cardiopulmonary resuscitation; ET: endotracheal tube; IO: intraosseous; IV: intravenous; PEA: pulseless electrical activity; pVT: pulseless ventricular tachycardia; VF: ventricular fibrillation.
Figure 5
Figure 5
Summary of the ventricular fibrillation and pulseless ventricular tachycardia (pVT) cardiac arrest sequence. This original illustration is from the eBook edition of the Pediatric Advanced Life Support (PALS) Instructor Manual, published by the American Heart Association (AHA), 2015. CPR: cardiopulmonary resuscitation.
Figure 6
Figure 6
Trial flowchart. PALS: pediatric advanced life support.
Figure 7
Figure 7
Time to cardiopulmonary resuscitation (CPR) and defibrillation attempts. Kaplan-Meier curves of time elapsed between the onset of simulated pulseless ventricular tachycardia (pVT) and initiation of chest compression (ie, CPR) for the first, second, third, and fourth defibrillation attempts for residents using the Guiding Pad (GP) app vs conventional pediatric advanced life support (PALS) pocket cards (PCs). Log-rank (Mantel-Cox) test comparing curves: χ2=0.0 and P=.97 for CPR; χ2=13.9 and P<.001 for the first defibrillation attempt; χ2=8.9 and P=.003 for the second defibrillation attempt; χ2=13.3 and P<.001 for the third defibrillation attempt; and χ2=9.5 and P=.002 for the fourth defibrillation attempt. ns: not significant.
Figure 8
Figure 8
Time to intraosseous (IO) route and drug delivery. Kaplan-Meier curves of time elapsed between the onset of simulated pulseless ventricular tachycardia (pVT) and the IO insertion, epinephrine, and amiodarone delivery for residents using the Guiding Pad (GP) app vs conventional pediatric advanced life support (PALS) pocket cards (PCs). Log-rank (Mantel-Cox) test comparing curves: χ2=0.4 and P=.55 for the IO route; χ2=0.6 and P=.44 for epinephrine; and χ2=7.5 and P=.006 for amiodarone. ns: not significant.
Figure 9
Figure 9
Association between time to defibrillation attempts and years of residency. Data are shown as a regression line (solid) with 95% CI (dashed lines). P values and r2 values are based on simple linear regression analysis. White (Guiding Pad app) and grey (pediatric advanced life support [PALS] pocket cards) open circles denote each individual value.
Figure 10
Figure 10
Association between time to chest compression or drug delivery and years of residency. Data are shown as a regression line (solid) with 95% CI (dashed lines). P values and r2 values are based on simple linear regression analysis. White (Guiding Pad app) and grey (pediatric advanced life support [PALS] pocket cards) open circles denote each individual value. CPR: cardiopulmonary resuscitation.
Figure 11
Figure 11
Time spent in seconds by cycles of chest compression and between defibrillation attempts and drug delivery during simulated pulseless ventricular tachycardia (pVT) scenarios. Solid horizontal lines denote mean and 95% CI. White (Guiding Pad app) and grey (pediatric advanced life support [PALS] pocket cards) open circles denote each individual value. The horizontal dashed line denotes the 120-sec American Heart Association (AHA) recommendation for a complete cycle. Delays between the first shock and epinephrine (epi) delivery, and between the second shock and amiodarone (amio) delivery, are expressed as the time to drug delivery minus the time to defibrillation attempt, by resident and by allocation group. A negative time point denotes a drug given before the expected defibrillation attempt.

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