Impact of a Mobile App on Paramedics' Perceived and Physiologic Stress Response During Simulated Prehospital Pediatric Cardiopulmonary Resuscitation: Study Nested Within a Multicenter Randomized Controlled Trial

Abstract

Background: Out-of-hospital cardiac arrests (OHCAs) are stressful, high-stake events that are associated with low survival rates. Acute stress experienced in this situation is associated with lower cardiopulmonary resuscitation performance in calculating drug dosages by emergency medical services. Children are particularly vulnerable to such errors. To date, no app has been validated to specifically support emergency drug preparation by paramedics through reducing the stress level of this procedure and medication errors.

Objective: This study aims to determine the effectiveness of an evidence-based mobile app compared with that of the conventional preparation methods in reducing acute stress in paramedics at the psychological and physiological levels while safely preparing emergency drugs during simulated pediatric OHCA scenarios.

Methods: In a parent, multicenter, randomized controlled trial of 14 emergency medical services, perceived and physiologic stress of advanced paramedics with drug preparation autonomy was assessed during a 20-minute, standardized, fully video-recorded, and highly realistic pediatric OHCA scenario in an 18-month-old child. The primary outcome was participants' self-reported psychological stress perceived during sequential preparations of 4 intravenous emergency drugs (epinephrine, midazolam, 10% dextrose, and sodium bicarbonate) with the support of the PedAMINES (Pediatric Accurate Medication in Emergency Situations) app designed to help pediatric drug preparation (intervention) or conventional methods (control). The State-Trait Anxiety Inventory and Visual Analog Scale questionnaires were used to measure perceived stress. The secondary outcome was physiologic stress, measured by a single continuous measurement of the participants' heart rate with optical photoplethysmography.

Results: From September 3, 2019, to January 21, 2020, 150 advanced paramedics underwent randomization. A total of 74 participants were assigned to the mobile app (intervention group), and 76 did not use the app (control group). A total of 600 drug doses were prepared. Higher State-Trait Anxiety Inventory-perceived stress increase from baseline was observed during the scenario using the conventional methods (mean 35.4, SD 8.2 to mean 49.8, SD 13.2; a 41.3%, 35.0 increase) than when using the app (mean 36.1, SD 8.1 to mean 39.0, SD 8.4; a 12.3%, 29.0 increase). This revealed a 30.1% (95% CI 20.5%-39.8%; P<.001) lower relative change in stress response in participants who used the app. On the Visual Analog Scale questionnaire, participants in the control group reported a higher increase in stress at the peak of the scenario (mean 7.1, SD 1.8 vs mean 6.4, SD 1.9; difference: -0.8, 95% CI -1.3 to -0.2; P=.005). Increase in heart rate during the scenario and over the 4 drugs was not different between the 2 groups.

Conclusions: Compared with the conventional method, dedicated mobile apps can reduce acute perceived stress during the preparation of emergency drugs in the prehospital setting during critical situations. These findings can help advance the development and evaluation of mobile apps for OHCA management and should be encouraged.

Trial registration: ClinicalTrials.gov NCT03921346; https://ichgcp.net/clinical-trials-registry/NCT03921346.

International registered report identifier (irrid): RR2-10.1186/s13063-019-3726-4.

Keywords: State-Trait Anxiety Inventory; cardiopulmonary resuscitation; drugs; emergency medical services; medication errors; mobile apps; mobile health; out-of-hospital cardiac arrest; paramedics; pediatrics; stress.

Conflict of interest statement

Conflicts of Interest: Geneva University Hospitals are owners of the PedAMINES app. The app is currently commercially available on Google Play Store and App Store (Apple) for research and educational purposes. JNS, CL, AG, FE, and SM declare individual intellectual property rights on this app and, as employees of Geneva University Hospitals, indirect institutional rewarding through its commercialization (ie, without personal enrichment). The authors declare no other relationships or activities that could appear to have influenced the submitted work. All authors have completed the International Committee of Medical Journal Editors uniform disclosure form and declare no support from commercial entities for the submitted work, and no financial relationships with any commercial entities that might have an interest in the submitted work in the previous 3 years.

©Matthieu Lacour, Laurie Bloudeau, Christophe Combescure, Kevin Haddad, Florence Hugon, Laurent Suppan, Frédérique Rodieux, Christian Lovis, Alain Gervaix, Frédéric Ehrler, Sergio Manzano, Johan N Siebert, PedAMINES Prehospital Group. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org), 07.10.2021.

Figures

Figure 1

PedAMINES (Pediatric Accurate Medication in Emergency Situations) app screenshot.

Figure 2

Course of the intervention. CPR: cardiopulmonary resuscitation; HR: heart rate; pOHCA: pediatric out-of-hospital cardiac arrest; STAI: State-Trait Anxiety Inventory; VAS: visual analogue scale.

Figure 3

Screening, randomization, and analysis.

Figure 4

State-Trait Anxiety Inventory Form Y-1 and Visual Analogic Score box plots per study arm. PedAMINES: Pediatric Accurate Medication in Emergency Situations; STAI: State Trait Anxiety Inventory; VAS: visual analogue scale.

Figure 5

Mean heart rate (error bars=SD) in the baseline, the 4 consecutive heart rate peaks numbered according to the sequential prescription of each drug, and recovery time points over the course of the scenario. HR: heart rate.