Clinical paper| Volume 127, P95-99, June 2018

Variability in the time to initiation of CPR in continuously monitored pediatric ICUs



      To study the influence of patient characteristics and unit ergonomics and human factors on the time to initiation of CPR.


      A single center study of children, 0 to 21 years old, admitted to an ICU who experienced cardiopulmonary arrest (CPA) requiring >1 min of chest compressions. Time of CPA was determined by analysis of continuous ECG, plethysmography, arterial blood pressure, and end-tidal CO2 (EtCO2) waveforms. Initiation of CPR was identified by the onset of cyclic artifact in the ECG waveform. Patient characteristics and unit ergonomics and human factors were examined including CPA cause, identification on the High-Risk Checklist (HRC), existing monitoring, ICU type, time of day, nursing shift change, and outcome.


      The median time from CPA to initiation of CPR was 50.5 s (IQR 26.5 to 127.5) in 36 CPAs. Forty-seven percent of patients experienced time from CPA to initiation of CPR of >1 min. There was no difference in CPA cause, ICU type, time of day, or nursing shift change.


      Nearly half of pediatric patients who experienced CPA in an ICU setting did not meet AHA guidelines for early initiation of CPR. This is an opportunity to study the recognition phase of CPA using continuous monitoring data with the aim of improving the understanding of and factors contributing to delays in initiation of CPR.


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        • Liss H.
        History of Resuscitation.
        Ann Emerg Med. 1986; 15: 8
        • Kouwenhoven W.B.
        • Jude J.R.
        • Knickerbocker G.G.
        Closed-chest cardiac massage.
        JAMA. 1960; 173: 1064-1067
        • Meaney P.A.
        • Bobrow B.J.
        • Mancini M.E.
        • Christenson J.
        • de Caen A.R.
        • Bhanji F.
        • et al.
        Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association.
        Circulation. 2013; 128: 417-435
        • Aufderheide T.P.
        • Lurie K.G.
        Death by hyperventilation: a common and life-threatening problem during cardiopulmonary resuscitation.
        Crit Care Med. 2004; 32: S345-S351
        • Hunt E.A.
        • Zimmer K.P.
        • Rinke M.L.
        • Shilkofski N.A.
        • Matlin C.
        • Garger C.
        • et al.
        Transition from a traditional code team to a medical emergency team and categorization of cardiopulmonary arrests in a children’s center.
        Arch Pediatr Adolesc Med. 2008; 162: 117-122
        • Sharek P.J.
        • Parast L.M.
        • Leong K.
        • Coombs J.
        • Earnest K.
        • Sullivan J.
        • et al.
        Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a Children’s Hospital.
        Jama. 2007; 298: 2267-2274
        • Martinez P.A.
        • Totapally B.R.
        The epidemiology and outcomes of pediatric in-hospital cardiopulmonary arrest in the United States during 1997 to 2012.
        Resuscitation. 2016; 105: 177-181
        • de Caen A.R.
        • Berg M.D.
        • Chameides L.
        • Gooden C.K.
        • Hickey R.W.
        • Scott H.F.
        • et al.
        Part 12: pediatric advanced life support: 2015 American Heart Association Guidelines Update for cardiopulmonary resuscitation and emergency cardiovascular care.
        Circulation. 2015; 132: S526-S542
        • amrick J.L.
        • Hamrick J.T.
        • Lee J.K.
        • Lee B.H.
        • Koehler R.C.
        • Shaffner D.H.
        Efficacy of chest compressions directed by end-tidal CO2 feedback in a pediatric resuscitation model of basic life support.
        J Am Heart Assoc. 2014; 3: e000450
        • Morgan R.W.
        • Kilbaugh T.J.
        • Shoap W.
        • Bratinov G.
        • Lin Y.
        • Hsieh T.C.
        A hemodynamic-directed approach to pediatric cardiopulmonary resuscitation (HD-CPR) improves survival.
        Resuscitation. 2017; 111: 41-47
        • Sutton R.M.
        • French B.
        • Meaney P.A.
        • Topjian A.A.
        • Parshuram C.S.
        • Edelson D.P.
        • et al.
        Physiologic monitoring of CPR quality during adult cardiac arrest: a propensity-matched cohort study.
        Resuscitation. 2016; 106: 76-82
        • Siems A.
        • Tomaino E.
        • Watson A.
        • Spaeder M.C.
        • Su L.
        Improving quality in measuring time to initiation of CPR during in-hospital resuscitation.
        Resuscitation. 2017; 118: 15-20
        • Cooper S.
        • Cade J.
        Predicting survival, in-hospital cardiac arrests: resuscitation survival variables and training effectiveness.
        Resuscitation. 1997; 35: 17-22
        • Herlitz J.
        • Bang A.
        • Alsen B.
        • Aune S.
        Characteristics and outcome among patients suffering from in hospital cardiac arrest in relation to the interval between collapse and start of CPR.
        Resuscitation. 2002; 53: 21-27
        • Su L.
        • Waller M.
        • Kaplan S.
        • Watson A.
        • Jones M.
        • Wessel D.L.
        Cardiac resuscitation events: one eyewitness is not enough.
        Pediatr Crit Care Med. 2015; 16: 335-342
        • Harvey A.
        • Bandiera G.
        • Nathens A.B.
        • LeBlanc V.R.
        Impact of stress on resident performance in simulated trauma scenarios.
        J Trauma Acute Care Surg. 2012; 72: 497-503
        • Lubrano R.
        • Cecchetti C.
        • Bellelli E.
        • Gentile I.
        • Loayza Levano H.
        • Orsini F.
        • et al.
        Comparison of times of intervention during pediatric CPR maneuvers using ABC and CAB sequences: a randomized trial.
        Resuscitation. 2012; 83: 1473-1477
        • Sekiguchi H.
        • Kondo Y.
        • Kukita I.
        Verification of changes in the time taken to initiate chest compressions according to modified basic life support guidelines.
        Am J Emerg Med. 2013; 31: 1248-1250
      1. Human Factors and Ergonomics Society Website [cited April 17, 2017].
        2017 (Available from:)
        • Su L.
        Why Studying Human Behavior is a Critical Component of Patient Safety.
        Curr Probl Pediatr Adolesc Health Care. 2015; 45: 367-369
        • Davis B.
        • Welch K.
        • Walsh-Hart S.
        • Hanseman D.
        • Petro M.
        • Gerlach T.
        • et al.
        Effective teamwork and communication mitigate task saturation in simulated critical care air transport team missions.
        Mil Med. 2014; 179: 19-23
        • Helmreich R.L.
        On error management: lessons from aviation.
        BMJ. 2000; 320: 781-785
        • Kolbe M.
        • Grote G.
        • Waller M.J.
        • Wacker J.
        • Grande B.
        • Burtscher M.J.
        • et al.
        Monitoring and talking to the room: autochthonous coordination patterns in team interaction and performance.
        J Appl Psychol. 2014; 99: 1254-1267
        • McComb S.
        • Simpson V.
        The concept of shared mental models in healthcare collaboration.
        J Adv Nurs. 2014; 70: 1479-1488
        • Mathieu J.E.
        • Heffner T.S.
        • Goodwin G.F.
        • Salas E.
        • Cannon-Bowers J.A.
        The influence of shared mental models on team process and performance.
        J Appl Psychol. 2000; 85: 273-283
        • Lim B.-C.
        • Klein K.J.
        Team mental models and team performance: a field study of the effects of team mental model similarity and accuracy.
        J Organiz Behav. 2006; 27: 403-418
        • Fackler J.C.
        • Watts C.
        • Grome A.
        • et al.
        Critical care physician cognitive task analysis: an exploratory study.
        Crit Care. 2009; 13: 8
        • Custer J.W.
        • White E.
        • Fackler J.C.
        • Xiao Y.
        • Tien A.
        • Lehmann H.
        • et al.
        A qualitative study of expert and team cognition on complex patients in the pediatric intensive care unit.
        Pediatr Crit Care Med. 2012; 13: 278-284
        • Flin R.
        • Youngson G.
        • Yule S.
        How do surgeons make intraoperative decisions?.
        Qual Saf Health Care. 2007; 16: 235-239
        • Eberle B.
        • Dick W.F.
        • Schneider T.
        • Wisser G.
        • Doetsch S.
        • Tzanova I.
        Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse.
        Resuscitation. 1996; 33: 107-116
        • Tibballs J.
        • Weeranatna C.
        The influence of time on the accuracy of healthcare personnel to diagnose paediatric cardiac arrest by pulse palpation.
        Resuscitation. 2010; 81: 671-675