Critical Event Checklists for Simulated Pediatric In-hospital Cardiac Arrests in Children with Heart Disease. a Randomized Clinical Trial

Background: Children with cardiac disease are at increased risk of dysrhythmias and in-hospital cardiac arrest (IHCA). Clinician adherence to best practice guidelines has been recognized as one of the most important contributors to improved patient outcomes. This study evaluated whether critical event checklists improve adherence to best practice guidelines during simulated dysrhythmias and cardiac arrest.

Methods: A randomized controlled trial was conducted in a cardiac ward in a tertiary care, academic children’s hospital. Unannounced simulated emergencies involving dysrhythmias resulting in hemodynamic deterioration in pediatric patients with underlying cardiac disease were conducted weekly over six 4-week resident rotations. Simulated dysrhythmias included supraventricular tachycardia, ventricular tachycardia, ventricular fibrillation, and bradycardia. Responders were pediatric and anesthesiology residents and interns, respiratory therapists, and bedside registered nurses. Each team of responders attended an orientation presentation at the beginning of each resident rotation. Teams were randomized to either the intervention (checklist) or control (no checklist) group and voluntarily participated in up to four different simulated scenarios over a 4-week pediatric cardiology rotation. Simulations were followed by debriefs using the PEARLS Healthcare Debriefing Tool. Simulations were video recorded and those with three or more participants were included for analysis. The primary outcome was adherence to best practice, expressed as the percentage of completed critical management steps. Secondary outcomes included participant perceptions of the checklist usefulness in identifying and managing dysrhythmias.

Results: A total of 24 simulations were conducted; one simulation was excluded due to an insufficient number of participants. Eighty one percent (95% confidence interval [CI], 74%-87%) of critical steps were completed with checklists available vs. 68% (95% CI, 60%-75%) without checklists (p < 0.05). Checklist use during resuscitations resulted in a 19% increase in completed critical steps in management. Results were similar in a multivariate analysis with adjustment for code leader level of training. The number of participants per simulation was similar for both study groups. Ninety three percent of study participants reported that they would use the checklists during a real arrest.

Conclusion: Checklists were associated with improved adherence to best practice guidelines during simulated resuscitations for pediatric dysrhythmias. These findings suggest that scenario specific checklists can be useful for the real-life management of dysrhythmias resulting in hemodynamic instability and IHCA in pediatric patients with underlying cardiac disease.