a b s t r a c t

Purpose: Approximately 14 000 pediatric out-of-hospital arrests occur annually. With this significant number and the diversity in the training backgrounds of medical providers, correct choice and placement of defibrillator pads are imperative to ensure maximum efficacy.

Methods: One hundred fifty-two Emergency medical care providers from 6 medical fields were recruited for the study. Each participant answered a series of questions to ascertain baseline knowledge of correct defibrillator pad choice and placement in 2 scenarios with mannequins weighted less than 15 kg and more than 15 kg. After the testing, each participant received an educational intervention. Six months after the first phase, participants received a questionnaire to ascertain knowledge retention.

Results: In the primary study phase, for correct pad choice for mannequins weighing less than 15 kg and more than 15 kg, overall results were 98% (95% confidence interval [CI], 94.1%-100%) and 38.8% (95% CI, 31.4%- 46.8%), respectively. In the second phase, pad choices for mannequins weighing less than 15 kg and more than 15 kg were 77.3% (95% CI, 68.6%-84.2%) and 60% (95% CI, 47.7%-71.1%). The rates of correct pad placement during the initial phase for mannequins weighing less than 15 kg and more than 15 kg were 5.8% (95% CI, 2.8%-11.2%) and 25.7%, respectively (95% CI, 19.4%-35.7%). Rates for correct pad placement (b 15-kg and N 15-kg mannequins) improved in the second phase to 68.2% (95% CI, 56%-78.4%) and 71.2% (95% CI, 62.8%-81.5%).

Conclusion: Pediatric emergency providers have poor understanding of pad choice and placement. Emergency medical care providers for children who are educated about the correct defibrillator pad choices and placement have improved knowledge and can retain that knowledge for at least 6 months.

(C) 2014

Introduction

The reported incidence of Pediatric out-of-hospital cardiac arrest varies from 2.6 to 19.7 cases a year per 100 000 [1]. An overall survival rate of hospital discharge is approximately 13% in all children with cardiopulmonary arrest in out-of-hospital and in-hospital settings combined [2].

? Prior presentations: American Academy of Pediatrics National Conference October 2012, New Orleans, LA (Phase 1 and 2 data); American College of Emergency Medicine October 2011, San Francisco, CA (phase 1 data only); and American Federation of Medical Research Eastern Regional Meeting, April 2012 (phase 1 data Only) Washington, DC-Awarded AFMR Eastern Regional Meeting Notable Poster Award.

?? Funding sources/disclosures: Inova Research Seed (Grant No. 10.098).

* Corresponding author. Division of Pediatric Emergency Medicine, Emory University School of Medicine, 1645 Tullie Circle, Atlanta, GA 3032. Tel.: +1 404 785

7141; fax: +1 404 785 7989.

E-mail addresses: [email protected], [email protected] (K.N. Fraser), [email protected] (M.M. Kou), [email protected] (J.M. Howell), [email protected] (K.T. Fullerton), [email protected] (C. Sturek).

In children, ventricular fibrillation is responsible for 5% to 15% of pediatric out-of-hospital arrests. The survival rate in pediatric in- hospital, pulseless cardiac arrest is 27% [2,3]. In studies of adult patients, the likelihood of survival from ventricular fibrillation decreases from 7% to 10% with each minute of delay to defibrillation after cardiac arrest [4]. Consequently, it is imperative that personnel are well educated in proper cardiopulmonary resuscitation manage- ment including defibrillator pad placement and usage. Because the outcome of return to spontaneous circulation is better for ventricular fibrillation than for pulse cardiac arrest, correct pad placement and usage may increase survival.

In 2005, the American Heart Association (AHA) guidelines stated that 1 paddle should be placed over the right side of the upper chest and the other at the apex of the heart to the left of the nipple over the left lower ribs [5]. The 2010 AHA guidelines were less restrictive and indicated that anterolateral, anteroposterior, anterior-left infrascap- ular, and anterior-right infrascapular were equally effective to treat atrial or ventricular arrhythmias [6]. A few studies have also noted

http://dx.doi.org/10.1016/j.ajem.2013.11.016

0735-6757/(C) 2014

Fig. 1. Correct placement of defibrillator pad per AHA guidelines.

that transthoracic impedance decreases with larger pad size but increases when placing pads to close together [7]. Correct placement of defibrillator pad per AHA guidelines is noted in Fig. 1.

Of note, there have been very few studies testing the resuscitation knowledge of pediatric medical personnel, specifically that of defibrillator pads. Our study is the first to identify pediatric medical care providers’ knowledge of defibrillator pad choice and placement. The goal of this study was to measure the baseline fund of knowledge of various emergency providers regarding choice and proper placement of defibrillator pads in children. An educational module was designed and implemented to improve providers’ knowledge and test knowledge retention in these areas. We hypothesized that an educational intervention would significantly improve fund of knowledge regarding the choice and proper placement of defibrillator pads in children. By improving the baseline knowledge of personnel in our facility as well as the Prehospital personnel with whom we collaborate, we hoped to ensure correct choice and placement of defibrillator pads in pediatric patients.

Ultimately, our aim was to improve the survival rate of pediatric patients who have a cardiac arrest in a “shockable rhythm.”

Methods

This observational educational interventional study was approved by the Inova Health Systems Institutional Review Board and funded by an Inova Research Seed Grant. The study was conducted from October 2010 to March 2011. To capture a realistic sample of providers who might respond to the resuscitation of a Pediatric cardiac arrest patient, emergency medical care providers were recruited from 6 medical fields. Participants were automatically included if they agreed to participate and fit the category of healthcare specialists from the following groups: emergency medicine attendings (EMs), emergency medicine residents (EMRs), pediatric residents (PRs), pediatric emergency department nurses (PEDN), adult emergency department nurses (AEDN), and prehospital personnel (emergency medical services [EMS]). The EM cohort included local participants from 3

academic institutions and 1 community hospital. The EMR group consisted of residents from 2 different EM programs. The PR, PEDN, and AEDN groups were all from 1 single large academic institution. Finally, the EMS group comprised 2 different regional EMS organizations and included some hospital-based EMS personnel. Participants who did not represent the 6 medical fields identified for comparison were not included. Fig. 2 notes the percent participation by participant type.

Participants completed a demographic sheet that included e-mail addresses for further contact (but no other identifying information). Demographics included relevant details pertaining to occupation, years of experience, pediatric advanced life support (PALS) certifica- tion, date of certification, percent of medical care they provided to children, and number of pediatric codes witnessed in the past year. Table 1 notes the demographic breakdown of the participants.

Phase 1

Baseline assessment was performed on participants individually in 2 brief scenarios portraying a pulseless patient (mannequin) in ventricular tachycardia, the first patient (mannequin) weighing less than 15 kg and the second patient (mannequin) weighing more than 15 kg. The participants were explicitly told the weight of the subjects at the beginning of each simulated scenario. Each simulated resuscitation scenario took no more than 90 seconds to complete. After being presented with an electrocardiogram dem- onstrating ventricular tachycardia, each participant was asked to identify the rhythm and choose from a selection the correct size of Medtronic defibrillator pads (Physio-Control Lifepack 500 Edge Redi Pak Electrode for N 15 kg and Physio-Control Inc Redmond, WA Lifepack Pediatric b 15 kg) and, lastly, to position the pads on the mannequin. The lead investigator documented the performance of each subject. A research assistant helped with setup and scenario changes. Each participant’s placement of the defibrillator pads was photographed for review at a later time to evaluate placement. Choices of pad size and placement were recorded as dichotomous outcomes: correct or incorrect. Photographs were used to confirm outcome accuracy. The primary investigator measured outcomes in an unblinded manner.

Directly after the completion of the scenarios, each participant received an educational intervention. The primary investigator described proper placement and size of defibrillator pads reinforcing the script visually with a mannequin demonstrating the correct pad choice and placement. The educational intervention explicitly out- lined the correct size and placement of defibrillator pads and choice

Fig. 2. Percent participation by participant type.

Phase 2“>Table 1

Demographic characteristics of study participants

Table 3

Choice of pads for mannequins weighing less than 15 kg

Characteristic PRs

EMRs

PEDNs

EMs

Prehospital

AEDNs

Participants Simulation (pre) results Survey (post) results

(n = 35) (n = 27) (n = 13) (n = 26) personnel

(n = 22)

Percent correct CI Percent correct CI

(EMS; n = 29)

PRs	100.0	88.2-100	64.0	44.4-77.8
EMRs	96.3	80.2-100	82.6	62.3-93.6
EMs	96.0	78.9-100	80.0	47.9-95.4
PEDNs	100.0	73.4-100	81.3	56.2-94.2
Prehospital	96.7	81.9-100	86.4	65.8-96.1

Years since professional school

<=3	95%	100%	69%	65%	66%	86%
N 3	5%	0%	31%	35%	28%	14%

Taken PALS course

Yes	100%	30%	100%	81%	75%	55%
No	0%	70%	0%	19%	24%	45%

Percent of pediatric patient encounters b 18 y

b25	0%	77%	0%	81%	66%	92%
25-50	9%	22%	0%	15%	26%	4%
50-75	9%	0%	8%	4%	0%	0%
75-99	82%	0%	15%	0%	0%	4%
100	0%	0%	77%	0%	7%	0%
No. of medical resuscitations last year
b10	97%	97%	91%	86%	100%	100%
10-15	3%	4%	8%	0%	0%	0%
N 15	0%	0%	0%	4%	0%	0%

directly after their completion of their baseline knowledge assess- ment. The participant was able to visually identify, based on AHA guidelines, the correct pad placement on mannequins that were used specifically for the educational environment.

2.1. Phase 2

In the second phase of the study, each participant was contacted at 6 months after the initial assessment and asked to complete a questionnaire via Survey Monkey [8]. The intent of the questionnaire was to determine if participants could continue to correctly identify proper choice and placement of defibrillator pads over time. After submission of the questionnaire, each participant was awarded a nominal gift for study completion. The overall survey response rate was 72% (Table 2).

To calculate the sample size in our study, it was predicted a priori that a 30% difference in pad placement and choice would be clinically significant. Our review of the emergency medicine literature did not identify data that described differences in knowledge of paddle placement between various trained emergency care providers, but a study of cardiologists and other groups of trained physicians from India demonstrated an 80% difference in rates of proper placement between groups. Differences among noncardiologist providers were not investigated [9].

The Power calculation estimated that a sample size of 180 subjects would have a power of 80% to detect a 30% difference in rate among subgroups.

After enrollment of 155 participants, a statistical difference was noted, and enrollment of participants was discontinued. Descriptive statistics were calculated, and subgroups were analyzed using either the Fisher exact test or ?² test. ? Value was set at .05 for all comparisons. Data were analyzed using SPSS statistics, v. 21 (IBM, Inc, Chicago, IL).

personnel (EMS)

AEDNs	100.0	82.5-100	71.4	11.3-55
Total group 3. Results	98.0	94.1-100	77.3	68.6-84.2

One hundred fifty-five participants were initially enrolled in this study. The study group of 152 subjects included 35 PRs, 27 EMRs, 13 PEDNs, 26 EMs, 29 prehospital personnel (EMS), and 22 AEDNs. Three PEDNs were excluded because a different mannequin was used during the initial data collection.

Tables 3 through 6 contain baseline and 6-month outcomes for knowledge of correct choice and placement of defibrillator pads by provider type. In the testing scenarios, the specific weight of the mannequin was described for the participant. For purposes of education, the existing 2 sizes of defibrillator pads (for patients b 15 kg and N 15 kg) were used. Among all participants, pad choice for the mannequins weighing less than 15 kg decreased during the study period from 98% (95% confidence interval [CI], 94.1%-100%) to 77.3% (95% CI, 68.6%-84,2%), but increased for the larger mannequin (N 15 kg) from 38.8% (95% CI, 31.4%-46.8%) to 60% (95% CI, 47.7%-

71.1%). Correct pad placement improved for both size mannequins from 5.8% (95% CI, 2.8%-11.2%) and 25.7% (95% CI, 19.4%-35.7%) to

68.2% (95% CI, 56%-78.4%) and 71.2% (95% CI, 62.8%-81.5%).

Based on hypothesis testing, providers without PALS experience performed better at placement of pads in mannequins weighing more than 15 kg than providers who had taken PALS. However, the CIs for these rates overlapped (PALS experience: 20.2% [95% CI, 13.7%-28.7%] vs 39.5% [95% CI, 26.3%-54.4%]). Providers who were trained by PALS and those not trained by PALS did not significantly differ regarding pad choice in both mannequins or placement in the mannequin weighing less than 15 kg.

In addition, there were no significant differences in choice or placement among participants who had multiple pediatric resuscita- tion experience compared with those who had limited pediatric code experience. These data are based on phase 1 of simulation. There were no significant differences in pad choice or placement based on percent of medical care provided to pediatric patients, except for those participants who had less than 25% of their practice comprising pediatric patients compared with those who had 100% of their practice comprising pediatric patients. This is denoted in Table 7. In participants who identified that they spent less than 25% of their patient care managing pediatric patients, pad placement and choice

Table 2

Survey response rate

Table 4

Choice of pads for mannequins weighing more than 15 kg

Participants Simulation (pre) results Survey (post) results

Survey participants	Percent responded			Percent correct	CI		Percent correct	CI
PRs	62% (22/35)		PRs	48.6	33-64.4		56.0	31.1-73.4
EMRs	85% (23/27)		EMRs	37.0	21.5-55.8		52.2	33-70.8
EMs	69% (18/26)		EMs	32.0	17.1-51.7		100.0	68-100
PEDNs	69% (9/13)		PEDNs	92.3	64.6-100		50.0	28-72
Prehospital personnel	62% (18/29)		EMS	26.7	14-44.7		45.5	28.9-63.4
AEDNs	63% (14/22)		AEDNs	18.2	6.7-39.1		85.7	58.8-97.2
Overall response rate	72%		Total group	38.8	31.4-46.8		60.0	47.7-71.1

Table 5

Pad placement for mannequins weighing less than 15 kg

Participants Simulation (pre) results Survey (post) results

	Percent correct	CI		Percent correct	CI
PRs	3.6	b0.01-19.2		72.0	52.2-85.9
EMRs	11.1	3-28.9		60.9	40.7-77.9
EMs	4.0	b 0.01-21.1		50.0	23.7-76.3
PEDNs	0.0	0-27		75.0	50-90.3
EMS	10.0	2.7-26.4		72.7	51.6-87.1
AEDNs	0.0	0-17.6		71.4	45-88.7
Total group	9.2	5.5-15		68.2	56-78.4

were not as accurate as those who spent 100% of their practice with pediatric patients.

4. Discussion

It is difficult to state how many cardiac arrests and subsequent deaths could be eliminated with proper knowledge of defibrillator pad position and placement. What is known is that incorrect placement can increase transthoracic impedance. Correctly sized defibrillator pads are designed for certain weighted patients, and incorrect sizing can lead to inadequate defibrillation.

Existing resuscitation literature demonstrates that in the place- ment of traditional defibrillator paddle, the adherence to paddle placement guidelines is poor. Such studies may be used in comparison owing to the similarities to the placement of pads vs paddles, and few to no studies have been performed using adhesive chest defibrillator pads. A study from England recruited 101 residents and attending staff to defibrillate a mannequin and showed that 65% of sternal paddles were placed within 5 cm of the position recommended by the European Resuscitation guidelines (similar guidelines to AHA). Most of the apical paddles were placed too medially and too cephalad, with only 22% placed within 5 cm of the position recommended [10]. An Indian study attempting to replicate these data with a larger group of physicians noted that only 17% of the total of 1187 physicians chose the correct position of both the paddles. The right sternal paddle was correctly placed by 35% of subjects, whereas the left paddle was correctly located by 17% of participants. Both paddle positions were wrongly depicted in 29% of physician subjects. Of note, 90% of cardiologists placed both paddles in the correct position [9]. Finally, a Japanese study of resuscitation skills of 33 teams of physicians, nurses, and paramedics noted that none of the teams correctly placed the sternal paddles in the proper position based on the European Resuscitation Council method [11]. Because it is very infrequent that cardiologists are the First responders on site when a cardiac arrest occurs, our study sought to determine the knowledge of personnel likely to be first responders and then provide an educational experience on proper pad placement. The paucity of studies with defibrillator pads further highlights the importance of our investiga-

Table 6

Pad placement for mannequins weighing more than 15 kg

Participants Simulation (pre) result Survey (post) results

	Percent correct	CI		Percent correct	CI
PRs	20.0	9.7-36.2		80.0	60.4-91.6
EMRs	37.0	21.5-55.8		60.9	40.7-77.9
EMs	16.0	5.8-35.2		80.0	47.9-95.4
PEDNs	30.8	12.4-58		87.5	62.7-97.8
EMS	26.7	14-44.7		59.1	38.7-76.8
AEDNs	27.3	12.9-48.4		71.4	45-88.7
Total group	25.7	19.4-35.7		71.8	62.8-81.5

Table 7

Percent of pediatric practice in reference to pad placement and choice

% of practice pediatric population CIs

b25% pediatric experience 26.3 (17.8-36.9)

100% pediatric experience 56.1 (40-70.1)

tion, which is one of the only studies that evaluates proper pad placement. Because choice of pads is another factor, this also further elucidates the need for evaluation of proper choice by medical care providers.

In this study, the 6 different groups of participants were intended to create a realistic sampling of medical providers who may respond to pediatric cardiac arrest. The heterogeneity of our participants may have led to multiplicity of results. However, this did not affect our initial result because each group had poor initial results and all groups improved with educational intervention.

It is unclear why the percent correct choice for the mannequins weighing less than 15 kg decreased in the second survey. It may have been the wording used to identify the smaller mannequin, but it was more likely associated with the artificiality of the survey compared with hands-on use of the mannequin. It is also unclear if participants were hypervigilant due to past errors and mistakenly chose the wrong pads. It is important to note that placing larger pads on smaller patients is more effective than no pads at all or the reverse smaller pads on larger patients.

Our study demonstrated that many of the health care providers either were not aware of product labeling or did not recall the proper placement of the product. In this era of new and improved technologies, it is important for clinicians to keep abreast of the use of each new product they are tasked to work with. During discussions with study participants, we noted that some were not aware of correct pad and position placement even after recently having taken PALS. This is possibly because the participant focused on portions of the PALS course that were relevant to their role or because proper pad placement and choice are not part of the educational outline of PALS for hospital monitor/defibrillator. Pediatric nurses appeared to be more knowledgeable about correct choice of pads but still performed poorly in comparison with AEDNs and EM residents in the placement of the pads. This is probably explained by the relatively increased frequency in which defibrillation is performed in adult patients. Some participants verbalized that they felt that knowledge of size and placement was not part of their responsibility. The latter point is particularly cogent as the medical field becomes more subspecialized; expertise that was once within a person’s Scope of practice may now not be part of their job expectations. However, at the very least, it is the responsibility of the resuscitation team leader to be knowledge- able about the correCT usage of any equipment required during a pediatric resuscitation. In addition, because defibrillation is recom- mended as the first intervention for a patient in ventricular fibrillation or pulseless ventricular tachycardia, all potential first responders should be competent regarding pediatric pad choice and placement. With respect to the potential benefit of a postassessment educational intervention, our analysis noted that overall improvement on placement and choice occurred across each group and the knowledge of correct placement could be retained for greater than 6 months. The continuing aim of our research was to educate the study participant on proper pad placement and choice of pads. With proper education, we can ensure improved knowledge in the care of pediatric patients and improved pediatric survival in defibrillation.

Study limitations included a convenience sample of participants

who were recruited at specific but variable times throughout the day. A few participants were interrupted by work-related telephone calls during the clinical assessment scenario. The artificiality of using a simulated scenario and mannequin to ascertain knowledge may also

have affected participants’ performance and reactions, which might have been more accurate when performing tasks on Live patients. This was not assessed.

Another limitation is the generalizabilty of our study population to other institutions. Whereas the EM, EMR, and EMS subgroups reflected an entire population of potential providers, the groups of registered nurses were employed at a single institution. The sub- groups of registered nurses did come from separate working environments, however, and did show subsequent performance improvements. It is also important to highlight the diversity of the EM, EMR, and EMS groups that are most likely to be first responders in a true pediatric arrest.

We were unable to perform follow-up testing in the same format as the pretest because of the constraints of subject availability (with numerous participants involved in their final year of graduate medical education). An online survey tool allowed us to use textual and graphic stimuli that mimicked the first phase of the study. The questionnaire response rate was 110 of 151. Thus, the timing of the second phase of our study led to a loss of 28% of our initial participants. The significant numbers of returned completed ques- tionnaires still allowed us to achieve statistical significance in placement and pad choice. Numerous studies have shown that it takes 6 months to determine if retention of information has been maintained [8,12,13].

Pediatric resuscitations and cardiac arrest are fortuitously a rare event. When they occur, it is essential that emergency medical providers are knowledgeable of the proper placement and type of pads to be used for defibrillation and cardioversion. Our study demonstrated that although pad choice and placement are part of the AHA guidelines, PALS certification had no bearing on correct pad choice and placement. This investigation also showed significant overall improvement in the performance of 6 groups of care providers after a standardized educational intervention. The extent of improve- ment in knowledge that can be embedded in such a short time frame in providers with multiple backgrounds shows the benefit of our study and supports further research to be performed in this area of pediatric resuscitation [14-16].

As we look to the future of this research endeavor, subsequent iterations of this study may benefit from using similarly skilled participants, with a simulated high-fidelity mannequin and/or standardized patients in both the primary knowledge assessment and follow-up retention evaluation. It would also be useful to analyze the impact of this intervention in a wider population of physicians and trainees including pediatric cardiologists, intensivist, and other

providers involved in pediatric critical care. Greater emphasis on defibrillator pad choice and placement in standardized advanced life support courses might also effect greater change in cardiac arrest Life expectancy.

Acknowledgments

The authors thank Kathi Huddleston, Former Director of Pediatric Clinical Research at Inova Fairfax Hospital for Children.

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