Comparing the Utility of a Standard Pediatric Resuscitation Cart With a Pediatric Resuscitation Cart Based on the Broselow Tape: A Randomize
http://www.100md.com
《小儿科》
Department of Pediatrics, Division of Pediatric Critical Care
Department of Pediatrics, Division of General Pediatrics
Department of Pediatrics, Division of Neonatology, Lucile Packard Children's Hospital, Stanford, California
ABSTRACT
Background. Access to resuscitation equipment is a critical component in delivering optimal care in pediatric arrest situations. Historically, children's hospitals and clinics have used a standard pediatric resuscitation cart ("standard cart") in which drawers are organized by intervention (eg, intubation module, intravenous module), requiring multiple drawers to be opened during a code. Many emergency departments, however, use a pediatric resuscitation cart based on the Broselow tape ("Broselow cart") in which each drawer is color coded and organized by patient length and weight ranges; each drawer contains all necessary equipment for resuscitation of a patient in that specific length/weight range. A literature review has revealed no studies examining the utility of either cart.
Objectives. To compare which resuscitation cart organization (standard versus Broselow) allows for faster access to equipment, more accurate selection of appropriately sized equipment, and better user satisfaction.
Methodology. We performed a prospective, randomized, controlled, crossover trial in which 21 pediatric health care providers were assigned the role of obtaining the appropriate equipment during 2 standardized, simulated codes alternately using either a standard or Broselow cart. Time to and accuracy of the selection of appropriate medical equipment along with posttesting satisfaction were measured. All simulations were performed in the Center for Advanced Pediatric Education at Stanford University Medical Center (Stanford, CA), a training facility designed to replicate the real medical environment with the technology to allow for videotaping of scenarios.
Results. Of the 21 subjects, 62% found the Broselow cart "easy" or "very easy" to use versus 33% for the standard cart. Of the 21 subjects, 67% preferred the Broselow cart, 10% preferred the standard cart, and 23% indicated no preference. Intubation supplies and nasogastric tubes were found significantly faster when using the Broselow cart (mean time: 29.1 and 20 seconds, respectively) versus the standard cart (mean time: 38.7 and 38.2 seconds, respectively). Correct equipment was provided a statistically significant 99% of the time with the Broselow cart versus 83% of the time with the standard cart. Ten percent of the subjects had prior experience with the Broselow cart versus 62% having experience with the standard cart.
Conclusions. Despite less prior experience with the Broselow cart, subjects in this study found it easier to use and preferred it over the standard cart. In addition, subjects located intubation equipment and nasogastric tubes significantly faster when using the Broselow cart, and correct equipment was provided significantly more often with the Broselow cart. These data suggest that sites caring for pediatric patients should consider modeling their resuscitation carts after the Broselow cart to enhance provider confidence and patient safety.
Key Words: critically ill children patient safety pediatric resuscitation pediatric resuscitation carts Broselow color coding
The response time of health care providers in a pediatric arrest is critical to patient survival.1 Quick and easy access to resuscitation equipment is a key component in delivering optimal care. Standard pediatric resuscitation equipment carts have historically been similar to adult resuscitation carts and have drawers organized by intervention: 1 drawer with intubation equipment, 1 with supplies for intravenous access, and 1 with resuscitation medications. During an emergency, multiple drawers must be opened to obtain the equipment necessary for patient stabilization. In addition, the equipment in each drawer must be sorted to find appropriately sized equipment for patients ranging in age from newborns to young adults. Health care professionals unfamiliar with the location of specific items in the cart may cause undue delay in securing the appropriate equipment during resuscitation. The drawers of pediatric resuscitation equipment carts based on the Broselow Pediatric Emergency Tape are color coded and organized by patient length and weight ranges. During an emergency, the Broselow Pediatric Emergency Tape is used to measure the patient's height, and the appropriate color-coded drawer is then opened. Each drawer contains all the equipment necessary for airway management and intravascular access to resuscitate a patient in that specific length/weight range.
Many emergency departments across the country use the Broselow color-coding system to organize their pediatric resuscitation equipment (S.A., unpublished survey data, 2004–2005). Children's hospitals and the pediatric wards of university and community hospitals, however, tend to use the standard organizational system. Our search of the literature found no studies comparing the Broselow resuscitation cart organization with standard resuscitation cart organization. A recent study by Shah et al2 compared a length-based guide of estimating resuscitation medication doses to that of a traditional approach to determining pediatric resuscitation medication doses and found significantly less variation in medication doses when using the length-based estimates. In this study we hoped to expand on this work by comparing the timeliness and accuracy of equipment delivery when using the size-based Broselow resuscitation cart system versus the traditional, standard resuscitation cart system in a simulated environment.
We hypothesized that the size-specific Broselow resuscitation cart would allow faster and more accurate access to the equipment and supplies needed during a pediatric resuscitation. In addition, we hypothesized that health care providers would find the Broselow resuscitation cart easier to use and prefer it over the standard resuscitation cart.
METHODS
We performed a prospective, randomized, controlled, crossover trial in which a convenience sample of 21 pediatric health care providers were asked to find equipment during 2 simulated resuscitation scenarios. The study subjects were randomly assigned to use either a standard resuscitation cart (control) or a Broselow color-coded resuscitation cart (intervention) during their first scenario. They were subsequently assigned to the opposite resuscitation cart during the second scenario.
Study Population
The study population consisted of 21 physicians and nurses at Lucile Packard Children's Hospital at Stanford University Medical Center (Stanford, CA) who are certified pediatric advanced life-support providers and are members of the hospital's pediatric resuscitation response team. The sample size of 21 was determined before enrollment based on the time and cost of using the medical simulator center. Subjects were recruited by using informational fliers distributed within the hospital inviting physicians and nurses to participate. Subjects were enrolled on a first-come, first-served basis. The study was approved by the Stanford University Institutional Review Board, and written informed consent was obtained from all subjects.
Study Methods
The simulated pediatric resuscitation scenarios took place at the Center for Advanced Pediatric Education between October 2003 and April 2004. The Center for Advanced Pediatric Education is a simulation-based training facility designed to replicate any hospital environment. It is outfitted with real, functional medical equipment. The neonatal and pediatric manikins (Neonatal Resuscitation Infant and MegaCode Kid; Laerdal Medical Corp, Wappingers Falls, NY) can be intubated and ventilated and can be altered to mimic many conditions such as open fractures and burns. The waveforms and numeric displays on bedside patient monitors (Neonatal CMS-2001; Agilent Technologies, Palo Alto, CA), controlled remotely by hand-held computers (Patient Monitor Driver; Advanced Medical Simulations, Binghamton, NY) from behind a 1-way mirror, function as surrogates for the vital signs of the manikins. Simulator personnel are skilled in creating the human interactions, stressful conditions, and complex environmental cues that exist in a real hospital environment. Subjects are asked to bring everything to the simulator center that he/she normally brings to his/her regular job in the hospital (eg, stethoscope, pocket handbooks). All of the activities occurring within the simulator space are recorded on digital videotape by multiple ceiling-mounted pan-tilt remote-controlled cameras and adjustable gain microphones.
After thorough orientation to the simulator space and equipment, each subject independently participated in 2 successive, simulated, randomly ordered resuscitation scenarios (an 8-year-old with septic/hypovolemic shock and a 1-year-old with status epilepticus) alternatively using a standard resuscitation cart and a Broselow color-coded resuscitation cart. The standard resuscitation cart was an exact replica of the pediatric resuscitation cart used at our institution (Fig 1 and Table 1). The Broselow resuscitation cart (Armstrong Medical Industries, Inc, Lincolnshire, IL) had color-coded drawers corresponding to particular length/weight ranges on the Broselow pediatric emergency tape (Fig 2 and Table 2). Within each drawer we placed 4 modules (intravenous module, intubation module, intraosseous module, and oxygen-delivery module); each module was placed in a Ziploc bag with a label delineating the contents of the bag. Both scenarios were scripted so that the resuscitation leader (a board-certified pediatrician with extensive experience in teaching through simulated resuscitation scenarios) asked study subjects to hand her specifically sized equipment in a particular order (Table 3). The Broselow tape itself was not used in these simulations, because the subjects were not asked to estimate the patients' weights.
The order of the scenarios and the order of the resuscitation carts were randomized independently by using a random number generator, which resulted in 4 potential pairings for subjects: (1) the Broselow resuscitation cart with the sepsis scenario followed by the standard resuscitation cart with the status epilepticus scenario; (2) the Broselow resuscitation cart with the status epilepticus scenario followed by the standard resuscitation cart with the sepsis scenario; (3) the standard resuscitation cart with the sepsis scenario followed by the Broselow resuscitation cart with the status epilepticus scenario; or (4) the standard resuscitation cart with the status epilepticus scenario followed by the Broselow resuscitation cart with the sepsis scenario. Subjects were randomly assigned to a pairing based on the pregenerated list that was available to study coordinators.
All scenarios were videotaped for data analysis. Subjects evaluated each cart for ease of use and cart preference by completing postscenario questionnaires.
Outcome Measures
The primary outcome measures were the times from the initial request by the resuscitation leader to the subjects' retrieval of the following medical equipment from the resuscitation carts:
endotracheal tube with stylet, laryngoscope with blade;
suction catheter;
nasogastric tube;
intravenous catheter.
These times were measured using the videotaped encounters. For cases in which the wrong piece or size of medical equipment was retrieved, the initial time to retrieve the wrong equipment was added to the time it took to retrieve the correct equipment after a second request from the resuscitation leader. Because data collection was objective in nature, the videotape reviewer (S.S.) was not blinded. Mean times to retrieve each piece of equipment from the 2 resuscitation carts were calculated and compared by using paired t tests. A second outcome measure was accuracy of medical equipment retrieval, which was compared by using the 2-tailed Fisher's exact test. The third outcome measure, ease of use for the resuscitation cart, was obtained by using a postscenario questionnaire, filled out by the study subjects, that used a 5-point Likert scale (from 1 [not at all easy] to 5 [very easy to use]). Finally, cart preference was assessed with a questionnaire filled out by the study subjects after the conclusion of both simulations.
Statistical Analysis
All statistical analyses were conducted based on intention to treat by using SAS 8 (SAS Institute Inc, Cary, NC). There were no subjects who dropped out. A P value of <.05 was taken as statistically significant.
RESULTS
All enrolled subjects completed the study; therefore, by using an intention-to-treat analysis, all subjects were accounted for. The majority of study subjects had prior experience in real pediatric resuscitations and were familiar with the standard resuscitation cart (Table 4). It took significantly more time for subjects to retrieve intubation equipment and nasogastric tubes from the standard resuscitation cart than from the Broselow color-coded resuscitation cart (Table 5). In addition, correct equipment was provided a statistically significant 99% of the time with the Broselow cart versus 83% of the time with the standard cart (Table 6). The perceived ease of use of each resuscitation cart is summarized in Fig 3. Two thirds of the study subjects preferred the Broselow color-coded resuscitation cart over the standard cart (Fig 4).
DISCUSSION
Despite less prior experience with the Broselow color-coded resuscitation cart, the pediatric health care providers in our study found it easier to use and preferred it over the standard resuscitation cart. In addition, the subjects retrieved intubation equipment, nasogastric tubes, and suction catheters faster from the Broselow cart and provided the resuscitation leader with the appropriately sized equipment 99% of the time. These data suggest that sites caring for pediatric patients should consider modeling their resuscitation equipment carts on the Broselow color-coded system to improve the response time of health care providers in pediatric arrest situations.
The Broselow color-coded resuscitation cart has intuitive advantages over the historically used, intervention-based standard resuscitation cart. In the field of pediatrics in which medication dosing and equipment size is determined by patient size, it seems logical that medications and equipment in a pediatric resuscitation cart also be grouped by patient size. Standard pediatric resuscitation equipment carts with drawers organized by intervention are inherently susceptible to delayed or erroneous equipment identification. For example, standard carts require the knowledge of how to estimate patient size and select appropriately sized equipment. Also, opening multiple drawers during a resuscitation event can be physically difficult, because equipment in 1 drawer can obstruct the opening or closing of the drawers immediately above or below it. Finally, once a drawer is open, health care providers still need to sort through multiple sizes of equipment to retrieve the appropriate item. Organizing a pediatric resuscitation cart by patient size, on the other hand, alleviates the need to estimate appropriate sizes of equipment, requires the opening of only 1 drawer, and leads to less sorting through equipment because fewer sizes are in each drawer. These features of the color-coded system used in the Broselow pediatric resuscitation cart allow health care providers to find appropriate equipment quickly and easily and have resulted in it being recommended in the most recent edition of the Textbook of Pediatric Advanced Life Support.3
Reports in both the professional and lay press highlight the seriousness of errors made during the provision of emergency care to children.4–7 The color-coded Broselow pediatric emergency tape and accompanying resuscitation cart, which organizes resuscitation equipment by patient size, was designed in the early 1980s in an effort to reduce the incidence of these medical errors.8 Published research related to the Broselow system has been limited to the verification of the accuracy of the Broselow tape. Several studies have shown that measurement of a pediatric patient's length using the Broselow tape provides an accurate estimate of the patient's weight.9, 10 Recently, the Broselow system was shown to reduce deviations from recommended medication doses and equipment sizes during simulated pediatric resuscitations.2 By directly comparing the functionality of the Broselow color-coded resuscitation cart to the standard resuscitation cart during simulated codes in a realistic setting, this study addresses the question of whether the intuitive advantages of the Broselow cart translate into real advantages at the bedside.
We identified at least 3 potential study limitations. The first limitation involves study design. A crossover design, with each subject serving as his or her own control, was chosen for 2 reasons. First, intersubject variability with regards to clinical experience was kept from confounding the analysis. Second, we were able to increase the statistical power available given the limited number of subjects. Learning effect, a potential problem in crossover trials, describes enhanced performance in a subject's second scenario resulting from participation in and experience gained during his or her first scenario. The influence of the learning effect in this study was minimized by randomizing the order of both the scenarios and type of resuscitation cart. Last, the differences between the 2 scenarios, specifically the size differences between the 2 simulated patients and the inherent differences in equipment sizes, served to reduce the relevant learning carried over from one scenario to the next.
The second limitation is that it is difficult to know if the statistically significant time differences in retrieving appropriate equipment found in this study are clinically significant. Retrieving intubation equipment 10 seconds faster or providing the wrong-sized nasogastric tube may or may not translate into increased patient survival or decreased morbidity. In adults, improved survival after cardiorespiratory arrest is related to early defibrillation.11, 12 Time data in the pediatric populations are currently lacking; however, time to effective ventilation is likely to be critical, because airway/respiratory compromise is a common precipitant of cardiorespiratory arrest in children.1, 3, 13 As increased numbers of institutions implement standard reporting templates for resuscitation events, more specific pediatric data should be available to delineate how time affects patient outcome in a resuscitation.1, 14
A third limitation lies in the study population itself. If this cohort volunteered because they recognized their own lack of resuscitation experience, they could be prone to making more errors, and the times measured in this study may be longer than if a randomized population of nurses and physicians were enrolled. In addition, the majority of our subjects were physicians; in many institutions, nurses obtain equipment during resuscitations. The effect of enrolling more physicians than nurses on the study outcomes is unclear, because both nurses and physicians should be able to find and identify resuscitation equipment in a well-organized pediatric resuscitation cart.
CONCLUSIONS
Based on the findings that the Broselow resuscitation cart decreases time to mobilize resuscitation equipment, increases the accurate selection of equipment, and is the preferred approach by experienced pediatric practitioners, hospitals and clinics caring for pediatric patients should consider grouping resuscitation equipment by patient size (by using the Broselow system) in their resuscitation carts to enhance provider confidence and patient safety. Additional studies are necessary to confirm these findings in the real clinical setting.
FOOTNOTES
Accepted Apr 13, 2005.
No conflict of interest declared.
REFERENCES
Reis AG, Nadkarni V, Perondi MB, Grisi S, Berg RA. A prospective investigation into the epidemiology of in-hospital pediatric cardiopulmonary resuscitation using the international Utstein reporting style. Pediatrics. 2002;109 :200 –209
Shah AN, Frush K, Luo X, Wears RL. Effect of an intervention standardization system on pediatric dosing and equipment size determination: a crossover trial involving simulated resuscitation events. Arch Pediatr Adolesc Med. 2003;157 :229 –236
Hazinski M, ed. Pediatric Advanced Life Support Provider Manual. Dallas, TX: American Heart Association; 2002
Kohn L, Corrigan J, Donaldson M, eds. To Err Is Human: Building a Safer Health System. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine; 2000
Miller MR, Zhan C. Pediatric patient safety in hospitals: a national picture in 2000 [published correction appears in Pediatrics. 2004;114:907]. Pediatrics. 2004;113 :1741 –1746
Bordley WC, Travers D, Scanlon P, Frush K, Hohenhaus S. Office preparedness for pediatric emergencies: a randomized, controlled trial of an office-based training program. Pediatrics. 2003;112 :291 –295
Institute of Medicine. Emergency Medical Services for Children. Washington, DC: National Academy Press; 1993
Broselow J, Luten R, inventors; Vital Signs, Inc, assignee. Broselow pediatric emergency tape. US patents 4713888, December 22, 1987;4823469 , April 25, 1989; and 5010656, April 30, 1991
Black K, Barnett P, Wolfe R, Young S. Are methods used to estimate weight in children accurate Emerg Med (Fremantle). 2002;14 :160 –165
Lubitz DS, Seidel JS, Chameides L, Luten RC, Zaritsky AL, Campbell FW. A rapid method for estimating weight and resuscitation drug dosages from length in the pediatric age group. Ann Emerg Med. 1988;17 :576 –581
Spearpoint KG, McLean CP, Zideman DA. Early defibrillation and the chain of survival in "in-hospital" adult cardiac arrest; minutes count. Resuscitation. 2000;44 :165 –169
Sandroni C, Ferro G, Santangelo S, et al. In-hospital cardiac arrest: survival depends mainly on the effectiveness of the emergency response. Resuscitation. 2004;62 :291 –297
Brown K, Bocock J. Update in pediatric resuscitation. Emerg Med Clin North Am. 2002;20 :1 –26, v
Jacobs I, Nadkarni V, Bahr J, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Councils of Southern Africa). Circulation. 2004;110 :3385 –3397(Swati Agarwal, MD, Suzann)
Department of Pediatrics, Division of General Pediatrics
Department of Pediatrics, Division of Neonatology, Lucile Packard Children's Hospital, Stanford, California
ABSTRACT
Background. Access to resuscitation equipment is a critical component in delivering optimal care in pediatric arrest situations. Historically, children's hospitals and clinics have used a standard pediatric resuscitation cart ("standard cart") in which drawers are organized by intervention (eg, intubation module, intravenous module), requiring multiple drawers to be opened during a code. Many emergency departments, however, use a pediatric resuscitation cart based on the Broselow tape ("Broselow cart") in which each drawer is color coded and organized by patient length and weight ranges; each drawer contains all necessary equipment for resuscitation of a patient in that specific length/weight range. A literature review has revealed no studies examining the utility of either cart.
Objectives. To compare which resuscitation cart organization (standard versus Broselow) allows for faster access to equipment, more accurate selection of appropriately sized equipment, and better user satisfaction.
Methodology. We performed a prospective, randomized, controlled, crossover trial in which 21 pediatric health care providers were assigned the role of obtaining the appropriate equipment during 2 standardized, simulated codes alternately using either a standard or Broselow cart. Time to and accuracy of the selection of appropriate medical equipment along with posttesting satisfaction were measured. All simulations were performed in the Center for Advanced Pediatric Education at Stanford University Medical Center (Stanford, CA), a training facility designed to replicate the real medical environment with the technology to allow for videotaping of scenarios.
Results. Of the 21 subjects, 62% found the Broselow cart "easy" or "very easy" to use versus 33% for the standard cart. Of the 21 subjects, 67% preferred the Broselow cart, 10% preferred the standard cart, and 23% indicated no preference. Intubation supplies and nasogastric tubes were found significantly faster when using the Broselow cart (mean time: 29.1 and 20 seconds, respectively) versus the standard cart (mean time: 38.7 and 38.2 seconds, respectively). Correct equipment was provided a statistically significant 99% of the time with the Broselow cart versus 83% of the time with the standard cart. Ten percent of the subjects had prior experience with the Broselow cart versus 62% having experience with the standard cart.
Conclusions. Despite less prior experience with the Broselow cart, subjects in this study found it easier to use and preferred it over the standard cart. In addition, subjects located intubation equipment and nasogastric tubes significantly faster when using the Broselow cart, and correct equipment was provided significantly more often with the Broselow cart. These data suggest that sites caring for pediatric patients should consider modeling their resuscitation carts after the Broselow cart to enhance provider confidence and patient safety.
Key Words: critically ill children patient safety pediatric resuscitation pediatric resuscitation carts Broselow color coding
The response time of health care providers in a pediatric arrest is critical to patient survival.1 Quick and easy access to resuscitation equipment is a key component in delivering optimal care. Standard pediatric resuscitation equipment carts have historically been similar to adult resuscitation carts and have drawers organized by intervention: 1 drawer with intubation equipment, 1 with supplies for intravenous access, and 1 with resuscitation medications. During an emergency, multiple drawers must be opened to obtain the equipment necessary for patient stabilization. In addition, the equipment in each drawer must be sorted to find appropriately sized equipment for patients ranging in age from newborns to young adults. Health care professionals unfamiliar with the location of specific items in the cart may cause undue delay in securing the appropriate equipment during resuscitation. The drawers of pediatric resuscitation equipment carts based on the Broselow Pediatric Emergency Tape are color coded and organized by patient length and weight ranges. During an emergency, the Broselow Pediatric Emergency Tape is used to measure the patient's height, and the appropriate color-coded drawer is then opened. Each drawer contains all the equipment necessary for airway management and intravascular access to resuscitate a patient in that specific length/weight range.
Many emergency departments across the country use the Broselow color-coding system to organize their pediatric resuscitation equipment (S.A., unpublished survey data, 2004–2005). Children's hospitals and the pediatric wards of university and community hospitals, however, tend to use the standard organizational system. Our search of the literature found no studies comparing the Broselow resuscitation cart organization with standard resuscitation cart organization. A recent study by Shah et al2 compared a length-based guide of estimating resuscitation medication doses to that of a traditional approach to determining pediatric resuscitation medication doses and found significantly less variation in medication doses when using the length-based estimates. In this study we hoped to expand on this work by comparing the timeliness and accuracy of equipment delivery when using the size-based Broselow resuscitation cart system versus the traditional, standard resuscitation cart system in a simulated environment.
We hypothesized that the size-specific Broselow resuscitation cart would allow faster and more accurate access to the equipment and supplies needed during a pediatric resuscitation. In addition, we hypothesized that health care providers would find the Broselow resuscitation cart easier to use and prefer it over the standard resuscitation cart.
METHODS
We performed a prospective, randomized, controlled, crossover trial in which a convenience sample of 21 pediatric health care providers were asked to find equipment during 2 simulated resuscitation scenarios. The study subjects were randomly assigned to use either a standard resuscitation cart (control) or a Broselow color-coded resuscitation cart (intervention) during their first scenario. They were subsequently assigned to the opposite resuscitation cart during the second scenario.
Study Population
The study population consisted of 21 physicians and nurses at Lucile Packard Children's Hospital at Stanford University Medical Center (Stanford, CA) who are certified pediatric advanced life-support providers and are members of the hospital's pediatric resuscitation response team. The sample size of 21 was determined before enrollment based on the time and cost of using the medical simulator center. Subjects were recruited by using informational fliers distributed within the hospital inviting physicians and nurses to participate. Subjects were enrolled on a first-come, first-served basis. The study was approved by the Stanford University Institutional Review Board, and written informed consent was obtained from all subjects.
Study Methods
The simulated pediatric resuscitation scenarios took place at the Center for Advanced Pediatric Education between October 2003 and April 2004. The Center for Advanced Pediatric Education is a simulation-based training facility designed to replicate any hospital environment. It is outfitted with real, functional medical equipment. The neonatal and pediatric manikins (Neonatal Resuscitation Infant and MegaCode Kid; Laerdal Medical Corp, Wappingers Falls, NY) can be intubated and ventilated and can be altered to mimic many conditions such as open fractures and burns. The waveforms and numeric displays on bedside patient monitors (Neonatal CMS-2001; Agilent Technologies, Palo Alto, CA), controlled remotely by hand-held computers (Patient Monitor Driver; Advanced Medical Simulations, Binghamton, NY) from behind a 1-way mirror, function as surrogates for the vital signs of the manikins. Simulator personnel are skilled in creating the human interactions, stressful conditions, and complex environmental cues that exist in a real hospital environment. Subjects are asked to bring everything to the simulator center that he/she normally brings to his/her regular job in the hospital (eg, stethoscope, pocket handbooks). All of the activities occurring within the simulator space are recorded on digital videotape by multiple ceiling-mounted pan-tilt remote-controlled cameras and adjustable gain microphones.
After thorough orientation to the simulator space and equipment, each subject independently participated in 2 successive, simulated, randomly ordered resuscitation scenarios (an 8-year-old with septic/hypovolemic shock and a 1-year-old with status epilepticus) alternatively using a standard resuscitation cart and a Broselow color-coded resuscitation cart. The standard resuscitation cart was an exact replica of the pediatric resuscitation cart used at our institution (Fig 1 and Table 1). The Broselow resuscitation cart (Armstrong Medical Industries, Inc, Lincolnshire, IL) had color-coded drawers corresponding to particular length/weight ranges on the Broselow pediatric emergency tape (Fig 2 and Table 2). Within each drawer we placed 4 modules (intravenous module, intubation module, intraosseous module, and oxygen-delivery module); each module was placed in a Ziploc bag with a label delineating the contents of the bag. Both scenarios were scripted so that the resuscitation leader (a board-certified pediatrician with extensive experience in teaching through simulated resuscitation scenarios) asked study subjects to hand her specifically sized equipment in a particular order (Table 3). The Broselow tape itself was not used in these simulations, because the subjects were not asked to estimate the patients' weights.
The order of the scenarios and the order of the resuscitation carts were randomized independently by using a random number generator, which resulted in 4 potential pairings for subjects: (1) the Broselow resuscitation cart with the sepsis scenario followed by the standard resuscitation cart with the status epilepticus scenario; (2) the Broselow resuscitation cart with the status epilepticus scenario followed by the standard resuscitation cart with the sepsis scenario; (3) the standard resuscitation cart with the sepsis scenario followed by the Broselow resuscitation cart with the status epilepticus scenario; or (4) the standard resuscitation cart with the status epilepticus scenario followed by the Broselow resuscitation cart with the sepsis scenario. Subjects were randomly assigned to a pairing based on the pregenerated list that was available to study coordinators.
All scenarios were videotaped for data analysis. Subjects evaluated each cart for ease of use and cart preference by completing postscenario questionnaires.
Outcome Measures
The primary outcome measures were the times from the initial request by the resuscitation leader to the subjects' retrieval of the following medical equipment from the resuscitation carts:
endotracheal tube with stylet, laryngoscope with blade;
suction catheter;
nasogastric tube;
intravenous catheter.
These times were measured using the videotaped encounters. For cases in which the wrong piece or size of medical equipment was retrieved, the initial time to retrieve the wrong equipment was added to the time it took to retrieve the correct equipment after a second request from the resuscitation leader. Because data collection was objective in nature, the videotape reviewer (S.S.) was not blinded. Mean times to retrieve each piece of equipment from the 2 resuscitation carts were calculated and compared by using paired t tests. A second outcome measure was accuracy of medical equipment retrieval, which was compared by using the 2-tailed Fisher's exact test. The third outcome measure, ease of use for the resuscitation cart, was obtained by using a postscenario questionnaire, filled out by the study subjects, that used a 5-point Likert scale (from 1 [not at all easy] to 5 [very easy to use]). Finally, cart preference was assessed with a questionnaire filled out by the study subjects after the conclusion of both simulations.
Statistical Analysis
All statistical analyses were conducted based on intention to treat by using SAS 8 (SAS Institute Inc, Cary, NC). There were no subjects who dropped out. A P value of <.05 was taken as statistically significant.
RESULTS
All enrolled subjects completed the study; therefore, by using an intention-to-treat analysis, all subjects were accounted for. The majority of study subjects had prior experience in real pediatric resuscitations and were familiar with the standard resuscitation cart (Table 4). It took significantly more time for subjects to retrieve intubation equipment and nasogastric tubes from the standard resuscitation cart than from the Broselow color-coded resuscitation cart (Table 5). In addition, correct equipment was provided a statistically significant 99% of the time with the Broselow cart versus 83% of the time with the standard cart (Table 6). The perceived ease of use of each resuscitation cart is summarized in Fig 3. Two thirds of the study subjects preferred the Broselow color-coded resuscitation cart over the standard cart (Fig 4).
DISCUSSION
Despite less prior experience with the Broselow color-coded resuscitation cart, the pediatric health care providers in our study found it easier to use and preferred it over the standard resuscitation cart. In addition, the subjects retrieved intubation equipment, nasogastric tubes, and suction catheters faster from the Broselow cart and provided the resuscitation leader with the appropriately sized equipment 99% of the time. These data suggest that sites caring for pediatric patients should consider modeling their resuscitation equipment carts on the Broselow color-coded system to improve the response time of health care providers in pediatric arrest situations.
The Broselow color-coded resuscitation cart has intuitive advantages over the historically used, intervention-based standard resuscitation cart. In the field of pediatrics in which medication dosing and equipment size is determined by patient size, it seems logical that medications and equipment in a pediatric resuscitation cart also be grouped by patient size. Standard pediatric resuscitation equipment carts with drawers organized by intervention are inherently susceptible to delayed or erroneous equipment identification. For example, standard carts require the knowledge of how to estimate patient size and select appropriately sized equipment. Also, opening multiple drawers during a resuscitation event can be physically difficult, because equipment in 1 drawer can obstruct the opening or closing of the drawers immediately above or below it. Finally, once a drawer is open, health care providers still need to sort through multiple sizes of equipment to retrieve the appropriate item. Organizing a pediatric resuscitation cart by patient size, on the other hand, alleviates the need to estimate appropriate sizes of equipment, requires the opening of only 1 drawer, and leads to less sorting through equipment because fewer sizes are in each drawer. These features of the color-coded system used in the Broselow pediatric resuscitation cart allow health care providers to find appropriate equipment quickly and easily and have resulted in it being recommended in the most recent edition of the Textbook of Pediatric Advanced Life Support.3
Reports in both the professional and lay press highlight the seriousness of errors made during the provision of emergency care to children.4–7 The color-coded Broselow pediatric emergency tape and accompanying resuscitation cart, which organizes resuscitation equipment by patient size, was designed in the early 1980s in an effort to reduce the incidence of these medical errors.8 Published research related to the Broselow system has been limited to the verification of the accuracy of the Broselow tape. Several studies have shown that measurement of a pediatric patient's length using the Broselow tape provides an accurate estimate of the patient's weight.9, 10 Recently, the Broselow system was shown to reduce deviations from recommended medication doses and equipment sizes during simulated pediatric resuscitations.2 By directly comparing the functionality of the Broselow color-coded resuscitation cart to the standard resuscitation cart during simulated codes in a realistic setting, this study addresses the question of whether the intuitive advantages of the Broselow cart translate into real advantages at the bedside.
We identified at least 3 potential study limitations. The first limitation involves study design. A crossover design, with each subject serving as his or her own control, was chosen for 2 reasons. First, intersubject variability with regards to clinical experience was kept from confounding the analysis. Second, we were able to increase the statistical power available given the limited number of subjects. Learning effect, a potential problem in crossover trials, describes enhanced performance in a subject's second scenario resulting from participation in and experience gained during his or her first scenario. The influence of the learning effect in this study was minimized by randomizing the order of both the scenarios and type of resuscitation cart. Last, the differences between the 2 scenarios, specifically the size differences between the 2 simulated patients and the inherent differences in equipment sizes, served to reduce the relevant learning carried over from one scenario to the next.
The second limitation is that it is difficult to know if the statistically significant time differences in retrieving appropriate equipment found in this study are clinically significant. Retrieving intubation equipment 10 seconds faster or providing the wrong-sized nasogastric tube may or may not translate into increased patient survival or decreased morbidity. In adults, improved survival after cardiorespiratory arrest is related to early defibrillation.11, 12 Time data in the pediatric populations are currently lacking; however, time to effective ventilation is likely to be critical, because airway/respiratory compromise is a common precipitant of cardiorespiratory arrest in children.1, 3, 13 As increased numbers of institutions implement standard reporting templates for resuscitation events, more specific pediatric data should be available to delineate how time affects patient outcome in a resuscitation.1, 14
A third limitation lies in the study population itself. If this cohort volunteered because they recognized their own lack of resuscitation experience, they could be prone to making more errors, and the times measured in this study may be longer than if a randomized population of nurses and physicians were enrolled. In addition, the majority of our subjects were physicians; in many institutions, nurses obtain equipment during resuscitations. The effect of enrolling more physicians than nurses on the study outcomes is unclear, because both nurses and physicians should be able to find and identify resuscitation equipment in a well-organized pediatric resuscitation cart.
CONCLUSIONS
Based on the findings that the Broselow resuscitation cart decreases time to mobilize resuscitation equipment, increases the accurate selection of equipment, and is the preferred approach by experienced pediatric practitioners, hospitals and clinics caring for pediatric patients should consider grouping resuscitation equipment by patient size (by using the Broselow system) in their resuscitation carts to enhance provider confidence and patient safety. Additional studies are necessary to confirm these findings in the real clinical setting.
FOOTNOTES
Accepted Apr 13, 2005.
No conflict of interest declared.
REFERENCES
Reis AG, Nadkarni V, Perondi MB, Grisi S, Berg RA. A prospective investigation into the epidemiology of in-hospital pediatric cardiopulmonary resuscitation using the international Utstein reporting style. Pediatrics. 2002;109 :200 –209
Shah AN, Frush K, Luo X, Wears RL. Effect of an intervention standardization system on pediatric dosing and equipment size determination: a crossover trial involving simulated resuscitation events. Arch Pediatr Adolesc Med. 2003;157 :229 –236
Hazinski M, ed. Pediatric Advanced Life Support Provider Manual. Dallas, TX: American Heart Association; 2002
Kohn L, Corrigan J, Donaldson M, eds. To Err Is Human: Building a Safer Health System. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine; 2000
Miller MR, Zhan C. Pediatric patient safety in hospitals: a national picture in 2000 [published correction appears in Pediatrics. 2004;114:907]. Pediatrics. 2004;113 :1741 –1746
Bordley WC, Travers D, Scanlon P, Frush K, Hohenhaus S. Office preparedness for pediatric emergencies: a randomized, controlled trial of an office-based training program. Pediatrics. 2003;112 :291 –295
Institute of Medicine. Emergency Medical Services for Children. Washington, DC: National Academy Press; 1993
Broselow J, Luten R, inventors; Vital Signs, Inc, assignee. Broselow pediatric emergency tape. US patents 4713888, December 22, 1987;4823469 , April 25, 1989; and 5010656, April 30, 1991
Black K, Barnett P, Wolfe R, Young S. Are methods used to estimate weight in children accurate Emerg Med (Fremantle). 2002;14 :160 –165
Lubitz DS, Seidel JS, Chameides L, Luten RC, Zaritsky AL, Campbell FW. A rapid method for estimating weight and resuscitation drug dosages from length in the pediatric age group. Ann Emerg Med. 1988;17 :576 –581
Spearpoint KG, McLean CP, Zideman DA. Early defibrillation and the chain of survival in "in-hospital" adult cardiac arrest; minutes count. Resuscitation. 2000;44 :165 –169
Sandroni C, Ferro G, Santangelo S, et al. In-hospital cardiac arrest: survival depends mainly on the effectiveness of the emergency response. Resuscitation. 2004;62 :291 –297
Brown K, Bocock J. Update in pediatric resuscitation. Emerg Med Clin North Am. 2002;20 :1 –26, v
Jacobs I, Nadkarni V, Bahr J, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Councils of Southern Africa). Circulation. 2004;110 :3385 –3397(Swati Agarwal, MD, Suzann)