Presentation
Development of a Novel Cardiac Arrest Ventilation Rate Metronome: A Human Factors and Implementation Science Approach
DescriptionBackground:
Pediatric in-hospital cardiac arrest (IHCA) is a serious problem that affects 18,000 children in the US each year. Less than half of these children survive their hospitalization, and among those who do, neurological morbidity is common. Previous investigations have demonstrated that while high-quality cardiopulmonary resuscitation (CPR) has been shown to improve IHCA outcomes, deviations from expert consensus guidelines are also common.
Most pediatric IHCAs have preceding respiratory pathophysiology, highlighting the importance of ensuring optimal ventilation during CPR. However, resuscitation teams infrequently achieve guideline-adherent ventilation rates. In a previous multicenter study of ventilation during pediatric CPR, 0/52 events had ventilation rates within goal range.
Recent pediatric data shows a 20% increase in survival with a favorable neurologic outcome with ventilation rates of 20-30 breaths per minute (bpm) during CPR. Given these data, the 2020 American Heart Association (AHA) life support guidelines changed the recommended ventilation rate during pediatric CPR with an advanced airway from 10 bpm to 20-30 bpm. As demonstrated in investigations of medication administration during cardiac arrests, clinicians often demonstrate slow uptake of recommended practices when AHA guidelines change. To date, there is a paucity of data on effective strategies to achieve guideline-adherent ventilation rates.
This presentation will summarize our team’s work to address this problem by designing a cardiac arrest ventilation rate metronome that has been implemented in our pediatric intensive care unit (PICU) to improve ventilation delivery during CPR utilizing human factors engineering and implementation science principles.
Metronome Development:
Our multidisciplinary team constructed a study framework utilizing the SEIPS 2.0 model with a macroergonomic description of the relevant subsystems. Local PICU guideline-adherent goal ventilation rates for CPR with an advanced airway were established by physician consensus: infants (<1 year): 30 bpm; children (1-17 years): 20 bpm; and adults (18 years and older): 10 bpm. This process was necessary given that the guidelines recommended a range of ventilation rates (20-30 bpm) for children while adult guidelines remain at 10 bpm.
We then conducted a contextual inquiry to assess clinicians’ perspectives on the acceptability, feasibility, and appropriateness of our proposed CPR ventilation metronome using purposive comprehensive sampling. The majority (74%) of the 107 respondents had participated in >10 cardiac arrests. Appropriateness, acceptability, and feasibility of the ventilation metronome were adequate with median scores of 4 (IQR 4,5), 4 (IQR 3,5), and 4 (IQR 4,4.5), respectively, on the 5-point Likert scale of the validated Implementation Appropriateness, Acceptability of Implementation, and Feasibility of Intervention Measures. Identified potential barriers to implementation of the proposed intervention were most commonly related to 1) cognitive taskload (personnel subsystem), 2) volume/noise (internal environment), and 3) patient-specific factors (technical subsystem).
In order to offer users the 3 required rate options in a physical device available in the care environment, the team decided to create a prototype of a simple digital app to be installed onto smartphones and attached to a physical cart available during CPR events. The app allows staff to select the metronome rate and also includes a visual cue for the metronome’s beat. A smartphone was chosen since it provides an intuitive interface and audio in a single device and offers ease of maintenance and replacement.
We held simulation sessions with PICU clinicians for metronome development and iterative refinement. Pause-and-reflect technique, semi-structured debriefs, and direct observations by study members were utilized. Specific areas of focus included: 1) audio; 2) visual; 3) controls; 4) placement; and 5) overall interaction with resuscitation care. Ultimately, consensus was reached on a design with options for rates of 10, 20, and 30 bpm. A wooden bell sound was selected for high saliency in loud clinical environments. Visual cues including color change of the selected rate and a scrolling bar were adopted. If needed, the smartphone can be removed from the CPR cart and placed in a more optimal location for the specific team and equipment configuration.
One notable finding from the design sessions revealed a potential patient safety issue with the metronome audio. The initial prototype sound was a rush of air. However, clinicians providing ventilations felt that their instinct was to provide a ventilation throughout the ‘whoosh’ sound, thereby changing the volume of the breath delivered. This sound was eliminated from the intervention to avoid the unintended consequence of altering the ventilation volume, which should be provided according to cardiac arrest guidelines and cannot be standardized to a particular duration of time.
Usability Testing:
After consensus was reached on the design, high-fidelity simulation usability testing was conducted. The team composition, scenario, and environment were constructed to resemble the macroergonomics of PICU resuscitations. Study team members observed team performance and semi-structured debriefs were held at the completion of each session. Participants were specifically asked if they made or could foresee making errors due to incorporating the ventilation metronome into the work system. Participants completed the System Usability Scale (SUS), with acceptable scores defined as a median SUS>68. Average ventilation rates were calculated during 30-second epochs of uninterrupted CPR with ventilation metronome use, with an average rate +/-2 bpm from the stated target considered to be within goal range.
Among 34 clinicians in three groups, the median SUS was 92.5 (IQR 85, 94.4). There were zero errors attributed to metronome use. Of 36 total uninterrupted 30-second epochs of CPR with ventilation metronome use, 34 (94%) had ventilation rates within goal range. There was consensus that the ventilation metronome did not distract from other tasks and was helpful to the clinician providing ventilations. These promising data were sufficient to proceed with a trial of the cardiac arrest ventilation metronome in our PICU.
Clinical Application:
The metronome was implemented in the Children’s Hospital of Philadelphia PICU, a 75-bed medical-surgical unit, in May 2024. Of eight cardiac arrests with an advanced airway in place and a CPR duration of greater than or equal to 2 minutes, the ventilation metronome was utilized in 5/8 (62.5%). Nearly half (44.4%; 8/18) of the epochs of CPR occurring with ventilation metronome use had ventilation rates within goal range, while 6.7% (1/15) of the CPR epochs without ventilation metronome use had ventilation rates within goal range. Median SUS score was 97.5 (IQR 74, 100; n=6). Narrative feedback from noted that: 1) the metronome did not distract resuscitation team members from other tasks and 2) it was less feasible to activate the metronome during relatively short (2-3 minute) events. Of note, multiple clinicians have provided feedback that a cognitive aid for the recommended ventilation rate for each age group would be helpful. We hypothesize that this knowledge gap has been identified because clinicians are more likely to discuss the goal ventilation rate since implementation of our intervention.
Importance and Conclusions:
Appropriate ventilation is an important component of high-quality CPR which is essential for better resuscitation outcomes. For children, a group in which the majority of cardiac arrests have preceding respiratory pathophysiology, reversing or avoiding inadequate ventilation can be especially important.
Ensuring adequate ventilation during pediatric CPR requires creating systems of care that enable clinicians to achieve goal rates. Utilizing human factors engineering and implementation science principles, we have successfully designed a digital audiovisual cardiac arrest ventilation metronome with high usability scores that has been implemented in a pilot trial during PICU cardiac arrests in our center.
While previous studies have demonstrated the utility of implementation science and human factors engineering in understanding and mitigating performance gaps in resuscitation care, this methodology remains underutilized to date, particularly in pediatric resuscitation science. Leveraging the strengths of human factors engineering is necessary to optimally address the complex drivers of resuscitation performance.
Pediatric in-hospital cardiac arrest (IHCA) is a serious problem that affects 18,000 children in the US each year. Less than half of these children survive their hospitalization, and among those who do, neurological morbidity is common. Previous investigations have demonstrated that while high-quality cardiopulmonary resuscitation (CPR) has been shown to improve IHCA outcomes, deviations from expert consensus guidelines are also common.
Most pediatric IHCAs have preceding respiratory pathophysiology, highlighting the importance of ensuring optimal ventilation during CPR. However, resuscitation teams infrequently achieve guideline-adherent ventilation rates. In a previous multicenter study of ventilation during pediatric CPR, 0/52 events had ventilation rates within goal range.
Recent pediatric data shows a 20% increase in survival with a favorable neurologic outcome with ventilation rates of 20-30 breaths per minute (bpm) during CPR. Given these data, the 2020 American Heart Association (AHA) life support guidelines changed the recommended ventilation rate during pediatric CPR with an advanced airway from 10 bpm to 20-30 bpm. As demonstrated in investigations of medication administration during cardiac arrests, clinicians often demonstrate slow uptake of recommended practices when AHA guidelines change. To date, there is a paucity of data on effective strategies to achieve guideline-adherent ventilation rates.
This presentation will summarize our team’s work to address this problem by designing a cardiac arrest ventilation rate metronome that has been implemented in our pediatric intensive care unit (PICU) to improve ventilation delivery during CPR utilizing human factors engineering and implementation science principles.
Metronome Development:
Our multidisciplinary team constructed a study framework utilizing the SEIPS 2.0 model with a macroergonomic description of the relevant subsystems. Local PICU guideline-adherent goal ventilation rates for CPR with an advanced airway were established by physician consensus: infants (<1 year): 30 bpm; children (1-17 years): 20 bpm; and adults (18 years and older): 10 bpm. This process was necessary given that the guidelines recommended a range of ventilation rates (20-30 bpm) for children while adult guidelines remain at 10 bpm.
We then conducted a contextual inquiry to assess clinicians’ perspectives on the acceptability, feasibility, and appropriateness of our proposed CPR ventilation metronome using purposive comprehensive sampling. The majority (74%) of the 107 respondents had participated in >10 cardiac arrests. Appropriateness, acceptability, and feasibility of the ventilation metronome were adequate with median scores of 4 (IQR 4,5), 4 (IQR 3,5), and 4 (IQR 4,4.5), respectively, on the 5-point Likert scale of the validated Implementation Appropriateness, Acceptability of Implementation, and Feasibility of Intervention Measures. Identified potential barriers to implementation of the proposed intervention were most commonly related to 1) cognitive taskload (personnel subsystem), 2) volume/noise (internal environment), and 3) patient-specific factors (technical subsystem).
In order to offer users the 3 required rate options in a physical device available in the care environment, the team decided to create a prototype of a simple digital app to be installed onto smartphones and attached to a physical cart available during CPR events. The app allows staff to select the metronome rate and also includes a visual cue for the metronome’s beat. A smartphone was chosen since it provides an intuitive interface and audio in a single device and offers ease of maintenance and replacement.
We held simulation sessions with PICU clinicians for metronome development and iterative refinement. Pause-and-reflect technique, semi-structured debriefs, and direct observations by study members were utilized. Specific areas of focus included: 1) audio; 2) visual; 3) controls; 4) placement; and 5) overall interaction with resuscitation care. Ultimately, consensus was reached on a design with options for rates of 10, 20, and 30 bpm. A wooden bell sound was selected for high saliency in loud clinical environments. Visual cues including color change of the selected rate and a scrolling bar were adopted. If needed, the smartphone can be removed from the CPR cart and placed in a more optimal location for the specific team and equipment configuration.
One notable finding from the design sessions revealed a potential patient safety issue with the metronome audio. The initial prototype sound was a rush of air. However, clinicians providing ventilations felt that their instinct was to provide a ventilation throughout the ‘whoosh’ sound, thereby changing the volume of the breath delivered. This sound was eliminated from the intervention to avoid the unintended consequence of altering the ventilation volume, which should be provided according to cardiac arrest guidelines and cannot be standardized to a particular duration of time.
Usability Testing:
After consensus was reached on the design, high-fidelity simulation usability testing was conducted. The team composition, scenario, and environment were constructed to resemble the macroergonomics of PICU resuscitations. Study team members observed team performance and semi-structured debriefs were held at the completion of each session. Participants were specifically asked if they made or could foresee making errors due to incorporating the ventilation metronome into the work system. Participants completed the System Usability Scale (SUS), with acceptable scores defined as a median SUS>68. Average ventilation rates were calculated during 30-second epochs of uninterrupted CPR with ventilation metronome use, with an average rate +/-2 bpm from the stated target considered to be within goal range.
Among 34 clinicians in three groups, the median SUS was 92.5 (IQR 85, 94.4). There were zero errors attributed to metronome use. Of 36 total uninterrupted 30-second epochs of CPR with ventilation metronome use, 34 (94%) had ventilation rates within goal range. There was consensus that the ventilation metronome did not distract from other tasks and was helpful to the clinician providing ventilations. These promising data were sufficient to proceed with a trial of the cardiac arrest ventilation metronome in our PICU.
Clinical Application:
The metronome was implemented in the Children’s Hospital of Philadelphia PICU, a 75-bed medical-surgical unit, in May 2024. Of eight cardiac arrests with an advanced airway in place and a CPR duration of greater than or equal to 2 minutes, the ventilation metronome was utilized in 5/8 (62.5%). Nearly half (44.4%; 8/18) of the epochs of CPR occurring with ventilation metronome use had ventilation rates within goal range, while 6.7% (1/15) of the CPR epochs without ventilation metronome use had ventilation rates within goal range. Median SUS score was 97.5 (IQR 74, 100; n=6). Narrative feedback from noted that: 1) the metronome did not distract resuscitation team members from other tasks and 2) it was less feasible to activate the metronome during relatively short (2-3 minute) events. Of note, multiple clinicians have provided feedback that a cognitive aid for the recommended ventilation rate for each age group would be helpful. We hypothesize that this knowledge gap has been identified because clinicians are more likely to discuss the goal ventilation rate since implementation of our intervention.
Importance and Conclusions:
Appropriate ventilation is an important component of high-quality CPR which is essential for better resuscitation outcomes. For children, a group in which the majority of cardiac arrests have preceding respiratory pathophysiology, reversing or avoiding inadequate ventilation can be especially important.
Ensuring adequate ventilation during pediatric CPR requires creating systems of care that enable clinicians to achieve goal rates. Utilizing human factors engineering and implementation science principles, we have successfully designed a digital audiovisual cardiac arrest ventilation metronome with high usability scores that has been implemented in a pilot trial during PICU cardiac arrests in our center.
While previous studies have demonstrated the utility of implementation science and human factors engineering in understanding and mitigating performance gaps in resuscitation care, this methodology remains underutilized to date, particularly in pediatric resuscitation science. Leveraging the strengths of human factors engineering is necessary to optimally address the complex drivers of resuscitation performance.
Authors
Event Type
Oral Presentations
TimeWednesday, April 28:30am - 9:00am EDT
LocationPier 9
Simulation and Education (SE)