PediAppRREST as a training tool for pediatric cardiac arrest: pilot study for an international simulation-based multicenter Randomized Controlled Trial

Background: Pediatric cardiac arrest (PCA), although rare, is associated with high mortality. Residents and young clinicians often do not undergo enough training and exposure to real life resuscitations to retain adequate knowledge and skills on pediatric advanced life support. Different strategies have been developed to improve the management of PCAs, including cognitive aids. While evidence showed cognitive aids to be effective in improving the management of cardiac arrest during resuscitation in the simulation setting, the effectiveness of cognitive aids as a training tool has not been studied yet. Aim of the study: The objective of this study is to evaluate whether the use of an audiovisual interactive app for tablets (PediAppRREST) in a training simulation of PCA could positively impact the management of a repeat similar scenario, in which no cognitive tool is available. The ultimate aim is to understand whether PediAppRREST could be implemented and benefit the education of healthcare professionals on PCAs. Materials and methods: This study is a pilot 2-parallel-group simulation-based randomized controlled trial involving residents in pediatrics, emergency medicine and anesthesiology at Padua University Hospital. The study included teams of four residents, including a PALS certified team leader. Teams were randomized to one of two study arms: an intervention group that used PediAppRREST app (PediAppRREST), and a control group that used a paper-based cognitive aid (the PALS pocket reference card) as cognitive tool for training. In each study arm, teams were further randomized to conduct simulated scenarios of either non-shockable or shockable PCAs. All teams conducted two simulated scenarios of PCA, the first with and the second without any cognitive tool. The primary outcome was the team resuscitation performance during the second scenario, measured by the Clinical Performance Tool (CPT). The secondary outcomes were the evaluation of self-knowledge retention (assessed by an ad hoc questionnaire), the assessment of performance/time to accomplish critical resuscitation interventions (assessed by two independent video-reviewers blinded to the study arm assignment), the rating of CPR quality and the measurement of team leader’s workload (NASA-TLX-workload scale). Results: This pilot analysis was conducted on 16 teams. The CPT score, expressed as mean (SD), was 30.1 (1.96) in the intervention group and 28.6 (3.46) in the control group (p-value=0.3042). Of the time critical actions, those resulting significantly different between the intervention and control arm were: time to call for help was less in the control group [(mdn 229 sec, IQR 1-3 109-333.25) vs (mdn 58 sec, IQR 1-3 33.75-125.50); p-value <0.01]; time of placement of IV access [(mdn 51.5 sec, IQR 1-3 41.50-72.50) vs (mdn 84 sec, IQR 1-3 52.50-103.50); p-value<0.03] and call for the first epinephrine [(mdn 41 sec, IQR 1-3 31.25-49.75) vs (mdn 68 sec, IQR 48.25-77.50); p-value<0.004], which were lower in the intervention group. The subjective knowledge retention and CPR quality were not statistically different in the two study groups. The team leader’s workload was significantly reduced in terms of mental demand [(mean 70.625, SD 12.082) vs (mean 83.75, SD 9.910); p-value≤0.021] and Raw-TLX score [(mean 53.958, SD 11.214) vs (mean 63.833, SD 6.172); p-value ≤0.010] in the intervention group. Conclusions: The use of the PediAppRREST cognitive aid as a training tool used to “prime” a team immediately before a PCA scenario, did not show to be more effective compared with the traditional PALS pocket reference card in respect to resuscitation performance assessed across several domains, including both objective and subjective assessments. The progress of this pilot work will inform the design of a future multicenter international study to investigate the optimal integration of cognitive aids for resuscitation training on PCA.