The EMRA Simulation Research Grant has made it possible for me to implement a multiyear pediatric emergency medicine (PEM) study that evaluates the effectiveness, usability, and workload implications of cognitive aids in pediatric advanced life support (PALS) adherence.
Pediatric cardiopulmonary emergencies represent stressful, high-acuity, low-frequency events with high morbidity and mortality. Furthermore, the vast majority of pediatric patients are seen in general EDs by emergency physicians who are not PEM-trained, and some physicians may be uncomfortable treating critically ill pediatric patients.
Currently, cognitive aids to maximize pediatric advanced life support (PALS) adherence exist most commonly as pocket cards, including the widely used American Heart Association (AHA) PALS reference card. Unfortunately, these cards aren’t always immediately available at point-of-care during a resuscitation event. Also, they can become outdated and are prone to wear-and-tear.
Only a few smartphone apps are available for PALS, and none have undergone rigorous validation.
In this study, partially funded by the EMRA Simulation Research Grant, we aimed to evaluate the impact of Massachusetts General Hospital’s (MGH) PALS app on adherence to PALS resuscitation algorithms using the Clinical Performance Tool (CPT), a validated PALS-based performance score, during simulated scenarios.
As secondary objectives, we aimed to assess whether MGH’s app improves correctness and expedites time-to-completion of therapeutic interventions during simulated PALS scenarios, compared to AHA’s card.
Additionally, we aimed to assess the app’s overall perceived usability and impact on participants’ perceived workload during simulated PALS scenarios.
We conducted a prospective, randomized, simulation-based trial of 37 senior Boston-based EM residents. Participants were randomized to either the intervention (MGH PALS app) or control (AHA PALS reference card) group.
On their scheduled day and time, participants came to Brigham and Women’s STRATUS Center for Medical Simulation. They were guided through a 15-minute pre-briefing period, during which they completed a survey detailing their baseline characteristics and experiences. They were also given time to familiarize themselves with their respective cognitive aid.
Next, they participated in 3 PALS simulations, each with a duration of 10 minutes. The simulations were:
- A respiratory arrest
- A pulseless nonshockable cardiac arrest
- A pulseless shockable cardiac arrest
Scenario prompts were identical to those described in the derivation and validation studies for the CPT. The scenario order was standardized, allowing for direct comparison across each scenario without influence of order.
Upon finishing, each scenario was debriefed with specific emphasis on teaching about the differences in care of children with respiratory and cardiac arrest.
Participants then spent 10 minutes completing the System Usability Scale (SUS) and NASA Task Load Index (NASA-TLX) surveys.
While final results of our study are pending, our initial analysis suggests no difference in CPT scores, correctness, or time to completion of therapeutic interventions between users of the MGH smartphone app and the AHA reference card.
However, a key finding: Participants reported they were much more likely to carry smartphones on shift vs. cards. According to our survey results, 97% always carried smartphones, and only 5% always carried reference cards. Plus, participants reported significantly easier usability and improved workload with the app vs. the card.
I’m grateful to be able to conduct this important simulation research, made possible by the EMRA Simulation Research Grant.
Editor’s notes: Congratulations to Dr. Ibia, recipient of the 2021 EMRA Simulation Research Grant. Dr. Ibia completed residency training at Harvard Affiliated EM Residency at Mass General Brigham, where he served as chief resident. He then pursued a PEM fellowship at Boston Children’s Hospital.
The MGH PALS app is available for download via the App Store and Google Play. Also access fast, updated, evidence-based PEM guidance on MobilEM, EMRA’s mobile app available for free download. Additionally, EMRA publishes several pediatric-focused resources and guides, including PEM Fundamentals, Basics of Emergency Medicine-Pediatrics, and the Pediatric Qwic Card, all available on Amazon. And finally, search categorically on emresident.org for PEM articles, including this one.