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reviewed in detail by an open, multidisciplinary committee provides an
opportunity to improve. The review process focuses on time to critical events
(completion of primary/secondary survey, vascular access, fluid/med
administration, etc.), adherence to expected protocols, teamwork measures
(including closed loop communication, ambient noise, anticipation of medications
and equipment, etc.), specific role performance, and identification of barriers and
facilitators to care. Specific resuscitation events are chosen for review by a
combination of provider request and identification of the highest-risk scenarios,
including the most complex and least common events. Process and system issues,
educational deficits, and other barriers to protocol-compliant care identified
through the video review process are addressed on an ongoing basis.
Interventions to improve quality of care in the resuscitation room can include
changes in the physical resources available, such as medications, fluids and
equipment, or personnel available. For example, movement of the EZ-IO
introducer and needles to the bed during room preparation prior to patient arrival
can decrease the time to vascular access. Assigning a second senior physician to
supervise CPR and other procedures in resuscitation events requiring CPR, can
decrease the burden on the leader physician and increase protocol compliance
with CPR. Using a Learning Healthcare System model, the continuous collection
of system and care process data in addition to important team- and patient-level
outcomes allows for ongoing identifications of new areas to be addressed and
effects of interventions. Other interventions to improve care may include
simulated resuscitative events to allow for practice of uncommon events and
identification of system and process weaknesses. Multidisciplinary simulations
that occur in the actual resuscitation environment are most likely to maximize
learning and identify latent barriers to care. In addition, participation in video
resuscitation review simulates cognitive decision making for the viewer. Finally,
intermittent group review of important findings from the quality improvement
efforts, targeted group education modules, and personal feedback on given
resuscitation events can support improvements in provider behavior to maximize
protocol adherence and decrease variability in resuscitation care. It is important

that EDs identify a feasible means to monitor resuscitation care and provide
ongoing local quality improvement to insure that optimal care is provided in this
high-stakes, error-prone environment.

ETHICAL ISSUES IN PEDIATRIC CARDIOPULMONARY
RESUSCITATION