REVIEW

CURRENT
OPINION Quality improvement and crisis resource
management in pediatric resuscitation
Sage R. Myers a,c and Aaron J. Donoghue a,b,c

Purpose of review
The pediatric resuscitation environment is a high-stakes, environment in which a multidisciplinary team must
work together with patient outcomes dependent, at least in part, on the performance of that team. Given
constraints of the environment and the nature of these events, quality improvement work in pediatric
resuscitation can be challenging. Ongoing collection of accurate and reliable data on team performance is
necessary to inform and evaluate change.

Recent findings
Despite the relative difficulty of quality improvement analysis and intervention implementation in the
resuscitation environment, these efforts can have significant impact on patient outcomes. Although there are
barriers to accurate data collection in real-life resuscitation, team performance of both technical and
nontechnical skills can be reliably measured in video-based quality improvement programs. Training of
nontechnical skills, using crisis resource management principles, can improve care delivery in resuscitation.

Summary
Striving toward a learning healthcare system model in resuscitation care delivery can allow for efficient
performance improvement. Given the possible impacts on mortality and quality of life of care delivered in
the resuscitation environment, all providers who could possibly face a resuscitation event – no matter how
rare – should consider how they are evaluating the quality of their care delivery in this arena.

Keywords
cardiopulmonary resuscitation, crisis resource management, quality improvement, resuscitation

INTRODUCTION
The pediatric resuscitation environment is a high-
stakes, fast-paced, safety-critical arena in which a
multidisciplinary team must work in concert
toward a common multipronged goal of stabiliza-
tion, diagnosis, and treatment [1–3]. Patient sur-
vival and other critical patient outcomes depend,
at least in part, on the performance of that team;
including nontechnical skills involving crisis
resource management (CRM). Given constraints
of the environment and the nature of these events,
quality improvement work in pediatric resuscita-
tion can be challenging. However, striving toward
a learning healthcare system (LHCS) model [4] can
allow for efficient performance improvement,
where all resuscitative care delivery is seen as an
opportunity for data collection to identify oppor-
tunities for improvement as well as evaluate
change in performance after quality improvement
initiatives. For this model to work, reliable
and accurate data sources must be consistently
utilized.
CASE
Your nurses come running back from triage with a
limp child that parents brought in because they
could not wake him up. He is placed on the
stretcher. You ask someone to place him on a moni-
tor and someone to feel for a pulse. No pulse can be
found, you ask someone to start chest compressions.
Someone is working on vascular access. You ask for
labs, fluids, epinephrine. Who can find out more
history? Have you done a rhythm check? No one can
find the pediatric defibrillator pads. Is your team
a
Division of Emergency Medicine, bDivision of Critical Care, Children’s
Hospital of Philadelphia and cPerelman School of Medicine at the
University of Pennsylvania, Philadelphia, Pennsylvania, USA
Correspondence to Sage R. Myers, MD, MSCE, Division of Emergency
Medicine, Children’s Hospital of Philadelphia, 3501 Civic Center Blvd,
CTRB, 2nd Floor, EM Offices, Philadelphia, PA 19104, USA.
Tel: +1 267 426 7939; fax: +1 215 590 4454;
e-mail: myerss@email.chop.edu
Curr Opin Pediatr 2019, 31:297–305
DOI:10.1097/MOP.0000000000000772

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Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Emergency and critical care medicine
KEY POINTS
 Quality improvement in pediatric resuscitation is
necessary, feasible, and can be high-yield for
outcomes improvement.
 Accurate data collection is difficult in the resuscitation
environment but vital for successful quality improvement
work; video review is a feasible and reliable method
for robust data collection.
 Adopting a learning healthcare system model for care
improvement in resuscitation incorporates continuous
data collection with simultaneous evaluation for areas
of improvement and testing of implemented
interventions.
 Crisis resource management principles underlie
excellent team performance in resuscitation and
evaluation of nontechnical skills is essential to
improving resuscitation care.
doing 15 : 2 compressions or continuous? No intra-
venous access yet, you need someone to locate a
pediatric interosseous needle. Is the epinephrine
drawn up? Are the chest compressions deep and
fast enough?
Need for quality improvement in
resuscitation
This scenario is typical of a pediatric resuscitation
event with incomplete information, multiple par-
allel processes, infrequently used materials, and
barriers to care delivery. A multidisciplinary group
of providers must jump into action at a moment’s
notice to work together to try to save a life. The
coordinated action of that group can mean the
difference between life and death. Therefore,
active quality improvement efforts are essential
to ensure ideal team performance. Hospital and
prehospital-based quality improvement work
has shown that true patient-level outcomes differ-
ences can be seen with improvements in specific
resuscitation skills including; compliance with
American Heart Association guidelines for cardio-
pulmonary resuscitation (CPR) performance over-
all [5] and with specific subcomponents of
compression depth [6] and perishock compression
pause [7], as well as for coordinated ‘pit crew’ team
performance [8]. In addition, quality improvement
work can lead to evaluation and questioning of
current resuscitation guidelines, which are often
consensus-based and/or fed by indirect scientific
evidence as opposed to direct outcomes studies.
&&
An important recent study by Sutton et al. [9 ]
found that for children undergoing resuscitation
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for in-hospital cardiac arrest, CPR rates lower than
current guideline recommendations (80–100 vs.
100–120 compressions per minute) were associ-
ated with improved survival and improved neuro-
logic outcomes. Although further study is needed
before changes in CPR guidelines are made, the
ability to fine-tune our current protocols based on
actual outcomes-driven knowledge to optimize
outcomes for children is exciting. Knowing that
quality improvement improvements can lead to
meaningful differences in patient outcomes and
patient care should motivate us to pursue
this work.
Difficulties posed by the resuscitation
environment
Quality improvement work depends on reliable data
concerning care delivery and outcomes to assess
opportunities for improvement and measure
change. As the case illustrates, the resuscitation
environment is rapidly-shifting, with many care
processes occurring simultaneously. Although chart
review is a tempting source of data due to its easy
accessibility, it has been shown to be markedly
unreliable in this environment [10]. Team member
recall is fraught with misinformation and bias [11].
In-person observation is limited both by its imprac-
ticality for rare, unplanned events that can occur at
any time, and by the difficulty in collecting data on
multiple processes of care simultaneously.
Video for quality improvement in
resuscitation
Video of care delivery in pediatric resuscitation has
been shown to be a feasible and reliable source of
data [12,13]. Software allows for the integration of
multiple camera angles, multiple audio sources, and
the patient monitor, which can be easily annotated
for collection of desired time points in care delivery
(Fig. 1). In addition, ancillary devices, such as video
laryngoscope or ultrasound, can be integrated into
the system to be captured simultaneously with the
other video data. Recently published studies have
&&
shown that data on CPR quality [13,14 ], intuba-
tion success and adverse events [10,12,15], timeli-
&&
ness of care delivery [16 ], guideline compliance
[17], and patient outcomes [15,18] can all be reliably
and accurately collected from video. Certain aspects
of CPR performance that cannot be reliably assessed
by video, such as recoil and depth [19], can be
included in full quality assessment by syncing data
collected directly by chest compression monitor
devices along with the video feed to fully assess
individual-level CPR performance.
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 QI and crisis resource management in pediatric resuscitation Myers and Donoghue

FIGURE 1. Example resuscitation video recorded on B-Line LiveCapture software (B-Line Medical, Washington, DC, USA) with
three camera angles, a monitor feed, and annotated time points (blue dots on timeline) marked by clinician quality
improvement reviewer (simulated resuscitation with patient actor). Photo captured as screenshot by authors.

Importance of crisis resource management/ Use of video to assess crisis resource

nontechnical skills in resuscitation
Nontechnical skills in the resuscitation environ-
ment drive excellent team performance [20]. CRM
has long been used to describe and train the neces-
sary team communication skills and coordinated
team action that are the foundation for excellent
healthcare teams [21]. CRM was derived from the
aviation industry, where decades ago it was recog-
nized that human error caused the vast majority of
airline crashes leading to the development of crew
resource management training to improve safety.
Aviation and emergency healthcare delivery share
many commonalities and both must rely a team
working together to address rare, sudden, unantici-
pated, life-threatening events. Healthcare-specific
CRM principles are delineated in Table 1, along with
definitions [21–23]. Training in CRM has been
shown to improve both team communication
& &
[24 ,25,26] and care delivery [26,27 ] in the resusci-
tation environment. The concept of team dynamics
has been incorporated into American Heart Associ-
ation life support courses since 2010, both as a
curricular component as well as part of the summa-
tive assessment for scenario-based testing.
management
Most studies of CRM, including both those evaluating
interventions to improve CRM performance and those
assessing the association between adherence to CRM
principles and patient care outcomes, have been con-
ducted in simulation. Assessing CRM in actual resus-
citation events is challenging, with multiple team
members acting simultaneously on multiple patient
care tasks in parallel. However, the ability to evaluate
the impact of nontechnical skill performance to actual
patient-level outcomes and evaluate the accuracy of
assessment on nontechnical skills via simulation, are
both necessary in the quest for optimized safety and
efficiency in care delivery. Video-based review of real-
life resuscitative care delivery allows for the most
&&
robust assessment of nontechnical skills [28 ], as it
allows for segments of care delivery to be watched
repeatedly, focusing on different simultaneous team
member actions and interactions, to create a full
assessment of CRM principles in action.
Tools for assessing team performance
When viewing or participating in a resuscitation
event, one can easily come away with a gestalt about

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Emergency and critical care medicine
Table 1. Key principles of crisis resource management for emergency medicine
Principles
Attention allocation (avoid fixation)
Triage/prioritization
Anticipation/planning
Communication
Leadership/assertiveness
Awareness and utilization of resources
Awareness and utilization of information
Routine re-evaluation of the situation
Effective coping with disruptions/distractions
Efficient use of team – distribute workload,
monitor & support members
Efficient management of multiple patients
Adapted from [21–23].
how well the team worked together. But true
improvement can happen only when these gestalt
feelings can be distilled down to objective analysis of
the component parts of the performance where
interventions can then be crafted to target specific
behaviors. A recently published systematic review
created an excellent survey of the tools currently
available to assess nontechnical skill performance
&&
and CRM skills within a medical team [29 ]. Table 2
lists some of the measurement tools that have been
specifically tested or used in pediatric populations.
Adjuncts to video-based team performance
measurement
As we consider more advanced assessment of team
performance in resuscitation through video review,
and trialing specific interventions to improve team
technical and nontechnical skills, there are adjunc-
tive data that could assist with this task. Measure-
&
ment of individual workload [38 ,39] can help
identify particular team members who carry higher
cognitive or physical workload and could be a target
for team member-specific interventions. In addition,
measurement of workload before and after quality
improvement interventions are implemented can
ensure that we consider the unintended consequence
of increasing workload with the intervention. Work-
load is often measured through physiologic monitor-
ing [40] or reflective self-report surveys, such as the
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Definitions
Place appropriately attention on key findings and avoid fixing attention on one
finding at the expense of missing important information
Place appropriate emphasis on most important aspects of care; appropriate order of
attention
Anticipate changes in patient over time or due to interventions; plan ahead for
possible necessary interventions
Effective transfer of information between team members
Clear leadership that is audible and decisive; avoid confusion of multiple people
giving orders
Recognize and use both personnel and physical resources to maximize efficiency and
effectiveness of care
Recognize and use all information about both team and patient; ask for information
when necessary
Re-evaluates patient status and response to interventions at appropriate intervals;
shares findings with team effectively
Does not miss important information or change in patient status due to distractions
Recognize individual team member contributions and avoid overwork/underwork of
members
Able to manage multiple patients at the same time when necessary without loss of
information or delay in care
&
NASA-TLX scale [41]. A recent study [38 ] using
NASA-TLX measurement of workload during simu-
lated CPR events found that, perhaps as expected,
team leaders had higher mental workload than CPR
providers (team members involved in CPR compres-
sion delivery), while CPR providers had higher phys-
ical workload. The average overall workload for team
leaders and CPR providers, however, was equal dur-
ing usual resuscitative care. Significantly, when CPR
providers were given a card that was placed on the
chest under their hands during compressions and
gave feedback on CPR quality, the CPR providers
had higher overall average workload than CPR pro-
viders without feedback, and also higher workload
than the team leaders. Team leader workload did not
change with addition of the device. The feedback
device did lead to increased depth compliance, and
it is possible that the increased workload related to
provision of higher quality chest compressions that
required more effort. But the differential changes
seen following introduction of a quality intervention
highlight the importance of workload measurement
among individual team members. A separate study
[42] of pediatric sepsis care delivery also used simula-
tion and NASA-TLX to evaluate individual team
member effort levels and found that the team leaders
had the highest workload in all subcategories except
physical and performance, leading to consideration
of interventions to decreased leader mental demand.
Methods to measure workload more objectively, and
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 QI and crisis resource management in pediatric resuscitation Myers and Donoghue

Table 2. Validated tools for assessment of nontechnical skills in resuscitation specific to resuscitation or pediatric emergencies

Validated clinically Validated in Forms of validity Forms of Number

(as opposed to pediatric tested reliability tested of
Tool simulation only) emergency (of 6 total)a (of 3 total)b studies

Team Emergency Assessment Measure X 3 3 5

(TEAM)
Modified Non-Technical Skills Scale for X X 2 2 3
Trauma (T-NOTECHS)
Observational Skill-based Clinical 2 2 3
Assessment Took for Resuscitation
(OSCAR)
Simulation Team Assessment Tool (STAT) X 2 1 1
Imperial Paediatric Emergency Training X 2 1 1
Toolkit (IPETT)
CARDIOTEAM checklist 2 1 1
KidSIM Team Performance Scale X 1 2 1
Unnamed by Von Wyl et al. 1 2 1
Prototype instrument to assess team 1 0 1
behavior during trauma resuscitation
Assessment of emergency physicians 1 0 1
nontechnical skills
Behavioral Assessment Tool (BAT)c X 1 2 5
Ottawa Global Rating Scaled 2 2 4

a
Content, construct, concurrent, convergent, and predictive validity and context specificity.
b
Internal consistency, interrater reliability, test–retest reliability.
c
Not included in review [30–34].
d
Not included in review [35–37].

over time during the resuscitation, rather than as an
overall summary of the event as NASA-TLX does,
would further improve our ability to precisely target
interventions to improve care delivery.
Eye tracking technology is another adjunctive
data source that has been used in quality improve-
ment efforts in the resuscitation environment
[43,44]. Interventions aimed at providing visual
information to the team (such as monitors and infor-
mation displays) can improve shared knowledge, but
can also be a distraction from attention to important
patient assessment. Eye tracking can help determine
relative attention or distraction at the level of the
individual team member, which can help idealize
information presentation. In addition, eye tracking
can assess performance for procedures where the
location of visual attention could impact procedural
success, such as video laryngoscopy in intubation.
Both in the assessment of procedural learning by
trainees [45], and in the development of technology
to assist procedural success, knowledge about the
visual attention of the provider can drive change.
Learning healthcare system
Quality improvement in the resuscitation environ-
ment must be thought of in terms of the LHCS model
[46,47] (Fig. 2). This LHCS model is defined by the
Institute of Medicine as a model where ‘science, infor-
matics, incentives, and culture are aligned for contin-
uous improvement and innovation, with best
practices seamlessly embedded in the care process. . .
and new knowledge captured as an integral by-prod-
uct of the care experience’ [46]. Although many areas
of healthcare delivery could benefit from the applica-
tion of this model, pediatric resuscitation quality
&&
improvement thrives under its tenants [48 ]. The
LHCS model promotes the ongoing collection and
analysis of data derived from care delivery. This anal-
ysis leads to identification of gaps in care delivery or
patient outcomes, as well as allowing for assessment of
change in important metrics after quality interven-
tions are implemented. Given the infrequent nature of
resuscitation events, the collection and analysis of
data from every episode, as supported by the LHCS
model, is extremely important. In addition, in this
fast-paced environment with vast amounts of data,
striving toward automation of data collection where
possible is key. It is important, however, not to trade
quantity and ease of collection for quality of data. We
know, for example, that the use of chart review for
many resuscitation events is inaccurate, and despite
the ease of data collection from electronic health
record databases, we must avoid using questionable

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Emergency and critical care medicine
FIGURE 2. Learning healthcare system model in resuscitation.
data to drive change in the resuscitation environ-
ment. However, there are many areas where auto-
mated data collect could be feasible. Defibrillator
data, monitor data, pump data, and ventilator data
are already collected in electronic format and could
easily be downloaded for analysis. The barrier, how-
ever, is interoperability and proprietary technology
[49,50]. This barrier is even higher when trying to
use that data in real time to guide rapid clinician
decision-making in a way that allows for optimal
recognition of change in condition or response to
treatment. Despite the argument that this data
belongs to the patient, and the patient should have
the right to use that data to improve their own
health, as it currently stands the data remains
trapped and siloed by lack of interoperability. Given
our current technology advances, it should be fea-
sible to create a resuscitation room where vast
quantities of patient-specific and team-specific data
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can be collected and analyzed in real time to be fed
back to the team in actionable form and used for
decision support. Inaccessibility of data hampers
the creation of this ‘resuscitation room of the
future’.
In an ideal system, data from resuscitative
events can continually be analyzed to allow for
identification of gaps in care delivery or outcomes,
leading to the creation of directed interventions
which are then enacted. Data from resuscitative
events then continue to be analyzed to look for
both intended and unintended changes in care
delivery or patient outcomes. In parallel to this
circle of change, other gaps in care delivery are being
identified through ongoing data analysis and sepa-
rate interventions being developed, implemented,
and analyzed. This LHCS model maximizes effi-
ciency of quality improvement work in an arena
where fast-moving, responsive change is the norm.
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 QI and crisis resource management in pediatric resuscitation Myers and Donoghue
Collaborative work in pediatric resuscitation
quality improvement
Given the infrequent nature of pediatric resuscita-
tion in general, and even more so for specific sub-
categories within resuscitation (such as intubation,
CPR delivery, sepsis, penetrating trauma), collabo-
ration in quality improvement efforts can speed
assessment and allow for rigorous analysis of inter-
ventions that would otherwise take unacceptably
long to study given low numbers at a single center
[51]. In response to this need, the VIPER (Videogra-
phy in Pediatric Emergency Research) network was
&&
formed [52 ]. Comprised of multiple pediatric hos-
pitals, and continuing to grow, VIPER brings
together investigators who already have ongoing
video-based quality improvement efforts in pediat-
ric resuscitation in place and allows for rigorous data
collection of patient care delivery in the resuscita-
tion environment across all centers. The increased
numbers of patients and providers allows for testing
of interventions in an efficient manner, including
important evaluation of true patient-level outcome
differences.
CASE REVIEW
In our original case there was a delay to the avail-
ability of pediatric defibrillator pads after they were
requested by the team leader. If our original case was
video recorded, we would see that the pads were
stored on the other side of the room, separate from
the defibrillator, and it took multiple providers
working together to locate and deliver them. This
leads to an easily testable intervention where the
pads are moved to a drawer in a cart that the
defibrillator sits on and pictorial signs are applied
to the drawer identifying the pediatric pad location.
Collecting time from CPR onset (or team leader
request) to pad placement before and after this
intervention would allow analysis of its effective-
ness. In addition, by video review, you recognize
that the compressor’s hand position was below the
nipple line and right of the sternum. Correlation
with the defibrillator feedback shows poor compli-
ance with depth during this compressor segment.
Through targeted feedback and guided practice, you
are able improve this compressor’s skill and
improvements can be found to translate to real-life
care in future video-recorded resuscitation events.
CONCLUSION
The power of video-based quality improvement in
resuscitation is seen when data derived from detailed
review of team performance and patient-level out-
comes illuminate areas for process improvement and
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then are subsequently used to analyze the effects of
targeted interventions. Both team technical skills and
nontechnical skills can be reliably and accurately
measured on an ongoing basis to create a LHCS model
for care delivery improvement. Given the possible
impacts on mortality and quality of life of care deliv-
ered in the resuscitation environment, all providers
who could possibly face a resuscitation event – no
matter how rare – should consider how they are
evaluating the quality of their care delivery in
this arena.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
S.R.M. holds a grant from the Emergency Services for
Children’s Targeted Issues program (H34MC30230) to
create a web-based toolkit for pediatric resuscitation
quality improvement in community hospitals. A.J.D.
has not conflicts to report.
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& interprofessional emergency medical team through a one-day crisis resource
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Simulation-based study showing that 1-day crisis resource management course
increases emergency medicine team technical performance in simulated resusci-
tation, with significant improvement seen in some specific aspects of patient care
but global scores not assessed. Education/training for nontechnical skills can have
impact on clinical performance, likely in a sustained manner as testing done
2 months after training.
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28. Cavicchiolo ME, Cavallin F, Staffler A, et al. Decision making and situational
&& awareness in neonatal resuscitation in low resource settings. Resuscitation
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Study performed in Mozambique using video recording of neonatal delivery room
management for consented patients to evaluate team performance during resus-
citation events. Found that, in this low-resource setting, training midwives in
resuscitation using both a modified Neonatal Resuscitation Program course
and low-dose, high-frequency training (no structured feedback) lead to some
improvement in subscales of team performance (task management and decision-
making) but many areas did not show significant improvement. Important qualifier
that many ‘teams’ were made up of one trained provider due to local standards.
Excellent example of use of video of real-life care delivery, feasible even in low-
resource settings.
29. Boet S, Etherington N, Larrigan S, et al. Measuring the teamwork
&& performance of teams in crisis situations: a systematic review of
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Systematic review of tools used for assessment of team nontechnical skills in
crisis situations, comparing them by demonstrated validity, reliability, numbers of
studies published, and populations tested. Found that, while tool selected will
depend somewhat on context, the Team Emergency Assessment Measure is the
most promising currently based on metrics evaluated. Excellent review of existing
tools with discussions that help guide researchers and quality improvement
workers to selection of appropriate tool to assess nontechnical skills in health-
care teams.
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learning versus instructor-modeled learning during a simulated clinical ex-
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new content to neonatal transport personnel using high-fidelity simulation. J
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and checklist scores in the validation of an evaluation tool to assess
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simulation to formally evaluate performance in the resuscitation of critically-ill
patients: the University of Ottawa Critical Care Medicine, High-fidelity Simu-
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& healthcare provider workload during simulated cardiac arrest. Resuscitation
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Demonstrates feasibility and importance of considering workload, and workload
distribution, when introducing quality improvement interventions into the resusci-
tation environment.
39. Parsons SE, Carter EA, Waterhouse LJ, et al. Assessment of workload during
pediatric trauma resuscitations. J Trauma Acute Care Surg 2012;
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Volume 31  Number 3  June 2019
 QI and crisis resource management in pediatric resuscitation Myers and Donoghue
46. Institute of Medicine. Integrating research and practice: health system leaders
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48. Verhoeff K, Saybel R, Mathura P, et al. Ensuring adequate vascular access in
&& patients with major trauma: a quality improvement initiative. BMJ Open Quality
2018; 7:e000090.
Formal quality improvement study to improve appropriate vascular access in
trauma patients, using multiple Plan-Do-Study-Act cycles that included interven-
tions such as reorganization of the intravenous carts and educational posters. Able
to improve the percentage of patient with adequate vascular access from 36% to
above 90% which was sustained. Excellent example of successful quality im-
provement work in resuscitation setting.
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collection from pediatric resuscitation using video review. Initial simulation-based
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