Pediatric Resuscitation Quality Lower Than Adult Resuscitation in OHCA Simulation

Pediatric resuscitation vs adult resuscitation for OHCA had lower quality and worse outcomes in a simulated environment.

Resuscitation performance is of lower quality and associated with higher cognitive load in pediatric scenarios compared with adult scenarios in a simulation study of out-of-hospital cardiac arrest (OHCA), according to findings published in JAMA Network Open.

The cross-sectional study aimed to assess the quality of resuscitation in adult and pediatric shockable and nonshockable OHCA via use of in situ high fidelity simulation in emergency medical service (EMS) professionals and evaluate the effects of cognitive load and knowledge.

The study was performed at 7 urban EMS agencies in the Portland, Oregon, metropolitan area between September 2020 and August 2021. Each EMS crew completed 4 simulation scenarios: an adult woman with shockable arrest and ventricular fibrillation on arrival; an adult woman with pulseless electrical activity; a school-aged child with ventricular fibrillation; and an infant with pulseless electrical activity. At EMS arrival all patients were pulseless.

The rates of errors were compared between the adult and pediatric scenarios. Defect-free care included correct cardiopulmonary resuscitation (CPR) depth, rate, compression-to-ventilation ratio, timely bag-mask ventilation (BVM), and timely defibrillation if applicable.

A total of 215 EMS clinicians from 39 crews participated (93% men; mean [SD] age, 38.7 [0.6] years). The EMS members had a mean (SD) of 10 (4.1) years of EMS experience.

In the pediatric scenarios, delays were observed in time to CPR, time to BVM, vascular access, and time to initial dose of epinephrine vs the adult scenarios. None of the pediatric shockable scenarios and 5 pediatric nonshockable scenarios (12.8%) were defect free, and 27 adult nonshockable scenarios (69.2%) were defect free.

In a comparison of the mean (SD) National Aeronautics and Space Administration task load index (NASA-TLX) scores of the paramedic team leader for each scenario, the highest cognitive load occurred in the pediatric nonshockable scenario (48.4 [13.8]), followed by the pediatric shockable scenario (43.6 [15.2]), adult shockable scenario (41.1 [13.7]), and adult nonshockable scenario (39.3 [13.3]).

Increased cognitive load may contribute to challenges in pediatric resuscitation.

The pediatric scenarios had significantly increased overall mean (SD) NASA-TLX scores compared with the adult scenarios with use of 1-way analysis of variance (ANOVA; pediatric, 45.4 [14.4]; adult, 41.2 [13.5]; P =.01). The mental demand subscale of the mean (SD) NASA-TLX was greater in the pediatric scenarios vs the adult scenarios (pediatric, 59.1 [20.7]; adult, 51.4 [21.1]; P =.01).

The difference in overall Clinical Teamwork Scale (CTS) in the 4 scenarios was not statistically significant per ANOVA (P =.062) and was relatively small in size. The overall knowledge test scores were not significantly different in the adult and pediatric knowledge assessments.

The multivariable model showed that the posterior probability of defect-free care was associated with scenario type. The probabilities of defect-free care were 67% (95% CI, 50%-84%), 29% (95% CI, 15%-44%), 17% (95% CI, 5%-28%), and 3% (95% CI, −3% to 8%) in the adult nonshockable, adult shockable, pediatric nonshockable, and pediatric shockable scenarios, respectively.

In further analysis, mental demand also was associated with scenario type. The pediatric nonshockable scenario was associated with a 10.6-point increase in mental demand (95% CI, 6.3-15.0 points). An increase in Pediatric Advanced Life Support knowledge assessment score was associated with a 5% increased probability of defect-free care (95% CI, 0.6%-10.3%). CTS, NASA-TLX score, years of experience, and Advanced Cardiac Life Support knowledge evaluation score were not associated with defect-free care.

The researchers noted that all events were simulated and cannot be correlated with clinical outcomes, and the results may be biased in favor of better overall performance than what would occur in a clinical setting. Also, the study was conducted in a single geographic area with relatively high OHCA survival and may not be generalizable to other EMS systems.

“In this study of simulated pediatric and adult OHCA, pediatric cases consistently had delays in initiating critical interventions and lower-quality care, while paramedics also experienced significantly higher cognitive load in the pediatric scenarios,” wrote the study authors. “Increased cognitive load may contribute to challenges in pediatric resuscitation.”

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Hansen M, Walker-Stevenson G, Bahr N, et al. Comparison of resuscitation quality in simulated pediatric and adult out-of-hospital cardiac arrest. JAMA Netw Open. Published online May 17, 2023. doi: 10.1001/jamanetworkopen.2023.13969