Accepted Manuscript

Title: Impact of a CPR Feedback Device on Healthcare

Provider Workload During Simulated Cardiac Arrest

Authors: Linda L. Brown, Yiqun Lin, Nancy M. Tofil, Frank

Overly, Jonathan P. Duff, Farhan Bhanji, Vinay M. Nadkarni,
Elizabeth A. Hunt, Alexis Bragg, David Kessler, Ilana Bank,
Adam Cheng, for the International Network for
Simulation-based Pediatric Innovation, Research, Education
CPR Investigators, (INSPIRE), Jennifer Davidson, Dawn
Taylor Peterson, Marjorie Lee White, John Zhong, Vincent
Grant, David Grant, Stephanie Sudikoff, Kimberly Marohn,
Jordan Duval-Arnould, Ronald Gottesman, Mark Adler, Jenny
Chatfield, Nnenna Chime

PII: S0300-9572(18)30321-6
DOI: https://doi.org/10.1016/j.resuscitation.2018.06.035
Reference: RESUS 7667

To appear in: Resuscitation

Received date: 22-3-2018

Revised date: 12-6-2018
Accepted date: 27-6-2018

Please cite this article as: Brown LL, Lin Y, Tofil NM, Overly F, Duff JP, Bhanji F,
Nadkarni VM, Hunt EA, Bragg A, Kessler D, Bank I, Cheng A, Davidson J, Peterson
DT, White ML, Zhong J, Grant V, Grant D, Sudikoff S, Marohn K, Duval-Arnould J,
Gottesman R, Adler M, Chatfield J, Chime N, Impact of a CPR Feedback Device on
Healthcare Provider Workload During Simulated Cardiac Arrest, Resuscitation (2018),
https://doi.org/10.1016/j.resuscitation.2018.06.035

This is a PDF file of an unedited manuscript that has been accepted for publication.
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Impact of a CPR Feedback Device on Healthcare Provider Workload During Simulated Cardiac
Arrest

Short Title: Impact of CPR feedback on provider workload

Linda L. Brown, MD MSCE1; Yiqun Lin MD2; Nancy M. Tofil MD, Med3; Frank Overly MD4;
Jonathan P. Duff MD5; Farhan Bhanji MD6; Vinay M. Nadkarni MD7; Elizabeth A. Hunt, MD,
MPH, PhD8; Alexis Bragg MD9; David Kessler MD, MSc10; Ilana Bank MD6; Adam Cheng

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MD2 for the International Network for Simulation-based Pediatric Innovation, Research and
Education (INSPIRE) CPR Investigators*

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Corresponding Author:
1
Linda L. Brown, MD, MSCE
Assistant Professor, Alpert Medical School of Brown University

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Department of Pediatrics and Emergency Medicine
Hasbro Children’s Hospital
Providence, RI 02903
Email: lbrown8@lifespan.org

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Phone: 401 444 6237
Fax: 401 444 5456

Authors:
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A
2
Yiqun Lin MD and Adam Cheng, MD, FRCPC
KidSIM-ASPIRE Simulation Research Program
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Alberta Children’s Hospital

University of Calgary
Email: jeffylin@hotmail.com; chenger@me.com
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3
Nancy M. Tofil MD, MEd
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Associate Professor of Pediatrics

University of Alabama at Birmingham, Birmingham, AL
UAB Pediatric Simulation Center at Children’s of Alabama
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Email: ntofil@peds.uab.edu
4
Frank Overly MD
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Hasbro Children’s Hospital

Alpert Medical School of Brown University
Email: foverly@lifespan.org
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5
Jonathan P. Duff MD
Stollery Children’s Hospital
University of Alberta
Email: jon.duff@albertahealthservices.ca
6
Farhan Bhanji MD and Ilana Bank, MD
Montreal Children’s Hospital

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McGill University
Email: farhan.bhanji@mcgill.ca, ilana.bank@mail.mcgill.ca

7
Vinay M. Nadkarni MD
The Children’s Hospital of Philadelphia
University of Pennsylvania Perelman School of Medicine
Email: nadkarni@email.chop.edu

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8
Elizabeth A. Hunt, MD, MPH, PhD
Johns Hopkins University School of Medicine

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Email: ehunt@jhmi.edu;
9
Alexis Bragg, MD

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Children’s Hospital Los Angeles,
University of California Los Angeles
Email: ebragg@chla.usc.edu

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10
David Kessler, MD, MSc
Columbia University College of Physicians and Surgeons
Email: dk2592@cumc.columbia.edu N
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*INSPIRE CPR Investigators (Group authors) include: Jennifer Davidson RN, Alberta
Children’s Hospital, j_spruyt@hotmail.com; Dawn Taylor Peterson PhD, University of Alabama
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at Birmingham and Children’s of Alabama, dawn.taylorpeterson@childrensal.org; Marjorie Lee

White MD, MPPM, Med, University of Alabama at Birmingham mlwhite@peds.uab.edu; John
Zhong MD, Children’s Medical Center of Dallas, john.zhong@childrens.com; Vincent Grant
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MD, Alberta Children’s Hospital, vinceinfrance@gmail.com; David Grant MBChB, MRCPCH,

Bristol Royal Hospital for Children, david.grant@nhs.net; Stephanie Sudikoff MD, Yale-New
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Haven Health, Stephanie.sudikoff@ynhh.org; Kimberly Marohn MD, Baystate Children’s

Hospital, Kimberly.marohnmd@bhs.org; Jordan Duval-Arnould, MPH, CPH, DrPH[c], Johns
Hopkins University School of Medicine, jordan@jhu.edu; Ronald Gottesman MD, Montreal
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Children’s Hospital, ronald.gottesman@mcgill.ca; Mark Adler, MD, Northwestern University

School of Medicine, m-adler@northwestern.edu, Jenny Chatfield, Alberta Children’s Hospital,
jenny.chatfield@albertahealthservices.ca, Nnenna Chime, MD, MPH, Albert Einstein College of
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Medicine and Children’s Hospital at Montefiore, nchime1@jhmi.edu.

Word Count: Abstract 225, Manuscript 2952

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Contributor’s Statements
Linda Brown: Dr. Brown conceptualized and designed the study, designed the data collection
instruments, coordinate and supervised data collection at one site, drafted the initial manuscript,
and approved the final manuscript as submitted.
Yiqun Lin: Dr. Lin conceptualized and designed the study, conducted the statistical analysis,
contributed to interpretation of data, drafted the initial manuscript, and approved the final
manuscript as submitted.

2
Nancy Tofil: Dr. Tofil conceptualized and designed the study, designed the data collection
instruments, coordinate and supervised data collection at one site, drafted the initial manuscript,
and approved the final manuscript as submitted.
Frank Overly: Dr. Overly conceptualized and designed the study, designed the data collection
instruments, coordinate and supervised data collection at one site, drafted the initial manuscript,
and approved the final manuscript as submitted.
Jonathan Duff: Dr. Duff conceptualized and designed the study, designed the data collection
instruments, coordinate and supervised data collection at one site, drafted the initial manuscript,

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and approved the final manuscript as submitted.
Farhan Bhanji: Dr. Bhanji conceptualized and designed the study, designed the data collection
instruments, coordinate and supervised data collection at one site, drafted the initial manuscript,

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and approved the final manuscript as submitted.
Vinay Nadkarni: Dr. Nadkarni conceptualized and designed the study, designed the data
collection instruments, contributed to interpretation of data, drafted the initial manuscript, and

SC
approved the final manuscript as submitted.
Elizabeth Hunt: Dr. Hunt conceptualized and designed the study, designed the data collection
instruments, coordinate and supervised data collection at one site, drafted the initial manuscript,
and approved the final manuscript as submitted.

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Alex Charnovich: Dr. Charnovich conceptualized and designed the study, designed the data
collection instruments, coordinate and supervised data collection at one site, drafted the initial
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manuscript, and approved the final manuscript as submitted.
David Kessler: Dr. Kessler conceptualized and designed the study, designed the data collection
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instruments, coordinate and supervised data collection at one site, drafted the initial manuscript,
and approved the final manuscript as submitted.
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Ilana Bank: Dr. Bank conceptualized and designed the study, designed the data collection
instruments, coordinate and supervised data collection at one site, drafted the initial manuscript,
and approved the final manuscript as submitted.
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Adam Cheng: Dr. Cheng conceptualized and designed the study, designed the data collection
instruments, coordinate and supervised data collection, contributed to analysis and interpretation
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of data, drafted the initial manuscript, and approved the final manuscript as submitted.

INSPIRE CPR Investigators (Jennifer Davidson, Dawn Taylor Peterson, Marjorie Lee White,
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John Zhong, Vincent Grant, David Grant, Stephanie Sudikoff, Kimberly Marohn, Nicola
Robertson, Jordan Duval-Arnould, Ronald Gottesman, Nnenna Chime, Mark Adler, Jenny
Chatfield): contributed to conceptualization and design of the study, coordinating and
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supervising data collection at one site, contributed to drafting the initial manuscript, and
approved the final manuscript as submitted.
Word count: 3114
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Abstract

Objective: We aimed to describe the differences in workload between team leaders and CPR

providers during a simulated pediatric cardiac arrest, to evaluate the impact of a CPR feedback

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device on provider workload, and to describe the association between provider workload and the

quality of CPR.

Methods: We conducted secondary analysis of data from a randomized trial comparing CPR

quality in teams with and without use of a real-time visual CPR feedback device.(1) Healthcare

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providers (team leaders and CPR providers) completed the NASA Task Load Index survey after

participating in a simulated cardiac arrest scenario. The effect of provider roles and real-time

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feedback on workload were compared with independent t-tests.

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Results: Team leaders reported higher levels of mental demand, temporal demand,

performance-related workload and frustration, while CPR providers reported comparatively

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higher physical workload. CPR providers reported significantly higher average workload

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(control 58.5 vs. feedback 62.3; p=0.035) with real-time feedback provided compared to the
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group without feedback. Providers with high workloads (average score >60) had an increased
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percentage of time with guideline-compliant CPR depth versus those with low workloads

(average score < 60) (p=0.034).

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Conclusions: Healthcare providers reported high workloads during a simulated pediatric cardiac
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arrest. Physical and mental workloads differed based on provider role. CPR providers using a
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CPR feedback device reported increased average workloads. The quality of CPR improved with

higher reported physical workloads.

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Clinical Trial Registration: Registration ID: NCT02075450; www.clinicaltrials.gov

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Abbreviations: Cardiopulmonary resuscitation (CPR), National Aeronautics and Space

Administration Task Load Index (NASA-TLX), chest compression fraction (CCF), chest
compressions (CC), basic life support (BLS), pediatric advanced life support (PALS), American
Heart Association (AHA), cardiopulmonary arrest (CPA), Just-in-Time (JIT)

Key Words: Cardiopulmonary Resuscitation, Workload, Quality, Resuscitation, Chest

Compressions

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Introduction
Pediatric patients suffering from in or out of hospital cardiopulmonary arrest (CPA)

require optimal management for the best possible outcomes.(2-6) In 2015, the European

Resuscitation Council and the American Heart Association released new guidelines with an

increased focus on quality cardiopulmonary resuscitation (CPR), emphasizing high quality chest

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compressions (CC) as a critical component of an effective resuscitation.(7-9) Guideline-

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compliant CC, with optimal rate, depth and recoil, is infrequently achieved by even the most

highly trained providers.(5, 10-12) Recent research has shown that CPR feedback devices can

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assist healthcare providers in delivering higher quality CPR, which may lead to improved patient

outcomes.(5, 10, 12-17) These devices vary, with some providing audiovisual feedback, visual

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feedback or hemodynamic-directed feedback; but all require the attention of one or more
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healthcare providers during the resuscitation. Information from the feedback device or system
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must be followed closely, with adjustments made in real-time, to result in the highest quality of
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CC.
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Although beneficial, implementing such new technology can have unintended

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consequences, which may include increasing the workload of healthcare team members.

Workload can be defined as a “hypothetical construct that represents the cost incurred by a
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human operator to achieve a particular level of performance.”(18) High workloads have been
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shown to result in poorer performance in a variety of settings.(19-23) The National Aeronautics

and Space Administration Task Load Index (NASA-TLX) is a multi-dimensional workload

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scoring tool that includes six subscales: mental demand, physical demand, temporal demand,

performance, effort and frustration.(24) These 6 dimensions of workload were chosen after an

exhaustive analysis of key features which define the workload experience of different people

performing a wide array of activities. The first three subscales of the survey represent demands

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that are imposed on the participant, while the performance, effort and frustration subscales result

from the interaction of the participant with the task.(25) Since its original publication in 1988,

the settings in which this scale has been used, with psychometric properties described, have

expanded from the laboratory setting and the aviation industry to the military and, most recently,

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to the medical community.(23, 26, 27)

The workload of the various members of a resuscitation team during cardiac arrest is

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unknown. It is also unclear how the level of workload affects the critical tasks within a

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resuscitation, including the provision of high quality CPR. Lastly, the impact of implementing a

CPR feedback device on provider workload has been unexplored. In this study, we aim to: (1)

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determine if the workload of team members differs based on provider role, (2) determine the

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impact of a CPR visual feedback device on provider workload, and (3) describe if physical
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workload of CPR providers is associated with quality of CPR during simulated pediatric cardiac
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arrest.
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Methods
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We conducted a secondary analysis of data from a prospective, multicenter, randomized

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controlled trial evaluating the impact of a real-time visual CPR feedback device on CPR quality

during a simulated pediatric cardiopulmonary arrest.(1) Institutional review board approval was
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secured at all sites, with informed consent from all participants. The study was designed,

conducted, and reported based upon published guidelines for simulation-based healthcare
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research.(28, 29)

Study Participants

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 Participants included residents, fellows, physicians, nurses and nurse practitioners who

were recruited from 10 children’s hospitals. Teams of three included two participants who were

assigned the role of CPR providers, responsible for providing CC, and one participant who was

assigned the role of team leader. All providers were certified in BLS, PALS or ACLS within the

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past two years. Specific inclusion and exclusion criteria can be found in the original publication

(CPRCARES study).(1)

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Outcome measures

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Participant perceptions of workload were collected via the NASA-TLX survey. NASA-

TLX scores are reported on a 0-100 scale for each domain, with scores of <40 reported as “low”

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and >60 considered “high” in similar environments.(24, 26) This survey was completed after the

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simulated CPA event and before any discussion or debriefing. CPR quality data was collected
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from the CPR feedback device (CC depth and rate). CC depth was measured as the proportion of
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CC during each 12 min simulated CPA with depth ≥ 50mm and CC rate was measured as the

proportion of time CC rate meeting AHA guidelines (100-120/minute).(7, 8)

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Primary Outcome Measure: NASA-TLX average score (mean scores of all 6 dimensions)
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Secondary Outcome Measures: NASA-TLX score for each dimension

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Study Procedures

Randomization
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Participants were randomized by team (of three participants) into one of four study arms.

Two of these teams received real-time feedback during CPA and the other two teams received no
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feedback during CPA. Two of the study arms also received a “Just-It-Time” (JIT) training video

just prior to CPA. All groups practiced CPR for two minutes on the manikin used in the study

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prior to the CPA scenario. Randomization was stratified by study site and conducted in blocks

of 4, thereby ensuring equal distribution of participants across study arms.

Interventions

The CPRCardTM (Laerdal Corporation) is a prototype CPR visual feedback device. It

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utilizes accelerometer technology to display and record the depth and rate of CC when placed on

the middle of the chest. The card provides visual feedback in real-time via light emitting diodes

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(LEDs) for both CC rate (three LEDs set at rates of < 100, 100-120 and > 120 compressions per

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minute) and depth (a stack of LEDs set at depths of <40 mm, 40-50mm for infant, 50-70mm for

child or adult on a hard surface and >70mm for child or adult on a soft surface).

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Standardized Simulated Scenarios, Confederate Actors and the Simulation Environment

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Following randomization, participants watched a standardized video-based orientation to
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the study. This was followed by: (1) Two minutes of CPR practice for all CPR providers; (2) A
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15-minute pediatric septic shock scenario followed by a 10-minute debriefing and completion of

the NASA-TLX survey; (3) A 12-minute pediatric simulated cardiopulmonary arrest scenario (a
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5-year-old child with pulseless electrical activity progressing to ventricular fibrillation); and (4)
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Completion of the NASA-TLX survey.

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The feedback card was taped to the center of the manikin’s chest for all study arms.

LED lights were then covered by black tape for groups who received no visual feedback. We
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strictly standardized the critical elements of the simulation across all sites to reduce potential

simulation-specific confounding variables.(28) We utilized a pre-programmed CPA scenario

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with a detailed scenario script, a standardized clinical environment with identical availability and

location of equipment across all recruitment sites, and confederate actors playing the

standardized roles of respiratory therapist and medication nurse. All actors received intensive

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training prior to study commencement, which resulted in a very high degree of compliance with

the pre-scripted actors roles (both of whom were not permitted to perform CPR).(30) All

institutions utilized the same pediatric manikin (SimJuniorTM, Laerdal Corporation: spring

constant 4.46kg/cm; 22.3kg of force required to press to 5cm; maximum compression depth of

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7cm), calibrated for CPR training. The manikin was also placed on a hard stretcher with no

mattress, thereby eliminating mattress compressibility as a confounding variable(31-33).

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Finally, we conducted a centralized review of all study videotapes to ensure compliance with all

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components of our standardized methodology.

Sample Size

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The sample size was calculated for the primary study, measuring the effect of real-time

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CPR feedback on the quality of CPR during simulated CPA, and was determined to be 108 teams
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(27 per study arm).10 As this study is a secondary analysis of exploratory data collected as part of
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the main study, we used the initial sample size calculation as a convenience sample for this

study. Two arms (54 teams) received real-time feedback and 2 arms (54 teams) received no
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feedback. The sample allows us to detect a medium effect size (cohen’s d = 0.54) with a
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significance level of 0.05 and a power of 0.8.

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Statistical Analysis

All data analyses were completed using statistical software (SPSS Statistics 21; IBM
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Corporation). Demographic characteristics were presented with descriptive statistics (count and

percentage). To evaluate the effect of provider roles on workload, average scores and scores for

6 dimensions of NASA TLX survey between team leader and CPR providers were compared

with independent t-tests for group with and without real-time feedback. To evaluate the impact

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of real-time feedback on workload, mean average scores and scores of 6 dimensions of NASA-

TLX survey were compared with independent t-test for both team leader and CPR providers. In

addition, a two-way factorial analysis of variance was done to explore the interaction between

role (CPR provider versus team leader) and real-time feedback on workload. Finally, the

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association between the quality of CPR and average workload was assessed for CPR providers

only. An average workload score of 60 was used as the cut point to evaluate the percentage of

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time with proper CC rate and the percentage of time with adequate depth. No definitive cut-off is

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universally used in the literature to define “high workload”. However, with the NASA TLX scale

ranging from 0 to 100, a cut-off of 60 has been used in similar environments to represent “high”

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reported workloads and is consistent with high workloads reported in a variety of other

environments.(19, 26, 34) N

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Results

Study Population
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A total of 372 participants were recruited (124 teams of 2 CPR providers and one team
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leader). 16 teams were excluded due to technical issues leaving 108 teams for analysis. The
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demographic characteristics of team leaders (TL) and CPR providers (CPR-P) are reported in

Table 1.
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Effect of Provider Role on Workload

The workload scores from the NASA-TLX surveys are shown in Table 2. For teams with
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no real-time feedback provided, no significant difference in average workload was found

between team leaders and CPR providers [TL 58.5 vs. CPR-P 58.2, Mean difference, MD

(95%CI): 0.3 (-3.9, 4.6), p = 0.886]. Team leaders had significantly higher mental demand (p <

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0.001), temporal demand (p < 0.001), performance (p = 0.025) and frustration (p < 0.001)

workload, but significantly lower physical demand (p < 0.001), compared with CPR providers.

For teams with real-time feedback, there was a significant difference in average workload

between team leader and CPR providers [TL 56.1 vs. CPR-P 62.3, MD (95%CI): 6.2 (2.5, 9.8), p

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= 0.001]. Team leaders had significantly higher mental demand (p < 0.001), but significantly

lower physical demand (p < 0.001) and effort (p = 0.032) workloads, compared with CPR

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providers.

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Effect of Real-Time Visual Feedback on Workload

Use of real-time feedback didn’t have a significant effect on workload for team leaders

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for either average workload [Control 58.2 vs. VisF 56.1, MD (95%CI) 2.0 (-2.2, 6.3), p = 0.344]

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or scores for all 6 dimensions. CPR providers, however, reported significantly higher average
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workload (Control 58.5 vs VisF 62.3, MD (95%CI) 3.8 (0.3, 7.4), p=0.035) and effort workload
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(p=0.033) with real-time feedback provided, compared to the group without feedback. The

reported workloads with and without feedback by provider role are shown in Figure 1. A two-
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way analysis of variance model suggests that there is an interaction between provider role and
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use of real-time feedback on average workload [F (1, 320) = 3.90, p = 0.049]. (Figure 2)
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Workload and CPR quality

CPR Providers with higher average workload (reporting score > 60) were noted to have a
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higher proportion of adequate CPR depth, compared with those who had a lower average

reported workload (p = .034) (Table 3). The difference of adequate rate percentage between 2
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groups was not statistically significant (p = .816).

Discussion

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 Pediatric resuscitations are complex and time-sensitive endeavors that require optimal

performance from all involved to produce the best possible outcomes. These tightly orchestrated

events involve intricate management, multi-tasking, resource allocation and re-allocation, and

timely decision-making, placing providers at high risk for task overload. Little is known, or has

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been reported about, provider workload during cardiac arrest events.

The results from this study highlight the potential differences in workload based on

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provider role. Although it may not be surprising that team leaders reported higher mental

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workloads and lower physical workloads than CPR providers in these simulated pediatric cardiac

arrest scenarios, it is notable that CPR providers still reported high mental workloads with all

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groups reporting subscale scores >60. Differences in workload by provider role have also been

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reported after a simulated pediatric sepsis resuscitation.(35) In this previously published work,
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team leaders reported higher average workloads than team members (51 vs 43.8, p<0.001) and
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higher mental demand than team members (73.4 vs 59.8, p<0.001). Although team members in

the sepsis study also reported higher physical demand than team leaders (28.6 vs 17.9 p<0.001),
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they reported notably lower physical demand and effort than in this study when CPR was
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required. This finding suggests that we should have a heightened awareness of the physical
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demands placed upon CPR providers, and consider implementing strategies (e.g. more frequent

provider switches) to modulate this issue.

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CPR feedback devices are quickly becoming a standard component in any

cardiopulmonary resuscitation. There are concerns, however, when adding new technology into
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an already complex, highly stressed environment. Our study is the first to report on the impact of

these devices on the subjective workload reported by the healthcare providers. Interestingly, the

use of real-time feedback seemed to increase workload across all domains. Comparison of the

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differences between these groups, however, found only effort (a response to the question “How

hard did you have to work to accomplish your level of performance?”) and average workload to

be statistically significant. Also notable, the use of real-time feedback seemed to decrease the

workload for the team leader in most domains, suggesting that feedback devices may reduce the

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need for team leaders to monitor CPR quality, thus reducing workload. This has potential

implications on overall team performance, as increased workload has been associated with a

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higher risk of error and decreased performance of both cognitive and procedural tasks.(19, 34)

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Therefore, decreasing the overall workload of team leaders may free up cognitive space for them

to address other clinically important tasks. It is also important to weigh the potential impact any

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new technology may have on workload against the improvements that may result from this

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technology. This is evident when discussing the increased CPR provider workload and the
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improvements noted in CPR quality with the use of a feedback device. Ultimately, gathering
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information about the impact new technology has on workload may allow for optimization and

smoother implementation of this technology into the clinical environment.

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Finally, the average reported workload was found to be higher among those providers
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that produced better average depth during compressions, suggesting that CPR feedback devices
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have a motivating effect on most CPR providers, leading to better quality compressions. This

result also suggests that poor quality CPR noted in many other cardiac arrest studies may be due,
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in part, to lack of provider effort, and less so due to other variables such as prior training, and

provider gender or physique(15, 36).

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We found that teams that had visual feedback tended to have higher reported frustration

levels especially by the team members. This can be an important finding as the use of these

feedback devices becomes more widespread. Many teams commented that they “didn’t believe”

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the feedback they were receiving from the device. Without directly addressing this concern,

team members performing chest compressions may not adjust their CPR technique, thus leading

to poor quality. The European Resuscitation Council and the American Heart Association have

increased the recommended depth of compressions with every recent update.(7, 9, 37-40)

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Despite the requirement for yearly recertification of CPR skills, the quality of CPR during

pediatric cardiac arrest is often suboptimal. Our results suggest two important considerations:

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(1) implementation of CPR feedback devices should be accompanied by orientation to the

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device, and training on the device, so that providers are confident in the quality of feedback they

receive; and (2) providers should be prepared to exert themselves harder during CPR when CPR

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feedback devices are in use.

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There are limitations with this study. The resuscitation team in our scenario consisted of
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one team leader, two team members, and two confederates (acting as a respiratory therapist and
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nurse). Team members were therefore required to perform CPR as well as other tasks (i.e. give

medications, operate the defibrillator). As this is just one possible team composition, it is
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possible that workload would vary with other team structures. These results are also based upon
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the use of one particular device, a visual feedback device placed on the chest wall, and may
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therefore not be generalized to other devices, such as those with audiovisual feedback or those

operated through a defibrillator. These results are also obtained in a simulated resuscitation and
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may differ in actual patient care.

There are also possible limitations regarding the use of the NASA-TLX. Although it is a well-
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validated and often utilized instrument, it is still a subjective evaluation of provider workload.

Also, the cardiac arrest scenario was run second after a pediatric sepsis scenario. As the

providers had already completed the survey once, it is possible that they may have been

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anticipating this second survey leading to decreased attention or changes in their responses due

to comparisons with the sepsis case. Furthermore, this is a sub-analysis of data, and it therefore

may be underpowered to detect small differences within the groups. Finally, this study was done

on a child-sized manikin. It is unclear how an adult sized patient or manikin would have

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changed the required and reported effort of participants.

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Conclusion
In this study, we identified differences between team leaders and team members in

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reported perceived workloads during simulated pediatric cardiac arrest. The implementation of a

real time visual CPR feedback device increased the perceived workload reported by team

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members. CPR providers who reported very high physical demand improved their CPR quality

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compared to those providers reporting lower workloads. Further study is needed to describe the
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variation of workload utilizing different feedback devices and team compositions.
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Conflict of Interest Statement: Adam Cheng (study design, writing, editing, and review)
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received funding from the Heart and Stroke Foundation of Canada and the Canadian Insititute for
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Health Research for this study. Vinay Nadkarni (study design, writing, editing and review of

manuscript) is supported by: Endowed Chair, Critical Care Medicine, Children’s Hospital of
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Philadelphia; and the following research grants: AHRQ RO3HS021583; Nihon Kohden America
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Research Grant; NIH/NHLBI RO1HL114484; NIH U01 HL107681; NIH/NHLBI

1U01HL094345-01; and NIH/NINDS 5R01HL058669-10. Nancy Tofil (study design, writing,

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editing, review of manuscript) was a speaker at the fall 2013 Laerdal Conference and spoke

using her own created materials, did not receive a speaker stipend, but was reimbursed for travel.

Elizabeth Hunt (study design, writing, editing, review) is supported by Drs. David S. and

Marilyn M. Zamierowski Endowed Directorship, Johns Hopkins Simulation Center and grants

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from the Laerdal Foundation for Acute Care Medicine and the Hartwell Foundation. The other

authors have no other financial or conflict of interests or disclosures.

Funding Source: This study was funded by a research grant from the Heart and Stroke

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Foundation of Canada and the Canadian Institute for Health Research. Funds were used for the

design of the study, as well as completion of data collection, analysis and interpretation of the

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data. The CPRCardsTM were provided by the Laerdal Corporation, and SimJunior manikins were

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also loaned to each site. No funds were received from the Laerdal Corporation.

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Conflict of Interest Statement: Adam Cheng (study design, writing, editing, and review)

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received funding from the Heart and Stroke Foundation of Canada and the Canadian Insititute for
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Health Research for this study. Vinay Nadkarni (study design, writing, editing and review of
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manuscript) is supported by: Endowed Chair, Critical Care Medicine, Children’s Hospital of

Philadelphia; and the following research grants: AHRQ RO3HS021583; Nihon Kohden America
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Research Grant; NIH/NHLBI RO1HL114484; NIH U01 HL107681; NIH/NHLBI

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1U01HL094345-01; and NIH/NINDS 5R01HL058669-10. Nancy Tofil (study design, writing,

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editing, review of manuscript) was a speaker at the fall 2013 Laerdal Conference and spoke

using her own created materials, did not receive a speaker stipend, but was reimbursed for travel.
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Elizabeth Hunt (study design, writing, editing, review) is supported by Drs. David S. and

Marilyn M. Zamierowski Endowed Directorship, Johns Hopkins Simulation Center and grants
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from the Laerdal Foundation for Acute Care Medicine and the Hartwell Foundation. The other

authors have no other financial or conflict of interests or disclosures.

16
Funding Source: This study was funded by a research grant from the Heart and Stroke

Foundation of Canada and the Canadian Institute for Health Research. Funds were used for the

design of the study, as well as completion of data collection, analysis and interpretation of the

data. The CPRCardsTM were provided by the Laerdal Corporation, and SimJunior manikins were

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also loaned to each site. No funds were received from the Laerdal Corporation.

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Figure 1: NASA TLX scores of participants

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* Significant difference between no feedback group and real-time feedback group in CPR Providers
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** Significant difference between team leaders and CPR providers when no feedback provided
*** Significant difference between team leaders and CPR providers when real-time feedback provided
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Figure 2: Interaction between provider role and use of real-time feedback on average work load

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Table 1: Demographic characteristics of participants

Count (%) No feedback Real-time feedback
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Team leader CPR Provider Team leader CPR Provider

Gender
Female 28 (51.9) 82 (75.9) 27 (50.0) 82 (75.9)
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Male 26 (48.1) 26 (24.1) 27 (50.0) 26 (24.1)

Profession
Physician 54 (100.0) 33 (30.6) 54 (100.0) 34 (31.5)
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Nurse 0 (0) 60 (55.5) 0 (0) 60 (55.5)

Other 0 (0) 15 (13.9) 0 (0) 14 (13.0)

Last BLS/ACLS/PALS course taken

< 12 months 38 (70.4) 89 (82.4) 36 (66.7) 81 (75.0)
>12 months 16 (29.6) 19 (17.6) 18 (33.3) 27 (25.0)

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 Chest compression on actual pediatric patients in the past 2 years
Never 20 (37.0) 69 (63.9) 19 (35.2) 65 (60.2)
1-5 times 25 (46.3) 34 (31.5) 26 (48.1) 35 (32.4)
6 times or more 9 (16.7) 5 (4.6) 9 (16.7) 8 (7.4)

Chest compression on simulated pediatric patients in the past 2 years

Never 5 (9.3) 25 (23.2) 2 (3.7) 28 (25.9)
1-5 times 33 (61.1) 67 (62.0) 34 (63.0) 56 (51.9)

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6 times or more 16 (29.6) 16 (14.8) 18 (33.3) 24 (22.2)

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Table 2: NASA TLX workload of participants
Mean (Standard deviation) Mental Physica Tempor Performa Effort Frustrati Averag
l al nce on e

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CPR No Feedback 63.2 78.3 59.1 38.7 71.9 39.7 58.5
Provider (21.7) (19.3) (21.5) (21.7) (19.3) (26.4) (14.7)
Real-time 64.1 82.9 60.5 43.1 76.9 46.3 62.3
Feedback (18.9) (15.4) (18.6) (21.2) (16.1) (24.5) (11.6)

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Team No Feedback 78.2 26.2 66.7 48.2 69.4 60.4 58.2
Leader (15.8) (23.7) (19.2) (20.9) (17.4) (23.3) (11.9)
Real-time
Feedback
76.6
(15.8)
20.6
(20.0)
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65.5
(18.2)
49.4
(20.1)
71.2
(15.5)
53.6
(22.6)
56.1
(10.3)
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Table 3: Workload and Quality of CPR

Average Average workload Difference p-
workload > 60 <60 (n=100) Mean (95% CI) value
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(n=116) Mean (SD)

Mean (SD)
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Percentage of
compression depth > 50 36.5 (26.3) 29.0 (25.3) 7.5 (0.57, 14.5) 0.034
mm
Percentage of
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compression of 100- 120/ 54.5 (35.1) 53.4 (36.7) 1.1 (-8.5, 10.8) 0.816
min
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