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7-Component CPR Model Improves In-Hospital Resuscitation of Children

Analysis  |  By Christopher Cheney  
   December 18, 2018

The John Hopkins Children's Center approach to cardiopulmonary resuscitation increases compliance with American Heart Association guidelines.

A new approach to cardiopulmonary resuscitation is helping to save children's lives at Johns Hopkins Children's Center in Baltimore.

Pediatric CPR is a challenge in the hospital setting. Every year, more than 6,000 children have in-hospital cardiac arrest and most do not survive to discharge.

In 2013, Johns Hopkins Children's Center started developing a new approach to CPR—Coaching, Objective‐Data Evaluation, Action‐linked phrases, Choreography, Ergonomics, Structured debriefing, and Simulation (CODE ACES2). The children's hospital published research on the approach this month.

Johns Hopkins Children's Center staff can reliably start chest compressions within 10 seconds, the lead author of the research, Elizabeth Hunt, MD, MPH, PhD, told HealthLeaders recently.

"The idea is to teach in medicine similar to how world class chess players, athletes and musicians train—to practice the right way over and over again while getting feedback from an expert mentor. This also helps our resuscitation team to decrease variability," said Hunt, who is director of the Johns Hopkins Medicine Simulation Center and an associate professor at Johns Hopkins University School of Medicine.

Under the CODE ACES2 approach, a debriefing is held after every cardiac arrest to review challenges that the resuscitation team encountered and identify any deviations from best practices.

From 2013 to 2016, more than 300 cardiac arrests were debriefed. During this period, the probability of attaining excellent CPR based on American Heart Association (AHA) compliance for rate, depth, and chest compression fraction rose from 19.9% to 44.3%.

CODE ACES2 has seven essential elements.

1. CPR coach plays monitor role

Use of a CPR coach is a unique aspect of CODE ACES2. The CPR coach monitors the chest compressor and airway manager for compliance with AHA guidelines, allowing the code team leader to focus on higher-level problem solving and managing the patient.

"This means as soon as the CPR coach notices the compressor stop chest compressions for any reason, they are very likely to notice immediately because they are not distracted by other tasks such as giving medications. As soon as they notice the pause, they will personally take over compressions then tell the compressor to take over from them," Hunt said.

2. Data gathered and evaluated

After every cardiac arrest, all data is gathered from the bedside monitor, defibrillator, EHR, and emergency alert systems. Metrics used to analyze the data include chest compression depth, chest compression rate, and time from loss of pulse to initiation of compressions.

Data is a key facet of CODE ACES2 debriefings. "Areas of high and low guidelines compliance are discussed during the debriefing to identify event factors that hinder or enhance performance," Hunt and her fellow researchers wrote.

3. Action-linked phrases encouraged

CPR team members speak observations aloud and link them with resuscitation actions such as, "There's no pulse, I'm starting compressions," which can decrease the time to starting compressions.

4. Choreography mapped out

The resuscitation team should have a shared mental model of how the team interacts with a room, the equipment, the patient, and each other. To keep resuscitation activities going, the CPR coach and code team leader are trained to direct team members to continue their tasks while next steps are discussed.

5. Ergonomics diagrammed

Johns Hopkins Children's Center used pre- and post-event "room diagramming" to attain the best room layout for a patient in cardiac arrest. Pre-event room diagrams include the location of surgeons, nurses, chest compressors, and defibrillators. The diagram plans were practiced in monthly resuscitation simulations. Unnecessary furniture and equipment were removed.

Room diagrams drawn after an event are part of data presented at debriefings.

6. Debriefing embraced

A CODE‐ACES2 debriefing takes about 45 minutes and starts with a privacy and confidentiality acknowledgement. The debriefing features clinical data analysis, review of peer-to-peer debriefing forms, examination of relevant therapy such as pharmacy, and critiques of CPR quality.

Staff members who participate in the briefing include the physician or nurse who was attending the patient before the cardiac arrest, the rescuer who initiated chest compressions, code team leader, CPR coach, airway manager, and pharmacist.

7. Simulations inform and prepare resuscitation teams

The optimal position of the CPR coach opposite from the chest compressor was determined through simulations, along with the positioning for the code team leader and defibrillator. Simulation has helped perfect other facets of the CODE‐ACES2 approach such as placement of the backboard.

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


More than 6,000 children have in-hospital cardiac arrest annually and most do not survive to discharge.

Johns Hopkins Children's Center has developed a new approach to pediatric resuscitation, including a CPR coach to monitor chest compressions and airway management.

The new approach increased achievement of excellent CPR based on American Heart Association guidelines from 19.9% of resuscitation events to 44.3%.

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