Pediatric Pharmacists’ Participation in Cardiopulmonary Resuscitation Events

Training of Pediatric Pharmacists.

The PPA recommends that pediatric pharmacists participating in CPR and rapid response events maintain appropriate certifications such as basic life support and pediatric advanced life support (PALS). Additional certifications can be considered, such as neonatal resuscitation program (NRP) certification for any pharmacists that practice in areas where neonatal patients may be admitted or in maternal-fetal care units. Advanced cardiac life support may be considered for any pharmacists who practice in areas where adult patients may be admitted, such as cardiac care units or emergency departments. Recommendations for credentialling pediatric pharmacists for CPR events are listed in Table 1. While these certifications can provide pharmacists with baseline knowledge, they alone may not adequately prepare pharmacists for routine participation in hospital CPR events, as they lack information related to specific aspects of pharmacotherapy, including medication dosing, manipulating multiple drug concentrations and dosing formulations, intravenous medication compatibility considerations, and bedside dose preparation. To fill in these gaps and improve the comfort of pharmacists responding to CPR events, the PPA recommends that pharmacy leadership support the creation of training competency programs for all pharmacist staff involved in CPR events. This training should include education sessions with pediatric case examples, hands-on mock codes using simulation labs for CPR events and common pediatric medical emergency scenarios, and continuing education programs. Several published articles support additional pharmacist training beyond the aforementioned certifications. Machado et al¹⁷ found that pharmacists had a more favorable attitude toward participating in CPR events if they felt they had adequate training. Roddy et al¹⁸ demonstrated that combined didactic education and pediatric simulation-based training increased pharmacist knowledge and confidence in pediatric emergency response.

Table 1.Recommendations for Credentialing for Pediatric Pharmacists for Cardiopulmonary Resuscitation Events

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Many institutional training programs have been published that focus on various aspects of pharmacotherapy during emergency response.^18–22 These training programs dedicated time for hands-on experience to help participants become familiar with code trays and intravenous admixtures. Many sessions emphasized identifying common medication errors, reviewing code dosing sheets and common algorithms, calculating patient-specific doses, preparing medications, and practicing closed-loop communication to enhance teamwork skills. These studies illustrate how training programs for pharmacists involved in CPR events can improve comfort levels and competency through education interventions, written assessments, certification, and practical training.

Pharmacist training sessions for pediatric emergencies within simulation laboratories and regular multidisciplinary mock codes provide valuable opportunities for pharmacists and pharmacy residents to identify different patterns of medication use, enhance communication skills in critical situations, and engage in postsimulation debriefing to discuss errors and successes.^23,24 Thompson Bastin et al²⁴ evaluated simulation exercises designed to prepare pharmacy residents for a 24-hour, in-house, on-call program. The investigators found that self-perceived preparedness increased following sepsis (p = 0.001) and stroke and status epilepticus (p = 0.042) exercises. These results highlight that simulation training incorporated into pharmacy residency programs can increase resident readiness for medical emergencies.

Before implementing an institution-specific training program, hospital pharmacy leadership should assess data and review patient safety guidelines to identify the specific training needs of their pharmacists. Pharmacists should be involved in institutional patient safety committees and quality assurance programs. Table 2 lists recommendations for education and training to prepare pharmacists for pediatric CPR events. Institutions should engage pharmacists in developing and implementing appropriate resources, such as standardized pediatric and neonatal medication code algorithms and weight-based reference cards for emergency medications to aid in medication preparation.

Table 2.Recommendations for Education and Training for Pediatric Pharmacists for Cardiopulmonary Resuscitation Events

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Participation in CPR Oversight Committees.

The PPA advocates for pediatric pharmacists to participate in CPR and rapid response committees. Pharmacist participation is crucial as these committees review CPR events for individual patients to identify areas for quality improvement and develop policies and procedures for such events. The findings from a retrospective multidisciplinary code review committee that included a pharmacist demonstrated that approximately 60% of reviewed code events resulted in education initiatives, and 47% resulted in a new policy or modification of an existing policy.¹⁵ A study by Anderson et al¹⁴ demonstrated the need for synchronous, multidisciplinary code review to provide rapid feedback and further identified that top-performing hospitals in emergency events had responsive, multidisciplinary leadership teams who listened and modified programs to align with the needs of their staff.¹⁴ Pharmacist participation in multidisciplinary code review committees can help identify departmental or hospital-wide deficiencies and lead to educational patient care improvement initiatives.

Additionally, pharmacists can be vital in overseeing emergency carts and kits for CPR, rapid-response situations, rapid-sequence intubations, and trauma responses. A lack of standardization and organization of emergency carts, particularly regarding medications, can adversely affect outcomes. Disorganization can lead to significant delays because response time is crucial for patient survival.^25,26 Pharmacists play a vital role in this process, as emphasized by the American Society of Health-System Pharmacists²⁷ and The Joint Commission,²⁸ to ensure that medications in emergency carts and kits are properly organized and stored, especially in drug shortages.

In addition to these responsibilities, pharmacists can contribute to developing institution-specific protocols and dosing tools for CPR events. Pediatric pharmacist expertise is particularly beneficial for creating protocols for emergencies, such as hyperkalemia and status epilepticus, which are not specifically covered in the 2020 PALS guidelines.²⁹ These protocols can help clinicians anticipate potential medication therapies tailored to the institution’s formulary. Furthermore, pharmacist involvement in developing dosing tools for emergency medications is crucial for preventing medication errors during CPR events, especially because children require weight-based dosing.

Participation in Individual Patient CPR and Rapid Response Events.

The PPA recommends that all hospitals have pediatric pharmacists respond to all neonatal and pediatric CPR events. The rarity of pediatric CPR events highlights the need for immediate access to a drug therapy expert for clinical pharmacotherapy recommendations. Additionally, the PPA suggests that institutions consider including a pediatric pharmacist on rapid response teams to offer therapy recommendations in line with the PALS guidelines and help ensure medication safety. Draper and Eppert³⁰ conducted a retrospective study that evaluated 74 CPR events in adults to determine compliance with American Heart Association advanced cardiac life support guidelines and found that compliance was more likely when a pharmacist was present (59.3% v 31.9%, p = 0.03). While this study did not specifically target pediatric patients, it seems reasonable to suggest that pediatric pharmacists could also ensure that medication regimens adhere to PALS recommendations.

Pharmacists attending emergency responses may bring additional medications that are not typically stored in emergency carts due to storage or regulatory requirements. In a retrospective cohort study conducted by Bembea et al,¹³ pediatric medical emergency teams showed that only 40% of medications ordered during an emergency response were readily available. Additional medications supplied by the responding pharmacist provided an additional 35% of dosages, increasing bedside availability of requested medications from 40% to 75%. By their involvement in developing and maintaining an emergency response team, pharmacists can understand their role and help identify additional medications or supplies that may be useful when responding to an emergency.

Pharmacists can also help reduce medication errors during CPR events, which are more common in pediatrics. Pediatric medication error rates are reported to be more than 70%, which is 3 times the error rate compared with adult institutions.³¹ However, the collaboration of clinical pharmacists with nursing staff has been shown to prevent 58% of medication errors and 72% of high-risk errors.²³ While these pediatric error rates are higher than reported adult rates, these error rates are not specific to medical emergencies. Medication error event rates would likely be higher during pediatric medical emergencies due to the high-stress environment, limited access to immediate resources, and involvement of mathematical calculations and drug manipulation. A systematic review and meta-analysis by Marufu et al³¹ reviewed pediatric and neonatal studies published from 2000 to 2020 that implemented interventions to reduce medication errors. Most studies used clinical pharmacist involvement as part of a multi-intervention approach that included education programs, independent double checks, and reduced interruptions while calculating and preparing weight-based doses. This meta-analysis surmised that the presence of a clinical pharmacist may help nurses make informed clinical decisions, provide updated reconstitution and dilution instructions at the bedside, and improve therapeutic interchange choices in light of intravenous incompatibilities or medication shortages. In addition to nursing support, pharmacists can also provide support for providers. A review of simulated CPR events found that the presence of a pediatric pharmacist significantly reduced medication errors made by pediatric resident physician trainees.³² Pharmacist involvement in the emergency response team can help mitigate medication errors and reduce medication turnaround time for safer delivery of medications to pediatric patients.^13,16

Owing to unforeseen medication shortages, emergency carts may be stocked with alternatives to the expected medications. Whether these stocked medications are alternative formulations or require the use of pharmacy-generated kits, the likelihood of medication errors increases when unfamiliar medications need to be prepared. Pediatric pharmacists assist clinicians in anticipating these changes and ensure that the most appropriate medication is selected, prepared, and administered accurately.