Discussion
ROSC, cardiac arrest, PediAppRREST
AIDS, CARDIAC ARREST
In this randomized clinical trial, we analyzed the effect of the use of the PediAppRREST tablet app on the management of a simulated case of pediatric cardiac arrest and found that its use was associated with fewer deviations from guidelines and a better team clinical performance compared with the use of the AHA reference pocket card and no cognitive aid. Given that deviations from recommendations are still frequent and are proven to affect clinical outcomes,The detected benefits of using the PediAppRREST app in our study could be related to its ability to provide multimodal interactive stepwise decision support to the team leader. In contrast, paper-based aids are static and usually display the entire algorithms in a 1-page format, requiring users to independently identify the correct steps in the algorithm and rapidly move through its decision nodes and treatment recommendations. This process can cause a mental overload in the users and in turn delay actions and increase management errors. Given the low complexity of the PediAppRREST cognitive aid, needing only a tablet as hardware support, it could potentially be easily implemented also in lower-resource settings. In addition, practice with the app through mental simulation could be facilitated and promoted by its download on personal smartphones.A 2022 meta-analysisTo our knowledge, only 1 other study has compared the effect of an electronic (smartphone app) cognitive aid with a paper-based aid and no cognitive aid, and it was conducted using adult case scenarios.With respect to the quality of CPR, we found that the use of the app did not impact chest compression quality metrics. However, this cognitive tool was not developed to support the compressors during CPR, thus an improvement of the quality of compressions was not expected. Different real-time feedback devices and a CPR coach have been proven to effectively improve the quality of compressions.Overall, our study found that the use of the PediAppRREST app globally improved the management of pediatric cardiac arrest, mostly by reducing omissions and errors that can impact clinical outcomes. The use of our app was associated with a higher proportion of ROSC than control groups. However, in our study, ROSC was achieved when predefined tasks were correctly completed during the management of the scenario. For this reason, while ROSC is an important outcome in real-life studies, it was not included as an outcome in our simulation-based trial.Most of the times to perform critical actions for resuscitation did not significantly differ between the study groups. This could be related to the limited prior exposure to the app by the team leaders, as the use of a new cognitive tool, by itself, takes time and cognitive effort. Professionals who frequently lead pediatric clinical emergencies and are not completely familiar with a cognitive aid could choose not to use it or could be delayed in their management by the tool; in contrast, cognitive aids could be more beneficial for less expert clinicians, for both ensuring all tasks are completed and for expediting management goals. Future studies should ascertain whether by improving users’ proficiency and efficiency in navigating PediAppRREST via increased practice could result in a reduction in time to perform critical actions compared with standard practice.While any cognitive support could potentially increase users’ workload, as it may distract from the management of the scenario by requiring extra attention and concentration to understand its use or follow its guidance, we found that the use of PediAppRREST was not associated with a higher perceived workload among users, and its usability was rated as good.