Abstract Body (Do not enter title and authors here): Introduction: Pediatric cardiac arrest (PCA) is a low-frequency, high acuity event, and mortality is twice as high for arrests that occur in a rural hospital compared to a children’s hospital. As such, there is an urgent need to identify individual and systems-based factors that could be translated from children’s hospitals to rural hospitals. This study sought to utilize a human factors approach to look at code leadership as one such factor through the use of tele-simulation in combination with eye tracking to assess differences in cardiopulmonary resuscitation (CPR) quality and visual attention among high frequency pediatric resuscitators -- pediatric emergency medicine and pediatric critical care (PEM-PCCM) physicians -- and low frequency pediatric resuscitators -- rural emergency medicine (REM), and pediatric resident (PEDS) groups -- during a simulated PCA.

Methods: We conducted a multi-center pilot, prospective, observational study in which we compared groups of PEM-PCCM physicians, REM physicians, and PEDS physicians who were asked to serve as code leaders in a tele-simulation scenario. Participants were given a live video feed and live communication with a remote simulation team and led a simulated PCA scenario. CPR performance was evaluated using CPR timing metrics as well as a validated clinical performance tool (CPT). Participant eye tracking was measured using a screen-based eye tracker to assess where participants were focusing during the simulation. All data were analyzed using linear mixed effects models.

Results: 30 physicians completed the study from 6 different hospitals, with 10 participants in each of the PEM-PCCM, REM, and PEDS groups. For the CPT score, both PEDS and REM groups scored lower than participants in the PEM-PCCM group (p<0.001 for both). Both PEDS and REM had significantly longer times to give epinephrine than PEM-PCCM (p=0.004 and 0.033, respectively). In terms of eye tracking, PEDS group spent much more time focused on the monitor than the PEM-PCCM group, who spent more time looking at the patient and team members (p=0.027) and had fewer overall fixations (p=0.032).

Conclusions: With standardized code teams, PEM-PCCM had higher clinical performance scores and faster times to clinically important CPR metrics than REM and PEDS groups. The PEM-PCCM group also spent less time focused on the monitor during PCA. This should be validated in a larger cohort, but has implications for resuscitation coaching.