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Care that is provided in adherence to established guidelines has been associated with improved survival. Lower mortality rates have been reported in higher\u2010volume hospitals, teaching hospitals, and trauma centers. The primary objective of this article was to explore the relationship of hospital characteristics, such as annual pediatric patient volume, to adherence to pediatric cardiac arrest guidelines during an in\u00a0situ simulation. Secondary objectives included comparing adherence to other team, provider, and system factors.<\/jats:p><\/jats:sec>Methods<\/jats:title>This prospective, multicenter, observational study evaluated interprofessional teams in their native emergency department (ED<\/jats:styled-content>) resuscitation bays caring for a simulated 5\u2010year\u2010old child presenting in cardiac arrest. The primary outcome, adherence to the American Heart Association pediatric guidelines, was assessed using a 14\u2010item tool including three component domains: basic life support (BLS<\/jats:styled-content>), pulseless electrical activity (PEA<\/jats:styled-content>), and ventricular fibrillation (VF<\/jats:styled-content>). Provider, team, and hospital\u2010level data were collected as independent data. ED<\/jats:styled-content>s were evaluated in four pediatric volume groups (low\u00a0<\u00a01,800\/year; medium 1,800\u20134,999; medium\u2010high 5,000\u20139,999; high\u00a0>\u00a010,000). Cardiac arrest adherence and domains were evaluated by pediatric patient volume and other team and hospital\u2010level characteristics, and path analyses were performed to evaluate the contribution of patient volume, systems readiness, and teamwork on BLS<\/jats:styled-content>, PEA<\/jats:styled-content>, and VF<\/jats:styled-content> adherence.<\/jats:p><\/jats:sec>Results<\/jats:title>A total of 101 teams from a spectrum of 50 ED<\/jats:styled-content>s participated including nine low pediatric volume (<1,800\/year), 36 medium volume (1,800\u20134,999\/year), 24 medium\u2010high (5,000\u20139,999\/year), and 32 high volume (\u226510000\/year). The median total adherence score was 57.1 (interquartile range\u00a0= 50.0\u201378.6). This was not significantly different across the four volume groups. The highest level of adherence for BLS<\/jats:styled-content> and PEA<\/jats:styled-content> domains was noted in the medium\u2010high\u2013volume sites, while no difference was noted for the VF<\/jats:styled-content> domain. The lowest level of BLS<\/jats:styled-content> adherence was noted in the lowest\u2010volume ED<\/jats:styled-content>s. Improved adherence was not directly associated with higher pediatric readiness survey (PRS<\/jats:styled-content>) score provider experience, simulation teamwork performance, or more providers with Pediatric Advanced Life Support (PALS<\/jats:styled-content>) training. ED<\/jats:styled-content>s in teaching hospitals with a trauma center designation that served only children demonstrated higher adherence compared to nonteaching hospitals (64.3 vs 57.1), nontrauma centers (64.3 vs. 57.1), and mixed pediatric and adult departments (67.9 vs. 57.1), respectively. The overall effect sizes for total cardiac adherence score are ED<\/jats:styled-content> type \u03b3\u00a0=\u00a00.47 and pediatric volume (low and medium vs. medium\u2010high and high) \u03b3\u00a0=\u00a00.41. A series of path analyses models was conducted that indicated that overall pediatric ED<\/jats:styled-content> volume predicted significantly better guideline adherence, but the effect of volume on performance was only mediated by the PRS<\/jats:styled-content> for the VF<\/jats:styled-content> domain.<\/jats:p><\/jats:sec>Conclusions<\/jats:title>This study demonstrated variable adherence to pediatric cardiac arrest guidelines across a spectrum of ED<\/jats:styled-content>s. Overall adherence was not associated with ED<\/jats:styled-content> pediatric volume. Medium\u2010high\u2013volume ED<\/jats:styled-content>s demonstrated the highest levels of adherence for BLS<\/jats:styled-content> and PEA<\/jats:styled-content>. Lower\u2010volume ED<\/jats:styled-content>s were noted to have lower adherence to BLS<\/jats:styled-content> guidelines. Improved adherence was not directly associated with higher PRS<\/jats:styled-content> score provider experience, simulation teamwork performance, or more providers with PALS<\/jats:styled-content> training. This study demonstrates that current approaches optimizing the care of children in cardiac arrest in the ED<\/jats:styled-content> (provider training, teamwork training, environmental preparation) are insufficient.<\/jats:p><\/jats:sec>","DOI":"10.1111\/acem.13564","type":"journal-article","created":{"date-parts":[[2018,9,8]],"date-time":"2018-09-08T11:12:57Z","timestamp":1536405177000},"page":"1396-1408","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":38,"title":["Adherence to Pediatric Cardiac Arrest Guidelines Across a Spectrum of Fifty Emergency Departments: A Prospective, In Situ, Simulation\u2010based Study"],"prefix":"10.1111","volume":"25","author":[{"given":"Marc","family":"Auerbach","sequence":"first","affiliation":[{"name":"Department of Pediatrics and Emergency Medicine Yale University School of Medicine New Haven 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