Despite years of investment to improve CPR and post-resuscitation care, many experts in the field have considered in-hospital cardiac arrest (IHCA) a largely unavoidable outcome for some children in cardiovascular intensive care units (CICUs). A recent initiative by 15 children’s hospitals challenges that notion.
A simple, low-technology cardiac arrest prevention practice bundle reduced IHCA incidence by an average of 30% across the participating centers. The results, published in JAMA Pediatrics, exceeded a targeted 25% reduction, and the practices used can be replicated in any institution, say project leaders Jeffrey Alten, M.D., attending physician at Cincinnati Children’s Hospital Medical Center CICU, and Michael Gaies, M.D., medical director of the Acute Care Cardiology Unit at Cincinnati Children’s.
The bundle, composed of five elements, was designed to promote situational awareness and communication to recognize and mitigate deterioration in high-risk patients. Each element of the bundle was specifically chosen to be minimal in cost and technology independent, allowing CICUs to adapt it to their local system, quality improvement resources and clinical workflow.
The project for creating the bundle came from a quality improvement initiative conducted within a collaborative learning network of CICU teams across the Pediatric Cardiac Critical Consortium (PC4), which aims to improve the quality of care for patients with critical pediatric and congenital cardiovascular disease. PC4 is part of Cardiac Networks United, a collaborative pediatric and congenital cardiovascular research and improvement network.
“This study represents the culmination of years of effort by so many within PC4,” says Gaies, who was the founder and executive director of PC4 during the study. “We collaborated with hospitals across the country to collect data and understand variation in performance on IHCA prevention. Leaders from these institutions then came together to improve the quality of care across hospitals.”
Monthly webinars led by project leaders featured education, data review and collaborative learning to empower teams toward successful implementation of the bundle. “The belief persists that IHCA is an inevitability of critical illness, but as early adopters of the bundle overcame obstacles and shared their improvement learnings on these webinars, this dogma was challenged. Confidence steadily increased among once reluctant participants that IHCA is indeed preventable,” says Alten. “Proving feasibility of IHCA prevention represents the most essential message of this project. Hopefully it will encourage spread of these IHCA prevention practices at other hospitals.”
The team analyzed data from 41,204 admissions, including 10,510 admissions at participating hospitals, with 2,664 of admissions receiving the bundle for an average of 4.4 days per patient. For all admissions, there was a 30% relative reduction in IHCA incidence rate during the intervention period, which translated to an average of 11 fewer IHCA events per month.
Medical City Children’s Hospital in Dallas, which participated in the collaborative, reduced its cardiac arrest rate by 49% using the bundle. “Our results demonstrate that identification of high-risk cardiac populations is possible, and a simple bedside cardiac arrest prevention bundle can result in significant reduction of cardiac arrest,” says Tia Raymond, M.D., pediatric cardiologist at Medical City Children’s.
Researchers in the study say this represents an important paradigm shift in critical care to prioritize IHCA prevention and reduce adverse events. “The best CPR is no CPR,” says Alten. “And this project was able to prevent CPR in almost 200 high-risk children during bundle implementation at these 15 hospitals.”
Future studies are needed to determine which bundle elements are most necessary for cardiac arrest prevention. More work is needed to roll out the care bundle to more hospitals. Although the details of interventions vary, the team leaders say the core elements of this bundle can likely be adapted to other critically ill populations, such as general pediatric and adult intensive care patients, and adult cardiovascular ICUs.
The cardiac arrest bundle
The bundle is composed of five elements and designed to promote situational awareness and communication to recognize and mitigate deterioration in high-risk patients.
This formal, multidisciplinary bedside discussion occurs separately from patient rounds and is designed to create situational awareness among the care team for high-risk patients. The twice-daily huddle includes a bedside nurse, nurse leader, attending physician, first-responding provider and respiratory therapist. Topics must include the most likely reason for an IHCA with a particular patient as well as mitigation and rescue plans. The goal is for the entire team to recognize early deterioration and agree on plans for reversal and rescue of a patient.
Vital sign discussion
This discussion can occur during the huddle and seeks to establish parameters for patient-specific vital sign targets, defining changes that may represent early deterioration. These parameters are posted in the patient’s room, programmed into the monitor, and require bedside clinician evaluation and reassessment if there are changes to these parameters.
This element also occurs during the huddle. The team discusses the use of pre-sedation for harmful stimuli since patients in weak condition are more likely to suffer sudden, adverse changes because of agitation or pain.
Since many IHCA episodes are preceded by acute hypotension, rapid administration of epinephrine may rescue a patient prior to cardiac arrest. The bundle calls for patient-specific doses to be pre-drawn and stored at the bedside.
Formal code review
All cardiac arrests must be reviewed within two weeks of the event—and ideally within 48 hours. Clinical staff involved in the event should be present during the review, and key learnings and improvement opportunities should be disseminated to the rest of the medical and nursing staff.