Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes*

Abstract

Objective: In-hospital cardiac arrest is an important public health problem. High-quality resuscitation improves survival but is difficult to achieve. Our objective is to evaluate the effectiveness of a novel, interdisciplinary, postevent quantitative debriefing program to improve survival outcomes after in-hospital pediatric chest compression events.

Design, setting, and patients: Single-center prospective interventional study of children who received chest compressions between December 2008 and June 2012 in the ICU.

Interventions: Structured, quantitative, audiovisual, interdisciplinary debriefing of chest compression events with front-line providers.

Measurements and main results: Primary outcome was survival to hospital discharge. Secondary outcomes included survival of event (return of spontaneous circulation for ≥ 20 min) and favorable neurologic outcome. Primary resuscitation quality outcome was a composite variable, termed "excellent cardiopulmonary resuscitation," prospectively defined as a chest compression depth ≥ 38 mm, rate ≥ 100/min, ≤ 10% of chest compressions with leaning, and a chest compression fraction > 90% during a given 30-second epoch. Quantitative data were available only for patients who are 8 years old or older. There were 119 chest compression events (60 control and 59 interventional). The intervention was associated with a trend toward improved survival to hospital discharge on both univariate analysis (52% vs 33%, p = 0.054) and after controlling for confounders (adjusted odds ratio, 2.5; 95% CI, 0.91-6.8; p = 0.075), and it significantly increased survival with favorable neurologic outcome on both univariate (50% vs 29%, p = 0.036) and multivariable analyses (adjusted odds ratio, 2.75; 95% CI, 1.01-7.5; p = 0.047). Cardiopulmonary resuscitation epochs for patients who are 8 years old or older during the debriefing period were 5.6 times more likely to meet targets of excellent cardiopulmonary resuscitation (95% CI, 2.9-10.6; p < 0.01).

Conclusion: Implementation of an interdisciplinary, postevent quantitative debriefing program was significantly associated with improved cardiopulmonary resuscitation quality and survival with favorable neurologic outcome.

Figure 1

Study diagram indicating resuscitation care practices. Censor period was a transition of 6 mo at the initiation of the project to allow for wash in time for providers to attend debriefing sessions. CPR = cardiopulmonary resuscitation.

Figure 2

Utstein style diagram. *One patient had index event during censor period and was not included in survival to hospital discharge or favorable neurologic outcome among survivors. CPR = cardiopulmonary resuscitation, CC = chest compression, ROSC = return of spontaneous circulation.

Figure 3

Multivariable logistic regression controlling for gender, age category, initial rhythm, and presence of vasoactive infusions at index arrest. ROSC refers to return of spontaneous circulation ≥ 20 min. Discharge indicates survival to hospital discharge. Good neuro indicates survival to discharge with performance category score (PCPC) score of 1–3 at discharge or no increase compared with admission PCPC status. *Adjusted odds ratio (aOR), 2.75; 95% CI, 1.01–7.5; p = 0.047 for index cardiopulmonary resuscitation (CPR) events after debriefing. †aOR, 2.5; 95% CI, 0.91–6.8; p = 0.075. Change in rate of ROSC after all CPR events was not significant (aOR, 1.55; 95% CI, 0.61–3.97; p = 0.36).

Figure 4

Percentage of cardiopulmonary resuscitation (CPR) epochs achieving targets (mean ± SE) for depth ≥ 38 mm, rate ≥ 100/min, CPR fraction > 90%, and leaning ≤ 10% of compressions. Excellent CPR defined as having all four CPR elements achieving targets. Analysis evaluates percentage of epochs without controlling for intraevent correlation. *p < 0.01.