Reducing Cardiac Arrests in the PICU: Initiative to Improve Time to Administration of Prearrest Bolus Epinephrine in Patients With Cardiac Disease

Abstract

Objectives: To evaluate the effectiveness of a quality-improvement initiative in reducing cardiac arrests in infants and children in the cardiac ICU.

Design: Prospective observational before-after cohort study.

Setting: Single pediatric cardiac ICU in the United Kingdom.

Patients: All patients less than 18 years old admitted to the ICU.

Intervention: Initial interdisciplinary training in cardiac arrest prevention followed by clinical practice change whereby patients with high-risk myocardium were identified on daily rounds. High-risk patients had bolus epinephrine preordered and prepared for immediate administration in the event of acute hypotension.

Measurements and main results: Interrupted time series analysis was used to compare the cardiac arrest rate in the 18 months before and 4.5 years after implementation. Mean monthly cardiac arrest rate was 17.2 per 1,000 patient days before and 7.6 per 1,000 patient days after the initiative (56% decrease). Patient characteristics and ICU interventions were similar in the control and intervention periods. In the time series analysis, monthly cardiac arrest rate in the ICU decreased by 12.4 per 1,000 patient days (95% CI, -1.5 to -23.3; p = 0.03) immediately following the intervention, followed by a nonsignificant downward trend of 0.36 per 1,000 patient days per month (95% CI, -1.3 to 0.6; p = 0.44). Bolus epinephrine was administered during 110 hypotension events in 77 patients (eight administrations per 1,000 ICU days); responder rate was 77%. There were no significant changes in ICU and hospital mortality.

Conclusions: Implementation of the initiative led to a significant, sustained reduction in ICU cardiac arrest rate.