Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2022 Jan 1;23(1):4-12.
doi: 10.1097/PCC.0000000000002816.

Assessment of a Situation Awareness Quality Improvement Intervention to Reduce Cardiac Arrests in the PICU

Maya Dewan  1   2   3   4   5   6 , Blaise Soberano  5 , Tina Sosa  5 , Matthew Zackoff  1   2 , Philip Hagedorn  1   5 , Patrick W Brady  1   5 , Ranjit S Chima  1   2 , Erika L Stalets  1   2 , Lindsey Moore  2 , Maria Britto  1   4 , Robert M Sutton  6 , Vinay Nadkarni  6 , Ken Tegtmeyer  1   2 , Heather Wolfe  6
Affiliations

Assessment of a Situation Awareness Quality Improvement Intervention to Reduce Cardiac Arrests in the PICU

Maya Dewan et al. Pediatr Crit Care Med. .

Abstract

Objectives: To use improved situation awareness to decrease cardiopulmonary resuscitation events by 25% over 18 months and demonstrate process and outcome sustainability.

Design: Structured quality improvement initiative.

Setting: Single-center, 35-bed quaternary-care PICU.

Patients: All patients admitted to the PICU from February 1, 2017, to December 31, 2020.

Interventions: Interventions targeted situation awareness and included bid safety huddles, bedside mitigation signs and huddles, smaller pod-based huddles, and an automated clinical decision support tool to identify high-risk patients.

Measurements and main results: The primary outcome metric, cardiopulmonary resuscitation event rate per 1,000 patient-days, decreased from a baseline of 3.1-1.5 cardiopulmonary resuscitation events per 1,000 patient-days or by 52%. The secondary outcome metric, mortality rate, decreased from a baseline of 6.6 deaths per 1,000 patient-days to 3.6 deaths per 1,000 patient-days. Process metrics included percent of clinical deterioration events predicted, which increased from 40% to 67%, and percent of high-risk patients with shared situation awareness, which increased from 43% to 71%. Balancing metrics included time spent in daily safety huddle, median 0.4 minutes per patient (interquartile range, 0.3-0.5), and a number needed to alert of 16 (95% CI, 14-25). Neither unit acuity as measured by Pediatric Risk of Mortality III scores nor the percent of deaths in patients with do-not-attempt resuscitation orders or electing withdrawal of life-sustaining technologies changed over time.

Conclusions: Interprofessional teams using shared situation awareness may reduce cardiopulmonary resuscitation events and, thereby, improve outcomes.

PubMed Disclaimer

Conflict of interest statement

Dr. Dewan receives career development support from the Agency for Healthcare Research and Quality (AHRQ) (K08-HS026975) and received support for article research from the National Institutes of Health (NIH). Dr. Britto received funding from the American Board of Pediatrics Foundation; she received support for article research from the AHRQ Dr. Sutton’s institution received funding from the NIH. Dr. Wolfe received funding from Zoll Medical. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Figures

Figure 1:
Figure 1:
Key driver diagram for overall SMART aim with linked interventions.
Figure 2:
Figure 2:
Proposed hypothesis to reduce cardiopulmonary arrest events with outline of process, outcome, and balancing metrics. CPR: cardiopulmonary resuscitation. DNAR: do not attempt resuscitation. WLST: withdrawal of life sustaining technologies
Figure 3:
Figure 3:
Statistical process chart (U-Chart) for cardiopulmonary resuscitation (CPR) events and unadjusted mortality in the PICU by month (n=patient-days each month).
Figure 4:
Figure 4:
Run chart of process measure percent predicted clinical deterioration events.
Figure 5:
Figure 5:
Statistical process control chart (P-Chart) for Shared Situation Awareness among high-risk (watcher) patients. No data was collection in April and May of 2020 due to the COVID-19 pandemic.
See this image and copyright information in PMC

Comment in

  • Optimizing Human Performance in ICUs.
    Su L, Kudchadkar SR. Su L, et al. Pediatr Crit Care Med. 2022 Jan 1;23(1):65-67. doi: 10.1097/PCC.0000000000002845. Pediatr Crit Care Med. 2022. PMID: 34989712 No abstract available.

References

    1. Holmberg MJ, Wiberg S, Ross CE, et al. Trends in Survival after Pediatric In-Hospital Cardiac Arrest in the United States. Circulation. Published online September 2019. doi:10.1161/CIRCULATIONAHA.119.041667 - DOI - PMC - PubMed
    1. Girotra S, Spertus JA, Li Y, Berg RA, Nadkarni VM, Chan PS. Survival trends in pediatric in-hospital cardiac arrests: an analysis from Get With the Guidelines-Resuscitation. Circ Cardiovasc Qual Outcomes. 2013;6(1):42–49. doi:10.1161/CIRCOUTCOMES.112.967968 - DOI - PMC - PubMed
    1. Alten JA, Klugman D, Raymond TT, et al. Epidemiology and Outcomes of Cardiac Arrest in Pediatric Cardiac ICUs. Pediatr Crit Care Med 2017;18(10):935–943. doi:10.1097/PCC.0000000000001273 - DOI - PMC - PubMed
    1. Niles DE, Dewan M, Zebuhr C, et al. A pragmatic checklist to identify pediatric ICU patients at risk for cardiac arrest or code bell activation. Resuscitation. 2016;99. doi:10.1016/j.resuscitation.2015.11.017 - DOI - PubMed
    1. Tibballs J, Kinney S. Reduction of hospital mortality and of preventable cardiac arrest and death on introduction of a pediatric medical emergency team. Pediatr Crit Care Med. 2009;10(3):306–312. doi:10.1097/PCC.0b013e318198b02c - DOI - PubMed