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Multicenter Study
. 2022 Oct 1;176(10):1027-1036.
doi: 10.1001/jamapediatrics.2022.2238.

Preventing Cardiac Arrest in the Pediatric Cardiac Intensive Care Unit Through Multicenter Collaboration

Jeffrey Alten  1 , David S Cooper  1 , Darren Klugman  2   3 , Tia Tortoriello Raymond  4 , Sharyl Wooton  5 , Janie Garza  4 , Katherine Clarke-Myers  6 , Jeffrey Anderson  1 , Sara K Pasquali  7 , Mohammed Absi  8 , Jeremy T Affolter  9   10 , David K Bailly  11 , Rebecca A Bertrandt  12 , Santiago Borasino  13 , Maya Dewan  14 , Yuliya Domnina  2   15 , John Lane  16 , Amy N McCammond  17 , Dana M Mueller  18   19 , Mary K Olive  7 , Laura Ortmann  20 , Parthak Prodhan  21 , Jun Sasaki  22   23 , Carly Scahill  24 , Luke W Schroeder  25 , David K Werho  19 , Hayden Zaccagni  13 , Wenying Zhang  26 , Mousumi Banerjee  27   28 , Michael Gaies  1 ; PC4 CAP Collaborators
Collaborators, Affiliations
Multicenter Study

Preventing Cardiac Arrest in the Pediatric Cardiac Intensive Care Unit Through Multicenter Collaboration

Jeffrey Alten et al. JAMA Pediatr. .

Abstract

Importance: Preventing in-hospital cardiac arrest (IHCA) likely represents an effective strategy to improve outcomes for critically ill patients, but feasibility of IHCA prevention remains unclear.

Objective: To determine whether a low-technology cardiac arrest prevention (CAP) practice bundle decreases IHCA rate.

Design, setting, and participants: Pediatric cardiac intensive care unit (CICU) teams from the Pediatric Cardiac Critical Care Consortium (PC4) formed a collaborative learning network to implement the CAP bundle consistent with the Institute for Healthcare Improvement framework; 15 hospitals implemented the bundle voluntarily. Risk-adjusted IHCA incidence rates were analyzed across 2 time periods, 12 months (baseline) and 18 months after CAP implementation (intervention) using difference-in-differences (DID) regression to compare 15 CAP and 16 control PC4 hospitals that chose not to participate in CAP but had IHCA rates tracked in the PC4 registry. Patients deemed at high risk for IHCA, based on a priori evidence-based criteria and empirical hospital-specific criteria, were selected to receive the CAP bundle. Data were collected from July 2018 to December 2019, and data were analyzed from March to August 2020.

Interventions: CAP bundle included 5 elements developed to promote increased situational awareness and communication among bedside clinicians to recognize and mitigate deterioration in high-risk patients.

Main outcomes and measures: Risk-adjusted IHCA incidence rate across all CICU admissions (IHCA events divided by all admissions).

Results: The bundle was activated in 2664 of 10 510 CAP hospital admissions (25.3%); admission characteristics were similar across study periods. There was a 30% relative reduction in risk-adjusted IHCA incidence rate at CAP hospitals (intervention period: 2.6%; 95% CI, 2.2-2.9; baseline: 3.7%; 95% CI, 3.1-4.0), but no change at control hospitals (intervention period: 2.7%; 95% CI, 2.3-2.9; baseline: 2.7%; 95% CI, 2.2-3.0). DID analysis confirmed significantly reduced odds of IHCA among all admissions at CAP hospitals compared with control hospitals during the intervention period vs baseline (odds ratio, 0.72; 95% CI, 0.56-0.91; P = .01). DID odds ratios were 0.72 (95% CI, 0.53-0.98) for the surgical subgroup, 0.74 (95% CI, 0.48-1.14) for the medical subgroup, and 0.72 (95% CI, 0.50-1.03) for the high-risk admission subgroup at CAP hospitals after intervention. All-cause risk-adjusted mortality rate did not change after intervention.

Conclusions and relevance: Implementation of this CAP bundle led to significant IHCA reduction across multiple pediatric CICUs. Future studies may determine if this bundle can be effective in other critically ill populations.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Dewan has received grants from the Agency for Healthcare Research and Quality during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Individual Hospital In-Hospital Cardiac Arrest (IHCA) Incidence Rate Change From Baseline to Intervention Among Cardiac Arrest Prevention (CAP) vs Control Hospitals
Each point indicates an individual hospital. There was significant variability among hospitals with respect to baseline and intervention IHCA incidence as well as direction and degree of change. CAP hospitals tended to have higher IHCA incidence rate during the baseline period but similar IHCA rates to control during the intervention period. A total of 14 of 15 CAP hospitals had lower rates of IHCA compared with 9 of 16 control centers.
Figure 2.
Figure 2.. Aggregate Monthly Risk-Adjusted In-Hospital Cardiac Arrest (IHCA) Incidence in Cardiac Arrest Prevention (CAP) Hospitals Compared With Control Hospitals
Comparative statistical process control P charts showing aggregate monthly risk-adjusted IHCA incidence at 15 CAP hospitals and 16 control hospitals. At CAP hospitals, starting in study month 18 during the intervention period, there was significant IHCA reduction, with special cause variation as determined by 8 consecutive months below the baseline rate. There was centerline shift, representing a 30% reduction in mean aggregate IHCA incidence from 3.7% to 2.6%. At control hospitals, there was no change in baseline risk-adjusted IHCA incidence (2.7%). The baseline period included study months 1 to 12, and the intervention period included study months 15 to 32. There was a 2-month transition period (dotted vertical line).
See this image and copyright information in PMC

Comment in

References

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