Establishing a Quality Improvement Program for Pediatric In-hospital Cardiac Arrest

Abstract

Background: Pediatric In-hospital Cardiac Arrest (IHCA) is a rare event with a 50-55% mortality rate. Techniques of Cardiopulmonary Resuscitation (CPR), medication and electrical therapy timing, team dynamics, simulation and debriefing programs are associated with improved outcomes. This study aimed to improve outcomes after IHCA by describing and implementing quality improvement processes that cross and coordinate among traditional siloed pediatric resuscitation team structures.

Methods: We chose three outcome measures: (1) return of spontaneous circulation (ROSC), (2) 24-hour survival after IHCA, and (3) survival to hospital discharge. Process outcomes include (1) hot debriefs performed with a standardized form, (2) code documentation using a revised form, and (3) formal code team review presented to a central Emergency Management Committee, using a standardized form.

Results: One hundred and thirty-two patients experienced 176 events during the 36-month study period. Survival to hospital discharge increased from 33% during year 1 to 60% during year 2 (P < 0.05) but decreased to 45% in year 3. Both hot debrief performance and code documentation process methods did not demonstrate widespread adoption, but formal code team review was documented in 80% of events quite rapidly.

Conclusions: There are common traits inherent to effective CPR team response. Ensuring optimal performance of these common tasks and techniques in every pediatric IHCA event in our hospital is being addressed by committee reorganization, task simplification, new technology acquisition and enhanced feedback loops. Early outcome analysis shows initial improvement in survival to hospital discharge after pediatric IHCA.

Fig. 1.

Key Driver Diagram describing a centralized and comprehensive pediatric IHCA response and quality improvement program.

Fig. 2.

QI Control charts for process measures. A, Debrief form use. B, Code documentation form use. C) Formal code review completion rates. Data are plotted on p-charts for the proportion of distinct code events, using the designated process measure over time.

Fig. 3.

Control charts for outcome measures. Data are plotted on p-charts for the proportion of individual event survival or patient survival. A, ROSC for all code events. B, 24-hour survival of all code events. Black boxes indicate data points consistent with special cause variation. C, Survival to hospital discharge of individual patients.