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Dispatcher-Assisted Cardiopulmonary Resuscitation Program and Outcomes After Pediatric Out-of-Hospital Cardiac Arrest. Pediatr Emerg Care 2019; 35:561-567. [PMID: 29200138 DOI: 10.1097/pec.0000000000001365] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES A dispatcher-assisted bystander cardiopulmonary resuscitation (DA-BCPR) is expected to influence the outcomes of pediatric out-of-hospital cardiac arrest (OHCA). Our objective was to measure the effect size of a DA-BCPR on survival outcomes according to location of the event. METHODS All emergency medical service treated OHCA patients younger than 19 years in Korea from January 2012 through December 2013 were analyzed. Patients with OHCA witnessed by emergency medical service providers and those with missing outcome information were excluded. Patients were categorized into the following categories: No-BCPR, BCPR without dispatcher assistance (BCPR-NDA), and BCPR-DA. The primary outcome was survival to hospital discharge. Multivariable logistic regression analysis was performed to calculate the adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for outcomes by exposure group (reference, No-BCPR group) with and without an interaction term between exposure and location of arrest. RESULTS A total of 1013 eligible patients were analyzed. Among these patients, 16.6% received BCPR-NDA, 23.2% received BCPR-DA, and 60.2% received no BCPR. After adjusting for potential confounders, compared with N0-BCPR group, AORs for survival were 1.79 (95% CI, 1.03-3.12) in BCPR group, 1.71 (95% CI, 0.85-3.46) in BCPR-NDA group, and 1.39 (95% CI, 0.72-2.69) in BCPR-DA group. The AORs for survival of BCPR-NDA and BCPR-DA in public location were 3.30 (95% CI, 1.12-9.72) and 2.95 (95% CI, 1.00-8.67), whereas BCPR-NDA and BCPR-DA in private locations were 1.62 (95% CI, 0.68-3.88) and 1.15 (95% CI, 0.53-2.51). CONCLUSION The DA-CPR was associated with better outcomes in pediatric OHCA patients whose arrest occurred in public locations, but no improvement in outcomes was identified in patients whose arrest occurred at private locations.
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Auerbach M, Brown L, Whitfill T, Baird J, Abulebda K, Bhatnagar A, Lutfi R, Gawel M, Walsh B, Tay KY, Lavoie M, Nadkarni V, Dudas R, Kessler D, Katznelson J, Ganghadaran S, Hamilton MF. Adherence to Pediatric Cardiac Arrest Guidelines Across a Spectrum of Fifty Emergency Departments: A Prospective, In Situ, Simulation-based Study. Acad Emerg Med 2018; 25:1396-1408. [PMID: 30194902 DOI: 10.1111/acem.13564] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/09/2018] [Accepted: 08/27/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Pediatric out-of-hospital cardiac arrest survival outcomes are dismal (<10%). Care that is provided in adherence to established guidelines has been associated with improved survival. Lower mortality rates have been reported in higher-volume hospitals, teaching hospitals, and trauma centers. The primary objective of this article was to explore the relationship of hospital characteristics, such as annual pediatric patient volume, to adherence to pediatric cardiac arrest guidelines during an in situ simulation. Secondary objectives included comparing adherence to other team, provider, and system factors. METHODS This prospective, multicenter, observational study evaluated interprofessional teams in their native emergency department (ED) resuscitation bays caring for a simulated 5-year-old child presenting in cardiac arrest. The primary outcome, adherence to the American Heart Association pediatric guidelines, was assessed using a 14-item tool including three component domains: basic life support (BLS), pulseless electrical activity (PEA), and ventricular fibrillation (VF). Provider, team, and hospital-level data were collected as independent data. EDs were evaluated in four pediatric volume groups (low < 1,800/year; medium 1,800-4,999; medium-high 5,000-9,999; high > 10,000). Cardiac arrest adherence and domains were evaluated by pediatric patient volume and other team and hospital-level characteristics, and path analyses were performed to evaluate the contribution of patient volume, systems readiness, and teamwork on BLS, PEA, and VF adherence. RESULTS A total of 101 teams from a spectrum of 50 EDs participated including nine low pediatric volume (<1,800/year), 36 medium volume (1,800-4,999/year), 24 medium-high (5,000-9,999/year), and 32 high volume (≥10000/year). The median total adherence score was 57.1 (interquartile range = 50.0-78.6). This was not significantly different across the four volume groups. The highest level of adherence for BLS and PEA domains was noted in the medium-high-volume sites, while no difference was noted for the VF domain. The lowest level of BLS adherence was noted in the lowest-volume EDs. Improved adherence was not directly associated with higher pediatric readiness survey (PRS) score provider experience, simulation teamwork performance, or more providers with Pediatric Advanced Life Support (PALS) training. EDs in teaching hospitals with a trauma center designation that served only children demonstrated higher adherence compared to nonteaching hospitals (64.3 vs 57.1), nontrauma centers (64.3 vs. 57.1), and mixed pediatric and adult departments (67.9 vs. 57.1), respectively. The overall effect sizes for total cardiac adherence score are ED type γ = 0.47 and pediatric volume (low and medium vs. medium-high and high) γ = 0.41. A series of path analyses models was conducted that indicated that overall pediatric ED volume predicted significantly better guideline adherence, but the effect of volume on performance was only mediated by the PRS for the VF domain. CONCLUSIONS This study demonstrated variable adherence to pediatric cardiac arrest guidelines across a spectrum of EDs. Overall adherence was not associated with ED pediatric volume. Medium-high-volume EDs demonstrated the highest levels of adherence for BLS and PEA. Lower-volume EDs were noted to have lower adherence to BLS guidelines. Improved adherence was not directly associated with higher PRS score provider experience, simulation teamwork performance, or more providers with PALS training. This study demonstrates that current approaches optimizing the care of children in cardiac arrest in the ED (provider training, teamwork training, environmental preparation) are insufficient.
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Affiliation(s)
- Marc Auerbach
- Department of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Linda Brown
- Department of Emergency Medicine, Alpert School of Medicine at Brown University, Providence, RI
| | - Travis Whitfill
- Department of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Janette Baird
- Department of Emergency Medicine, Alpert School of Medicine at Brown University, Providence, RI
| | - Kamal Abulebda
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Ambika Bhatnagar
- Department of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Riad Lutfi
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Marcie Gawel
- Department of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Barbara Walsh
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Boston University, Boston, MA
| | - Khoon-Yen Tay
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Megan Lavoie
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Robert Dudas
- Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David Kessler
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY
| | - Jessica Katznelson
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sandeep Ganghadaran
- Department of Critical Care Medicine and Pediatrics, Children's Hospital at Montefiore, Bronx, NY
| | - Melinda Fiedor Hamilton
- Department of Critical Care Medicine and Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
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Abstract
OBJECTIVE The aim of the study was to evaluate outcomes after pediatric out-of-hospital cardiopulmonary interventions (CPIs) by emergency medical services (EMS). METHODS Children (age, ≤18 years) who received CPI by EMS from 2001 to 2008 were identified from the Utah Department of Health. Cardiopulmonary intervention was defined as oxygenation, ventilation or CPR, and transport to a hospital by EMS. Univariate and multivariable regression analyses evaluated associations between potential predictors and outcomes (death and new neurologic dysfunction). RESULTS A total of 464 patients (58% male) received EMS attention. For the 71% patients (327) who were alive on EMS arrival, 63% (205) received CPI without CPR. Of note, 6% (12) of these patients died after arrival to the hospital and new neurologic dysfunction was diagnosed in 6% (13). Among the 12 patients who died, 50% (6) were younger than 1 year.On multivariable regression analysis, factors associated with increased risk of death before and in-hospital are the following: age younger than 1 year (odds ratio [OR], 0.26; 95% confidence interval [CI], 0.17-0.39), shorter EMS transport time (OR, 0.94; 95% CI, 0.89-0.99), and longer EMS dispatch time (OR, 1.23; 95% CI, 1.08-1.40). Factors associated with increased risk of new neurologic dysfunction are the following: lack of pulse (OR, 0.14; 95% CI, 0.04-0.53), requiring CPR (OR, 6.15; 95% CI, 1.48-25.6), and CPR duration (OR, 1.20; 95% CI, 1.05-1.37). CONCLUSIONS Age younger than 1 year, shorter transport time, and longer dispatch time were associated with increased risk of death. Being pulseless upon discovery and receiving CPR were associated with new neurologic dysfunction. Maximizing EMS transport interventions for patients younger than 1 year requiring CPI may improve patient outcomes.
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Smith CM, Colquhoun MC. Out-of-hospital cardiac arrest in schools: A systematic review. Resuscitation 2015; 96:296-302. [PMID: 26386373 DOI: 10.1016/j.resuscitation.2015.08.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 08/10/2015] [Accepted: 08/25/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) in children and adolescents is rare, with a minority of cases occurring at school. When OHCA does occur at school it is more likely to affect an adult than a student. Developing comprehensive strategies to treat cardiac arrest occurring at schools would be helped by accurate data regarding its epidemiology. METHODS A systematic review was undertaken. An electronic search strategy of MEDLINE and EMBASE databases was devised and relevant papers reporting data on school-based OHCA incidence and/or outcome in both adults and children were identified. Further articles were obtained from the bibliographies of these papers and from related articles. RESULTS Nine studies were included in the systematic review. Cardiac arrest incidence was one per 23.8-284.1 schools per year. Cardiac arrest incidence amongst students, reported in some studies, was 0.17-4.4 per 100,000 students per year. Studies also reported, although not universally, rates of witnessed OHCA (25.0-97.2%), VF (57.4-67.6%), bystander CPR (25.0-94.4%) and automated external defibrillator (AED) use (23.4-91.5%). Survival to hospital discharge or at one month was between 31.9% and 71.2%. CONCLUSION Cardiac arrest in schools is rare, and more likely to occur in adults than children. Outcomes are better than OHCA occurring at other locations, probably due to the high proportion of witnessed arrests and high rates of bystander CPR. It is likely that school-based AEDs will rarely be needed, but have the potential to make a dramatic impact on outcome.
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Affiliation(s)
| | - Michael C Colquhoun
- Resuscitation Council (UK), Tavistock House North, Tavistock Square, London WC1H 9HR, UK
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