Clinical PaperA quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality – A report from the ROC epistry-cardiac arrest☆
Introduction
Pediatric out-of-hospital cardiac arrest (p-OHCA) affects thousands of children around the world each year.1, 2, 3, 4 Over the past decade, there have been significant improvements in survival after pediatric in-hospital cardiac arrest5; yet, p-OHCA continues to be associated with poor outcome. Best estimates reveal that less than 10% of children will survive to hospital discharge with favorable neurological outcome after p-OHCA.1, 2, 3 The potential years of lost productive life are substantial.
Several studies have demonstrated that professional rescuer CPR has room for improvement.6, 7, 8, 9, 10 Inadequate chest compression rate9, 11, 12 and depth,10, 13 and long interruptions in CPR,6, 7, 8 have been particularly problematic. As of yet, these studies have excluded p-OHCA resuscitation, focusing on either adult or in-hospital pediatric CPR quality. As high CPR quality is associated with improved cardiac arrest outcome,6, 9, 10, 14, 15 investigations designed to describe current practice and suggest areas for improvements in prehospital resuscitation quality are an attractive approach to improve outcomes.
When compared to adults, relatively little quantitative CPR data have been collected in children during cardiac arrest. As a result, pediatric CPR guidelines have been developed with data often extrapolated from adult and animal investigations.16, 17 Most of what we know about pediatric resuscitation quality comes from single center in-hospital investigations.12, 14, 18, 19, 20 As such, there is a need for larger pediatric studies that can describe resuscitation practice, and rigorously evaluate the association between CPR quality measures and survival in children.
The main objective of this study was to describe the quality of CPR performed during p-OHCA resuscitation attempts. The secondary objective was to evaluate the association between American Heart Association (AHA) guidelines and survival outcomes. We hypothesized that the quality of out-of-hospital pediatric CPR would frequently not meet recommended care targets, and further, that CPR performed in compliance with AHA guidelines17 is associated with improved short term survival.
Section snippets
Design and setting
This was a prospective observational cohort study of data collected from the Resuscitation Outcomes Consortium (ROC). The ROC consists of 36,000 EMS professionals within 260 EMS agencies transporting patients to 287 different hospitals.21 This study includes ROC epistry-cardiac arrest22 patients treated by EMS and for whom pediatric CPR quality data was available (101 agencies from 11 sites). Appropriate local institutional review boards (U.S.) or research ethics boards (Canada) granted a
Results
Between December 2005 to December 2012, 2564 cases of pediatric cardiac arrest were treated by the EMS agencies of the ROC. All but 390 were excluded from the current study for the reasons indicated in Fig. 1. Quantitative CC depth was available for 153 cases (pediatric n = 34; adolescent n = 119). There were notable differences between the subjects in the final cohort and the excluded population. Excluded patients were younger with characteristics typical of infant cardiac arrest (e.g., more
Discussion
In this large multi-center study of out-of-hospital pediatric CPR quality, we observed that prehospital rescuer CPR frequently did not meet AHA guidelines during p-OHCA resuscitation attempts. In spite of a definition of event compliance requiring only 60% of the minutes to have achieved quality goals, less than 25% of the resuscitations met both rate and CPR fraction targets. Achieving 2010 AHA depth targets (≥51 mm) was even less common, as only 16% of resuscitations from 2011 and later
Conclusions
These data fill an important gap in our knowledge related to p-OHCA resuscitation. In this multi-center observational study of pediatric CPR quality, professional rescuers often failed to achieve compliance with AHA guidelines. Encouragingly, CCF and depth have both increased significantly over time in this large multi-center cohort. Future interventions to improve p-OHCA resuscitation quality may improve survival outcomes.
Conflict of interest statement
Dr. Robert M. Sutton receives funding from the National Institute of Child Health and Human Development (NICHD; K23HD062629) and has received a speaker honoraria from Zoll Medical. Dr. Christian Vaillancourt is supported by a University of Ottawa Research Chair. He has received funding from the Canadian Institutes of Health Research, the Heart and Stroke Foundation of Canada, and the National Institutes of Health (NIH) for work related to cardiac arrest and prehospital care. Dr. Mohamud Daya
Acknowledgements
Financial disclosure: The ROC is supported by a series of cooperative agreements to 10 regional clinical centers and one Data Coordinating Center (5U01 HL077863 – University of Washington Data Coordinating Center, HL077865 – University of Iowa, HL077866 – Medical College of Wisconsin, HL077867 – University of Washington, HL077871 – University of Pittsburgh, HL077872 – St. Michael's Hospital, HL077873 – Oregon Health and Science University, HL077881 – University of Alabama at Birmingham,
References (32)
- et al.
Out-of-hospital pediatric cardiac arrest: an epidemiologic review and assessment of current knowledge [see comment]
Ann Emerg Med
(2005) - et al.
The impact of increased chest compression fraction on return of spontaneous circulation for out-of-hospital cardiac arrest patients not in ventricular fibrillation
Resuscitation
(2011) - et al.
First quantitative analysis of cardiopulmonary resuscitation quality during in-hospital cardiac arrests of young children
Resuscitation
(2014) - et al.
2010 American heart association recommended compression depths during pediatric in-hospital resuscitations are associated with survival
Resuscitation
(2014) - et al.
Quantitative analysis of chest compression interruptions during in-hospital resuscitation of older children and adolescents
Resuscitation
(2009) - et al.
Pushing harder, pushing faster, minimizing interruptions… but falling short of 2010 cardiopulmonary resuscitation targets during in-hospital pediatric and adolescent resuscitation
Resuscitation
(2013) - et al.
Rationale, development and implementation of the resuscitation outcomes consortium epistry-cardiac arrest
Resuscitation
(2008) - et al.
Epidemiology and outcomes from out-of-hospital cardiac arrest in children: the resuscitation outcomes consortium epistry-cardiac arrest
Circulation
(2009) - et al.
Nationwide improvements in survival from out-of-hospital cardiac arrest in Japan
Circulation
(2012) - et al.
Regional variation in out-of-hospital cardiac arrest incidence and outcome
J Am Med Assoc
(2008)
Survival trends in pediatric in-hospital cardiac arrests: an analysis from get with the guidelines-resuscitation
Circ Cardiovasc Qual Outcomes
Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation
Circulation
Perishock pause: an independent predictor of survival from out-of-hospital shockable cardiac arrest
Circulation
Relationship between chest compression rates and outcomes from cardiac arrest
Circulation
What is the role of chest compression depth during out-of-hospital cardiac arrest resuscitation?
Crit Care Med
Chest compression rates during cardiopulmonary resuscitation are suboptimal: a prospective study during in-hospital cardiac arrest
Circulation
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2015.04.010.
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See Appendix A.