Elsevier

Resuscitation

Volume 93, August 2015, Pages 150-157
Resuscitation

Clinical Paper
A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality – A report from the ROC epistry-cardiac arrest

https://doi.org/10.1016/j.resuscitation.2015.04.010Get rights and content

Abstract

Aim

High-quality cardiopulmonary resuscitation (CPR) may improve survival. The quality of CPR performed during pediatric out-of-hospital cardiac arrest (p-OHCA) is largely unknown. The main objective of this study was to describe the quality of CPR performed during p-OHCA resuscitation attempts.

Methods

Prospective observational multi-center cohort study of p-OHCA patients ≥1 and <19 years of age registered in the Resuscitation Outcomes Consortium (ROC) Epistry database. The primary outcome was an a priori composite variable of compliance with American Heart Association (AHA) guidelines for both chest compression (CC) rate and CC fraction (CCF). Event compliance was defined as a case with 60% or more of its minute epochs compliant with AHA targets (rate 100–120 min−1; depth ≥38 mm; and CCF ≥0.80). In a secondary analysis, multivariable logistic regression was used to evaluate the association between guideline compliance and return of spontaneous circulation (ROSC).

Results

Between December 2005 and December 2012, 2564 pediatric events were treated by EMS providers, 390 of which were included in the final cohort. Of these events, 22% achieved AHA compliance for both rate and CCF, 36% for rate alone, 53% for CCF alone, and 58% for depth alone. Over time, there was a significant increase in CCF (p < 0.001) and depth (p = 0.03). After controlling for potential confounders, there was no significant association between AHA guideline compliance and ROSC.

Conclusions

In this multi-center study, we have established that there are opportunities for professional rescuers to improve prehospital CPR quality. Encouragingly, CCF and depth both increased significantly over time.

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,

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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.

    1

    See Appendix A.

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