Prevention ‘bundle’ reduces in-hospital cardiac arrest in pediatric ICUs
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A collaborative network of pediatric cardiac intensive care teams significantly decreased rates of in-hospital cardiac arrest over 18 months using a low-technology prevention practice bundle, independent of secular trends, data show.
In a quality improvement study including 31 hospitals, researchers found that the 15 cardiac ICUs implementing the cardiac arrest prevention (CAP) bundle saw a 30% relative reduction in aggregate cardiac arrest rate after implementation compared with 16 control hospitals.
The five-element bundle included mandatory twice-daily multidisciplinary “safety huddles” that provided bedside, “just-in-time” training to rescue patients from imminent arrest, as well as the optional elements of vital sign discussion, discussion of pre-sedation for noxious stimuli, emergency medication such as a patient-specific dose of rapid epinephrine drawn up and available at bedside, and a formal code review within 2 weeks of any cardiac arrest event.
Healio spoke with David K. Werho, MD, a cardiac intensivist in the division of pediatric cardiology at Rady Children’s Hospital-San Diego, and Jeffrey Alten, MD, professor of pediatrics, cardiac intensive care, at Cincinnati Children’s Hospital Medical Center, about how the CAP bundle program was designed, the challenges of discussing worst-case outcomes with physicians and parents, and the importance of sustaining progress going forward. Data about the CAP bundle program were recently published in JAMA Pediatrics.
Healio: How was this CAP plan of care developed?
Werho: When the Pediatric Cardiac Critical Care Consortium, or PC4, initially formed, the group was conducting research on outcomes and epidemiology because it was the first time there was a registry that included all the data elements that would allow for a deep dive into some of these ICU outcomes. One of the first things the consortium looked at was cardiac arrest, because that is a very common complication in the cardiac ICU and one that leads to mortality. The group observed several patient populations at higher risk for cardiac arrest. Using those patient populations, we moved to create this project.
Alten: When we looked at the rough data for cardiac arrest across centers in the consortium, we could see that cardiac arrest rates were very different among centers. We then conducted a study that looked at cardiac arrest across all these centers and did risk adjustment, so no center could say they have a higher rate of cardiac arrest due to having sicker patients. We leveled the playing field as best we could with our risk adjustment models. We showed in 2017 that the cardiac arrest rate was still different among centers. There was a group of five or six centers that were preventing cardiac arrest very well, and there was a group of other centers that had high cardiac arrest rates. What are the centers that are preventing cardiac arrest doing that the other centers are not doing? That led to this study.
Healio: How was this new study designed? What were you and your colleagues assessing across the participating hospitals?
Alten: The study design was quite simple. Pediatric cardiac ICU teams from 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. We originally wanted to do what we would call a factorial design, where centers each implement different elements in the cardiac arrest prevention bundle to determine which elements worked the best. Instead, to improve adaptability for all 15 centers, we took the approach of only mandating the “safety huddle” element. Then, the centers can choose where they want to implement the other optional elements. Twelve of 15 participating centers were using all five elements of the prevention bundle. We had monthly webinars led by QI experts that helped centers overcome obstacles to bundle implementation and for all centers to learn from each other’s successes.
We tracked and discussed data in real time, assessing how people were implementing the bundle, and also the ultimate outcome: Were we decreasing pediatric in-hospital cardiac arrest?
Healio: What did you observe?
Alten: We looked at 12 months of baseline data across the 15 centers that had such data available. We tracked cardiac arrest rate monthly. We wanted to see the first time that we saw, in aggregate, when the cardiac arrest rate dropped. In about 3 months, the cardiac arrest rate across all centers was starting to decrease. That lower rate was maintained. There was a 30% relative reduction in risk-adjusted in-hospital cardiac arrest incidence rate across CAP hospitals (intervention period, 2.6%; 95% CI, 2.2-2.9; baseline, 3.7%; 95% CI, 3.1-4). There was no change at control hospitals.
Soon, we plan to follow these hospitals at 2 years to see if we sustain some of these results.
Healio: Dr. Werho, at Rady Children’s, the rate of cardiac arrest fell dramatically. Did that surprise you and your colleagues? How was that achieved?
Werho: We were surprised. Here in the Rady Children’s Heart Institute, we are always trying to find ways to improve the outcomes of our patients. About a year after joining PC4, which was also coincidently a year into my career here at Rady, the cardiac arrest prevention project came about, and we had the opportunity to participate. I will say I was a little skeptical, as a lot of people were, wondering if this CAP bundle could really work. What happened is this program empowered us to get everybody on the same page about the worst-case scenario. It forced us to do that. A lot of people are glass half-full people. With this program, we are looking at the patients who are at the highest risk for cardiac arrest and talking about it with the team, and then teaching about it, teaching the nurses what to look for. Then, we go a step further and prepare to react quickly and early in those situations. That is what changed the patient outcomes.
Healio: Is it safe to say there was a psychological shift in the way care was being provided by thinking this way?
Werho: Yes. Our nurses here became incredibly empowered and incredibly enthusiastic about the cardiac arrest prevention bundle. Even a few months in, if somebody had forgotten to do their CAP rounds, with me as the clinical champion, it would have been my job to nudge them and say, “Hey, this is what we're supposed to be doing.” I did not have to do that, because our nurses loved it so much. They were the ones who would say, “We need to do CAP rounds this shift.” Having that buy-in from the nurses was incredibly helpful. There was a shift in the entire mental model of the unit. It was, “This is what we are looking for, we are going to be on high alert for it. And if it happens, we are prepared. This is what we are going to do next.”
Alten: What Dr. Werho said is something we saw in all of the participating centers. If you implemented the CAP bundle full force, it became ingrained in your culture and nurses bought into it. The nurses got to the point where they wanted everyone to utilize the CAP bundle because they loved the discussions, loved being part of a team, taking care of the child together. It is not lip service to say that if you have a great nurse at the bedside, who is a proactive leader on the clinical team, that the child has the best chance to be OK.
Healio: How did the parents of these children in the pediatric ICUs respond to this prevention program?
Alten: People were very nervous about having these types of discussions with the parents. However, the parents actually loved hearing that, when it came to their child, we were preparing for worst-case scenarios to keep their child safe. Of course, we had to prep the parents because we talk about things like chest compressions. But parents embraced the program. It is a change in philosophy to have the parents intimately involved in such conversations.
From the physician standpoint, as well, one of the biggest things we had to do is convince physicians that cardiac arrest is preventable. There are very few projects out there that directly attack cardiac arrest prevention — almost none. We can work together to prevent cardiac arrest. It is about team performance more than anything else.
Healio: What are the next steps? How can these data be translated across the critical care consortium going forward?
Werho: The main lessons learned here relate to culture and sustainability. What we found at Rady Children's Hospital is when you implement a plan and it improves patient care, then it really does become ingrained in the culture of your unit. Now, CAP is just part of what we do for our highest-risk patients. It is part of our culture.
Once these study findings are fully disseminated across the collaborative, it is very easy for anyone to do these things, like Dr. Alten mentioned. This is very low-cost, low technology. This is about teamwork, communication, collaboration and preparation.
As the word gets out, more centers, not just across the consortium, but across disciplines, pediatric intensive care units, other surgical units or maybe even adult units, can use similar practices to prevent cardiac arrest in their patient populations.
Reference:
Alten J, et al. JAMA Pediatr. 2022;doi:10.1001/jamapediatrics.2022.2238.
For more information:
Jeffrey Alten, MD, can be reached at jeffrey.alten@cchmc.org.
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