Simple ‘practice bundle’ helped achieve 30% reduction across 15 hospitals
San Diego, CA – July 5, 2022 – Despite years of investment to improve CPR and post-resuscitation care, many experts in the field have considered in-hospital cardiac arrest (IHCA) a largely unavoidable outcome for some children in cardiothoracic intensive care units (CTICUs). A recent quality improvement (QI) initiative at Rady Children’s Hospital–San Diego and 14 other hospitals, challenges that notion.
In a study published July 5, 2022, in JAMA Pediatrics, this group of investigators report that implementing a low-technology cardiac arrest prevention (CAP) practice bundle reduced IHCA incidence by an average of 30% across the participating centers. The results exceeded a targeted 25% reduction, and the practice changes used can be replicated in any institution. At Rady Children’s Hospital, the rate of cardiac arrests in the CTICU decreased to zero for nine consecutive months after starting the bundle. “Our team and model of care in the CTICU and the Rady Children’s Heart Institute have evolved to achieve outstanding outcomes in our patients and CAP was an important part of that evolution,” says Dr. Rohit Rao, the medical director of the CTICU at Rady Children’s Hospital.
The study reports the results of a quality improvement initiative that was conducted within a collaborative learning network of CTICU teams across the Pediatric Cardiac Critical Consortium (PC4), which aims to improve the quality of care to patients with critical pediatric and congenital cardiovascular disease in North America and abroad. Each institution implemented a cardiac arrest prevention practice bundle within their CICUs with data analyzed at 12 months and 18 months after implementation.
“This study represents the culmination of years of effort by so many within PC4,” says Dr. Michael Gaies, a pediatric cardiologist at Cincinnati Children’s Hospital, the founder and Executive Director of PC4 during the study, and the study’s senior investigator. “We collaborated with hospitals across the country to collect data and understand variation in performance on IHCA prevention. Leaders from these institutions then came together to improve the quality of care across hospitals.”
The CAP bundle was designed to promote situational awareness and communication to recognize and mitigate deterioration in high-risk patients. Each element of the bundle was specifically chosen to be minimal in cost and technology independent, allowing CICUs to adapt to their local system, QI resources, and clinical workflow. The bundles were comprised of several elements, including a mandatory twice-daily safety huddle.
“This CAP project represents the first multicenter initiative aimed directly at IHCA prevention; and its success was made possible by the collaborative learning network formed by the 15 PC4 CAP hospitals,” says Dr. Jeffrey Alten, an attending physician at Cincinnati Children’s Hospital, and project leader for CAP. “Belief still persists that IHCA is an inevitability of critical illness, but as early adopters of the CAP bundle overcame obstacles and shared their improvement learnings on these webinars, this dogma was challenged, and confidence steadily increased among other hospital teams that IHCA is indeed preventable. Proving feasibility of IHCA prevention represents the most essential message of this project, and hopefully will encourage spread of these IHCA prevention practices at other hospitals.”
The team ultimately analyzed data from 41,204 admissions, including 10,510 admissions at CAP hospitals, with 2664 of CAP admissions receiving the CAP bundle for an average of 4.4 days per patient. For all admissions at CAP hospitals, there was a 30% relative reduction in IHCA incidence rate during the intervention period, which translated to an average of 11 fewer IHCA events per month at CAP hospitals.
“When I started my career in cardiac intensive care, I thought that most cardiac arrests in very sick children with critical heart disease were not preventable, but through our participation in the CAP project, I have seen how working collaboratively with outstanding teams at the bedside here at Rady Children’s as well as with physicians and scientists across the country, can shift the paradigm. Seeing is believing and I have seen many patients who had a cardiac arrest prevented by a nurse or young physician who acted quickly based on our CAP bundle discussion,” says Dr. David Werho, a pediatric cardiac intensivist at Rady Children’s Hospital and a co-author of the study.
Researchers in the study say this represents an important paradigm shift in critical care to prioritize IHCA prevention and reduce adverse events. “The best CPR is no CPR,” says Dr. Alten. “And this project was able to prevent CPR in almost 200 high-risk children during CAP implementation at these 15 hospitals.”
Future studies are needed to determine which bundle elements are most necessary for cardiac arrest prevention and more work is needed to roll out the care bundle to more hospitals. Also, while the details of interventions would vary, the team leaders say the core elements of this bundle likely can be adapted to other critically ill populations, such as general pediatric and adult intensive care patients, and adult cardiovascular ICUs.
About the Study
Participating centers were: Cincinnati Children’s Hospital Medical Center, Children’s National Hospital, Medical City Children’s Hospital, Le Bonheur Children’s Hospital, Children’s Mercy Hospital, Primary Children’s Hospital, Children’s Wisconsin, University of Alabama at Birmingham, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Phoenix Children’s Hospital, Benioff Children’s Hospital, Seattle Children’s Hospital, University of Nebraska Medical Center Children’s Hospital and Medical Center, Arkansas Children’s Hospital, Nicklaus Children’s Hospital, Children’s Hospital Colorado, Medical University of South Carolina, Rady Children’s Hospital, and the University of Michigan.
Key funding sources included Congenital Heart Alliance of Cincinnati, Children’s Heart Foundation, and Castin’ ‘N Catchin’ Charity Organization via Children’s of Alabama.