Improving Pediatric Emergency Department Cardiopulmonary Resuscitation Performance: A Quality Improvement Initiative

Purpose/Objectives: Pediatric out-of-hospital cardiac arrest (OHCA) is a rare event with a high mortality rate. The 2020 American Heart Association (AHA) Pediatric Advanced Life Support (PALS) guidelines recommend high-quality cardiopulmonary resuscitation (CPR), early epinephrine administration, and end-tidal capnography (ETCO2) monitoring as mechanisms of improving outcomes. We hypothesized that the implementation of a cardiac arrest bundle to standardize the initial minutes of the emergency department (ED) resuscitation for OHCA would lead to improved CPR quality and compliance with AHA recommendations. The five elements of the bundle were time to: intravenous or intraosseous catheter (IV/IO) placement, first epinephrine administration, advanced airway placement, ETCO2 application and monitoring, and initial cardiac rhythm verbalization. Our SMART aim was to reduce the time of completion of the cardiac arrest bundle from 302 seconds to less than 120 seconds within one year for patients presenting to our resuscitation bay with OHCA.

Design/Methods: This quality improvement study was performed at an academic pediatric ED with an annual volume of 62,000 patients and an annual average of 30 cardiac arrests. A multidisciplinary team including physicians, nurses, paramedics, and respiratory therapists developed a standardized choreography for ED cardiopulmonary resuscitation. This choreography was disseminated to the ED staff from December 2020-March 2021 using both didactic sessions and in-situ simulation sessions. To assess the effect of the intervention, the time to performance of each of the five bundle elements was measured by standardized review of video recordings from our resuscitation bay. Balancing measures included time off the chest and time to defibrillator pad placement. Specific and actionable feedback was emailed to all care team members after each OHCA.

Results: We analyzed 56 cardiac arrests from May 2019 through May 2021. Time to bundle completion improved from 302 seconds to 147 seconds (Fig 2). Time to advanced airway placement, ETCO2 application, and rhythm check all decreased to under 120 seconds. Time to IV/IO placement and first epinephrine administration remain above 120 seconds.

Conclusion/Discussion: Pediatric OHCA is a rare event with a high mortality rate. To improve morbidity and mortality, it is crucial for pediatric ED teams to provide high-quality cardiac arrest care. Our implementation of a standardized cardiac arrest bundle shows promise to decrease time to crucial interventions in children presenting with OHCA.