(Screen 1 - 5:45 PM Friday) Sustainability of a Cardiac Arrest Prevention Bundle to Reduce In-Hospital Cardiac Arrest and Mortality in the Pediatric CICU

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Abstract:

Background: Children with cardiac disease are at higher risk of in-hospital cardiac arrest (CA), resulting in significant morbidity and mortality. Despite extensive investment in resources to improve cardiopulmonary resuscitation and post-resuscitation care, there has been minimal investment in preventative strategies. We sought to develop a quality improvement bundle to prevent CA in high-risk cardiac patients.

Methods: A CA prevention (CAP) bundle was implemented in our 20-bed CICU via collaboration with the Pediatric Cardiac Critical Care Consortium (PC4). Statistical process control (SPC) methodology tracked CA rates over time. The CAP bundle targeted patients defined a priori as high-risk for CA: neonates after CPB surgery, neonates/infants after single-ventricle palliation (pulmonary artery band and systemic-to-pulmonary artery shunt), and medical patients requiring intubation within 4 hours of admission. CAP bundle included: 1) multidisciplinary safety huddles creating situational awareness about CA prevention, 2) delineating patient-specific vital signs and CA mitigation plans, 3) pre-sedation plan for bedside interventions, 4) patient-specific bedside epinephrine, and 5) CA event review. The bundle continued for a maximum of 7 days in surgical patients, 3 days in medical patients, or 24-hours post extubation. Time periods spanned 16 months (baseline 1/2017-4/2018), 18 months (CAP implementation 5/2018-12/2019), and 30 months (CAP sustain 1/2020-6/2022).

Results: There were 440 CICU admissions in the baseline period, 351 in the CAP implementation period and 728 in the CAP sustain period with 0, 100, and 106 patients placed on the bundle during these respective periods. In SPC analysis, there was special-cause variation beginning in the 10th month of CAP implementation with a shift from the historical baseline (5.5 to 0.0 CA/1000 CICU days). Surgical volume and complexity declined during this period and thus the baseline was not shifted. A return to surgical volume and complexity began in the 18th month of CAP implementation and a new baseline was set with a 45% CA reduction from the historical baseline (5.5 to 3.0 CA/1000 CICU days). A second special-cause variation with a provisional shift from the new baseline occurred in the 20th CAP sustain month with a 57% reduction in CA (3.0 to 1.3 CA/1000 CICU days). Hospital mortality declined from 3.2% during the baseline to 1.7% during the CAP intervention + CAP sustain period, for an overall mortality reduction of 47% since implementation of the bundle.

Conclusions: Reduction in CA is achievable through implementation of bundled interventions targeting proactive CA prevention, and led to a 45% reduction in CA. Sustained and continued improvement of this bundle is possible and led to an overall 57% CA rate reduction and an overall reduction in hospital mortality of 47%. Proactive CA prevention via this bundle if adopted by other ICUs may potentially reduce harm and save lives from pediatric CA.