Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes*

Abstract

Objective: In-hospital cardiac arrest is an important public health problem. High-quality resuscitation improves survival but is difficult to achieve. Our objective is to evaluate the effectiveness of a novel, interdisciplinary, postevent quantitative debriefing program to improve survival outcomes after in-hospital pediatric chest compression events.

Design, setting, and patients: Single-center prospective interventional study of children who received chest compressions between December 2008 and June 2012 in the ICU.

Interventions: Structured, quantitative, audiovisual, interdisciplinary debriefing of chest compression events with front-line providers.

Measurements and main results: Primary outcome was survival to hospital discharge. Secondary outcomes included survival of event (return of spontaneous circulation for ≥ 20 min) and favorable neurologic outcome. Primary resuscitation quality outcome was a composite variable, termed "excellent cardiopulmonary resuscitation," prospectively defined as a chest compression depth ≥ 38 mm, rate ≥ 100/min, ≤ 10% of chest compressions with leaning, and a chest compression fraction > 90% during a given 30-second epoch. Quantitative data were available only for patients who are 8 years old or older. There were 119 chest compression events (60 control and 59 interventional). The intervention was associated with a trend toward improved survival to hospital discharge on both univariate analysis (52% vs 33%, p = 0.054) and after controlling for confounders (adjusted odds ratio, 2.5; 95% CI, 0.91-6.8; p = 0.075), and it significantly increased survival with favorable neurologic outcome on both univariate (50% vs 29%, p = 0.036) and multivariable analyses (adjusted odds ratio, 2.75; 95% CI, 1.01-7.5; p = 0.047). Cardiopulmonary resuscitation epochs for patients who are 8 years old or older during the debriefing period were 5.6 times more likely to meet targets of excellent cardiopulmonary resuscitation (95% CI, 2.9-10.6; p < 0.01).

Conclusion: Implementation of an interdisciplinary, postevent quantitative debriefing program was significantly associated with improved cardiopulmonary resuscitation quality and survival with favorable neurologic outcome.

Conflict of interest statement

The remaining authors have disclosed that they do not have any potential conflicts of interest.

Figures

Figure 1

Study diagram indicating resuscitation care practices. Censor period was a transition of 6 mo at the initiation of the project to allow for wash in time for providers to attend debriefing sessions. CPR = cardiopulmonary resuscitation.

Figure 2

Utstein style diagram. *One patient had index event during censor period and was not included in survival to hospital discharge or favorable neurologic outcome among survivors. CPR = cardiopulmonary resuscitation, CC = chest compression, ROSC = return of spontaneous circulation.

Figure 3

Multivariable logistic regression controlling for gender, age category, initial rhythm, and presence of vasoactive infusions at index arrest. ROSC refers to return of spontaneous circulation ≥ 20 min. Discharge indicates survival to hospital discharge. Good neuro indicates survival to discharge with performance category score (PCPC) score of 1–3 at discharge or no increase compared with admission PCPC status. *Adjusted odds ratio (aOR), 2.75; 95% CI, 1.01–7.5; p = 0.047 for index cardiopulmonary resuscitation (CPR) events after debriefing. †aOR, 2.5; 95% CI, 0.91–6.8; p = 0.075. Change in rate of ROSC after all CPR events was not significant (aOR, 1.55; 95% CI, 0.61–3.97; p = 0.36).

Figure 4

Percentage of cardiopulmonary resuscitation (CPR) epochs achieving targets (mean ± SE) for depth ≥ 38 mm, rate ≥ 100/min, CPR fraction > 90%, and leaning ≤ 10% of compressions. Excellent CPR defined as having all four CPR elements achieving targets. Analysis evaluates percentage of epochs without controlling for intraevent correlation. *p < 0.01.