A multicenter study led by two Cincinnati Children’s physicians finds that in-hospital cardiac arrest (IHCA) can be prevented for some children in cardiac intensive care units (CICU). This can greatly improve care, outcomes and quality of life for these children.

Jeffrey Alten, MD, an attending physician at Cincinnati Children’s CICU, and Michael Gaies, MD, medical director of the Acute Care Cardiology Unit at Cincinnati Children’s, led the study. A group of 15 pediatric CICUs implemented a low-technology, low-cost cardiac arrest prevention (CAP) practice bundle. The hospitals are part of the Pediatric Cardiac Critical Consortium (PC4), an international quality improvement collaborative that Gaies founded in 2009.

Use of the bundle reduced IHCA occurrence by 30%, exceeding a targeted 25% reduction. Results were published in JAMA Pediatrics in July 2022.

“We collaborated with hospitals across the country to collect data and understand variation in performance on IHCA prevention,” says Gaies. “Leaders from these institutions came together to share best practices and improve the quality of care across hospitals.” The practice bundle—designed by Alten—can be replicated at any institution.

Elements of the CAP Bundle

The CAP bundle promotes situational awareness and communication to recognize and mitigate deterioration in high-risk patients. Each element is minimal in cost and is technology independent, allowing CICUs to adapt to their own clinical workflow, resources and systems. The bundle includes five elements:

1. CAP safety huddle. This is a formal, multidisciplinary bedside discussion separate from patient rounds. It is designed to create situational awareness amongst the entire care team for high-risk patients. The huddle:

• Occurs twice daily
• Includes a bedside nurse, nurse leader, attending physician, first-responding provider and respiratory therapist
• Discussion topics must include the most likely reason for an IHCA with each patient, plus mitigation and rescue plans

The goal is for the entire team to recognize early deterioration and agree on plans for reversal and/or rescue of a patient.

2. Vital sign discussion. This can occur during the CAP safety huddle. Goals include:

• Establish parameters for patient-specific vital sign goals and targets
• Define changes that may represent early deterioration
• Post parameters in the patient’s room

• Program parameters into the monitor

• Require bedside clinician evaluation and reassessment if there are changes to parameters

3. Discussion of pre-sedation. This conversation also takes place during the CAP safety huddle. The care team addresses the use of pre-sedation for noxious stimuli as patients with tenuous conditions are more likely to suffer hemodynamic collapse related to agitation or pain. Compliance for this element is based on the discussion, not ordering a pre-sedation agent.

4. Emergency medication. Many IHCA episodes are preceded by acute hypotension. Rapid administration of epinephrine may rescue a patient before cardiac arrest. The bundle calls for patient-specific doses of epinephrine to be pre-drawn and stored at the bedside.

5. Formal code review. This element calls for all cardiac arrests to be reviewed within two weeks of the event—and ideally within 48 hours. Clinical staff involved should be present during the review. Key learnings and improvement opportunities should be shared with all medical and nursing staff.

Prioritizing the Prevention of Cardiac Arrest in High-Risk CICU Patients

This study represents an important paradigm shift in critical care to prevent IHCA and reduce adverse events.

“The best CPR is no CPR,” Alten says. “This project was able to prevent CPR in almost 200 high-risk children during CAP implementation at these 15 hospitals.”

Alten and Gaies expect to see use of the CAP bundle grow.

• More work will help roll out the care bundle to additional hospitals.

• Future studies can determine bundle elements most necessary for cardiac arrest prevention.

• Core bundle elements likely could be adapted to other critically ill populations, such as:

  • Adult cardiac ICU patients

  • Adult intensive care patients

  • General pediatric patients

PC4 aims to improve the quality of care for patients with critical pediatric and congenital cardiovascular disease in North America and abroad. PC4 is part of Cardiac Networks United (CNU), a collaborative pediatric and congenital cardiovascular research and improvement network that provides infrastructure for improvement work.

Funding for the study came from several sources including the Children's Heart Foundation, the Congenital Heart Alliance of Cincinnati and Castin’ ‘N Catchin’ at Children’s of Alabama.