Elsevier

Resuscitation

Volume 92, July 2015, Pages 94-100
Resuscitation

Clinical paper
Cardiopulmonary resuscitation for in-hospital events in the emergency department: A comparison of adult and pediatric outcomes and care processes

https://doi.org/10.1016/j.resuscitation.2015.04.027Get rights and content

Abstract

Objectives

To compare outcomes from in-hospital cardiopulmonary resuscitation (CPR) in the emergency department (ED) for pediatric and adult patients and to identify factors associated with differences in outcomes between children and adults.

Methods

Retrospective analysis of the Get With The Guidelines – Resuscitation database from January 1, 2000 to September 30, 2010. All patients with CPR initiated in the ED requiring chest compressions for ≥2 min were eligible; trauma patients were excluded. Patients were divided into children (<18 yo) and adults (≥18 yo). Patient, event, treatment, and hospital factors were analyzed for association with outcomes. Univariate analysis was performed comparing children and adults. Multivariate analysis was used to determine factors associated with outcomes.

Results

16,834 events occurred in 608 centers (16,245 adult, 537 pediatric). Adults had more frequent return of spontaneous circulation (53% vs 47%, p = 0.02), 24 h survival (35% vs 30%, p = 0.02), and survival to discharge (23% vs 20%, p = NS) than children. Children were less frequently monitored (62% vs 82%) or witnessed (79% vs 88%), had longer duration (24 m vs 17 m), more epinephrine doses (3 vs 2), and more frequent intubation attempts (64% vs 55%) than adults. There were no differences in time to compressions, vasopressor administration, or defibrillation between children and adults. On multivariate analysis, age had no association with outcomes.

Conclusions

Survival following CPR in the ED is similar for adults and children. While univariate differences exist between children and adults, neither age nor specific processes of care are independently associated with outcomes.

Introduction

In-hospital cardiopulmonary resuscitation (CPR) has seen improving outcomes in both adult and pediatric patients over the past few decades. Among in-hospital locations where CPR is performed, the emergency department (ED) constitutes a minority of such events, comprising 9–11% of all in-hospital CPR events in both adult and pediatric patients.1, 2, 3 Outcomes among patients receiving CPR during an ED visit are likely influenced in a more complex manner by prehospital care, premorbid medical conditions, and variances in care processes that patients in other in-hospital settings. Few studies have exclusively examined this subset of patients.

Previously published studies from the American Heart Association Get With the Guidelines – Resuscitation registry (formerly the National Registry of Cardiopulmonary Resuscitation) on outcomes from CPR in the ED have yielded results that differ greatly between adult and pediatric patients. Children receiving CPR in the ED have been shown to have much poorer survival when compared to CPR outcomes in other in-hospital locations.1, 4 Adults, by contrast, were found to be twice as likely to survive to hospital discharge when compared with events in the intensive care unit (ICU) or ward when analyzed within the same database.2

Reasons for the differences in outcomes between children and adults following CPR in the ED are not clear. The epidemiology and underlying physiology of cardiac arrest is significantly different between pediatric and adult patients, with children having a greater prevalence of respiratory and circulatory insufficiency as underlying causes leading up to cardiac arrest, as opposed to sudden cardiac death.5 It is possible that children arresting in the ED are in a more advanced state of acidosis, hypoxia, and metabolic deterioration at the time CPR is initiated. Additionally, pediatric cardiac arrest events are much less common than adult events. Even at tertiary pediatric centers, the incidence of cardiac arrests in the ED is very low1, 4; in non-pediatric EDs, where more than 90% of pediatric patients are initially managed, these events are even less common. It is possible that, as a result of infrequent clinical experience, care delivery to pediatric patients is less optimal during CPR, which may negatively influence outcomes.

With the present study, we sought to clarify factors that contributed to this marked discrepancy in the influence of ED as a location on CPR outcomes between adults and children. We performed an analysis of the American Heart Association Get With the Guidelines – Resuscitation database examining outcomes following CPR in the ED among children and adults. We hypothesized that children would have worse survival outcomes than adults, and that we would identify significant factors related to patient, event, treatment, and hospitals that were independently associated with outcomes.

Section snippets

Methods

This was a retrospective cohort study of the Get With the Guidelines – Resuscitation database (GWTG-R, formerly the National Registry of Cardiopulmonary Resuscitation, or NRCPR), a multihospital registry of CPR events sponsored by the American Heart Association. Hospitals voluntarily participate in the database for the primary purpose of quality improvement and as such are not required to obtain institutional review board approval or informed consent from patients or families. The study was

Results

Of 200,602 events requiring CPR at 608 hospitals during the study period, 16,782 (8%) occurred in the emergency department. 16,245/189,654 (8.6%) of adult events and 537/10,948 (5%) of pediatric events were initiated in the ED. 52 patients (<1%) were excluded due to missing data on outcomes or age. 66/537 (12%) of pediatric patients and 594/16,245 (4%) of adult patients had missing or incomplete data on 24 h survival and were excluded from analysis of 24 h survival and survival to discharge.

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Discussion

In our study, we demonstrated that survival from cardiac arrest in the emergency department was not significantly different between adults and children when controlled for important patient, event, hospital, and clinical factors. Unadjusted comparison between children and adults demonstrated lower incidence of ROSC and 24 h survival among pediatric patients; however, this association did not remain significant in multivariate analysis. Important differences between pediatric and adult patients

Conclusions

Outcomes from cardiac arrest occurring in the emergency department do not differ significantly between children and adults. Significant differences exist between children and adults with respect to patient, event, and treatment characteristics, but these differences were not independently associated with survival. Future studies should evaluate the impact of age-specific therapies for pre-arrest pathophysiology on outcomes from cardiac arrest in the early phases of in-hospital care in the

Conflict of interest statement

No authors have any financial conflicts of interest to disclose pertinent to the current study.

Acknowledgements

This study was supported by the Nicholas Crognale Endowed Chair for Emergency Medicine and the Russell Raphaely Endowed Chair for Critical Care Medicine at the Children's Hospital of Philadelphia.

References (17)

There are more references available in the full text version of this article.

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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2015.04.027.

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