Clinical paperCardiopulmonary resuscitation for in-hospital events in the emergency department: A comparison of adult and pediatric outcomes and care processes☆
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.
A
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.
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A novel depth estimation algorithm of chest compression for feedback of high-quality cardiopulmonary resuscitation based on a smartwatch
2018, Journal of Biomedical InformaticsCitation Excerpt :allowing full chest recoil after each compression, minimizing pauses in compressions, and avoiding excessive ventilation [4,5]. There has been wide variability of survival for cardiac arrests published in the literature, but the overall reported survival rate remains poor [6–10]. Research findings have shown that the quality of CPR during resuscitation has a significant impact on survival and patient outcomes, whether CPR is initiated by a layperson in the prehospital environment, an emergency physician in the emergency department (ED), or a clinician in the inpatient ward [11–14].
Hypoxic-Ischemic Encephalopathy in Infants and Older Children
2017, Swaiman's Pediatric Neurology: Principles and Practice: Sixth EditionMeta-analysis of outcomes of the 2005 and 2010 cardiopulmonary resuscitation guidelines for adults with in-hospital cardiac arrest
2016, American Journal of Emergency MedicineCitation Excerpt :Survival outcomes after resuscitation were associated with age, electrocardiography rhythm, the timing of cardiac arrest, where CPR was performed, and the duration of CPR [6]. Adults had more frequent ROSC, 24-hour survival, and survival to discharge than children from in-hospital CPR in emergency department during 2000 to 2010 [7]. It is unknown whether the recent improvements are due to the new 2010 guidelines or to an increased number of trained bystanders or other reasons.
Epidemiology of pediatric cardiopulmonary resuscitation
2020, Jornal de PediatriaCitation Excerpt :In a prospective multicenter observational study that included adults and children in emergency services, it was observed that most rhythms during CPA were non-shockable and survival at hospital discharge was higher in children than in adults (27% vs. 18%, OR 2.29; 95% CI: 1.95•2.68).60 In turn, a more recent, multicenter retrospective study using the same database as the previous study found that survival at hospital discharge was similar between adults and children (23% vs. 20%).61 Considering the different hospital sectors, survival at hospital discharge was observed in 13.7•47% in pediatric ICU studies,62•64 12.8% in multicenter studies in pediatric emergency services,65 and 37•39.2% when considering all hospital sectors.66,67
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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.