Postcardiac Arrest Care Delivery in Pediatric Intensive Care Units: A Plan and Call to Action

Background: Despite national pediatric postcardiac arrest care (PCAC) guidelines to improve neurological outcomes and survival, there are limited studies describing PCAC delivery in pediatric institutions. This study aimed to describe PCAC delivery in centers belonging to a resuscitation quality collaborative. Methods: An institutional review board-approved REDCap survey was distributed electronically to the lead resuscitation investigator at each institution in the international Pediatric Resuscitation Quality Improvement Collaborative. Data were summarized using descriptive statistics. A chi-square test was used to compare categorical data. Results: Twenty-four of 47 centers (51%) completed the survey. Most respondents (58%) belonged to large centers (>1,000 annual pediatric intensive care unit admissions). Sixty-seven percent of centers reported no specific process to initiate PCAC with the other third employing order sets, paper forms, or institutional guidelines. Common PCAC targets included temperature (96%), age-based blood pressure (88%), and glucose (75%). Most PCAC included electroencephalogram (75%), but neuroimaging was only included at 46% of centers. Duration of PCAC was either tailored to clinical improvement and neurological examination (54%) or time-based (45%). Only 25% of centers reported having a mechanism for evaluating PCAC adherence. Common barriers to effective PCAC implementation included lack of time and limited training opportunities. Conclusions: There is wide variation in PCAC delivery among surveyed pediatric institutions despite national guidelines to standardize and implement PCAC.


INTRODUCTION
Following resuscitation from cardiac arrest, patients experience postcardiac arrest syndrome defined by brain injury, myocardial dysfunction, and systemic reperfusion injury. 1 Postcardiac arrest care (PCAC) is a guideline-based approach that includes targeted temperature management, monitoring for and treating seizures, targeting normal oxygenation and ventilation, preventing hypotension, and maintaining normoglycemia. 1 There are conflicting data on the survival effect of individual PCAC elements, and no studies have evaluated their joint effect as a bundle of care. 1 Clinical trials on targeted temperature management found no difference in survival with a good functional outcome between therapeutic hypothermia and therapeutic normothermia. 2,3Despite the high frequency of seizures after cardiac arrest, 4,5 there is insufficient evidence linking the treatment of seizures with outcomes. 17][8] Hypotension is associated with lower survival after cardiac arrest, 9,10 but the survival effect of manipulating blood pressure after arrest remains unclear. 1 Finally, although hypoglycemia and hyperglycemia are associated with unfavorable outcomes in critically ill children, 11 no clinical trials have focused on the postarrest period. 1 The 2020 American Heart Association (AHA) Pediatric Advanced Life Support guidelines 12 and the scientific statement on pediatric PCAC 1 provide goals and Pediatric Quality and Safety management strategies for postarrest care based on consensus among pediatric and adult specialists and a review of the past 20 years of literature.It is unknown how these national guidelines have been implemented into local PCAC practice. 12A survey of emergency hospitals treating adults after cardiac arrest reported that less than half of centers had local guidelines for PCAC.Of those institutions with local guidelines, 39% reported that the guidelines were not always applied. 13 Similar studies have not been published on children, and there is a lack of data on providers' perceptions of barriers to implementation.The purpose of this study is to describe the reported variation of PCAC delivery in intensive care units (ICUs) participating in the Pediatric Resuscitation Quality (PediRES-Q) Collaborative (ClinicalTrials.govNCT02708134).

METHODS
The PediRES-Q collaborative comprises pediatric ICUs from institutions worldwide that vary in size, geographic location, and academic support and share a collective purpose of conducting research and quality improvement (QI) projects to improve pediatric resuscitation. 14Surveys were distributed electronically using REDCap to resuscitation investigators at institutions belonging to PediRES-Q (Richmond, Va.).REDCap is a secure web application for managing surveys and databases. 15The investigators responding to the surveys were pediatric intensivists from Pediatric Intensive Care Units (PICUs) or mixed units (combined PICU and cardiac ICU) who regularly attend monthly PediRES-Q meetings and are directly involved with PCAC at their institution.
The survey included closed and open-ended questions organized into four sections: characteristics of the institution, PCAC implementation and understanding, PCAC bundle components, and PCAC adherence.Survey questions were assessed for readability, clarity, and inclusive response options on a group of volunteer investigators belonging to PediRES-Q before distributing electronically to the primary investigator at each of the 47 centers.The collaborative sent two reminder e-mails and announcements were made at two of the monthly videoconferences.Not all survey questions were mandatory, and we included partially completed surveys in the analysis.The institutional review board of the Children's Hospital of Philadelphia deemed the study exempted.Data are summarized using descriptive statistics, and chi-square testing was used to compare groups.Statistical analysis was performed with R Statistical Software version 4.0.4(Vienna, Austria).

DISCUSSION
This is the first study to describe pediatric intensivists' reported PCAC implementation at pediatric institutions.There was considerable variability in reported PCAC implementation, with most centers relying on attendingdirected care to implement and guide PCAC without standardized order sets, paper forms, or institutional guidelines.Most centers reported not using specific criteria to initiate PCAC.Additionally, PCAC duration was highly variable, with its length most often determined by clinical improvement/neurological examination and less frequently by set time intervals.Few centers have practices incorporating all components of postarrest care as suggested by Pediatric Advanced Life Support guidelines.
These findings are not surprising because other established care guidelines are also poorly adopted into reliable practice patterns. 16These pediatric institutions Similar to infection prevention bundles to prevent lineassociated infections (central line-associated bloodstream infection), 17 we suggest PCAC may be best delivered as a bundle with the benefit derived from its multiple elements, and likely when parts of the bundle are missing, the efficacy of PCAC decreases. 18,19Yet, most institutions reported incomplete implementation of all components of PCAC.Finally, evaluation of bundle adherence, a key component of care bundle implementation and effectiveness, 20 was notably low across centers.

Next Steps
The

What Should Be?
The AHA statement on pediatric PCAC delineates management strategies that should be instituted after cardiac arrest and serves as the sole reference for the US pediatric centers providing PCAC. 1 In translating these recommendations to the bedside, several knowledge gaps persist, including understanding the optimal targets and therapies that affect outcomes, outlining ways to track the impact of PCAC, determining the effect of using a bundle of care, identifying the necessary team members and institutional features to influence outcomes, and defining the best measures to define these outcomes. 1hus far, PCAC clinical trials evaluating postarrest outcomes have focused exclusively on temperature management (eg, target temperature and duration). 2,21No other PCAC components, nor the bundle, have been evaluated in a clinical trial.Lack of clarity on the effectiveness of PCAC components and the PCAC bundle is a significant barrier to establishing postarrest care quality indicators, which have thus far not been delineated in the pediatric population.Such quality metrics were recently published for PCAC after adult out-of-hospital arrest. 22The absence of quality metrics and benchmarks hinder the implementation of QI initiatives and is a necessary step in improving PCAC delivery.

How We Get There?
Successful implementation of QI initiatives must focus on understanding the intervention's effects and the contextual factors that influence implementation. 23Thus, the first step in improving PCAC delivery is to leverage cardiac arrest databases to fill existing knowledge gaps.Available registries and collaboratives include PediRES-Q, 24 AHA-Get With The Guidelines, 25 Therapeutic Hypothermia After Cardiac Arrest, 2 Pediatric Cardiac Critical Care Consortium, 26 Extracorporeal Life Support Organization, 27 Cardiac Arrest Registry to Enhance Survival, and Canadian Resuscitation Outcomes Consortium. 28Data sharing agreements, direct reporting from electronic medical records, and shared definitions for data elements of these databases would greatly enhance participation to defray the cost and resources required to participate.
The second step is to understand the facilitators and barriers to implementing QI initiatives, which as highlighted by Dewan et al, 23 are not unique to postarrest care.In their study of contextual factors affecting the implementation of resuscitation QI interventions in centers belonging to pediRES-Q, the authors highlight disparities in center performance despite universal access to the same interventions.Facilitators of QI implementation included a unified institutional approach to QI, a focus on learning from failures and trying new approaches, leadership support beyond the divisional level, strong motivation to improve, knowledge sharing with key stakeholders at other institutions, and prioritization of goals.Barriers included low QI team tenure (eg, rotating medical providers), lack of resources and time, lack of formalized QI knowledge or training, and lack of buy-in from leaders and staff.Further understanding of contextual factors that influence QI success with the use of tools such as the Model for Understanding Success in Quality framework 29 and application of this knowledge by strong local teams trained in implementation science and QI are key to improving PCAC delivery. 23he final step in improving PCAC delivery is to continue providing a unified approach for PCAC implementation and evaluation, such as that offered by pediRES-Q. 24The collaborative provides a publicly available postresuscitation care checklist outlining the management goals during the postarrest period that participating sites can print for use at the bedside. 30Furthermore, the collaborative provides a platform for data collection through which participating sites can submit data on PCAC delivery and compare center performance.The collaborative also serves as a place for knowledge sharing and support through monthly meetings and access to a network of providers at other institutions.Finally, the data and research infrastructure provided by the collaborative can be used for ongoing assessment of PCAC application through an implementation science approach while measuring its effectiveness on outcomes through a hybrid study design.
We encourage institutions to consider QI initiatives derived from locally identified PCAC barriers and facilitators.Based on the themes identified through our survey, some potential key drivers and interventions that could be implemented across multiple plan-do-studyact cycles include: improving institutional engagement (identification of PCAC champions at each institution with active participation in PediRES-Q meetings); improving staff understanding (periodic staff education and refreshers, structured review of cases where PCAC was used); increasing PCAC training opportunities (integration of PCAC care into cardiac arrest simulation); implementing PCAC tools (use of a bedside checklist such as the PediRES-Q PREP checklist, 30 creation of an electronic medical record order set outlining PCAC interventions and goals, huddles during daytime and nighttime rounds to evaluate goals and compliance); and instituting mechanisms for evaluating PCAC adherence (use of PCAC report cards, data collection through institutional cardiac arrest registries, data submission to PediRES-Q).Statistical process control 31 can be used to track process metrics (eg, PCAC adherence-defined as the percentage of bundle treatment goals achieved per cardiac arrest event) and outcome metrics (eg, survival and favorable neurological outcome) to inform future interventions.

Limitations
There are several limitations to our study.This was a survey of physicians within an international collaborative with a modest response rate.Survey responses are what people say they do and may not reflect actual practice.These physicians and the institutions they represent may not portray the most common views because physicians interested in PCAC are likely overrepresented in this population.These physicians also have a potential for reporting bias given that the individuals responding to the surveys regularly participate in all stages of PCAC, and this may overrepresent how PCAC is delivered.Additionally, we did not perform systematic pretesting or validation of our survey before its administration, which may decrease the validity of our results.

CONCLUSIONS
There is wide variation in PCAC delivery among the PICUs surveyed.We identified potential common themes and opportunities, such as standardizing PCAC initiation methods, bundle components, and training, adherence, and evaluation methods that QI and implementation science interventions could target to improve PCAC effectiveness.We believe that every pediatric institution that cares for children postcardiac arrest, should identify a PCAC champion who can lead the charge to help improve PCAC delivery.

Table 1 .
Characteristics of PCAC initiation *Respondents were able to select more than one option.†Three of five respondents reported using specific GCS levels: GCS 2 (one respondent), GCS 6 (two respondents).CICU, cardiac intensive care unit; GCS, Glasgow coma scale; NICU, neonatal intensive care unit.