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Survival Rates Following Pediatric In-Hospital
Cardiac Arrests During Nights and Weekends
Farhan Bhanji, MD, MSc(Ed),FRCP C; AlexisA . Topjian, MD, MSCE; Vinay M. Nadkarni, MD, MS;
Amy H. Praestgaard, MS; Elizabeth A. Hunt, MD, MPH, PhD; Adam Cheng, MD, FRCPC;
Peter A. Meaney, MD, MPH; Robert A. Berg, MD; for the American Heart Association’s
Get With the Guidelines–Resuscitation Investigators
IMPORTANCE Nearly 6000 hospitalized children in the United States receive
cardiopulmonary resuscitation (CPR) annually. Little is known about whether the survival of
these children is influenced by the time of the event (eg, nighttime or weekends). Differences
in survival could have important implications for hospital staffing, training, and resource
allocation.
OBJECTIVE To determine whether outcomes after pediatric in-hospital cardiac arrests differ
during nights and weekends compared with days/evenings and weekdays.
DESIGN, SETTING, AND PARTICIPANTS This study included a total of 354 hospitals participating
in the American Heart Association’s Get With the Guidelines–Resuscitation registry from
January 1, 2000, to December 12, 2012. Index cases (12404 children) from all children
younger than 18 years of age receiving CPR for at least 2 minutes were included. Data analysis
was performed in December 2014 and June 2016. We aggregated hourly blocks of time, using
previously defined time intervals of day/evening and night, as well as weekend. Multivariable
logistic regression models were used to examine the effect of independent variables on
survival to hospital discharge. We used a combination of a priori variables based on previous
literature (including age, first documented rhythm, location of event in hospital,
extracorporeal CPR, and hypotension as the cause of arrest), as well as variables that were
identified in bivariate generalized estimating equation models, and maintained significance of
Pⱕ.15 in the final multivariable models.
MAIN OUTCOMES AND MEASURES The primary outcome measure was survival to hospital
discharge, and secondary outcomes included return of circulation lasting more than
20 minutes and 24-hour survival.
RESULTS Of 12 404 children (56.0% were male), 8731 (70.4%) experienced a return of
circulation lasting more than 20 minutes, 7248 (58.4%) survived for 24 hours, and 4488
(36.2%) survived to hospital discharge. After adjusting for potential confounders, we found
that the rate of survival to hospital discharge was lower during nights than during
days/evenings (adjusted odds ratio, 0.88 [95% CI, 0.80-0.97]; P= .007) but was not
different between weekends and weekdays (adjusted odds ratio, 0.92 [95% CI, 0.84-1.01];
P= .09).
CONCLUSIONS AND RELEVANCE The rate of survival to hospital discharge was lower for
pediatric CPR events occurring at night than for CPR events occurring during daytime and
evening hours, even after adjusting for many potentially confounding patient-, event-, and
hospital-related factors.
JAMA Pediatr. 2017;171(1):39-45. doi:10.1001/jamapediatrics.2016.2535
Published online November 7, 2016.
Author Affiliations: Author
affiliations are listed at the end of this
article.
Group Information: The American
Heart Association’s Get With the
Guidelines–Resuscitation
Investigators are listed at the end of
the article.
Corresponding Author: Farhan
Bhanji, MD, MSc(Ed), FRCPC,
Department of Pediatrics, McGill
University,Room B06-3834, 1001
Decarie Ave, Montreal, QC H4A 3J1,
Canada (farhan.bhanji@mcgill.ca).
Research
JAMA Pediatrics | Original Investigation
(Reprinted) 39
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Nearly 6000 children in the United States receive in-
hospital cardiopulmonary resuscitation (CPR) each
year,
1
with a rate of 2% to 6% in pediatric intensivec are
settings.
2,3
Most of these children do not survive to hospital
discharge.
4
Although survival rates following pediatric in-
hospital CPR have improved over the last decade, the variabil-
ity in survival rates suggests potential opportunities for
improvement.
5,6
Recent prehospital and in-hospital cardiac arrest studies
of adults, as well as a prehospital study of children, have dem-
onstrated worse outcomes for patients who had a cardiac ar-
rest at night rather than during the day.
7-12
Similar in-hospital
studies of children are lacking and could yield different re-
sults based on the progressive nature of respiratory failure and
shock that typically precede pediatric cardiac arrest,
4
theo-
retically making it a more predictable event.
The American Heart Association’s Get Withthe Guidelines–
Resuscitation (GWTG-R) registry is a large multicenter regis-
try of in-hospital cardiac arrests with standardized data re-
porting methods. We used the GWTG-R database to evaluate
survival rates for children who had an in-hospital cardiac ar-
rest by time of day and day of week. We hypothesized that out-
comes would be worse during nights and weekends,even when
adjusted for potential confounding patient-, event-, and hos-
pital-related factors.
Methods
The GWTG-R registry is the only national registry of in-
hospital cardiac arrests in North America. The primary pur-
pose is quality improvement based on the recording of de-
identified data in compliance with the Health Insurance
Portability and Accountability Act. Dataare collected prospec-
tively, and participation in the registry is voluntary. The
GWTG-R registry uses standardized definitions and report-
ing forms based on the Utstein template,
13,14
allowing for more
uniform practice in the collection and review of resuscitation
data. Details of hospital certification, data collection and re-
porting methods, and integrity verification have previously
been reported.
7,15
Adult and pediatric patients, employees, and visitors
requiring resuscitation in a hospital facility were eligible for
inclusion in the registry. The 6 domains of data that were
collected relate to (1) facility data, (2) patient demographic
data, (3) pre-event data, (4) event data, (5) outcome data, and
(6) quality improvement data.
16
Institutional review board approval was not required for
participation in the continuous quality improvement activi-
ties of the registry but was obtained from the McGill Univer-
sity Faculty of Medicine institutional review board for this re-
search study. Informed consent was not required because the
data were deidentified.
Inclusion and Exclusion Criteria
All children younger than 18 yearsof age who received CPR for
at least 2 minutes were eligible for inclusion in this study. Only
index events were included (ie, the first CPR event)for any pa-
tient receiving CPR more than once during a hospitalization.
Exclusion criteria were children whose resuscitation began
outside of the hospital, newborns who experienced cardiac
arrest in the delivery room, cardiac arrests that involved an
obstetric patient, events that werelimited to a shock by an im-
plantable cardioverter-defibrillator, or events that occurred in
a patient with a do-not-attempt-resuscitation order. Sequen-
tial data from 354 participating hospitals from January 1, 2000,
to December 12, 2012, were analyzed.
Outcomes
The prospectively selected primary outcome variable was sur-
vival to hospital discharge. Secondary outcome variables in-
cluded return of circulation lasting more than 20 minutes and
24-hour survival. Patients who survived to the initiation of ex-
tracorporeal CPR or cardiopulmonary bypass were included as
having a return of circulation.
Exposures
We aggregated hourly blocks of time, with day/evening de-
fined as 7:00 AM to 10:59 PM and night as 11:00 PM to 6:59 AM.
Weekdays were defined as 7:00 AM on Monday until 10:59 PM
on Friday, and weekends were defined as 11:00 PM on Friday
to 6:59 AM on Monday.
7
Using time of day (day/eveningvs night)
and weekend/weekdayc ategories,we compared primary (sur-
vival to hospital discharge) and secondary outcome variables
using the χ
2
test. We applied locally weighted scatterplot
smoothing regression methods to confirm the time of break-
ing point for sensitivity analyses.
Secondary Analysis
To compare outcomes during days vs nights, we chose to ag-
gregate and compare 7-hour epochs from 9 AM to 4 PM vs mid-
night to 7 AM as time frames that would consistently be con-
sidered days and nights irrespectiveof hospital staffing patterns.
Again, using time of day (day vs night)and weekend/weekday
categories, we compared survival to hospital discharge among
children. Monday to Fridaywere considered as weekdays, and
Saturday and Sunday were considered as weekends. For the
nights, Monday to Thursday wereconsidered weekdays, while
Friday to Sunday were considered weekends.
Key Points
Question Do survival rates after pediatric in-hospital cardiac
arrests differ during nights and weekends compared with
days/evenings and weekdays?
Findings In this national registry-based cohort study of
hospitalized children younger than 18 years of age receiving
cardiopulmonary resuscitation (CPR), the rate of survival to
hospital discharge was 36.2% (4488 of 12 404 children) overall.
After adjusting for important potential confounders, we found that
the rate of survival to hospital discharge was significantly lower
during nights than during days/evenings, but there was no
difference between weekends and weekdays.
Meaning The rate of survival to hospital discharge was lower for
pediatric CPR events occurring at night than for CPR events
occurring during daytime and evening hours.
Research Original Investigation Survival Rates After Pediatric In-Hospital Cardiac Arrests During Nights and Weekends
40 JAMA Pediatrics January 2017 Volume 171, Number 1 (Reprinted) jamapediatrics.com
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Statistical Analysis
Multivariable logistic regression models were used to exam-
ine the effect of independent variables on survival to hospital
discharge, 24-hour survival, and return of circulation. Selec-
tion of a priori variables was based on previous literature and
included age, first documented rhythm, location of event in
hospital, extracorporeal CPR, and hypotension as the cause of
arrest.
17
The final multivariable model was developed by fit-
ting bivariate generalized estimating equation (GEE) models
for each potential confounder and including the variable in the
subsequent stage of analysis if the statistical significance was
P≤ .10 for the primary outcome. Notably, the GEE model ac-
counts for clustering by site. Next, all of these selected vari-
ables were included in a multivariable GEE model for each time
of day and weekday/weekend exposure. If a variable re-
mained statistically significant at a level of P≤ .15 for the pri-
mary outcome, it was incorporated into the final multivari-
able model. We included patient’s sex in the final multivariable
GEE models, although it did not meet all of the criteria al-
ready described.
The final multivariable GEE model for survival to dis-
charge included several potential confounders: age; sex;race;
illness category; preexisting sepsis; hypotension as the cause
of arrest; metabolic or electrolyte disturbance; location of event
in hospital; electrocardiographic monitoring; presence of ar-
terial lines; central venous access or mechanical ventilation at
the time of the cardiac arrest; vasoactive infusions of dobuta-
mine, dopamine, or epinephrine; first documented rhythm;
duration of CPR; epinephrine use; extracorporeal CPR; and the
use of pharmacologic interventions of atropine, sodium bicar-
bonate, calcium chloride, or gluconate and lidocaine.
All Pvalues are 2 sided with a significance level set at .05.
Statistical analyses were performed using SAS version 9.3 (SAS
Institute Inc).
Results
There were 12 404 index pediatric CPR events thatmet the in-
clusion criteria over the 12-year, 11-month period. Of these
events, 8568 occurred during daytime or evening hours, and
3836 occurred at night. Weekday cardiac arrests (between 7 AM
on Monday to 11 PM on Friday) accounted for 8586 events, and
the remaining 3818 cardiac arrests occurred on weekends. The
354 hospitals contributing data during this time period had a
median size of 333 beds (interquartile range, 219-499 beds),
including 16 that were self-classified as “freestanding” chil-
dren’s hospitals.
Patients’ characteristics, presented by time of day (day/
evening vs night), are outlined in Table 1. Patients experienc-
ing a CPR event at night were not different from those expe-
riencing an event during the day with respect to age, sex,
hypotensive cause of the cardiac arrest, or first documented
rhythm. A higher percentage of patients had their CPR event
in an intensive care setting at night compared with in the day/
evening. However, fewer patients had a witnessed event at
night. Patients’ characteristics, presented by day of the week
(weekday vs weekend), are outlined in Table 1. Patients expe-
riencing a CPR event on weekends were not different from
those experiencing an event during weekdays with respect to
age, sex, hypotensive cause of the cardiac arrest, or first docu-
mented rhythm. A higher percentage of patientshad their CPR
event in an intensivec are settingon weekends compared with
on weekdays, yet fewer had a witnessed event on weekends.
Of 12 404 children, 8731 (70.4%) experienced a return of
circulation lasting more than 20 minutes, 7248 (58.4%) sur-
vived for 24 hours, and 4488 (36.2%) survived to hospital dis-
charge. The unadjusted rate of survival to hospital discharge
was lower for children who had a CPR event occurring atnight
(1300 of 3836 [33.9%]) than for children who had a CPR event
occurring during the day or evening (3188 of 8568 [37.2%])
(P< .001). Similarly, the unadjusted rate of survival to hospi-
tal discharge was lower on weekends (1266 of 3818 children
[33.2%]) than weekdays (3222 of 8586 children [37.5%])
(P< .001). Survival to hospital discharge is characterized by
the hour of the day in Figure 1 and by the day of the week in
Figure 2, with worse outcomes on Saturday and Sunday.
After adjusting for potential confounders, we found that
the rate of survival to hospital discharge remained lower at
night than during the day/evening (adjusted odds ratio [OR],
0.88 [95% CI, 0.80-0.97]; P= .007). Although the absolute rate
of survival to hospital discharge remained lower on week-
ends than on weekdays, this difference did not reach statisti-
cal significance (adjusted OR, 0.92 [95% CI, 0.84-1.01]; P= .09).
Adjusted rates of 24-hour survival were lower at night than
during the day/evening (adjusted OR, 0.80 [95% CI, 0.73-
0.87]; P< .001) and were lower during the weekends than dur-
ing the weekdays (adjusted OR, 0.87 [95% CI, 0.78-0.97];
P= .01). Return of circulation was not significantly different
at night compared with during the day/evening and was not
significantly different during weekends compared with week-
days (Table 2 and Table 3). Using locally weighted scatterplot
smoothing regression methods, we identified 7 PM as an ap-
propriate breaking point for sensitivity analyses.
When categorized as the 7-hour daytime epoch (9 AM to
4PM) and the 7-hour nighttime epoch (midnight to 7 AM)in
secondary analysis, 3797 CPR events occurred during the
daytime epoch, and 3298 CPR events occurred during the
nighttime epoch. The unadjusted rate of survival to hospital
discharge was lower for children who had CPR events during
the 7-hour nighttime epoch than during the 7-hour daytime
epoch (33.4% [1102 of 3298] vs 39.1% [1485 of 3797]; P< .001).
After adjusting for a priori (age, first documented rhythm,
location of event in hospital, extracorporeal CPR, and hypo-
tensive cause of arrest) and all known potential confounders,
we found that the rate of survival to hospital discharge was
lower during nighttime epochs than during daytime epochs
(adjusted OR, 0.85 [95% CI, 0.76-0.95]; P= .005).
The unadjusted rate of survival to hospital discharge was
lower during weekend daytime epochs than during weekday
daytime epochs (33.1% [309 of 933 children] vs 41.1% [1176 of
2864 children]; P< .001). However, the rate of surviv al to hos-
pital discharge was not demonstrably different on weekend
nighttime epochs compared with weekday nighttime epochs
(32.9% [602 of 1828 children] vs 34.0% [500 of 1470 chil-
dren]; P= .51). After adjusting for potential confounders, we
Survival Rates After Pediatric In-Hospital Cardiac Arrests During Nights and Weekends Original Investigation Research
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found that the difference in the rate of survival to hospital dis-
charge approached significance between weekend daytime ep-
ochs and weekday daytime epochs (adjusted OR, 0.85 [95%
CI, 0.70-1.02]; P= .07) but not between weekend nighttime ep-
ochs and weekday nighttime epochs (adjusted OR, 0.94 [95%
CI, 0.79-1.12]; P= .51).
Discussion
In the large, prospective GWTG-R in-hospital cardiac arrest
registry, the rate of survival to hospital discharge was lower
for pediatric CPR events occurring at night than for CPR
events occurring during daytime and evening hours, even
after adjusting for many potentially confounding patient-,
event-, and hospital-related factors. The lower survival rate
among these children whose cardiac arrests occurred at
nighttime are consistent with the lower survival rates among
adults whose in-hospital cardiac arrests occurred at night-
time.
7
In addition, a recent pediatric out-of-hospital
investigation
12
showed a lower rate of survival to hospital dis-
charge when the cardiac arrest occurred at nighttime despite
no difference in the rate of return of spontaneous circulation
at nighttime. Kitamura et al
12
postulated that the differences
in survival may have been related to differences in postresus-
citation care once the patients arrived in the hospital. Similar
Table 1. Description of Study Sample, Excluding Delivery Room, Obstetric, and Other/Visitor Events
Variable
All Patients,
No. (%)
Patients, No. (%)
PValue
Patients, No. (%)
PValueDay/Evening Night Weekday Weekend
Total 12 404 8568 3836 8586 3818
Age, median (IQR), y 0.3 (0.0-2.4) 0.3 (0.0-2.4) 0.2 (0.0-2.4) .05 0.3 (0.0-2.2) 0.3 (0.0-3.0) .21
Sex
Male 6932 (56.0) 4804 (56.2) 2128 (55.6)
.55
4783 (55.8) 2149 (56.5)
.48
Female 5448 (44.0) 3748 (43.8) 1700 (44.4) 3791 (44.2) 1657 (43.5)
Race
White 6482 (52.6) 4499 (52.9) 1983 (52.1)
.75
4527 (53.1) 1955 (51.6)
.02
African American 3110 (25.2) 2137 (25.1) 973 (25.5) 2164 (25.4) 946 (25.0)
Asian/Pacific Islander 265 (2.2) 177 (2.1) 88 (2.3) 163 (1.9) 102 (2.7)
Other/unknown/not documented 2461 (20.0) 1696 (19.9) 765 (20.1) 1677 (19.7) 784 (20.7)
Event location (3-level)
ICU 9724 (78.4) 6565 (76.6) 3159 (82.4)
<.001
6627 (77.2) 3097 (81.1)
<.001
ED 821 (6.6) 580 (6.8) 241 (6.3) 521 (6.1) 300 (7.9)
General, inpatient 444 (3.6) 302 (3.5) 142 (3.7) 324 (3.8) 120 (3.1)
Other 1413 (11.4) 1120 (13.1) 293 (7.6) 1112 (13.0) 301 (7.9)
Illness category
Medical–cardiac 1786 (14.4) 1246 (14.6) 540 (14.1)
<.001
1255 (14.6) 531 (13.9)
<.001
Medical–noncardiac 4290 (34.6) 2924 (34.1) 1366 (35.6) 2936 (34.2) 1354 (35.5)
Surgical–cardiac 2177 (17.6) 1575 (18.4) 602 (15.7) 1615 (18.8) 562 (14.7)
Surgical–noncardiac 943 (7.6) 704 (8.2) 239 (6.2) 690 (8.0) 253 (6.6)
Newborn 2482 (20.0) 1637 (19.1) 845 (22.0) 1678 (19.6) 804 (21.1)
Trauma 720 (5.8) 477 (5.6) 243 (6.3) 406 (4.7) 314 (8.2)
Immediate factor related to event
Acute respiratory insufficiency 5639 (50.4) 3840 (49.6) 1799 (52.3) .008 3838 (49.6) 1801 (52.1) .02
Hypotension 5531 (49.4) 3826 (49.4) 1705 (49.6) .86 3787 (49.0) 1744 (50.5) .14
First documented pulseless rhythm
Asystole 2671 (35.4) 1807 (34.7) 864 (37.0)
.40
1806 (34.6) 865 (37.3)
.04
PEA 2837 (37.6) 1984 (38.1) 853 (36.5) 1966 (37.7) 871 (37.5)
PVT 368 (4.9) 251 (4.8) 117 (5.0) 270 (5.2) 98 (4.2)
VF 458 (6.1) 319 (6.1) 139 (6.0) 336 (6.4) 122 (5.3)
Unknown/not documented 1204 (16.0) 841 (16.2) 363 (15.5) 839 (16.1) 365 (15.7)
Discovery status at time of event
Witnessed arrest 11 749 (94.8) 8144 (95.1) 3605 (94.0) .02 8158 (95.1) 3591 (94.1) .02
Monitored via electrocardiography 11 617 (93.7) 8015 (93.6) 3602 (93.9) .41 8037 (93.6) 3580 (93.8) .79
CPR, No. of patients 11 759 8122 3637 8128 3631
Duration of CPR, median (IQR),
min
12.0 (5.0-28.0) 12.0 (4.0-27.0) 13.0 (5.0-30.0) <.001 12.0 (4.0-28.0) 12.0 (5.0-28.0) .54
Abbreviations: CPR, cardiopulmonary resuscitation; ED, emergency department; ICU, intensive care unit; IQR, interquartile range; PEA, pulseless electrical activity;
PVT, pulseless ventricular tachycardia;VF, ventricular fibrillation.
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findings of lower survival at night were noted for adult out-of-
hospital cardiac arrests.
8
Lower survival rates at nighttime are an important, yet un-
derrecognized public health concern. This is especially perti-
nent because suboptimal resuscitative efforts are a poten-
tially preventable harm.
18
Assuming an annual CPR rate of
6000 events per year, we found that simply improving over-
all survival (currently at 36.2%) to match the weekday day-
time epoch survival (41.1%) would result in almost 300 addi-
tional children’s lives saved per year in the UnitedStates. These
findings may have important implications for hospital staff-
ing, training, and resource allocation.
Although the results of our study are concerning, they are
not entirely surprising because they align with pediatric lit-
erature demonstrating worse outcomes for critically ill chil-
dren admitted to pediatric intensivec are unitsduring the eve-
ning and nighttime,
19
as well as for newborns who may require
resuscitation.
20,21
Interestingly, the study by Stewart et al
21
also
demonstrated worse outcomes for newborns during the
months of July and August when staffing of hospitals is typi-
cally reduced and when more senior physicians are less likely
to be present.
Potential causes for the decreased survival rate after pe-
diatric cardiac arrest at night are important to identify. Hos-
pitals tend to have fewer senior health care professionals
22
and
more junior health care professionals working at night,
23
per-
haps influencing the recognition and response to deteriorat-
ing patients and those experiencing cardiac arrest. In addi-
tion, medical error is more common,
24
and there is reduced
proficiency in performing psychomotor skills
25
at night. None-
theless, performance in other appropriately staffed and re-
sourced time-sensitive domains, such as trauma,
26
has over-
come the so-called weekend effect. In the GWTG-R adult study
7
comparing survival after in-hospital cardiac during daytime/
evenings vs nights, survival rates were only similar for the 2
time periods in the emergency department and trauma ser-
vice—2 domains that tend to have more consistent coverage
with titrated staffing patterns and the presence of attending
physicians throughout the day, evening, and night.
Similarly, the rates of return of spontaneous circulation
were not different between nights and weekendsin the study
on pediatric out-of-hospital cardiac arrests, whereas the rates
of 30-day survival were.
12
Again, these data on pediatric out-
of-hospital cardiac arrests suggest that the “night” and “week-
end” effects may have been overcomein the emergency medi-
cal services system but not in the hospital system.
Limitations
Our study has several limitations that should be considered
when interpreting the results. Participation in the GWTG-R reg-
istry is voluntary,w ith the potential for a selection bias of par-
ticipating centers that could limit extrapolation.
27
The data
were accumulated over a long time period, from 2000 to 2012,
when secular trends in resuscitation education and practice
may have taken place, which might have masked some diur-
nal or weekday/weeknight variation. Second, the large GWTG-R
Figure 1. Rate of Survival to Hospital Discharge by Hour of Day
When Cardiopulmonary Resuscitation Occurred
20 30 5040
Unadjusted Survival
Rate, % (95% CI)
Unadjusted Survival,
No./Total No. (%)Hour Low Rate High Rate
07:00 144/466 (30.9)
08:00 210/548 (38.3)
09:00 281/565 (38.6)
10:00 216/536 (40.3)
11:00 203/536 (37.9)
12:00 194/543 (35.7)
01:00 226/545 (41.5)
02:00 218/556 (39.2)
03:00 210/516 (40.7)
04:00 220/568 (38.7)
05:00 183/495 (37.0)
06:00 220/535 (41.1)
07:00 176/542 (32.5)
08:00 213/587 (36.3)
09:00 190/542 (35.1)
10:00 147/488 (30.1)
11:00 198/538 (36.8)
12:00 171/530 (32.3)
01:00 145/449 (32.3)
02:00 161/480 (33.5)
03:00 150/439 (34.2)
04:00 157/475 (33.1)
05:00 175/481 (36.4)
06:00 143/444 (32.2)
Day/evening
Night
Figure 2. Rate of Survival to Hospital Discharge by Day of Week
When Cardiopulmonary Resuscitation Occurred
0 30 5020 40
Unadjusted Survival Rate, % (95% CI)
10
Day
Unadjusted Survival,
No./Total No. (%)
Monday 608/1711 (35.5)
Tuesday 616/1711 (36.0)
Wednesday 718/1920 (37.4)
Thursday 727/1873 (38.8)
Friday 718/1860 (38.6)
Saturday 572/1734 (33.0)
Sunday 529/1595 (33.2)
Weekdays
Weekends
Table 2. Survival Outcomes at Night vs Day/Evening
Outcome Adjusted OR (95% CI) PValue
Survival to hospital discharge 0.88 (0.80-0.97) .007
Survival to 24 h 0.80 (0.73-0.87) <.001
Return of circulation 0.89 (0.79-1.01) .06
Abbreviation: OR, odds ratio.
Table 3. SurvivalOutcomes on Weekends vs Weekdays
Outcome Adjusted OR (95% CI) PValue
Survival to hospital discharge 0.92 (0.84-1.01) .09
Survival to 24 h 0.87 (0.78-0.97) .01
Return of circulation 1.00 (0.89-1.12) .97
Abbreviation: OR, odds ratio.
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data set, based on the Utstein template, allows for the adjust-
ment for a large number of potential confounders but cannot
account for unmeasured confounding variables. Third, the pri-
mary outcome variable in this study was survival to hospital
discharge. Unfortunately, neurological outcome data were fre-
quently missing for patients included in this study, thereby lim-
iting our ability to address this important outcomew ithout po-
tential biases. Fourth, although the study does highlight an
important public health concern, it does not identify the un-
derlying causes for the differences in survival.
Future research might explore the effect of hospital staff-
ing, better patient monitoringw ithearlier detection of decom-
pensation, the presence of a rapid response team, the quality of
CPR,
28-30
post-event quantitativedebriefing,
31,32
and postarrest
management (eg, targetedtemperature management or hemo-
dynamic support
33
) on the differential survival during day/
evening vs night. Although these observational findings do not
identify the specific mechanisms that will eliminate disparity
in night vs day survival, they may have important implications
for hospital staffing, training, and resource allocation. Of note,
the absolute difference in witnessed cardiac arrests was relatively
small at night compared with during the day/evening(1.1%), even
though it was statistically significant. An alternative explana-
tion of the day-nightdifference is that there are different patholo-
gies operating at night.A formal cost-benefit or cost-effectiveness
study would be required to assess the cost, personnel, and edu-
cation that would be required to achieve daytime/nighttime and
weekday/weekend parity in survival outcomes.
A final limitation of the study may have been the lack of
power to demonstrate differences in outcomes on weekends.
The absolute rate of survival during the weekend daytime (33%)
was lower than during the weekday daytime (41%) and was
quite similar to the absolute rate of survival during the week-
day nighttime (34%).Nevertheless, the adjusted OR for week-
end daytime survival to hospital discharge was 0.85 (95% CI,
0.70-1.02) (P= .07). We speculate that the much smaller num-
ber of patients in this pediatric GWTG-R study may have
masked the true difference in outcomes on weekends in con-
trast to the adult GWTG-R study that showed worse out-
comes on weekend daytimes.
7
Conclusions
In this large, prospective GWTG-R in-hospital cardiac arrest reg-
istry, the rate of survival to hospital discharge was lower for
pediatric patients who experienced CPR events at night than
for those who experienced CPR events during daytimeand eve-
ning hours, even after adjusting for important potentiallycon-
founding patient-, event-, and hospital-related factors. Al-
though the absolute rate of survival to hospital discharge was
lower on weekends than weekdays, this difference did not
reach statistical significance when adjusted for confounding
factors. Discrepancy between daytime and nighttime out-
comes represents an important patientsafety concern that war-
rants further investigation.
ARTICLE INFORMATION
Accepted for Publication: July 18, 2016.
Published Online: November 7, 2016.
doi:10.1001/jamapediatrics.2016.2535
Author Affiliations: Centre for Medical Education
and Department of Pediatrics, McGill University,
Montreal, Quebec, Canada (Bhanji); Royal College
of Physicians and Surgeons of Canada, Ottawa,
Ontario, Canada (Bhanji); Departments of
Anesthesia and Critical Care Medicine and of
Pediatrics, The Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania (Topjian, Nadkarni,
Meaney,Berg ); University of Pennsylvania
Perelman School of Medicine, Philadelphia (Topjian,
Nadkarni, Praestgaard, Meaney, Berg);
Departments of Anesthesiology and Critical Care
Medicine and of Pediatrics, Johns Hopkins
University School of Medicine, Baltimore, Maryland
(Hunt); Department of Pediatrics, Alberta
Children’s Hospital, Calgary, Alberta, Canada
(Cheng).
Author Contributions: Dr Bhanji and Ms
Praestgaard had full access to all of the data in the
study and take responsibility for the integrity of the
data and the accuracy of the data analysis.
Concept and design: Bhanji, Nadkarni, Hunt, Cheng,
Meaney,Berg.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: Bhanji, Topjian,
Nadkarni, Praestgaard, Meaney.
Critical revision of the manuscript for important
intellectual content: Topjian, Nadkarni, Praestgaard,
Hunt, Cheng, Meaney, Berg.
Statistical analysis: Bhanji, Praestgaard, Meaney.
Obtaining funding: Nadkarni.
Administrative, technical, or material support:
Cheng, Berg.
Study supervision: Nadkarni, Cheng, Meaney,Berg.
Conflict of Interest Disclosures: None reported.
Group Information: The American Heart
Association’s Get With the Guidelines–Resuscitation
Investigators were Tia T. Raymond, MD, Medical
City Children’s Hospital; Alexis A. Topjian, MD,
MSCE, Elizabeth Foglia, MD, MA, Vinay Nadkarni,
MD, and Robert Sutton, MD,The Children’s Hospital
of Philadelphia; Emilie Allen, MSN, RN, CCRN,
Parkland Health and Hospital System; Melania
Bembea, MD, MPH, Johns Hopkins University
School of Medicine; Ericka Fink, MD, University of
Pittsburgh School of Medicine; Michael G. Gaies,
MD, MPH, University of Michigan; Anne-Marie
Guerguerian, MD, PhD, and Chris Parshuram,MB,
ChB, DPhil, The Hospital for Sick Children; Monica
Kleinman, MD, Boston Children’sHospital; Lynda J.
Knight, RN, CCRN, CPN, Stanford Children’s Health
Hospital; Peter C. Laussen, MBBS, University of
Toronto; Taylor Sawyer,DO, MEd, Seattle Children’s
Hospital; and Stephen M. Schexnayder,MD,
Arkansas Children’s Hospital.
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