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Abstract

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 (12 404 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 P ≤ .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.
Copyright 2017 American Medical Association. All rights reserved.
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
P.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.
Research Original Investigation Survival Rates After Pediatric In-Hospital Cardiac Arrests During Nights and Weekends
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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.
Survival Rates After Pediatric In-Hospital Cardiac Arrests During Nights and Weekends Original Investigation Research
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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.
REFERENCES
1. Knudson JD, Neish SR, Cabrera AG, et al.
Prevalence and outcomes of pediatric in-hospital
cardiopulmonary resuscitation in the United States:
an analysis of the Kids’ Inpatient Database. Crit Care
Med. 2012;40(11):2940-2944.
2. MolerFW, Meert K, Donaldson AE, et al;
Pediatric Emergency Care Applied Research
Network. In-hospital versus out-of-hospital
pediatric cardiac arrest: a multicenter cohort study.
Crit Care Med. 2009;37(7):2259-2267.
3. ReisAG, Nadkarni V, Perondi MB, Grisi S, Berg RA.
A prospective investigation into the epidemiology of
in-hospital pediatric cardiopulmonary resuscitation
using the international Utstein reporting style.
Pediatrics. 2002;109(2):200-209.
4. KleinmanME, Chameides L , SchexnayderSM,
et al. Part 14: pediatric advanced life support: 2010
American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Circulation. 2010;122(18)(suppl
3):S876-S908.
5. GirotraS, Spertus JA, Li Y, Berg RA, Nadkarni VM,
Chan PS; American Heart Association Get With the
Guidelines–Resuscitation Investigators. Survival
trends in pediatric in-hospital cardiac arrests: an
analysis from Get With the Guidelines-Resuscitation.
Circ Cardiovasc Qual Outcomes. 2013;6(1):42-49.
6. Jayaram N, Spertus JA, Nadkarni V,et al;
American Heart Association’s Get with the
Guidelines–Resuscitation Investigators. Hospital
variation in survival after pediatric in-hospital
cardiac arrest. Circ Cardiovasc Qual Outcomes.
2014;7(4):517-523.
7. Peberdy MA, Ornato JP, Larkin GL, et al; National
Registry of Cardiopulmonary Resuscitation
Investigators. Survival from in-hospital cardiac
arrest during nights and weekends. JAMA. 2008;
299(7):785-792.
Research Original Investigation Survival Rates After Pediatric In-Hospital Cardiac Arrests During Nights and Weekends
44 JAMA Pediatrics January 2017 Volume 171, Number 1 (Reprinted) jamapediatrics.com
Copyright 2017 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 10/19/2022
Copyright 2017 American Medical Association. All rights reserved.
8. BagaiA, McNally BF, Al-Khatib SM, et al.
Temporaldifferences in out-of-hospital cardiac
arrest incidence and survival. Circulation. 2013;128
(24):2595-2602.
9. Wallace SK, Abella BS, Shofer FS, et al. Effect of
time of day on prehospital care and outcomes after
out-of-hospital cardiac arrest. Circulation. 2013;127
(15):1591-1596.
10. KarlssonLI, Wissenberg M, Fosbøl EL, et al.
Diurnal variations in incidence and outcome of
out-of-hospital cardiac arrest including prior
comorbidity and pharmacotherapy: a nationwide
study in Denmark. Resuscitation. 2014;85(9):1161-1168.
11. Koike S, TanabeS, Ogawa T, et al. Effect of time
and day of admission on 1-month survival and
neurologically favourable 1-month survival in
out-of-hospital cardiopulmonary arrest patients.
Resuscitation. 2011;82(7):863-868.
12. Kitamura T, KiyoharaK, Nitta M, Nadkarni VM,
Berg RA, Iwami T.Survival following witnessed
pediatric out-of-hospital cardiac arrests during
nights and weekends. Resuscitation. 2014;85(12):
1692-1698.
13. CumminsRO, Chamberlain D, Hazinski MF, et al;
American Heart Association. Recommended
guidelines for reviewing, reporting, and conducting
research on in-hospital resuscitation: the
in-hospital ‘Utstein style’. Circulation. 1997;95(8):
2213-2239.
14. JacobsI, Nadkarni V, Bahr J, et al; International
Liaison Committee on Resuscitation; American Heart
Association; European Resuscitation Council;
Australian Resuscitation Council; New Zealand
Resuscitation Council; Heart and Stroke Foundation
of Canada; InterAmerican Heart Foundation;
Resuscitation Councils of Southern Africa; ILCOR
Task Forceon Cardiac Arrest and Cardiopulmonary
Resuscitation Outcomes. Cardiac arrest and
cardiopulmonary resuscitation outcome reports:
update and simplification of the Utstein templates
for resuscitation registries: a statement for
healthcare professionals from a task force of the
International Liaison Committee on Resuscitation
(American Heart Association, European
Resuscitation Council, Australian Resuscitation
Council, New Zealand Resuscitation Council, Heart
and Stroke Foundation of Canada, InterAmerican
Heart Foundation, Resuscitation Councils of
Southern Africa). Circulation. 2004;110(21):3385-3397.
15. PeberdyMA, Kaye W, Ornato JP,et al.
Cardiopulmonary resuscitation of adults in the
hospital: a report of 14720 cardiac arrests from the
National Registry of Cardiopulmonary Resuscitation.
Resuscitation. 2003;58(3):297-308.
16. OrtmannL , Prodhan P, Gossett J,et al;
American Heart Association’s Get With the
Guidelines–Resuscitation Investigators. Outcomes
after in-hospital cardiac arrest in children with
cardiac disease: a report from Get With the
Guidelines–Resuscitation. Circulation. 2011;124(21):
2329-2337.
17. MeaneyPA, Nadkarni VM, Cook EF, et al;
American Heart Association National Registry of
Cardiopulmonary Resuscitation Investigators.
Higher survival rates among younger patients after
pediatric intensive care unit cardiac arrests. Pediatrics.
2006;118(6):2424-2433.
18. MeaneyPA, Bobrow BJ, Mancini ME, et al; CPR
Quality Summit Investigators, the American Heart
Association Emergency Cardiovascular Care
Committee, and the Council on Cardiopulmonary,
Critical Care, Perioperative and Resuscitation.
Cardiopulmonary resuscitation quality: improving
cardiac resuscitation outcomes both inside and
outside the hospital: a consensus statement from
the American Heart Association [published
corrections appear in Circulation. 2013;128(8):e120
and 128(2):e408]. Circulation. 2013;128(4):417-435.
19. AriasY, Taylor DS, Marcin JP. Association
between evening admissions and higher mortality
rates in the pediatric intensive care unit. Pediatrics.
2004;113(6):e530-e534.
20. HellerG, Misselwitz B, Schmidt S. Early
neonatal mortality, asphyxia related deaths, and
timing of risk births in Hesse, Germany, 1990-8:
observational study.BMJ. 2000;321(7256):274-275.
21. Stewart JH, Andrews J, Cartlidge PH. Numbers
of deaths related to intrapartum asphyxia and
timing of birth in all Wales perinatal survey,1993-5.
BMJ. 1998;316(7132):657-660.
22. NeedlemanJ, Buerhaus P, Mattke S,Stewart M,
Zelevinsky K. Nurse-staffing levels and the quality
of care in hospitals. N Engl J Med. 2002;346(22):
1715-1722.
23. Folkestad L, Brabrand M, Hallas P. Supervision
of junior doctors and allocation of work tasks
regarding admissions and further treatment of
acute admitted patients [in Danish]. Ugeskr Laeger.
2010;172(22):1662-1666.
24. HendeyGW, Barth BE, Soliz T. Overnight and
postcall errors in medication orders. Acad Emerg Med.
2005;12(7):629-634.
25. Kuhn G. Circadian rhythm, shift work, and
emergency medicine. Ann Emerg Med. 2001;37(1):
88-98.
26. CarrBG, Jenkins P, Branas CC, et al. Does the
trauma system protect against the weekend effect?
J Trauma. 2010;69(5):1042-1047.
27. BradleySM, Huszti E, Warren SA, Merchant RM,
Sayre MR, Nichol G. Duration of hospital participation
in Get With the Guidelines–Resuscitation and survival
of in-hospital cardiac arrest. Resuscitation. 2012;83
(11):1349-1357.
28. Sutton RM, French B, Niles DE, et al. 2010
American Heart Association recommended
compression depths during pediatric in-hospital
resuscitations are associated with survival.
Resuscitation. 2014;85(9):1179-1184.
29. AbellaBS, Sandbo N, Vassilatos P, et al. Chest
compression rates during cardiopulmonary
resuscitation are suboptimal: a prospective study
during in-hospital cardiac arrest. Circulation. 2005;
111(4):428-434.
30. ChristensonJ, Andrusiek D, Everson-StewartS,
et al; Resuscitation Outcomes Consortium
Investigators. Chest compression fraction determines
survival in patients with out-of-hospital ventricular
fibrillation. Circulation. 2009;120(13):1241-1247.
31. Wolfe H, Zebuhr C, Topjian AA, et al.
Interdisciplinary ICU cardiac arrest debriefing
improves survival outcomes. Crit Care Med. 2014;
42(7):1688-1695.
32. EdelsonDP, Litzinger B, Arora V, et al.
Improving in-hospital cardiac arrest process and
outcomes with performance debriefing. Arch Intern
Med. 2008;168(10):1063-1069.
33. Topjian AA, French B, Sutton RM, et al. Early
postresuscitation hypotension is associated with
increased mortality following pediatric cardiac
arrest. Crit Care Med. 2014;42(6):1518-1523.
Survival Rates After Pediatric In-Hospital Cardiac Arrests During Nights and Weekends Original Investigation Research
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... These difference in the survivals between this study and other studies in sub-Saharan countries may be because this study was conducted in a facility with advanced pediatric life support training, and with more resuscitation resources. We found a very low survival to hospital discharge at only 5% is a low rate than most reported studies in medium and high-income countries [9][10][11][12][13], we believe this finding is contributed by inadequate post resuscitation care after the initial survival, also delayed presentation, and advanced pathophysiology of underlying diseases at presentation. ...
... Patients who had IHCA during the daytime and evening hours were more likely to survive at 24 h compared to those who had cardiac arrest during nighttime. The lower survival rate among patients who had cardiac arrests at nighttime are consistent with other studies [9,11,14]. Lower survival rate at nighttime is an important, yet underrecognized concern. In our hospital, there is only one attending physician available during nighttime, and the resuscitation rooms are shared by residents and medical officers. ...
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Background Cardiopulmonary resuscitation (CPR) is an emergency procedure performed to restore heart function to minimize anoxic injury to the brain following cardiac arrest. Despite the establishment of emergency department and training on Pediatric Advanced Life Support (PALS) at Muhimbili National Hospital (MNH) the outcomes of pediatric in-hospital cardiac arrest have not been documented. We ought to determine the outcomes and factors associated with 24-h survival after pediatric in-hospital cardiac arrests at MNH in Tanzania. Methods We conducted a retrospective study of all patients aged 1 month to 18 years who had in-hospital cardiac arrests (IHCA) prompting CPR in the Emergency Medicine Department (EMD) at MNH, Tanzania from January 2016 to December 2019. Data was collected from electronic medical record (Wellsoft) system using a standardized and pretested data collection form that recorded clinical baseline, pre-arrest, arrest, and post-arrest parameters. Bivariate and multivariable logistic regression analyses were performed to assess the influence of each factor on 24-h survival. Results A total of 11,951 critically ill patients were screened, and 257 (2.1%) had cardiac arrest at EMD. Among 136 patients enrolled, the median age was 1.5 years (interquartile range: 0.5–3 years) years, and the majority 108 (79.4%) aged ≤ 5 years, and 101 (74.3%) had been referred from peripheral hospitals. Overall stained return of spontaneous circulation was achieved in 70 (51.5%) patients, 24-h survival was attained in 43 (31.3%) of patients, and only 7 patients (5.2%) survived to hospital discharge. Factors independently associated with 24-h survival were CPR event during the day/evening (p = 0.033), duration of CPR ≤ 20 min (p = 0.000), reversible causes of cardiac arrest being identified (p = 0.001), and having assisted/mechanical ventilation after CPR (p = 0.002). Conclusion In our cohort of children with cardiac arrest, survival to hospital discharge was only 5%. Factors associated with 24-h survival were CPR events during the daytime, short duration of CPR, recognition of reversible causes of cardiac arrest, and receiving mechanical ventilation. Future studies should explore the detection of decompensation, the quality of CPR, and post-cardiac arrest care on the outcomes of IHCA.
... This decrease in mortality can be attributed to a reduction in infectious causes of death and improvements in health and care promotion. [1][2][3][4] Still, most of these deaths could have been prevented through actions involving diagnosis, early treatment, and reversibility of the final mechanism of death, i.e., cardiopulmonary arrest (CPA). 1 The CPA etiology differs between the pediatric and adult populations, with greater mortality and severe neurological sequelae in the former. In pediatric patients, CPA events occur mostly below the age of 1 year and are associated with a mortality rate of 46.8%. ...
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Background There is a growing body of literature that suggests increased rates of morbidity and mortality for pediatric conditions admitted on a weekend compared with weekdays. Whether this association is seen in Nigerian children presenting with neurologic emergencies is not certain. Understanding the effect of weekend admission on the outcome of pediatric neurologic emergencies is important to allocate personnel and resources more efficiently. This study was conducted to determine whether weekend and out-of-hour duty affect the outcome of neurological emergencies in children. Subjects and Methods This study used a cross-sectional analytic design over an 18-month period. Children aged 1 month–18 years presenting with neurologic emergencies were prospectively recruited over an 18-month period. The association between the dependent variable and independent variables was tested using the Chi-squared test and odds ratio. The level of statistical significance was accepted as P < 0.05. Results A total of 146 children with neurologic emergencies were seen during the study period with 33.6% occurring on weekends. The average duration of stay (DOS) was 7.6 (±5.7) days. There was no difference in DOS between children based on the day of admission ( P = 0.241) or the hour of admission ( P = 0.155). Eleven (7.5%) of study subjects died during the study period. There was no difference in outcome based on day ([weekends – 6.1% vs. weekday – 8.2%] [ P = 0.896]) or hour of admission ([out-of-hour – 7.3% vs. working hours – 7.7%] [ P = 0.958]). Conclusions Weekend and out-of-hour duty does not affect the outcome of neurological emergencies in children.
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Objectives Data to support epinephrine dosing intervals during cardiopulmonary resuscitation (CPR) are conflicting. The objective of this study was to evaluate the association between epinephrine dosing intervals and outcomes. We hypothesized that dosing intervals less than 3 minutes would be associated with improved neurologic survival compared with greater than or equal to 3 minutes. Design This study is a secondary analysis of The ICU-RESUScitation Project (NCT028374497), a multicenter trial of a quality improvement bundle of physiology-directed CPR training and post-cardiac arrest debriefing. Setting Eighteen PICUs and pediatric cardiac ICUs in the United States. Patients Subjects were 18 years young or younger and 37 weeks old or older corrected gestational age who had an index cardiac arrest. Patients who received less than two doses of epinephrine, received extracorporeal CPR, or had dosing intervals greater than 8 minutes were excluded. Interventions The primary exposure was an epinephrine dosing interval of less than 3 vs. greater than or equal to 3 minutes. Measurements and Main Results The primary outcome was survival to discharge with a favorable neurologic outcome defined as a Pediatric Cerebral Performance Category score of 1–2 or no change from baseline. Regression models evaluated the association between dosing intervals and: 1) survival outcomes and 2) CPR duration. Among 382 patients meeting inclusion and exclusion criteria, median age was 0.9 years (interquartile range 0.3–7.6 yr) and 45% were female. After adjustment for confounders, dosing intervals less than 3 minutes were not associated with survival with favorable neurologic outcome (adjusted relative risk [aRR], 1.10; 95% CI, 0.84–1.46; p = 0.48) but were associated with improved sustained return of spontaneous circulation (ROSC) (aRR, 1.21; 95% CI, 1.07–1.37; p < 0.01) and shorter CPR duration (adjusted effect estimate, –9.5 min; 95% CI, –14.4 to –4.84 min; p < 0.01). Conclusions In patients receiving at least two doses of epinephrine, dosing intervals less than 3 minutes were not associated with neurologic outcome but were associated with sustained ROSC and shorter CPR duration.
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Purpose To evaluate the relationship between pre‐ and postoperative joint line convergence angle (JLCA) changes and patient‐reported outcome measures related to medial open‐wedge high tibial osteotomy (MOWHTO). Methods Sixty‐one patients (71 knees) who underwent MOWHTO were examined. Preoperative and 2‐year postoperative radiographic parameters (hip–knee–ankle angle, weight‐bearing line ratio, medial proximal tibial angle and JLCA) were measured, and knee injury and osteoarthritis outcome scores (KOOS) were assessed. Patients were divided into two groups: group D (decreased JLCA compared with preoperative status) included 44 knees with a ΔJLCA < 0° and group I (increased JLCA and no‐change JLCA compared with preoperative status) included 27 knees with a ΔJLCA ≥ 0°. KOOS sub‐scores and the proportion of patients whose improvement exceeded the minimum clinically important difference (MCID) were compared between both groups using Student's t tests, Mann–Whitney U tests and chi‐square tests. Multiple regression analysis was performed to determine the factor that had an influential effect on the postoperative KOOS total. Results Significant differences in 2‐year postoperative KOOS were observed between the two groups, including total, symptom, pain and activities of daily living scores. Group D had significantly more patients who achieved MCID for both KOOS symptoms and pain scores than group I did. Multivariate analysis indicated that JLCA change and body mass index were significantly associated with the postoperative KOOS total. Conclusion Patients with decreased JLCA had better 2‐year post‐MOWHTO KOOS and better symptom and pain improvements. Therefore, strategies that reduce JLCA are crucial to improving clinical outcomes, and efforts should be made to improve JLCA in surgical techniques. Level of Evidence Level Ⅳ, Case series.
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OBJECTIVES Rapid response system (RRS) activations resulting in emergency transfers (ETs) and codes outside the ICU are associated with increased mortality and length of stay. We aimed to evaluate the patient and care team characteristics of RRS activations resulting in ETs and codes outside the ICU (together classified as “deterioration events”) versus those that did not result in a deterioration event. METHODS For each RRS activation at our institution from 2019 to 2021, data were gathered on patient demographics and medical diagnoses, care team and treatment factors, and ICU transfer. Descriptive statistics, bivariate analyses, and multivariable logistic regression using a backward elimination model selection method were performed to assess potential risk factors for deterioration events. RESULTS Over the 3-year period, 1765 RRS activations were identified. Fifty-three (3%) activations were deemed acute care codes, 64 (4%) were noncode ETs, 921 (52%) resulted in nonemergent transfers to an ICU, and 727 (41%) patients remained in an acute care unit. In a multivariable model, any complex chronic condition (adjusted odds ratio, 6.26; 95% confidence interval, 2.83–16.60) and hematology/oncology service (adjusted odds ratio, 2.19; 95% confidence interval, 1.28–3.74) were independent risk factors for a deterioration event. CONCLUSIONS Patients with medical complexity and patients on the hematology/oncology service had a higher risk of deterioration events than other patients with RRS activations. Further analyzing how our hospital evaluates and treats these specific patient populations is critical as we develop targeted interventions to reduce deterioration events.
Article
BACKGROUND The structure and staffing of hospitals greatly impact patient outcomes, with frequent changes occurring during nights and weekends. This retrospective cohort study assessed the impact of admission timing on in-hospital management and outcomes for patients with stroke receiving reperfusion therapy in China using data from a nationwide registry. METHODS Data from patients receiving reperfusion therapy were extracted from the Chinese Stroke Center Alliance. Hospital admission time was categorized according to day/evening versus night and weekday versus weekend. Primary outcomes were in-hospital death or discharge against medical advice, hemorrhage transformation, early neurological deterioration, and major adverse cardiovascular events. Logistic regression was performed to compare in-hospital management performance and outcomes based on admission time categories. RESULTS Overall, 42 381 patients received recombinant tissue-type plasminogen activator (r-tPA) therapy, and 5224 underwent endovascular treatment (EVT). Patients admitted during nighttime had a higher probability of receiving r-tPA therapy within 4.5 hours from onset or undergoing EVT within 6 hours from onset compared with those admitted during day/evening hours (adjusted odds ratio, 1.04 [95% CI, 1.01–1.08]; P =0.021; adjusted odds ratio, 1.72 [95% CI, 1.59–1.86]; P <0.001, respectively). However, no significant difference was observed between weekend and weekday admissions for either treatment. No notable differences were noted between weekends and weekdays or nighttime and daytime periods in door-to-needle time for r-tPA or door-to-puncture time for EVT initiation. Furthermore, weekend or nighttime admission did not have a significant effect on the primary outcomes of r-tPA therapy or EVT. Nevertheless, in patients undergoing EVT, a higher incidence of pneumonia was observed among those admitted at night compared with those admitted during day/evening hours (adjusted odds ratio, 1.22 [95% CI, 1.05–1.42]; P =0.011). CONCLUSIONS Patients admitted at nighttime were more likely to receive r-tPA therapy or EVT within the time window recommended in the guidelines. However, patients receiving EVT admitted at night had an increased risk of pneumonia.
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Understanding temporal differences in the incidence and outcomes of out-of-hospital cardiac arrest (OHCA) has important implications for developing preventative strategies and optimizing systems for OHCA care. We studied 18,588 OHCAs of presumed cardiac etiology in patients ≥18 years who received resuscitative efforts by emergency medical services (EMS) and were enrolled in the Cardiac Arrest Registry to Enhance Survival (CARES) from 10/01/2005-12/31/2010. We evaluated temporal variability in OHCA incidence and survival to hospital discharge. There was significant variability in the frequency of OHCA by hour of the day (p<0.001), day of the week (p<0.001), and month of the year (p<0.001), with the highest incidence occurring during the daytime, from Friday to Monday, in December. Survival to hospital discharge was lowest for OHCA occurring overnight (2301-0700h; 7.1%) versus daytime (0701-1500h; 10.8%) versus evening (1501-2300h; 11.3%) (p<0.001), and during the winter (8.8%) versus spring (11.1%) versus summer (11.0%) versus fall (10.0%) (p<0.001). There was no difference in survival to hospital discharge between OHCA occurring on weekends and weekdays (9.5% vs. 10.4%, p=0.06). After multivariable adjustment for age, sex, race, witness status, layperson resuscitation, first monitored cardiac rhythm and EMS response time, compared with daytime and spring, survival to hospital discharge remained lowest for OHCA occurring overnight (OR 0.81, 95% CI 0.70-0.95, p=0.008) and during the winter (OR 0.81, 95% CI 0.70-0.94, p=0.006), respectively. There is significant temporal variability in the incidence of and survival after OHCA. The relative contribution of patient pathophysiology, likelihood of being observed, pre-hospital and hospital based resuscitative factors deserves further exploration.
Article
Background: The relationship between survival rate following pediatric out-of-hospital cardiac arrests (OHCAs) and time of day or day of week is unknown. Methods: A nationwide, prospective, population-based observational investigation of consecutive witnessed pediatric OHCAs (<18 years) with resuscitation attempts was conducted from January 2005 to December 2011. Days were defined as 9:00 am to 4:59 pm, nights as 5:00 pm to 8:59 am, weekdays as Mondays to Fridays, and weekends as Saturdays, Sundays, and national holidays. Primary outcome was one-month survival and secondary outcome was survival with favorable neurologic outcome, defined as cerebral performance category 1 or 2. Results: A total of 3278 bystander-witnessed pediatric OHCAs were registered. One month survival rate was significantly lower during nights than days (15.5% [95% CI: 13.8-17.2%] versus 23.3% [95% CI: 21.1-25.6%]; P<0.001 and during weekends/holidays (15.7% [95% CI: 13.6-18.0%] than weekdays (20.4% [95% CI: 18.7-22.2%]; P=0.001. Survival rate with favorable neurologic outcome was substantially lower during nights 7.5% [95% CI: 6.3-8.8%] than days (12.2% [95% CI: 10.6-14.1%]; P<0.001), and during weekends/holidays (7.7% [95% CI: 6.2-9.5%] than weekdays (10.4% [95% CI: 9.2-11.8%]; P=0.012). After adjusting for potential confounding factors, one-month survival rate remained significantly lower during nights compared to days (odds ratio 0.68; 95% CI: 0.56-0.82), and during weekends/holidays compared to weekdays (odds ratio 0.79; 95% CI, 0.65-0.97). Conclusions: One-month survival rate following bystander-witnessed pediatric OHCAs was lower during nights and weekends/holidays than days and weekdays, even when adjusted for potentially confounding factors.
Article
Background: Although survival after in-hospital cardiac arrest is likely to vary among hospitals caring for children,validated methods to risk-standardize pediatric survival rates across sites do not currently exist. Methods and results: From 2006 to 2010, within the American Heart Association's Get With the Guidelines-Resuscitation registry for in-hospital cardiac arrest, we identified 1551 cardiac arrests in children (<18 years). Using multivariable hierarchical logistic regression, we developed and validated a model to predict survival to hospital discharge and calculated risk-standardized rates of cardiac arrest survival for hospitals with a minimum of 10 pediatric cardiac arrest cases. A total of 13 patient-level predictors were identified: age, sex, cardiac arrest rhythm, location of arrest, mechanical ventilation, acute nonstroke neurological event, major trauma, hypotension, metabolic or electrolyte abnormalities, renal insufficiency, sepsis, illness category, and need for intravenous vasoactive agents prior to the arrest. The model had good discrimination (C-statistic of 0.71), confirmed by bootstrap validation (validation C-statistic of 0.69). Among 30 hospitals with ≥10 cardiac arrests, unadjusted hospital survival rates varied considerably (median, 37%; interquartile range, 24-42%; range, 0-61%). After risk-standardization, the range of hospital survival rates narrowed (median, 37%; interquartile range, 33-38%; range, 29-48%), but variation in survival persisted. Conclusions: Using a national registry, we developed and validated a model to predict survival after in-hospital cardiac arrest in children. After risk-standardization, significant variation in survival rates across hospitals remained. Leveraging these models, future studies can identify best practices at high-performing hospitals to improve survival outcomes for pediatric cardiac arrest. (
Article
Aim: Gaps exist in pediatric resuscitation knowledge due to limited data collected during cardiac arrest in real children. The objective of this study was to evaluate the relationship between the 2010 American Heart Association (AHA) recommended chest compression (CC) depth (≥51 mm) and survival following pediatric resuscitation attempts. Methods: Single-center prospectively collected and retrospectively analyzed observational study of children (>1 year) who received CCs between October 2006 and September 2013 in the intensive care unit (ICU) or emergency department (ED) at a tertiary care children's hospital. Multivariate logistic regression models controlling for calendar year and known potential confounders were used to estimate the association between 2010 AHA depth compliance and survival outcomes. The primary outcome was 24-h survival. The primary predictor variable was event AHA depth compliance, prospectively defined as an event with ≥60% of 30-s epochs achieving an average CC depth ≥51 mm during the first 5 min of the resuscitation. Results: There were 89 CC events, 87 with quantitative CPR data collected (23 AHA depth compliant). AHA depth compliant events were associated with improved 24-h survival on both univariate analysis (70% vs. 16%, p<0.001) and after controlling for potential confounders (calendar year of arrest, gender, first documented rhythm; aOR 10.3; CI(95): 2.75-38.8; p<0.001). Conclusions: 2010 AHA compliant chest compression depths (≥51 mm) are associated with higher 24-h survival compared to shallower chest compression depths, even after accounting for potentially confounding patient and event factors.
Article
The "2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care" increased the focus on methods to ensure that high-quality cardiopulmonary resuscitation (CPR) is performed in all resuscitation attempts. There are 5 critical components of high-quality CPR: minimize interruptions in chest compressions, provide compressions of adequate rate and depth, avoid leaning between compressions, and avoid excessive ventilation. Although it is clear that high-quality CPR is the primary component in influencing survival from cardiac arrest, there is considerable variation in monitoring, implementation, and quality improvement. As such, CPR quality varies widely between systems and locations. Victims often do not receive high-quality CPR because of provider ambiguity in prioritization of resuscitative efforts during an arrest. This ambiguity also impedes the development of optimal systems of care to increase survival from cardiac arrest. This consensus statement addresses the following key areas of CPR quality for the trained rescuer: metrics of CPR performance; monitoring, feedback, and integration of the patient's response to CPR; team-level logistics to ensure performance of high-quality CPR; and continuous quality improvement on provider, team, and systems levels. Clear definitions of metrics and methods to consistently deliver and improve the quality of CPR will narrow the gap between resuscitation science and the victims, both in and out of the hospital, and lay the foundation for further improvements in the future.
Article
In-hospital cardiac arrest is an important public health problem. High-quality resuscitation improves survival but is difficult to achieve. Our objective is to evaluate the effectiveness of a novel, interdisciplinary, postevent quantitative debriefing program to improve survival outcomes after in-hospital pediatric chest compression events. Single-center prospective interventional study of children who received chest compressions between December 2008 and June 2012 in the ICU. Structured, quantitative, audiovisual, interdisciplinary debriefing of chest compression events with front-line providers. Primary outcome was survival to hospital discharge. Secondary outcomes included survival of event (return of spontaneous circulation for ≥ 20 min) and favorable neurologic outcome. Primary resuscitation quality outcome was a composite variable, termed "excellent cardiopulmonary resuscitation," prospectively defined as a chest compression depth ≥ 38 mm, rate ≥ 100/min, ≤ 10% of chest compressions with leaning, and a chest compression fraction > 90% during a given 30-second epoch. Quantitative data were available only for patients who are 8 years old or older. There were 119 chest compression events (60 control and 59 interventional). The intervention was associated with a trend toward improved survival to hospital discharge on both univariate analysis (52% vs 33%, p = 0.054) and after controlling for confounders (adjusted odds ratio, 2.5; 95% CI, 0.91-6.8; p = 0.075), and it significantly increased survival with favorable neurologic outcome on both univariate (50% vs 29%, p = 0.036) and multivariable analyses (adjusted odds ratio, 2.75; 95% CI, 1.01-7.5; p = 0.047). Cardiopulmonary resuscitation epochs for patients who are 8 years old or older during the debriefing period were 5.6 times more likely to meet targets of excellent cardiopulmonary resuscitation (95% CI, 2.9-10.6; p < 0.01). Implementation of an interdisciplinary, postevent quantitative debriefing program was significantly associated with improved cardiopulmonary resuscitation quality and survival with favorable neurologic outcome.
Article
To describe the association of systolic hypotension during the first 6 hours after successful resuscitation from pediatric cardiopulmonary arrest with in-hospital mortality. Retrospective cohort study. Fifteen children's hospitals associated with the Pediatric Emergency Care Applied Research Network. Patients between 1 day and 18 years old who had a cardiopulmonary arrest, received chest compressions more than 1 minute, had a return of spontaneous circulation more than 20 minutes, and had a systolic blood pressure documented within 6 hours of arrest. None. Three hundred eighty-three patients had complete data for analysis. Patients with a documented minimum systolic blood pressure less than fifth percentile for age and sex within the first 6 hours following return of spontaneous circulation were considered to have early postresuscitation hypotension. Two hundred fourteen patients (56%) had early postresuscitation hypotension. One hundred eighty-four patients (48%) died prior to hospital discharge. After controlling for patient and cardiopulmonary arrest characteristics, hypotension in the first 6 hours following return of spontaneous circulation was associated with a significantly increased odds of in-hospital mortality (adjusted odds ratio = 1.71; 95% CI, 1.02-2.89; p = 0.042) and odds of unfavorable outcome (adjusted odds ratio = 1.83; 95% CI, 1.06-3.19; p = 0.032). In the first 6 hours following successful resuscitation from pediatric cardiac arrest, systolic hypotension was documented in 56% and was associated with a higher rate of in-hospital mortality and worse hospital discharge neurologic outcomes.
Article
Background: Despite ongoing efforts to improve the quality of pediatric resuscitation, it remains unknown whether survival in children with in-hospital cardiac arrest has improved. Methods and results: Between 2000 and 2009, we identified children (<18 years of age) with an in-hospital cardiac arrest at hospitals with >3 years of participation and >5 cases annually within the national Get With The Guidelines-Resuscitation registry. Multivariable logistic regression was used to examine temporal trends in survival to discharge. We also explored whether trends in survival were attributable to improvement in acute resuscitation or postresuscitation care and examined trends in neurological disability among survivors. Among 1031 children at 12 hospitals, the initial cardiac arrest rhythm was asystole and pulseless electrical activity in 874 children (84.8%) and ventricular fibrillation and pulseless ventricular tachycardia in 157 children (15.2%), with an increase in cardiac arrests due to pulseless electrical activity over time (P for trend <0.001). Risk-adjusted rates of survival to discharge increased from 14.3% in 2000 to 43.4% in 2009 (adjusted rate ratio per year, 1.08; 95% confidence interval, 1.01-1.16; P for trend=0.02). Improvement in survival was driven largely by an improvement in acute resuscitation survival (risk-adjusted rates: 42.9% in 2000, 81.2% in 2009; adjusted rate ratio per year: 1.04; 95% confidence interval, 1.01-1.08; P for trend=0.006). Moreover, survival trends were not accompanied by higher rates of neurological disability among survivors over time (unadjusted P for trend=0.32), suggesting an overall increase in the number of survivors without neurological disability over time. Conclusions: Rates of survival to hospital discharge in children with in-hospital cardiac arrests have improved over the past decade without higher rates of neurological disability among survivors.