Multimodal neurologic prognostication (MM-NP) after cardiac arrest has been shown to enhance prognostic accuracy, however, it is vastly underutilized in real-world settings. Guideline-discordant practices and healthcare disparities in post-cardiac arrest care have been widely reported. Process standardization may reduce practice variations and mitigate cognitive biases. We describe several steps taken at our institution to build robust systems of care and ensure consistent, equitable MM-NP.Our program is founded on multidisciplinary collaboration. A group of stakeholders worked to build and refine our protocols based on current guidelines and evidence, tailored to the institutional context and resources. Our partnership extends to the clinical space where patients are cared for by the critical care and neurology teams, leveraging the combined expertise of these disciplines. Regular didactics on neuroprognostication delivered to our trainees aim to emphasize the importance of performing a nuanced, multimodal assessment, accounting for clinical confounders (e.g., sedation), acknowledging uncertainty, and allowing for sufficient time to prognosticate.We also leverage the electronic health record (EHR) to implement standardized order sets, documentation and tools to facilitate consistency in care. Ongoing evaluation of processes is critical in recognizing and mitigating challenges while ensuring constant refinements of the infrastructure. In addition to optimizing prognostication itself, compassionate and transparent prognosis communication is a critical element of goal-concordant care.Regular review with key stakeholders and the clinical teams coupled with EHR-based data extraction allow for assessment of impact to ensure system optimization and sustainable growth.

Introduction Medical staff on acute care wards respond to in-hospital emergencies, yet they are often poorly prepared due to the infrequency of pediatric cardiopulmonary events. We developed this rapid cycle deliberate practice simulation to improve the skills and knowledge required to initiate high-quality CPR and prepare for the arrival of the code blue response team. Methods This 30-minute simulation was performed in situ within hospital rooms and required low-fidelity equipment. Participants resuscitated an unresponsive, pulseless infant. The simulation was conducted three times, with each participant cycling through each role. Critical actions included checking for responsiveness and calling for help, starting compressions, ventilating the patient, and placing defibrillation pads while maintaining high-quality CPR. Results Participants' (attending physicians', pediatric trainees', advanced practice providers', registered nurses') self-reported confidence, as rated based on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree), significantly improved in providing high-quality CPR (n = 151; Z = 9.4; p < .01) and managing airway, breathing, and circulation in the first 3 minutes of a code situation (n = 154; Z = 9.6; p < .01). Knowledge scores (four multiple-choice questions) assessing high-quality CPR principles improved from a mean 68% to 85% (n = 151; p < .01). Respondents indicated they found the training session to be helpful, with a mean score of 4.8 on a 5-point Likert scale (1 = not at all helpful, 5 = extremely helpful). Discussion This multidisciplinary simulation was well received and improved participants' confidence in responding to pediatric cardiopulmonary emergencies and knowledge of high-quality CPR principles.

Objective We aimed to describe the risk factors and outcomes of recurrent in-hospital cardiac arrest (IHCA) in a large pediatric cohort. Methods A retrospective cohort study of patients <= 18 years from the American Heart Association's Get With The Guidelines (R) -Resuscitation Registry with single or recurrent IHCA who achieved return of spontaneous circulation and were not placed on extracorporeal membrane oxygenation with their initial IHCA were included. Patients were categorized into two groups for analysis: (1) single IHCA or (2) recurrent ICHA. Initial IHCAs from each category were analyzed and compared. Continuous variables were expressed as medians with interquartile ranges and compared via rank sum test. Categorical variables were expressed as percentages and compared via chi square test. Outcomes were assessed in a matched cohort. Results A total of 10,019 patients, 2,225 (22.2%) experienced a recurrent IHCA. Recurrent IHCA patients were more likely to be medical cardiac (21.3 vs. 19%; p = 0.01) or trauma patients (7.5 vs. 5.3%; p < 0.001) and have higher acuity (27.8 vs. 22.7%; p < 0.001). Initial IHCA for recurrent IHCA patients were more likely to occur in the pediatric intensive care unit (44.2 vs. 39.6%; p < 0.001) or cardiac intensive care unit (11.5 vs. 9.5%; p = 0.006) versus other inpatient locations. There was no difference in initial IHCA duration between groups. After matching, patients with a recurrent IHCA had a lower rate of survival to hospital discharge (42.1 vs. 65.3%; p < 0.001). Conclusion In a matched cohort, patients with recurrent IHCA had lower rates of survival compared with those with a single IHCA. Higher acuity and intensive care unit location during initial IHCA event were associated with increased risk for recurrent IHCA.

OBJECTIVES:To improve continuity of care, some PICUs assign a continuity attending (CA) physician for children with prolonged hospitalizations. Little is known about how this intervention impacts familial caregivers' experiences. The objective of this study was to provide in-depth descriptions of family perspectives about continuity of care during prolonged PICU hospitalizations for children with and without a PICU CA.DESIGN:Qualitative semi-structured interviews.SETTING:Single center cohort, from October 2021 to December 2022, at an academic PICU in the United States.PARTICIPANTS:Familial caregivers (n = 39) of critically ill children hospitalized in the PICU for greater than or equal to 14 days were purposively sampled, stratified by group: 18 with a PICU CA and 21 without a PICU CA.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:Semi-structured interviews were audio recorded, transcribed, coded, and analyzed in the context of the continuity of care model using a realist thematic approach. Familial caregivers described six themes related to relational, informational, and management continuity: 1) familiar providers who demonstrate empathy for the child improve family members' comfort and trust (Relational); 2) providers who know and use a child's baseline health status to inform clinical decision-making alleviate family members' stress (Relational, Management); 3) information loss during care team transitions frustrates families (Informational, Management); 4) known providers enhance caregiver communication (Informational); 5) familiar providers who value a family's expertise about their child's care (Relational, Management); and 6) take responsibility for the child's long-term care plan (Management) decrease parental stress.CONCLUSIONS:As PICU patient medical complexity and length of stay increase, familial caregivers' needs transition from understanding day-to-day management to navigating care team transitions and partnering with providers to develop long-term care plans. Targeted interventions to increase provider continuity that consider relational, informational, and management continuity are needed to optimize patient outcomes and family experiences.

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

Introduction: Over 15,000 children experience in-hospital cardiac arrest (IHCA) each year in the United States. Following the return of spontaneous circulation (ROSC) for most children, the focus turns to providing high quality post-resuscitation care. Extracorporeal life support (ECLS) can be used in the post-arrest period to restore adequate hemodynamics, however the use of post-arrest ECLS is not well described. This study aimed to describe patients who receive post-arrest ECLS to support the development of evidence-based guidelines for this therapy. Methods: Multi-center retrospective study of pediatric patients in the prospectively collected Pediatric Resuscitation Quality (pediRES-Q) Collaborative database, a multicenter international collaborative of children’s hospitals. All patients ≤ 18 years of age in the pediRES-Q database who received ECLS after an initial IHCA between July 1, 2015 and June 2, 2021 were included. Patients were excluded if they received extracorporeal cardiopulmonary resuscitation, defined as cannulation and initiation of ECLS during the IHCA and return of circulation with ELCS. Primary outcome was survival to intensive care unit (ICU) discharge. Results: A total of 56 patients were included, median age was 0.8 years (IQR 0.1-5 years). The most common illness category was medical cardiac (18 patients, 32%) followed by surgical cardiac (14 patients, 25%). Among the cohort, 31 (55%) patients were cannulated via the neck vessels, 10 (18%) through an open chest, and 6 (11%) via femoral vessels. The Pediatric ICU was the most common location, (28 patients, 50%) and the majority of patients were on a vasoactive agent at the time of their arrest (33 patients, 59%). The most common initial rhythm when CPR began was pulseless electrical activity (20 patients, 36%) patients followed by bradycardia (17 patients, 30%) and median duration of CPR was 38 minutes (IQR 19-56 minutes). 30 patients (54%) survived to ICU discharge, 25 (83%) of whom had a good neurologic outcome (PCPC ≤ 2 or unchanged from baseline). Conclusions: More than half of patients who required ECLS in the post-arrest period survived to discharge, with over 80% with good neurologic outcome. Further investigation is needed to support the development of guidelines for initiation of ECLS in the post-arrest period.

Introduction: Recurrent in-hospital cardiac arrest (IHCA) is associated with increased morbidity and mortality in adult and pediatric patients. Event and patient-specific factors are associated with the risk for recurrent IHCA. We aimed to describe the risk factors and outcomes of recurrent IHCA in a large pediatric cohort. We hypothesized that patients who suffered recurrent IHCA would have worse survival outcomes. Methods: Retrospective cohort study of patients ≤18 years from the American Heart Association’s Get With The Guidelines®-Resuscitation Registry with single or recurrent IHCA who achieved ROSC and were not placed on ECMO with their initial IHCA. Recurrent IHCA was defined as ≥ 2 IHCAs within the same hospitalization. Categorical variables were expressed as percentages and compared via Chi square test. Continuous variables were expressed as medians with interquartile ranges and compared via rank sum test. Outcomes were assessed in a match cohort based on age, disease category, duration of first arrest, and acuity. Acuity was defined as low if no invasive airway or arterial line was present, defined as medium if one was present, and defined as high if both were present at the time of the IHCA. Results: From January 2010 to January 2022, 2225/10019 (22.2%) pediatric patients experienced a recurrent IHCA. Recurrent IHCA patients compared to single IHCA were more likely to be medical cardiac (21.3% vs. 19%; p=0.01) or trauma patients (7.5% vs. 5.3%; P< 0.001) and have higher acuity (27.8% vs. 22.7%; p< 0.001). Recurrent IHCAs were more likely to occur in the PICU (44.2% vs. 39.6%; p< 0.001) or CICU (11.5% vs. 9.5%; p=0.006) versus other inpatient locations and there was no difference in the duration of arrest. After matching, pediatric patients with a recurrent IHCA had worse survival to hospital discharge (44.1% vs 61.5%; p< 0.001). Conclusions: Higher acuity and ICU location during the initial IHCA event was associated with increased risk for recurrent IHCA in pediatric patients. Additionally, recurrent IHCA is associated with worse survival outcomes in the total cohort and following exact matching.

RESCUE events, when patients require transfer to the intensive care unit (ICU) from acute care and need resuscitation with noninvasive or invasive positive pressure ventilation and/or blood pressure support, are associated with a 14.3% mortality risk at Seattle Children’s Hospital (SCH). Of 456 rapid response calls in 2012, 191 (41.9%) calls resulted in a transfer to the ICU. Of these transfers, 98 (51%) met the criteria for a RESCUE event. There was a failure in both recognition and response to clinical deterioration despite having a rapid response team (RRT). There was no effective and systematic method to identify and respond to early clinical deterioration to prevent a RESCUE event in the hospital.

Aim of study: To determine outcomes in pediatric patients who had an in-hospital cardiac arrest and subsequently received extracorporeal car-diopulmonary resuscitation (ECPR). Our secondary objective was to identify cardiopulmonary resuscitation (CPR) event characteristics and CPR quality metrics associated with survival after ECPR.Methods: Multicenter retrospective cohort study of pediatric patients in the pediRES-Q database who received ECPR after in-hospital cardiac arrest between July 1, 2015 and June 2, 2021. Primary outcome was survival to ICU discharge. Secondary outcomes were survival to hospital discharge and favorable neurologic outcome at ICU and hospital discharge.Results: Among 124 patients included in this study, median age was 0.9 years (IQR 0.2-5) and the majority of patients had primarily cardiac disease (92 patients, 75%). Survival to ICU discharge occurred in 61/120 (51%) patients, 36/61 (59%) of whom had favorable neurologic outcome. No demographic or clinical variables were associated with survival after ECPR.Conclusion: In this multicenter retrospective cohort study of pediatric patients who received ECPR for IHCA we found a high rate of survival to ICU discharge with good neurologic outcome.

Objective: To evaluate the association between hyperoxia in the first 24 hours after in-hospital pediatric cardiac arrest and mortality and poor neu-rological outcome. Methods: This is a retrospective cohort study of inpatients in a freestanding children's hospital. We included all patients younger than 18 years of age with in-hospital cardiac arrest between December 2012 and December 2019, who achieved return of circulation (ROC) for longer than 20 min-utes, survived at least 24 hours after cardiac arrest, and had documented PaO2 or SpO2 during the first 24 hours after ROC. Hyperoxia was defined as having at least one level of PaO2 above 200 mmHg in the first 24 hours after cardiac arrest. Results: There were 187 patients who met eligibility criteria, of whom 48% had hyperoxia during the first 24 hours after cardiac arrest. In-hospital mortality was 41%, with similar mortality between oxygenation groups (hyperoxia 45% vs no hyperoxia 38%). We did not observe an association between hyperoxia and in-hospital mortality or poor neurological outcome after adjusting for confounders (odds ratio 1.2, 95% confidence interval 0.5-2.8). On sensitivity analysis using two additional cutos of PaO2 (>150 mmHg and > 300 mmHg), there was also no association with in-hospital mortality or poor neurological outcome after adjusting for confounders. Similarly, on multivariable logistic regression using SpO2 > 99% as the expo -sure, there was no dierence in the frequency of death or poor neurological outcome at hospital discharge. Conclusion: Hyperoxia after pediatric cardiac arrest was common and was not associated with worse in-hospital outcomes.

Roberts, J. S.1; Barry, D.2; Farris, R. W.1; Wilkes, J. J.1; Masse, E.3; Rutman, L. E.1 Author Information

OBJECTIVES:To identify a PICU Core Outcome Measurement Set (PICU COMS), a set of measures that can be used to evaluate the PICU Core Outcome Set (PICU COS) domains in PICU patients and their families. DESIGN:A modified Delphi consensus process. SETTING:Four webinars attended by PICU physicians and nurses, pediatric surgeons, rehabilitation physicians, and scientists with expertise in PICU clinical care or research ( n = 35). Attendees were from eight countries and convened from the Pediatric Acute Lung Injury and Sepsis Investigators Pediatric Outcomes STudies after PICU Investigators and the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network PICU COS Investigators. SUBJECTS:Measures to assess outcome domains of the PICU COS are as follows: cognitive, emotional, overall (including health-related quality of life), physical, and family health. Measures evaluating social health were also considered. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Measures were classified as general or additional based on generalizability across PICU populations, feasibility, and relevance to specific COS domains. Measures with high consensus, defined as 80% agreement for inclusion, were selected for the PICU COMS. Among 140 candidate measures, 24 were delineated as general (broadly applicable) and, of these, 10 achieved consensus for inclusion in the COMS (7 patient-oriented and 3 family-oriented). Six of the seven patient measures were applicable to the broadest range of patients, diagnoses, and developmental abilities. All were validated in pediatric populations and have normative pediatric data. Twenty additional measures focusing on specific populations or in-depth evaluation of a COS subdomain also met consensus for inclusion as COMS additional measures. CONCLUSIONS:The PICU COMS delineates measures to evaluate domains in the PICU COS and facilitates comparability across future research studies to characterize PICU survivorship and enable interventional studies to target long-term outcomes after critical illness.

Background:Resuscitation practices in pediatric hospitals have not been compared, and whether practices differ between freestanding pediatric only hospitals and combined hospitals (which care for adults and children) is unknown. Methods:We surveyed hospitals that submit data on pediatric in-hospital cardiac arrest (IHCA) to Get-With-The Guidelines®-Resuscitation, to elicit information on resuscitation practices. Hospitals were categorized as pediatric only and combined hospitals, and rates of resuscitation practices were compared. Results:Thirty-three hospitals with ≥5 IHCA events between 2017-2019 completed the survey, of which 9 (27.3%) were pediatric only and 24 (72.7%) were combined hospitals. Overall, 18 (54.5%) hospitals used a device to measure chest compression quality, 16 (48.5%) had a staff member monitor chest compression quality, 10 (30.3%) used lanyards or hats to designate code leaders during a resuscitation, 16 (48.5%) routinely conducted code debriefings immediately after a resuscitation, and 7 (21.2%) conducted mock codes at least quarterly with 17 (51.5%) reporting no set schedule. Pediatric only hospitals were more likely to employ a device to measure chest compressions (88.9% vs. 41.7%; P = 0.02), conduct code debriefings always or frequently after resuscitations (77.8% vs. 37.5%, P = 0.04), use lanyards or a hat to designate the code team leader during resuscitations (66.7% vs. 16.7%, P = 0.006), and allow nurses to defibrillate using an AED (77.8% vs. 29.2%, P = 0.01). There were no differences in simulation frequency or other resuscitation practices between the two hospital groups. Conclusions:Across hospitals caring for children, substantial variation exists in resuscitation practices, with notable differences between pediatric only and combined hospitals.

Background:Hospitalized patients and caregivers who use a language other than English have worse health outcomes, including longer length of stay, more frequent readmissions, and increased rates of in-hospital adverse events. Children who experience clinical deterioration (as measured by a Rapid Response Team event) during a hospitalization are at increased risk for adverse events and mortality.Methods:We describe the results of a retrospective cohort study using hospital records at a free-standing, quaternary children's hospital, to examine the association of language of care with outcomes (transfer to intensive care, adverse event, mortality prior to discharge) following Rapid Response Team event, and whether increased interpreter use among patients who use a language other than English is associated with improved outcomes following Rapid Response Team event.Results:In adjusted models, Rapid Response Team events for patients who use a language other than English were associated with higher transfer rates to intensive care (RR 1.1, 95% CI 1.01, 1.21), but not with adverse event or mortality. Among patients who use a language other than English, use of 1-2 interpreted sessions per day was associated with lower transfer rates to intensive care compared to use of less than one interpreted session per day (RR 0.79, 95% 0.66, 0.95).Conclusion:Rapid Response Team events for hospitalized children of families who use a language other than English are more often followed by transfer to intensive care, compared with Rapid Response Team events for children of families who use English. Improved communication with increased interpreter use for hospitalized children who use a language other than English may lead to improvements in Rapid Response Team outcomes.

Background In the UK, there is evidence that girls’ physical activity tends to decline to a greater extent than boys as they enter adolescence. ‘Role models’ could play a vital role in inspiring girls to become or remain physically active. The CHARMING Programme is a primary school-based community linked role-model programme, co-developed in 2016, with children, parents, schools and wider stakeholders. It involves different types of physical activity delivered for 1-h each week by a community provider and peer role models (e.g. older girls from secondary schools) joining in with the sessions. The programme ultimately aims to increase and sustain physical activity levels among 9–10-year-old girls. This study aims to assess the feasibility and acceptability of the CHARMING Programme and of evaluating it using a randomised trial. Methods This study is a feasibility cluster randomised controlled trial, with embedded process evaluation and health economic evaluation. Approximately 90 Year 5 (i.e. 9–10-year-old) girls will be recruited across six primary schools in Mid-South Wales. Participating schools will be allocated to the programme: control on a 2:1 basis; four intervention schools will run the CHARMING Programme and two will continue with usual practice. A survey and accelerometer will be administered at baseline and repeated at 12 months. Interviews and focus groups will be conducted post-intervention delivery. The primary aim is to assess feasibility of a future randomised trial via the recruitment of schools, participants and role models; randomisation; retention; reach; data collection completion rates; programme adherence; and programme fidelity, views on intervention acceptability and programme barriers and facilitators. Secondary aims are to evaluate established physical activity outcome measures for children plus additional health economic outcomes for inclusion in a future full-scale trial. Discussion The results of this study will inform decisions on whether and how to proceed to a full-scale evaluation of the effectiveness and cost-effectiveness of the CHARMING Programme to improve or sustain physical activity. Trial registration ClinicalTrials.gov ISRCTN36223327. Registered March 29, 2021

Technological advancements and rapid expansion in the clinical use of extracorporeal life support (ECLS) across all age ranges in the last decade, including during the COVID-19 pandemic, has led to important ethical considerations. As a costly and resource intensive therapy, ECLS is used emergently under high stakes circumstances where there is often prognostic uncertainty and risk for serious complications. To develop a research agenda to further characterize and address these ethical dilemmas, a working group of specialists in ECLS, critical care, cardiothoracic surgery, palliative care, and bioethics convened at a single pediatric academic institution over the course of 18 months. Using an iterative consensus process, research questions were selected based on: (1) frequency, (2) uniqueness to ECLS, (3) urgency, (4) feasibility to study, and (5) potential to improve patient care. Questions were categorized into broad domains of societal decision-making, bedside decision-making, patient and family communication, medical team dynamics, and research design and implementation. A deeper exploration of these ethical dilemmas through formalized research and deliberation may improve equitable access and quality of ECLS-related medical care.

The objective of this article was to identify demographic and clinical factors associated with early recurrent arrest (RA; <48 hours) and late RA (≥48 hours) among pediatric inpatients following an initial in-hospital cardiac arrest. A retrospective cohort study of inpatients was performed in a free-standing academic quaternary care children's hospital. All inpatients were <18 years old with a cardiac arrest event requiring ≥1 minute of cardiopulmonary resuscitation with the return of spontaneous circulation sustained for ≥20 minutes at Seattle Children's Hospital from February 1, 2012, to September 18, 2019. Of the 237 included patients, 20 (8%) patients had an early RA and 30 (13%) had a late RA. Older age and severe prearrest acidosis were associated with a higher risk of early RA, odds ratios (OR) = 1.2 (95% confidence interval [CI]: 1.1-1.3) per additional year and 4.6 (95% CI: 1.2-18.1), respectively. Prearrest organ dysfunction was also associated with a higher risk of early RA with an OR of 3.3 (95% CI: 1.1-9.4) for respiratory dysfunction, OR = 1.4 (95% CI: 1.1-1.9) for each additional dysfunctional organ system, and OR = 1.1 (95% CI: 1-1.2) for every one-point increase in PELOD2 score. The neonatal illness category was associated with a lower risk of late RA, OR 0.3 (95% CI: 0.1-0.97), and severe postarrest acidosis was associated with a higher risk of late RA, OR = 4.2 (95% CI: 1.1-15). Several demographic and clinical factors offer some ability to identify children who sustain a recurrent cardiac arrest, offering a potential opportunity for intervention to prevent early recurrent arrest.

1N/A, Oklahoma City, OK 2University of Washington Children’s Hospital, Seattle, WA 3University of Washington, Seattle, WA

Hayman, William; Farris, Reid; Rutman, Lori; Bettinger, Brendan; Barry, Dwight; Roberts, Joan Author Information