March 2016

CPR for Children Gets Smarter

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Heart-stopping. Critical moment. Life-or-death. The catchphrases that have come to define powerful dramatic scenes have real-life antecedents in pediatric intensive care units (PICUs), where sick children are at the highest risk of cardiac arrest in the hospital. More than half of children who experience cardiac arrest in this setting do not survive to hospital discharge.

That life-or-death balance is tipping in favor of survival, however, thanks to clinicians’ and research scientists’ persistent push toward discovery. Research at The Children’s Hospital of Philadelphia, combining basic and translational investigation with bedside implementation of clinical therapies, is at the forefront of that decades-long effort to make cardiopulmonary resuscitation (CPR) smarter.

More than 3,000 children die each year in the U.S. alone after cardiac arrest in hospitals, the equivalent of one full school bus crashing with no survivors each day. Unlike adult cardiac arrest victims who may have complex underlying health conditions, among children who need CPR, the average age is 3, and many of the causes are rapidly reversible. The number of high quality of life years saved by implementation of CHOP’s pioneering approach to resuscitation is enormous.

“It is amazing that a persistent, systematic translational approach making small changes to our everyday protocols can add up to innovations that make a huge difference for so many children,” said Vinay Nadkarni, MD, MS, a critical care physician at CHOP and professor at the Perelman School of Medicine at the University of Pennsylvania.

Vignette: A Child’s Cardiac Arrest

To see some of the ways CHOP’s spectrum of activity in CPR quality research has been saving more lives, imagine the scene when a little boy’s heart suddenly stops. Count up the steps that contribute to making CHOP a “clinical learning laboratory” with a culture of continuous resuscitation learning and quality improvement.

One: When the child is admitted to CHOP’s PICU, the care team identifies him as being at high risk for a cardiac arrest, based on his clinical situation. They begin preparing family and staff about what to do in the event it actually occurs — a series of steps that simply does not occur at most other hospitals.

Two: It happens. Alarms blare from equipment at the child’s hospital bed when he goes into cardiac arrest. At CHOP, bedside healthcare providers who arrive first to perform CPR have already practiced the technique earlier that same week using one of the unit’s unique rolling refresher carts — unlike the past standard practice of taking a refresher CPR course only once every two years or so, away from the site of care. This innovative approach was pioneered at CHOP by Dr. Nadkarni and Research Program Manager Dana Niles, MS, D.Phil (cand).

Three: In their efforts to resuscitate the little boy in arrest, clinicians focus their attention on the blood pressure reading on the patient’s continuous monitoring equipment to ensure their efforts have the intended physiological effect — improving upon the old methods, in which they focused predominantly on how fast and how deep they were compressing the child’s chest, regardless of measurable effect. (They have practiced this focus on blood pressure readings using a CHOP-developed training manikin, too.)

Four: Later, after the critical incident is over, the clinicians and trainees in the PICU gather to review the quantitative data that has been downloaded from the bedside monitors and compiled into a “report card” showing the strengths and weaknesses of the team’s performance. The debriefing resembles what professional sports teams do as they review the tapes of the game using guided reflection (coaching). Many in attendance at the debriefing were not assigned to this patient, or were not on duty during the arrest. Natural human curiosity and the desire of the CHOP team to optimize performance at these dramatic, life-or-death situations, draws a crowd to these sessions.

The CHOP team has demonstrated that its model of post-arrest debriefings significantly improved both CPR quality and patients’ survival. Patient survival with favorable neurological outcomes has doubled.

Expanding Impact Through Clinical Research Networks and Beyond

With a new grant from the National Institutes of Health awarded this spring, CHOP research scientists aim to disseminate this single-site success via a multi-site national clinical trial. In the study, the CHOP team will test whether the bundled approach of bedside refresher training, resuscitation to physiologic blood pressure targets, and post-arrest debriefing for the entire unit, leads to similar improvements in outcomes at other children’s hospitals throughout the Collaborative Pediatric Critical Care Research Network, (CPCCRN, pronounced “Capcorn”).

Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, CPCCRN comprises a core group of eight top-tier medical centers with an intense focus on studying resuscitation improvement in pediatric ICUs. This and other larger clinical research networks for resuscitation, such as the pediatric Resuscitation Collaborative (RES-Q) led by CHOP and supported by an unrestricted educational grant from the Zoll Corporation, extend the work CHOP does as a single center into a more robust national and international hub of quality improvement and clinical research. The evidence-based methods that demonstrate success in these concentric circles of broader networks, in turn, shape the guidelines of organizations such as the American Heart Association (AHA), which set the standard for how all hospitals handle resuscitation nationwide.

CHOP experts themselves play important roles in guiding these national practice shifts. For example, Dr. Nadkarni chairs the scientific advisory board of the AHA Get with the Guidelines-Resuscitation national registry of CPR and its International Liaison Committee linking the AHA with global counterpart resuscitation councils. Alexis Topjian, MD, MSCE, chairs the pediatric research task force for AHA’s national resuscitation registry. Peter Meaney MD, MPH, leads the AHA Pediatric International Task Force on Resuscitation and developed a Saving Children’s Lives program that is taking these programs globally.

Years of Research Underlying a Personalized Approach to Resuscitation

The newly funded CPCCRN-wide trial incorporates physiologic targets for CPR, a shift that makes the technique much more personalized to each patient.

“Not only does it make sense clinically to pay attention to blood pressure, when restoring blood flow is the desired outcome, it’s also practical in that, when you run to the bedside and look at the monitor and someone is delivering CPR, the blood pressure number is right there,” said Robert Sutton, MD, MSCE, an attending critical care physician and associate professor at Penn, who is principal investigator of the new multi-site trial.

Before these methods could ever be tried on patients, though, researchers at CHOP tested their efficacy in laboratory settings. Dr. Sutton’s studies in the lab of Critical Care Division Chief and Penn Professor Robert Berg, MD, showed that targeting physiological outcomes improves survival after resuscitation of large animals compared to standard rate- and depth-based targets, across a wide range of disease models.

To bring this more personalized approach into the clinic, where most clinicians in most hospitals are not taught to use patients’ available physiologic readings such as blood pressure to guide CPR performance, the CHOP team further needed to create effective training tools and methods.

Making Training Manikins Better

During her fellowship several years ago, Heather Wolfe, MD, now an attending critical care physician at CHOP and assistant professor at Penn, worked with Matthew R. Maltese, PhD, to develop a training manikin that could be used to train clinicians to perform CPR targeting physiologic readings. Dr. Maltese, the department’s director of biomechanics research, a research assistant professor at Penn, and lead for the FDA-funded Philadelphia Pediatric Medical Device Consortium, oversees resuscitation-related research efforts that include modifying training manikins and building models to test pressure impacts on a child-sized chest with potential novel CPR methods.

As part of a long-term successful engineering training program in which students at Drexel and Penn learn while working at CHOP, Drs. Wolfe and Maltese guided Drexel student Veronika Legkobitova who helped build prototypes of a manikin that felt lifelike while delivering realistic data to an attached display monitor with simulated blood-pressure readings.

Subsequently, Dr. Wolfe led a six-month study comparing CPR training methods for clinicians at CHOP using the new manikin.

“We found that at the end of just three months the providers that were trained using a blood pressure target were retaining skills better than providers trained on the same manikin but taught to focus only on depth and rate targets,” Dr. Wolfe said.

Dr. Wolfe also leads the debriefings to follow up after each cardiac arrest incident in the PICU. In the new multi-site trial, she will develop and use telemedicine and site visits to train CPCCRN-participating hospitals to replicate the format of these debriefings.

From Discovery to Impact

While CHOP leads ongoing efforts to improve CPR, it is clear that the research to date has already had a major impact on practice nationally and internationally.

“CHOP has led the field in discovering what is important for the quality of CPR for children, in the knowledge exchange and implementation science of how to perform and disseminate high quality CPR, and in modeling how CPR affects outcomes and quality of life for critically ill and injured children,” Dr. Nadkarni said. “Kids are not just little adults. We’ve led the field in trying to figure out the impact of age, size, and developmental life cycle on performance and outcomes of CPR.”

In 2015, the Institute of Medicine (IOM) issued a report highlighting strategies to improve survival following cardiac arrest for patients of all ages, including collecting and centralizing data about cardiac arrest treatment outcomes (a process CHOP began more than 15 years ago), improving care delivery through continuous quality improvement programs (a point of pride in CHOP’s programs), and investing in research (a comprehensive undertaking, as described above).

“Seeing how well what we did here pioneered exactly what the IOM now prescribes is amazing; I’m stunned actually,” Dr. Berg said.

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