Kristen Coletti, Children's Hospital of Philadelphia, Wynnewood, PA, United States; Jacqueline Chandler, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Danielle Cestare, Childrens Hospital of Philadelphia, Ewing, NJ, United States; Anne Ades, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Katie Behringer, Childrens Hospital of Philadelphia, Drexel Hill, PA, United States; Liz Boyle, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Lauren Heimall, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Heather Hopkins, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Trish Hunt-Kada, Childrens Hospital of Philadelphia, Media, PA, United States; Alison Kovacs, Childrens Hospital of Philadelphia, Haddon Heights, NJ, NJ, United States; Taylor Milchling, Children's Hospital of Philadelphia, Blackwood, NJ, United States; Kira Rakus, Children’s Hospital of Philadelphia, Sewell, NJ, United States; Megan Snyder, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Mary Haggerty, Children's Hospital of Philadelphia, haddonfield, NJ, United States
Neonatologist Children's Hospital of Philadelphia Wynnewood, Pennsylvania, United States
Background: High quality CPR is associated with improved neurologic outcomes and survival after in-hospital cardiac arrest. As higher complexity, older infants are cared for in Level IV NICUs, centers increasingly resuscitate using Pediatric Advanced Life Support (PALS) instead of Neonatal Resuscitation Program. At our center, PALS became the default CPR guideline in 9/2023 regardless of gestational age or arrest etiology. Confusion regarding PALS application to achieve high-quality CPR was identified. Objective: Improve achievement of high-quality CPR during cardiac arrests ≥ 1 minute between 9/1/2024-10/1/2025 in a 100-bed, level IV NICU using quality improvement methodology. Design/Methods: Our initial PDSA cycle focused on implementing a CPR coach during each cardiac arrest to give compressors feedback about CPR quality and to cognitively unload the code leader. One hundred eighty-five front line clinicians and nurses were trained. Subsequent PDSA cycles focused on communication about high-risk patients, preassigning nursing code roles, and creation of badge tags with CPR metrics.
The primary outcome measures were chest compression (CC) depth (>4cm), chest compression fraction (CCF), rate (100-120bpm), and pause duration < 10 seconds. Process measures were defibrillator use to obtain CPR feedback and satisfaction with the CPR coach role obtained via survey. A balancing measure was code leadership confusion after CPR coach implementation. Results: Data were obtained from 29 cardiac arrests (13 pre-study 8/2022-8/2024; 16 study period). Median patient weight was 5.3kg (IQR 4.8, 7.0), GA 33 weeks (IQR 28, 36) and postmenstrual age 54 weeks (IQR 50, 62). CCF (Fig 1) and pause duration (Fig 2) improved, noting special cause variation with sustained process change. Mean depth improved (Fig 3), though remained below goal. CC rate was at goal 68% of the time, which did not change during the study period. Defibrillator use for CPR feedback improved from 18% to 49% (p=0.001). No confusion regarding code leadership occurred after CPR coach implementation. Code teams reported universal satisfaction with the CPR coach (n=15), noting improved task coordination (100%), timing of pulse checks/compressor rotation (92%), adherence to quality guidelines (92%), adherence to compression/ventilation ratios (75%), and mental offloading of the code leader (67%).
Conclusion(s): Quality improvement methodology facilitated improvement in CCF, depth and pause duration, though not rate during CPR. CPR coaches were well received by clinicians and perceived to improve CPR coordination and quality in a level IV NICU.
Mean Chest Compression Fraction per Event - X chart Figure 1 FINAL.pdfControl chart demonstrating improvement in chest compression fraction (time spent doing chest compressions/time of entire cardiac arrest) from 87% to 93% over time.
Pause Duration < 10 seconds during CPR over Time - P chart Fig 2.pdfControl chart demonstrating that pauses in CPR were shorter over time (54% of pauses were
Mean Compression Depth over Time - Xbar Chart Fig 3.pdfControl chart demonstrating that compression depth improved from 2.29 to 2.88 cms over time.
