10 things to know to improve pediatric out-of-hospital cardiac arrest survival in your community

By Peter Antevy, MD

The following is paid content sponsored by Pulsara

Easy problems have easy answers – complex problems require complex answers. However, in pediatrics, we’ve taken an easy problem and made it unnecessarily complicated. Pediatric resuscitation isn’t that complex (BVM – compressions – Epi), yet over the last 3 decades we’ve been convinced otherwise. Why? Many have focused on one thing – getting the child’s weight. We’ve been convinced that a single tool or widget will get us through a difficult pediatric call. It’s time to change this mentality.

As a pediatric emergency physician for 17 years, and EMS medical director for the last 7, I have seen both sides of the story and have much greater clarity and insight into something that has eluded us for some time. There is one thing that is undeniably true, yet is contrary to popular belief – success in pediatric arrest relies highly on efforts prior to arrival on scene. This includes the efforts of bystanders, the 9-1-1 call-takers, and those of EMS professionals. Some of these ideas are contrarian, yet we now have data to back them up. Here are 10-steps your agency can take to improve pediatric out-of-hospital cardiac survival in your community.

1. Know your data!

With ‘value based care’ and meaningful use upon us, EMS agencies will soon have to provide data that demonstrates the provision of high quality care. (1) In pediatric cardiac arrest, outcomes rely on high rates of bystander CPR, effective telecommunicator CPR, and efficient EMS care. Within these chain-of-survival elements there are numerous data points sitting on the surface that can be used as a springboard towards improved care for children. Efforts must be made to track arrest statistics for pediatric patients continuously, on a local level, and benchmarked nationally. In the near future, simply saying “we do a great job taking care of pediatric patients” will not be enough. Knowing your data is paramount.

2. Develop an ongoing bystander CPR plan in your community

Up to 50% of bystanders will not initiate chest compressions on children in cardiac arrest. (2) Instead, parents will dial 9-1-1 first to ‘get permission’ to begin CPR. Stop for a moment to consider how this happened and how detrimental this is to survival. The difference between life and death in arrest victims is measured in seconds and minutes, not hours. Changing the ‘culture’ of your community is not a simple task by any means and it requires a multi-pronged approach. CPR education should start when children are 9-years of age and should be a requirement for graduation from high school. (3) Courses teaching CPR should take minutes, not hours, and be reinforced continuously. We must ‘reprogram’ the layperson to not be afraid of initiating CPR on a child who is not responsive and not breathing normally. Utilizing 9-1-1 as the gatekeeper to CPR initiation is harmful.

If the predominant parental belief is that CPR should only be initiated after receiving the “go-ahead” from the 9-1-1 call taker, then the system has failed. Finally, innovative strategies such as PulsePoint, a CAD connected smartphone app, can provide a unique launch point for increasing community engagement. EMS agencies should be driving this type of engagement within their local communities in order to get the word out on how early CPR dramatically impacts outcomes.

3. Listen to every pediatric cardiac arrest 911 audio

The second step in the chain of survival is telecommunicator CPR (T-CPR). If a parent has not initiated CPR prior to the call to 9-1-1, the call taker holds the critical lifeline to neurologic intact survival. How do you know how well your community is doing? The answer is simple – listen to the tapes – every single one. This habit will yield enormous insight into what is truly happening in your community. It may even explain disparities in outcomes when compared to similar communities. Here are some simple things to look for:

• Has CPR been started prior to the 911 call?
• How does the call taker determine the presence of cardiac arrest?
• How fast does the call-taker get the caller to put hands-on-chest?
• What is the sentence construction of the call-taker – is it an active or passive voice?
  • “Are you able to start CPR” vs. “I need you to start CPR now.”

As an initial exercise, listen to the next five 9-1-1 calls (pediatric and adult). Once you do this it’s time to begin a formal CQI plan for T-CPR based on an important AHA scientific publication on the topic. Published performance measures include:

1. Percentage of total Out-of-Hospital Cardiac Arrest (OHCA) cases correctly identified by Public Safety Answering Point (PSAP) (Performance goal 75%).
2. Percentage of OHCA cases correctly identified by PSAP that were recognizable (Performance goal 95%).
3. Percentage of call-taker recognized OHCA receiving T-CPR (Performance goal 75%).
4. Median time between 911 call and OHCA recognition
5. Median time between 911 call and first T-CPR directed compression

4. Implement a “No-No-Go” strategy for T-CPR

Diving a bit deeper into T-CPR, great work has been done by the group in Seattle, notably Drs. Mickey Eisenberg and Thomas Rea as well as Dr. Ben Bobrow in Arizona. The strategy they utilize is called “No-No-Go” and it’s quite impactful. (4,5) The call-taker must quickly determine “is the patient responsive?” and “is the patient breathing normally?” If answers to both questions are “No” then it’s “Go” (CPR is started).

The recently released AHA performance benchmark time, described above, for first compression directed by telecommunicators is less than 180 seconds from time of call, or less than 120 seconds from address acquisition. (6) To accomplish this, the time to hands-on-chest must be a metric that the call-takers are evaluated on. Hands-on-chest within 180 seconds requires close collaboration between medical direction, EMS leadership and dispatchers. It is important to emphasize that “No-No-Go” works extraordinarily well when coupled with the flexibility of an empowered dispatch system that allows “suspension” of the typical 9-1-1 interrogation methods. Importantly, after implementation, a dedicated team should review each call, evaluate the metrics, and refine the process with a continued focus on quality improvement. (6)

This type of process can also benefit from collaboration with other EMS colleagues. For example, Julie Buckingham, EMD QI Program Manager at King County EMS, assisted the Anchorage Fire Department (AFD) with T-CPR and “No-No-Go” through the Resuscitation Academy. At this year’s Eagles Conference in Dallas, Dr. Mike Levy, AFDs Medical Director, attributed the training to a measurable improvement in outcomes.

Figure: Excerpted from AHA T-CPR Program Recommendations and Performance Measures (6)

5. Have a pre-arrival discussion with your partner en-route to the scene

EMS professionals begin their care of the patient before arriving on scene. Dr. Daniel Kahneman coined the term ‘System 1 Thinking,’ which, amongst other things, describes how the human brain begins to play out scenarios immediately after hearing information (e.g. “5 –year-old in arrest”). (7) It’s an automatic process and occurs at warp speed. EMS professionals, as it turns out, also decide whether they will stay on scene before they arrive to the scene. Since System 1 cannot be activated prior to arrival in the pediatric scenario (weight not known until after arrival), the brain immediately leans toward leaving – a defeat before the battle has begun!

To counteract this, a pre-arrival discussion between the EMS team en-route to the scene is imperative. We educate providers to rapidly determine the dose of Epinephrine 0.1 mg/mL for cardiac arrest prior to arrival and then divide roles into a “front person,” who addresses the child and family, and a second provider who draws up medications and provides equipment. This critical step gives clear direction, manages crews’ expectations and has the potential to significantly sway outcomes.

6. Add an age based dosing strategy and customize the tool to your agency

The length-based tape is important and has saved countless lives over the years, yet there is a significant drawback to only using a length-based tool. It prohibits the provider from starting the pre-arrival portion of the call – a step which plays directly into confidence and willingness of the provider to provide high quality on-scene care. Knowing the volume of cardiac arrest Epinephrine prior to arrival on scene of a pediatric arrest will make a significant impact on outcomes. Doing so will allow children to receive the same high quality field care that adult cardiac arrest victims receive.

Data demonstrates that utilizing a customized age-based dosing tool provides the same accuracy as length-based estimation, while also decreasing pediatric medication errors by 3-fold. (8,9) So, while a length-based tape is essential, it should enter your algorithm secondarily, and only as needed (age unknown, child larger or smaller than stated age, or if the provider is unsure). Understanding that the resuscitation sequence truly begins prior to arrival makes this point easier to comprehend.

7. Own the scene

When the doors of the ambulance open after you arrive on scene, family members are often panicked and desperate for help. This will often lead to increased provider anxiety, especially during calls that require rapid and effective care. Overcoming this issue requires you to channel your inner ‘Dr. Phil.’ A calming and confident demeanor combined with effective communication is of critical importance. To get to this place, pre-hospital pediatric training must incorporate training focused on communication and on-scene demeanor with small doses of simulated parental stress to inoculate the learner. The Resuscitation Academy in Seattle does a superb job teaching high performance CPR. Using their methodologies along with the well-rehearsed (scripted) communicative strategies described will yield long term results.

8. Stay on scene with kids in cardiac arrest

There should be no doubt that moving pediatric arrest patients to the ambulance in order to “get to the hospital quickly” is the wrong thing to do. A 2016 study demonstrated that outcomes in pediatric out-of-hospital cardiac arrest were highest if providers stayed on scene for 25-30 minutes. (10) This is exactly what we do for adults and there is no reason that children shouldn’t receive the same standard of care. If a parent or a police officer brings the child to your arriving vehicle, it’s ok to utilize the back of the ambulance, but don’t roll the wheels, and be sure to have a team member explain to the family why the ambulance isn’t moving.

With the proper tools and education you should be able to ask your crews for a minimum of one round of ALS on scene. The training needed to accomplish this goal is 4 hours. Then, once outcomes improve, adult and pediatric care will gradually align, and on-scene time will increase for the pediatric population. Crews in all 50 States are now staying on scene longer than they ever have to achieve ROSC simply by changing the context and understanding Kahneman’s psychological principles. Many more children will have the chance to live normal lives if we focus our efforts on this important practice.

9. Get to Closure

The arrest lifecycle of the paramedic starts when the tones go off at the station. En-route preparation and on-scene care are the two pillars that help balance the emotional toll a provider takes on an arrest call. To get to closure emotionally, the pre-hospital provider must be able to feel that they gave the child the best chance to survive. An op-ed in JAMA last year labeled this phenomenon ‘Resuscitations that never end.’ (11) It explained that if building blocks of closure have not been reached, the provider will never get closure, and over a 30-year career this is a deadly combination. The risk of suicide for EMS professionals is three times that of the lay-population, and not getting to closure is a critical piece of this puzzle.

10. Treat kids like little adults

Yes I said it. As a pediatric emergency physician turned EMS Medical Director, I have seen the light, and have made a 180-degree turn with my feeling towards this issue. I was taught throughout my career that “kids are not just little adults” and there is still truth to this – for the non-emergent situation. However, a child in cardiac arrest, or one having a seizure, or a hypoglycemic episode, should receive the same algorithmic therapy as the adult with the same 3 problems. Convincing health care providers that a “different treatment” is required creates anxiety and diminishes the confidence of those very providers. Based on the research done by Kahneman, we know that this mentality will always result in “load and go” pathology. It’s time that we re-align the emergency care for children with that of the adult. It must start in paramedic schools and continue to field care across this country.

References:

1. Becknell, J., Simon, L. (2016, December). Beyond EMS data collection: Envisioning an information-driven future for Emergency Medical Services (Report No. DOT HS 812 361). Washington, DC: National Highway Traffic Safety Administration.
2. Naim MY, Burke RV, McNally BF, et al. Characteristics and impact of bystander cardiopulmonary resuscitation following pediatric out of hospital cardiac arrest in the United States: a study from the Cardiac Arrest Registry to Enhance Survival (CARES). Program and abstracts of the American Heart Association Scientific Sessions; November 7-11, 2015; Orlando, Florida. Abstract 16428.
3. Fleischhackl, R., Nuernberger, A., Sterz, F., Schoenberg, C., Urso, T., Habart, T., … Chandra-Strobos, N. (2009). School children sufficiently apply life supporting first aid: a prospective investigation. Critical Care, 13(4), R127. http://doi.org/10.1186/cc7984
4. Bobrow BJ, Spaite DW, Vadeboncoeur TF, Hu C, Mullins T, Tormala W, Dameff C, Gallagher J, Smith G, Panczyk M. Implementation of a Regional Telephone Cardiopulmonary Resuscitation Program and Outcomes After Out-of-Hospital Cardiac Arrest. JAMA Cardiol. 2016;1(3):294–302. doi:10.1001/jamacardio.2016.0251
5. Eisenberg MS, Bobrow BJ, Rea T. Fulfilling the Promise of “Anyone, Anywhere” to Perform CPR. JAMA. 2014;311(12):1197–1198. doi:10.1001/jama.2014.1485
6. Telephone CPR (T-CPR) Program Recommendations and Performance Measures. American Heart Association Website: http://bit.ly/2wbeRQL
7. Kahneman, D. Thinking, Fast and Slow. New York, NY: Farrar, Straus and Giroux; 2011
8. Young, T. et al. Finger counting: an alternative method for estimating pediatric weights. American Journal of Emergency Medicine. Volume 32, Issue 3, Pages 243–247, March 2014.
9. Rappaport, L. et. al., Comparison of Errors Using Two Length-Based Tape Systems for Prehospital Care in Children. Prehosp Emerg Care. 2016 Jul-Aug;20(4):508-17.
10. Tijssen JA et. al., Time on the scene and interventions are associated with improved survival in pediatric out-of-hospital cardiac arrest. Resuscitation. 2015 Sep;94:1-7. doi: 10.1016/j.resuscitation.2015.06.012.
11. Thomas TA, McCullough LB. Resuscitations That Never End Originating From Unresolved Integrity-Related Moral Distress. JAMA Pediatr. 2016;170(6):521–522. doi:10.1001/jamapediatrics.2016.0030

About the Author

Peter Antevy, MD, is the Founder and Chief Medical Officer of Pediatric Emergency Standards, Inc., and innovator of the Handtevy Pediatric System. He serves as the EMS Medical Director for the Coral Springs Fire Department, Davie Fire Rescue, Southwest Ranches Fire-Rescue, American Ambulance and Transitional Health Solutions in Florida. He is associate EMS Medical Director for Palm Beach County Fire Rescue and the Seminole Tribe of Florida’s Fire Rescue Department. Dr. Antevy also serves as Medical Director at the Coral Springs Fire Academy and for Broward College’s EMS program and is a pediatric emergency medicine physician at Joe DiMaggio Children’s Hospital in Hollywood, Fla. Reach him at Peter@Handtevy.com.