How a QI Project Dramatically Increased Pediatric Survival After Cardiopulmonary Arrest

How a QI Project Dramatically Increased Pediatric Survival After Cardiopulmonary Arrest 150 150 Jeb Phillips

A survival rate of 37-48 percent among young heart surgery patients who experience code events is the norm. A multidisciplinary review process helped achieve an 81 percent rate at Nationwide Children’s Hospital.

Survival rates have remained stubbornly low for young heart surgery patients who experience cardiopulmonary arrest; critical care literature reports that fewer than 50 percent of these patients live to discharge.

The Heart Center at Nationwide Children’s Hospital decided in 2010 to change the way it reviewed code events in an effort to improve outcomes. Traditional mortality and morbidity review conferences can take place long after an event, making it difficult to recreate the exact circumstances. They often also include only physicians, excluding many staff members who provide care.

The new process, described in a recent publication in the American Journal of Critical Care, led the survival rate for these particularly vulnerable patients to climb to 81 percent at Nationwide Children’s. The percentage of code events deemed “preventable” declined as well.

While some initiatives are institution-specific, the process itself is reproducible for many children’s hospitals, says Andrew R. Yates, MD, cardiologist and critical care physician at Nationwide Children’s and senior author of the publication.

“Outside of time from individuals, we used no resources that were not already available,” says Dr. Yates. “What you must have, though, is buy-in from your leadership. The blame-free environment that Nationwide Children’s fosters allows us to conduct these reviews so we can learn about gaps in our knowledge and fix them.”

The crucial step in the process is “casting a wide net” for a multidisciplinary, core group of individuals who will conduct the reviews. The core team at Nationwide Children’s ultimately included two cardiothoracic intensive care physicians, a cardiothoracic surgeon, a cardiologist, a cardiac anesthesiologist, an advanced practice nurse, nursing leaders from the Cardiothoracic Intensive Care Unit (CTICU) and the separate cardiac step-down unit, a nurse educator, a clinical pharmacist, a respiratory therapist and a quality improvement coordinator.

Other staff members who were directly involved in individual events were added when those events were reviewed. It sounds like a large group, but each person has a different perspective on cardiopulmonary arrest, Dr. Yates says. A core group also makes it easier to spot themes from case to case.

Timeliness matters as well. A team member was assigned to gather important clinical data, including telemetry, within 72 hours of an arrest to ensure it was readily available for analysis. The group tried to meet within one week of the event, before memories began to fade.

Between 2010 and 2013, 47 code events were reviewed. The majority of the cases involved patients younger than 1 year, and hypotension/hypoperfusion and acute respiratory insufficiency were the most common causes of arrest. The process led to dozens of changes in the CTICU, in The Heart Center and hospital-wide. Among those that Dr. Yates says were most important:

  • A CTICU physician now serves as medical control for transport and admission of cardiac patients, even if the Emergency Department, Pediatric Intensive Care Unit or Neonatal Intensive Care Unit actually accepts the patient
  • Preoperative screening for respiratory viruses in high risk patients, which has since been expanded to all cardiac surgery patients
  • Standardization of room setups, equipment locations and materials stocked in the CTICU
  • A focus on “closed-loop” communication tools, so that concerns noted by bedside nurses can be effectively transmitted to and addressed by physicians
  • Implementation of monthly care conferences with patient families to improve long-term planning and communication with chronic patients

The process is continuing, says Angela C. Blankenship, lead author of the study and advanced nurse practitioner at The Heart Center.

“We have significantly improved outcomes, and that is exciting for us,” she says. “We will continue our effort to save more lives here, and we hope that our model can help other hospitals save lives as well.”



Blankenship AC, Fernandez RP, Joy BF, Miller JC, Naguib A, Cassidy SC, Simsic J, Phelps C, Harrison S, Galantowicz M, Yates AR. Multidisciplinary review of code events in a heart center. American Journal of Critical Care. 2016 July;25(4):e90-7.

About the author

Jeb is the Managing Editor, Executive Communications, in the Department of Marketing and Public Relations at Nationwide Children's Hospital. He contributes feature stories and research news to PediatricsOnline, the hospital’s electronic newsletter for physicians and other health care providers, and to Pediatrics Nationwide. He has served as a communications specialist at the Center for Injury Research and Policy at The Research Institute and came to Nationwide Children’s after 14-year career as daily newspaper reporter, most recently at The Columbus Dispatch.