Liebe Kolleg*innen
Die Reanimation mit dem besten Outcome ist immer noch jene, welche nie stattgefunden hat, weil sie verhindert werden konnte. Die Prävention, das frühzeitige Erkennen eines kritischen Zustandes und das sofortige Treffen geeigneter Massnahmen, um eine weitere Verschlechterung zu verhindern, ist von zentraler Bedeutung.
Wenn es dennoch zu einem Herz-Kreislaufstillstand bei einem Kind kommt, muss die Reanimation lückenlos und qualitativ hochwertig durchgeführt werden.
Um dies zu gewährleisten, müssen die involvierten Fachleute entsprechend geschult und regelmässig trainiert werden.
Seit vielen Jahren engagieren sich hochmotivierte, fachlich bestens ausgebildete und im klinischen Alltag routinierte Instruktor*innen und Trainer*innen in verschiedenen Kursformaten und Simulationen, um Berufskolleg*innen auf den Ernstfall vorzubereiten. Je nach Bildungsformat erfolgt die Schulung individuell oder in interprofessionellen, interdisziplinären Behandlungsteams.
Eine systematische und flächendeckende Reanimations-Datenerfassung fehlt bisher in den deutschsprachigen Ländern Europas (DACH-Länder Deutschland, Österreich und Schweiz). Abgeleitet von den Zahlen aus Amerika oder Japan kann man davon ausgehen, dass in den DACH-Ländern infolge Herz-Kreislaufstillstand jährlich ca. 5’000 pädiatrische Patienten reanimiert werden. 1), 2)
Auch wenn sich die Überlebensrate im Laufe der Zeit verbessert hat, bleibt das Outcome bei Kinderreanimationen verbesserungswürdig. Die Morbiditätsfolgen sind für die Patient*innen, das Umfeld wie auch für die Gesellschaft enorm. 3)
Die Autoren des vorliegenden DACH Positionspapiers empfehlen die Implementierung von 10 evidenz-basierten Thesen in den Berufsalltag, um damit die Überlebensrate und die Morbidität pädiatrischer Patienten im Falle einer Reanimation weiter zu verbessern.
POLICY BRIEF
published: 07 October 2020
doi: 10.3389/fped.2020.549710
Frontiers in Pediatrics | www.frontiersin.org 1October 2020 | Volume 8 | Article 549710
Edited by:
Arjan Te Pas,
Leiden University, Netherlands
Reviewed by:Philipp Deindl,
University Medical Center
Hamburg-Eppendorf, Germany Robert Jan Houmes,
Erasmus Medical Center, Netherlands
*Correspondence:Florian Hoffmann
florian.hoffmann@
med.uni-muenchen.de
Specialty section:
This article was submitted to
General Pediatrics and Pediatric Emergency Care,
a section of the journal Frontiers in Pediatrics
Received: 07 April 2020
Accepted: 31 August 2020
Published: 07 October 2020
Citation:
Jung P, Brenner S, Bachmann I,
Both C, Cardona F,
Dohna-Schwake C, Eich C, Eifinger F, Huth R, Heimberg E, Landsleitner B, Olivieri M, Sasse M, Weisner T,
Wagner M, Warnke G, Ziegler B, Boettiger BW, Nadkarni V and
Hoffmann F (2020) More Than 500
Kids Could Be Saved Each Year! Ten
Consensus Actions to Improve Quality of Pediatric Resuscitation in
DACH-Countries (Austria, Germany,
and Switzerland).
Front. Pediatr. 8:549710.
doi: 10.3389/fped.2020.549710 More Than 500 Kids Could Be Saved
Each Year! Ten Consensus Actions to
Improve Quality of Pediatric
Resuscitation in DACH-Countries
(Austria, Germany, and Switzerland)
Philipp Jung
1
, Sebastian Brenner 2
, Iris Bachmann 3
, Christian Both 3
,
Francesco Cardona 4
, Christian Dohna-Schwake 5
, Christoph Eich 6
, Frank Eifinger 7
,
Ralf Huth 8
, Ellen Heimberg 9
, Bernd Landsleitner 10
, Martin Olivieri 11
, Michael Sasse 12
,
Thomas Weisner 1
, Michael Wagner 4
, Gert Warnke 13
, Bernhard Ziegler 14
,
Bernd W. Boettiger 15
, Vinay Nadkarni 16
and Florian Hoffmann 11
* on behalf of Austrian 17
,
German 18
, Swiss 19
Resuscitation Councils
1 University Children’s Hospital, University Hospital Schl eswig-Holstein, Lübeck, Germany,2
Neonatology and Pediatric
Intensive Care, University Hospital Carl Gustav Carus, Univ ersity of Dresden, Dresden, Germany,3
University Children’s
Hospital Zürich, Zurich, Switzerland, 4
Division of Neonatology, Pediatric Intensive Care and Neuro pediatrics, Department of
Pediatrics, Medical University of Vienna, Vienna, Austria ,5
Department of Pediatrics, University Medicine Essen, Esse n,
Germany, 6
Department of Anaesthesia, Pediatric Intensive Care and Eme rgency Medicine, Auf der Bult Children’s Hospital,
Hanover, Germany, 7
Children’s Hospital, Cologne, Germany, 8
University Children’s Hospital, Mainz, Germany, 9
Department
of Pediatric Cardiology, Pulmology and Intensive Care Medic ine, University Children’s Hospital, Tuebingen, Germany,
10 Children’s Hospital, Nuremberg, Germany, 11
Dr. von Hauner University Children’s Hospital, Ludwig-Max imilians-University
Munich, Munich, Germany, 12
University Children’s Hospital, Medical School Hannover, Hanover, Germany,13
University
Children’s Hospital Graz, Graz, Austria, 14
University Children’s Hospital Salzburg, Salzburg, Austr ia,15
Department of
Anaesthesiology and Intensive Care Medicine, Medical Facul ty, University Hospital of Cologne, Cologne, Germany,
16 Children’s Hospital of Philadelphia, University of Pennsy lvania Perlman School of Medicine, Philadelphia, PA, Unite d States,
17 Austrian Resuscitation Council, Graz, Austria, 18
German Resuscitation Council, Ulm, Germany, 19
Swiss Resuscitation
Council, Zurich, Switzerland
• Quality and outcome of pediatric resuscitation often does not achieve recommended
goals.
• Quality improvement initiatives with the aim of better sur vival rates and decreased
morbidity of resuscitated children are urgently needed.
• These initiatives should include an action framework for a comprehensive,
fundamental, and interprofessional reorientation of clin ical and organizational
structures concerning resuscitation and post-resuscitat ion care of children.
• The authors of this DACH position statement suggest the imp lementation of 10
evidence-based actions (for out-of-hospital and in-house cardiac arrests) that should
improve survival rates and decrease morbidity of resuscita ted children with better
neurological outcome and quality of life.
Keywords: cardiopulmonary resuscitation, children, cardi ac arrest, quality improvement, patient safety, pediatric
Jung et al.Ten Actions to Improve Pediatric CPR
INTRODUCTION
Until recently, circulatory/respiratory arrest in children
has received little attention in DACH-countries (Austria,
Germany, and Switzerland). Exact numbers of children needing
resuscitation are not available for DACH due to insufficient
registry and audit infrastructure. When data from North
America and Japan are extrapolated, ∼5,000 cardiac arrests in
children (in- and out of hospital) occur in the DACH-countrie s
per year (
1,2).
Despite a generic trend of improvement in survival rates
over time, the overall outcome after cardiac arrest in child ren is
still poor. Many successfully resuscitated pediatric patient s have
reduced quality of life with persistent impairments in physica l,
psychological, and executive function, as well as emotional
impairment, which are of considerable concern to families an d
society (
3).
Recent studies show that the quality of pediatric resuscitati on
often does not achieve recommended standards (
4–6). Based
on substantial international study data, the authors of thi s
DACH position statement suggest the implementation of 10
evidence-based actions (for out-of-hospital and in-house c ardiac
arrests, OHCA and IHCA) that should improve survival rates
and decrease morbidity of resuscitated children with bette r
neurological outcome and quality of life. Due to existing da ta
survival rates with good neurological outcome (PCPC 1 and 2)
in OHCA are between 2 and 12%, in IHACA 19–39% (
7–10).
Depending on that our initiative in actions could improve the
rate of survival with good neurological outcome in a range fr om
10 (OHCA) to 20% (IHCA). This would roughly estimated lead
up to a minimum of 500 children/year with better outcomes in
DACH-countries, with a total of >35,000 life-years saved.
The following 10 actions/theses—like the “10 Bad Boll These s
for 10,000 lives” (
11) published for adult resuscitation—are
intended to provide the action framework for a comprehensive,
fundamental, and interprofessional reorientation of clini cal and
organizational structures concerning resuscitation and po st
resuscitation care of children. The following theses and ba sic
principles are also endorsed by the Austrian, German, and Swis s
Resuscitation Councils.
ACTIONABLE RECOMMENDATIONS
Action/Thesis 1
Preventing pediatric cardiac arrest has the highest priority. The best resuscitation is one that was prevented (
12).
Although there is contradictory evidence for the benefit of
early warning scores (
13–15), especially for the reduction of
mortality, we call for highlighting this topic with advancin g
systematic implementation and promoting further development
and validation of early warning systems. Medical emergency
teams must be formed to take care of these children at risk
for resuscitation.
Action/Thesis 2
Regular mandatory training in basic life support focusing on
adequate chest compressions and ventilation improves patient outcome. Additional short “just-in-time” training sessions
can
improve the retention of resuscitation skills. Pediatric basic life support (PBLS) should be practiced with al l
staff caring for acute ill pediatric patients in inter-professionaland
interdisciplinary training sessions (
16–21).
The timely initiation of basic life support and proper
performance of high quality CPR including the use of an
automated external defibrillator (AED) is a mandatory skill for
health care providers. High quality PBLSis characterized by
correct depth and rate of compression, adequate chest recoil,
and sufficient ventilation. Interruptions need to be minimize d.
Provision of optimal PBLS has been shown to improve the
survival of children (
22,23).
During training, participants should receive adequate
feedback on performance by real-time audio-visual feedback
devices and instructors (
24,25). These instructors should be
qualified trainers ∗
[e.g., for internationally approved course
formats by the European Resuscitation Council (ERC) or the
American Heart Association (AHA)]. Training groups should
not exceed eight participants. Although it is unclear what the
best training frequency should be, we suggest training sess ions
twice annually and for at least 2 h each,also because that seems
to be convertible. These sessions must be mandatory and offere d
during ones regular schedule. Additionally “just-in-time” training may be provided to
frontline providers to refresh resuscitation skills and are intended
to support regular PBLS trainings. “Rolling refresher” means
a manikin is positioned on a cart which is “rolled” directly
on to the ward. This training is short (5–10 min) and low-
threshold. Content and frequency of training may be adapted
to individual needs and have been successfully implemented t o
improve necessary basic skills or chest compression quality i n
particular (
26–29).
Action/Thesis 3
Medical staff working with acutely ill infants should receive
appropriate pediatric life support training (e.g., EPALS, PALS,
PEARS, EPILS, etc., according to their role). This training
must include aspects of crew-resource management. Further
research on the most effective mechanisms to provide training
is needed. All medical staff working in high-risk areas ( intensive care
units ,high dependency units , andpediatric emergency rooms)
should receive appropriate pediatric advanced life support
training titrated to their scope of practice. Internationall y
approved course formats are provided by the European
Resuscitation Council (ERC) [EPALS] or by the American Heart
Association (AHA) [PEARS, PALS]. These formats extend training to advanced issues during
resuscitation, and also include team aspects such as teamwork
and leadership, task management, timely decision making, as w ell
as situation awareness. They also teach adequate provision of c are
to critically ill patients (preventing resuscitation) as outl ined by
current ILCOR resuscitation guidelines.
Recent initiatives to improve resuscitation efforts in pediatri cs
have focused on the implementation of action-linked phrases,
cognitive aids, rapid cycle deliberate practice, CPR coaches ,
Frontiers in Pediatrics | www.frontiersin.org 2October 2020 | Volume 8 | Article 549710
Jung et al.Ten Actions to Improve Pediatric CPR
comprehensive debriefing, and simulation training ( 29).
Reflection on current practice and research to provide the most
effective way of optimize resuscitation efforts and how to train
staff are urgently needed.
Action/Thesis 4
The use of objective (e.g., live feedback systems) and subjective
feedback (e.g., CPR-coach) optimizes the quality of chest
compressions and should be used in both, training as well as
in daily prehospital and clinical work. Quality of basic life support skills, especially chest
compressions, decisively impacts patient outcome and can
be optimized by using live feedback systems (
30,31). Feedback
systems approved for pediatric patients should be routinely
used. They can increase chest compression quality by offering
real-time information about compression rate, compression
depth, and leaning force. They should be routinely used in
training sessions as well as in daily in- and out-of-hospital
routine. Therefore, they should be cost-effective and easy to use.
However, during both real and simulated cardiac arrests,
providers often deliver poor CPR despite receiving visual (and
sometimes verbal) feedback from the defibrillator. A CPR coac h
is a trained person who provides real-time verbal feedback of
CPR performance and improves compliance to CPR guidelines.
This also supports the resuscitation leader so she/he can focu s
on other aspects during resuscitation. In the presence of CPR
feedback technology, the addition of a trained CPR coach int o
resuscitation teams adds to CPR quality metrics which in tur n
are associated with improved survival outcomes from pediatri c
cardiac arrest (
32–34).
Action/Thesis 5
Structured debriefings of resuscitations lead to improvements
in care and outcomes of resuscitated children. Structured debriefings of emergency situations are already
recommended by the ERC and other resuscitation societies.
Debriefings can take place immediately (“hot”) and/or after a
certain period of time (“cold”) after the resuscitation even t.
Ideally, they should include at least the team members invol ved
in the code. Participation in debriefings may also include non –
involved team members as these debriefings are a valuable
learning opportunity. Debriefings have a positive impact on team
performance and employee satisfaction, leading to an increas e of
the quality of care. Furthermore, they increase survival ra tes of
resuscitated children (
35,36).
Action/Thesis 6
Post-resuscitation treatment is critical to improve outcome
of resuscitated children and should follow standardized
protocols. The aim is to set up specialized centers for pediatric
post-resuscitation care. As in adults, post-resuscitation treatment and the level of
care for children after cardiac arrest impacts outcome (
37).
Treatment includes targeted temperature management, lung-
protective ventilation achieving normoxia, and the preventi on of
hypocapnia. Furthermore, managing blood pressure to provide
adequate cerebral perfusion, avoid burden of hypotension (
38), avoiding disturbances of blood glucose and electrolytes,
administering adequate analgesia and sedation, as well as
monitoring to detect and treat status epilepticus are mandato ry.
Care also extends to the family of the patient and initiation
of early rehabilitation of pediatric patients after resuscita tion
(
39–42). This level of care is not available in every pediatric
department. Therefore approved “Pediatric Cardiac Arrest
Centers,” either physical or virtual, should be established
correspondingly to post-resuscitation care centers in adult s (
43).
These centers may also support less specialized units (e.g., by
telemedicine) in initial stabilization or allow transfer o f these
children to these centers.
Action/Thesis 7
Basic data of every resuscitated child should be entered into an
audit or registry. Registry participation should be obligatory
for every hospital and EMS system, and should include
preclinical, in-hospital, and post-hospital outcome data. Although a resuscitation registry currently exists in German y,
very little data of resuscitated children in the DACH region
are recorded. Establishing a registry that collects preclinic al, in-
hospital, and post-hospital outcome (neurological and in gener al)
data from every pediatric resuscitation is essential to guar antee
quality improvement. As existing data bases are still voluntary ,
steps must be taken to ensure every hospital treating pediatric
patients participates in either a local, European, or worldwide
registry (e.g., Pediatric Resuscitation Quality Collabora tive,
PediResQ, https://www.pedires- q.org) (
44,45).
A template for a successful registry is the TraumaRegister R
of
the German Trauma Society (DGU, http://www.traumaregister-
dgu.de/index.php?id=144), which has set standards worldwid e
for the quality management of seriously injured patients (
46).
At present, it involves nine countries with over 700 participat ing
hospitals and more than 270,000 documented cases since 1993.
Action/Thesis 8
Children’s hospitals require regular exchange and networking
to deliver better quality of care and improve quality. In addition to post-resuscitation therapy, successfully
resuscitated children often require treatment from severa l
pediatric sub-specialties (e.g., pediatric intensive care, n eurology,
cardiology, infectious disease, radiology, psychology, and
rehabilitation). However, only few children’s hospitals ca n
offer all of these services. Despite of a centralization in post-
resuscitation care the implementation of telemedical and ot her
network structures are needed to provide comprehensive health
care to ensure quality and efficiency. As in Neonatology certai n
parameters should be identified that reflect quality of care (
47).
These parameters should allow a comparability of care and
identify further research and education topics.
Action/Thesis 9
Every children’s hospital should have medical and nursing
supervisors for clinical resuscitation who are responsible
for implementing adequate on-site and ongoing pediatric
resuscitation services and training.
Frontiers in Pediatrics | www.frontiersin.org 3October 2020 | Volume 8 | Article 549710
Jung et al.Ten Actions to Improve Pediatric CPR
The quality of resuscitation after IHCA and related outcomes
vary greatly from hospital to hospital and also from time
of day (
48,49). In order to achieve the best possible result
from resuscitation, a dedicated contact person is necessary .
This “resuscitation supervisor” should be established in ev ery
children’s hospital. The primary tasks of the supervisor are the implementation,
organization, education, and monitoring of in-hospital
resuscitation training and data management. In addition,
this person should be the central point of contact for all
matters related to pediatric resuscitation in the hospital an d
the preferred contact for other external hospitals or emergen cy
services. The resuscitation supervisor has to be supported
effectively by the hospital management in terms of time, logist ics,
and administration.
Action/Thesis 10
Hospitals should aim to implement and integrate
all recommendations above
to achieve improvements in
pediatric resuscitation. In order to improve the outcome of critically ill children in
the long-term, a comprehensive and unified system concept is
needed. Ideally, allof the above actions should be considered and
implemented as a complete package. However, it may be more feasible to start with few elements
first and aim to implement the others stepwise until the complete
proposed bundle is put into practice.
CONCLUSIONS
Physical and mental disability resulting from a child’s car diac
arrest is of exceptional family and societal importance. The t otal
number of pediatric cardiac arrest resuscitations is much lo wer
(10%) compared to adults. However, if outcomes are calculated
in terms of quality of life years saved, the impact has high
economic relevance. With these 10 actions/theses we want to focus the broad field
of topics concerning pediatric resuscitation. It all starts w ith theimportance of improving the prevention and detection of life-
threatening events in children, in order to avoid pediatric c
ardiac
arrest. When resuscitation is necessary, it can only be effect ive
if consistent and effective training is consistently offered and
titrated to the appropriate scope of advanced pediatric care. Learning from every patient is most important. The
quality of resuscitation and post-resuscitation care must be
measured and evaluated, and this data has to be used to
identify challenges to optimize care. A structured collecti on
of treatments and outcome data in a centralized mandatory
audit/registry offers the possibility of identifying in- and
out-of-hospital care strengths (what went well and why) and
challenges and creates roadmaps for quality improvement.
It has to be possible that short and long-term outcomes
are linked with the initial resuscitation parameters to
learn and show how the early performance impacts the
later outcome. Our goal is to improve the outcome after pediatric cardiac
arrest in the DACH-region and around the world. We feel
confident that the implementation of these 10 actions/theses w ill
improve current care and be of great benefit for all.
AUTHOR CONTRIBUTIONS
All authors conceived and designed the consensus of the 10
actions for improvement of pediatric CPR. All authors performed
substantial revisions of this article. All authors gave the ir final
approval of the version to be published.
FUNDING
A constituting meeting of the working group in March 2018 was
financially supported by the company ZOLL Medical.
ACKNOWLEDGMENTS
These actions are endorsed by the Austrian, German, and Swis s
Resuscitation Councils.
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Conflict of Interest: The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be c onstrued as a
potential conflict of interest.
Copyright © 2020 Jung, Brenner, Bachmann, Both, Cardona, Dohna- Schwake, Eich,
Eifinger, Huth, Heimberg, Landsleitner, Olivieri, Sasse, Wei sner, Wagner, Warnke,
Ziegler, Boettiger, Nadkarni and Hoffmann. This is an open-acc ess article distributed
under the terms of the Creative Commons Attribution License (CC BY). The use,
distribution or reproduction in other forums is permitted, p rovided the original
author(s) and the copyright owner(s) are credited and that th e original publication
in this journal is cited, in accordance with accepted academ ic practice. No use,
distribution or reproduction is permitted which does not co mply with these terms.
Frontiers in Pediatrics | www.frontiersin.org 6October 2020 | Volume 8 | Article 549710
Darüber hinaus hat der Swiss Resuscitation Council SRC mit der «nationalen Überlebensstrategie bei Kreislaufstillstand» und dem daraus abgeleiteten Selbstbeurteilungstool ein Instrument entwickelt, mit dessen Hilfe die verschiedenen Mitglieder der Rettungskette (wie Rettungsdienste, Ärzt*innen in der eigenen Praxis, Spitäler etc) die Reife ihres Reanimationssystems bestimmen und allfälligen Handlungsbedarf identifizieren können.
Ich danke an dieser Stelle allen Instruktor*innen und Trainer*innen für ihr hohes Engagement und die unermüdliche Bereitschaft, Wissen zu teilen und Fertigkeiten zu vermitteln.
Ich danke auch Ihnen, liebe Leser*innen, dass Sie am Ball bleiben und für Ihr Interesse, sich selber und im Team kontinuierlich weiter zu bilden, um auch in diesem Bereich gemeinsam besser zu werden.
Den Verantwortlichen der präklinischen und innerklinischen Versorgung unserer Patienten gilt es zu danken für die Schaffung der nötigen Infrastruktur und den passenden Rahmenbedingungen, um die optimale Reanimation und die anschliessende Versorgung im Team zu erlernen und zu trainieren und durch ein fundiertes Debriefing nach einer Reanimation wichtige Erkenntnisse zu gewinnen.
Von all dem profitieren letztendlich unsere jungen Patient*innen.
Quellen
Nagata T, Abe T, Noda E, Hasegawa M, Hashizume M, Hagihara A. Factors associated with the clinical outcomes of pediatric out-of-hospital cardiac arrest in Japan. BMJ Open. (2014) 4:e003481. doi: 10.1136/bmjopen-2013-003481
Girotra S, Spertus JA, Li Y, Berg RA, Nadkarni VM, Chan PS. American heart association get with the guidelines-resuscitation investigators. Survival trends in pediatric in-hospital cardiac arrests: an analysis from Get with the Guidelines-Resuscitation. Circ Cardiovasc Qual Outcomes. (2013) 6:42–9. doi 10.1161/CIRCOUTCOMES.112.967968
van Zellem L, Utens EM, Madderom M, Legerstee JS, Aarsen F, Tibboel D, et al. Cardiac arrest in infants, children, and adolescents: long-term emotional and behavioral functioning. Eur J Pediatr. (2016) 175:977–86. doi: 10.1007/s00431-016-2728-4
Weitere Informationen
Korrespondenz:
Autoren/Autorinnen
Dr. med. Iris Irene Bachmann Holzinger , Interdisziplinäre Notfallstation Simulations- und Trainingszentrum, Universitäts- Kinderspital Zürich - Eleonorenstiftung
