Elsevier

Resuscitation

Volume 188, July 2023, 109853
Resuscitation

Clinical paper
Hospital ECMO capability is associated with survival in pediatric cardiac arrest

https://doi.org/10.1016/j.resuscitation.2023.109853Get rights and content

Abstract

Aim

Extracorporeal membrane oxygenation (ECMO) provides temporary support in severe cardiac or respiratory failure and can be deployed in children who suffer cardiac arrest. However, it is unknown if a hospital’s ECMO capability is associated with better outcomes in cardiac arrest. We evaluated the association between pediatric cardiac arrest survival and the availability of pediatric extracorporeal membrane oxygenation (ECMO) at the treating hospital.

Methods

We identified cardiac arrest hospitalizations, including in- and out-of-hospital, in children (0–18 years old) using data from the Health Care Utilization Project (HCUP) National Inpatient Sample (NIS) between 2016 and 2018. The primary outcome was in-hospital survival. Hierarchical logistic regression models were built to test the association between hospital ECMO capability and in-hospital survival.

Results

We identified 1276 cardiac arrest hospitalizations. Survival of the cohort was 44%; 50% at ECMO-capable hospitals and 32% at non-ECMO hospitals. After adjusting for patient-level factors and hospital factors, receipt of care at an ECMO- capable hospital was associated with higher in-hospital survival, with an odds ratio of 1.49 [95% CI 1.09, 2.02]. Patients who received treatment at ECMO-capable hospitals were younger (median 3 years vs 11 years, p < 0.001) and more likely to have a complex chronic condition, specifically congenital heart disease. A total of 10.9% (88/811) of patients at ECMO-capable hospitals received ECMO support.

Conclusion

A hospital's ECMO capability was associated with higher in-hospital survival among children suffering cardiac arrest in this analysis of a large United States administrative dataset. Future work to understand care delivery differences and other organizational factors in pediatric cardiac arrest is necessary to improve outcomes.

Introduction

After a pediatric cardiac arrest, survival remains remarkably low: 6–13% of patients experiencing cardiac arrests outside of the hospital and 24–43% in-hospital survive to hospital discharge.1, 2, 3, 4, 5 There is significant variation in survival among hospitals caring for children experiencing a cardiac arrest, but the factors associated with this variation are not well understood.6 Organizational factors, including hospital teaching status,7, 8 hospital location,8, 9, 10 annual hospital volume of mechanically ventilated pediatric patients,11 and hospital volume of cardiopulmonary resuscitation12 have been associated with outcomes in pediatric cardiac arrest. Specialized centers may allow for concentration of hospital resources and expertise, and has been shown to improve survival among adult cardiac arrest survivors.13, 14, 15, 16 The American Heart Association recommends the regionalization of post-cardiac arrest care, including transporting patients to specialized cardiac arrest centers.17 If the ability to deliver extracorporeal membrane oxygenation (ECMO) is associated with survival in pediatric cardiac arrest, it would be an important factor to consider when identifying specialized cardiac arrest centers.

Providing extracorporeal membrane oxygenation (ECMO) for a child requires intense multidisciplinary coordination and hospital resources. Prior studies have demonstrated an association between receiving care at a center capable of providing ECMO and improved survival in patients with respiratory failure.18, 19, 20 These studies suggest ECMO capability may be an indicator of hospital quality and the teams and resources required to maintain the availability in the center may confer benefit to even those who do not directly receive ECMO.21 Understanding the relationship between ECMO availability and patient survival following cardiac arrest may inform post-arrest care and referral guidance for this high-risk group.

This study uses a large nationally-representative administrative claims database to test the association between a hospital's ECMO capability and survival in pediatric cardiac arrest. We hypothesized treatment at a hospital with the ability to provide ECMO is associated with improved survival in pediatric cardiac arrests.

Section snippets

Data source and study population

We used the Agency for Healthcare Research and Quality (AHRQ) sponsored Health Care Utilization Project (HCUP) National Inpatient Sample (NIS). This database represents a 20% stratified sample of United States hospitals.22 This analysis was determined to be not-regulated as human subjects research by the University of Michigan Institutional Review Board (HUM00197127).

We identified children aged 0–18 years whose admission contained a diagnosis code for cardiac arrest from 2016-2018. Cardiac

Results

We identified 2692 hospitalizations containing a diagnosis of cardiac arrest. After the exclusion of hospitalizations which included a transfer to (n = 1,012) or from the institution (n = 235), a neonatal indication (n = 172), and missing demographic data (zip code or sex) (n = 23), 1276 hospitalizations were included (Table 1). Those 1276 hospitalizations occurred at 599 hospitals across the National Inpatient Sample years 2016, 2017, and 2018 (note that one hospital may be represented

Discussion

In this analysis of a large United States claims database, children hospitalized at an ECMO-capable hospital had a 1.5 times higher odds of survival compared to those hospitalized at a non-ECMO hospital following cardiac arrest. Children who received care at ECMO hospitals were younger and more likely to have complex chronic conditions, including congenital heart disease.

Our study showed an association between hospitals that provided ECMO services and survival after cardiac arrest. We

Conclusions

In this national cohort of pediatric cardiac arrest hospitalizations, hospitalization at an ECMO-capable center was associated with higher odds of survival compared to those hospitalized at non-ECMO centers, despite very few patients receiving ECMO support. Research is needed to understand whether there are practice or organizational differences between ECMO and non-ECMO hospitals that can improve outcomes in this critical population.

Disclosures

RPB is the ELSO Registry Chair and receives support unrelated to this work from the National Institutes of Health R01 HL153519; K12 HL138039. EFC is supported by career development awards from the National Institutes of Health, NHLBI (K12-HL138039).

CRediT authorship contribution statement

Blythe E. Pollack: Conceptualization, Data curation, Formal analysis, Methodology, Visualization, Writing – original draft, Writing – review & editing. Ryan P. Barbaro: Conceptualization, Methodology, Supervision, Visualization, Writing – review & editing. Stephen M. Gorga: Methodology, Visualization, Writing – review & editing. Erin F. Carlton: Methodology, Visualization, Writing – review & editing. Michael Gaies: Methodology, Visualization, Writing – review & editing. Joseph G. Kohne:

Declaration of Competing Interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: ‘Ryan P. Barbaro reports financial support was provided by National Institutes of Health. Erin F. Carlton reports financial support was provided by National Institutes of Health.’.

References (37)

  • N. Jayaram et al.

    Survival after out-of-hospital cardiac arrest in children

    J Am Heart Assoc

    (2015)
  • S.R. Brown et al.

    Outcomes after in-hospital pediatric recurrent cardiac arrests

    Pediatr Crit care Med

    (2020)
  • N. Jayaram et al.

    Hospital variation in survival after pediatric in-hospital cardiac arrest

    Circ Cardiovasc Qual Outcomes

    (2014)
  • A. Czarnecki et al.

    Association between hospital teaching status and outcomes after out-of-hospital cardiac arrest

    Circ Cardiovasc Qual Outcomes

    (2019)
  • B.G. Carr et al.

    A national analysis of the relationship between hospital factors and post-cardiac arrest mortality

    Intensive Care Med

    (2009)
  • M.R. Mooney et al.

    Therapeutic hypothermia after out-of-hospital evaluation of a regional system to increase access to cooling

    Circ (New York, NY)

    (2011)
  • D.W. Spaite et al.

    Statewide regionalization of postarrest care for out-of-hospital cardiac arrest: Association with survival and neurologic outcome

    Ann Emerg Med

    (2014)
  • K.B. Kern

    Usefulness of cardiac arrest centers – Extending lifesaving post-resuscitation therapies: The Arizona experience

    Circ J

    (2015)
  • Cited by (4)

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