Clinical paperHospital ECMO capability is associated with survival in pediatric cardiac arrest
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)
- et al.
Survival from pediatric out-of-hospital cardiac arrest during nights and weekends
JACC Asia
(2022) - et al.
Unchanged pediatric out-of-hospital cardiac arrest incidence and survival rates with regional variation in North America
Resuscitation
(2016) - et al.
The association between hospital type and mortality among critically ill children in US EDs
Resuscitation
(2013) - et al.
Outcomes of paediatric out-of-hospital cardiac arrest according to hospital characteristics defined by the annual number of paediatric patients with invasic mechanical ventilation: A nationwide study in Japan
Resuscitation
(2020) - et al.
Association between Hospital volume of cardiopulmonary resuscitation for in-hospital cardiac arrest and survival to Hospital discharge
Resuscitation
(2020) - et al.
Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial
Lancet (British Ed)
(2009) - et al.
Validation of an ICD code for accurately identifying emergency department patients who suffer an out-of-hospital cardiac arrest
Resuscitation
(2018) - et al.
Early ECPR for out-of-hospital cardiac arrest: Best practice in 2018
Resuscitation
(2018) - et al.
Trends in survival after pediatric in-hospital cardiac arrest in the United States
Circ (New York, NY)
(2019) - et al.
Heart disease and stroke statistics-2021 Update: A report from the American Heart Association
Circ (New York, NY)
(2021)
Survival after out-of-hospital cardiac arrest in children
J Am Heart Assoc
Outcomes after in-hospital pediatric recurrent cardiac arrests
Pediatr Crit care Med
Hospital variation in survival after pediatric in-hospital cardiac arrest
Circ Cardiovasc Qual Outcomes
Association between hospital teaching status and outcomes after out-of-hospital cardiac arrest
Circ Cardiovasc Qual Outcomes
A national analysis of the relationship between hospital factors and post-cardiac arrest mortality
Intensive Care Med
Therapeutic hypothermia after out-of-hospital evaluation of a regional system to increase access to cooling
Circ (New York, NY)
Statewide regionalization of postarrest care for out-of-hospital cardiac arrest: Association with survival and neurologic outcome
Ann Emerg Med
Usefulness of cardiac arrest centers – Extending lifesaving post-resuscitation therapies: The Arizona experience
Circ J
Cited by (4)
Advances in pediatric emergency from 2023
2024, American Journal of Emergency MedicineCardiopulmonary Resuscitation, Epinephrine, and Extracorporeal Membrane Oxygenation: Finding the Right Balance
2023, Pediatric Critical Care Medicine