Abstract 130: Root Cause Analysis of Cardiopulmonary Resuscitation in Pediatric Cardiac Unit
Background: A systematic comprehensive root cause analysis (RCA) is a powerful method of learning, leading to greater patient safety: Cardiac arrests are known to be the result of patient’s condition and are influenced by factors such as: failure to monitor, observe, or act; delay in diagnosis, inadequate handover, failure to note faulty equipment and or not following an agreed protocol without clinical justification. Objective: The goal of this initiative was to establish an unprejudiced, multidisciplinary team process to analyze all cardiopulmonary resuscitations (CPR) for system improvement and patient outcomes.
Methods: In our tertiary pediatric cardiac intensive care unit (CICU), RCA of each CPR event was initiated as an informative, non-punitive, and continuous quality improvement method within a week of the event to enhance patient management, safety and outcomes. The process included discussions with those who provided the care, and review of all documents relating to case including debriefing and code information.Assimilated information was presented and discussed monthly in a multidisciplinary meeting to understand factors contributing to arrest and suggest and promote strategies to improve the system or modify practice.
Results: From December 2007 to May2013 there were 98 CPR events. Forty-five events occurred during day shift. Surgical patients were classified using RACHS-1 risk categories. There were 5 events in category 2; 25 in 3, 13 in 4, 3 in 5, and 12 in category 6. Eleven events in post hybrid procedure for hypoplastic left heart syndrome, 16 in heart transplant, 5 in preoperative patients and 8 events in other conditions. Median age of patients was 69 days (2days to 19yrs). Median CPR time was 7 mins (1 to 100 mins). There were 33 ECMO support after CPR episodes. In 51 events, review suggested possible areas for improvement in management: residual lesions requiring intervention (10), preload and electrolyte problem (13), hypoxia (7), low cardiac output (10) and multiple factors in 11 events.
Conclusion: RCA after CPR is feasible in a busy pediatric CICU. Considering the complexity of patients, care and system, these reviews can serve as a model tool to enhance patient care, education of team and possibly avert some CPR events.
- © 2013 by American Heart Association, Inc.