Abstract
Objective:
Differences between adult and pediatric in-hospital cardiac arrest (IHCA) are well-described. While most adults are cared for on adult services, pediatric services often admit adults, particularly those with chronic conditions. The objective of this study is to describe IHCA in adults admitted to pediatric services.
Design:
Retrospective cohort analysis from the American Heart Association’s Get With The Guidelines®-Resuscitation registry of a subpopulation of adults with IHCA while admitted to pediatric services. Multivariable logistic regression was used to evaluate adjusted survival outcomes and compare outcomes between age groups (18-21, 22-25, and ≥ 26 years of age).
Setting:
Hospitals contributing to the Get With The Guidelines®-Resuscitation registry.
Patients:
Adult-aged patients (≥ 18 years) with an index pulseless IHCA while admitted to a pediatric service from 2000-2018.
Interventions:
None.
Measurements and Main Results:
A total of 491 adult IHCAs were recorded on pediatric services at 17 sites, during the 19 years of review, and these events represented 0.1% of all adult IHCAs. In total, 221 cases met inclusion criteria with 139 events excluded due to an initial rhythm of bradycardia with poor perfusion. Median patient age was 22 years (interquartile range 19, 28). Ninety-eight percent of patients had at least one pre-existing condition. Return of spontaneous circulation occurred in 63% of events and 30% of the patients survived to discharge. All age groups had similar rates of survival to discharge (range 26-37%, p = 0.37), and survival did not change over the study period (range 26-37%, p = 0.23 for adjusted survival to discharge).
Conclusions:
In this cohort of adults with IHCA while admitted to a pediatric service, we failed to find an association between survival outcomes and age. Additional research is needed to better understand resuscitation in this population.
Keywords: resuscitation, cardiac arrest, cardiopulmonary resuscitation, survival, pediatrics, American Heart Association
Differences between adult and pediatric in-hospital cardiac arrest (IHCA) have been well-described (1–5). When compared with pediatric IHCA, adult IHCAs occur much more frequently, are more likely to be attributable to cardiac conditions, are more likely to occur in non-critical care units than in intensive care units (ICUs), and are more likely to have initial shockable rhythms (1,2,3,6). Approximately 50% of pediatric in-hospital CPR events occur in the setting of an initial rhythm of bradycardia with poor perfusion despite the presence of a pulse (7). In comparison, adult cardiac arrest guidelines do not recommend CPR for patients with a pulse, even for symptomatic bradycardia (8). Survival outcomes also differ between adults and children, with approximately 20% of adults surviving to discharge after IHCA compared with approximately 40% of children (4,5).
While most patients ≥ 18 years of age in the US are cared for on adult services, some adults are admitted to pediatric units (9–11). Previous data have shown that by comparison to their pediatric counterparts, adults admitted to pediatric services are more likely to have chronic conditions (12). A 2013 study also reported an association between older age and increased mortality risk in adults admitted to PICUs (10). To date, description of cardiac arrest in adults admitted to pediatric services has been limited. One study reported 33 instances of IHCA in adult patients admitted to a children’s hospital in a 5-year period (13). In that cohort, the majority of patients (76%) had multiple comorbidities and 64% had congenital heart disease. Overall survival to discharge was 52% and the survival rate was higher in patients 18-24 years of age than in patients 25 years of age and older (78% and 20% respectively, p = 0.002).
The aim of this study was to utilize the American Heart Association’s (AHA) Get With The Guidelines®-Resuscitation (GWTG-R) registry to better characterize IHCA in this population. We hypothesized that older patient age would be associated with lower rates of return of spontaneous circulation (ROSC) and survival to discharge. We also hypothesized that there would be an association between survival outcomes and event time periods, with higher rates of survival in later year groupings.
Materials and Methods
Patients were derived from the GWTG-R registry, a voluntary IHCA quality improvement registry in the US. The Get With The Guidelines® (GWTG) programs are provided by the AHA. Participating hospitals submit information regarding medical history, hospital care, and outcomes of patients hospitalized for cardiac arrest using an online, interactive case report form and Patient Management Tool™ (IQVIA, Parsippany, New Jersey). The registry’s design and data collection have been previously described (13). All participating hospitals are required to comply with local regulatory guidelines. IQVIA serves as the data collection (through their Patient Management Tool – PMT™) and coordination center for the AHA/American Stroke Association GWTG programs. The University of Pennsylvania serves as the data analytic center and has an agreement to prepare the data for research purposes. The present study was reviewed by the Boston Children’s Hospital IRB and determined to be exempt (IRB-P00036223). The corresponding author had full access to all the data and takes responsibility for its integrity and the analysis.
We identified adult-aged patients (≥ 18 years) between 2000 and 2018 with an index pulseless cardiac arrest while admitted to a pediatric service. We defined adults as patients ≥ 18 years to align with GWTG-R classifications: patients ≥ 18 are included in the adult database while patients < 18 are included in the pediatric database. Cases were included if the patient received ≥ 1 minute of CPR and/or defibrillation. Obstetric patients, visitors/employees, and those admitted to non-acute hospitals were excluded.
Variables collected included demographics, pre-arrest and cardiac arrest characteristics, and outcomes. The primary outcome was survival to discharge. Secondary outcomes included ROSC, 24-hour survival, and survival to discharge with favorable or unchanged neurologic outcome. We also described the percentage of events meeting AHA cardiac arrest quality metrics: confirmation of airway device placement in trachea, time to first shock ≤ 2 minutes in events with shockable rhythms, time to epinephrine ≤ 5 minutes in events with nonshockable rhythms, and monitored or witnessed arrest. Due to a large amount of missing data on neurologic status, survival with favorable or unchanged neurologic outcome was omitted from the analysis. We a priori divided the cohort into 3 groups (18-21 years of age, 22-25 years of age, and 26 years of age and older) to assess the association between age and outcome.
Descriptive statistics are presented as counts with frequencies or medians with interquartile ranges (IQRs). Outcomes and quality metrics were compared between groups using Fisher’s exact or chi-squared tests, as appropriate. P-values less than 0.05 were considered significant and all p-values are 2-sided. To assess temporal trends in outcomes, events were divided into year groupings based on publication years of AHA guideline updates (2000-2005, 2006-2010, 2011-2015, and 2016-2018). Unadjusted and adjusted data were examined for each grouping. Multivariable logistic regression was performed to assess the relationship between year grouping and outcome. Generalized estimating equations were used to account for correlations within hospital. Calendar year was the independent variable with 2000-2005 as the reference group. We controlled for age, sex, illness category (cardiac or non-cardiac), and initial rhythm. Temporal trends were tested using a non-parametric test for trend. Thirty-five of the 221 patients were > 40 years at the time of arrest. To ensure that these patients did not bias our results if misclassified, we re-ran all analyses with these patients excluded as a post hoc sensitivity analysis. Statistical analysis was performed using the STATA IC statistical package (StataCorp 16.0; College Station, TX).
Results
Of 377,186 adult IHCAs recorded between 2000 and 2018, 491 (0.1%) occurred on a pediatric service. Of those 491 events, 221 met eligibility criteria (Figure 1). Of note, 139 events were excluded due to an initial non-pulseless rhythm of bradycardia with poor perfusion. Seventeen centers contributed all included events. Sixteen of the centers had information about admission type: all reported that hospital admissions are restricted to primarily children. Patient and event characteristics are presented in Table 1. Median patient age was 22 years (IQR 19, 28, range: 18-82) and median event duration was 19 minutes (IQR 6, 35). Two-hundred and sixteen of the 221 patients (98%) had at least one pre-existing condition, with respiratory insufficiency occurring in 120/221 (54%) and cardiac disease being present in 84/221 (38%). When excluding events occurring in the emergency department or procedural areas, 132/221 (79%) occurred in ICUs and 35/221 (21%) occurred in non-ICU patient units. Over the four time intervals, we failed to identify any increase or decrease trend in these proportions (p-value for trend over time = 0.15) (Figure 2). In most events, the initial rhythm was nonshockable (133/198; 61%). Sixty-five events (65/198; 30%) had an initial shockable rhythm (ventricular fibrillation [VF] or pulseless ventricular tachycardia [pVT]).
Figure 1.
Identification of Cohort of Adult-Aged Patients Admitted to Pediatric Services
Table 1.
Prearrest and Arrest Characteristics
| Characteristic | All (n=221) | 18-21 years (n=110) | 22-25 years (n=39) | ≥26 years (n=72) |
|---|---|---|---|---|
| Female, n (%) | 85 (38) | 43 (39) | 20 (51) | 22 (31) |
| Hospital Size (beds), n (%) | ||||
| < 250 | 8 (4) | 6 (5) | 2 (5) | 0 (0) |
| 250-500 | 168 (76) | 82 (75) | 22 (57) | 64 (89) |
| > 500 | 45 (20) | 22 (20) | 15 (38) | 8 (11) |
| Pre-existing Conditions, n (%) | ||||
| Respiratory insufficiency | 120 (54) | 56 (51) | 25 (64) | 39 (54) |
| Renal insufficiency | 41 (19) | 16 (15) | 10 (26) | 15 (21) |
| Cardiac disease | 84 (38) | 38 (35) | 16 (41) | 30 (42) |
| Illness category, n (%) | ||||
| Medical cardiac | 35 (16) | 20 (18) | 6 (15) | 9 (13) |
| Surgical cardiac | 49 (22) | 18 (16) | 10 (26) | 21 (29) |
| Medical non-cardiac | 91 (41) | 61 (55) | 18 (46) | 12 (17) |
| Surgical non-cardiac | 19 (9) | 10 (9) | 2 (5) | 7 (10) |
| Trauma | 27 (12) | 1 (1) | 3 (8) | 23 (32) |
| Event Duration,* median (IQR), minutes | 19 (6, 35) | 23 (5.5, 38.5) | 14 (6, 28) | 13 (7, 29) |
| Location of Event, n (%) | ||||
| ICU | 132 (60) | 68 (62) | 28 (72) | 36 (50) |
| Non-ICU patient wards | 35 (16) | 28 (25) | 3 (8) | 4 (6) |
| Perioperative | 29 (13) | 11 (10) | 6 (15) | 12 (17) |
| Other | 25 (11) | 3 (3) | 2 (5) | 20 (28) |
| Initial rhythm, n (%) | ||||
| Asystole | 61 (28) | 30 (27) | 8 (21) | 23 (32) |
| PEA | 72 (33) | 35 (32) | 14 (36) | 23 (32) |
| VT/VF | 65 (30) | 32 (29) | 11 (29) | 22 (30) |
| Unknown/not documented | 23 (10) | 13 (12) | 6 (15) | 4 (6) |
| Medication Administration, n (%) | ||||
| Epinephrine | 187 (85) | 91 (83) | 33 (85) | 63 (88) |
| Sodium bicarbonate | 126 (57) | 73 (66) | 21 (54) | 32 (44) |
| Calcium | 110 (50) | 61 (55) | 15 (38) | 34 (47) |
| Amiodarone/lidocaine | 54 (25) | 32 (29) | 10 (25) | 12 (17) |
| Other Interventions, n (%) | ||||
| Defibrillation if shockable initial rhythm | 61/65 (94) | 29/32 (91) | 10/11 (91) | 22/22 (100) |
| Extracorporeal cardiopulmonary resuscitation (ECPR) | 16 (7) | 11 (10) | 3 (8) | 2 (3) |
4 missing information on duration
Figure 2.
Events occurring in locations other than the ICU or non-ICU patient wards were excluded from this analysis.
Survival outcomes are presented in Table 2. One hundred and forty patients (63%) had ROSC, 115 patients (52%) survived for at least 24 hours, and 67 patients (30%) survived to discharge. We failed to identify any difference across age groups in rates of ROSC, 24-hour survival, or survival to discharge. Percentage survival to discharge, by age groupings, were 26% (29/110) for patients 18-21 years of age, 37% (14/38) for patients 22-25 years of age, and 33% (24/72) for patients ≥ 26 years of age (p = 0.37). Percentage survival to discharge for those with an initial shockable rhythm and those with an initial nonshockable rhythm were 37/65 (57%) and 24/133 (18%), respectively. We failed to identify a difference in either unadjusted or adjusted survival outcomes over time (Figure 3).
Table 2.
Cardiac Arrest Outcomes By Age Group
| All (n=221) | 18-21 years (n=110) | 22-25 years (n=39) | ≥ 26 years (n=72) | p-value† | |
|---|---|---|---|---|---|
|
| |||||
| Outcome, n (%) | |||||
| Survival to Hospital Discharge* | 67 (30) | 29 (26) | 14 (37) | 24 (33) | 0.37 |
| 24-hour Survival | 115 (52) | 58 (53) | 24 (62) | 33 (46) | 0.30 |
| Any Return of Spontaneous Circulation | 140 (63) | 73 (66) | 27 (69) | 40 (56) | 0.24 |
1 patient missing hospital discharge survival data
P Values for the comparison between age groups were calculated using Fisher’s exact tests
Figure 3.
Adjusted analysis includes sex, age at cardiac arrest, initial pulseless rhythm, location of arrest, and whether the patient had a preexisting cardiac illness.
Of 53 patients with invasive airway placement during or after the arrest, 47 (89%) had documented confirmation of airway device placement in trachea. In the 122 patients with nonshockable initial rhythms whose time to epinephrine was able to be evaluated, 97 (79.5%) received epinephrine within five minutes. Two hundred and six (93%) patients had a witnessed or monitored arrest. Of the 61 patients with an initial shockable rhythm whose time to defibrillation was able to be evaluated, 37 (59%) received defibrillation within two minutes.
Sensitivity Analysis Results
When limiting our cohort to patients aged 18-40, 186 patients (84% of the total cohort) remained. Patient and event characteristics are presented in Supplemental Table 1. Survival outcomes are presented in Supplemental Table 2. We again failed to identify differences across age groups in rates of ROSC, 24-hour survival, or survival to discharge. Percentage survival to discharge, by age groupings, were 26% (29/110) for patients 18-21 years of age, 37% (14/38) for patients 22-25 years of age, and 35% (13/37) for patients ≥ 26 years of age (p = 0.37).
Discussion
To our knowledge, this is the first multi-center investigation of IHCA in adults admitted to pediatric services. In a national IHCA registry, 0.1% of all events occurred in individuals > 18 years of age admitted to a pediatric service, and these patients commonly had pre-existing respiratory and cardiac conditions. Survival to discharge in the cohort was 30%. While we hypothesized that increasing age would be associated with decreased survival, we failed to find such an association. We also failed to find an association between time periods in the GWTG 2000 – 2018 dataset and survival.
Survival to discharge in our cohort is similar to previously published contemporary rates of survival after IHCA of 40% for children and 20% for adults (4,5). Previous data have shown that older age in adults admitted to PICUs is associated with greater odds of mortality when controlling for severity of illness (10). Furthermore, a single center cohort of 33 adult IHCAs occurring in a children’s hospital during a 5-year period showed that older adults (≥ 25 years) had lower survival to discharge than younger adults (18-24 years) (13). Therefore, we hypothesized that we would find an association between lower survival rates and increasing age. However, contrary to our hypothesis, we failed to find a difference in survival outcomes between age groups. There are several potential reasons for this. First, our cohort consists primarily of young adults (median age 22 years), who may have lower accrued morbidity than older adult cohorts. In addition, we theorize that older adults being cared for on pediatric services could be excluded from this cohort due to a higher likelihood of ‘do not resuscitate’ status. Finally, this convenience sample may have been underpowered to detect a difference between age groups.
As discussed previously, there are differences between pediatric and adult IHCA, some of which are associated with outcomes. For instance, Berg et al showed that the decreasing proportion of pediatric IHCA occurring outside ICUs was temporally associated with an increased rate of ROSC (2). In addition, cardiac arrests with an initial shockable rhythm, which are more common in adults, have been associated with increased survival rates compared with arrests with an initial nonshockable rhythm (3, 15, 16). It is, therefore, notable to comment on these characteristics in our cohort. In our cohort, 79% of events occurred in an ICU and 21% occurred on a general unit. This is more similar to previously published pediatric data, in which > 85% of IHCAs occurred in ICUs, while adult studies report that approximately 50% of adult IHCAs occur in ICUs (2, 17, 18). This is likely related to the high priority placed by pediatric systems of care on avoiding arrests outside ICUs. The high frequency of pre-existing conditions in our cohort could also contribute to the high proportion of ICU events: medically complex patients may be more likely to be admitted to the ICU.
Thirty percent of the patients in our cohort had an initial shockable rhythm, which is higher than the published rates of 9% and 15.3% in children and adults, respectively (19). We theorize this may be related to the association between arrhythmogenic arrests and conditions such as congenital heart disease and neuromuscular diseases, which are common reasons for adults to continue seeking care at pediatric centers. Regardless of the etiology of this finding, pediatric clinicians must be prepared to recognize and treat shockable rhythms, particularly in adult patients.
To our knowledge, there are no published data reporting whether pediatric services treat adult IHCA using adult advanced life support (ALS) guidelines, pediatric ALS (PALS) guidelines, or a hybrid approach. Interestingly, there were 139 cases excluded from this study in which adult patients admitted to pediatric services received CPR for an initial rhythm of bradycardia. Provision of CPR for bradycardia with poor perfusion is included in PALS guidelines but not in ALS guidelines (8, 20). In fact, about half of children with IHCA have an initial rhythm of bradycardia with poor perfusion (7, 21, 22). The presence of 139 adult IHCA cases on pediatric services with an initial rhythm of bradycardia with poor perfusion provides one example of pediatric treatment guidelines being utilized for adult patients admitted to pediatric services.
As a measure of resuscitation quality, we analyzed the AHA adult IHCA benchmarking process measures in our cohort. The AHA recognizes hospitals that demonstrate ≥ 85% compliance with each measure. In our cohort, only 79.5% of eligible patients received epinephrine within five minutes and only 68% of eligible patients received defibrillation within ≤ 2 minutes. By comparison, in Anderson et al’s GWTG-R study of adult IHCA resuscitation process measures, 89.7% of eligible patients received epinephrine within 5 minutes and 59.7% of eligible patients received defibrillation within 2 minutes (23–25). In both our cohort and Anderson’s cohort, the percentage of events achieving guideline-adherent time to defibrillation was below the AHA’s recognition threshold. Importantly, the percentage of events achieving guideline-adherent time to epinephrine in our cohort was lower than in adult IHCA overall and was also below the AHA’s recognition threshold. Epinephrine administration guidelines do not differ for adult and pediatric populations, indicating that this potential difference in resuscitation performance is unlikely to be a result of differences in clinician training related to the age of their patient population. Further investigation is needed to determine if this is a clinically relevant difference, or if there are barriers contributing to delays in epinephrine administration. With the exception of timing of epinephrine administration, analysis of resuscitation process measures in our cohort does not suggest that adults admitted to pediatric services are being provided a lower quality of arrest care.
Our findings should be interpreted in light of several limitations. The cohort sample size is small despite use of data from the robust GWTG-R registry. With only 17 sites contributing all events, the findings are likely generalizable only to select pediatric institutions that are more likely to admit adults. The age range of patients in the cohort was 18-82 years, raising concern for misclassification, particularly for the older adults. Due to the retrospective nature of the study, we are unable to return to charts and verify that patient age was entered correctly. However, when excluding patients over 40 years (those most likely to be misclassified) in the sensitivity analysis, our results remained the same, making this unlikely to cause significant bias.
Conclusions
The prevalence of IHCA occurring in adults admitted to pediatric services in the GWTG-R registry was low. Survival to discharge in our cohort was 30% compared to previously reported survival rates of 20% in adult IHCA and 40% in pediatric IHCA. We failed to identify differences in survival outcomes with increasing age or over time. Our findings support the need for additional research to better understand IHCA characteristics and resuscitation processes in adults admitted to pediatric services. In addition, further investigation is needed to inform pediatric healthcare systems caring for adults how to achieve optimal outcomes.
Supplementary Material
Supplemental Table 1. Sensitivity Analysis Prearrest and Arrest Characteristics
Supplemental Table 2. Sensitivity Analysis Cardiac Arrest Outcomes By Age Group
Research in context.
Pediatric services often care for adult patients, particularly those with chronic conditions. There are limited data describing in-hospital cardiac arrest in adult patients being cared for on pediatric services.
This retrospective analysis of a large cardiac arrest registry identified 221 cases of IHCA in adults admitted to pediatric services, which is 0.1% of all adult IHCA events in the registry during the study’s 19-year time period.
In this cohort, survival to discharge after IHCA was 30%, which is similar to previously published contemporary rates of survival to discharge after IHCA for children (40%) and adults (20%).
At the bedside.
This retrospective study of 221 IHCAs in adults admitted to pediatric services did not identify an association between increasing patient age and survival outcomes.
There were 139 events excluded due to an initial rhythm of bradycardia with poor perfusion, providing evidence that some adults received treatment according to pediatric guidelines since CPR provision for this rhythm is not in adult guidelines.
Differences in patient and event characteristics and cardiac arrest treatment guidelines must be considered by pediatric services caring for adults. Further research is needed to describe and optimize resuscitation processes for this patient population.
Acknowledgements
The authors would like to acknowledge the members of the AHA’s GWTG-R Adult Taskforce: Anne Grossestreuer PhD; Ari Moskowitz MD; Dana Edelson MD MS; Joseph Ornato MD; Mary Ann Peberdy MD; Matthew Churpek MD MPH PhD; Monique Anderson Starks MD MHS; Paul Chan MD MSc; Saket Girotra MBBS SM; Sarah Perman MD MSCE; Zachary Goldberger MD MS. All participating institutions were required to comply with local regulatory and privacy guidelines and, if required, to secure institutional review board approval. Because data were used primarily at the local site for quality improvement, sites were granted a waiver of informed consent under the common rule.
Conflicts of Interest and Source of Funding
There were no external funding sources for this work.
Dr. Kleinman is Vice Chair of the GWTG—Resuscitation Pediatric Research Task Force.
Dr. Donnino’s work is funded in part by the NIH grant K24HL127101 and R01HL136705.
Dr. Ross’s work is supported by NHLBI: K23HL148312.
Copyright Form Disclosure:
Dr. Ross’ institution received funding from the National Heart, Lung, and Blood Institute. Drs. Ross and Donnino received support for article research from the National Institutes of Health. Dr. Donnino disclosed that he is a volunteer for the American Heart Association (AHA). Dr. Kleinman (disclosed that she is the vice chair of the AHA Get with the Guidelines-Resuscitation Pediatric Task Force. The remaining authors have disclosed that they do not have any potential conflicts of interest.
Footnotes
The work was performed at The Children’s Hospital of Philadelphia, Boston Children’s Hospital, and Beth Israel Deaconess Medical Center.
Reprints will not be ordered.
References
- 1.Holmberg MJ, Ross CE, Fitzmaurice GM, et al. Annual Incidence of Adult and Pediatric In-Hospital Cardiac Arrest in the United States. Circ Cardiovasc Qual Outcomes 2019; 12:e005580. [PMC free article] [PubMed] [Google Scholar]
- 2.Berg RA, Sutton RM, Holubkov R, et al. Ratio of PICU versus ward cardiopulmonary resuscitation events is increasing. Crit Care Med 2013; 41:2292–2297 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Nadkarni VM, Larkin GL, Peberdy MA, et al. First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. J Am Med Assoc 2006; 295:50–57 [DOI] [PubMed] [Google Scholar]
- 4.Girotra S, Nallamothu BK, Spertus JA, et al. Trends in survival after in-hospital cardiac arrest. N Engl J Med 2012; 367:1912–1920 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Holmberg MJ, Wiberg S, Ross CE, et al. Trends in Survival after Pediatric In-Hospital Cardiac Arrest in the United States. Circulation 2019; 140:1398–1408 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Perman SM, Stanton E, Soar J, et al. Location of in-hospital cardiac arrest in the united states-variability in event rate and outcomes. J Am Heart Assoc 2016; 5:e003638. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Donoghue A, Berg RA, Hazinski MF, et al. Cardiopulmonary resuscitation for bradycardia with poor perfusion versus pulseless cardiac arrest. Pediatrics 2009; 124:1541–1548 [DOI] [PubMed] [Google Scholar]
- 8.Panchal AR, Bartos JA, Cabañas JG, et al. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S366–S468 [DOI] [PubMed] [Google Scholar]
- 9.Goodman DM, Mendez E, Throop C, et al. Adult survivors of pediatric illness: The impact on pediatric hospitals. Pediatrics 2002; 110:583–589 [DOI] [PubMed] [Google Scholar]
- 10.Edwards JD, Houtrow AJ, Vasilevskis EE, et al. Multi-institutional profile of adults admitted to pediatric intensive care units. JAMA Pediatr 2013; 167:436–443 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Edwards JD, Vasilevskis EE, Yoo EJ, et al. Adults with childhood-onset chronic conditions admitted to US pediatric and adult intensive care units. J Crit Care 2015; 30:201–206 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Goodman DM, Hall M, Levin A, et al. Adults with chronic health conditions originating in childhood: Inpatient experience in children’s hospitals. Pediatrics 2011; 128:5–13 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.O’Halloran AJ, Callif CG, Romano JC, et al. In-Hospital Cardiac Arrest in Adult Patients Admitted to a Quaternary Children’s Center. Pediatr Emerg Care 2022; Epub ahead of print [DOI] [PubMed] [Google Scholar]
- 14.Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 2003; 58:297–308 [DOI] [PubMed] [Google Scholar]
- 15.Sasson C, Rogers MAM, Dahl J, et al. Predictors of survival from out-of-hospital cardiac arrest a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2010; 3:63–81 [DOI] [PubMed] [Google Scholar]
- 16.Tham LP, Wah W, Phillips R, et al. Epidemiology and outcome of paediatric out-of-hospital cardiac arrests: A paediatric sub-study of the Pan-Asian resuscitation outcomes study (PAROS). Resuscitation 2018; 125:111–117 [DOI] [PubMed] [Google Scholar]
- 17.Wu ET, Li MJ, Huang SC, et al. Survey of outcome of CPR in pediatric in-hospital cardiac arrest in a medical center in Taiwan. Resuscitation 2009; 80:443–448 [DOI] [PubMed] [Google Scholar]
- 18.López-Herce J, García C, Domínguez P, et al. Characteristics and outcome of cardiorespiratory arrest in children. Resuscitation 2004; 63:311–320 [DOI] [PubMed] [Google Scholar]
- 19.Virani SS, Alonso A, Benjamin EJ, et al. Heart disease and stroke statistics—2020 update: A report from the American Heart Association. Circulation 2020; 141:e139–e596 [DOI] [PubMed] [Google Scholar]
- 20.Topjian AA, Raymond TT, Atkins D, et al. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S469–S523 [DOI] [PubMed] [Google Scholar]
- 21.Morgan RW, Reeder RW, Meert KL, et al. Survival and Hemodynamics During Pediatric Cardiopulmonary Resuscitation for Bradycardia and Poor Perfusion Versus Pulseless Cardiac Arrest. Crit Care Med 2020; 48:881–889 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Khera R, Tang Y, Girotra S, et al. Pulselessness After Initiation of Cardiopulmonary Resuscitation for Bradycardia in Hospitalized Children. Circulation 2019; 140:370–378 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Anderson ML, Nichol G, Dai D, et al. Association Between Hospital Process Composite Performance and Patient Outcomes After In-Hospital Cardiac Arrest Care. JAMA Cardiol. 2016; 1:37–45 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Chan PS, Nichol G, Krumholz HM, et al. Hospital variation in time to defibrillation after in-hospital cardiac arrest. Arch Intern Med 2009; 169:1265–1273 [DOI] [PubMed] [Google Scholar]
- 25.Khera R, Chan PS, Donnino M, et al. Hospital Variation in Time to Epinephrine for Nonshockable In-Hospital Cardiac Arrest. Circulation 2016; 134:2105–2114 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplemental Table 1. Sensitivity Analysis Prearrest and Arrest Characteristics
Supplemental Table 2. Sensitivity Analysis Cardiac Arrest Outcomes By Age Group