Policy Brief ARTICLE
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)
- 1University Children's Hospital, University Hospital Schleswig-Holstein, Lübeck, Germany
- 2Neonatology and Pediatric Intensive Care, University Hospital Carl Gustav Carus, University of Dresden, Dresden, Germany
- 3University Children's Hospital Zürich, Zurich, Switzerland
- 4Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Medical University of Vienna, Vienna, Austria
- 5Department of Pediatrics, University Medicine Essen, Essen, Germany
- 6Department of Anaesthesia, Pediatric Intensive Care and Emergency Medicine, Auf der Bult Children's Hospital, Hanover, Germany
- 7Children's Hospital, Cologne, Germany
- 8University Children's Hospital, Mainz, Germany
- 9Department of Pediatric Cardiology, Pulmology and Intensive Care Medicine, University Children's Hospital, Tuebingen, Germany
- 10Children's Hospital, Nuremberg, Germany
- 11Dr. von Hauner University Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
- 12University Children's Hospital, Medical School Hannover, Hanover, Germany
- 13University Children's Hospital Graz, Graz, Austria
- 14University Children's Hospital Salzburg, Salzburg, Austria
- 15Department of Anaesthesiology and Intensive Care Medicine, Medical Faculty, University Hospital of Cologne, Cologne, Germany
- 16Children's Hospital of Philadelphia, University of Pennsylvania Perlman School of Medicine, Philadelphia, PA, United States
- 17Austrian Resuscitation Council, Graz, Austria
- 18German Resuscitation Council, Ulm, Germany
- 19Swiss Resuscitation Council, Zurich, Switzerland
• Quality and outcome of pediatric resuscitation often does not achieve recommended goals.
• Quality improvement initiatives with the aim of better survival 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 clinical and organizational structures concerning resuscitation and post-resuscitation care of children.
• The authors of this DACH position statement suggest the implementation of 10 evidence-based actions (for out-of-hospital and in-house cardiac arrests) that should improve survival rates and decrease morbidity of resuscitated children with better neurological outcome and quality of life.
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-countries per year (1, 2).
Despite a generic trend of improvement in survival rates over time, the overall outcome after cardiac arrest in children is still poor. Many successfully resuscitated pediatric patients have reduced quality of life with persistent impairments in physical, psychological, and executive function, as well as emotional impairment, which are of considerable concern to families and society (3).
Recent studies show that the quality of pediatric resuscitation often does not achieve recommended standards (4–6). Based on substantial international study data, the authors of this DACH position statement suggest the implementation of 10 evidence-based actions (for out-of-hospital and in-house cardiac arrests, OHCA and IHCA) that should improve survival rates and decrease morbidity of resuscitated children with better neurological outcome and quality of life. Due to existing data 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 from 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 Theses for 10,000 lives” (11) published for adult resuscitation—are intended to provide the action framework for a comprehensive, fundamental, and interprofessional reorientation of clinical and organizational structures concerning resuscitation and post resuscitation care of children. The following theses and basic principles are also endorsed by the Austrian, German, and Swiss Resuscitation Councils.
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 advancing 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.
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.
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 PBLS is characterized by correct depth and rate of compression, adequate chest recoil, and sufficient ventilation. Interruptions need to be minimized. 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 sessions twice annually and for at least 2 h each, also because that seems to be convertible. These sessions must be mandatory and offered 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 to improve necessary basic skills or chest compression quality in particular (26–29).
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, and pediatric emergency rooms) should receive appropriate pediatric advanced life support training titrated to their scope of practice. Internationally 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 well as situation awareness. They also teach adequate provision of care to critically ill patients (preventing resuscitation) as outlined by current ILCOR resuscitation guidelines.
Recent initiatives to improve resuscitation efforts in pediatrics have focused on the implementation of action-linked phrases, cognitive aids, rapid cycle deliberate practice, CPR coaches, 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.
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 coach 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 focus on other aspects during resuscitation. In the presence of CPR feedback technology, the addition of a trained CPR coach into resuscitation teams adds to CPR quality metrics which in turn are associated with improved survival outcomes from pediatric cardiac arrest (32–34).
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 event. Ideally, they should include at least the team members involved 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 increase of the quality of care. Furthermore, they increase survival rates of resuscitated children (35, 36).
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 prevention 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 mandatory. Care also extends to the family of the patient and initiation of early rehabilitation of pediatric patients after resuscitation (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 adults (43). These centers may also support less specialized units (e.g., by telemedicine) in initial stabilization or allow transfer of these children to these centers.
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 Germany, very little data of resuscitated children in the DACH region are recorded. Establishing a registry that collects preclinical, in-hospital, and post-hospital outcome (neurological and in general) data from every pediatric resuscitation is essential to guarantee 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 Collaborative, PediResQ, https://www.pedires-q.org) (44, 45).
A template for a successful registry is the TraumaRegister® of the German Trauma Society (DGU, http://www.traumaregister-dgu.de/index.php?id=144), which has set standards worldwide for the quality management of seriously injured patients (46). At present, it involves nine countries with over 700 participating hospitals and more than 270,000 documented cases since 1993.
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 several pediatric sub-specialties (e.g., pediatric intensive care, neurology, cardiology, infectious disease, radiology, psychology, and rehabilitation). However, only few children's hospitals can offer all of these services. Despite of a centralization in post-resuscitation care the implementation of telemedical and other network structures are needed to provide comprehensive health care to ensure quality and efficiency. As in Neonatology certain 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.
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.
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 every 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 and the preferred contact for other external hospitals or emergency services. The resuscitation supervisor has to be supported effectively by the hospital management in terms of time, logistics, and administration.
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, all of 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.
Physical and mental disability resulting from a child's cardiac arrest is of exceptional family and societal importance. The total number of pediatric cardiac arrest resuscitations is much lower (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 with the importance of improving the prevention and detection of life-threatening events in children, in order to avoid pediatric cardiac arrest. When resuscitation is necessary, it can only be effective 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 collection 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 will improve current care and be of great benefit for all.
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 their final approval of the version to be published.
A constituting meeting of the working group in March 2018 was financially supported by the company ZOLL Medical.
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
These actions are endorsed by the Austrian, German, and Swiss Resuscitation Councils.
1. 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
2. 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
3. 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
4. Niles DE, Duval-Arnould J, Skellett S, Knight L, Su F, Raymond TT, et al. Characterization of pediatric in-hospital cardiopulmonary resuscitation quality metrics across an international resuscitation collaborative. Pediatr Crit Care Med. (2018) 19:421–32. doi: 10.1097/PCC.0000000000001520
5. Meert K, Telford R, Holubkov R, Slomine BS, Christensen JR, Berger J, et al. Pediatric in-hospital cardiac arrest: factors associated with survival and neurobehavioural outcome one year later. Resuscitation. (2018) 124:96–105. doi: 10.1016/j.resuscitation.2018.01.013
6. Hunt EA, Walker AR, Shaffner DH, Miller MR, Pronovost PJ. Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes. Pediatrics. (2008) 121:e34–43 doi: 10.1542/peds.2007-0029
7. Young KD, Gausche-Hill M, McClung CD, Lewis RJ. A prospective, population-based study of the epidemiology and outcome of out-of-hospital pediatric cardiopulmonary arrest. Pediatrics. (2004) 114:157–64. doi: 10.1542/peds.114.1.157
8. Moler FW, Silverstein FS, Holubkov R, Slomine BS, Christensen JR, Nadkarni VM, et al. Therapeutic hypothermia after out-of-hospital cardiac arrest in children. N Engl J Med. (2015) 372:1898–908. doi: 10.1056/NEJMoa1411480
9. Matos RI, Watson SR, Nadkarni VM, Huang HH, Berg RA, Meaney PA, et al. Duration of cardiopulmonary resuscitation and illness category impact survival and neurological outcomes for in-hospital peddiatric cardiac arrests. Circulation. (2013) 127:442–51. doi: 10.1161/CIRCULATIONAHA.112.125625
10. Moler FW, Silverstein FS, Holubkov R, Slomine BS, Christensen JR, Nadkarni VM, et al. Therapeutic hypothermia after in- hospital cardiac arrest in children. N Engl J Med. (2017) 376:318–29. doi: 10.1056/NEJMoa1610493
12. Akre M, Finkelstein M, Erickson M, Liu M, Vanderbilt L, Billman G. Sensitivity of the pediatric early warning score to identify patient deterioration. Pediatrics. (2010) 125:e763–69. doi: 10.1542/peds.2009-0338
13. Bell D, Mac A, Ochoa Y, Gordon M, Gregurich AM, Taylor T. The Texas children's hospital pediatric advanced warning score as a predictor of clinical deterioration in hospitalisied infants and children: a modification of the PEWS tool. J Pediatr Nurs. (2013) 28:e2–9. doi: 10.1016/j.pedn.2013.04.005
14. Lambert V, Matthews A, MacDonell R, Fitzsimons J. Pediatric early warning systems for detecting and responding to clinical deterioration in children: a systematic review. BMJ Open. (2017) 7:e014497. doi: 10.1136/bmjopen-2016-014497
15. Parshuram CS, Dryden-Palmer K, Farrell C, Gottesman R, Gray M, Hutchison JS, et al. Effect of a pediatric early warning system on all-cause mortality in hospitalized pediatric patients: the EPOCH randomized clinical trial. JAMA. (2018) 319:1002–12. doi: 10.1001/jama.2018.0948
16. Rubio-Gurung S, Putet G, Touzet S, Gauthier-Moulinier H, Jordan I, et al. In situ simulation training for neonatal resuscitation: an RCT. Pediatrics. (2014) 134:e790–e97. doi: 10.1542/peds.2013-3988
17. Theilen U, Fraser L, Jones P, Leonard P, Simpson D. Regular in-situ simulation training of pediatric Medical Emergency Team leads to sustained improvements in hospital response to deteriorating patients, improved outcomes in intensive care and financial savings. Resuscitation. (2017) 115:61–7. doi: 10.1016/j.resuscitation.2017.03.031
20. Andreatta P, Frankel J, Boblick Smith S, Bullough A, Marzano D. Interdisciplinary team training identifies discrepancies in institutional policies and practices. Am J Obstet Gynecol. (2011) 205:298–301. doi: 10.1016/j.ajog.2011.02.022
21. Phipps MG, Lindquist DG, McConaughey E, O'Brien JA, Raker CA, Paglia MJ. Outcomes from a labor and delivery team training program with simulation component. Am J Obstet Gynecol. (2012) 206:3–9. doi: 10.1016/j.ajog.2011.06.046
22. Andreatta P, Saxton E, Thompson M, Annich G. Simulation-based mock codes significantly correlate with improved pediatric patient cardiopulmonary arrest survival rates. Pediatr Crit Care Med. (2011) 12:33–8. doi: 10.1097/PCC.0b013e3181e89270
23. Sutton RM, Reeder RW, Landis W, Meert KL, Yates AR, Berger JT, et al. Chest compression rates and pediatric in-hospital cardiac arrest survival outcomes. Resuscitation. (2018) 130:159–66. doi: 10.1016/j.resuscitation.2018.07.015
24. Sutton RM, Niles D, Meaney PA, Aplenc R, French B, Abella BS, et al. “Booster” training: evaluation of instructor-led bedside cardiopulmonary resuscitation skill training and automated corrective feedback to improve cardiopulmonary resuscitation compliance of Pediatric Basic Life Support providers during simulated cardiac arrest. Pediatr Crit Care Med. (2011) 12:e116–21. doi: 10.1097/PCC.0b013e3181e91271
25. Wagner M, Bibl K, Hrdliczka E, Steinbauer P, Stiller M, Gröpell P, et al. Effects of feedback on chest compression quality: a randomized simulation study. Pediatrics. (2019) 143:e20182441. doi: 10.1542/peds.2018-2441
26. Niles DE, Sutton RM, Donoghue A, Kalsi MS, Roberts K, Boyle L, et al. “Rolling Refresher”: a novel approach to maintain CPR psychomotor skill competence. Resuscitation. (2009) 80:909–12. doi: 10.1016/j.resuscitation.2009.04.021
27. Niles DE, Nishisaki A, Sutton RM, Elci OU, Meaney PA, O'Connor KA, et al. Improved retention of chest compression psychomotor skills with brief “Rolling Refresher” training. Simul Healthc. (2017) 12:213–19. doi: 10.1097/SIH.0000000000000228
28. Cheng A, Brown LL, Duff JP, Davidson J, Overly F, Tofil NM, et al. Improving cardiopulmonary resuscitation with a CPR feedback device and refresher simulations (CPR CARES Study). JAMA Pediatr. (2015) 169:137–44. doi: 10.1001/jamapediatrics.2014.2616
29. Hunt EA, Duval-Arnould JM, Nelson-McMillan KL, Bradshaw JH, Diener-West M, Perretta JS, et al. Pediatric resident resuscitation skills improve after “rapid-cycle deliberate practice” training. Resuscitation. (2014) 85:945–51. doi: 10.1016/j.resuscitation.2014.02.025
30. Gude P, Lukas RP, Weber TP, Wecker S, Bohn A. Einfluss von Unterstützungssystemen bei der Reanimation: eine prospective Simulationsstudie zur Untersuchung von Metronom und Echtzeit-Feedback. NOTARZT. (2016) 32:271–76. doi: 10.1055/s-0042-110688
31. Kramer-Johanson J, Myklebust H, Wik L, Fellows B, Svensson L, Sørebø H, et al. Quality of out-of-hospital cardiopulmonary resuscitation with real time automated feedback: a prospective interventional study. Resuscitation. (2006) 71:283–92. doi: 10.1016/j.resuscitation.2006.05.011
32. Hunt EA, Jeffers J, McNamara L, Newton H, Ford K, Bernier M, et al. Improved cardiopulmonary resuscitation performance with CODE ACES2: a resuscitation quality bundle. J Am Heart Assoc. (2018) 7:e009860. doi: 10.1161/JAHA.118.009860
33. Cheng A, Duff JP, Kessler D, Tofil NM, Davidson J, Lin Y, et al. Optimizing CPR performance with CPR coaching for pediatric cardiac arrest: a randomized simulation-based clinical trial. Resuscitation. (2018) 132:33–40. doi: 10.1016/j.resuscitation.2018.08.021
34. Pfeiffer S, Lauridsen KG, Wenger J, Hunt EA, Haskell S, Atkins DL, et al. Code team structure and training in the pediatric resuscitation quality international collaborative. Pediatr Emerg Care. (2019). doi: 10.1097/PEC.0000000000001748. [Epub ahead of print].
35. Wolfe H, Zebuhr C, Topijan A, Nishisaki A, Niles DE, Meaney PA, et al. Interdisciplinary ICU cardiac arrest debriefing improves survival outcome. Crit Care Med. (2014) 42:1688–95. doi: 10.1097/CCM.0000000000000327
36. Maconochie IK, Bingham R, Eich C, López-Herce J, Rodríguez-Núñez A, Rajka T, et al. European resuscitation council guidelines for resuscitation 2015: section 6. Pediatric life support. Resuscitation. (2015) 95:223–48. doi: 10.1016/j.resuscitation.2015.07.028
37. Kido T, Iwagami M, Yasunaga H, Abe T, Enomoto Y, Matsui H, et al. Outcomes of paediatric out-of-hospital cardiac arrest according to hospital characteristic defined by the annual number of paediatric patients with invasive mechanical ventilation: a nationwide study in Japan. Resuscitation. (2020) 148:49–56. doi: 10.1016/j.resuscitation.2019.12.020
38. Topjian AA, Sutton RM, Reeder RW, Telford R, Meert KL, Yates AR, et al. The association of immediate post cardiac arrest diastolic hypertension and survival following pediatric cardiac arrest. Resuscitation. (2019) 141:88–95. doi: 10.1016/j.resuscitation.2019.05.033
39. Topjian AA, French B, Sutton RM, Conlon T, Nadkarni VM, Moler FM, et al. Early postresuscitation hypotension is associated with increased mortality following pediatric cardiac arrest. Crit Care Med. (2014) 42:1518–23. doi: 10.1097/CCM.0000000000000216
40. Topjian AA, Gutierrez-Colina AM, Sanchez SM, Berg RA, Friess SH, Dlugos DJ, et al. Electrographic status epilepticus is associated with mortality and worse short-term outcome in critically ill children. Crit Care Med. (2013) 41:215–23. doi: 10.1097/CCM.0b013e3182668035
41. Ferguson LP, Durward A, Tibby SM. Relationship between arterial partial oxygen pressure after resuscitation from cardiac arrest and mortality in children. Circulation. (2012) 126:335–42. doi: 10.1161/CIRCULATIONAHA.111.085100
42. Conlon TW, Falkensammer CB, Hammond RS, Nadkarni VM, Berg RA, Topjian AA, et al. Association of left ventricular systolic function and vasopressor support with survival following pediatric out-of-hospital cardiac arrest. Pediatr Crit Care Med. (2015) 16:146–54. doi: 10.1097/PCC.0000000000000305
43. Scholz KH, Andresen D, Böttiger BW, Busch HJ, Fischer M, Frey N, et al. Quality indicators and structural requirements for Cardiac Arrest Centers-German Resuscitation Council (GRC)]. Anaesthesist. (2017) 66:360–62. doi: 10.1007/s00101-017-0311-7
45. Gräsner JT, Seewald S, Bohn A, Fischer M, Messelken M, Jantzen T, et al. Deutsches reanimationsregister - wissenschaft und reanimationsforschung. Anaesthesist. (2014) 63:470–6. doi: 10.1007/s00101-014-2324-9
47. Rochow N, Landau-Crangle E, Lee S, Schuenemann H, Fusch C. Quality indicators but not Admission Volumes of neonatal intensive care units are effective in reducing mortality rates of preterm infants. PLoS One. (2016) 11:e0161030 doi: 10.1371/journal.pone.0161030
48. Sutton RM, Wolfe H, Nishisaki A, Leffelman J, Niles D, Meaney PA, et al. Pushing harder, pushing faster, minimizing interruptions.but falling short of 2010 cardiopulmonary resuscitaion targets during in-hospital pediatric and adolescent resuscitation. Resuscitation. (2013) 84:1680–84. doi: 10.1016/j.resuscitation.2013.07.029
Keywords: cardiopulmonary resuscitation, children, cardiac arrest, quality improvement, patient safety, pediatric
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
Received: 07 April 2020; Accepted: 31 August 2020;
Published: 07 October 2020.
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
Copyright © 2020 Jung, Brenner, Bachmann, Both, Cardona, Dohna-Schwake, Eich, Eifinger, Huth, Heimberg, Landsleitner, Olivieri, Sasse, Weisner, Wagner, Warnke, Ziegler, Boettiger, Nadkarni and Hoffmann. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Florian Hoffmann, email@example.com