Adverse Safety Events in Emergency Medical Services Care of Children With Out-of-Hospital Cardiac Arrest

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Key Points

Question

What are the frequency of and factors associated with severe adverse safety events in emergency medical services care of children with out-of-hospital cardiac arrest?

Findings

In this cohort study of 1019 encounters, 60% of patients experienced at least 1 severe adverse safety event. Neonates had increased odds of a severe adverse safety event compared with adolescents.

Meaning

These findings suggest that decreasing severe adverse safety events may improve current poor outcomes for children with out-of-hospital cardiac arrest, especially younger children.

Abstract

This cohort study used medical record review to characterize the frequency of and factors associated with adverse safety events in pediatric out-of-hospital cardiac arrest treated by emergency medical services (EMS).

Abstract

Importance

Survival for children with out-of-hospital cardiac arrest (OHCA) remains poor despite improvements in adult OHCA survival.

Objective

To characterize the frequency of and factors associated with adverse safety events (ASEs) in pediatric OHCA.

Design, Setting, and Participants

This population-based retrospective cohort study examined patient care reports from 51 emergency medical services (EMS) agencies in California, Georgia, Oregon, Pennsylvania, Texas, and Wisconsin for children younger than 18 years with an OHCA in which resuscitation was attempted by EMS personnel between 2013 and 2019. Medical record review was conducted from January 2019 to April 2022 and data analysis from October 2022 to February 2023.

Main Outcomes and Measure

Severe ASEs during the patient encounter (eg, failure to give an indicated medication, 10-fold medication overdose).

Results

A total of 1019 encounters of EMS-treated pediatric OHCA were evaluated; 465 patients (46%) were younger than 12 months. At least 1 severe ASE occurred in 610 patients (60%), and 310 patients (30%) had 2 or more. Neonates had the highest frequency of ASEs. The most common severe ASEs involved epinephrine administration (332 [30%]), vascular access (212 [19%]), and ventilation (160 [14%]). In multivariable logistic regression, the only factor associated with severe ASEs was young age. Neonates with birth-related and non–birth-related OHCA had greater odds of a severe ASE compared with adolescents (birth-related: odds ratio [OR], 7.0; 95% CI, 3.1-16.1; non–birth-related: OR, 3.4; 95% CI, 1.2-9.6).

Conclusions and Relevance

In this large geographically diverse cohort of children with EMS-treated OHCA, 60% of all patients experienced at least 1 severe ASE. The odds of a severe ASE were higher for neonates than adolescents and even higher when the cardiac arrest was birth related. Given the national increase in out-of-hospital births and ongoing poor outcomes of OHCA in young children, these findings represent an urgent call to action to improve care delivery and training for this population.

Related collections

Most cited references 48

Record: found
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The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.

Erik von Elm, Douglas G. Altman, Matthias Egger … (2008)

Much biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study's generalisability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover three main study designs: cohort, case-control, and cross-sectional studies. We convened a 2-day workshop in September, 2004, with methodologists, researchers, and journal editors to draft a checklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE statement) that relate to the title, abstract, introduction, methods, results, and discussion sections of articles.18 items are common to all three study designs and four are specific for cohort, case-control, or cross-sectional studies.A detailed explanation and elaboration document is published separately and is freely available on the websites of PLoS Medicine, Annals of Internal Medicine, and Epidemiology. We hope that the STROBE statement will contribute to improving the quality of reporting of observational studies

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Interrater reliability: the kappa statistic

Mary L McHugh (2012)

The kappa statistic is frequently used to test interrater reliability. The importance of rater reliability lies in the fact that it represents the extent to which the data collected in the study are correct representations of the variables measured. Measurement of the extent to which data collectors (raters) assign the same score to the same variable is called interrater reliability. While there have been a variety of methods to measure interrater reliability, traditionally it was measured as percent agreement, calculated as the number of agreement scores divided by the total number of scores. In 1960, Jacob Cohen critiqued use of percent agreement due to its inability to account for chance agreement. He introduced the Cohen’s kappa, developed to account for the possibility that raters actually guess on at least some variables due to uncertainty. Like most correlation statistics, the kappa can range from −1 to +1. While the kappa is one of the most commonly used statistics to test interrater reliability, it has limitations. Judgments about what level of kappa should be acceptable for health research are questioned. Cohen’s suggested interpretation may be too lenient for health related studies because it implies that a score as low as 0.41 might be acceptable. Kappa and percent agreement are compared, and levels for both kappa and percent agreement that should be demanded in healthcare studies are suggested.

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Pediatric complex chronic conditions classification system version 2: updated for ICD-10 and complex medical technology dependence and transplantation

Chris Feudtner, James Feinstein, Wenjun Zhong … (2014)

Background The pediatric complex chronic conditions (CCC) classification system, developed in 2000, requires revision to accommodate the International Classification of Disease 10th Revision (ICD-10). To update the CCC classification system, we incorporated ICD-9 diagnostic codes that had been either omitted or incorrectly specified in the original system, and then translated between ICD-9 and ICD-10 using General Equivalence Mappings (GEMs). We further reviewed all codes in the ICD-9 and ICD-10 systems to include both diagnostic and procedural codes indicative of technology dependence or organ transplantation. We applied the provisional CCC version 2 (v2) system to death certificate information and 2 databases of health utilization, reviewed the resulting CCC classifications, and corrected any misclassifications. Finally, we evaluated performance of the CCC v2 system by assessing: 1) the stability of the system between ICD-9 and ICD-10 codes using data which included both ICD-9 codes and ICD-10 codes; 2) the year-to-year stability before and after ICD-10 implementation; and 3) the proportions of patients classified as having a CCC in both the v1 and v2 systems. Results The CCC v2 classification system consists of diagnostic and procedural codes that incorporate a new neonatal CCC category as well as domains of complexity arising from technology dependence or organ transplantation. CCC v2 demonstrated close comparability between ICD-9 and ICD-10 and did not detect significant discontinuity in temporal trends of death in the United States. Compared to the original system, CCC v2 resulted in a 1.0% absolute (10% relative) increase in the number of patients identified as having a CCC in national hospitalization dataset, and a 0.4% absolute (24% relative) increase in a national emergency department dataset. Conclusions The updated CCC v2 system is comprehensive and multidimensional, and provides a necessary update to accommodate widespread implementation of ICD-10.

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Author and article information

Journal

Journal ID (nlm-ta): JAMA Netw Open

Journal ID (iso-abbrev): JAMA Netw Open

Title: JAMA Network Open

Publisher: American Medical Association

ISSN (Electronic): 2574-3805

Publication date (Electronic): 12 January 2024

Publication date Collection: January 2024

Publication date PMC-release: 12 January 2024

Volume: 7

Issue: 1

Electronic Location Identifier: e2351535

Affiliations

[1 ]Department of Pediatrics, Oregon Health and Science University, Portland

[2 ]Department of Emergency Medicine, Oregon Health and Science University, Portland

[3 ]Department of Pediatric Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada

[4 ]Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada

[5 ]Public Health Division, Multnomah County Health Department, Portland, Oregon

[6 ]Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas

[7 ]Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee

[8 ]Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

[9 ]Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania

[10 ]Department of Pediatrics, Akron’s Children’s Hospital, Akron, Ohio

[11 ]Department of Pediatrics, Medical College of Wisconsin, Milwaukee

[12 ]Department of Obstetrics, Gynecology, and Reproductive Biology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts

Author notes

Article Information

Accepted for Publication: November 27, 2023.

Published: January 12, 2024. doi:10.1001/jamanetworkopen.2023.51535

Corresponding Author: Carl O. Eriksson, MD, MPH, Department of Pediatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, CDRC 1231, Portland, OR 97239 ( eriksson@ 123456ohsu.edu ).

Author Contributions: Drs Eriksson and Bahr had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Eriksson, Meckler, Hansen, Walker-Stevenson, Aufderheide, Guise.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Eriksson, Bahr, Meckler, Hansen, Walker-Stevenson, Aufderheide, Luetje, Guise.

Critical review of the manuscript for important intellectual content: Meckler, Hansen, Idris, Aufderheide, Daya, Fink, Jui, Martin-Gill, Mcgaughey, Pelletier, Thomas, Guise.

Statistical analysis: Eriksson, Walker-Stevenson.

Obtained funding: Meckler, Hansen, Aufderheide, Guise.

Administrative, technical, or material support: Bahr, Hansen, Walker-Stevenson, Idris, Jui, Luetje, Martin-Gill, Guise.

Supervision: Eriksson, Daya, Guise.

Conflict of Interest Disclosures: Dr Eriksson reported receiving grants from National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of the Health (NIH) during the conduct of the study. Dr Bahr reported receiving grants from the NHLBI during the conduct of the study. Dr Hansen reported receiving grants from the NHLBI during the conduct of the study and being a co-owner of Promedix Inc, a prerevenue medical device company, outside the submitted work. Dr Idris reported receiving grants from the US Centers for Disease Control and Prevention during the conduct of the study and serving as an unpaid member of the clinical advisory board for Stryker. Dr Aufderheide reported receiving grants from the Agency for Healthcare Research and Quality, the NHLBI, the National Institute of Neurological Disorders and Stroke, Inflammatix, Zoll Medical, Cytovale, Abbott, and MeMed; receiving equipment from Zoll Medical; and receiving consulting fees from Medtronic during the conduct of the study. Dr Daya reported grants receiving from the NIH during the conduct of the study and receiving personal fees from Tualatin Valley Fire and Rescue for emergency medical services medical director duties outside the submitted work. Dr Fink reported receiving grants from the NIH during the conduct of the study and outside the submitted work and serving on the Pediatric Critical Care Medicine subboard for the American Board of Pediatrics. Dr Jui reported receiving grants from the NHLBI during the conduct of the study. Dr Martin-Gill reported receiving grants from the US Department of Defense, the NIH, the Kaiser Foundation/Gordon and Betty Moore Foundation, and the American Academy of Sleep Medicine Foundation outside the submitted work. Dr Pelletier reported receiving grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development outside the submitted work. Dr Guise reported receiving grants from the NIH and the NHLBI during the conduct of the study. No other disclosures were reported.

Funding/Support: This work was supported by grant R01HL141429 from the NHLBI, principal investigator Dr Guise.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Group Information: Child Safety Initiative–Emergency Medical Services for Children members appear in Supplement 2.

Data Sharing Statement: See Supplement 3.

Article

Publisher ID: zoi231509

DOI: 10.1001/jamanetworkopen.2023.51535

PMC ID: 10787316

PubMed ID: 38214931

SO-VID: 7399a477-e757-4364-b3da-8ab0aff4ec65

License:

This is an open access article distributed under the terms of the CC-BY License.

Adverse Safety Events in Emergency Medical Services Care of Children With Out-of-Hospital Cardiac Arrest

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Key Points

Question

Findings

Meaning

Abstract

Abstract

Importance

Objective

Design, Setting, and Participants

Main Outcomes and Measure

Results

Conclusions and Relevance

Related collections

Ecosystem services

Most cited references 48

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.

Interrater reliability: the kappa statistic

Pediatric complex chronic conditions classification system version 2: updated for ICD-10 and complex medical technology dependence and transplantation

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Journal

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