Reducing Chest Compression Pauses During Pediatric ECPR

Objective: To quantify chest compression (CC) pauses during pediatric ECPR (CPR incorporating ECMO) and implement sustainable quality improvement (QI) initiatives to reduce CC pauses during ECMO cannulation. Methods: We retrospectively identified baseline CC pause characteristics during pediatric ECPR events (pre-intervention), deployed QI interventions to reduce CC pause length, and then prospectively quantified CC pause metrics post-QI interventions (post-intervention). Data were gathered from a single center review of CC-pause characteristics in children less than 18 years old with a PICU ECPR arrest. QI Interventions included: (1) sharing baseline CC data with ECPR stakeholders, (2) establishing consensus among providers regarding areas for improvement, and (3) creating a communication aid to encourage counting CC pauses out loud. Multidisciplinary ECPR simulations allowed for practice of these skills. Using telemetry data, CC pause metrics were analyzed in the medical (CPR before cannulation) and surgical (CPR during ECMO cannulation, demarcated by the sterile draping of the patient) phases of ECPR, pre- and post-intervention. Results: Pre-intervention, 11 ECPR events (5 central cannulation, 6 peripheral cannulation) met inclusion criteria compared with 14 ECPR events (2 central, 12 peripheral) post-intervention. Pre-intervention analysis identified longer CC pauses and lower chest compression fraction (CCF) during the surgical versus medical phase of ECPR. Compared to pre-intervention data, CCF during the surgical phase of ECPR improved from 66% to 81% (73-85%) post-intervention (P = .02). Median CC pause length was significantly reduced from 20 s pre-intervention to 10.5 (9-13) seconds post-intervention (P = .01). There was no change in the surgical phase of ECPR duration (44 min pre- vs 41 min post-intervention, P = .8) or survival to hospital discharge (45% vs 21%, P = .4). Conclusion: Simple and feasible communication interventions during ECPR can minimize CC pauses, increase CCF and improve CPR quality without prolonging the time needed for ECMO cannulation.