'We want every baby to go home.' Cardiac arrests plummet with Cincinnati Children's plan

'We want every baby to go home.' Cardiac arrests plummet with Cincinnati Children's plan

Like any 4-year-old, James loves to play outside. He would eat chicken nuggets for every meal if permitted. He interrupts his mom, Kaitlyn Baker of Independence, to show her the sea-green tablet he’s clutching and to tell her whatever is on his mind at the moment.James is different from most 4-year-olds, too, says one of his doctors. He was born on Valentine's Day 2018 and moved to Cincinnati Children's Hospital Medical Center because he had a congenital heart defect.

And he lived through an impending cardiac arrest at just 2 weeks old

James lived to become the tiniest baby known to be on a mechanical heart, says Dr. Jeffrey Alten, attending cardiologist in the Cincinnati Children's cardiac intensive care unit. Then he had a heart transplant and started a more normal life.

But about that first part: James lived.



Bedside huddles yield 30% drop in cardiac arrests

A Cincinnati Children’s Hospital Medical Center cardiac intensive care unit nurse saved James from cardiac arrest with an epi-spritzer. It's a diluted shot of the heart-starting medication epinephrine. And while that may seem routine, it is how and why, and how quickly, it was done that makes it unique.

At the time, the hospital was leading an effort to get a cardiac arrest prevention bundle in hospitals across the country as a quality improvement study. Fifteen children's cardiac ICUs across the country were involved.

The idea was to prevent cardiac arrests in the hospitals because inevitably, some happen with these fragile babies and children. A rescue with CPR is the next best thing to prevention, but it is not ideal, Alten said, because the child could be harmed during the process. So, he thought, why not try harder to prevent them altogether?

James' result wasn't part of the study, but as a baby in the cardiac ICU, he got the protocol: Twice-a-day bedside huddles that continue today.

In those sessions, every team member on every case goes over the child's vital signs and every plan of action. That way, all team members are empowered to act if it appears the patient is going into cardiac arrest. Among the plans was the use of the epi-spritzer, if a team member believed the tiny patient's condition was deteriorating.

Alten designed the "low-tech" care bundle while at Alabama Children's Hospital. He joined Cincinnati Children's in 2017. A year later, the Pediatric Cardiac Critical Care Consortium, a quality-improvement group of hospitals, agreed to join the study, said founder Dr. Michael Gaies, now medical director of Cincinnati Children's acute care cardiology unit. Funding came from several sources including the Children's Heart Foundation and the Congenital Heart Alliance of Cincinnati.

The care prevented more than 200 children from cardiac arrest during the study, research shows. The hospital teams saw a 30% drop in cardiac arrests in their ICUs. The Journal of the American Medical Association published the study July 5.

'I remember thinking, I don’t know if he’s going to die'

James' case is an example of what the pediatric cardiology teams hoped would happen, the doctors said.

The Cincinnati Children's cardiac ICU nurse, Alten said, was empowered to act without getting a physician's nod if the baby started having symptoms consistent with going into cardiac arrest. The nurse had already prepared the injectable epi-spritzer that Alten had recommended for James and kept it beside James’ bed.

James' mom remembers the night vividly: She had been sleeping in her baby's hospital room. Her husband, Eric Baker, was out working a night shift.

“I woke up in the middle of the night," she said. "I started to get scared, thinking, ‘Something is wrong.'"

“His heart was making it hard for him to breathe,” Baker said. “I remember thinking, 'I don’t know if he’s going to die tonight.'”

Eric Baker got to Cincinnati Children’s around 4 a.m.

“All of a sudden James lets out this horrible scream,” Kaitlyn Baker said. “I look at the screens just beeping. His heart starts plummeting.

"The nurse runs in and grabs him and puts him on the bed and gives him the epi-spritzer.”

Then Alten was there, talking to the nurse. And James was OK.

Alten said the few minutes it would've taken for him to learn of James' condition and give the order and for the nurse to prepare the epi-spritzer might've been too long to prevent cardiac arrest in the infant.

Taking known steps, ensuring they happen

Congenital heart defects are the most common type of birth defect in the United States, affecting nearly 1% of, or about 40,000, births each year, according to the Centers for Disease Control and Prevention. Pediatric cardiac ICU team members are all trained in how to care for these children and infants, Alten said.

The study's huddles were about doing things that all cardiac ICU professionals know. But they were done with specificity and without fail for each patient.

Gaies said the approach can be replicated at any pediatric cardiac ICU. The results are profound, he said, adding, "It changed the way we all practiced our specialty."

The ultimate goal of the care bundle is simple, Alten said: “We want every single baby to go home."

Just like James.