Cincinnati Children’s strategy reduces cardiac arrests

Like any 4 year old, James loves to play outside. He would eat chicken nuggets with every meal if allowed. He interrupts his mother, Kaitlyn Baker of Independence, to show her the aqua green tablet he’s holding in his arms and tell her what he’s thinking right now.

James is also different from most 4-year-olds, 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 experienced imminent cardiac arrest at just 2 weeks old.

James lived to become the smallest baby known to be on a mechanical heart, says Dr. Jeffrey Alten, attending cardiologist at 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.

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James Baker at 6 weeks, after his heart transplant at Cincinnati Children's Hospital Medical Center.

Bedside gatherings lead to a 30% drop in cardiac arrests

A nurse in the Cardiac Intensive Care Unit at Cincinnati Children’s Hospital Medical Center saved James from cardiac arrest with an epi-spritzer. It’s a diluted dose of epinephrine, a drug that fires the heart. And while it may seem routine, it’s how, 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 package into hospitals nationwide as part of a quality improvement study. Fifteen children’s cardiac intensive care units across the country were involved.

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

Kaitlyn and Eric Baker, of Independence, Kentucky, with their son James, 4, at home on August 1.

James’ result was not part of the study, but as a baby in the cardiac intensive care unit, he followed protocol: twice-daily bedside huddles that continue today.

During these sessions, each team member on each case reviews the child’s vital signs and each course of action. In this way, all team members are empowered to act if it appears that the patient is in cardiac arrest. Among the plans was the use of the epi-spritzer, if a member of the team thought the little patient’s condition was deteriorating.

Alten designed the “low-tech” care package 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 the 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, according to the research. Hospital teams have seen a 30% drop in cardiac arrests in their intensive care units. The Journal of the American Medical Association published the study on July 5.

James Baker, 4, plays at his home in Independence, Kentucky.

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

James’ case is an example of what pediatric cardiology teams have been hoping for, the doctors said.

The Cincinnati Children’s Cardiac Intensive Care nurse, Alten said, was empowered to act without getting a doctor’s approval if the baby began showing symptoms consistent with cardiac arrest. The nurse had already prepared the injectable epi-spritzer that Alten had recommended for James and had kept it next to James’ bed.

James’ mother remembers the night vividly: she was sleeping in her baby’s hospital room. Her husband, Eric Baker, worked nights.

“I woke up in the middle of the night,” she said. “I started to get scared, thinking, ‘Something’s wrong. “”

“His heart was preventing him from breathing,” Baker said. “I remember thinking, ‘I don’t know if he’s going to die tonight.'”

Eric Baker, of Independence, Kentucky, plays with his 4-year-old son James.  James, a heart transplant recipient at Cincinnati Children's Hospital Medical Center, was not part of a study focused on bedside huddles in the cardiac ICU, but received the same treatment as children in the study, preventing impending cardiac arrest.

Eric Baker arrived at 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 beeping. His heart begins to collapse.

“The nurse comes running in and grabs him, puts him on the bed and gives him the epi-spritzer.”

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

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

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

The study caucuses aimed to do things that all cardiac critical care professionals are familiar with. But they were done with specificity and without fail for each patient.

Gaies said the approach can be replicated in any pediatric cardiac intensive care unit. The results are profound, he said, adding, “It has changed the way we all practice our specialty.”

The ultimate goal of the care set is simple, Alten said: “We want every baby to come home.”

Just like James.