Characteristics and outcomes of AED use in pediatric cardiac arrest in public settings: The influence of neighborhood characteristics

Journal Pre-proof Characteristics and outcomes of AED use in pediatric cardiac arrest in public settings: The influence of neighborhood characteristics H. Griffis, L. Wu, M.Y. Naim, R. Bradley, J. Tobin, B. McNally, K. Vellano, L. Quan, D. Markenson, J.W. Rossano, The CARES Surveillance Group

PII:

S0300-9572(19)30704-X

DOI:

https://doi.org/10.1016/j.resuscitation.2019.09.038

Reference:

RESUS 8302

To appear in:

Resuscitation

Received Date:

1 February 2019

Revised Date:

27 August 2019

Accepted Date:

9 September 2019

Please cite this article as: Griffis H, Wu L, Naim MY, Bradley R, Tobin J, McNally B, Vellano K, Quan L, Markenson D, Rossano JW, Characteristics and outcomes of AED use in pediatric cardiac arrest in public settings: The influence of neighborhood characteristics, Resuscitation (2019), doi: https://doi.org/10.1016/j.resuscitation.2019.09.038

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.

1 Characteristics and Outcomes of AED use in Pediatric Cardiac Arrest in Public Settings: The Influence of Neighborhood Characteristics

Griffis, H1-3; Wu, L4; Naim, MY3-5; Bradley, R6; Tobin, J7; McNally, B8; Vellano, K8; Quan, L9; Markenson, D10; Rossano, JW3-5; the CARES Surveillance Group

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1. Healthcare Analytics Unit, The Children’s Hospital of Philadelphia

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2. PolicyLab, The Children’s Hospital of Philadelphia

4. The Children’s Hospital of Philadelphia

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3. Cardiac Center Research Core, The Children’s Hospital of Philadelphia

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5. Division of Critical Care, The Children’s Hospital of Philadelphia 6. Division of Emergency Medical Services and Disaster Medicine, University of Texas

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Health Science Center

7. Division of Trauma Anesthesiology, University of Southern California

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8. Department of Emergency Medicine, Emory University 9. Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Washington School of Medicine 10. Sky Ridge Medical Center

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Corresponding author:

Heather Griffis, PhD 2716 South Street Roberts Center Room 11282 Philadelphia, PA 19126 215-590-6353 [email protected]

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Word count: 2045

3 Abstract

Background: Automated external defibrillators (AEDs) are critical in the chain of survival following out-of-hospital cardiac arrest (OHCA), yet few studies have reported on AED use and outcomes among pediatric OHCA. This study describes the association between bystander AED use, neighborhood characteristics and survival outcomes following public pediatric OHCA.

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Methods: Non-traumatic OHCAs among children less than18 years of age in a public setting

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between from January 1, 2013 through December 31, 2017 were identified in the CARES

database. A neighborhood characteristic index was created from the addition of dichotomous

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values of 4 American Community Survey neighborhood characteristics at the Census tract level:

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median household income, percent high school graduates, percent unemployment, and percent African American. Multivariable logistic regression models assessed the association of OHCA

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characteristics, the neighborhood characteristic index and outcomes. Results: Of 971 pediatric OHCA, AEDs were used by bystanders in 10.3% of OHCAs. AEDs

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were used on 2.3% of children ≤ 1 year (infants), 8.3% of 2-5 year-olds, 12.4% of 6-11 yearolds, and 18.2% of 12-18 year-olds (p<0.001). AED use was more common in neighborhoods with a median household income of >$50,000 per year (12.3%; p=0.016), <10% unemployment (12.1%; p=0.002), and >80% high school education (11.8%; p=0.002). Greater survival to

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hospital discharge and neurologically favorable survival were among arrests with bystander AED use, varying by neighborhood characteristics. Conclusions: Bystander AED use is uncommon in pediatric OHCA, particularly in high-risk neighborhoods, but improves survival. Further study is needed to understand disparities in AED use and outcomes.

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Keywords: pediatric OHCA; cardiac arrest; AED

5 Introduction Out-of-hospital cardiac arrest (OHCA) occurs among approximately 350,000 adults and 7,000 children per year in the United States. Survival is low, ranging from 2% to 15% depending on patient characteristics, location of the OHCA, and post-resuscitation care factors 1-3. While improvements have been made in OHCA survival among adults, survival among children has stagnated2-4. Rapid bystander response in the form of cardiopulmonary resuscitation (CPR) and

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automatic external defibrillation (AED) vastly improves OHCA survival5. To date, there are

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limited studies and few population-based data on the use of AEDs among pediatric patients2,6. AEDs provide an important link in the chain of survival following OHCA; in the event of

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an OHCA, bystander AED use includes retrieving an AED and applying it to the OHCA patient.

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When available in a public setting, AEDs are easy for bystanders to use 7. Their use in pediatric cardiac arrest is recommended by the American Academy of Pediatrics, American Heart

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Association, and the American Red Cross8. However, bystander AED use among all pediatric OHCAs remains low at around 2-3%9, although this increases up to 28% if including first

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responders [i.e. police officers or EMTs (emergency medical technicians)] utilizing an AED6. Low rates of bystander AED use may be due to limited access to public AEDs, lack of knowledge and/or poor training regarding AED use, misconceptions about AED use in children, lack of available of pediatric AED pads, or other factors10-12.

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The location of a public cardiac arrest can influence the likelihood that a bystander will

use an AED prior to EMS arrival, particularly the availability of an AED in the neighborhood. For example, the density and availability of AEDs varies by neighborhoods; subsequently, bystanders may not have access to a nearby AED to utilize in the event of a cardiac arrest in particular locations13. Additionally, neighborhood characteristics, such as higher socioeconomic

6 status and neighborhood race/ethnic composition, are associated with the provision of bystander CPR14,15 as well as bystander AED use16. For pediatric OHCAs, bystander CPR is strongly associated with neighborhood characteristics17.Likewise, pediatric arrests in areas with higher median household income, educational attainment and white-populated neighborhoods are more likely to receive an AED prior to emergency medical services (EMS) arrival6. To better understand bystander AED use among pediatric OHCA patients and survival

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outcomes, this study describes 1) the association between bystander AED use and pediatric

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OHCA neighborhood characteristics and 2) the relationship of bystander AED use to survival outcomes following pediatric OHCA. We hypothesized that bystander AED use would be more

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common among older children, witnessed arrests, and arrests with a shockable rhythm9,10

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whereas AED use would be less common in neighborhoods characterized by lower income, higher unemployment, and minority race/ethnicity14,15.

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Methods Data

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We utilized the Cardiac Arrest Registry to Enhance Survival (CARES) database, a registry of non-traumatic OHCAs spanning 69 communities in 19 states as well as 23 statewide registries across the US. CARES has a catchment area that includes more than 120 million people, over 1400 Emergency Medical Service (EMS) agencies and over 1900 hospitals. Data

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from January 1, 2013 through December 31, 2017 includes patient demographic, pre-hospital OHCA, and Census tract-level characteristics of the OHCA location. Census tract characteristics were gleaned from the American Community Survey (ACS) 2016 5-year estimates and linked to the OHCA tract location. Variables of Interest

7 Patients less than 18 years of age whose cardiac arrest was in a public setting were included; public arrests include public buildings, streets or highways, recreation centers, or transportation centers. Patients who arrested at a non-public location (private residential, healthcare facility or nursing home) or whose arrest was witnessed by a 911 responder were excluded from the analytic dataset. Demographic variables included: age in years (less than or equal 1, 2 to 5, 6 to 11, and 12

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to 18), gender, and race/ethnicity (white, black, Hispanic, other and unknown). Additional

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variables included bystander CPR, bystander witnessed arrest, and shockable rhythm.

A neighborhood characteristic index was created from four variables from the ACS:

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median household income, percent unemployment, percent African American and percent high

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school education. The index was a sum of the dichotomized variables at the corresponding distributions: median household income <$50,000 per year (1) vs. >$50,000 per year (0);

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unemployment >10% (1) vs. unemployment <10% (0); >80% African American residents (1) vs. <80% African American residents (0); and <80% of residents with a high school education (1)

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vs. >80% with a high school education (0). A neighborhood index score equaled the summed scores, ranging from 0 (lowest risk) to 4 (highest risk). Outcomes

The primary outcome of interest was bystander AED use in public locations, defined as a

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bystander utilizing an AED at the scene of the arrest before EMS or first responder arrival, regardless of whether defibrillation occurred. Secondary outcomes of interest were survival to hospital discharge and neurologically

favorable survival. Neurologically favorable survival was defined as a Cerebral Performance Category (CPC) score of 1 or 2 vs 3, 4 or 5: CPC 1: good cerebral performance; or CPC 2:

8 moderate cerebral disability at hospital discharge vs 3: severe cerebral disability; CPC 4: coma or vegetative state; or CPC 5: brain death; or death. Analysis Descriptive statistics were reported via contingency table analysis using Chi-square test and Fishers exact tests to assess the relationship between demographic and pre-hospital characteristics and bystander AED use. To assess factors associated with survival to hospital

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discharge and neurologically favorable survival outcomes, multivariable logistic regression

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models were utilized that included bystander AED use in addition to pre-hospital and

demographic factors. An interaction term of bystander AED use and neighborhood index value

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was included. A two-sided test of significance was used where p<0.05 represented statistically

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significant findings. All analyses were conducted in STATA Version 15. Results

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A total of 7,818 pediatric cardiac arrests were available in the CARES data from 2013 to 2017. Of these, 971 pediatric OHCAs occurred during the five-year period with evaluable data.

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AEDs were used by bystanders in 100 (10.3%) events. The rate of AED use did not change significantly over time (p=0.65) [Table 1]. AEDs were used among 2.3% of children aged ≤ 1 year (infants), 8.3% of 2-5 year-olds, 12.4% of 6-11 year-olds, and 18.2% of 12-18 year-olds (p<0.001). No difference in AED use was found between male and female OHCAs (p=0.743).

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AED use was more common with the provision of bystander CPR (19.0%) versus no bystander CPR (0.01%), witnessed arrests (16.0%) versus unwitnessed arrests (4.7%), and arrests with a shockable rhythm (23.6%) versus non-shockable rhythm (6.3%) (p<0.001 for all). Of note, bystander CPR prior to first responders or EMS occurred in only half of the instances of cardiac arrest (51.9%).

9 AED use was more common in arrest locations with median household incomes of >$50,000 per year (12.3%; p=0.016), <10% unemployment (12.1%; p=0.002), and >80% high school education (11.8%; p=0.002) [Table 2]. There was a negative association between the neighborhood characteristic index and bystander AED use [Figure 1]: AEDs were used among 13.6% of OHCAs in neighborhoods with an index value of 0 compared to 5.3% of OHCAs in neighborhoods with an index value of 3 or 4 (p=0.007).

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Overall unadjusted survival to hospital discharge among this cohort of public pediatric

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OHCAs was 26.2%; among infants, survival to discharge was 7.5% compared to 31.1% for 2-5 year-olds, 31.7% for 6-11 year-olds, and 40.8% for 12-18 year-olds. Adjusting for demographic

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and pre-hospital factors, survival outcomes were more favorable across index scores when AEDs

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were used (Figure 2). Among OHCAs with no bystander AED use, the adjusted survival to hospital discharge rate was 26.0% (95% CI 22.5%, 29.5%) in neighborhoods with an index value

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of 0 compared to 20.8% (95% CI 15.6%, 25.9%) with an index value of 2 or more (p=0.108). Comparably, among OHCAs with bystander AED use, the adjusted survival to hospital discharge

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rate was 35.2% (95% CI 25.8%, 44.5%) in neighborhoods with an index value of 0 compared to 12.7% (95% CI 0.0%, 25.1%) with an index value of 2 or more (p=0.020). Survival was the same for low risk neighborhoods without bystander AED and high risk neighborhoods with bystander AED use (p=0.109). While the adjusted probability of survival estimate is lower for

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OHCAs with a bystander utilizing an AED compared to OHCAs without a bystander utilizing an AED in neighborhoods with an index value of 2+, this is not significantly different to due the small sample size and wide confidence intervals of these estimates. The overall rate for neurologically-favorable survival was 24.5%. Adjusted probabilities for neurologically favorable survival were similar for OHCAs in which a bystander utilized an

10 AED in neighborhoods with scores of 0 or 1 [31.1% (95% CI: 22.5%, 39.7%) and 36.3% (95% CI 17.8%, 54.9%) respectively] (Figure 3).Additionally, adjusted neurologically-favorable survival rates were significantly higher in neighborhoods with scores of 0 or 1 compared to neighborhoods with a score of 2 or more on the index value [12.8% (95% CI 0.0, 25.3%) (pvalues 0.047 and 0.044, respectively)]. Discussion

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This study has three main findings. First, bystander AED use is uncommon among public

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pediatric OHCAs and varies by demographic and pre-hospital characteristics for OHCAs.

Secondly, bystander AED use is significantly more common among OHCAs that occur in

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neighborhoods that have higher socioeconomic status. Thirdly, the use of AEDs by bystanders is

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related to better survival outcomes.

Overall, only one in ten pediatric OHCAs received an AED by a bystander in our study.

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We found patient age, provision of bystander CPR, witnessed status and shockable rhythm were all associated with bystander AED use, similar to previous studies among pediatric OHCAs6,8,18.

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Recent studies show variable rates of bystander-applied AEDs among adult OHCAs, ranging from 6% for adult public and residential OHCAs, and up to 19% among adult OHCAs in public spaces only19.

In addition to demographic and pre-hospital characteristics, the neighborhood in which an

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OHCA took place was also related to bystander AED use. The additive index of neighborhood characteristics showed a graded pattern of AED use. Consequently, higher bystander AED use translated to survival to discharge and neurologically favorable survival—OHCAs with bystander AED use were more likely to survive, and OHCAs occurring in neighborhoods with fewer risk factors without AED use were less likely to survive. These findings could be due to

11 several factors, including level of willingness for bystanders to act, education about AED use, and availability of an AED in the neighborhood. Prior research shows that neighborhoods with higher socioeconomic status are more likely to have a higher density of AEDs13. Given these findings, increasing education by promoting bystander response may increase the likelihood of bystander AED use and subsequent pediatric OHCA survival. Bystander CPR only occurred in half of the instances of cardiac arrest, suggesting a need to

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promote bystander CPR awareness and intervention alongside AED use. Better public education

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is needed in the use of CPR and AEDs, particularly in children, with a focus on high-risk

neighborhoods and areas with low bystander CPR and AED provision. For example, a school

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training program that promoted bystander response via students training and educating friends

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and family reported a significant increase in CPR knowledge among participants 20. Additionally, increasing the density of AEDs, making AEDs more visible and/or

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redistributing the locations of AEDs across neighborhoods may also increase the likelihood of bystander AED provision. Expanding technology via smart phones provides the opportunity to

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locate AEDs in particular geographic areas in real-time21 and alert bystanders when an OHCA occurs nearby via a mobile application22. Utilizing drone technology to deliver an AED to the exact location of an OHCA in real-time can also increase the availability of AEDs23, particularly in rural areas and urban areas with low AED density. These possibilities not only increase

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education and awareness of AED, but also decrease the distribution disparity of AED locations across different neighborhood. This retrospective study was subject to general limitations of CARES, such as potential

for bias, and limited sample size. There may be important arrest characteristics or other

12 confounders that are not recorded in CARES and thus not available for analysis. CARES may not be generalizable to the entire US, but it captures a large representative portion. Conclusion Bystander AED use is uncommon in children suffering OHCA, particularly in high risk neighborhoods, but there is a survival benefit. Further study is needed to understand these

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disparities in AED use and outcomes after AED use.

13 Conflicts of interest: none

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Acknowledgements: none

14 References

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Lee SY, Ro YS, Shin SD, et al. Interaction effects between highly-educated neighborhoods and dispatcher-provided instructions on provision of bystander cardiopulmonary resuscitation. Resuscitation. 2016;99:84-91. Tobin JM, Ramos W, Wernicki P, Quan L, Rossano JW. Bystander CPR is associated with improved neurologically favourable survival in cardiac arrest following drowning. Resuscitation. 2017;115:39-43. Pollack RA, Brown SP, Rea T, et al. Impact of Bystander Automated External Defibrillator Use on Survival and Functional Outcomes in Shockable Observed Public Cardiac Arrests. Circulation. 2018;137(20):2104–2113. Rios MD, Han J, Cano A, et al. Pay It Forward: High School Video-based Instruction Can Disseminate CPR Knowledge in Priority Neighborhoods. West J Emerg Med. 2018;19(2):423-429. Merchant RM, Asch DA, Hershey JC, et al. A Crowdsourcing Innovation Challenge to Locate and Map Automated External Defibrillators. Circulation: Cardiovascular Qualtiy and Outcomes. 2013;6:229-236. Brooks SC, Simmons G, Worthington H, Bobrow BJ, Morrison LJ. The PulsePoint Respond mobile device application to crowdsource basic life support for patients with out-ofhospital cardiac arrest: challenges for optimal implementation. Resuscitation. 2015;98:20-26. Pulver A, Wei R, Mann C. Locating AED Enabled Medical Drones to Enhance Cardiac Arrest Response Times. Prehospital Emergency Care. 2016;20(3):378-389.

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17.

16 Figure Legends:

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Figure 1. Distribution of bystander AED use by neighborhood index value. Neighborhood index is sum of dichotomized variables at the corresponding distributions: median household income <$50,000 per year (1) vs. >$50,000 per year (0); unemployment >10% (1) vs. unemployment <10% (0); >80% African American residents (1) vs. <80% African American residents (0); and <80% of residents with a high school education (1) vs. >80% with a high school education (0). A neighborhood index score equaled the summed scores, ranging from 0 (lowest risk) to 4 (highest risk). Index values of 3 and 4 were collapsed to due few OHCAs in category 4. For each index value, the percent of OHCAs with a bystander applying an AED is presented on the y-axis.

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P<0.001

12 10 8

6.3

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8.8

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13.6

5.3

6 4

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Percent bystander AED use

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2 0 1

2

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0

3+

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Index value

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Figure 2. Adjusted survival to discharge by bystander AED use and neighborhood index. The xaxis shows the interaction of index value and bystander AED use. Y axis is the marginal probability of survival to discharge, with 95% confidence intervals. Characteristics included in the multivariable model include: age (< or equal to 1 year; 2 to 5 years; 6 to 11 years, and 12 and older), gender (male/female), race/ethnicity (white, black, Hispanic, other, unknown), bystander CPR (yes/no), witnessed (yes/no) and shockable (yes/no).

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50 35.2 36.8 40

28.5 26.0

30

20.8

12.7

20

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Adjusted percent survival to discharge

60

10

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0 Index value 0

Index value 1

Index value 1

Index value 2+

Index value 2+

No bystander AED use

Bystander AED use

No bystander AED use

Bystander AED use

No bystander AED use

Bystander AED use

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Index value 0

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*Characteristics included in the multivariable model include: age (< or equal to 1 year; 2 to 5 years; 6 to 11 years, and 12 and older), gender (male/female), race/ethnicity (white, black, Hispanic, other, unknown), bystander CPR (yes/no), witnessed (yes/no) and shockable (yes/no); 95% confidence intervals are shown

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Figure 3. Adjusted neurologically favorable survival by bystander AED use and neighborhood index. The x-axis shows the interaction of index value and bystander AED use. Y axis is the marginal probability of survival to discharge, with 95% confidence intervals. Characteristics included in the multivariable model include: age (< or equal to 1 year; 2 to 5 years; 6 to 11 years, and 12 and older), gender (male/female), race/ethnicity (white, black, Hispanic, other, unknown), bystander CPR (yes/no), witnessed (yes/no) and shockable (yes/no).

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Adjusted percent neurologically favoriable survival

60 50 36.3

31.1 40 30

25.7

24.8

19.5

12.8

20 10 0 Index value 0

Index value 1

Index value 1

Index value 2+

Index value 2+

No bystander AED use

Bystander AED use

No bystander AED use

Bystander AED use

No bystander AED use

Bystander AED use

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Index value 0

*Characteristics included in the multivariable model include: age (< or equal to 1 year; 2 to 5 years; 6 to 11 years, and 12 and

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(yes/no) and shockable (yes/no); 95% confidence intervals shown

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older), gender (male/female), race/ethnicity (white, black, Hispanic, other, unknown), bystander CPR (yes/no), witnessed

19 Table 1. Distribution of demographic and pre-hospital characteristics by bystander AED use

Characteristics

All

No bystander AED used

Bystander AED used

(N=971)

(n=871)

(n=100)

N

%

n

%

n

%

Year of arrest

0.653 130

13.4%

117

13.4%

2014

145

14.9%

125

14.4%

2015

212

21.8%

191

21.9%

2016

228

23.5%

205

2017

256

26.4%

233

2 to 5

132

6 to 11

145

Gender

35.8%

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Female Male

346

340

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348

13.0% 20.0%

21

21.0%

23.5%

23

23.0%

26.8%

23

23.0%

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20

<0.001 39.0%

8

8.0%

13.6%

121

13.9%

11

11.0%

14.9%

127

14.6%

18

18.0%

283

32.5%

63

63.0%

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<=1

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Age

13

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2013

12 to 18

35.6%

0.743

316

32.5%

282

32.4%

34

34.0%

655

67.5%

589

67.6%

66

66.0%

Race/ethnicity White

P-value

0.830 307

31.6%

273

31.3%

34

34.0%

20 African 264

27.2%

240

27.6%

24

24.0%

Hispanic

87

9.0%

80

9.2%

7

7.0%

Other

32

3.3%

28

3.2%

4

4.0%

Unknown

281

28.9%

250

28.7%

31

31.0%

Bystander CPR 467

48.1%

463

53.2%

Yes

504

51.9%

408

46.8%

4

4.0%

96

96.0%

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ro

No

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American

witnessed arrest 489

Witnessed

482

49.6%

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Shockable rhythm

50.4%

466

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Unwitnessed

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Bystander

405

<0.001

53.5%

23

23.0%

46.5%

77

77.0%

<0.001

Nonshockable

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Shockable

<0.001

746

76.8%

699

80.3%

47

47.0%

225

23.2%

172

19.7%

53

53.0%

21 Table 2. Distribution of neighborhood characteristics by bystander AED use

>80% HS diploma

11.8

92/779

<80% HS diploma

4.2

8/192

Unemployment <10%

12.1

87/717

Unemployment >10%

5.1

13/254

Median HH income> 50k

12.3

70/571

Median HH income< 50k

7.5

30/400

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10.7

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Percent African American <80%

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Percent African American >80%

3.5

0.002

0.002

98/914 2/57

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n

0.016

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%

p value

ro

Bystander AED used

0.112