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Monitoring of rare events
Pediatric Peri-Operative Cardiac Arrest (POCA) Registry
  1. S Jones,
  2. A Raffles
  1. Child Health Department, East and North Herts NHS Trust, Queen Elizabeth 2 Hospital, Welwyn Garden City, Hertfordshire AL7 4HQ, UK
  1. Correspondence to:
 Dr A Raffles, Child Health Department, East and North Herts NHS Trust, Queen Elizabeth 2 Hospital, Howlands, Welwyn Garden City, Hertfordshire AL7 4HQ, UK;

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An international registry of rare events such as the Pediatric Peri-Operative Cardiac Arrest (POCA) Registry in the US would allow the development of valid standards against which clinical performance could be measured.

With rare conditions, or specific events which do not occur very often, it can be difficult to perform prospective studies which yield sufficient data from which meaningful interpretations can be made. The incidence of cardiopulmonary arrest from any cause—an especially rare event in children—remains at a level such that the collection of quality data is a rarity. Numerous historical studies have reported the incidence and causation of cardiopulmonary arrest,1–3 but most of these use retrospective data, addressing different variables and outcome measures which make a comparison of the data impossible. However, the existence of the Pediatric Peri-Operative Cardiac Arrest (POCA) Registry described in this issue by Posner et al4 shows that collection of large amounts of data from a widely spread geographical population using a sound methodology is, in fact, a realistic possibility.

The success of the POCA Registry can be attributed to its disease specific approach. Despite the fact that paediatric perioperative cardiac arrest remains a relatively rare occurrence, by concentrating on this one specific well defined event the data collected covers most of the centres in North America where anaesthetics are administered to children. In this data retrieval system events occurring within different types of institution providing services for different populations are included, and the quality of the data is improved by minimising the bias that exists when data are collected from a single institution.

This study draws on the audit system established by the American Society of Anaesthesiology Closed Claims Project5 whose database has already proved to be an effective means of describing rare events and identifying possible causative mechanisms. To establish such a database in other countries such as the UK would require the formation of a central coordinating centre with further “panel members” nationwide, all of which would require staffing and subsequent funding. It is, however, equally important to acknowledge the initial enthusiasm that existed to establish the Registry. Posner et al4 state that in 1994 “anaesthesiologists from over 50 hospitals throughout the United States and Canada expressed an interest in contributing data to a registry to investigate causes of cardiac arrest among paediatric anaesthetic patients”. From 1994 to 2002 the number of institutions involved in the Registry has remained relatively stable at approximately 60. Two factors have led to this.

  • With sound methodology, anonymity is maintained. This subsequently minimises under-reporting of cases as fear of litigation is reduced because it is impossible for cases to be traced back to their original institutions.

  • There is a commitment to ensuring that the Registry remains relatively high profile by persistently advertising its existence at annual meetings.

Within the UK, particularly in the wake of the Bristol Inquiry, it is difficult to believe that a similar level of enthusiasm does not exist. In the current media climate it is important that the medical profession is seen to be assessing the incidence and causes of adverse events openly, no matter how rare, and the establishment of a UK registry should be welcomed. With annual meetings such as the Royal College of Paediatrics and Child Health Annual Spring Meeting, there are also mechanisms in place to advertise the existence of such registers.

In 1990 there was an international consensus on the uniform collection of resuscitation data6 and in 1995 a paediatric specific template, the Utstein template, was published.7 This is a standardised method which allows for the collection of data from different clinical situations in a comparable form. Several studies from the US have been published using this template, but relatively few exist for the UK. However, the collection of such data has enormous implications. With internationally agreed standards, not only is it possible to compare outcomes within different scenarios, but also within different patient groups from geographically diverse populations using different types of services. The international community will benefit as more data can be collected, incidence rates truly calculated, causative factors identified, and processes which have better outcomes can be adopted while less favourable processes can be readdressed.

With the expectations of healthcare professionals to practise evidence-based medicine and the availability of numerous sources of information, it is logical to standardise data collection internationally. By using processes such as the POCA Registry, methodologically sound systems are established which allow information on rare events/conditions to be shared with the international community. Such information will allow the individual practitioner to ensure that information made available to the patient is not only standardised, but also up to date, accurate, and comparable across nations. This, in turn, will allow valid comparisons of outcome and causality to be made, resulting in an improvement in clinical performance and the development of valid clinical standards against which unit and individual performance can be measured.

An international registry of rare events such as the Pediatric Peri-Operative Cardiac Arrest (POCA) Registry in the US would allow the development of valid standards against which clinical performance could be measured.