Every year, about 15,000 U.S. hospitalized children need cardiopulmonary resuscitation (CPR) to restart their hearts. Many do not survive.

Survival from in-hospital cardiac arrest is lower for Black than for white adults. A new study found the same pattern for hospitalized children.

“Children’s survival from in-hospital cardiac arrest is much better than it was a few decades ago,” said LDI Senior Fellow Amanda O’Halloran. “But these advances aren’t benefiting all kids equally.”

O’Halloran discovered racial and ethnic inequities in children’s survival after in-hospital CPR by analyzing national hospital administrative data from more than a decade, with LDI Senior Fellows Garrett Keim, Joseph Rossano, Nadir Yehya, and LDI Associate Fellow Cody-Aaron Gathers and colleagues.

The authors say that equitably improving in-hospital resuscitation for children and adults requires hospital-level changes and national data infrastructure on cardiac arrests. O’Halloran answered questions about the study’s findings and their implications for improving resuscitation care for children.

What motivated you to study outcomes of pediatric in-hospital CPR?

O’Halloran: Our research team has a long-standing passion for understanding and addressing inequities in critical care outcomes. For hospitalized adults, racial and ethnic differences in cardiac arrest outcomes are partly explained by hospital-level factors. It was critical to investigate whether similar inequities exist for children.

Our study supports the American Heart Association’s 2030 Impact Goal of equitably increasing survival from pediatric in-hospital cardiac arrest, including among underrepresented populations and communities with low socioeconomic status.

A smaller study of selected hospitals in a quality improvement registry found no association between race and children’s survival from in-hospital cardiac arrest. However, we were concerned that the study couldn’t identify real survival differences due to the types of hospitals and data it used.

How does your study advance our understanding of children’s survival after in-hospital cardiac arrest and CPR?

O’Halloran: We used the Kids’ Inpatient Database (KID) from 1997 to 2019, which contains hospital administrative data representing the entire country. Among 6.2 million pediatric hospital admissions, we studied the 27,332 children who received in-hospital CPR.

We found that children whose race or ethnicity was reported as Black, American Indian, Alaska Native, Asian, Pacific Islander, or Hispanic were more likely (16% to 37% higher odds) than white children to die in the hospital after receiving CPR.

This novel finding suggests that racial and ethnic differences in in-hospital cardiac arrest outcomes also exist for children. Recognizing these disparities is the first step toward identifying their causes and ultimately, designing interventions to ensure that every child—regardless of race or ethnicity—has an equal chance of surviving cardiac arrest.

We also investigated associations between pediatric in-hospital mortality after CPR and hospitals’ proportion of Black patients. This metric is a potential indicator of hospital resources and resuscitation infrastructure and is associated with adult outcomes after in-hospital cardiac arrest. Examining differences in survival after in-hospital CPR based on hospital composition can move us toward understanding—and ultimately addressing—the mechanisms driving them.

Similar to adults, children receiving CPR at hospitals with the highest proportion of Black patients had 50% higher odds of dying before discharge than children at hospitals serving the lowest proportion. We saw no difference in survival by children with public or private insurance coverage, but children with no insurance, who weren’t charged, or whose families paid out of pocket, had lower survival than children with insurance.

How can we save more kids after in-hospital cardiac arrest and eliminate racial and ethnic disparities in survival?

O’Halloran: Improvements in CPR training and quality and advances in resuscitation science have greatly improved care for pediatric in-hospital cardiac arrest, which was largely unsurvivable a few decades ago. However, our results suggest that these advances may not be equitably distributed.

Hospital differences in resuscitation care are important contributors to outcome disparities. Better access to technology, such as extracorporeal membrane oxygenation (ECMO), which temporarily provides lung and heart support, and higher nurse-to-patient ratios may improve outcomes.

All hospitals treat children with cardiac arrest—regardless of region, neighborhood, or rural or urban location—and should be prepared to provide high-quality resuscitation. “Pediatric readiness” is supported by strong guidelines from organizations including the American Academy of Pediatrics, American College of Emergency Physicians, Emergency Nurses Association, and the National Pediatric Readiness Project. However, there is no national mandate for these policies, and hospitals appear to vary widely in preparedness for pediatric cardiac arrest.

What additional research do we need to address differences in pediatric cardiac arrest survival?

O’Halloran: We’re interested in studying hospital-level characteristics such as resuscitation policies and nurse-to-patient ratios for links to pediatric survival after in-hospital cardiac arrest, but the data aren’t available in the KID. We’d like to study the effects of illness severity, cardiac arrest interventions performed, and additional demographics, which will require clinical datasets. Our ultimate goal is to identify the drivers of survival after in-hospital cardiac arrest and use that knowledge to develop clinical interventions to improve resuscitation systems for all children.

The U.S. needs a comprehensive cardiac arrest registry to advance research on this topic. There’s currently no nationwide registry for in-hospital or out-of-hospital cardiac arrest. Accurate data describing the full landscape of cardiac arrest in the U.S would be invaluable in advancing the field of resuscitation science and saving more lives.

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The study, “Race, Ethnicity, Insurance Payer, and Pediatric Cardiac Arrest Survival” was published on September 2, 2025 in JAMA Network Open. Authors include Amanda J. O’Halloran, Garrett Keim, Cody-Aaron Gathers, Jessica Fowler, Maryam Y. Naim, Joseph W. Rossano, Robert A. Berg, Robert M. Sutton, Nadir Yehya, Ryan W. Morgan.

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