Association Between Hospital Recognition for Resuscitation Guideline Adherence and Rates of Survival for In-Hospital Cardiac Arrest

Correlation between hospital rates of survival to discharge and long-term survival for in-hospital cardiac arrest: Insights from Get With The Guidelines®-Resuscitation registry

AIM

Given challenges in collecting long-term outcomes for survivors of in-hospital cardiac arrest (IHCA), most studies have focused on in-hospital survival. We evaluated the correlation between a hospital's risk-standardized survival rate (RSSR) at hospital discharge for IHCA with its RSSR for long-term survival.

METHODS

We identified patients ≥65 years of age with IHCA at 472 hospitals in Get With The Guidelines®-Resuscitation registry during 2000-2012, who could be linked to Medicare files to obtain post-discharge survival data. We constructed hierarchical logistic regression models to compute RSSR at discharge, and 30-day, 1-year, and 3-year RSSRs for each hospital. The association between in-hospital and long-term RSSR was evaluated with weighted Kappa coefficients.

RESULTS

Among 56,231 Medicare beneficiaries (age 77.2 ± 7.5 years and 25,206 [44.8%] women), 10,536 (18.7%) survived to discharge and 8,485 (15.1%) survived to 30 days after discharge. Median in-hospital, 30-day, 1-year, and 3-year RSSRs were 18.6% (IQR, 16.7-20.4%), 14.9% (13.2-16.7%), 10.3% (9.1-12.1%), and 7.6% (6.8-8.8%), respectively. The weighted Kappa coefficient for the association between a hospital's RSSR at discharge with its 30-day, 1-year, and 3-year RSSRs were 0.72 (95% CI, 0.68-0.76), 0.56 (0.50-0.61), and 0.47 (0.41-0.53), respectively.

CONCLUSIONS

There was a strong correlation between a hospital's RSSR at discharge and its 30-day RSSR for IHCA, although this correlation weakens over time. Our findings suggest that a hospital's RSSR at discharge for IHCA may be a reasonable surrogate of its 30-day post-discharge survival and could be used by Medicare to benchmark hospital performance for this condition without collecting 30-day survival data.

Higher Survival With the Use of Extracorporeal Cardiopulmonary Resuscitation Compared With Conventional Cardiopulmonary Resuscitation in Children Following Cardiac Surgery: Results of an Analysis of the Get With The Guidelines-Resuscitation Registry

OBJECTIVES

Extracorporeal membrane oxygenation to support cardiopulmonary resuscitation (CPR) is increasingly used in children suffering cardiac arrest after cardiac surgery. However, its efficacy in promoting survival has not been evaluated. We compared survival of pediatric cardiac surgery patients suffering in-hospital cardiac arrest who were resuscitated with extracorporeal CPR (E-CPR) to those resuscitated with conventional CPR (C-CPR) using propensity matching.

DESIGN

Retrospective study using multicenter data from the American Heart Association Get With The Guidelines-Resuscitation registry (2008-2020).

SETTING

Multicenter cardiac arrest database containing cardiac arrest and CPR data from U.S. hospitals.

PATIENTS

Cardiac surgical patients younger than 18 years old who suffered in-hospital cardiac arrest and received greater than or equal to 10 minutes of CPR.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Among 1223 patients, 741 (60.6%) received C-CPR and 482 (39.4%) received E-CPR. E-CPR utilization increased over the study period ( p < 0.001). Duration of CPR was longer in E-CPR compared with C-CPR recipients (42 vs. 26 min; p < 0.001). In a propensity score matched cohort (382 E-CPR recipients, 382 C-CPR recipients), E-CPR recipients had survival to discharge (odds ratio [OR], 2.22; 95% CI, 1.7-2.9; p < 0.001). E-CPR survival was only higher when CPR duration was greater than 18 minutes. Propensity matched analysis using patients from institutions contributing at least one E-CPR case ( n = 35 centers; 353 E-CPR recipients, 353 C-CPR recipients) similarly demonstrated improved survival in E-CPR recipients compared with those who received C-CPR alone (OR, 2.08; 95% CI, 1.6-2.8; p < 0.001).

CONCLUSIONS

E-CPR compared with C-CPR improved survival in children suffering cardiac arrest after cardiac surgery requiring CPR greater than or equal to 10 minutes.

Compliance with cardiopulmonary resuscitation guidelines in witnessed in-hospital cardiac arrest events and patient outcome on monitored versus non-monitored wards

BACKGROUND

Adherence to cardiopulmonary resuscitation (CPR) guidelines in treatment of in-hospital cardiac arrest (IHCA) have been associated with favourable patient outcome. The aim of this study was to evaluate if compliance with initial CPR guidelines and patient outcome of witnessed IHCA events were associated with the place of arrest defined as monitored versus non-monitored ward.

METHODS

A total of 956 witnessed IHCA events in adult patients at six hospitals during 2018 to 2019, were extracted from the Swedish Registry of Cardiopulmonary Resuscitation. Initial CPR guidelines were: ≤1 min from collapse to alert of the rapid response team, ≤1 min from collapse to start of CPR, ≤3 min from collapse to defibrillation of shockable rhythm.

RESULTS

The odds of compliance with guidelines was higher on monitored wards vs non-monitored wards, even after adjustment for factors that could affect staffing and resources. The place of arrest was not a significant factor for sustained return of spontaneous circulation, survival at 30 days, or neurological status at discharge, when adjusting for clinically relevant confounders. Compliance with initial CPR guidelines remained a significant factor for survival to 30 days and favourable neurological outcome at discharge regardless of other confounders.

CONCLUSION

Compliance with initial CPR guidelines was higher in witnessed IHCA events on monitored wards than on non-monitored wards, which indicates that healthcare professionals in monitored wards are quicker to recognize a cardiac arrest and initiate treatment. When initial CPR guidelines are followed, the place of arrest does not influence patient outcome.

Outcomes of in-hospital cardiac arrests during and after office hours in a single tertiary centre in Singapore

INTRODUCTION

In-hospital cardiac arrest (IHCA) is a significant healthcare burden with a paucity of data in Singapore. Various factors, including time of cardiac arrest, affect survival from acute resuscitation.

METHODS

This was a retrospective cohort study that evaluated the characteristics of patients who sustained an IHCA, including the Cardiac Arrest Survival Post Resuscitation In-hospital (CASPRI) scores, and the impact of arrest time in 220 consecutive cardiac arrests occurring in a tertiary hospital. The primary outcome was rate of return of spontaneous circulation (ROSC) post-IHCA, and the secondary outcome was 90-day survival.

RESULTS

The ROSC rate among patients with IHCA out of and during office hours was 69.5% and 75.4%, respectively (odds ratio [OR] 0.74, 95% confidence interval [CI] 0.39-1.42). There were no statistically significant differences between the CASPRI scores of both groups. After adjusted analysis, the OR of ROSC post-IHCA out of office hours as compared to that during office hours was 0.78 (95% CI 0.39-1.53). The 90-day survival rate of patients who had an IHCA out of and during office hours was 25.7% and 34.6%, respectively (OR 0.65, 95% CI 0.32-1.34). The adjusted OR of 90-day survival was 0.66 (0.28-1.59).

CONCLUSION

The results of this observational study did not show an association between the timing of cardiac arrest and the rate of ROSC or 90-day survival.

Does Compliance with Resuscitation Practice Guidelines Differ Between Pediatric Intensive Care Units and Cardiac Intensive Care Units?

Objective: Hospitalized children with cardiac disease have the highest rate of cardiac arrest compared to other disease types. Different intensive care unit (ICU) models exist, but it remains unknown whether resuscitation guideline adherence is different between cardiac ICUs (CICU) and general pediatric ICUs (PICU). We hypothesize there is no difference in resuscitation practices between unit types. Design: Retrospective observational study. Setting: The American Heart Association's Get With The Guidelines®-Resuscitation (GWTG-R) registry. Patients: Children < 18 years old with medical or surgical cardiac disease who had cardiopulmonary arrest from 2014 to 2018. Intervention: None. Measurements and Main Results: Events were assessed for compliance with GWTG-R achievement measures of time to first chest compressions ≤ 1 min, time to intravenous/intraosseous epinephrine ≤ 5 min, time to first shock ≤ 2 min for ventricular fibrillation (VF)/pulseless ventricular tachycardia (VT), and confirmation of endotracheal tube placement. Additional practices were evaluated for consistency with Pediatric Advanced Life Support (PALS) recommendations. Eight hundred and eighty-six patients were evaluated, 687 (79%) in CICUs and 179 (21%) in PICUs. 484 (56%) had surgical cardiac disease. There were no differences in GWTG-R achievement measures or PALS recommendations between ICU types in univariable or multivariable models. Amiodarone, lidocaine, and nonstandard medication use did not differ by unit type. Extracorporeal cardiopulmonary resuscitation (ECPR) was more common in CICUs for both medical (16% vs 7%) and surgical (25% vs 2.5%) categories (P < .0001). Conclusions: Resuscitation compliance for patients with cardiac disease is similar between CICUs and PICUs. Patients were more likely to receive ECPR in CICUs. Additional study should evaluate how ICU type affects arrest outcomes in children with cardiac disease.

Updating the model for Risk-Standardizing survival for In-Hospital cardiac arrest to facilitate hospital comparisons

BACKGROUND

Risk-standardized survival rates (RSSR) for in-hospital cardiac arrest (IHCA) have been widely used for hospital benchmarking and research. The novel coronavirus 2019 (COVID-19) pandemic has led to a substantial decline in IHCA survival as COVID-19 infection is associated with markedly lower survival. Therefore, there is a need to update the model for computing RSSRs for IHCA given the COVID-19 pandemic.

METHODS

Within Get With The Guidelines®-Resuscitation, we identified 53,922 adult patients with IHCA from March, 2020 to December, 2021 (the COVID-19 era). Using hierarchical logistic regression, we derived and validated an updated model for survival to hospital discharge and compared the performance of this updated RSSR model with the previous model.

RESULTS

The survival rate was 21.0% and 20.8% for the derivation and validation cohorts, respectively. The model had good discrimination (C-statistic 0.72) and excellent calibration. The updated parsimonious model comprised 13 variables-all 9 predictors in the original model as well as 4 additional predictors, including COVID-19 infection status. When applied to data from the pre-pandemic period of 2018-2019, there was a strong correlation (r = 0.993) between RSSRs obtained from the updated and the previous models.

CONCLUSION

We have derived and validated an updated model to risk-standardize hospital rates of survival for IHCA. The updated model yielded RSSRs that were similar to the initial model for IHCAs in the pre-pandemic period and can be used for supporting ongoing efforts to benchmark hospitals and facilitate research that uses data from either before or after the emergence of COVID-19.

Acting on the potentially reversible causes of traumatic cardiac arrest: Possible but not sufficient

INTRODUCTION

Traumatic cardiac arrest (TCA) guidelines emphasize specific actions that aim to treat the potential reversible causes of the arrest. The aim of this study was to measure the impact of these recommendations on specific rescue measures carried out in the field, and their influence on short-term outcomes in the resuscitation of TCA patients.

METHODS

We conducted a retrospective study of all TCA patients treated in two emergency medical units, which are part of the Northern Alps Emergency Network, from January 2004 to December 2017. We categorised cases into three periods: pre-guidelines (from January 2004 to December 2007), during guidelines (from January 2008 to December 2011), and post-guidelines (from January 2012 to December 2017). Local guidelines, a physician education programme, and specific training were set up during the post-guidelines period to increase adherence to recommendations. Utstein variables, and specific rescue measures were collected: advanced airway management, fluid administration, pelvic stabilisation or tourniquet application, bilateral thoracostomy, and thoracotomy procedures. The primary endpoint was survival rate at day 30 with good neurological status (cerebral performance category scores 1 & 2) in each period, considering the pre-guidelines period as the reference.

RESULTS

There were 287 resuscitation attempts in the TCA cases included, and 279 specific interventions were identified with a significant increase in the number of fluid expansions (+16%), bilateral thoracostomies (+75%), and pelvic stabilisations (+25%) from the pre- to post-guidelines periods. However, no improvement in survival over time was found.

CONCLUSION

Reversible measures were applied but to a varying degree, and may not adequately capture pre-hospital performance on overall TCA survival.

Polypharmacy prior to in-hospital cardiac arrest among patients with cardiopulmonary diseases: A pilot study

Background

Patterns of medication administration prior to in-hospital cardiac arrest (I-HCA) and the potential impact of these on patient outcomes is not well-established. Accordingly, types of medications administered in the 72 h prior to I-HCA were examined in relation to initial rhythms of I-HCA and survival.

Methods

A retrospective, pilot study was conducted among 96 patients who experienced I-HCA. Clinical characteristics and treatments including medications were extracted from electronic health records. Relative risk (RR) of medications or class of medications associated with the initial rhythms of I-HCA and return of spontaneous circulation (ROSC) were calculated.

Results

Two distinct sub-groups were identified that did not survive to hospital discharge (n = 31): 1) those who received either vasopressin/desmopressin (n = 16) and 2) those who received combinations of psychotherapeutic agents with anxiolytics, sedatives, and hypnotics (n = 15) prior to I-HCA. The risk of pulseless electrical activity and asystolic arrest was high in patients who received sympathomimetic agents alone or in combination with β-Adrenergic blocking agents, (RR = 1.40, 1.41, respectively). Vasopressin and a combination of vasopressin and fentanyl were associated with risk of unsuccessful ROSC (RR = 2.50, 2.38, respectively).

Conclusions

The types of medications administered during inpatient care may serve as a surrogate marker for identifying patients at risk of specific initial rhythms of I-HCA and survival.

Trajectory of Risk-Standardized Survival Rates for In-Hospital Cardiac Arrest

BACKGROUND

A hospital's risk-standardized survival rate (RSSR) for in-hospital cardiac arrest has emerged as an important metric to benchmark and incentivize hospital resuscitation quality. We examined whether hospital performance on the RSSR metric was stable or dynamic year-over-year and whether low-performing hospitals were able to improve survival outcomes over time.

METHODS AND RESULTS

We used data from 84 089 adult patients with an in-hospital cardiac arrest from 166 hospitals with continuous participation in Get With The Guidelines-Resuscitation from 2012 to 2017. A 2-level hierarchical regression model was used to compute RSSRs during a baseline (2012-2013) and two follow-up periods (2014-2015 and 2016-2017). At baseline, hospitals were classified as top-, middle-, and bottom-performing if they ranked in the top 25%, middle 50%, and bottom 25%, respectively, on their RSSR metric during 2012 to 2013. We compared hospital performance on RSSR during follow-up between top, middle, and bottom-performing hospitals' at baseline. During 2012 to 2013, 42 hospitals were identified as top-performing (median RSSR, 31.7%), 82 as middle-performing (median RSSR, 24.6%), and 42 as bottom-performing (median RSSR, 18.7%). During both follow-up periods, >70% of top-performing hospitals ranked in the top 50%, a substantial proportion remained in the top 25% of RSSR during 2014 to 2015 (54.6%) and 2016 to 2017 (40.4%) follow-up periods. Likewise, nearly 75% of bottom-performing hospitals remained in the bottom 50% during both follow-up periods, with 50.0% in the bottom 25% of RSSR during 2014 to 2015 and 40.5% in the bottom 25% during 2016 to 2017. While percentile rankings were generally consistent over time at ≈45% of study hospitals, ≈1 in 5 (21.4%) bottom-performing hospitals showed large improvement in percentile rankings over time and a similar proportion (23.7%) of top-performing hospitals showed large decline in percentile rankings compared with baseline.

CONCLUSIONS

Hospital performance on RSSR during baseline period was generally consistent over 4 years of follow-up. However, 1 in 5 bottom-performing hospitals had large improvement in survival over time. Identifying care and quality improvement innovations at these sites may provide opportunities to improve in-hospital cardiac arrest care at other hospitals.

Association of Hospital-Level Acute Resuscitation and Postresuscitation Survival With Overall Risk-Standardized Survival to Discharge for In-Hospital Cardiac Arrest

IMPORTANCE

Survival after in-hospital cardiac arrest depends on 2 distinct phases: responsiveness and quality of the hospital code team (ie, acute resuscitation phase) and intensive and specialty care expertise (ie, postresuscitation phase). Understanding the association of these 2 phases with overall survival has implications for design of in-hospital cardiac arrest quality measures.

OBJECTIVE

To determine whether hospital-level rates of acute resuscitation survival and postresuscitation survival are associated with overall risk-standardized survival to discharge for in-hospital cardiac arrest.

DESIGN, SETTINGS, AND PARTICIPANTS

This observational cohort study included 86 426 patients with in-hospital cardiac arrest from January 1, 2015, through December 31, 2018, recruited from 290 hospitals participating in the Get With The Guidelines-Resuscitation registry.

EXPOSURES

Risk-adjusted rates of acute resuscitation survival, defined as return of spontaneous circulation for at least 20 minutes, and postresuscitation survival, defined as survival to discharge among patients achieving return of spontaneous circulation.

MAIN OUTCOMES AND MEASURES

The primary outcome was overall risk-standardized survival rate (RSSR) for in-hospital cardiac arrest calculated using a previously validated model. The correlation between a hospital's overall RSSR and risk-adjusted rates of acute resuscitation and postresuscitation survival were examined.

RESULTS

Of 86 426 patients with in-hospital cardiac arrest, the median age was 67.0 years (interquartile range [IQR], 56.0-76.0 years); 50 665 (58.6%) were men, and 71 811 (83.1%) had an initial nonshockable cardiac arrest rhythm. The median RSSR was 25.1% (IQR, 21.9%-27.7%). The median risk-adjusted acute resuscitation survival was 72.4% (IQR, 67.9%-76.9%), and risk-adjusted postresuscitation survival was 34.0% (IQR, 31.5%-37.7%). Although a hospital's RSSR was correlated with survival during both phases, the correlation with postresuscitation survival (ρ, 0.90; P < .001) was stronger compared with the correlation with acute resuscitation survival (ρ, 0.50; P < .001). Of note, there was no correlation between risk-adjusted acute resuscitation survival and postresuscitation survival (ρ, 0.09; P = .11). Compared with hospitals in the lowest RSSR quartile, hospitals in the highest RSSR quartile had higher rates of acute resuscitation survival (75.4% in quartile 4 vs 66.8% in quartile 1; P < .001) and postresuscitation survival (40.3% in quartile 4 vs 28.7% in quartile 1; P < .001), but the magnitude of difference was larger with postresuscitation survival.

CONCLUSIONS AND RELEVANCE

The findings suggest that hospitals that excel in overall in-hospital cardiac arrest survival, in general, excel in either acute resuscitation or postresuscitation care but not both; efforts to strengthen postresuscitation care may offer additional opportunities to improve in-hospital cardiac arrest survival.

Prospective Evaluation of Cardiopulmonary Resuscitation Performed in Dogs and Cats According to the RECOVER Guidelines. Part 2: Patient Outcomes and CPR Practice Since Guideline Implementation

Cardiopulmonary resuscitation (CPR) outcomes have not been prospectively described since implementation of the Reassessment Campaign on Veterinary Resuscitation (RECOVER) guidelines. This study aimed to prospectively describe CPR outcomes and document arrest variables in dogs and cats at a U.S. veterinary teaching hospital since implementation of the RECOVER guidelines using the 2016 veterinary Utstein-style CPR reporting guidelines. One-hundred and seventy-two dogs and 47 cats that experienced cardiopulmonary arrest (CPA) underwent CPR following implementation of the RECOVER guidelines and were prospectively included. Supervising clinicians completed a data form for CPR events immediately following completion of CPR from December 2013 to June 2018. Seventy-five (44%) dogs and 26 (55%) cats attained return of spontaneous circulation (ROSC), 45 dogs (26%) and 16 cats (34%) had ROSC ≥ 20 min, 13 dogs (8%) and 10 cats (21%) were alive 24 h after CPR, and 12 dogs (7%) and 9 cats (19%) survived to hospital discharge. The most common cause of death in animals with ROSC ≥ 20 min was euthanasia. Patient outcomes were not significantly different since publication of the RECOVER guidelines except for a higher feline survival to hospital discharge rate. Dogs (p = 0.02) but not cats with initial shockable rhythms had increased rates of ROSC while the development of a shockable rhythm during CPR efforts was not associated with ROSC (p = 0.30). In closed chest CPR an end-tidal carbon dioxide (EtCO₂) value of >16.5 mmHg was associated with a 75% sensitivity and 64% specificity for achieving ROSC. Since publication of the RECOVER guidelines, CPR practice did not clinically significantly change at our institution and no improvement of already high ROSC rates was noted. The percentage of cats surviving to hospital discharge was higher than previously reported and the reason for this improvement is not evident with these results. Euthanasia remains a major confounding factor in assessing intermediate and long-term CPR outcomes in dogs and cats.