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Greater adherence to in-hospital cardiac arrest guidelines may save more lives
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U.S. hospitals with stricter adherence to in-hospital cardiac arrest guidelines have higher survival rates and improved neurological outcomes compared with other hospitals with lower adherence, researchers reported in JAMA Cardiology.
Monique L. Anderson, MD, MHS , from the Duke Clinical Research Institute, Duke University Medical Center, and colleagues calculated a hospital process composite performance score for in-hospital cardiac arrest care for 35,283 patients enrolled in the American Heart Association’s Get With the Guidelines–Resuscitation program. All patients who were aged 18 years and older received in-hospital cardiac arrest care at 261 U.S. hospitals from 2010 to 2012. The median age was 67 years and 58% were men.
The hospital process composite performance was based on adherence to the following five American College of Cardiology/AHA guideline recommendations:
- device confirmation of correct endotracheal tube placement;
- a monitored or witnessed cardiac arrest event;
- time to first chest compression 1 minute;
- time to first defibrillation delivered at 2 minutes for ventricular tachycardia or ventricular fibrillation; and
- administration of epinephrine or vasopressin for pulseless events within 5 minutes.
Scores were calculated for each patient using opportunity-based scoring and then combined for each hospital and categorized into quartiles.
The primary endpoint was risk-standardized survival rates and favorable neurologic status at hospital discharge.
Hospital process composite performance scores ranged from 47.6% to 94.2%. Median performance scores across hospital quartiles were 82.6% (interquartile range [IQR], 78.9%-84.3%), 88% (IQR, 86.7%-88.9%), 91.5% (IQR, 90.4%-92.3%) and 94.8% (IQR, 93.9%-95.9%), with quartile 4 having the highest performance score.
Risk-standardized hospital survival, increased with higher performance quartiles (21.1%, 21.4%, 22.8% and 23.4%, respectively; P < .001 for trend). After adjusting for potential confounders, the data revealed a 22% higher odds of survival (adjusted OR = 1.22; 95% CI, 1.08-1.37) with each 10% increase in performance score. Patients discharged from hospitals in the higher quartiles were also more likely to have favorable neurologic status (17.7%, 17%, 17.5% and 19.9%; P < .001 for trend), according to the findings.
The researchers reported that the guideline recommendations with the greatest adherence were monitored or witnessed cardiac events (P = .004 for increase across quartiles) and time to first compressions of 1 minute (P = .01 for increase across quartiles).
“Patients at the hospitals in the highest process composite performance quartile were more likely to be in the [ICU] at the time of arrest, less likely to have cardiac arrests at night, and more likely to undergo interventions, such as mechanical ventilation, hemodialysis, vasopressors, arterial catheters and vascular access,” Anderson and colleagues wrote.
The researchers concluded that if all hospitals had higher performance scores, an estimated 22,990 to 24,200 lives could be saved. – by Tracey Romero
D isclosure: The study was funded by the Duke Clinical Research Institute. Anderson reports receiving personal funding by the NIH Common Fund. Please see full study for a list of all other researchers’ relevant financial disclosures.
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