In-Hospital-Arrest Survival Up at Centers Following Guidelines

Pam Harrison

February 26, 2016

CHICAGO, IL — Patients treated for in-hospital cardiac arrest at centers more apt to follow the relevant guidelines are likelier to survive and have better neurologic outcomes than those managed at hospitals with poorer guideline adherence, suggests an analysis based on registry data[1].

"We know that hospital care is variable . . . and we've also shown that survival is variable, and now this study shows that that variability does impact survival," Dr Monique Anderson (Duke University Medical Center, Durham, NC) told heartwire from Medscape. She is lead author on the study published February 24, 2016 in JAMA Cardiology.

For the analysis, investigators studied 35,283 adults treated from 2010 to 2012 for in-hospital cardiac arrest at 261 hospitals participating in the American Heart Association's prospective Get with the Guidelines–Resuscitation (GWTG-R) registry.

Researchers developed a composite performance score for in-hospital cardiac arrest based on five guideline-recommended process measures, applying the scores to the care of all patients in the analysis.

The median hospital score was 89.7%, but there was significant variation.

Median Hospital Process Composite Performance Scores (Interquartile Range)

Quartile 1, % (IQR, %) Quartile 2, % (IQR, %) Quartile 3, % (IQR, %) Quartile 4, % (IQR, %)
82.6 (IQR 78.9–84.3) 88 (IQR 86.7–88.9) 91.5 (IQR 90.4–92.3) 94.8 (IQR 93.9–95.9)

"Hospitals in the highest quartile for the hospital-process composite performance had significantly higher adherence to all individual guideline measures for in-hospital cardiac arrest compared with hospitals in other quartiles," the report notes.

The greatest variation in an individual performance measure was seen for confirmation of endotracheal tube placement, with median scores ranging from a low of 70.8% at quartile-1 hospitals to 94.3% at quartile-4 hospitals (P=0.01).

There was also a significant variation by hospital across quartiles in initiating first defibrillation shock within 2 minutes or less in cases of ventricular tachycardia or ventricular fibrillation (P=0.01).

Variation in Adherence to Individual Guideline-Recommended Process Measures

Measure Quartile 1 (%) Quartile 2 (%) Quartile 3 Quartile 4 (%)
Time to first chest compressions ≤1 min 89.8 93.2 95.9 98.2
Time to first shock ≤2 min for VF or VT 49.4 56.1 59.2 66.5
Time to IV, IO epinephrine, or vasopressin bolus given to pulseless adults ≤5 min 82.6 87.9 89.6 93.2

Still, the primary outcome of interest was survival to discharge, measured as risk-standardized survival rates (RSSRs), as Anderson noted. The report says "unadjusted survival to discharge was 22.4% overall, ranging from 20.7% in the lowest quartile to 23.6% in the hospitals quartile (P<0.001)."

After adjustment for patient and event characteristics, the RSSRs were 21.1% for hospitals in the first quartile; 21.4% for hospitals in the second quartile, and 22.8% for hospitals in the third quartile. Hospitals in the highest quartile had an RSSR of 23.4% (P<0.001).

Each 10% increase in hospital process composite performance was associated with a 22% greater survival (adjusted OR 1.22, 95% CI 10.8–1.37; P=0.01).

Hospitals in the highest quartile of performance also had the highest percentage of in-hospital cardiac-arrest patients discharged with a favorable neurologic status, at an adjusted rate of 19.9% compared with 17.7% for those in the lowest quartile.

"These are hospitals participating in a quality-improvement registry," observed Anderson, "and I believe that quality is likely less for hospitals who do not collect any of their data." So the next step toward improved quality, she said, "is measuring your data and acting where major deficits are identified. I think efforts like public reporting and pay for performance could certainly drive the . . . needle on improving quality."

Anderson reported no relevant financial relationships; disclosures for the coauthors are listed in the article.

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