Three Practices Linked to In-Hospital Cardiac-Arrest Survival

Deborah Brauser

April 21, 2016

KANSAS CITY, MO — Not all resuscitation strategies after a patient has an in-hospital cardiac arrest are equally beneficial when it comes to survival rates, suggests new research[1].

A study of 131 acute-care hospitals in the US showed that only three practices were significantly associated with increased survival after multivariable adjustment. These were: watching closely for chest-compression interruptions (P=0.01); providing "adequate resuscitation training," as reported by staff (P=0.02); and frequent reviews of cardiac-arrest cases (P=0.03).

The investigators, led by Dr Paul S Chan (Saint Luke's Mid America Heart Institute, Kansas City, MO), note that no study before has examined this type of association with survival.

"These strategies can form the foundation for best practices for resuscitation care at hospitals," they write.

The findings were published online April 6, 2016 in JAMA Cardiology.

"Get With the Guidelines"

The investigators note that about 200,000 US patients experience an in-hospital cardiac arrest each year, with hospital survival rates ranging between 11% and 35%.

As reported by heartwire from Medscape, past research has shown higher survival rates for out-of-hospital cardiac arrest after bystander interventions and hypothermia. However, strategies linked to survival after in-hospital arrest "remain undefined," note the researchers.

For the current study, they examined survey results from hospitals who participated in the Get With the Guidelines–Resuscitation registry. From January 2012 through December 2013, all had had at least 20 in-hospital cardiac-arrest cases.

Although the "risk-standardized survival rates . . . varied substantially" among the hospitals, the median rate was 23.7% (range 9.2%–37.5%). The adjusted mean odds ratio (OR) for survival was 1.47 (95% CI 1.4–1.6).

After the hospitals were divided into quintiles based on survival rates, those in the top had a median survival rate of 31% vs 19% for those in the bottom. Patient factors, geographic locations, bed numbers, and rural/urban status did not differ significantly between the top, middle, and bottom quintiles. However, the top group had more academic hospitals.

When specific resuscitation practices were examined, the adjusted OR for after-arrest survival was 8.55 for assessing cardiac-arrest cases on a monthly basis (95% CI 1.8–40.0) and 6.85 when the assessments were on a quarterly basis (95% CI 1.5–31.3), 3.23 for training cited as adequate (95% CI 1.2–8.3), and 2.71 for monitoring for stops in chest compressions (95% CI 1.2–5.9).

Interestingly less than 35% of all participating hospitals reported doing the last practice—but more than 50% of the top quintile did.

Confirmation "Will Be Critical"

Resuscitation practices that were not significantly associated with survival included simulated training with mock codes, using a dedicated resuscitation team or intraresuscitation monitoring device, patient defibrillation from non–critical-care nursing staff, and immediate debriefings.

However, the researchers note that some of these strategies may have fallen victim to the study being underpowered and that the range was wide for some of the confidence intervals. "Further study . . . in a larger hospital sample may be warranted to look for their targeted effect on outcomes," they write.

As for the practices that were significant, they note that tools are now needed to improve their use, especially in the lower-quintile hospitals, and confirmation of the benefits will be "critical."

The study was funded by grants from the National Heart, Lung, and Blood Institute. Get with the Guidelines-Resuscitation is funded by the American Heart Association. The study authors have reported no relevant financial relationships.

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