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Resuscitation-Related Care and Survival of In-Hospital Cardiac Arrest
Quick Takes
- Survival after in-hospital cardiac arrest depends on: a) acute resuscitation care (including responsiveness and quality of the hospital code team), and b) postresuscitation care (including intensive and specialty care expertise).
- In this cohort study of >86,000 patients with in-hospital cardiac arrest from nearly 300 hospitals, the overall risk-standardized survival rate was more strongly correlated with its risk-adjusted postresuscitation survival than with acute resuscitation survival. There was no correlation between risk-adjusted acute resuscitation and postresuscitation survival.
- Postresuscitation care may represent an important area of opportunity to improve in-hospital cardiac arrest survival.
Study Questions:
Are rates of acute resuscitation and postresuscitation survival associated with rates of overall risk-adjusted survival to discharge for in-hospital cardiac arrest?
Methods:
The authors studied 86,426 patients with in-hospital cardiac arrest from January 1, 2015, through December 31, 2018, recruited from 290 hospitals participating in the American Heart Association (AHA) Get With The Guidelines (GWTG)-Resuscitation Registry. Risk-adjusted rates of acute resuscitation survival were defined as return of spontaneous circulation for ≥20 minutes and postresuscitation survival was defined as survival to discharge among patients achieving return of spontaneous circulation. 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 analyzed.
Results:
The final cohort included 86,426 patients with in-hospital cardiac arrest with a median age of 67.0 years (interquartile range [IQR], 56.0-76.0 years), 58.6% were men, and 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%). A hospital’s RSSR was correlated with survival during both phases; however, the correlation with postresuscitation survival was stronger as compared with the correlation with acute resuscitation survival. There was no correlation between risk-adjusted acute resuscitation survival and postresuscitation survival.
Conclusions:
The authors concluded that hospitals that excel in overall in-hospital cardiac arrest survival excel in either acute resuscitation care or postresuscitation care but not both. As current quality improvement efforts predominantly focus on acute resuscitation care, efforts to enhance postresuscitation care may offer additional opportunities to improve in-hospital cardiac arrest survival in this vulnerable patient population.
Perspective:
This is an important observational cohort study of >86,000 patients with in-hospital cardiac arrest from 290 hospitals in the AHA-GWTG Registry that demonstrated a nearly three-fold difference in overall rates of in-hospital cardiac arrest survival (14.1-40.8%). The authors found that a hospital’s rate of overall survival was correlated with both acute resuscitation and postresuscitation survival; however, the correlation with the latter was stronger. Furthermore, there was no correlation between a hospital’s rate of acute resuscitation and postresuscitation survival. The current GWTG-Resuscitation award system recognizes hospitals for high-quality resuscitation primarily based on acute resuscitation care metrics, including time from cardiac arrest to initiation of chest compression and time from cardiac arrest to first defibrillation, among others. This study highlights an important unmet need to develop and validate hospital strategies that distinguish top-performing hospitals in postresuscitation care.
Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Prevention, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Acute Coronary Syndrome, Arrhythmias, Cardiac, Cardiopulmonary Resuscitation, Critical Care, Electric Countershock, Heart Arrest, Patient Discharge, Quality Improvement, Resuscitation, Risk Adjustment, Secondary Prevention, Survival Rate
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