For In-Hospital Cardiac Arrest Patients, Quality Care Tied to Better Survival

Hospitals vary substantially in the ways that they treat patients who have in-hospital cardiac arrest. Better adherence to guideline-based care could potentially save tens of thousands of lives per year and lead to more patients having better neurologic function at discharge, a registry study suggests.

Using data from the American Heart Association’s Get With The Guidelines-Resuscitation program, researchers led by Monique L. Anderson, MD, of Duke Clinical Research Institute (Durham, NC), looked at the experiences of 35,283 adults who had in-hospital cardiac arrest at 261 US hospitals between 2010 and 2012. Outcomes were assessed by quartiles, according to adherence to 5 guideline-recommended process measures at the hospital level.

The median likelihood that hospitals met all 5 measures was 89.7%, varying from 82.6% in the lowest quartile to 94.8% in the highest. The greatest variations were seen for conformation of endotracheal tube placement and first defibrillation shock at 2 minutes or less for ventricular fibrillation or tachycardia, whereas monitoring or witnessing cardiac events and achieving a time to first compressions of 1 minute or less were more consistent, though still differed significantly by quartile.

Hospitals with the highest overall performance were more apt to be teaching hospitals and to have cardiac surgery capabilities and more beds.

The differences in performance appear to translate into disparate outcomes, Anderson and colleagues report. Risk-standardized hospital survival to discharge was lowest in the poorest performers at 21.1% and highest in the best performers at 23.4% (P < .001 for trend). Each 10% rise in overall performance was linked to a 22% higher likelihood of survival (adjusted OR 1.22; 95% CI 1.08-1.37).

Favorable neurologic status at discharge showed a similar pattern, with an adjusted rate of 17.7% seen in the lowest quartile and 19.9% in the highest (P < .001).

‘You Have to Move Very, Very Fast’

“Successful treatment of [in-hospital cardiac arrest] requires rapid implementation of several processes of care within a short and defined period,” the authors note.

Indeed, the situation here differs from what happens with other acute cardiovascular events, Anderson told TCTMD. “Cardiac arrest is . . . a condition where you have to move very, very fast,” she said. “You’re implementing these processes within the first 5 minutes of the cardiac arrest.” The 90-minute window for STEMI door-to-balloon time is comparatively long, she noted, as is the window for giving tPA in stroke.

Many hospitals do a good job, but others “can do better,” she said. “Personally, I’d want compliance to be 100% at all of the hospitals.” Were that the case, and with the assumption of approximately 200,000 in-hospital cardiac arrests occurring annually in the United States, a ballpark estimate of lives saved per year is 24,000, according to the paper.

The fact that observed variations in cardiac arrest care were clearly linked to outcomes could be useful in inspiring change, Anderson noted. “Then, something like public reporting or pay for performance may help to incentivize institutions to [strive harder].”

Source: 
Anderson ML, Nichol G, Dai D, et al. Association between hospital process composite performance and patient outcomes after in-hospital cardiac arrest care. JAMA Cardiol. 2016;Epub ahead of print.

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