The latest up-to-date statistics on in-hospital cardiac arrest published by the American Heart Association (1) show an incidence of over 200,000 cases per year. Intensivists, critical care nurses and rapid response teams are often involved in these events, but despite rapid mobilisation of staff and equipment, in-hospital cardiac arrests are still associated with poor prognosis: overall survival rates in adults remain around 23%, but with large variations ranging from 11% to 35%. Resuscitation practices in this field are also rapidly evolving, and are not sufficiently explored.
In order to identify those practices associated with higher rates of survival, Dr. Chan and his team analysed data concerning 204 American hospitals active in the GWTG-R (Get With The Guidelines®-Resuscitation registry), and who were willing to participate in a specific survey of resuscitation strategies (2). Cases were entered from January 1, 2012 through December 31; 2013; with the exclusion of those from paediatric hospitals, hospitals not responding to the survey, or those with fewer than 20 cardiac arrests during the 2 year period. The final sample included 17613 adult patients from 131 hospitals. The survey reported 45 items on 22 key resuscitation strategies, and questions on hospital culture, including administrative leadership, quality improvement policy, safety and perceived barriers at one’s hospital. A risk-standardised survival rate for each hospital was determined, based on a hierarchical model using 9 predictors of survival to hospital discharge: age, initial cardiac arrest rhythm, hospital location of arrest; hypotension, sepsis, metastatic or haematologic malignant tumor and hepatic insufficiency, mechanical ventilation or need for IV vasopressors preceding cardiac arrest.
"The three practices associated with significantly better performance were adequate staff training, monitoring for interruptions in chest compressions and frequent review of cardiac arrest cases."
The hospital sample was divided into three groups of risk-standardised survival rates: top quintile, middle 3 quintiles, and bottom quintile. Characteristics of hospitals and patients were then compared, showing a large variability in outcomes, ranging from 9.2% to 37.5% of survival rate [OR 1.47(95% CI, 1.41-1.57)]. One result which is particularly noteworthy from this study is that the use of specific devices for CPR (metronome, autopulse, LUCAS) did not have an impact on patient survival. The three practices associated with significantly better performance were adequate staff training, monitoring for interruptions in chest compressions and frequent review of cardiac arrest cases.
Some limitations, like a lack of power to evaluate some of the strategies, or the fact that data were reported by a single identified correspondent in each hospital, may affect the interpretation of the results. However, this study represents an excellent starting point for further studies on the subject, to question our practices and search for new strategies in a field where survival rates still need to improve.
Article review prepared and submitted by Carole Rocchietti and Silvia Calviño Günther, members of the ESICM Journal Review Club.
2. Chan PS, Krein SL, Tang F, Iwashyna TJ, Harrod M, Kennedy M, Lehrich J, Kronick S, Nallamothu BK, for the American Heart Association’s Get With The Guidelines-Resuscitation Investigators. Resuscitation Practices Associated With Survival After Ih-Hospital Cardiac Arrest. JAMA Cardiol. 6 April 2016. doi:10.1001/jamacardio.2016.0073