In-Hospital Cardiac Arrest

In-Hospital Cardiac Arrest
How to Measure and Improve Systems of Care
Using
Get With The Guidelines: Resuscitation
To Improve Care
1
COMMON BELIEF
Cardiac arrest outcomes are maximized in the
hospital environment because these facilities
contain large numbers of highly qualified
health-care providers with the necessary
training and equipment to respond promptly
and appropriately to the event.
In-Hospital Arrest Outcomes
Any ROC
Survived Event
Discharged Alive
80.0%
70.0%
68.3%
62.9%
60.0%
49.9%
50.0%
40.0%
54.8%
47.6%
42.1%
36.5%
30.0%
17.8%
20.0%
11.4%
10.0%
0.0%
VF/P-VT
PEA/Asystole
All Rhythms
(Source: NRCPR Adult Index Events 1/2000 – 7/2005, Data Received Thru 07/31/2005)
CPA = 216,779
ARC = 25,839
MET = 165,350
5
Developing A
Data
Collection
Culture Of
High Quality
Resuscitation
Reporting/
Benchmarking
Training/
Retraining
Feedback
(individual &
organizational)
AHA Adult Chain of Survival
• Immediate recognition & activation of
emergency response system
• Early CPR
• Rapid defibrillation
• Effective advanced life support
• Integrated post-cardiac arrest care
© 2010 American Heart Association. All rights reserved.
Moving Hospitals Toward A
Performance Improvement Approach
For In-Hospital Cardiac Arrest
Four Key Metrics Based On Data Of What Matters
1.
2.
3.
4.
Increase Survival to Discharge
Decrease Time to Defibrillation
Decrease Unmonitored/Unwitnessed Arrests
Eliminate Time of Day/Day of Week Outcome Variances
Variability in Outcomes
An Opportunity to Save More Lives
IHCA—GWTG-R
Survival:
-- Top 25% = 28%
-- Bottom 25% = 10%
11/20/2011
© 2010 American Heart Association. All rights reserved.
9
Using the American Heart Association's National Registry of
Cardiopulmonary Resuscitation for performance improvement.
Hunt EA, Mancini ME, Truitt TL: NRCPR Investigators
Jt Comm J Qual Patient Saf. 2009 Jan;35(1):13-20.
ABTRACT: Data suggest that the overall quality of inhospital resuscitation is suboptimal and contributes to
poor patient outcomes. In 2000 the AHA created NRCPR as an evidence-based hospital safety program.
Participating hospitals voluntarily join and pay an annual fee that includes data support and report generation.
The primary purpose is to support local facility efforts in practice management and performance improvement .
The Chain of Survival illustrates the series of critical, interdependent actions necessary to maximize patient
outcome from sudden cardiac arrest. NRCPR specifically addresses each link and helps hospitals develop,
implement, and monitor their resuscitation processes in a manner that builds on available evidence. On
enrollment, each hospital identifies a coordinator who is instructed on a standardized method for abstracting
data and how to enter data into the database. The database is managed centrally and provides organizations
with ongoing, quarterly, and annual reports related to their resuscitation events. NRCPR is used as a local PI
tool as well as a source of data that scientists are analyzing to further the understanding of inhospital
resuscitation processes and outcomes. PMID: 19213296 [PubMed - indexed for MEDLINE]
11/20/2011
©2010, American Heart Association
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©2010, American Heart Association
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 Delayed Defibrillation Occurred in 2045 Patients (30.1%)
•
Delayed defibrillation was associated with a significantly lower probability of surviving to
hospital discharge (22.2%, vs. 39.3% when defibrillation was not delayed; adjusted odds
ratio, 0.48; 95% confidence interval, 0.42 to 0.54; P<0.001)
•
A graded association was seen between increasing time to defibrillation and lower rates of
survival to hospital discharge for each minute of delay (P for trend <0.001)
•
Characteristics associated with delayed defibrillation included:
– black race
– noncardiac admitting diagnosis
– occurrence of cardiac arrest
• at a hospital with fewer than 250 beds
• in an unmonitored hospital unit
• during after-hours periods (5 p.m. to 8 a.m. or weekends)
11/20/2011
©2010, American Heart Association
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©2010, American Heart Association
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©2010, American Heart Association
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©2010, American Heart Association
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Are we resuscitating people right?
Does Time of Day Make A Difference??
D (%)
E (%) N (%)
Characteristics
p (D=E)
vs. N
Event Occurrence
34
33
34
ns
Survived Event
49
48
41
<0.001
Survived to Discharge
18
18
13
<0.001
Non-ICU Survival to Discharge
19
20
13
<0.001
ICU Survival to Discharge
17
17
13
<0.001
Monitored &/or Witnessed
89
89
82
<0.001
Time of Day
Time of Day
24 hour survival
1
3
5
7
9
11
13
15
17
19
21
23
0
0.5
1
Odds Ratio
1.5
Impact of Resuscitation System Errors on Survival from In-hospital Cardiac Arrest. Resuscitation. 2011 Sept 29. [Epub ahead of
print] Ornato JP, Peberdy MA, Reid R, Feeser VR, Dhindsa HS. For the American Heart Association Get With The Guidelines-Resuscitation
(GWTG-R) Investigators
11/20/2011
©2010, American Heart Association
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Effect of Resuscitation Errors
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©2010, American Heart Association
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Is A Life As Important As A Car Race?