Survival by the Fittest: Hospital‐Level Variation in Quality of Resuscitation Care

Abstract

HomeJournal of the American Heart AssociationVol. 3, No. 1Survival by the Fittest: Hospital‐Level Variation in Quality of Resuscitation Care Open AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessEditorialPDF/EPUBSurvival by the Fittest: Hospital‐Level Variation in Quality of Resuscitation Care Shashank S. Sinha, Lena M. Chen and Brahmajee K. Nallamothu Shashank S. SinhaShashank S. Sinha Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI Search for more papers by this author , Lena M. ChenLena M. Chen Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI VA Ann Arbor Healthcare System, Ann Arbor, MI Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI Search for more papers by this author and Brahmajee K. NallamothuBrahmajee K. Nallamothu Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI Search for more papers by this author Originally published28 Feb 2014https://doi.org/10.1161/JAHA.113.000768Journal of the American Heart Association. 2014;3:e000768IntroductionDespite several advances in resuscitation care over the last decade, in‐hospital cardiac arrest (IHCA) remains common and is linked to poor survival. Approximately 200 000 hospitalized patients suffer IHCA and undergo cardiopulmonary resuscitation in the United States annually, with fewer than 20% surviving to discharge.1, 2, 3 Not surprisingly, a great deal of attention has been placed on reducing IHCA event rates and improving outcomes. Although there is some indication that this focus is improving risk‐adjusted survival over time, little is understood about the underlying mechanisms behind these trends. It remains unknown what specific hospital factors or processes of care are responsible for delivering high‐quality resuscitation care and what modifiable quality metrics best address outcomes.To begin to address these questions first requires the ability to identify the best hospitals. This is no easy task given the inherent heterogeneity of patients suffering IHCA—ranging from those with acute illnesses, such as acute myocardial infarction or sepsis, to those with chronic end‐stage diseases like cancer. However, a risk‐adjustment model for survival was recently developed and validated that included 9 clinical variables, using data gathered from nearly 50 000 patients within the Get With The Guidelines (GWTG)‐Resuscitation registry.1 Good discrimination and excellent calibration of the model permits it to be employed, for the first time, to facilitate benchmarking across hospitals as an initial step toward improving quality in resuscitation.The study published by Merchant et al4 in this edition of Journal of the American Heart Association (JAHA) builds on this critical work.5 It documents wide variability in risk‐adjusted survival rates across hospitals. Based on data compiled from 135 896 index IHCA events at 468 hospitals within the GWTG‐Resuscitation registry, the investigators found the observed median in‐hospital survival rate for the bottom decile was 8.3% (range 0% to 10.7%) and for the top decile it was 31.4% (28.6% to 51.7%)—a nearly 4‐fold difference. After adjusting for 36 predictors of in‐hospital survival, significant variation remained across sites: the bottom decile with a median in‐hospital survival rate of 12.4% (0% to 15.6%) versus the top decile with a median rate of 22.7% (21% to 36.2%). Only 24 of 46 hospitals (52%) remained in the top decile for IHCA survival after risk adjustment, which highlighted the importance of accounting for patient case‐mix. Perhaps the most compelling finding was the median odds ratio for risk‐adjusted in‐hospital survival of 1.42 (95% CI 1.37 to 1.46). This statistic indicates a 42% difference in the odds of survival for patients with a similar case‐mix at 2 different randomly selected hospitals.So why might such large variation in outcomes exist across hospitals? Resuscitation‐specific factors remain to be fully elucidated and are not readily apparent from the study by Merchant et al. However, many possibilities have been suggested in prior studies. Duration of resuscitation varies across hospitals and may contribute to differences in survival. Based on our recent work, we found that patients at hospitals with longer durations of resuscitation had higher rates of return to spontaneous circulation (adjusted risk ratio 1.12, 95% CI 1.06 to 1.18, P<0.0001) and survival to discharge (1.12, 1.02 to 1.23, P=0.021), independent of measured patient characteristics.6 We also found that the median duration of resuscitation was just 20 minutes for nonsurvivors and many received shorter attempts. Importantly, these findings suggest that hospitals that reliably implement processes that systematically extend resuscitation care may have better outcomes. If so, duration of resuscitation could potentially serve as a quality metric for assessing IHCA care. However, further investigation is needed to establish the optimal duration of resuscitation attempts.Another resuscitation‐specific factor that may contribute to a wide variation in case‐survival may be time to defibrillation.7, 8 Current expert recommendations suggest hospitalized patients with pulseless VT or VF receive defibrillation within 2 minutes after recognition of cardiac arrest. In spite of this, prior work has found that delayed defibrillation (beyond the 2‐minute threshold) occurs in almost one‐third of hospitalized patients (30.1%) with a VF or pulseless VT arrest. Patient factors associated with delayed defibrillation included black race and a non‐cardiac admitting diagnosis. Significant hospital‐related factors included small hospital size (less than 250 beds), occurrence of cardiac arrest in an unmonitored inpatient bed, and occurrence of cardiac arrest after hours (ie, 5 pm to 8 am or weekends). Delayed defibrillation was associated with a significantly lower probability of survival to hospital discharge (22.2% versus 39.3% when defibrillation was not delayed; adjusted odds ratio 0.48; 95% confidence interval 0.42 to 0.54, P<0.001). Thus, in this vulnerable high‐risk population of patients with VF or pulseless VT, rapid defibrillation may be a marker of high‐quality resuscitation care.What about other hospital factors outside of resuscitation care? For example, it is plausible that top performing institutions with respect to resuscitation are simply better at implementing and monitoring the general processes of care needed to deliver high‐quality care for multiple conditions. However, hospitals that perform better on publicly reported outcomes for 3 common medical conditions (acute myocardial infarction, heart failure, or pneumonia) do not have better cardiac arrest survival rates.2 This indicates that the quality signal from cardiac arrest is distinct from that conveyed by the other measures.2 Indirectly, these data point toward the need for quality improvement efforts specific to resuscitation care to improve survival for patients with IHCA. While the aforementioned studies have focused on survival after IHCA, it is also plausible that hospitals with high case‐survival rates do a poor job of preventing cardiac arrests among their critically ill hospitalized patients in the first place. However, prior work has found that hospitals with exceptional rates of survival for IHCA are also better at preventing cardiac arrests, even after adjusting for patient case mix.3The extent to which significant variation in hospital survival may be related to differences in care prior to IHCA, acute resuscitation care, and post‐resuscitation care remains to be determined. Specifically, interventions targeted at preventing cardiac arrests (eg, telemetry monitoring, rapid response teams, remote intensive care unit monitoring, etc.), improving acute resuscitation care (eg, times to defibrillation and vasopressors, high‐quality chest compressions with minimal interruptions), optimizing post‐resuscitation survival (eg, therapeutic hypothermia) as well as strengthening training and teamwork through better resuscitation systems of care (eg, simulations of and debriefing after cardiac arrest) need to be investigated (Figure). High‐fidelity simulation studies have established the critical role of effective leadership, teamwork, and communication in resuscitation performance.9 Indeed, this emphasis on teamwork and leadership skills for advanced cardiovascular life support (ACLS) and pediatric advanced life support (PALS) providers is reflected in a Class I, Level of Evidence B recommendation in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.10 An eclectic array of methodological strategies, both quantitative and qualitative, will need to be employed to further elucidate best practices at top‐performing institutions and to make these strategies available to a greater number of hospitals.11Download PowerPointFigure 1. Putative hospital factors or processes of care contributing to differences in quality of resuscitation care. Prior investigations have suggested that resuscitation performance and quality may be related to prevention of IHCA, delivery of acute and post‐resuscitation care, and organizational aspects with respect to systems of care. CPR indicates cardiopulmonary resuscitation; ICU, intensive care unit; IHCA, in‐hospital cardiac arrest.By documenting wide variation in survival after IHCA, Merchant et al.'s study4 makes evident both the challenges and opportunities for improving care for patients who undergo cardiac arrest. Future studies should identify those resuscitation‐specific interventions that are likely to have the greatest effect on survival after IHCA and thereby provide a larger number of institutions with the tools for improving their performance.Sources of FundingDr Chen is supported by K08HS020671 from the Agency for Healthcare Research and Quality (AHRQ).DisclosuresNone.Footnotes*Correspondence to: Shashank S. Sinha, MD, University of Michigan Cardiovascular Center, 1500 East Medical Center Drive, SPC 5853, Ann Arbor, MI 48109‐5853. E‐mail: [email protected]umich.eduThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.References1 Chan PS, Berg RA, Spertus JA, Schwamm LH, Bhatt DL, Fonarow GC, Heidenreich PA, Nallamothu BK, Tang F, Merchant RM; Investigators AG‐R . Risk‐standardizing survival for in‐hospital cardiac arrest to facilitate hospital comparisons. J Am Coll Cardiol. 2013; 62:601–609.CrossrefMedlineGoogle Scholar2 Chen LM, Nallamothu BK, Krumholz HM, Spertus JA, Tang F, Chan PS; American Heart Association's Get With The Guidelines‐Resuscitation I . Association between a hospital's quality performance for in‐hospital cardiac arrest and common medical conditions. Circ Cardiovasc Qual Outcomes. 2013a; 6:700–707.LinkGoogle Scholar3 Chen LM, Nallamothu BK, Spertus JA, Li Y, Chan PS; American Heart Association's Get With the Guidelines‐Resuscitation I . Association between a hospital's rate of cardiac arrest incidence and cardiac arrest survival. JAMA Intern Med. 2013b; 173:1186–1195.CrossrefMedlineGoogle Scholar4 Merchant RM, Berg RA, Yang L, Becker LB, Groeneveld PW, Chan PS. Hospital variation in survival after in‐hospital cardiac arrest. J Am Heart Assoc. 2014; 3:e000400 doi:10.1161/JAHA.113.000400LinkGoogle Scholar5 Merchant RM, Yang L, Becker LB, Berg RA, Nadkarni V, Nichol G, Carr BG, Mitra N, Bradley SM, Abella BS, Groeneveld PW; American Heart Association Get With the Guideline‐Resuscitation I . Variability in case‐mix adjusted in‐hospital cardiac arrest rates. Med Care. 2012; 50:124–130.CrossrefMedlineGoogle Scholar6 Goldberger ZD, Chan PS, Berg RA, Kronick SL, Cooke CR, Lu M, Banerjee M, Hayward RA, Krumholz HM, Nallamothu BK; American Heart Association Get With The Guidelines‐Resuscitation I . Duration of resuscitation efforts and survival after in‐hospital cardiac arrest: an observational study. Lancet. 2012; 380:1473–1481.CrossrefMedlineGoogle Scholar7 Chan PS, Krumholz HM, Nichol G, Nallamothu BK; American Heart Association National Registry of Cardiopulmonary Resuscitation I . Delayed time to defibrillation after in‐hospital cardiac arrest. N Engl J Med. 2008; 358:9–17.CrossrefMedlineGoogle Scholar8 Chan PS, Nichol G, Krumholz HM, Spertus JA, Nallamothu BK; American Heart Association National Registry of Cardiopulmonary Resuscitation I . Hospital variation in time to defibrillation after in‐hospital cardiac arrest. Arch Intern Med. 2009; 169:1265–1273.CrossrefMedlineGoogle Scholar9 Hunziker S, Johansson AC, Tschan F, Semmer NK, Rock L, Howell MD, Marsch S. Teamwork and leadership in cardiopulmonary resuscitation. J Am Coll Cardiol. 2011; 57:2381–2388.CrossrefMedlineGoogle Scholar10 Field JM, Hazinski MF, Sayre MR, Chameides L, Schexnayder SM, Hemphill R, Samson RA, Kattwinkel J, Berg RA, Bhanji F, Cave DM, Jauch EC, Kudenchuk PJ, Neumar RW, Peberdy MA, Perlman JM, Sinz E, Travers AH, Berg MD, Billi JE, Eigel B, Hickey RW, Kleinman ME, Link MS, Morrison LJ, O'Connor RE, Shuster M, Callaway CW, Cucchiara B, Ferguson JD, Rea TD, Vanden Hoek TL. Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010; 122:S640–S656.LinkGoogle Scholar11 Chan PS, Nallamothu BK. Improving outcomes following in‐hospital cardiac arrest: life after death. 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McHugh M, Rochman M, Sloane D, Berg R, Mancini M, Nadkarni V, Merchant R and Aiken L (2016) Better Nurse Staffing and Nurse Work Environments Associated With Increased Survival of In-Hospital Cardiac Arrest Patients, Medical Care, 10.1097/MLR.0000000000000456, 54:1, (74-80), Online publication date: 1-Jan-2016. January 27, 2014Vol 3, Issue 1Article InformationMetrics © 2014 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.https://doi.org/10.1161/JAHA.113.000768PMID: 24584744 Manuscript receivedJanuary 23, 2013Manuscript acceptedJanuary 27, 2014Originally publishedFebruary 28, 2014 Keywordssurvivalsystems of careresuscitationcardiac arrestEditorialsPDF download SubjectsCardiopulmonary Resuscitation and Emergency Cardiac Care