Get With The Guidelines-Resuscitation Research Articles

Does Compliance with Resuscitation Practice Guidelines Differ Between Pediatric Intensive Care Units and Cardiac Intensive Care Units?

Objective: Hospitalized children with cardiac disease have the highest rate of cardiac arrest compared to other disease types. Different intensive care unit (ICU) models exist, but it remains unknown whether resuscitation guideline adherence is different between cardiac ICUs (CICU) and general pediatric ICUs (PICU). We hypothesize there is no difference in resuscitation practices between unit types. Design: Retrospective observational study. Setting: The American Heart Association's Get With The Guidelines®-Resuscitation (GWTG-R) registry. Patients: Children < 18 years old with medical or surgical cardiac disease who had cardiopulmonary arrest from 2014 to 2018. Intervention: None. Measurements and Main Results: Events were assessed for compliance with GWTG-R achievement measures of time to first chest compressions ≤ 1 min, time to intravenous/intraosseous epinephrine ≤ 5 min, time to first shock ≤ 2 min for ventricular fibrillation (VF)/pulseless ventricular tachycardia (VT), and confirmation of endotracheal tube placement. Additional practices were evaluated for consistency with Pediatric Advanced Life Support (PALS) recommendations. Eight hundred and eighty-six patients were evaluated, 687 (79%) in CICUs and 179 (21%) in PICUs. 484 (56%) had surgical cardiac disease. There were no differences in GWTG-R achievement measures or PALS recommendations between ICU types in univariable or multivariable models. Amiodarone, lidocaine, and nonstandard medication use did not differ by unit type. Extracorporeal cardiopulmonary resuscitation (ECPR) was more common in CICUs for both medical (16% vs 7%) and surgical (25% vs 2.5%) categories (P < .0001). Conclusions: Resuscitation compliance for patients with cardiac disease is similar between CICUs and PICUs. Patients were more likely to receive ECPR in CICUs. Additional study should evaluate how ICU type affects arrest outcomes in children with cardiac disease.

Editor’s Choice Articles for January

Editor’s Choice Articles for January

Abstract 05: Hospital Variation In Epinephrine Administration Prior To Defibrillation For Cardiac Arrest Due To Shockable Rhythm

Background: Contrary to guidelines, we recently found that epinephrine administration before first defibrillation for in-hospital cardiac arrest (IHCA) due to a shockable rhythm is not uncommon. However, the extent to which the above practice varies across hospitals and its association with hospital-level survival is unknown. Methods: Using 2000-19 data from the Get With The Guidelines ® -Resuscitation (GWTG-R) registry, we identified 57,816 adult patients (521 sites) with an index IHCA due to an initial shockable rhythm who received at least 1 defibrillation prior to achieving return of spontaneous circulation. We constructed multivariable hierarchical regression models to examine site-level variation in epinephrine before first defibrillation and its association with hospital survival. Results: Overall, the median rate of epinephrine before defibrillation was 18.8% and varied markedly across hospitals (range: 0%-70.6%, median odds ratio [OR] 1.50; 95% C.I. 1.43 - 1.57). Compared to hospitals in the lowest quartile (Q1) for epinephrine before defibrillation, hospitals in the highest quartile (Q4) were more likely to be major teaching hospitals and have more hospital beds. After adjusting for baseline variables, the median risk-standardized survival was 42.5% (IQR: 39.2%-46.0%). Compared to Q1 hospitals (epinephrine first rate of 0-12.4%), there was a stepwise decline in risk-standardized survival at hospitals with higher rates of epinephrine before first defibrillation: Q2: RR 0.95 [0.90-0.99]; Q3: RR 0.91 [0.87-0.96]; Q4: RR 0.81 [0.77-0.86]; P value for trend &lt;0.001. Conclusions: For patients with shockable IHCA, there is marked hospital variation in epinephrine administration prior to first defibrillation, and this practice is associated with lower rates of survival to discharge. Hospital efforts to prioritize immediate defibrillation for patients with shockable IHCA are urgently needed.

Predicting neurological outcomes after in-hospital cardiac arrests for patients with Coronavirus Disease 2019

BackgroundMachine learning models are more accurate than standard tools for predicting neurological outcomes in patients resuscitated after cardiac arrest. However, their accuracy in patients with Coronavirus Disease 2019 (COVID-19) is unknown. Therefore, we compared their performance in a cohort of cardiac arrest patients with COVID-19. MethodsWe conducted a retrospective analysis of resuscitation survivors in the Get With The Guidelines®-Resuscitation (GWTG-R) COVID-19 registry between February 2020 and May 2021. The primary outcome was a favorable neurological outcome, indicated by a discharge Cerebral Performance Category score ≤ 2. Pre- and peri-arrest variables were used as predictors. We applied our published logistic regression, neural network, and gradient boosted machine models developed in patients without COVID-19 to the COVID-19 cohort. We also updated the neural network model using transfer learning. Performance was compared between models and the Cardiac Arrest Survival Post-Resuscitation In-Hospital (CASPRI) score. ResultsAmong the 4,125 patients with COVID-19 included in the analysis, 484 (12 %) patients survived with favorable neurological outcomes. The gradient boosted machine, trained on non-COVID-19 patients was the best performing model for predicting neurological outcomes in COVID-19 patients, significantly better than the CASPRI score (c-statistic: 0.75 vs 0.67, P < 0.001). While calibration improved for the neural network with transfer learning, it did not surpass the gradient boosted machine in terms of discrimination. ConclusionOur gradient boosted machine model developed in non-COVID patients had high discrimination and adequate calibration in COVID-19 resuscitation survivors and may provide clinicians with important information for these patients.

Resuscitation Using ECPR During In-Hospital Cardiac Arrest (RESCUE-IHCA) Mortality Prediction Score and External Validation.

The aim of this study was to develop and validate a score to accurately predict the probability of death for adult extracorporeal cardiopulmonary resuscitation (ECPR). ECPR is being increasingly used to treat refractory in-hospital cardiac arrest (IHCA), but survival varies from 20% to 40%. Adult patients with extracorporeal membrane oxygenation for IHCA (ECPR) were identified from the American Heart Association GWTG-R (Get With the Guidelines-Resuscitation) registry. A multivariate survival prediction model and score were developed to predict hospital death. Findings were externally validated in a separate cohort of patients from the Extracorporeal Life Support Organization registry who underwent ECPR for IHCA. A total of 1,075 patients treated with ECPR were included. Twenty-eight percent survived to discharge in both the derivation and validation cohorts. A total of 6 variables were associated with in-hospital death: age, time of day, initial rhythm, history of renal insufficiency, patient type (cardiac vs noncardiac and medical vs surgical), and duration of the cardiac arrest event, which were combined into the RESCUE-IHCA (Resuscitation Using ECPR During IHCA) score. The model had good discrimination (area under the curve: 0.719; 95% CI: 0.680-0.757) and acceptable calibration (Hosmer and Lemeshow goodness of fit P=0.079). Discrimination was fair in the external validation cohort (area under the curve: 0.676; 95% CI: 0.606-0.746) with good calibration (P=0.66), demonstrating the model's ability to predict in-hospital death across a wide range of probabilities. The RESCUE-IHCA score can be used by clinicians in real time to predict in-hospital death among patients with IHCA who are treated with ECPR.

Abstract 9152: Incidence of Cardiac Arrest Among Medicare Beneficiaries

Introduction: Although survival for in-hospital cardiac arrest (IHCA) has improved substantially over the last two decades, survival rates have plateaued in recent years. Our understanding of incidence of IHCA remains limited. We measured incidence of IHCA among Medicare beneficiaries and evaluated hospital variation in incidence of IHCA. Methods: We used an observational cohort study using data from 2014-2017 Get with the Guidelines-Resuscitation (GWTG-R) data linked with Medicare inpatient data summarized by hospital. Hospital incidence of IHCA among Medicare beneficiaries was calculated as the total number of patients 65 years and older with an IHCA divided by the total number of Medicare admissions. Multivariable hierarchical regression models were used to adjust hospital incidence rates for differences in case-mix across study hospitals and evaluate its the association with hospital variables. Results: Among a total of 4.5 million admissions at 170 hospitals, 38,630 patients experienced an IHCA. The median risk-adjusted IHCA incidence was 8.3 per-1000 admissions. Even after adjusting for differences in case-mix index, IHCA incidence varied markedly across hospitals (Figure 1) ranging from 2.1 per-1000 admissions to 24.7 per-1000 admissions (interquartile range: 6.5-11.4; median odds ratio: 1.52; 95% credible interval 1.45-1.59). Among hospital variables, a higher case-mix index, higher nurse staffing and teaching status were associated with a lower hospital incidence of IHCA. Conclusions: Incidence of IHCA varies markedly across hospitals, even after adjustment for differences in patient case-mix. Hospital variables including case-mix severity, nurse staffing and teaching status were significantly associated with incidence rates. Future studies are needed to better understand processes of care at hospitals with exceptionally low IHCA incidence to identify best practices for cardiac arrest prevention.

Abstract 227: Cover Up- It's a Code Blue: Protecting Staff without Compromising Patient Outcomes

Introduction: During the COVID-19 pandemic, hospitals across the globe have been challenged with following the chain of survival with Get With The Guidelines (GWTG) metrics of time to epinephrine, CPR and early defibrillation while ensuring resuscitation teams are protected with recommended PPE. Healthcare organizations are seeking innovative processes to implement PPE during resuscitation events (codes) while maintaining a timely response. Hypothesis: Utilization of for PPE for Airborne Precautions for all resuscitation events can be achieved without compromising patient outcomes or GWTG metrics. Methods: In collaboration with Infection Prevention and Control (IPAC), the Resuscitation Subcommittee at an academic medical center developed a modified airborne PPE workflow for both inpatient and outpatient resuscitation events. For staff safety, all patients are considered as COVID-19 positive during a code response. Identifying timely donning and doffing techniques of PPE as paramount for maintaining GWTG metrics, a Safety Officer was implemented as an additional member of the code team. The role of the Safety Officer is to assist with the PPE process and to monitor code team compliance. Other measures implemented included attaching PPE supply bags to all code carts for easy access, adding viral filters on the bag valve masks, conducting educational mock code events, and providing online resources for staff. To measure process outcomes, pre COVID-19 pandemic GWTG metrics, mortality, and survival to discharge rates were compared with COVID-19 metrics utilizing the modified airborne PPE workflow. Conclusions: Despite additional use of PPE, the hospital has maintained patient outcomes and adhered to the GWTG resuscitation measures of time to epinephrine, CPR and defibrillation while ensuring the utmost safety of the code team during the COVID-19 pandemic. Table 1: GWTG-Award Measures *Preliminary Results

Beyond the Limit: Double Sequential Defibrillation as an Alternative Therapy for Refractory Ventricular Fibrillation

The incidence of out-of-hospital cardiac arrest (OHCA) reported from the Resuscitation Outcomes Consortium (ROC) and the CARES registry in 2016 suggests that 110.8 individuals per 100,000 population or 347,000 adults annually suffer from OHCA in the United States (US); likewise, the incidence of in-hospital cardiac arrest (IHCA) reported by Get With The Guidelines-Resuscitation (GWTG-R) suggests that each year, 209,000 people are treated for IHCA. Double sequential defibrillation (DSD) has been proposed as an alternative treatment for refractory ventricular fibrillation (VF) as there appears to be a trend of promising outcomes, including termination of refractory VF, sustained ROSC, increased short term survival and favorable outcomes to hospital discharge. We report a case of prolonged resuscitation of an 72-year-old man who developed pulseless ventricular tachycardia (pVT) that progressed to refractory VF terminated by DSD. In addition, we provide a quick reference that summarizes the characteristics and resuscitative parameters of the reported case.

Prospective validation of the Good Outcome Following Attempted Resuscitation (GO-FAR) score for in-hospital cardiac arrest prognosis

AimWe aimed to prospectively validate the Good Outcome Following Attempted Resuscitation (GO-FAR) score, which predicts the likelihood of survival to discharge neurologically intact or with minimal deficits (conscious, alert, and able to work) after in-hospital cardiac arrest (IHCA). MethodsInpatients experiencing an index episode of IHCA between 2010 and 2016 in hospitals participating in the Get With the Guidelines® — Resuscitation (GWTG-R) Registry were included. The score’s performance was prospectively validated in both all GWTG-R hospitals and in a subset of hospitals not part of the GWTG-R registry when the score was originally developed using prospective data. Score performance was stratified by hospital size, presence of residency training programs, and type of hospital ownership. Discrimination was measured by the c-statistic, calibration using a Hosmer-Lemeshow plot, and classification accuracy by the survival rates in each risk group. ResultsA total of 62,131 inpatients in 386 hospital were included. The GO-FAR score had similar discrimination (c-statistic 0.75, 95% CI 0.748−0.758), calibration, and classification accuracy as in the original study. Survival rates were somewhat higher due to a secular increase in survival of IHCA. In hospitals that were not part of the derivation population, the score performed as well as in the hospitals used to derive the score (c-statistic 0.75). The score performed similarly in hospitals of different sizes (c-statistic of 0.80 and 0.75 for hospital with ≤100 and >100 beds, respectively), with and without residency training programs (c-statistics of 0.76 and 0.75, respectively), and with different ownership structures (c-statistic of 0.79 for private, 0.74 for military government, and 0.76 for nonprofit hospital). ConclusionsThe GO-FAR score accurately classifies patients into risk groups based on their likelihood of survival to discharge with a good neurologic outcome following an episode of IHCA. Recalibration may be necessary using different point score cutoffs as IHCA survival increases.

Abstract 265: Improving Compliance with Get with the Guidelines-Resuscitation Metrics by Standardizing Code Note Documentation

Background: Accurate documentation of in-hospital cardiac arrest is essential to patient care. Recently, the American Heart Association created Get with the Guidelines-Resuscitation (GWTG-R) to facilitate the capture, analysis, and reporting of cardiac arrest data. GWTG-R criteria include witnessed events, confirmation of airway, two minute time-to-shock for ventricular tachycardia or fibrillation, and five minute time-to-first dose of epinephrine for pulseless electrical activity. The goal of our study was to increase adherence to GWTG-R measures by improving the quality of documentation of cardiac arrests by resident code leaders through the development and implementation of a standardized code note template. Methods: A retrospective chart review was performed on resident-authored code notes before and after implementation of a standardized code note. An electronic medical record template was developed which highlighted GWTG-R metrics. This note was made available to all resident physician code leaders. Reviewed notes were assessed for documentation of GWTG-R metrics and clinical reasoning. Results: Twenty-two notes were reviewed prior to and seventeen notes after implementation of a standardized code note template. 14/17 (82%) of post-implementation notes used the standardized template. All GWTG-R categories and clinical reasoning documentation trended toward improvement. Documentation of time-to-epinephrine significantly increased from 5.9% to 91.7% (Figure 1). Conclusions: Development of a standardized code note template improved documentation of GWTG-R quality measures for in-hospital cardiac arrest. Hospital compliance with guidelines improved following this intervention, qualifying for GWTG-R Bronze for three consecutive months of compliance. Expansion of the standardized code note for widespread use by providers throughout the hospital is expected to continue to improve code documentation and hospital compliance with GWTG-R.

Abstract 23: Incidence of Adult In-Hospital Cardiac Arrest in the United States

Introduction: Current incidence estimates of in-hospital cardiac arrest in the United States are based on data from more than a decade ago, with an estimated 200,000 adult cases per year. The aim of this study was to estimate the contemporary incidence of in-hospital cardiac arrest in adult patients, which may better inform the public health impact of in-hospital cardiac arrest in the United States. Methods: Using the Get With The Guidelines®-Resuscitation (GWTG-R) registry, we developed a negative binomial regression model to estimate the incidence of index in-hospital cardiac arrests in adult patients (&gt;18 years) between 2008 and 2016 based on hospital-level characteristics. The model coefficients were then applied to all United States hospitals, using data from the American Hospital Association Annual Survey, to obtain national incidence estimates. Hospitals only providing care to pediatric patients were excluded from the analysis. Additional analyses were performed including both index and recurrent events. Results: There were 154,421 index cardiac arrests from 388 hospitals registered in the GWTG-R registry. A total of 6,808 hospitals were available in the American Hospital Association database, of which 6,285 hospitals provided care to adult patients. The average annual incidence was estimated to be 283,700 in-hospital cardiac arrests. When including both index and recurrent cardiac arrests, the average annual incidence was estimated to 344,800 cases. Conclusions: Our analysis indicates that there are approximately 280,000 adult patients with in-hospital cardiac arrests per year in the United States. This estimate provides the contemporary annual incidence of the burden from in-hospital cardiac arrest in the United States.

The association of Duration of participation in get with the guidelines-resuscitation with quality of Care for in-Hospital Cardiac Arrest

BackgroundLarge variations exist in the care processes and outcomes for patients who experience in-hospital cardiac arrest (IHCA). We examined if Get With The Guidelines-Resuscitation (GWTG-R) participation duration was associated with improved care processes. Methods and ResultsWe calculated an overall process composite performance score for IHCA patients using five guideline-recommended process measures, calculating composite adherence among patients, and grouped at hospitals based on GWTG-R participation duration. Trend tests using logistic regression with generalized estimating equations examined the impact of participation duration on quality. Using multivariable regression models adjusting for patient factors, hospital factors, secular trends, and GWTG-R participation duration, we assessed the association between participation duration and process composite performance. We examined 149,551 patients from 447 hospitals (2000–2012). Over the study period we saw decreases in: median age of cardiac arrest (71 to 67 years), the proportion of whites (69.2% to 66.6%), and pulseless ventricular tachycardia/ventricular fibrillation frequency (32.3% to 17.3%). Hospitals were increasingly more likely to be in urban locations and have higher nurse-to-bed ratios. Guideline performance adherence improved with participation duration for several individual process measures and overall process composite performance: process composite score (P-value trend P < .001), confirmation of endotracheal tube (P < .001 trend), monitored/witnessed event (P < .001 trend), time to first chest compressions ≤1 minute (P < .001 trend), and time to vasopressor use ≤5 minutes (P-value trend = 0.0004). There was a decrease in adherence as duration of participation increased for time to defibrillation ≤2 minutes (P-value trend = 0.005). After adjusting for several factors including calendar time, GWTG-R participation duration was independently associated with improved process composite performance (OR 1.05 per year, 95% CI 1.03–1.07). ConclusionsGWTG-R participation duration was associated with a significant improvement in IHCA quality of care, yet significant opportunities remain to find ways to maximize quality of care in this high-risk patient group.

Predicting in-hospital mortality for initial survivors of acute respiratory compromise (ARC) events: Development and validation of the ARC Score

AimAcute respiratory compromise (ARC) is a common and highly morbid event in hospitalized patients. To date, however, few investigators have explored predictors of outcome in initial survivors of ARC events. In the present study, we leveraged the American Heart Association’s Get With The Guidelines®-Resuscitation (GWTG-R) ARC data registry to develop a prognostic score for initial survivors of ARC events. MethodsUsing GWTG-R ARC data, we identified 13,193 index ARC events. These events were divided into a derivation cohort (9807 patients) and a validation cohort (3386 patients). A score for predicting in-hospital mortality was developed using multivariable modeling with generalized estimating equations. ResultsThe two cohorts were well balanced in terms of baseline demographics, illness-types, pre-event conditions, event characteristics, and overall mortality. After model optimization, nine variables associated with the outcome of interest were included. Age, hypotension preceding the event, and intubation during the event were the greatest predictors of in-hospital mortality. The final score demonstrated good discrimination in both the derivation and validation cohorts. The score was also very well calibrated in both cohorts. Observed average mortality was <10% in the lowest score category of both cohorts and >70% in the highest category, illustrating a wide range of mortality separated effectively by the scoring system. ConclusionsIn the present study, we developed and internally validated a prognostic score for initial survivors of in-hospital ARC events. This tool will be useful for clinical prognostication, selecting cohorts for interventional studies, and for quality improvement initiatives seeking to risk-adjust for hospital-to-hospital comparisons.

Body mass index and outcomes of in-hospital ventricular tachycardia and ventricular fibrillation arrest

BackgroundDue to higher transthoracic impedance, obese patients may be less likely to be successfully defibrillated from ventricular tachycardia or ventricular fibrillation (VT/VF) arrest. However, the association between patient body mass index (BMI), defibrillation success, and survival outcomes of VT/VF arrest are poorly understood. MethodsWe evaluated 7110 patients with in-hospital VT/VF arrest at 286 hospitals within the Get With The Guidelines®-Resuscitation (GWTG-R) Multicenter Observational Registry between 2006 and 2012. Patients were categorized as underweight (BMI<18.5kg/m2), normal weight (BMI 18.5–24.9kg/m2), over-weight (BMI 25.0–29.9kg/m2), obese (BMI 30.0–34.9kg/m2), and extremely obese (BMI≥35.0kg/m2). Using generalized linear mixed regression, we determined the risk-adjusted relationship between BMI and patient outcomes while accounting for clustering by hospitals. The primary outcome was successful first shock defibrillation (a post-shock rhythm other than VT/VF) with secondary outcomes of return of spontaneous circulation, survival to 24h, and survival to discharge. ResultsAmong adult patients suffering VT/VF arrest, 304 (4.3%) were underweight, 2061 (29.0%) were normal weight, 2139 (30.1%) were overweight, and 2606 (36.6%) were obese or extremely obese. In a risk-adjusted analysis, we observed no interaction between BMI and energy level for the successful termination of VT/VF with first shock. Furthermore, the risk-adjusted likelihood of successful first shock termination of VT/VF did not differ significantly across BMI categories. Finally, when compared to overweight patients, obese patients had similar risk-adjusted likelihood of survival to hospital discharge (odds ratio 0.786, 95% confidence interval 0.593–1.043). ConclusionsThere was no significant difference in the likelihood of successful defibrillation with the first shock attempt among different BMI categories.

Association Between Hospital Process Composite Performance and Patient Outcomes After In-Hospital Cardiac Arrest Care.

Survival rates after in-hospital cardiac arrest (IHCA) vary significantly among US centers; whether this variation is owing to differences in IHCA care quality is unknown. To evaluate hospital-level variation to determine whether hospital process composite performance measures of IHCA care quality are associated with patient outcomes. Using data from the American Heart Association's Get With the Guidelines-Resuscitation (GWTG-R) program, we analyzed 35 283 patients 18 years or older with IHCA treated at 261 US hospitals from January 1, 2010, through December 31, 2012. We calculated the hospital process composite performance score for IHCA using 5 guideline-recommended process measures. Opportunity-based scores were calculated for all patients, aggregated at the hospital level, divided into quartiles, and then associated with risk-standardized survival and neurologic status by a test for trend. The scores were then evaluated through hierarchical logistic regression and reported as odds ratios per 10% increment in hospital process composite performance. Acute care treatments for IHCA. The primary outcome was survival to discharge measured as risk standard survival rates, and the secondary outcome was favorable neurologic status at hospital discharge. Of the 35 283 adults included in this study, the median age was 67 years (interquartile range [IQR] 56-78 years), and 57.9% were male. The median IHCA hospital process composite performance was 89.7% (interquartile range, 85.4%-93.1%) and varied among hospital quartiles from 82.6% (lowest) to 94.8% (highest). The IHCA hospital process composite performance was linearly associated with risk-standardized hospital survival to discharge rates: 21.1%, 21.4%, 22.8%, and 23.4% from lowest to highest performance quartiles, respectively (P < .001). After adjustment, each 10% increase in a hospital's process composite performance was associated with a 22% higher odds of survival (adjusted odds ratio, 1.22; 95% CI, 1.08-1.37; P = .01). Hospital process composite quality performance was also associated with favorable neurologic status at discharge (P = .004). The quality of guideline-based care for IHCA varies significantly among US hospitals and is associated with patient survival and neurologic outcomes.

Abstract 252: The Association of Award Recognition From Get With the Guidelines-Resuscitation with Improved Survival Rates in In-Hospital Cardiac Arrest Events

Background and Objectives: It is estimated that over 200,000 adults experience in-hospital cardiac arrest each year. Overall survival to discharge has remained relatively unchanged for decades and survival rates remain at about 20% (Elenbach et al., 2009). Get With The Guidelines-Resuscitation (GWTG-R) is an in-hospital quality improvement program designed to improve adherence to evidence-based care of patients who experience an in-hospital resuscitation event. GWTG-R focuses on four achievement measures. The measures for adult patients include time to first chest compression of less than or equal to one minute, device confirmation of correct endotracheal tube placement, patients with pulseless VF/VT as the initial documented rhythm with a time to first shock of less than or equal to two minutes, and events in which patients were monitored or witnessed at the time of cardiac arrest. The objective of this abstract is to examine the association between hospital adherence to GWTG-R and in-hospital cardiac arrest survival rates. Methods: A retrospective review of adult in-hospital cardiopulmonary arrest (CPA) patients (n=1849) from 21 Michigan, Illinois, and Indiana hospitals using the GWTG-R database was conducted from January 2014 through December 2014. This study included adult CPA patients that did and did not survive to discharge. Results: The review found that hospitals that had attained 84.6% or higher thresholds in all four achievement measures for at least one year, which is award recognition status, had a significantly improved in-hospital CPA survival to discharge rate of 29.6%. Hospitals that did not obtain award status had a CPA survival to discharge rate of 24.3%. The national survival rate for in-hospital adult CPA survival to discharge is 20%. Hospitals that did not achieve award recognition status still demonstrated improvement in survival rate when compared to the national survival rate, indicating the importance of a quality improvement program such as GWTG-R. No significant difference was found between in-hospital adult CPA survival rate and race between GWTG-R award winning and non-award winning hospitals. Hospitals that earned award recognition from GWTG-R had a survival to discharge rate of 30.2% for African Americans and 29.6% for whites. Hospitals that were did not earn award recognition from GWTG-R had a survival to discharge rate of 20.0% for African Americans and 20.1% for whites. Conclusions: Survival of in-hospital adult CPA patients improved significantly when GWTG-R measures are adhered to. Survival of in-hospital adult CPA patients also improves with implementation of GWTG-R. It is crucial that hospitals collect and analyze data regarding resuscitation processes and outcomes. Quality improvement measures can then be implemented in order to assist with improving in-hospital CPA survival rates.

Rapid Response to the Call for More METs.

Rapid response teams (RRTs), also known as medical emergency teams (MET), are used as an effort to avoid “failure to rescue” situations in which patients unknowingly deteriorate in acute care facilities. Particularly in children, deterioration is usually not sudden, and we often have missed opportunities along the way to intervene before emergent resuscitation is needed. In fact, one of the 2008 National Patient Safety Goals was to “improve recognition and response to changes in a patient’s condition,” and several organizations created toolkits to aid institutions in formation of RRTs.1–3 The American Heart Association’s (AHA) Get With the Guidelines-Resuscitation (GWTG-R) registry is a database of >300 hospitals including information before, during, and after cardiac arrest.4 In 2000, this began with the AHA’s national registry for cardiopulmonary resuscitation, and this transitioned to GWTG-R in 2010. The first publication from the GWTG-R MET module described by Raymond et al contains data from 3647 MET events in 151 hospitals from January 2006 to February 2012, certainly the largest cohort of such events published in …

Abstract 188: Pediatric Medical Emergency Team Response and Outcomes: A Report of 4,181 Events From the AHA Get With the Guidelines®-Resuscitation Registry

Background: In-hospital cardiac arrest (CA) is often preceded by signs and symptoms that predict subsequent deterioration. In response, hospitals created Medical Emergency Teams (METs) to bring skilled resources to the bedside with the aim of improving outcomes. Objective: Describe a cohort of pediatric MET events from the AHA Get With the Guidelines-Resuscitation (GWTG-R) registry. Methods: We analyzed consecutive pediatric (&lt; 18 yrs) MET events submitted to the AHA GWTG-R from Jan 2006 - Feb 2012. We excluded MET events in outpatient, critical care, newborn nurseries, delivery rooms, emergency departments (ED) and interventional/diagnostic areas. Results: We identified 4,181 MET events from 170 U.S. hospitals: median age 3.0 yrs (IQR = 0.0-13.0) with 52% male. Majority of MET events were in general inpatient wards (N = 3136, 75%) and telemetry/step-down units (N = 580, 13%). Medical (71%) and surgical (15%) non-cardiac patients were most frequent. Median length of MET event was 29.0 mins (IQR = 17.0-47.0). Most frequent triggers included: decreased oxygen saturation (30%), difficulty breathing (24%), staff concern (23%), tachypnea (21%), mental status changes (16%), and respiratory depression (12%). Within 24 hrs prior to MET call, 15% were transferred from an ICU, and 22% were admitted from the ED. Frequent non-drug interventions included: oxygen (58%), peripheral IV placement (30%), CXR (16%), suctioning (15%), and ICU consult (12%). Frequent drug interventions included: fluid bolus (21%), inhaled bronchodilators (16%), and anti-epileptics (7%). Almost half were transferred to the ICU (n = 2022, 48%), 236 (6%) progressed to require emergency assisted ventilation, and 18 patients (0.43%) progressed to CA. Survival to discharge was 92% (N = 3789). Conclusions: MET events occurred in general inpatient wards for objective indications, included assisted ventilation or CPR in 6.4%, and were associated with 8% hospital mortality. After treatment in 87% of events, 39% remained on inpatient wards, suggesting MET associated treatments may have stabilized or improved the condition of children judged to be clinically deteriorating by ward staff. Frequent events after ED admission or ICU transfer may represent an opportunity to improve the system of care.

Adrenaline (epinephrine) dosing period and survival after in-hospital cardiac arrest: A retrospective review of prospectively collected data

Background and aimExpert guidelines for treatment of cardiac arrest recommend administration of adrenaline (epinephrine) every three to five minutes. However, the effects of different dosing periods of epinephrine remain unclear. We sought to evaluate the association between epinephrine average dosing period and survival to hospital discharge in adults with an in-hospital cardiac arrest (IHCA). MethodsWe performed a retrospective review of prospectively collected data on 20,909 IHCA events from 505 hospitals participating in the Get With The Guidelines-Resuscitation (GWTG-R) quality improvement registry. Epinephrine average dosing period was defined as the time between the first epinephrine dose and the resuscitation endpoint, divided by the total number of epinephrine doses received subsequent to the first epinephrine dose. Associations with survival to hospital discharge were assessed by using generalized estimating equations to construct multivariable logistic regression models. ResultsCompared to a referent epinephrine average dosing period of 4 to <5min per dose, survival to hospital discharge was significantly higher in patients with the following epinephrine average dosing periods: for 6 to <7min/dose, adjusted odds ratio [OR], 1.41 (95%CI: 1.12, 1.78); for 7 to <8min/dose, adjusted OR, 1.30 (95%CI: 1.02, 1.65); for 8 to <9min/dose, adjusted OR, 1.79 (95%CI: 1.38, 2.32); for 9 to <10min/dose, adjusted OR, 2.17 (95%CI: 1.62, 2.92). This pattern was consistent for both shockable and non-shockable cardiac arrest rhythms. ConclusionLess frequent average epinephrine dosing than recommended by consensus guidelines was associated with improved survival of in-hospital cardiac arrest.

Abstract 65: Racial Disparities in Outcomes Following Nonshockable In-Hospital Cardiac Arrest

Background: Black patients have previously been shown to have worse outcomes from ventricular arrhythmias. This discrepancy was largely explained by individual patient characteristics and racial clustering by hospital. However, the vast majority of in-hospital cardiac arrests are due to pulseless electrical activity (PEA) and asystole and little is known about the relationship between race and outcomes in this patient group. Methods: We analyzed PEA and asystolic in-hospital cardiac arrests in the Get With The Guidelines-Resuscitation (GWTG-R) database from 2000 to 2009. A generalized estimating equation model was used to estimate the average survival difference between black and white patients in the study population. Multilevel conditional fixed effects logistic regression models were then used to estimate the relationship between race and survival to discharge and ROSC, sequentially controlling for hospital, patient demographics, comorbidities, arrest characteristic, process measures and interventions in place at the time of arrest. Results: We identified 76,385 eligible index arrests with a presenting rhythm of PEA or asystole, of which 19,236 (25%) were black. Black patients were younger on average (63 vs 71 years, p&lt;0.001) and had more comorbidities than their white counterparts. Survival to discharge was 13% for white patients and 10% for black patients (unadjusted OR 0.83; 95% CI 0.78-0.88). This effect remained nearly constant after controlling for hospital, patient, and event-specific confounders (adjusted OR 0.85; 95% CI 0.79-0.92). Similar results were shown for ROSC (adjusted OR 0.88; 95% CI 0.84-0.92). Conclusion: Black patients have significantly lower survival rates after in-hospital PEA and asystolic arrests. Hospital, patient demographics, event characteristics, and co-morbidities as measured in the GWTG-R database failed to explain this discrepancy. Furthermore, the consistency between the outcomes differences in ROSC and survival to discharge suggest that there are unmeasured intra-arrest and/or pre-arrest racial differences present. This is in contrast to shockable cardiac arrests in the same database, in which the disparity was greatly reduced after accounting for measured confounders.