Guidelines-Resuscitation Registry Research Articles

Use of Initial Endotracheal Versus Intravenous Epinephrine During Neonatal Cardiopulmonary Resuscitation in the Delivery Room: Review of a National Database

To assess whether initial epinephrine administration by endotracheal tube (ET) in newly born infants receiving chest compressions and epinephrine in the delivery room (DR) is associated with lower rates of return of spontaneous circulation (ROSC) than newborns receiving initial intravenous (IV) epinephrine. We conducted a retrospective review of neonates receiving chest compressions and epinephrine in the DR from the AHA Get With The Guidelines-Resuscitation registry from October 2013 through July 2020. Neonates were classified according to initial route of epinephrine (ET vs IV). The primary outcome of interest was ROSC in the DR. In total, 408 infants met inclusion criteria; of these, 281 (68.9%) received initial ET epinephrine and 127 (31.1%) received initial IV epinephrine. The initial ET epinephrine group included those infants who also received subsequent IV epinephrine when ET epinephrine failed to achieve ROSC. Comparing initial ET with initial IV epinephrine, ROSC was achieved in 70.1% vs 58.3% (adjusted risk difference 10.02; 95% CI 0.05-19.99). ROSC was achieved in 58.3% with IV epinephrine alone, and 47.0% with ET epinephrine alone, with 40.0% receiving subsequent IV epinephrine. This study suggests that initial use of ET epinephrine is reasonable during DR resuscitation, as there were greater rates of ROSC compared with initial IV epinephrine administration. However, administration of IV epinephrine should not be delayed in those infants not responding to initial ET epinephrine, as almost one-half of infants who received initial ET epinephrine subsequently received IV epinephrine before achieving ROSC.

Risk Factors and Outcomes for Recurrent Pediatric In-Hospital Cardiac Arrest: Retrospective Cohort Study from the American Heart Association's Get with the Guidelines-Resuscitation Registry

Abstract Objective We aimed to describe the risk factors and outcomes of recurrent in-hospital cardiac arrest (IHCA) in a large pediatric cohort. Methods A retrospective cohort study of patients ≤18 years from the American Heart Association's Get With The Guidelines®-Resuscitation Registry with single or recurrent IHCA who achieved return of spontaneous circulation and were not placed on extracorporeal membrane oxygenation with their initial IHCA were included. Patients were categorized into two groups for analysis: (1) single IHCA or (2) recurrent ICHA. Initial IHCAs from each category were analyzed and compared. Continuous variables were expressed as medians with interquartile ranges and compared via rank sum test. Categorical variables were expressed as percentages and compared via chi square test. Outcomes were assessed in a matched cohort. Results A total of 10,019 patients, 2,225 (22.2%) experienced a recurrent IHCA. Recurrent IHCA patients were more likely to be medical cardiac (21.3 vs. 19%; p = 0.01) or trauma patients (7.5 vs. 5.3%; p < 0.001) and have higher acuity (27.8 vs. 22.7%; p < 0.001). Initial IHCA for recurrent IHCA patients were more likely to occur in the pediatric intensive care unit (44.2 vs. 39.6%; p < 0.001) or cardiac intensive care unit (11.5 vs. 9.5%; p = 0.006) versus other inpatient locations. There was no difference in initial IHCA duration between groups. After matching, patients with a recurrent IHCA had a lower rate of survival to hospital discharge (42.1 vs. 65.3%; p < 0.001). Conclusion In a matched cohort, patients with recurrent IHCA had lower rates of survival compared with those with a single IHCA. Higher acuity and intensive care unit location during initial IHCA event were associated with increased risk for recurrent IHCA.

Hospital Variation in Epinephrine Administration Before Defibrillation for Cardiac Arrest Due to Shockable Rhythm.

Contrary to advanced cardiac life support guidelines that recommend immediate defibrillation for shockable in-hospital cardiac arrest (IHCA), epinephrine administration before first defibrillation is common and associated with lower survival at a "patient-level." Whether this practice varies across hospitals and its association with "hospital-level" IHCA survival remains unknown. The purpose of this study was to determine hospital variation in rates of epinephrine administration before defibrillation for shockable IHCA and its association with IHCA survival. Observational cohort study. Five hundred thirteen hospitals participating in the Get With The Guidelines Resuscitation Registry. A total of 37,668 adult patients with IHCA due to an initial shockable rhythm from 2000 to 2019. Epinephrine before first defibrillation. Using multivariable hierarchical regression, we examined hospital variation in epinephrine administration before first defibrillation and its association with hospital-level rates of risk-adjusted survival. The median hospital rate of epinephrine administration before defibrillation was 18.8%, with large variation across sites (range, 0-68.8%; median odds ratio: 1.54; 95% CI, 1.47-1.61). Major teaching status and annual IHCA volume were associated with hospital rate of epinephrine administration before defibrillation. Compared with hospitals with the lowest rate of epinephrine administration before defibrillation (Q1), there was a stepwise decline in risk-adjusted survival at hospitals with higher rates of epinephrine administration before defibrillation (Q1: 44.3%, Q2: 43.4%; Q3: 41.9%; Q4: 40.3%; p for trend < 0.001). Administration of epinephrine before defibrillation in shockable IHCA is common and varies markedly across U.S. hospitals. Hospital rates of epinephrine administration before defibrillation were associated with a significant stepwise decrease in hospital rates of risk-adjusted survival. Efforts to prioritize immediate defibrillation for patients with shockable IHCA and avoid early epinephrine administration are urgently needed.

Adults Are Not Just Large Kids: Caring for Adults in Pediatric Hospitals.

Adults Are Not Just Large Kids: Caring for Adults in Pediatric Hospitals.

Editor’s Choice Articles for January

Editor’s Choice Articles for January

Characteristics and Outcomes of Cardiac Arrest in Adult Patients Admitted to Pediatric Services: A Descriptive Analysis of the American Heart Association's Get With The Guidelines-Resuscitation Data.

Differences between adult and pediatric in-hospital cardiac arrest (IHCA) are well-described. Although most adults are cared for on adult services, pediatric services often admit adults, particularly those with chronic conditions. The objective of this study is to describe IHCA in adults admitted to pediatric services. Retrospective cohort analysis from the American Heart Association's Get With The Guidelines-Resuscitation registry of a subpopulation of adults with IHCA while admitted to pediatric services. Multivariable logistic regression was used to evaluate adjusted survival outcomes and compare outcomes between age groups (18-21, 22-25, and ≥26 yr old). Hospitals contributing to the Get With The Guidelines-Resuscitation registry. Adult-aged patients (≥ 18 yr) with an index pulseless IHCA while admitted to a pediatric service from 2000 to 2018. None. A total of 491 adult IHCAs were recorded on pediatric services at 17 sites, during the 19 years of review, and these events represented 0.1% of all adult IHCAs. In total, 221 cases met inclusion criteria with 139 events excluded due to an initial rhythm of bradycardia with poor perfusion. Median patient age was 22 years (interquartile range, 19-28 yr). Ninety-eight percent of patients had at least one pre-existing condition. Return of spontaneous circulation occurred in 63% of events and 30% of the patients survived to discharge. All age groups had similar rates of survival to discharge (range 26-37%; p = 0.37), and survival did not change over the study period (range 26-37%; p = 0.23 for adjusted survival to discharge). In this cohort of adults with IHCA while admitted to a pediatric service, we failed to find an association between survival outcomes and age. Additional research is needed to better understand resuscitation in this population.

Early changes in hospital resuscitation practices during the COVID-19 pandemic

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic resulted in many disruptions in care for patients experiencing in-hospital cardiac arrest (IHCA). We sought to identify changes made in hospital resuscitation practices during progression of the COVID-19 pandemic. MethodsWe conducted a descriptive qualitative study using in-depth interviews of clinical staff leadership involved with resuscitation care at a select group of U.S. acute care hospitals in the national American Heart Association Get With The Guidelines-Resuscitation registry for IHCA. We focused interviews on resuscitation practice changes for IHCA since the initiation of the COVID-19 pandemic. We used rapid analysis techniques for qualitative data summarization and analysis. ResultsA total of 6 hospitals were included with interviews conducted with both physicians and nurses between November 2020 and April 2021. Three topical themes related to shifts in resuscitation practice through the COVID-19 pandemic were identified: 1) ensuring patient and provider safety and wellness (e.g., use of personal protective equipment); 2) changing protocols and training for routine educational practices (e.g., alterations in mock codes and team member roles); and 3) goals of care and end of life discussions (e.g., challenges with visitor and family policies). We found advances in leveraging technology use as an important topic that helped institutions address challenges across all 3 themes. ConclusionsEarly on, the COVID-19 pandemic resulted in many changes to resuscitation practices at hospitals placing an emphasis on enhanced safety, training, and end of life planning. These lessons have implications for understanding how systems may be better designed for resuscitation efforts.

Resuscitation Quality in the ICU: A Retrospective Analysis

American Heart Association quality metrics of resuscitation include time to epinephrine≤ 5 min, time to defibrillation≤ 2 min, and confirmation of airway device placement in trachea. This study examined trends in adherence to these quality metrics in the ICU and identified predictors of failure to adhere to these metrics. What is the registered adherence to time to epinephrine≤ 5 min, time to defibrillation≤ 2 min, and confirmation of airway device placement in trachea in the ICU setting? This was a retrospective analysis. Using the Get With The Guidelines-Resuscitation registry, adult patients with an index cardiac arrest in adult ICUs between 2006 and 2018 in the United States were identified. Modified Poisson regression with generalized estimation equations were used for the analyses. A total of 97,009 adult ICU patients from 538 hospitals were identified using the Get With The Guidelines-Resuscitation registry, and 75,668 patients were included in the final analysis. From 2006 to 2018, adherence to time to epinephrine≤ 5min increased from 93%(95%CI, 93-94) to 98%(95%CI, 97-98), time to defibrillation≤ 2min increased from 72%(95%CI, 69-75) to 75%(95%CI, 72-78), and confirmation of airway device placement in trachea increased from 93%(95%CI, 91-94) to 97%(95%CI, 96-98). Nonwitnessed status (P< .001), nonmonitored status (P= .003), and nighttime arrest (P= .002) were associated with adherence failure for time to epinephrine≤ 5 min, whereas a noncardiac (P< .001) or traumatic (P< .001) illness category, renal insufficiency (P= .001), and nighttime arrest (P= .03) were associated with adherence failure for time to defibrillation≤ 2 min. Overall, quality metric adherence was high in the ICU, with the exception of time to defibrillation≤ 2 min.

Variation Across Hospitals in In-Hospital Cardiac Arrest Incidence Among Medicare Beneficiaries

Although survival for in-hospital cardiac arrest (IHCA) has improved substantially over the last 2 decades, survival rates have plateaued in recent years. A better understanding of hospital differences in IHCA incidence may provide important insights regarding best practices for prevention of IHCA. To determine the incidence of IHCA among Medicare beneficiaries, and evaluate hospital variation in incidence of IHCA. This observational cohort study analyzes 2014 to 2017 data from 170 hospitals participating in the Get With The Guidelines-Resuscitation registry, linked to Medicare files. Participants were adults aged 65 years and older. Statistical analysis was performed from January to December 2021. Case-mix index, teaching status, and nurse-staffing. Hospital incidence of IHCA among Medicare beneficiaries was estimated as the number of IHCA patients divided by the total number of hospital admissions. Multivariable hierarchical regression models were used to calculate hospital incidence rates adjusted for differences in patient case-mix and evaluate the association of hospital variables with IHCA incidence. Among a total of 4.5 million admissions at 170 hospitals, 38 630 patients experienced an IHCA during 2014 to 2017. Among the 38 630 patients with IHCAs, 7571 (19.6%) were non-Hispanic Black, 26 715 (69.2%) were non-Hispanic White, and 16 732 (43.3%) were female; the mean (SD) age at admission was 76.3 (7.8) years. The median risk-adjusted IHCA incidence was 8.5 per 1000 admissions (95% CI, 8.2-9.0 per 1000 admissions). After adjusting for differences in case-mix index, IHCA incidence varied markedly across hospitals ranging from 2.4 per 1000 admissions to 25.5 per 1000 admissions (IQR, 6.6-11.4; median odds ratio, 1.51 [95% CI, 1.44-1.58]). Among hospital variables, a higher case-mix index, higher nurse staffing, and teaching status were associated with a lower hospital incidence of IHCA. This cohort study found that the incidence of IHCA varies markedly across hospitals, and hospitals with higher nurse staffing and teaching status had lower IHCA 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.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Abstract 10476: Patient Characteristics and Survival Outcomes of Cardiac Arrest in the Cardiac Catheterization Laboratory: Insights from Get with the Guidelines-Resuscitation Registry

Background: The characteristics and outcomes of in-hospital cardiac arrest (IHCA) in the cardiac catheterization laboratory (CCL) have not been well-described. We compared the characteristics and outcomes of patients with an IHCA in the CCL versus those in the operating room (OR) and the intensive care unit (ICU). Methods: Within the American Heart Association’s Get With the Guidelines-Resuscitation® registry, we identified patients 18 years of age or older with an IHCA in the CCL, OR, or ICU between 2000 and 2019. We compared rates of survival to discharge for patients in the CCL, OR, and ICU. Additionally, we examined predictors of survival to discharge for patients with IHCA in the CCL. Results: There were 6866, 5181, and 181,832 patients with an IHCA in the CCL, OR, and ICU, respectively. Patients with IHCAs in the CCL were more likely to have a shockable cardiac arrest rhythm as compared with those in the OR and ICU. Overall, 2614 (38.1%) patients with IHCA in the CCL survived to discharge, as compared with 30,833 (16.9%) from the ICU and 2096 (40.5%) from the OR. After adjustment for 27 patient and cardiac arrest factors, patients with IHCA in CCL were more likely to survive to discharge as compared with those with IHCA from the ICU (odds ratio, 1.37 [95% CI: 1.29-1.46], p&lt;0.001). In contrast, they were less likely to survive to discharge as compared with those with IHCA in the OR (odds ratio, 0.81 [95% CI: 0.69-0.94], p=0.006). Predictors of survival to discharge in patients with IHCA in the CCL included white race, pulseless ventricular tachycardia/fibrillation, and IHCA during normal hours and on weekdays, while having myocardial infarction during this or prior hospitalization was associated with less survival to discharge. (Table). Conclusion: IHCA in the CCL is not uncommon and has a lower survival rate as compared with IHCA in other procedural areas such as the OR. The reasons for this difference deserve further study given that response to IHCAs in both settings should be similar.

Abstract 9588: Higher Survival With the Use of Extracorporeal Cardiopulmonary Resuscitation Compared With Conventional Cardiopulmonary Resuscitation in Children Undergoing Cardiac Surgery: Analysis of the Get With the Guidelines Registry©

Introduction: Extracorporeal cardiopulmonary resuscitation (E-CPR) has been increasingly utilized during in-hospital arrest in postoperative pediatric cardiac surgical patients. Despite this and the significant associated mortality, few pediatric multicenter analyses have evaluated if E-CPR increases survival for in-hospital cardiac arrest compared with conventional cardiopulmonary resuscitation (C-CPR). Methods: Children &lt;18 years in the Get with the Guidelines-Resuscitation Registry© suffering in-hospital cardiac arrest following cardiac surgery who received ≥10 minutes of CPR between January 2008 and December 2020 were included. We compared patient factors, pre-arrest comorbid conditions, and survival to hospital discharge for E-CPR and C-CPR groups. Results: Among 1219 patients from 56 institutions, 483 patients (39.6%) received E-CPR. Nearly 75% (910/1219) of patients were &lt;1 year of age with 39% (477/1219) under 1 month. Older patients were more likely to receive E-CPR (p=0.004). E-CPR utilization increased over the study period (p&lt;0.001). Non-Hispanic White patients accounted for almost half of the population (575/1219) and were also more likely to receive E-CPR (p=0.044) compared to other races/ethnicities. Patients with cyanotic cardiac malformations (p=0.005), congestive heart failure prior to admission (p=0.007), and hypotension prior to arrest (p=0.014) were also more likely to receive E-CPR. Unadjusted survival of the index CPR event (98% vs. 63%, p&lt;0.001) and to hospital discharge (47% vs 39%, p=0.007) were both higher in the E-CPR compared to C-CPR group. Conclusions: In a large, multicenter study of pediatric cardiac surgical patients suffering in-hospital arrest, we found that E-CPR is commonly used and had significantly higher survival to hospital discharge compared with C-CPR. E-CPR is an important rescue strategy for children with heart disease and centers performing cardiac surgery should develop E-CPR programs.

Survival outcomes and resuscitation process measures in maternal in-hospital cardiac arrest

Maternal in-hospital cardiac arrest is a rare event with the potential for resuscitation treatment delays because of the difficulty accessing hospital obstetrical units and limited simulation training or resuscitation experience of obstetrical staff. However, it is unclear whether survival rates and processes of care differ between women with a maternal in-hospital cardiac arrest and those with a nonmaternal in-hospital cardiac arrest. We aimed determine whether to there are delays in process measures and differences in survival outcomes between pregnant and nonpregnant women who have in-hospital cardiac arrest. Using data from 2000 to 2019 in the Get With The Guidelines-Resuscitation registry, we compared resuscitation outcomes between women aged 18 to 50 years with a maternal or nonmaternal in-hospital cardiac arrest. Using a nonparsimonious propensity score, we matched patients with a maternal in-hospital cardiac arrest to as many as 10 women with a nonmaternal in-hospital cardiac arrest. We constructed conditional logistic regression models to compare survival outcomes (survival to discharge, favorable neurologic survival [discharge cerebral performance score of 1], and return of spontaneous circulation) and processes of care (delayed defibrillation [>2 minutes] and administration of epinephrine [>5 minutes]) between women with a maternal in-hospital cardiac arrest vs those with a nonmaternal in-hospital cardiac arrest. Overall, 421 women with a maternal in-hospital cardiac arrest were matched by propensity score to 2316 women with a nonmaternal in-hospital cardiac arrest. The mean age among propensity score-matched women with a maternal in-hospital cardiac arrest was 31.4 (standard deviation, 6.5) years, where 33.7% were of Black race and 86.9% had an initial nonshockable cardiac arrest rhythm. Unadjusted survival rates were higher in women with a maternal in-hospital cardiac arrest than in women with a nonmaternal in-hospital cardiac arrest: survival to discharge of 45.1% vs 26.5%, survival with cerebral performance category 1 status of 36.1% vs 17.7%, and return of spontaneous circulation of 75.8% vs 70.6%. After adjustment, there was no difference in the likelihood of survival to discharge (odds ratio, 1.19; 95% confidence interval, 0.82-1.73) or return of spontaneous circulation (odds ratio, 0.94; 95% confidence interval, 0.65-1.35) between women with a maternal in-hospital cardiac arrest and those with a nonmaternal in-hospital cardiac arrest. However, women with a maternal in-hospital cardiac arrest were more likely to have favorable neurologic survival (odds ratio, 1.57; 95% confidence interval, 1.06-2.33). Compared with women with a nonmaternal in-hospital cardiac arrest, women with a maternal in-hospital cardiac arrest had similar rates of delayed defibrillation (42.5% vs 34.4%; odds ratio, 1.14 [95% confidence interval, 0.41-3.18]; P=.31) and delayed administration of epinephrine (13.8% vs 10.6%; odds ratio, 0.96 [95% confidence interval, 0.50-1.86]; P=.09). Although concerns have been raised about resuscitation outcomes in women with a maternal in-hospital cardiac arrest, the rates of survival and resuscitation processes of care were not worse in women with a maternal in-hospital cardiac arrest.

Comparison of Machine Learning Methods for Predicting Outcomes After In-Hospital Cardiac Arrest.

Prognostication of neurologic status among survivors of in-hospital cardiac arrests remains a challenging task for physicians. Although models such as the Cardiac Arrest Survival Post-Resuscitation In-hospital score are useful for predicting neurologic outcomes, they were developed using traditional statistical techniques. In this study, we derive and compare the performance of several machine learning models with each other and with the Cardiac Arrest Survival Post-Resuscitation In-hospital score for predicting the likelihood of favorable neurologic outcomes among survivors of resuscitation. Analysis of the Get With The Guidelines-Resuscitation registry. Seven-hundred fifty-five hospitals participating in Get With The Guidelines-Resuscitation from January 1, 2001, to January 28, 2017. Adult in-hospital cardiac arrest survivors. None. Of 117,674 patients in our cohort, 28,409 (24%) had a favorable neurologic outcome, as defined as survival with a Cerebral Performance Category score of less than or equal to 2 at discharge. Using patient characteristics, pre-existing conditions, prearrest interventions, and periarrest variables, we constructed logistic regression, support vector machines, random forests, gradient boosted machines, and neural network machine learning models to predict favorable neurologic outcome. Events prior to October 20, 2009, were used for model derivation, and all subsequent events were used for validation. The gradient boosted machine predicted favorable neurologic status at discharge significantly better than the Cardiac Arrest Survival Post-Resuscitation In-hospital score (C-statistic: 0.81 vs 0.73; p < 0.001) and outperformed all other machine learning models in terms of discrimination, calibration, and accuracy measures. Variables that were consistently most important for prediction across all models were duration of arrest, initial cardiac arrest rhythm, admission Cerebral Performance Category score, and age. The gradient boosted machine algorithm was the most accurate for predicting favorable neurologic outcomes in in-hospital cardiac arrest survivors. Our results highlight the utility of machine learning for predicting neurologic outcomes in resuscitated patients.

Epidemiology and outcomes of infants after cardiopulmonary resuscitation in the neonatal or pediatric intensive care unit from a national registry

AimCardiopulmonary resuscitation (CPR) in hospitalized infants is a relatively uncommon but high-risk event associated with mortality. The study objective was to identify factors associated with mortality and survival among infants who receive CPR in the neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU). MethodsRetrospective observational study of infants with an index CPR event in the NICU or PICU between 1/1/06 and 12/31/18 in the American Heart Association’s Get With The Guidelines-Resuscitation registry. Associations between patient, event, unit, and hospital factors and the primary outcome, mortality prior to discharge, were examined using multivariable logistic regression. ResultsAmong 3521 infants who received CPR, 2080 (59%) died before discharge, with 25% mortality during CPR and 40% within 24 h. Mortality prior to discharge occurred in 65% and 47% of cases in the NICU and PICU, respectively. Factors most strongly independently associated with pre-discharge mortality were vasoactive agent before CPR (adjusted odds ratio (aOR): 2.77, 95% confidence interval (CI) 2.15–3.58), initial pulseless condition (aOR: 2.38, 95% CI 1.46–3.86) or development of pulselessness (aOR: 2.36, 95% CI 1.78–3.12), and NICU location compared with PICU (aOR: 3.85, 95% CI 2.86–5.19). Endotracheal intubation during CPR was associated with decreased odds of pre-discharge mortality (aOR: 0.40, 95% CI 0.33−0.49). ConclusionInfants who receive CPR in the intensive care unit experience high mortality rates; identifiable patient, event, and unit factors increase the odds of mortality. Further investigation should explore the association between unit type, resuscitation processes, and mortality.

Pediatric Extracorporeal Cardiopulmonary Resuscitation ELSO Guidelines.

Pediatric Extracorporeal Cardiopulmonary Resuscitation ELSO Guidelines.

Neonatal delivery room CPR: An analysis of the Get with the Guidelines®—Resuscitation Registry

BackgroundCardiopulmonary resuscitation (CPR) in the delivery room (DR) after birth is rare. We hypothesized that factors related to maternal, delivery, infant and resuscitation event characteristics associated with outcomes could be identified. We also hypothesized there would be substantial variation from the Neonatal Resuscitation Program (NRP) algorithm. MethodsRetrospective review of all neonates receiving chest compressions in the DR from the AHA Get With The Guidelines—Resuscitation registry from 2001 to 2014. The primary outcome was return of spontaneous circulation (ROSC) in the DR. Secondary outcome was survival to hospital discharge. Descriptive statistics were used to characterize data. Odds ratios with confidence intervals were calculated as appropriate to compare survivors and non-survivors. ResultsThere were 1153 neonates who received chest compressions in the DR. ROSC was achieved in 968 (84%) newborns and 761 (66%) survived to hospital discharge. Fifty-one percent of the cohort received chest compressions without medications. Cardiac compressions were initiated within the first minute of life in 76% of the events, and prior to endotracheal intubation in 79% of the events. In univariate analysis, factors such as prematurity, number of endotracheal intubation attempts, increased time to first adrenaline dose, and CPR duration were associated with decreased odds of ROSC in the DR. Longer CPR duration was associated with decreased odds of ROSC in multivariate analysis. ConclusionIn this cohort of infants receiving chest compressions following delivery, recognizable pre-birth risk factors as well as resuscitation interventions associated with increased and decreased odds of achieving ROSC were identified. Chest compressions were frequently initiated in the first minute of the event and often prior to endotracheal intubation. Further investigations should focus on methods to decrease time to critical resuscitation interventions, such as successful endotracheal intubation and administration of the first dose of adrenaline, in order to improve DR-CPR outcomes.

Circadian variation of in-hospital cardiac arrest

BackgroundOut of hospital cardiac arrests, especially those due to ventricular tachyarrhythmias, have higher incidence in the morning. It is unknown whether in-hospital cardiac arrests follow a similar pattern. Aim of the studyThe purpose of this study was to analyze the circadian variation of in-hospital cardiac arrest incidence. MethodsThis retrospective review of data from the multicenter Get With The Guidelines-Resuscitation registry between 2000 and 2014 used multivariable hierarchical logistic regression analysis to examine circadian rhythm of in-hospital cardiac arrest over a 24-h cycle, stratified by initial shockable versus non-shockable rhythm. ResultsAmong 154,038 patients, initial rhythm was recorded as asystole or pulseless electrical activity (non-shockable) in 124,918 (81%), and ventricular fibrillation or ventricular tachycardia (shockable) in 29,120 (19%). Among non-shockable events, the highest relative proportion occurred during 0400−0759 (17.9%), followed by 0000−0359 (17.1%). For shockable rhythms the greatest relative proportion occurred between 2000−2359 (17.0%), followed by 1200−1559 (16.9%). Multivariable analysis showed that the relative risk of non-shockable compared to shockable arrest was slightly higher from midnight through 0359 (aOR 1.13; 95% CI 1.06–1.20, p < 0.001) and from 0400 through 0759 h (aOR 1.14; 95% CI 1.07−1.22, p < 0.001). Although statistically significant, the magnitude of difference in incidence by time of day was small in both groups. ConclusionsAlthough small differences in the relative frequency of in-hospital cardiac arrest (both shockable and non-shockable rhythms) were noted during different time intervals, in-hospital cardiac arrest occurs with nearly equal frequency throughout the day. Our findings have important implications for hospital staffing models to ensure that quality of resuscitation care is consistent regardless of time.

Association of Hospital-Level Acute Resuscitation and Postresuscitation Survival With Overall Risk-Standardized Survival to Discharge for In-Hospital Cardiac Arrest

Survival after in-hospital cardiac arrest depends on 2 distinct phases: responsiveness and quality of the hospital code team (ie, acute resuscitation phase) and intensive and specialty care expertise (ie, postresuscitation phase). Understanding the association of these 2 phases with overall survival has implications for design of in-hospital cardiac arrest quality measures. To determine whether hospital-level rates of acute resuscitation survival and postresuscitation survival are associated with overall risk-standardized survival to discharge for in-hospital cardiac arrest. This observational cohort study included 86 426 patients with in-hospital cardiac arrest from January 1, 2015, through December 31, 2018, recruited from 290 hospitals participating in the Get With The Guidelines-Resuscitation registry. Risk-adjusted rates of acute resuscitation survival, defined as return of spontaneous circulation for at least 20 minutes, and postresuscitation survival, defined as survival to discharge among patients achieving return of spontaneous circulation. The primary outcome was overall risk-standardized survival rate (RSSR) for in-hospital cardiac arrest calculated using a previously validated model. The correlation between a hospital's overall RSSR and risk-adjusted rates of acute resuscitation and postresuscitation survival were examined. Of 86 426 patients with in-hospital cardiac arrest, the median age was 67.0 years (interquartile range [IQR], 56.0-76.0 years); 50 665 (58.6%) were men, and 71 811 (83.1%) had an initial nonshockable cardiac arrest rhythm. The median RSSR was 25.1% (IQR, 21.9%-27.7%). The median risk-adjusted acute resuscitation survival was 72.4% (IQR, 67.9%-76.9%), and risk-adjusted postresuscitation survival was 34.0% (IQR, 31.5%-37.7%). Although a hospital's RSSR was correlated with survival during both phases, the correlation with postresuscitation survival (ρ, 0.90; P < .001) was stronger compared with the correlation with acute resuscitation survival (ρ, 0.50; P < .001). Of note, there was no correlation between risk-adjusted acute resuscitation survival and postresuscitation survival (ρ, 0.09; P = .11). Compared with hospitals in the lowest RSSR quartile, hospitals in the highest RSSR quartile had higher rates of acute resuscitation survival (75.4% in quartile 4 vs 66.8% in quartile 1; P < .001) and postresuscitation survival (40.3% in quartile 4 vs 28.7% in quartile 1; P < .001), but the magnitude of difference was larger with postresuscitation survival. The findings suggest that hospitals that excel in overall in-hospital cardiac arrest survival, in general, excel in either acute resuscitation or postresuscitation care but not both; efforts to strengthen postresuscitation care may offer additional opportunities to improve in-hospital cardiac arrest survival.

Abstract 353: Association Between Hospital Resuscitation Team Leader Credentials and Survival Outcomes for In-hospital Cardiac Arrest

Background: It is unclear if survival rates for in-hospital cardiac arrest (IHCA) vary across hospitals depending on whether resuscitations are typically led by an attending physician, physician trainee, or a non-physician. We sought to determine the association between resuscitation team leader credentials and IHCA survival. Methods: A nationwide survey was done in 2018 to elicit information on resuscitation practices across hospitals participating in the Get With The Guidelines-Resuscitation registry for IHCA. Using responses from the question of “Who typically leads codes at your institution”, we grouped hospitals based on their typical type of resuscitation team leader: attending physician, physician trainee, or non-physician. Responses from the survey were linked to survival outcomes within the registry. We compared risk-adjusted hospital rates of survival to discharge, return of spontaneous circulation [ROSC] and favorable neurological survival for 2015-2017 between these 3 hospital groups using multi variable hierarchical regression. Results: Overall, 193 hospitals had a minimum of 20 IHCAs and completed the study survey, representing a total of 44,477 IHCAs (mean age of 65.0 ± 15.5, 40.8% were females). Most hospitals had resuscitations led by physicians, with 121 (62.7%) led by an attending physician, 58 (30.0%) by a physician-trainee, and 14 (7.3%) by a non-physician. Risk-standardized rates of survival to discharge were similar across hospitals, regardless of whether resuscitations were typically led by an attending physician, physician trainee, or non-physician (25.6±4.8%, 25.9±4.7%, and 25.7±3.6%, respectively; p = 0.88). Similarly, there were no differences between the 3 groups in risk-adjusted rates of ROSC (71.7±6.3%, 73±6.3%, and 73.4±6.4%; P = 0.30) and favorable neurological survival (21.6±7.1%, 22.7±6.1%, and 20.9±6.5%; P = 0.50; Figure). Conclusion: Among hospitals in a national registry, IHCA resuscitations were usually led by physicians. However, there was no association between a hospital’s typical resuscitation team leader credentials and IHCA survival outcomes.