New Recommendations to Improve Outcomes After In-Hospital Cardiac Arrest

Disclosure: Dr. Callaway has nothing to disclose.
Pub Date: Monday, March 11, 2013
Author: Clifton W. Callaway, MD, PhD
Affiliation: University of Pittsburgh, UPMC Health System

Morrison LJ, et al; on behalf of the American Heart Association Emergency Cardiovascular Care Committee, Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Cardiovascular Nursing, Council on Clinical Cardiology, and Council on Peripheral Vascular Disease. Strategies for improving survival after in-hospital cardiac arrest in the United States: 2013 consensus recommendations: a consensus statement from the American Heart Association. Circulation. 2013: published online before print March 11, 2013, 10.1161/CIR.0b013e31828b2770.
http://circ.ahajournals.org/lookup/doi/10.1161/CIR.0b013e31828b2770

Survival from cardiac arrest that occurs outside the hospital has increased steadily in many countries over the past decade.¹ This improvement cannot be linked to any single change in care, but really represents the culmination of quality improvement in many parts of the emergency response to cardiac arrest. Rapid recognition of the emergency, bystander cardiopulmonary resuscitation (CPR), automated external defibrillators, improved response times, increased use of coronary revascularization and in-hospital therapies to improve neurological recovery all contribute. Cardiac arrest that occurs in the hospital affects an equally large number of patients and may have similar trends in survival, but has been more difficult to quantify.²  Furthermore, the system improvements used to enhance out-of-hospital cardiac arrest (OHCA) survival may not be appropriate or relevant for in-hospital cardiac arrest (IHCA). The AHA Consensus Statement “Strategies for Improving Survival After In-Hospital Cardiac Arrest in the United States: 2013 Consensus Recommendations” defines the current state and sets a roadmap for improving survival after IHCA.³

Key differences between system responses to IHCA and OHCA are enumerated in this document. Obvious factors include the types of patients, associated comorbidities, and different backgrounds of emergency responders in the hospital. Less obvious factors include the difficulty of defining and detecting IHCA. For example, current statistics about the incidence of IHCA (an estimated 3.7 IHCA per 1000 hospital admissions) are derived primarily from in-hospital code teams. Because these teams are usually not activated for critical care areas (ICU, emergency department, or operating room), as many as one-half of IHCA may not be documented in current research. The true number of adult IHCA may be as many as 6.7 per 1000 admissions, or over 200,000 patients per year. The Consensus document correctly calls for efforts to capture these “hidden” cardiac arrests in order that observational, epidemiological and experimental studies can advise treatments that are useful for all IHCA.

Specific steps are outlined to improve our understanding of IHCA. Research relies on high-quality data.  The Consensus Statement calls for comprehensive registries of IHCA that use common definitions over time. The AHA’s own Get With The Guidelines®-Resuscitation registry is one example. Barriers to collecting administrative data include the fact that coding for cardiac arrest is unreliable, and single ICD-9 or ICD-10 codes are not always used for the IHCA situations and treatments of interest. The Consensus Statement calls for refinement of the coding process to facilitate quality monitoring and benchmarking over time. Furthermore, a common approach to including or excluding patients with advanced directives or do-not-attempt-resuscitation (DNAR) orders is essential for comparing outcomes across locations. 

These recommendations draw attention to the common practice of limiting or withdrawing life-sustaining treatment after both IHCA and OHCA. The rate for this practice is quite high, but we are relatively ignorant about how often that decision is informed by prognosis. In many cases, it may represent more complex judgments and discussions by providers and patient families about the pre-arrest wishes and underlying disease of the patient. When withdrawal of life-sustaining treatment occurs before reliable prediction of outcome is possible, the final outcomes must be considered unknown or censored. Changing the status of a patient to DNAR status is associated with lower survival after OHCA.⁴ Similar effects may occur in IHCA. Proper assessment of progress in IHCA survival requires that we systematically and consistently record the timing of status changes or care limitation, and also that we study the rationale for these decisions. Practice improvement may actually mandate that we increase the duration of support for patients after IHCA.

Specific care pathways can be recommended based on the data that are available. For example, rapid recognition of IHCA, proper training of hospital personnel to provide initial CPR and defibrillation, and performance of high-quality CPR are critical. Recent data have highlighted variability in the quality of CPR delivered by providers. Potential solutions with evidence for implementation include training, debriefing, and real-time monitors that coach CPR delivery. In OHCA, initiatives to improve CPR quality occupy the largest part of the training cycle. It is conceivable that all professional providers, both in the hospital and out of the hospital, will need to measure and optimize delivery of chest compressions, proportion of time spent performing compressions, as well as depth and rate of compressions.

Good post-cardiac arrest care increases the probability of meaningful survival. Efforts to ensure rapid treatment of acute coronary syndromes and induced hypothermia after IHCA should match those efforts for OHCA. One controversial issue is the recent trend to develop regional centers for treatment of patients after cardiac arrest.  While certain patients may benefit from tertiary or specialty care, one concern is the loss of this service line in smaller hospitals. Regional plans to ensure that every patient has equitable access to best care whether via inter-hospital transfer or enhancement of local capacity must be developed. This type of regional planning may be a culture change for the disposition and care of patients after IHCA.

There are several opportunities for improvement that are unique to IHCA. These include the use of rapid response teams. The data for the effects of these teams remain confusing because of the heterogeneity of reporting and definitions. The Consensus Statement recommends to carefully evaluate whether these teams benefit the final outcome of the patient (surviving to return home in a functional state) as opposed to reducing one metric (such as IHCA outside of the ICU). In addition, standards for cardiac monitoring, preparation of response carts and equipment, and training of non-emergency hospital personnel are quite different in scope than any aspect of OHCA. Structured debriefing of all of the participants in an attempted resuscitation has improved response and outcomes in selected centers.  These techniques can be applied immediately in most institutions.

In summary, the “Strategies for Improving Survival After In-Hospital Cardiac Arrest in the United States: 2013 Consensus Recommendations” are a call for specific actions. This document helps to distinguish the research agenda for IHCA as distinct from OHCA. It also outlines specific steps that can be initiated today to improve outcomes for hundreds of thousands of patients who suffer IHCA in the United States each year.

1. Kitamura T, Iwami T, Kawamura T, Nitta M, Nagao K, Nonogi H, Yonemoto N, Kimura T, for the Japanese Circulation Society Resuscitation Science Study Group. Nationwide improvements in survival from out-of-hospital cardiac arrest in Japan. Circulation. 2012;126:2834-2843.
2. Girotra S, Nallamothu BK, Spertus JA, Li Y, Krumholz HM, Chan PS, for the American Heart Association Get with the Guidelines–Resuscitation Investigators. Trends in survival after in-hospital cardiac arrest.  N Engl J Med. 2012;367:1912-1920.
3. Morrison LJ, Neumar RW, Zimmerman JL, Link MS, Newby LK, McMullan PW Jr, Vanden Hoek T, Halverson CC, Doering L, Peberdy MA, Edelson DP; on behalf of the American Heart Association Emergency Cardiovascular Care Committee, Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Cardiovascular Nursing, Council on Clinical Cardiology, and Council on Peripheral Vascular Disease. Strategies for improving survival after in-hospital cardiac arrest in the United States: 2013 consensus recommendations: a consensus statement from the American Heart Association. Circulation. 2013: published online before print March 11, 2013, 10.1161/CIR.0b013e31828b2770
4. 4. Richardson DK, Zive D, Daya M, Newgard CD. The impact of early do not resuscitate (DNR) orders on patient care and outcomes following resuscitation from out of hospital cardiac arrest.  Resuscitation. 2012 Aug 30. doi:pii: S0300-9572(12)00750-2. 10.1016/j.resuscitation.2012.08.327.

-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --