Hospitals vary in care quality when treating patients for in-hospital cardiac arrest

An analysis of patients with in-hospital cardiac arrest found those treated at hospitals that had greater adherence to guideline-recommended therapies had higher survival rates. The researchers also observed that there was a significant variation in the quality of care at U.S. hospitals.

If all hospitals had the same quality of care standards as the best performing hospitals, an additional 22,900 to 24,200 lives could be saved, according to the researchers. They defined in-hospital cardiac arrest as apnea, unresponsiveness and lack of a palpable central pulse.

Lead researcher Monique L. Anderson, MD, of the Duke Clinical Research Institute in Durham, N.C., and colleagues published their results online in JAMA Cardiology on Feb. 24.

“Significant opportunities remain for improving adherence to guideline-recommended care overall and with individual process-of-care measures,” they wrote. “Of importance, enhancing process quality of care may improve outcomes for the many patients with [in-hospital cardiac arrest].”

The researchers mentioned that the American Heart Association (AHA) released a consensus statement identifying several strategies to improve survival from in-hospital cardiac arrest. They added that more than 200,000 patients each year are treated for in-hospital cardiac arrest in the U.S.

They obtained data from the AHA’s Get With the Guidelines-Resuscitation program, an ongoing, prospective, hospital-based registry and quality improvement program for patients with in-hospital cardiac arrest.

The analysis included 35,283 adults from 261 U.S. hospitals who participated in the program from Jan. 1, 2010, through Dec. 31, 2012. The researchers excluded facilities that had fewer than 20 admissions and had participated in the program for less than a year. They also excluded cardiac arrests that occurred in operating rooms, procedural suites and the emergency department.

Anderson and colleagues evaluated five AHA/American College of Cardiology guideline-recommended acute care process measures: device confirmation of correct endotracheal tube placement; a monitored or witnessed cardiac arrest event; time to first chest compression less than or equal to one minute; time to first defibrillation delivered at less than or equal to two minutes for ventricular tachycardia or ventricular fibrillation; and administration of epinephrine or vasopressin for pulseless events within five minutes.

The median hospital process composite performance score was 89.7 percent, but it varied significantly with a range from 47.6 percent to 94.2 percent. The researchers calculated the hospital process composite performance scores using opportunity-based scoring, which they defined as the sum of correct care divided by total care opportunities.

Hospitals in the highest quartile for process composite performance had significantly higher adherence rates to each of the individual guideline-recommended acute care process measures compared with hospitals in the three other quartiles.

The researchers noted that the greatest increase and difference in the quartiles were in the confirmation of endotracheal tube placement and first defibrillation shock at two minutes for ventricular tachycardia or ventricular fibrillation. The least variance between quartiles was found in the monitored or witnessed cardiac events and the time to first compression of one minute or less.

After making adjustments, the researchers said a 10 percent increase in a hospital’s process composite performance was associated with 22 percent higher odds of survival. They added that the hospital process composite quality performance was associated with favorable neurologic status at hospital discharge.

The study had a few limitations, according to the researchers, including that it was an observational study that could not determine causation between process-of-care measures and outcomes. They also mentioned that hospitals volunteer to participate in the AHA’s Get With the Guidelines-Resuscitation program, so they may be more interested than other hospitals in improving the quality of care.

In addition, they only included five guideline-recommended process measures and acknowledged other measures may be more or less associated with survival and neurologic outcomes. Further, they said their data had a cross-sectional association between adherence to process quality and outcomes and that a longitudinal study that accounted for changes in hospital process performance was needed to establish an association between quality and outcomes.