ORIGINAL RESEARCH
Hospital Cardiac Arrest Resuscitation Practice in the United States: A Nationally Representative Survey Dana P. Edelson, MD, MS1*, Trevor C. Yuen, BA1, Mary E. Mancini, RN, PhD2, Daniel P. Davis, MD3, Elizabeth A. Hunt, MD, MPH, PhD4, Joseph A. Miller, MS5, Benjamin S. Abella, MD, MPhil6 1
Department of Medicine, University of Chicago, Chicago, Illinois; 2College of Nursing, University of Texas at Arlington, Arlington, Texas; 3Department of Emergency Medicine, University of California, San Diego, San Diego, California; 4Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; 5Society of Hospital Medicine, Philadelphia, Pennsylvania; 6Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
BACKGROUND: In-hospital cardiac arrest (IHCA) outcomes vary widely between hospitals, even after adjusting for patient characteristics, suggesting variations in practice as a potential etiology. However, little is known about the standards of IHCA resuscitation practice among US hospitals. OBJECTIVE: To describe current US hospital practices with regard to resuscitation care. DESIGN: A nationally representative mail survey. SETTING: A random sample of 1000 hospitals from the American Hospital Association database, stratified into 9 categories by hospital volume tertile and teaching status (major teaching, minor teaching, and nonteaching). SUBJECTS: Surveys were addressed to each hospital’s cardiopulmonary resuscitation (CPR) committee chair or chief medical/quality officer. MEASUREMENTS: A 27-item questionnaire.
An estimated 200,000 adult patients suffer cardiac arrest in US hospitals each year, of which 20.8 Similarly, CPR feedback devices have an even higher level of evidence recommendation in the 2010 AHA guidelines than capnography, yet only 4% of hospitals reported utilizing them. Although it is true that introducing these CPR assist technologies into a hospital would require some effort on the part of hospital leadership, it is important to recognize the potential role such devices might play in the larger context of a resuscitation quality program to optimize clinical outcomes from IHCA. Several differences were noted between hospitals based on teaching status. Although all hospitals were more likely to rely on physicians to lead resuscitations, nonteaching hospitals were more likely to report routine leadership by nurses and pharmacists. Nonteaching hospitals were also less likely to have a CPR committee, even after adjusting for hospital size. In addition, these hospitals were also more likely to report the lack of a clinical champion as a barrier to quality improvement. There were several limitations to this study. First, this was a descriptive survey that was not tied to outcomes. As such, we are unable to draw conclusions about which practices correlate with decreased incidence of cardiac arrest and improved survival. Second, this was an optional survey with a somewhat limited response rate. Even though the characteristics of the nonresponding hospitals were similar to the responding hospitals, we cannot rule out the possibility that a selection bias was introduced, which would likely overestimate adherence to the guidelines. Self-reported responses may have introduced additional errors. Finally, the short interval between the release of the 2010 guidelines and the administration of the first survey may have contributed to the variability in implementation of some practices, but many of the recommendations had been previously included in the 2005 guidelines. We conclude that there is wide variability between hospitals and within practices for resuscitation care. Future work should seek to understand which practices are associated with improved patient outcomes
An Official Publication of the Society of Hospital Medicine
| Edelson et al
and how best to implement these practices in a more uniform fashion. Acknowledgements The authors thank Nancy Hinckley, who championed the study; David Chearo, Christelle Marpaud, and Martha Van Haitsma of the University of Chicago Survey Lab for their assistance in formulating and distributing the survey; and JoAnne Resnic, Nicole Twu, and Frank Zadravecz for administrative support. Disclosures: This study was supported by the Society of Hospital Medicine with a grant from Philips Healthcare (Andover, MA). Dr. Edelson is supported by a career development award from the National Heart, Lung, and Blood Institute (K23 HL097157). In addition, she has received research support and honoraria from Philips Healthcare (Andover, MA), research support from the American Heart Association (Dallas, TX) and Laerdal Medical (Stavanger, Norway), and an honorarium from Early Sense (Tel Aviv, Israel). Dr. Hunt has received research support from the Laerdal Foundation for Acute Medicine (Stavanger, Norway), the Hartwell Foundation (Memphis, TN), and the Arthur Vining Davis Foundation (Jacksonville, FL), and honoraria from the Kansas University Endowment (Kansas City, KS), JCCC (Overland Park, KS), and the UVA School of Medicine (Charlottesville, VA) and the European School of Management (Berlin, Germany). Dr. Mancini is supported in part by an Agency for Healthcare Research and Quality grant (R18HS020416). In addition, she has received research support from the American Heart Association (Dallas, TX) and Laerdal Medical (Stavanger, Norway), and honoraria from Sotera Wireless, Inc. (San Diego, CA). Dr. Abella has received research support from the National Institutes of Health (NIH), Medtronic Foundation (Minneapolis, MN), and Philips Healthcare (Andover, MA); has volunteered with the American Heart Association; and received honoraria from Heartsine (Belfast, Ireland), Velomedix (Menlo Park, CA), and Stryker (Kalamazoo, MI). Mr. Miller is employed by the Society of Hospital Medicine.
References 1. Girotra S, Nallamothu BK, Spertus JA, Li Y, Krumholz HM, Chan PS. Trends in survival after in-hospital cardiac arrest. N Engl J Med. 2012;367(20):1912–1920. 2. Merchant RM, Yang L, Becker LB, et al. Incidence of treated cardiac arrest in hospitalized patients in the United States. Crit Care Med. 2011;39(11):2401–2406. 3. Chan PS, Nichol G, Krumholz HM, et al. Racial differences in survival after in-hospital cardiac arrest. JAMA. 2009;302(11):1195–1201. 4. Chan PS, Nichol G, Krumholz HM, Spertus JA, Nallamothu BK. Hospital variation in time to defibrillation after in-hospital cardiac arrest. Arch Intern Med. 2009;169(14):1265–1273. 5. Goldberger ZD, Chan PS, Berg RA, et al. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study. Lancet. 2012;380(9852):1473–1481. 6. Chan PS, Krumholz HM, Nichol G, Nallamothu BK. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008; 358(1):9–17. 7. 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care science. Circulation. 2010;122(18 suppl 3):S640–S946. 8. Meaney PA, Bobrow BJ, Mancini ME, et al. Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation. 2013;128(4):417–435. 9. American Hospital Association. 2008 AHA annual survey. AHA data viewer: survey instruments. 2012; Available at: http://www.ahadataviewer.com/about/hospital-database. Accessed October 11, 2013. 10. The American Association for Public Opinion Research. Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys. 7th ed. Deerfield, IL: AAPOR; 2011. 11. Lomas J, Anderson GM, Domnick-Pierre K, Vayda E, Enkin MW, Hannah WJ. Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians. N Engl J Med. 1989;321(19):1306–1311. 12. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282(15):1458–1465. 13. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 2003;362(9391): 1225–1230. 14. Gabbott D, Smith G, Mitchell S, et al. Cardiopulmonary resuscitation standards for clinical practice and training in the UK. Accid Emerg Nurs. 2005;13(3):171–179.
Journal of Hospital Medicine Vol 9 | No 6 | June 2014
357
Hospital Cardiac Arrest Resuscitation Practice in the United States: A Nationally Representative Survey Dana P. Edelson, MD, MS1*, Trevor C. Yuen, BA1, Mary E. Mancini, RN, PhD2, Daniel P. Davis, MD3, Elizabeth A. Hunt, MD, MPH, PhD4, Joseph A. Miller, MS5, Benjamin S. Abella, MD, MPhil6 1
Department of Medicine, University of Chicago, Chicago, Illinois; 2College of Nursing, University of Texas at Arlington, Arlington, Texas; 3Department of Emergency Medicine, University of California, San Diego, San Diego, California; 4Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; 5Society of Hospital Medicine, Philadelphia, Pennsylvania; 6Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
BACKGROUND: In-hospital cardiac arrest (IHCA) outcomes vary widely between hospitals, even after adjusting for patient characteristics, suggesting variations in practice as a potential etiology. However, little is known about the standards of IHCA resuscitation practice among US hospitals. OBJECTIVE: To describe current US hospital practices with regard to resuscitation care. DESIGN: A nationally representative mail survey. SETTING: A random sample of 1000 hospitals from the American Hospital Association database, stratified into 9 categories by hospital volume tertile and teaching status (major teaching, minor teaching, and nonteaching). SUBJECTS: Surveys were addressed to each hospital’s cardiopulmonary resuscitation (CPR) committee chair or chief medical/quality officer. MEASUREMENTS: A 27-item questionnaire.
An estimated 200,000 adult patients suffer cardiac arrest in US hospitals each year, of which 20.8 Similarly, CPR feedback devices have an even higher level of evidence recommendation in the 2010 AHA guidelines than capnography, yet only 4% of hospitals reported utilizing them. Although it is true that introducing these CPR assist technologies into a hospital would require some effort on the part of hospital leadership, it is important to recognize the potential role such devices might play in the larger context of a resuscitation quality program to optimize clinical outcomes from IHCA. Several differences were noted between hospitals based on teaching status. Although all hospitals were more likely to rely on physicians to lead resuscitations, nonteaching hospitals were more likely to report routine leadership by nurses and pharmacists. Nonteaching hospitals were also less likely to have a CPR committee, even after adjusting for hospital size. In addition, these hospitals were also more likely to report the lack of a clinical champion as a barrier to quality improvement. There were several limitations to this study. First, this was a descriptive survey that was not tied to outcomes. As such, we are unable to draw conclusions about which practices correlate with decreased incidence of cardiac arrest and improved survival. Second, this was an optional survey with a somewhat limited response rate. Even though the characteristics of the nonresponding hospitals were similar to the responding hospitals, we cannot rule out the possibility that a selection bias was introduced, which would likely overestimate adherence to the guidelines. Self-reported responses may have introduced additional errors. Finally, the short interval between the release of the 2010 guidelines and the administration of the first survey may have contributed to the variability in implementation of some practices, but many of the recommendations had been previously included in the 2005 guidelines. We conclude that there is wide variability between hospitals and within practices for resuscitation care. Future work should seek to understand which practices are associated with improved patient outcomes
An Official Publication of the Society of Hospital Medicine
| Edelson et al
and how best to implement these practices in a more uniform fashion. Acknowledgements The authors thank Nancy Hinckley, who championed the study; David Chearo, Christelle Marpaud, and Martha Van Haitsma of the University of Chicago Survey Lab for their assistance in formulating and distributing the survey; and JoAnne Resnic, Nicole Twu, and Frank Zadravecz for administrative support. Disclosures: This study was supported by the Society of Hospital Medicine with a grant from Philips Healthcare (Andover, MA). Dr. Edelson is supported by a career development award from the National Heart, Lung, and Blood Institute (K23 HL097157). In addition, she has received research support and honoraria from Philips Healthcare (Andover, MA), research support from the American Heart Association (Dallas, TX) and Laerdal Medical (Stavanger, Norway), and an honorarium from Early Sense (Tel Aviv, Israel). Dr. Hunt has received research support from the Laerdal Foundation for Acute Medicine (Stavanger, Norway), the Hartwell Foundation (Memphis, TN), and the Arthur Vining Davis Foundation (Jacksonville, FL), and honoraria from the Kansas University Endowment (Kansas City, KS), JCCC (Overland Park, KS), and the UVA School of Medicine (Charlottesville, VA) and the European School of Management (Berlin, Germany). Dr. Mancini is supported in part by an Agency for Healthcare Research and Quality grant (R18HS020416). In addition, she has received research support from the American Heart Association (Dallas, TX) and Laerdal Medical (Stavanger, Norway), and honoraria from Sotera Wireless, Inc. (San Diego, CA). Dr. Abella has received research support from the National Institutes of Health (NIH), Medtronic Foundation (Minneapolis, MN), and Philips Healthcare (Andover, MA); has volunteered with the American Heart Association; and received honoraria from Heartsine (Belfast, Ireland), Velomedix (Menlo Park, CA), and Stryker (Kalamazoo, MI). Mr. Miller is employed by the Society of Hospital Medicine.
References 1. Girotra S, Nallamothu BK, Spertus JA, Li Y, Krumholz HM, Chan PS. Trends in survival after in-hospital cardiac arrest. N Engl J Med. 2012;367(20):1912–1920. 2. Merchant RM, Yang L, Becker LB, et al. Incidence of treated cardiac arrest in hospitalized patients in the United States. Crit Care Med. 2011;39(11):2401–2406. 3. Chan PS, Nichol G, Krumholz HM, et al. Racial differences in survival after in-hospital cardiac arrest. JAMA. 2009;302(11):1195–1201. 4. Chan PS, Nichol G, Krumholz HM, Spertus JA, Nallamothu BK. Hospital variation in time to defibrillation after in-hospital cardiac arrest. Arch Intern Med. 2009;169(14):1265–1273. 5. Goldberger ZD, Chan PS, Berg RA, et al. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study. Lancet. 2012;380(9852):1473–1481. 6. Chan PS, Krumholz HM, Nichol G, Nallamothu BK. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008; 358(1):9–17. 7. 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care science. Circulation. 2010;122(18 suppl 3):S640–S946. 8. Meaney PA, Bobrow BJ, Mancini ME, et al. Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation. 2013;128(4):417–435. 9. American Hospital Association. 2008 AHA annual survey. AHA data viewer: survey instruments. 2012; Available at: http://www.ahadataviewer.com/about/hospital-database. Accessed October 11, 2013. 10. The American Association for Public Opinion Research. Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys. 7th ed. Deerfield, IL: AAPOR; 2011. 11. Lomas J, Anderson GM, Domnick-Pierre K, Vayda E, Enkin MW, Hannah WJ. Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians. N Engl J Med. 1989;321(19):1306–1311. 12. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282(15):1458–1465. 13. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 2003;362(9391): 1225–1230. 14. Gabbott D, Smith G, Mitchell S, et al. Cardiopulmonary resuscitation standards for clinical practice and training in the UK. Accid Emerg Nurs. 2005;13(3):171–179.
Journal of Hospital Medicine Vol 9 | No 6 | June 2014
357
