Daniel P. Davis, MD

We appreciate the opportunity to continue dialogue regarding the optimal timing of defibrillation, standardized guidelines, and healthy skepticism as to whether they apply to all settings and patient populations. The transition to a single shock followed by resumption of chest compressions over 3 stacked shocks represents the integration of 2 concepts into a single algorithm.[1] The first reflects concern about delays in chest compressions related to rhythm analysis and charge of an automated external defibrillator. This justified a single shock followed by chest compressions to avoid unnecessary pauses. The same guidelines also recommended 2 minutes of cardiopulmonary resuscitation (CPR) prior to the initial and each subsequent defibrillation attempt, providing substrate to the myocardium and increasing the likelihood of shock success.[2, 3, 4] The underlying physiological concept is described by Weisfeldt and Becker as part of their 3‐phase model of ventricular fibrillation.[2, 5] Large randomized out‐of‐hospital studies have demonstrated that high‐quality CPR may prime the heart before defibrillation, as suggested by the 3‐phase model.[6, 7, 8]

Regardless of the theoretical construct(s) upon which the original recommendations were based, we agree with Mr. Stewart that these are misapplied to the inpatient setting that allow for expeditious attempts at defibrillation and stacking of subsequent attempts.

We appreciate the opportunity to continue dialogue regarding the optimal timing of defibrillation, standardized guidelines, and healthy skepticism as to whether they apply to all settings and patient populations. The transition to a single shock followed by resumption of chest compressions over 3 stacked shocks represents the integration of 2 concepts into a single algorithm.[1] The first reflects concern about delays in chest compressions related to rhythm analysis and charge of an automated external defibrillator. This justified a single shock followed by chest compressions to avoid unnecessary pauses. The same guidelines also recommended 2 minutes of cardiopulmonary resuscitation (CPR) prior to the initial and each subsequent defibrillation attempt, providing substrate to the myocardium and increasing the likelihood of shock success.[2, 3, 4] The underlying physiological concept is described by Weisfeldt and Becker as part of their 3‐phase model of ventricular fibrillation.[2, 5] Large randomized out‐of‐hospital studies have demonstrated that high‐quality CPR may prime the heart before defibrillation, as suggested by the 3‐phase model.[6, 7, 8]

Regardless of the theoretical construct(s) upon which the original recommendations were based, we agree with Mr. Stewart that these are misapplied to the inpatient setting that allow for expeditious attempts at defibrillation and stacking of subsequent attempts.

We appreciate the opportunity to continue dialogue regarding the optimal timing of defibrillation, standardized guidelines, and healthy skepticism as to whether they apply to all settings and patient populations. The transition to a single shock followed by resumption of chest compressions over 3 stacked shocks represents the integration of 2 concepts into a single algorithm.[1] The first reflects concern about delays in chest compressions related to rhythm analysis and charge of an automated external defibrillator. This justified a single shock followed by chest compressions to avoid unnecessary pauses. The same guidelines also recommended 2 minutes of cardiopulmonary resuscitation (CPR) prior to the initial and each subsequent defibrillation attempt, providing substrate to the myocardium and increasing the likelihood of shock success.[2, 3, 4] The underlying physiological concept is described by Weisfeldt and Becker as part of their 3‐phase model of ventricular fibrillation.[2, 5] Large randomized out‐of‐hospital studies have demonstrated that high‐quality CPR may prime the heart before defibrillation, as suggested by the 3‐phase model.[6, 7, 8]

Regardless of the theoretical construct(s) upon which the original recommendations were based, we agree with Mr. Stewart that these are misapplied to the inpatient setting that allow for expeditious attempts at defibrillation and stacking of subsequent attempts.

Cardiopulmonary arrest (CPA) is a major cause of morbidity and mortality, both in the out‐of‐hospital environment as well as the inpatient setting.[1, 2] Unlike the out‐of‐hospital environment, inpatient CPA is unique in that healthcare providers are present during the prearrest period. In theory, this allows the opportunity to intervene and potentially prevent arrest. However, multiple investigators have demonstrated that the vast majority of inpatient CPA victims demonstrate abnormal vital signs prior to arrest without antecedent therapeutic intervention.[3, 4, 5]

Rapid response teams (RRTs) were created to institutionalize the response to at‐risk patients based on chief complaint or vital sign abnormalities. Early evaluation by a critical care team and initiation of appropriate therapy based on defined activation criteria should prevent deterioration in a substantial portion of patients at risk for CPA. Unfortunately, RRTs have not consistently demonstrated improved outcomes on the incidence of CPA and hospital mortality.[6, 7, 8, 9, 10, 11, 12, 13, 14] Although some investigators have reported a decrease in nonintensive care unit (ICU) arrests, it has been posited that this finding appears to be highly associated with either an increase in ICU arrests or more aggressive do not attempt resuscitation (DNAR) orders.[8]

Another potential explanation is an absence of training models that focus on the primary inpatient healthcare providers who are directly responsible for the afferent portion of an RRT program. Here we describe our experience with a novel RRT curriculum, in which unit managers (ie, charge nurse) play an essential role, and substantial education is directed toward primary responders such as bedside nurses and respiratory therapists. This approach is implemented through our novel resuscitation curriculum, which represents a comprehensive approach to inpatient resuscitation management built around critical links between continuous quality improvement (CQI) data, training, and special initiatives.

METHODS

RESULTS

Starting preimplementation year 2006 through postimplementation years 2007 to 2011, the incidence of non‐ICU CPA decreased from 2.7 to 1.1 arrests per 1000 discharges (P<0.0001). The incidence of ICU CPA remained unchanged following program implementation (P=0.532) (Figure 1). Overall hospital mortality also decreased over the study period 2006 to 2011 (2.12%1.74%, P<0.001) (Figure 2). Overall hospital CMI for fiscal years 2005/2006 through 2011/2012 were significantly different (1.47 vs 1.67, P<0.0001). No difference was observed in the pre‐ and postimplementation period likelihood of DNAR status among nonsurvivors with initial return of spontaneous circulation at the time of CPA resuscitation (76% vs 75%, P=0.841).

Figure 1

Figure 2

Starting fiscal year 2005to 2011, there were a total of 546 total CPAs with 247 non‐ICU CPAs observed between both hospital systems. Since its implementation starting at Q3 of 2007, a total of 1729 RRT activations throughout all inpatient areas were observed through 2011. The overall relationship between Code Blue activations starting July 2005 and the RRT since its implementation is displayed in Figure 3. No relationship was detected between the number of Code Blue and RRT activations on each unit (r=0.17, P=0.242). However, the year‐over‐year (fiscal years 2007/20082008/2009) change in RRT activations for each unit was inversely related to the change in Code Blue activations; the individual units with an increase in RRT activations experienced a decrease in Code Blue activations, and units with a decrease in RRT activations experienced an increase in Code Blue activations (r=0.68, P<0.001) (Figure 4).

Figure 3

Figure 4

The time per RRT activation appeared to stabilize after the first program year, whereas the number of RRT activations per month has increased over time. The RRT activation etiologies based on chief complaint reported to the RRT nurse are displayed in Figure 5. Only 3% of activations resulted in no intervention; most of these represented seizures that resolved prior to RRT arrival or syncope episodes for noninpatients. The most common interventions were airway management (27%), fluid therapy (18%), and respiratory treatments (15%). The vast majority of patients (99%) survived the RRT response. A total of 56% of RRT activations resulted in disposition to a higher level of care (43% upgraded to ICU status, 13% upgraded to intermediate care unit status), whereas the remaining 44% of patients stayed on their original unit.

Figure 5

DISCUSSION

One of the primary rationales for hospital admission is the ability to observe and monitor patients to identify deterioration and prevent CPA. Thus, the failure of RRT programs to consistently demonstrate improvements in overall hospital mortality is somewhat perplexing. Here we present 4 years of data starting at the initiation of our RRT program. During our period of observation, we noted a significant inverse relationship between the activations of the RRT and incidence of CPA. Additionally, we noticed a significant decrease in non‐ICU arrests and in overall hospital mortality that appears to be associated with initiation of our novel RRT (Figures 1 and 2, respectively). In postintervention year 1, the unadjusted implementation of our RRT was associated with approximately 57% of the improvement of in‐hospital mortality. We noted a decrease of non‐ICU mortality from 45 deaths in fiscal year 2006 to 2007 to 21 deaths in fiscal year 2007 to 2008. Additionally, the number of non‐ICU Code Blue activations also declined during this period, from 56 to 34, with a survival to hospital discharge rate of 38% (fiscal year 2007 to 2008). In the second full year postimplementation, the activation of the RRT appears to be associated with a similar amount of reduction in in‐hospital mortality (52%) (see Supporting Table 2 in the online version of this article). We do not believe that initiation of our novel RRT accounts for all the variance in reduction of overall mortality. However, we posit that much of our success likely reflects our unique combined approach to a multifaceted life‐support training curriculum. Finally, though not statistically investigated, RRT activation etiology appears to be relatively uniform with respiratory, suspected cardiovascular, and clinical intuition accounting for a large majority of activations through the study period (Figure 5).

Multiple potential explanations exist to account for the lack of outcomes data to fully support RRT programs, with a failure to follow published RRT activation guidelines listed as a key factor.[7, 8, 19] It is unclear whether this reflects inconsistent activation protocols, as many hospitals lack specific published guidelines, whereas others may have more have rigid protocols. Another consideration is possible reluctance to activate a specialized team by primary in‐hospital caregivers due in part to intimidation or a lack of specific training. Interestingly, the routine presence of a physician with RRT activations has been postulated to be inhibitory in this regard and result in critical delays to resuscitative care.[20, 21, 22]

The vast majority of our RRT activations survived the initial response. This is an important metric not only for determining the competency of RRT providers in initiating therapies but also reflects the willingness of inpatient staff to activate RRT early in the course of a patient's deterioration, as delayed activation has been previously associated with increased mortality.[23, 24, 25] The relatively high RRT survival rate could be interpreted as reflecting some degree of overactivation. Of note, based upon hospital CMI, overall patient acuity appeared to continuously increase during and after the observation period. However, the incidence of RRT activations in which no therapies were initiated was extremely low, and more than half of patients were transferred to a higher level of care. We posit that benchmarking such metrics in the future may help institutions guide their resuscitation programs.

Our current RRT configuration of a dedicated critical care trained nurse and respiratory therapist plus unit manager (ie, charge nurse) is a departure from the traditional RRT historically consisting of a dedicated critical care trained nurse and/or respiratory therapist, and physician(s).[26] Perhaps more important than team configuration is our novel concept of individual unit managers regularly rounding on their own most at‐risk patients, which may add a layer of familiarity and increased likelihood of identifying even subtle changes associated with eventual decompensation. Unfortunately, we did not assess the charge nurse decision‐making process regarding RRT activation. This approach differs from Gerdik et al., who have demonstrated a positive association with the ability of the patient and/or family to activate the RRT. [27] Though similar, our approach also differs from the strategy of a dedicated RRT nurse rounding on high risk patients identified through physician and nurse surveys that have also shown a significant reduction in admission deaths.[26, 28, 29] Although the strategies may differ on the specific team members initiating the deployment of the RRT, what they appear to have in common is the proactive component of the identification of at‐risk patients. Additionally, we employ an annual RRT educational seminar for potential primary responders including bedside nurses, respiratory therapists, and physical therapists. Our novel resuscitation program and RRT education allows modulation of the life‐support curriculum to emphasize the importance of early recognition and response to at‐risk patients based upon our activation criteria and evaluation of activation trends (see Supporting Table 1 in the online version of this article). Finally, the presence of the charge nurse as part of the RRT is important, not only as part of the afferent arm of the program but also to enhance unit responsibility for detecting deterioration. It is our belief that an aggressive resuscitation CQI program with efferent links to unit managers amplifies the perception of ownership by primary providers and enhances the culture of resuscitation.

A lack of understanding as to the etiology of CPA in the inpatient environment may also limit the effectiveness of protocol and monitoring strategies. Our current resuscitation program places great emphasis on the taxonomy of our in‐hospital cardiac arrests and classifying inpatient events to help guide CQI efforts. These classifications provide a scaffolding for life‐support education and can result in changes to treatment algorithms or initiate new programs to target particular patient populations. An example includes the implementation of respiratory monitoring strategies in perioperative patients at high risk for obstructive sleep apnea.

Several limitations to this analysis must be considered. The study was not a randomized prospective trial and lacks internal validation. The before‐and‐after study was limited by the inclusion of only 1 complete preimplementation year (2006), which may have introduced a bias related to the inherent inability to properly evaluate secular trends. As such, this study cannot compare the relative effectiveness of our novel RRT participants and curriculum versus the traditional RRTs previously described.[26] Additionally, we also excluded data from both the emergency department and operating arena. Both are reported to have overall higher survival rates due to differences in arrest etiology, monitoring, anticipation, and available personal.[30, 31] We used CMI coefficients to explore the possibility of a decrease in patient acuity during the study. However, we noticed an increasing case‐mix coefficient value suggesting higher patient acuity, which would predict increased mortality rather than the decrease we observed.

One must also consider how the introduction of an RRT may increase DNAR orders and subsequently affect overall mortality by artificially lowering it.[32] Trends in DNAR during our period of observation were not significantly different. However, if an increase in DNAR orders did artificially improve non‐ICU CPA outcomes, one would expect unchanged or increased overall hospital mortality. In contrast, we found improvement in all outcomes including overall hospital mortality (Figure 2).

CONCLUSIONS

Our novel RRT program, with an emphasis on inclusion of non‐ICU charge nurses as part of the team and universal RRT education integrated within life support training, appears to be effective at decreasing the incidence of non‐ICU CPA and overall hospital mortality.

Disclosure: Nothing to report.

Cardiopulmonary arrest (CPA) is a major cause of morbidity and mortality, both in the out‐of‐hospital environment as well as the inpatient setting.[1, 2] Unlike the out‐of‐hospital environment, inpatient CPA is unique in that healthcare providers are present during the prearrest period. In theory, this allows the opportunity to intervene and potentially prevent arrest. However, multiple investigators have demonstrated that the vast majority of inpatient CPA victims demonstrate abnormal vital signs prior to arrest without antecedent therapeutic intervention.[3, 4, 5]

Rapid response teams (RRTs) were created to institutionalize the response to at‐risk patients based on chief complaint or vital sign abnormalities. Early evaluation by a critical care team and initiation of appropriate therapy based on defined activation criteria should prevent deterioration in a substantial portion of patients at risk for CPA. Unfortunately, RRTs have not consistently demonstrated improved outcomes on the incidence of CPA and hospital mortality.[6, 7, 8, 9, 10, 11, 12, 13, 14] Although some investigators have reported a decrease in nonintensive care unit (ICU) arrests, it has been posited that this finding appears to be highly associated with either an increase in ICU arrests or more aggressive do not attempt resuscitation (DNAR) orders.[8]

Another potential explanation is an absence of training models that focus on the primary inpatient healthcare providers who are directly responsible for the afferent portion of an RRT program. Here we describe our experience with a novel RRT curriculum, in which unit managers (ie, charge nurse) play an essential role, and substantial education is directed toward primary responders such as bedside nurses and respiratory therapists. This approach is implemented through our novel resuscitation curriculum, which represents a comprehensive approach to inpatient resuscitation management built around critical links between continuous quality improvement (CQI) data, training, and special initiatives.

METHODS

RESULTS

Starting preimplementation year 2006 through postimplementation years 2007 to 2011, the incidence of non‐ICU CPA decreased from 2.7 to 1.1 arrests per 1000 discharges (P<0.0001). The incidence of ICU CPA remained unchanged following program implementation (P=0.532) (Figure 1). Overall hospital mortality also decreased over the study period 2006 to 2011 (2.12%1.74%, P<0.001) (Figure 2). Overall hospital CMI for fiscal years 2005/2006 through 2011/2012 were significantly different (1.47 vs 1.67, P<0.0001). No difference was observed in the pre‐ and postimplementation period likelihood of DNAR status among nonsurvivors with initial return of spontaneous circulation at the time of CPA resuscitation (76% vs 75%, P=0.841).

Figure 1

Figure 2

Starting fiscal year 2005to 2011, there were a total of 546 total CPAs with 247 non‐ICU CPAs observed between both hospital systems. Since its implementation starting at Q3 of 2007, a total of 1729 RRT activations throughout all inpatient areas were observed through 2011. The overall relationship between Code Blue activations starting July 2005 and the RRT since its implementation is displayed in Figure 3. No relationship was detected between the number of Code Blue and RRT activations on each unit (r=0.17, P=0.242). However, the year‐over‐year (fiscal years 2007/20082008/2009) change in RRT activations for each unit was inversely related to the change in Code Blue activations; the individual units with an increase in RRT activations experienced a decrease in Code Blue activations, and units with a decrease in RRT activations experienced an increase in Code Blue activations (r=0.68, P<0.001) (Figure 4).

Figure 3

Figure 4

The time per RRT activation appeared to stabilize after the first program year, whereas the number of RRT activations per month has increased over time. The RRT activation etiologies based on chief complaint reported to the RRT nurse are displayed in Figure 5. Only 3% of activations resulted in no intervention; most of these represented seizures that resolved prior to RRT arrival or syncope episodes for noninpatients. The most common interventions were airway management (27%), fluid therapy (18%), and respiratory treatments (15%). The vast majority of patients (99%) survived the RRT response. A total of 56% of RRT activations resulted in disposition to a higher level of care (43% upgraded to ICU status, 13% upgraded to intermediate care unit status), whereas the remaining 44% of patients stayed on their original unit.

Figure 5

DISCUSSION

One of the primary rationales for hospital admission is the ability to observe and monitor patients to identify deterioration and prevent CPA. Thus, the failure of RRT programs to consistently demonstrate improvements in overall hospital mortality is somewhat perplexing. Here we present 4 years of data starting at the initiation of our RRT program. During our period of observation, we noted a significant inverse relationship between the activations of the RRT and incidence of CPA. Additionally, we noticed a significant decrease in non‐ICU arrests and in overall hospital mortality that appears to be associated with initiation of our novel RRT (Figures 1 and 2, respectively). In postintervention year 1, the unadjusted implementation of our RRT was associated with approximately 57% of the improvement of in‐hospital mortality. We noted a decrease of non‐ICU mortality from 45 deaths in fiscal year 2006 to 2007 to 21 deaths in fiscal year 2007 to 2008. Additionally, the number of non‐ICU Code Blue activations also declined during this period, from 56 to 34, with a survival to hospital discharge rate of 38% (fiscal year 2007 to 2008). In the second full year postimplementation, the activation of the RRT appears to be associated with a similar amount of reduction in in‐hospital mortality (52%) (see Supporting Table 2 in the online version of this article). We do not believe that initiation of our novel RRT accounts for all the variance in reduction of overall mortality. However, we posit that much of our success likely reflects our unique combined approach to a multifaceted life‐support training curriculum. Finally, though not statistically investigated, RRT activation etiology appears to be relatively uniform with respiratory, suspected cardiovascular, and clinical intuition accounting for a large majority of activations through the study period (Figure 5).

Multiple potential explanations exist to account for the lack of outcomes data to fully support RRT programs, with a failure to follow published RRT activation guidelines listed as a key factor.[7, 8, 19] It is unclear whether this reflects inconsistent activation protocols, as many hospitals lack specific published guidelines, whereas others may have more have rigid protocols. Another consideration is possible reluctance to activate a specialized team by primary in‐hospital caregivers due in part to intimidation or a lack of specific training. Interestingly, the routine presence of a physician with RRT activations has been postulated to be inhibitory in this regard and result in critical delays to resuscitative care.[20, 21, 22]

The vast majority of our RRT activations survived the initial response. This is an important metric not only for determining the competency of RRT providers in initiating therapies but also reflects the willingness of inpatient staff to activate RRT early in the course of a patient's deterioration, as delayed activation has been previously associated with increased mortality.[23, 24, 25] The relatively high RRT survival rate could be interpreted as reflecting some degree of overactivation. Of note, based upon hospital CMI, overall patient acuity appeared to continuously increase during and after the observation period. However, the incidence of RRT activations in which no therapies were initiated was extremely low, and more than half of patients were transferred to a higher level of care. We posit that benchmarking such metrics in the future may help institutions guide their resuscitation programs.

Our current RRT configuration of a dedicated critical care trained nurse and respiratory therapist plus unit manager (ie, charge nurse) is a departure from the traditional RRT historically consisting of a dedicated critical care trained nurse and/or respiratory therapist, and physician(s).[26] Perhaps more important than team configuration is our novel concept of individual unit managers regularly rounding on their own most at‐risk patients, which may add a layer of familiarity and increased likelihood of identifying even subtle changes associated with eventual decompensation. Unfortunately, we did not assess the charge nurse decision‐making process regarding RRT activation. This approach differs from Gerdik et al., who have demonstrated a positive association with the ability of the patient and/or family to activate the RRT. [27] Though similar, our approach also differs from the strategy of a dedicated RRT nurse rounding on high risk patients identified through physician and nurse surveys that have also shown a significant reduction in admission deaths.[26, 28, 29] Although the strategies may differ on the specific team members initiating the deployment of the RRT, what they appear to have in common is the proactive component of the identification of at‐risk patients. Additionally, we employ an annual RRT educational seminar for potential primary responders including bedside nurses, respiratory therapists, and physical therapists. Our novel resuscitation program and RRT education allows modulation of the life‐support curriculum to emphasize the importance of early recognition and response to at‐risk patients based upon our activation criteria and evaluation of activation trends (see Supporting Table 1 in the online version of this article). Finally, the presence of the charge nurse as part of the RRT is important, not only as part of the afferent arm of the program but also to enhance unit responsibility for detecting deterioration. It is our belief that an aggressive resuscitation CQI program with efferent links to unit managers amplifies the perception of ownership by primary providers and enhances the culture of resuscitation.

A lack of understanding as to the etiology of CPA in the inpatient environment may also limit the effectiveness of protocol and monitoring strategies. Our current resuscitation program places great emphasis on the taxonomy of our in‐hospital cardiac arrests and classifying inpatient events to help guide CQI efforts. These classifications provide a scaffolding for life‐support education and can result in changes to treatment algorithms or initiate new programs to target particular patient populations. An example includes the implementation of respiratory monitoring strategies in perioperative patients at high risk for obstructive sleep apnea.

Several limitations to this analysis must be considered. The study was not a randomized prospective trial and lacks internal validation. The before‐and‐after study was limited by the inclusion of only 1 complete preimplementation year (2006), which may have introduced a bias related to the inherent inability to properly evaluate secular trends. As such, this study cannot compare the relative effectiveness of our novel RRT participants and curriculum versus the traditional RRTs previously described.[26] Additionally, we also excluded data from both the emergency department and operating arena. Both are reported to have overall higher survival rates due to differences in arrest etiology, monitoring, anticipation, and available personal.[30, 31] We used CMI coefficients to explore the possibility of a decrease in patient acuity during the study. However, we noticed an increasing case‐mix coefficient value suggesting higher patient acuity, which would predict increased mortality rather than the decrease we observed.

One must also consider how the introduction of an RRT may increase DNAR orders and subsequently affect overall mortality by artificially lowering it.[32] Trends in DNAR during our period of observation were not significantly different. However, if an increase in DNAR orders did artificially improve non‐ICU CPA outcomes, one would expect unchanged or increased overall hospital mortality. In contrast, we found improvement in all outcomes including overall hospital mortality (Figure 2).

CONCLUSIONS

Our novel RRT program, with an emphasis on inclusion of non‐ICU charge nurses as part of the team and universal RRT education integrated within life support training, appears to be effective at decreasing the incidence of non‐ICU CPA and overall hospital mortality.

Disclosure: Nothing to report.

Cardiopulmonary arrest (CPA) is a major cause of morbidity and mortality, both in the out‐of‐hospital environment as well as the inpatient setting.[1, 2] Unlike the out‐of‐hospital environment, inpatient CPA is unique in that healthcare providers are present during the prearrest period. In theory, this allows the opportunity to intervene and potentially prevent arrest. However, multiple investigators have demonstrated that the vast majority of inpatient CPA victims demonstrate abnormal vital signs prior to arrest without antecedent therapeutic intervention.[3, 4, 5]

Rapid response teams (RRTs) were created to institutionalize the response to at‐risk patients based on chief complaint or vital sign abnormalities. Early evaluation by a critical care team and initiation of appropriate therapy based on defined activation criteria should prevent deterioration in a substantial portion of patients at risk for CPA. Unfortunately, RRTs have not consistently demonstrated improved outcomes on the incidence of CPA and hospital mortality.[6, 7, 8, 9, 10, 11, 12, 13, 14] Although some investigators have reported a decrease in nonintensive care unit (ICU) arrests, it has been posited that this finding appears to be highly associated with either an increase in ICU arrests or more aggressive do not attempt resuscitation (DNAR) orders.[8]

Another potential explanation is an absence of training models that focus on the primary inpatient healthcare providers who are directly responsible for the afferent portion of an RRT program. Here we describe our experience with a novel RRT curriculum, in which unit managers (ie, charge nurse) play an essential role, and substantial education is directed toward primary responders such as bedside nurses and respiratory therapists. This approach is implemented through our novel resuscitation curriculum, which represents a comprehensive approach to inpatient resuscitation management built around critical links between continuous quality improvement (CQI) data, training, and special initiatives.

METHODS

RESULTS

Starting preimplementation year 2006 through postimplementation years 2007 to 2011, the incidence of non‐ICU CPA decreased from 2.7 to 1.1 arrests per 1000 discharges (P<0.0001). The incidence of ICU CPA remained unchanged following program implementation (P=0.532) (Figure 1). Overall hospital mortality also decreased over the study period 2006 to 2011 (2.12%1.74%, P<0.001) (Figure 2). Overall hospital CMI for fiscal years 2005/2006 through 2011/2012 were significantly different (1.47 vs 1.67, P<0.0001). No difference was observed in the pre‐ and postimplementation period likelihood of DNAR status among nonsurvivors with initial return of spontaneous circulation at the time of CPA resuscitation (76% vs 75%, P=0.841).

Figure 1

Figure 2

Starting fiscal year 2005to 2011, there were a total of 546 total CPAs with 247 non‐ICU CPAs observed between both hospital systems. Since its implementation starting at Q3 of 2007, a total of 1729 RRT activations throughout all inpatient areas were observed through 2011. The overall relationship between Code Blue activations starting July 2005 and the RRT since its implementation is displayed in Figure 3. No relationship was detected between the number of Code Blue and RRT activations on each unit (r=0.17, P=0.242). However, the year‐over‐year (fiscal years 2007/20082008/2009) change in RRT activations for each unit was inversely related to the change in Code Blue activations; the individual units with an increase in RRT activations experienced a decrease in Code Blue activations, and units with a decrease in RRT activations experienced an increase in Code Blue activations (r=0.68, P<0.001) (Figure 4).

Figure 3

Figure 4

The time per RRT activation appeared to stabilize after the first program year, whereas the number of RRT activations per month has increased over time. The RRT activation etiologies based on chief complaint reported to the RRT nurse are displayed in Figure 5. Only 3% of activations resulted in no intervention; most of these represented seizures that resolved prior to RRT arrival or syncope episodes for noninpatients. The most common interventions were airway management (27%), fluid therapy (18%), and respiratory treatments (15%). The vast majority of patients (99%) survived the RRT response. A total of 56% of RRT activations resulted in disposition to a higher level of care (43% upgraded to ICU status, 13% upgraded to intermediate care unit status), whereas the remaining 44% of patients stayed on their original unit.

Figure 5

DISCUSSION

One of the primary rationales for hospital admission is the ability to observe and monitor patients to identify deterioration and prevent CPA. Thus, the failure of RRT programs to consistently demonstrate improvements in overall hospital mortality is somewhat perplexing. Here we present 4 years of data starting at the initiation of our RRT program. During our period of observation, we noted a significant inverse relationship between the activations of the RRT and incidence of CPA. Additionally, we noticed a significant decrease in non‐ICU arrests and in overall hospital mortality that appears to be associated with initiation of our novel RRT (Figures 1 and 2, respectively). In postintervention year 1, the unadjusted implementation of our RRT was associated with approximately 57% of the improvement of in‐hospital mortality. We noted a decrease of non‐ICU mortality from 45 deaths in fiscal year 2006 to 2007 to 21 deaths in fiscal year 2007 to 2008. Additionally, the number of non‐ICU Code Blue activations also declined during this period, from 56 to 34, with a survival to hospital discharge rate of 38% (fiscal year 2007 to 2008). In the second full year postimplementation, the activation of the RRT appears to be associated with a similar amount of reduction in in‐hospital mortality (52%) (see Supporting Table 2 in the online version of this article). We do not believe that initiation of our novel RRT accounts for all the variance in reduction of overall mortality. However, we posit that much of our success likely reflects our unique combined approach to a multifaceted life‐support training curriculum. Finally, though not statistically investigated, RRT activation etiology appears to be relatively uniform with respiratory, suspected cardiovascular, and clinical intuition accounting for a large majority of activations through the study period (Figure 5).

Multiple potential explanations exist to account for the lack of outcomes data to fully support RRT programs, with a failure to follow published RRT activation guidelines listed as a key factor.[7, 8, 19] It is unclear whether this reflects inconsistent activation protocols, as many hospitals lack specific published guidelines, whereas others may have more have rigid protocols. Another consideration is possible reluctance to activate a specialized team by primary in‐hospital caregivers due in part to intimidation or a lack of specific training. Interestingly, the routine presence of a physician with RRT activations has been postulated to be inhibitory in this regard and result in critical delays to resuscitative care.[20, 21, 22]

The vast majority of our RRT activations survived the initial response. This is an important metric not only for determining the competency of RRT providers in initiating therapies but also reflects the willingness of inpatient staff to activate RRT early in the course of a patient's deterioration, as delayed activation has been previously associated with increased mortality.[23, 24, 25] The relatively high RRT survival rate could be interpreted as reflecting some degree of overactivation. Of note, based upon hospital CMI, overall patient acuity appeared to continuously increase during and after the observation period. However, the incidence of RRT activations in which no therapies were initiated was extremely low, and more than half of patients were transferred to a higher level of care. We posit that benchmarking such metrics in the future may help institutions guide their resuscitation programs.

Our current RRT configuration of a dedicated critical care trained nurse and respiratory therapist plus unit manager (ie, charge nurse) is a departure from the traditional RRT historically consisting of a dedicated critical care trained nurse and/or respiratory therapist, and physician(s).[26] Perhaps more important than team configuration is our novel concept of individual unit managers regularly rounding on their own most at‐risk patients, which may add a layer of familiarity and increased likelihood of identifying even subtle changes associated with eventual decompensation. Unfortunately, we did not assess the charge nurse decision‐making process regarding RRT activation. This approach differs from Gerdik et al., who have demonstrated a positive association with the ability of the patient and/or family to activate the RRT. [27] Though similar, our approach also differs from the strategy of a dedicated RRT nurse rounding on high risk patients identified through physician and nurse surveys that have also shown a significant reduction in admission deaths.[26, 28, 29] Although the strategies may differ on the specific team members initiating the deployment of the RRT, what they appear to have in common is the proactive component of the identification of at‐risk patients. Additionally, we employ an annual RRT educational seminar for potential primary responders including bedside nurses, respiratory therapists, and physical therapists. Our novel resuscitation program and RRT education allows modulation of the life‐support curriculum to emphasize the importance of early recognition and response to at‐risk patients based upon our activation criteria and evaluation of activation trends (see Supporting Table 1 in the online version of this article). Finally, the presence of the charge nurse as part of the RRT is important, not only as part of the afferent arm of the program but also to enhance unit responsibility for detecting deterioration. It is our belief that an aggressive resuscitation CQI program with efferent links to unit managers amplifies the perception of ownership by primary providers and enhances the culture of resuscitation.

A lack of understanding as to the etiology of CPA in the inpatient environment may also limit the effectiveness of protocol and monitoring strategies. Our current resuscitation program places great emphasis on the taxonomy of our in‐hospital cardiac arrests and classifying inpatient events to help guide CQI efforts. These classifications provide a scaffolding for life‐support education and can result in changes to treatment algorithms or initiate new programs to target particular patient populations. An example includes the implementation of respiratory monitoring strategies in perioperative patients at high risk for obstructive sleep apnea.

Several limitations to this analysis must be considered. The study was not a randomized prospective trial and lacks internal validation. The before‐and‐after study was limited by the inclusion of only 1 complete preimplementation year (2006), which may have introduced a bias related to the inherent inability to properly evaluate secular trends. As such, this study cannot compare the relative effectiveness of our novel RRT participants and curriculum versus the traditional RRTs previously described.[26] Additionally, we also excluded data from both the emergency department and operating arena. Both are reported to have overall higher survival rates due to differences in arrest etiology, monitoring, anticipation, and available personal.[30, 31] We used CMI coefficients to explore the possibility of a decrease in patient acuity during the study. However, we noticed an increasing case‐mix coefficient value suggesting higher patient acuity, which would predict increased mortality rather than the decrease we observed.

One must also consider how the introduction of an RRT may increase DNAR orders and subsequently affect overall mortality by artificially lowering it.[32] Trends in DNAR during our period of observation were not significantly different. However, if an increase in DNAR orders did artificially improve non‐ICU CPA outcomes, one would expect unchanged or increased overall hospital mortality. In contrast, we found improvement in all outcomes including overall hospital mortality (Figure 2).

CONCLUSIONS

Our novel RRT program, with an emphasis on inclusion of non‐ICU charge nurses as part of the team and universal RRT education integrated within life support training, appears to be effective at decreasing the incidence of non‐ICU CPA and overall hospital mortality.

Disclosure: Nothing to report.

An estimated 200,000 adult patients suffer cardiac arrest in US hospitals each year, of which <20% survive to hospital discharge.[1, 2] Patient survival from in‐hospital cardiac arrest (IHCA), however, varies widely across hospitals, and may be partly attributed to differences in hospital practices.[3, 4, 5] Although there are data to support specific patient‐level practices in the hospital, such as delivery of electrical shock for ventricular fibrillation within 2 minutes of onset of the lethal rhythm,[6] little is known about in‐hospital systems‐level factors. Similar to patient‐level practices, some organizational and systems level practices are supported by international consensus and guideline recommendations.[7, 8] However, the adoption of these practices is poorly understood. As such, we sought to gain a better understanding of current US hospital practices with regard to IHCA and resuscitation with the hopes of identifying potential targets for improvement in quality and outcomes.

METHODS

We conducted a nationally representative mail survey between May 2011 and November 2011, targeting a stratified random sample of 1000 hospitals. We utilized the US Acute‐Care Hospitals (FY2008) database from the American Hospital Association to determine the total population of 3809 community hospitals (ie, nonfederal government, nonpsychiatric, and nonlong‐term care hospitals).[9] This included general medical and surgical, surgical, cancer, heart, orthopedic, and children's hospitals. These hospitals were stratified into tertiles by annual in‐patient days and teaching status (major, minor, nonteaching), from which our sample was randomly selected (Table 1). We identified each hospital's cardiopulmonary resuscitation (CPR) committee (sometimes known as code committee, code blue committee, or cardiac arrest committee) chair or chief medical/quality officer, to whom the paper‐based survey was addressed, with instructions to forward to the most appropriate person if someone other than the recipient. This study was evaluated by the University of Chicago institutional review board and deemed exempt from further review.

Figure 1

RESULTS

Responses were received from 439 hospitals (425 complete and 14 partially complete), yielding a response rate of 44%. One subject ID was removed from the survey and could not be identified, so it was excluded from any analyses. Hospital demographics were similar between responders and nonresponders (P=0.50) (Table 1). Respondents who filled out the surveys included chief medical/quality officers (n=143 [33%]), chairs of CPR committees (n=64 [15%]), members of CPR committees (n=29 [7%]), chiefs of staff (n=33 [8%]), resuscitation officers/nurses (n=27 [6%]), chief nursing officers (n=13 [3%]), and others (n=131 [30%]).

Table 2 summarizes structure, equipment, quality improvement, and pre‐ and postarrest practices across the hospitals. Of note, 77% of hospitals (n=334) reported having a predesignated, dedicated code team, and 66% (n=281) reported standardized defibrillator make and model throughout their hospital. However, less than one‐third of hospitals utilized any CPR assist technology (eg, CPR quality sensor or mechanical CPR device). The majority of hospitals reported having a rapid response team (RRT) (n=391 [91%]). Although a therapeutic hypothermia protocol for postarrest care was in place in over half of hospitals (n=252 [58%]), utilization of hypothermia for patients with return of spontaneous circulation was infrequent.

Hospitals reported that routine responders to IHCA events included respiratory therapists (n=414 [95%]), critical care nurses (n=406 [93%]), floor nurses (n=396 [90%]), attending physicians (n=392 [89%]), physician trainees (n=162 [37%]), and pharmacists (n=210 [48%]). Figure 1 shows the distribution of responders and team leaders by hospital type. Of the nonteaching hospitals, attending‐level physicians were likely to respond at 94% (265/281) and routinely lead the resuscitations at 84% (236/281), whereas, of major teaching hospitals, attending physicians were only likely to respond at 71% (30/42) and routinely lead at 19% (8/42).

Two‐thirds of the hospitals had a CPR committee (n=270 [66%]), and 196 (49%) had some staff time dedicated to resuscitation quality improvement. Hospitals with a specific committee dedicated to resuscitation and/or dedicated staff for resuscitation quality improvement were more likely to routinely track cardiac arrest data (odds ratio [OR]: 3.64, 95% confidence interval [CI]: 2.056.47 and OR: 2.02, 95% CI: 1.16‐3.54, respectively) and review the data (OR: 2.67, 95% CI: 1.45‐4.92 and OR: 2.18, 95% CI: 1.22‐3.89, respectively), after adjusting for teaching status and hospital size. These hospitals were also more likely to engage in simulation training and debriefing (Table 3).

Ninety percent (n=391) of respondents agreed that there is room for improvement in resuscitation practice at my hospital, and 70% (n=302) agreed that improved resuscitation would translate into improved patient outcomes. Overall, 78% (n=338) cited at least 1 barrier to improved resuscitation quality, of which the lack of adequate training (n=233 [54%]) and the lack of an appropriate champion (n=230 [53%]) were the most common. In subgroup analysis, nonteaching hospitals were significantly more likely to report the lack of a champion than their teaching counterparts (P=0.001) (Figure 2). In addition, we analyzed the data by hospitals that reported lack of a champion was not a barrier and compared them to those for whom it was, and found significantly higher adherence across all the measures in Table 2 supported by the 2010 guidelines, with the exception of real‐time feedback (data not shown).

Figure 2

DISCUSSION

In this nationally representative sample of hospitals, we found considerable variability in cardiac arrest and resuscitation structures and processes, suggesting potential areas to target for improvement. Some practices, including use of RRTs and defibrillator standardization, were fairly routine, whereas others, such as therapeutic hypothermia and CPR assist technology, were rarely utilized. Quality initiatives, such as data tracking and review, simulation training, and debriefing were variable.

Several factors likely contribute to the variable implementation of evidence‐based practices. Guidelines alone have been shown to have little impact on practice by physicians in general.[11] This is supported by the lack of correlation we found between the presence, absence or strength of specific American Heart Association (AHA) emergency cardiovascular care treatment recommendations and the percent of hospitals reporting performing that measure. It is possible that other factors, such as a lack of familiarity or agreement with those guidelines, or the presence of external barriers, may be contributing.[12, 13] Specifically, the importance of a clinical champion was supported by our finding that hospitals reporting lack of a champion as a barrier were less likely to be adherent with guidelines. However, because the study did not directly test the impact of a champion, we wanted to be careful to avoid overstating or editorializing our results.

Some of the variability may also be related to the resource intensiveness of the practice. Routine simulation training and debriefing interventions, for example, are time intensive and require trained personnel to institute. That may explain the correlation we noted between these practices and the presence of CPR committee and dedicated personnel. The use of dedicated personnel was rare in this study, with less than half of respondents reporting any dedicated staff and a median of 0.5 full‐time equivalents for those reporting positively. This is in stark contrast to the routine use of resuscitation officers (primarily nurses dedicated to overseeing resuscitation practices and education at the hospital) in the United Kingdom.[14] Such a resuscitation officer model adopted by US hospitals could improve the quality and intensity of resuscitation care approaches.

Particularly surprising was the high rate of respondents (70%) reporting that they do not utilize any CPR assist technology. In the patient who does not have an arterial line, use of quantitative capnography is the best measure of cardiac output during cardiac arrest, yet only one‐quarter of hospitals reported using it, with no discrepancy between hospital type or size. A recent summit of national resuscitation experts expounded on the AHA guidelines suggesting that end‐tidal carbon dioxide should be used in all arrests to guide the quality of CPR with a goal value of >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 and how best to implement these practices in a more uniform fashion.

An estimated 200,000 adult patients suffer cardiac arrest in US hospitals each year, of which <20% survive to hospital discharge.[1, 2] Patient survival from in‐hospital cardiac arrest (IHCA), however, varies widely across hospitals, and may be partly attributed to differences in hospital practices.[3, 4, 5] Although there are data to support specific patient‐level practices in the hospital, such as delivery of electrical shock for ventricular fibrillation within 2 minutes of onset of the lethal rhythm,[6] little is known about in‐hospital systems‐level factors. Similar to patient‐level practices, some organizational and systems level practices are supported by international consensus and guideline recommendations.[7, 8] However, the adoption of these practices is poorly understood. As such, we sought to gain a better understanding of current US hospital practices with regard to IHCA and resuscitation with the hopes of identifying potential targets for improvement in quality and outcomes.

METHODS

We conducted a nationally representative mail survey between May 2011 and November 2011, targeting a stratified random sample of 1000 hospitals. We utilized the US Acute‐Care Hospitals (FY2008) database from the American Hospital Association to determine the total population of 3809 community hospitals (ie, nonfederal government, nonpsychiatric, and nonlong‐term care hospitals).[9] This included general medical and surgical, surgical, cancer, heart, orthopedic, and children's hospitals. These hospitals were stratified into tertiles by annual in‐patient days and teaching status (major, minor, nonteaching), from which our sample was randomly selected (Table 1). We identified each hospital's cardiopulmonary resuscitation (CPR) committee (sometimes known as code committee, code blue committee, or cardiac arrest committee) chair or chief medical/quality officer, to whom the paper‐based survey was addressed, with instructions to forward to the most appropriate person if someone other than the recipient. This study was evaluated by the University of Chicago institutional review board and deemed exempt from further review.

Figure 1

RESULTS

Responses were received from 439 hospitals (425 complete and 14 partially complete), yielding a response rate of 44%. One subject ID was removed from the survey and could not be identified, so it was excluded from any analyses. Hospital demographics were similar between responders and nonresponders (P=0.50) (Table 1). Respondents who filled out the surveys included chief medical/quality officers (n=143 [33%]), chairs of CPR committees (n=64 [15%]), members of CPR committees (n=29 [7%]), chiefs of staff (n=33 [8%]), resuscitation officers/nurses (n=27 [6%]), chief nursing officers (n=13 [3%]), and others (n=131 [30%]).

Table 2 summarizes structure, equipment, quality improvement, and pre‐ and postarrest practices across the hospitals. Of note, 77% of hospitals (n=334) reported having a predesignated, dedicated code team, and 66% (n=281) reported standardized defibrillator make and model throughout their hospital. However, less than one‐third of hospitals utilized any CPR assist technology (eg, CPR quality sensor or mechanical CPR device). The majority of hospitals reported having a rapid response team (RRT) (n=391 [91%]). Although a therapeutic hypothermia protocol for postarrest care was in place in over half of hospitals (n=252 [58%]), utilization of hypothermia for patients with return of spontaneous circulation was infrequent.

Hospitals reported that routine responders to IHCA events included respiratory therapists (n=414 [95%]), critical care nurses (n=406 [93%]), floor nurses (n=396 [90%]), attending physicians (n=392 [89%]), physician trainees (n=162 [37%]), and pharmacists (n=210 [48%]). Figure 1 shows the distribution of responders and team leaders by hospital type. Of the nonteaching hospitals, attending‐level physicians were likely to respond at 94% (265/281) and routinely lead the resuscitations at 84% (236/281), whereas, of major teaching hospitals, attending physicians were only likely to respond at 71% (30/42) and routinely lead at 19% (8/42).

Two‐thirds of the hospitals had a CPR committee (n=270 [66%]), and 196 (49%) had some staff time dedicated to resuscitation quality improvement. Hospitals with a specific committee dedicated to resuscitation and/or dedicated staff for resuscitation quality improvement were more likely to routinely track cardiac arrest data (odds ratio [OR]: 3.64, 95% confidence interval [CI]: 2.056.47 and OR: 2.02, 95% CI: 1.16‐3.54, respectively) and review the data (OR: 2.67, 95% CI: 1.45‐4.92 and OR: 2.18, 95% CI: 1.22‐3.89, respectively), after adjusting for teaching status and hospital size. These hospitals were also more likely to engage in simulation training and debriefing (Table 3).

Ninety percent (n=391) of respondents agreed that there is room for improvement in resuscitation practice at my hospital, and 70% (n=302) agreed that improved resuscitation would translate into improved patient outcomes. Overall, 78% (n=338) cited at least 1 barrier to improved resuscitation quality, of which the lack of adequate training (n=233 [54%]) and the lack of an appropriate champion (n=230 [53%]) were the most common. In subgroup analysis, nonteaching hospitals were significantly more likely to report the lack of a champion than their teaching counterparts (P=0.001) (Figure 2). In addition, we analyzed the data by hospitals that reported lack of a champion was not a barrier and compared them to those for whom it was, and found significantly higher adherence across all the measures in Table 2 supported by the 2010 guidelines, with the exception of real‐time feedback (data not shown).

Figure 2

DISCUSSION

In this nationally representative sample of hospitals, we found considerable variability in cardiac arrest and resuscitation structures and processes, suggesting potential areas to target for improvement. Some practices, including use of RRTs and defibrillator standardization, were fairly routine, whereas others, such as therapeutic hypothermia and CPR assist technology, were rarely utilized. Quality initiatives, such as data tracking and review, simulation training, and debriefing were variable.

Several factors likely contribute to the variable implementation of evidence‐based practices. Guidelines alone have been shown to have little impact on practice by physicians in general.[11] This is supported by the lack of correlation we found between the presence, absence or strength of specific American Heart Association (AHA) emergency cardiovascular care treatment recommendations and the percent of hospitals reporting performing that measure. It is possible that other factors, such as a lack of familiarity or agreement with those guidelines, or the presence of external barriers, may be contributing.[12, 13] Specifically, the importance of a clinical champion was supported by our finding that hospitals reporting lack of a champion as a barrier were less likely to be adherent with guidelines. However, because the study did not directly test the impact of a champion, we wanted to be careful to avoid overstating or editorializing our results.

Some of the variability may also be related to the resource intensiveness of the practice. Routine simulation training and debriefing interventions, for example, are time intensive and require trained personnel to institute. That may explain the correlation we noted between these practices and the presence of CPR committee and dedicated personnel. The use of dedicated personnel was rare in this study, with less than half of respondents reporting any dedicated staff and a median of 0.5 full‐time equivalents for those reporting positively. This is in stark contrast to the routine use of resuscitation officers (primarily nurses dedicated to overseeing resuscitation practices and education at the hospital) in the United Kingdom.[14] Such a resuscitation officer model adopted by US hospitals could improve the quality and intensity of resuscitation care approaches.

Particularly surprising was the high rate of respondents (70%) reporting that they do not utilize any CPR assist technology. In the patient who does not have an arterial line, use of quantitative capnography is the best measure of cardiac output during cardiac arrest, yet only one‐quarter of hospitals reported using it, with no discrepancy between hospital type or size. A recent summit of national resuscitation experts expounded on the AHA guidelines suggesting that end‐tidal carbon dioxide should be used in all arrests to guide the quality of CPR with a goal value of >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 and how best to implement these practices in a more uniform fashion.

An estimated 200,000 adult patients suffer cardiac arrest in US hospitals each year, of which <20% survive to hospital discharge.[1, 2] Patient survival from in‐hospital cardiac arrest (IHCA), however, varies widely across hospitals, and may be partly attributed to differences in hospital practices.[3, 4, 5] Although there are data to support specific patient‐level practices in the hospital, such as delivery of electrical shock for ventricular fibrillation within 2 minutes of onset of the lethal rhythm,[6] little is known about in‐hospital systems‐level factors. Similar to patient‐level practices, some organizational and systems level practices are supported by international consensus and guideline recommendations.[7, 8] However, the adoption of these practices is poorly understood. As such, we sought to gain a better understanding of current US hospital practices with regard to IHCA and resuscitation with the hopes of identifying potential targets for improvement in quality and outcomes.

METHODS

We conducted a nationally representative mail survey between May 2011 and November 2011, targeting a stratified random sample of 1000 hospitals. We utilized the US Acute‐Care Hospitals (FY2008) database from the American Hospital Association to determine the total population of 3809 community hospitals (ie, nonfederal government, nonpsychiatric, and nonlong‐term care hospitals).[9] This included general medical and surgical, surgical, cancer, heart, orthopedic, and children's hospitals. These hospitals were stratified into tertiles by annual in‐patient days and teaching status (major, minor, nonteaching), from which our sample was randomly selected (Table 1). We identified each hospital's cardiopulmonary resuscitation (CPR) committee (sometimes known as code committee, code blue committee, or cardiac arrest committee) chair or chief medical/quality officer, to whom the paper‐based survey was addressed, with instructions to forward to the most appropriate person if someone other than the recipient. This study was evaluated by the University of Chicago institutional review board and deemed exempt from further review.

Figure 1

RESULTS

Responses were received from 439 hospitals (425 complete and 14 partially complete), yielding a response rate of 44%. One subject ID was removed from the survey and could not be identified, so it was excluded from any analyses. Hospital demographics were similar between responders and nonresponders (P=0.50) (Table 1). Respondents who filled out the surveys included chief medical/quality officers (n=143 [33%]), chairs of CPR committees (n=64 [15%]), members of CPR committees (n=29 [7%]), chiefs of staff (n=33 [8%]), resuscitation officers/nurses (n=27 [6%]), chief nursing officers (n=13 [3%]), and others (n=131 [30%]).

Table 2 summarizes structure, equipment, quality improvement, and pre‐ and postarrest practices across the hospitals. Of note, 77% of hospitals (n=334) reported having a predesignated, dedicated code team, and 66% (n=281) reported standardized defibrillator make and model throughout their hospital. However, less than one‐third of hospitals utilized any CPR assist technology (eg, CPR quality sensor or mechanical CPR device). The majority of hospitals reported having a rapid response team (RRT) (n=391 [91%]). Although a therapeutic hypothermia protocol for postarrest care was in place in over half of hospitals (n=252 [58%]), utilization of hypothermia for patients with return of spontaneous circulation was infrequent.

Hospitals reported that routine responders to IHCA events included respiratory therapists (n=414 [95%]), critical care nurses (n=406 [93%]), floor nurses (n=396 [90%]), attending physicians (n=392 [89%]), physician trainees (n=162 [37%]), and pharmacists (n=210 [48%]). Figure 1 shows the distribution of responders and team leaders by hospital type. Of the nonteaching hospitals, attending‐level physicians were likely to respond at 94% (265/281) and routinely lead the resuscitations at 84% (236/281), whereas, of major teaching hospitals, attending physicians were only likely to respond at 71% (30/42) and routinely lead at 19% (8/42).

Two‐thirds of the hospitals had a CPR committee (n=270 [66%]), and 196 (49%) had some staff time dedicated to resuscitation quality improvement. Hospitals with a specific committee dedicated to resuscitation and/or dedicated staff for resuscitation quality improvement were more likely to routinely track cardiac arrest data (odds ratio [OR]: 3.64, 95% confidence interval [CI]: 2.056.47 and OR: 2.02, 95% CI: 1.16‐3.54, respectively) and review the data (OR: 2.67, 95% CI: 1.45‐4.92 and OR: 2.18, 95% CI: 1.22‐3.89, respectively), after adjusting for teaching status and hospital size. These hospitals were also more likely to engage in simulation training and debriefing (Table 3).

Ninety percent (n=391) of respondents agreed that there is room for improvement in resuscitation practice at my hospital, and 70% (n=302) agreed that improved resuscitation would translate into improved patient outcomes. Overall, 78% (n=338) cited at least 1 barrier to improved resuscitation quality, of which the lack of adequate training (n=233 [54%]) and the lack of an appropriate champion (n=230 [53%]) were the most common. In subgroup analysis, nonteaching hospitals were significantly more likely to report the lack of a champion than their teaching counterparts (P=0.001) (Figure 2). In addition, we analyzed the data by hospitals that reported lack of a champion was not a barrier and compared them to those for whom it was, and found significantly higher adherence across all the measures in Table 2 supported by the 2010 guidelines, with the exception of real‐time feedback (data not shown).

Figure 2

DISCUSSION

In this nationally representative sample of hospitals, we found considerable variability in cardiac arrest and resuscitation structures and processes, suggesting potential areas to target for improvement. Some practices, including use of RRTs and defibrillator standardization, were fairly routine, whereas others, such as therapeutic hypothermia and CPR assist technology, were rarely utilized. Quality initiatives, such as data tracking and review, simulation training, and debriefing were variable.

Several factors likely contribute to the variable implementation of evidence‐based practices. Guidelines alone have been shown to have little impact on practice by physicians in general.[11] This is supported by the lack of correlation we found between the presence, absence or strength of specific American Heart Association (AHA) emergency cardiovascular care treatment recommendations and the percent of hospitals reporting performing that measure. It is possible that other factors, such as a lack of familiarity or agreement with those guidelines, or the presence of external barriers, may be contributing.[12, 13] Specifically, the importance of a clinical champion was supported by our finding that hospitals reporting lack of a champion as a barrier were less likely to be adherent with guidelines. However, because the study did not directly test the impact of a champion, we wanted to be careful to avoid overstating or editorializing our results.

Some of the variability may also be related to the resource intensiveness of the practice. Routine simulation training and debriefing interventions, for example, are time intensive and require trained personnel to institute. That may explain the correlation we noted between these practices and the presence of CPR committee and dedicated personnel. The use of dedicated personnel was rare in this study, with less than half of respondents reporting any dedicated staff and a median of 0.5 full‐time equivalents for those reporting positively. This is in stark contrast to the routine use of resuscitation officers (primarily nurses dedicated to overseeing resuscitation practices and education at the hospital) in the United Kingdom.[14] Such a resuscitation officer model adopted by US hospitals could improve the quality and intensity of resuscitation care approaches.

Particularly surprising was the high rate of respondents (70%) reporting that they do not utilize any CPR assist technology. In the patient who does not have an arterial line, use of quantitative capnography is the best measure of cardiac output during cardiac arrest, yet only one‐quarter of hospitals reported using it, with no discrepancy between hospital type or size. A recent summit of national resuscitation experts expounded on the AHA guidelines suggesting that end‐tidal carbon dioxide should be used in all arrests to guide the quality of CPR with a goal value of >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 and how best to implement these practices in a more uniform fashion.