According to the American Heart Association (AHA), more than 200,000 adults and 6,000 children have in-hospital cardiac arrests (IHCAs) each year, and survival has remained relatively unchanged for decades. Research shows that only about one-quarter of IHCA patients survive to hospital discharge. “IHCA has not received the same level of focused research as out-of-hospital cardiac arrest (OHCA),” says Laurie J. Morrison, MD, MSc. “There are many gaps in science, policy, and institutional application and accountability for the care of IHCA patients.”
Recently, the AHA released a consensus statement on strategies for improving survival after IHCA. Published in an issue of Circulation, the scientific statement is organized into four sections, based on scientific evidence from IHCA studies or reasonable extrapolation from the literature on OHCA. These include: 1) epidemiology, 2) best practices, 3) culture change and standardized reporting and benchmarking, and 4) conclusions and recommendations.
“The consensus statement on IHCA gives healthcare providers, clinical leaders, administrators, regulators, and policymakers an overview of the various issues related to reporting, planning, and performing best practices for IHCA,” says Dr. Morrison, who was lead author of the AHA’s scientific statement. “It also documents what is known and should be applied to ongoing care and what is unknown about IHCA and should be researched to advance care.”
Gathering Reliable Data on In-Hospital Cardiac Arrest
According to the AHA, there is great variation across the country in how IHCAs are defined and counted and whether or not they are reported annually. “A serious obstacle to providing better care for IHCAs is the inability to gather reliable data,” says Dr. Morrison. “We must be able to count how many IHCAs occur and report comparable outcomes across institutions, identify the leaders in care, and share best practices. Science needs to be applied to everyday care more quickly to improve outcomes.” Compounding the problem is that current guidelines lump together the literature for both IHCAs and OHCAs.
All cardiac arrests that occur within a particular hospital can test the institution’s response and system of care (Table 1). Accordingly, the AHA recommends that a strategy be in place to ensure comprehensive monitoring and institutional reporting of outcomes for arrests in all areas, including the ED, diagnostic services, surgical suites, long-term care, and employee areas. “Hospitals that provide care for both acute and long-term patients may lump or split these patients when they report incidence or just select what to report, which makes it hard to compare,” adds Dr. Morrison. Another important component to ensuring consistent reporting of institutional IHCA is how to count multiple arrests in the same patient during the same admission. Each arrest in the same patient may be counted differently across institutions.
A Comprehensive Guide from the AHA
The best practices section of the AHA scientific statement is divided into three sections: 1) pre-arrest, 2) intra-arrest, and 3) post-arrest. The discussion for each section provides information on the specific topic as well as care pathways that should be followed during the time interval. Each section also provides data on process issues relating to how care is provided and quality improvement measures to consider, such as real-time feedback and automated equipment that can replace staff and deliver similar care.
“There are many gaps in science, policy, and institutional application and accountability for the care of IHCA patients.”
The AHA scientific statement provides several key conclusions and recommendations, one of the most important being that all hospital staff be competent in recognizing a cardiac arrest, performing chest compressions, and using publicly available automated external defibrillators as a minimum requirement for staffing (Table 2). Using definitions across hospitals, all institutions should be required to report IHCAs, including survival rates and do-not-attempt-to-resuscitate rates in all admitted patients before arrest. Billing codes should also be modified to allow for the collection of more specific and accurate data for IHCA.
Changing the Culture to Improve In-Hospital Cardiac Arrest
Improving IHCA outcomes requires a change in the culture with standardized reporting, enhanced knowledge and training, and better systems of care, Dr. Morrison says. “Efforts are needed to overcome cultural impediments to change. With aggressive management and better reporting, we can document how guideline-based care improves outcomes. This is the first step in changing to a culture of hope for victims of IHCA. Changing the culture can improve behavior and practice compliance in healthcare staff. Published data inform the public, who play a role in improving healthcare performance.”
Considering that many gaps in science remain, the AHA indicates that more research unique to IHCA is needed. It also recommends that IHCAs be recognized as their own entity rather than be grouped together with OHCAs. “For the time being,” says Dr. Morrison, “the AHA’s consensus statement can guide implementation strategies to help clinicians adhere to current practice guidelines when caring for IHCAs. Our recommendations can be a great asset for institutional leaders, regulatory bodies, and research-funding agencies.”
Readings & Resources (click to view)
Morrison LJ, Neumar RW, Zimmerman JL, et al; on behalf of the American Heart Association Emergency Cardiovascular Care Committee, Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Peripheral Vascular Disease. Strategies for improving survival after in-hospital cardiac arrest in the United States: 2013 consensus recommendations: a consensus statement from the American Heart Association. Circulation. 2013 Mar 11 [Epub ahead of print]. Available at: http://circ.ahajournals.org/content/early/2013/03/11/CIR.0b013e31828b2770.full.pdf+html.
Field JM, Hazinski MF, Sayre MR, et al. Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl):S640-S656.
Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care [published correction appears in Circulation. 2011;123:e236]. Circulation. 2010;122(suppl):S729-S767.
Peberdy MA, Cretikos M, Abella BS, et al. Recommended guidelines for monitoring, reporting, and conducting research on medical emergency team, outreach, and rapid response systems: an Utstein-style scientific statement: a scientific statement from the International Liaison Committee on Resuscitation (American Heart Association, Australian Resuscitation Council, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, and the New Zealand Resuscitation Council); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiopulmonary, Perioperative, and Critical Care; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research. Circulation. 2007;116:2481-2500.