In-hospital Cardiac Arrest: No Longer ‘Unsalvageable’

In-hospital cardiac arrest accounts for approximately160,000 deaths in the U.S. every year—similar to deaths from lung cancer—and yet it receives little attention and limited research funding. Those studying this silent epidemic say that decreasing the morbidity and mortality associated with in-hospital cardiac arrest is attainable and should be a focus of every provider’s quality improvement efforts.

One of those researchers, Paul S. Chan, MD, of Saint Luke’s Health System in Kansas City, Mo., feels that paying more attention to preventing and responding appropriately to in-hospital cardiac arrest can make a huge impact. He cites the great leaps made in improving care for heart failure and MI over the past few decades, contending that similar strides can be made in improving survival after in-hospital cardiac arrest.

The American Heart Association has made in-hospital cardiac arrest a focus for quality improvement with its Get With the Guidelines-Resuscitation (GWTG-R) registry, which collects information about resuscitation cases from participating hospitals and offers feedback on resuscitative practices and outcomes. The registry also uses the information collected to develop evidence-based guidelines and best practices. Currently, more than 1,550 hospitals participate in the registry, and studies of outcomes using registry data indicate that attention to the problem is producing results.

Survival is improving

	ACS-NSQIP = American College of SurgeonsNational Surgical Quality Improvement Program; CPR = cardiopulmonary resuscitation
	Source: JAMA Surg 2013;148[1]:14-21

Studying adults who experienced in-hospital cardiac arrest and using acute resuscitation survival (rate of return of spontaneous circulation for at least 20 minutes) and survival to discharge as endpoints, Chan and colleagues found encouraging trends among hospitals participating in GWTG-R (N Engl J Med 2012;367:1912-1920). Survival to discharge improved from 13.7 percent in 2000 to 22.3 percent in 2009. Acute resuscitation survival improved from 42.7 percent to 54.1 percent over the same period, and post-resuscitation survival increased from 32 percent to 42.9 percent.

There are similar trends in the pediatric arena. Between 2 and 6 percent of children admitted to intensive care units experience in-hospital cardiac arrest every year. Survival rates are poor and survivors often are left with neurological impairment. But a study of urban teaching hospitals with pediatric residency or fellowship programs participating in GWTG-R showed improvement among this vulnerable population as well (Circ Cardiovasc Qual Outcomes 2013; 6:42-49). Survival to discharge increased from 14.3 percent in 2000 to 43.4 percent in 2009 and post-resuscitation survival increased from 42.9 percent to 81.2 percent over the same time period. The researchers found no significant change in the percentage of survivors who experienced neurological impairment.  

Saket Girotra, MD, an interventional cardiologist at the University of Iowa Hospital and co-author with Chan of the adult and pediatric studies, suggests there are a number of factors supporting increased survival of in-hospital cardiac arrest. Prompt recognition of patient distress, quality of chest compressions, timely defibrillation when necessary, proper administration of optimal medication, the engagement of hospital leadership in organizing better resuscitation team coordination and improved aftercare stand out among them. “All these are likely contributors, but we don’t yet have data to tell us what is driving these improvements. That is the next step for research,” he says.

There is some evidence that length of resuscitation efforts has an impact on survival (Lancet 2012;380:1473-1481). Again working with the GWTG-R registry, researchers analyzed the duration of resuscitation attempts in non-survivors at more than 400 hospitals to determine the mean length of resuscitation attempts before termination of rescue efforts. Overall, the mean length was 12 minutes for survivors and 20 minutes for non-survivors. But the researchers noted substantial variation between hospitals, with the hospitals in the quartile with the longest duration of resuscitation attempts (mean of 25 minutes) engaging in resuscitative efforts 50 percent longer than hospitals in the quartile with the shortest duration of resuscitation (mean of 16 minutes). They found that patients who had cardiac arrests within hospitals with longer mean resuscitation attempt times were more likely to survive than those whose arrests occurred in hospitals with shorter mean resuscitation times.

Another recent study by a different team of researchers looked at cardiopulmonary resuscitation in surgical patients, and identified a potentially potent weapon against in-hospital arrest and mortality—prevention. This study found that complications, especially pneumonia and sepsis, preceded the large majority of cardiac arrests in surgical patients (JAMA Surg 2013;148[1]:14-21). Survival among these patients was poor—overall mortality at 30 days was 71.6 percent—but the authors concluded that many of these deaths could have been avoided through prevention of complications and expedient diagnosis and treatment of complications when they occurred. 

Misperceptions impede progress

The opinion that the in-hospital cardiac arrest patient is unsalvageable persists, according to Chan. “There is a perception of futility that these patients are very, very sick, that they are unlikely to survive and that if they do survive, they will be neurologically devastated. Twenty years ago, that may have been true in many cases, but our research is showing it’s not true anymore,” he says.

In-hospital cardiac arrest is now less likely to be a result of MI or to be related to cardiovascular disease than it was in 2000, according to the analyses of GWTG-R data. Patients suffering in-hospital cardiac arrest are younger than they were in 2000 and more likely to have septicemia or other infections, to have been on mechanical ventilation and to have received intravenous vasopressors.

“Also, and very significantly, is that most patients who survive to discharge leave the hospital with no or minor neurological disability,” says Girotra. The study on survival outcomes showed that in 2000 half the patients who survived to discharge left the hospital with severe or clinically significant neurological disability, but by 2009, that percentage had dropped to 38.8 percent.

The study on duration of resuscitation attempts also examined neurologic status among patients who survived to discharge, and showed that those who survived long resuscitation attempts fared no worse neurologically than those whose resuscitations were shorter.

Researchers are currently exploring costs associated with survival of in-hospital cardiac arrest, aftercare, readmission and other variables, compared with the costs of surviving heart failure. “We are trying to paint an accurate picture of these patients to determine the amount of resources it takes to care for them after survival, and whether the outlook for these patients is really as pessimistic as is sometimes thought,” Chan says.

More granular data are necessary to identify the drivers of increased survival of in-hospital cardiac arrest and Chan says there is a need for funding to study cardiac arrest as a disease process. “If we can pinpoint exactly what the high-performing hospitals are doing well, we can establish good guidelines and best practices,” Girotra says. “Then, perhaps, we will see the sort of improvement that we have seen in MI survival extend to these patients, at all hospitals.”