TRANSITION OF CARE IN CARDIAC ARREST RESUSCITATION SYSTEMS

Transitions of care occur as patients move between different health care providers and departments and are fundamental components of managing care for patients who initially survive cardiac arrest. Although care transitions from the hospital setting to the outpatient setting (following discharge) have been studied more rigorously than care transitions from the prehospital EMS setting to the hospital emergency department, or between hospital wards, the literature largely finds that a number of patient safety and quality deficiencies arise during transitions of care (Coleman and Berenson, 2004; Halasyamani et al., 2006; Snow et al., 2009). The handoff between providers or care teams can increase adverse events through medication errors, incomplete communication of relevant patient medical history affecting treatments, or lack of appropriate follow-up care (Coleman et al., 2006; Cook et al., 2000; Moore et al., 2003). Studies on the effect of hospital-based care transitions on patient outcomes in the cardiac arrest setting are limited (see Chapter 4 for an in-depth discussion of care transitions from EMS to hospital); much of the following discussion is based on extrapolations of studies done in relevant emergency care settings.

Figure 5-1 illustrates the complex care pathway for cardiac arrest patients. The initial OHCA pathway may involve prehospital responses from bystanders and EMS personnel to the emergency department (ED) care teams. Post-arrest care (e.g., therapeutic hypothermia) for OHCA patients can be initiated prior to arrival in the ED. Therefore, adequate communication between ambulatory care physicians and EMS or hospital physicians is essential for ensuring delivery of continuous, highquality care (Snow et al., 2009). For cardiac arrest patients, important clinical information should include the patient's clinical history and standardized EMS data (e.g., the location of the arrest, the time from collapse to initiation of cardiopulmonary resuscitation [CPR], initial cardiac rhythm, and administered drugs). As discussed in Chapter 2, establishing a standardized data template for EMS and hospital systems is vital to ensure that clinical decisions requiring timely assessments and implementation occur rapidly and that critical care services are then initiated quickly. Additionally, providers and care teams across multiple settings need to communicate effectively and have access to complete clinical information to be able to make appropriate decisions regarding postarrest care for individual patients.

FIGURE 5-1

Transition of care for cardiac arrest patients who survive to hospital discharge. ^aIHCA care pathway can begin at any location within the hospital (e.g., emergency department, cardiac catheterization laboratory, intensive care unit, medical/surgical wards). (more...)

Within hospitals, resuscitation teams initially evaluate and manage IHCA patients in various nonintensive care areas. Similar to OHCA, IHCA patients who achieve ROSC and are stabilized should be transported to an intensive care unit (ICU) or critical care unit (CCU), and require timely decisions about subsequent post-arrest treatments and care. Hospital transition protocols and communication infrastructure should be in place to ensure that important information regarding cardiac arrest patients be relayed efficiently and seamlessly among health care providers who work in different teams and units. Post-arrest care for patients within, and subsequently transitioning out of, the ICU into hospital-based step-down units is similar for both OHCA and IHCA survivors, and requires care pathways that are individualized to the needs and preferences of the patient. Care focuses on continued rehabilitation and neurologic recovery, therapy focused on prevention of recurrent events (e.g., management of heart failure and myocardial ischemia burdens and placement of implantable cardioverter defibrillators to respond to future arrests), and comfort care, and requires additional coordination between multidisciplinary providers. Following hospital discharge, patients receive continued care in home-based or rehabilitation facilities.

Each of these transitions of care represents opportunities to improve care quality by reducing errors or miscommunication during handoffs. Successful transitions require the establishment of a communication infrastructure to relay important clinical information between providers and departments in an efficient and effective manner, so that critical data are not lost and the care is not compromised in any way (Snow et al., 2009). Thus, emphasis on transitions of care is a good first step to ensure that patients are receiving the care they need in a continuous manner across sites of care.

IN-HOSPITAL CARDIAC ARREST

Approximately 200,000 cases of IHCA (Merchant et al., 2011) are reported in adults, and another 6,000 IHCA cases occur in children each year, representing a major patient safety and public health concern in the United States (Chan et al., 2010; Morrison et al., 2013; Nadkarni et al., 2006). Although survival rates following IHCA have improved over the past decade, currently, approximately half of all adult patients achieve ROSC following an IHCA, and less than one-quarter survive to hospital discharge (Chan, 2015; Girotra, 2012). IHCA outcomes are somewhat better for children, with 43 percent surviving to hospital discharge in 2009 (Girotra et al., 2013). These limited outcomes occur despite a substantial amount of resources that are devoted to the management and care of IHCA patients each year. Recent studies assessing trends in the Get With The Guidelines-Resuscitation (GWTG-R) registry database have found improvements in patient outcomes; the rates of clinically significant neurologic disability (defined as a Cerebral Performance Category [CPC] score >1) decreased (33 to 28 percent) among survivors (Girotra et al., 2012), while survival rates increased from 16 to 24 percent between 2000 and 2013 (Chan, 2015). While this increase in IHCA survival could be partially due to Hawthorne effects within participating hospitals, or reflect a positive shift in population health, it likely also represents improvements in resuscitation treatments and care.

This section focuses on several unique aspects of IHCA that distinguish it from OHCA. IHCA, in many ways, is a different clinical condition that affects a unique population subset, possibly with more severe illness or comorbidities that can influence treatment strategies and outcomes. This section describes IHCA epidemiology, incidence, and outcomes. It then reviews the current state of evidence regarding hospitals' approaches to managing and treating IHCA, and describes recent shifts in evidence related to teamwork and leadership efforts on resuscitation teams, along with advances in quality improvement tools and technology.

Epidemiology

Although the basic cardiac arrest rhythms and pathophysiology are similar for OHCA and IHCA, their underlying causes can be markedly different. First, approximately 90 percent of OHCAs are of cardiac etiology and occur unexpectedly (Daya et al., 2015). Conversely, IHCA is usually caused by underlying cardiac conditions less than half of the time, and patients often have demonstrable deterioration prior to the event (Chan, 2015; Morrison et al., 2013). The proportions of presenting arrhythmias and corresponding survival rates for OHCA and IHCA also differ, as shown in Table 5-1. The percent of IHCAs that present with pulseless electrical activity (PEA) is more than double that for OHCA, and asystole accounts for approximately 30 percent more cases of OHCAs than IHCAs. Because ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) (i.e., shockable rhythms) that are left untreated for several minutes after onset can degenerate into asystole, it is reasonable to suggest that a higher percentage of OHCAs are initiated by shockable rhythms, which transition to asystole. These factors are associated with marked differences in survival rates by arrhythmias and event location.

TABLE 5-1

Percentage of Presenting Arrhythmias and Survival to Discharge for IHCA and OHCA.

Typically, IHCA patients also have more secondary comorbidities and additional acute disease processes, which affect overall health outcomes and recovery following cardiac arrest. Additionally, response times to IHCA compared to OHCA are generally shorter, and the arrests are frequently witnessed, which leads to decreased ischemic burden time (i.e., the time between the onset of the arrest and ROSC). Faster ROSC may reduce the risk, duration, and severity of the post-arrest syndrome. Finally, the types of treatments available to OHCA and IHCA patients are similar, but they have been variably studied across the conditions (e.g., therapeutic hypothermia).

Incidence and Outcomes of Pediatric IHCA

Among children, there are substantial differences between IHCA and OHCA, which plays a major role in their care and outcomes. Most children who experience IHCA have an underlying health condition; 61 percent of children experience respiratory failure prior to the event and 29 percent experience shock (Nadkarni et al., 2006; Reis et al., 2002). These underlying illnesses greatly affect post-arrest management.

Infants and children who suffer arrest from respiratory insufficiency often have preceding prolonged periods of increasing hypotension, hypoxia, and acidosis, resulting in extensive asphyxial end-organ damage (Nadkarni et al., 2006). Patients with congenital heart disease often suffer arrest in the post-operative period, and the altered hemodynamics from unique anatomy and physiology complicated by the consequences of prolonged cardiopulmonary bypass require distinctive care protocols. Examples include patients with single-ventricle physiology or pulmonary artery hypertension. Asystole and PEA are the most frequent initial rhythms observed in IHCA pediatric patients, constituting 85 percent of all arrests, while VF and pVT constitutes 15 percent of all arrests (Girotra et al., 2013). Neonates, especially those in the delivery room, require separate expertise and protocols.

Pediatric outcomes following IHCA, in a select group of hospitals, have improved over the past several decades. The unadjusted survival-to-discharge rate increased from 14.3 percent in 2000 to 43.4 percent in 2009 (Girotra et al., 2012). These improvements have been largely due to improvement in acute resuscitation survival, defined as ROSC for at least 20 minutes, from 43 percent to 81 percent. Encouragingly the number of pediatric survivors with favorable neurologic outcomes is also increasing (Girotra et al., 2013).

Disparities in Incidence and Outcomes of IHCA

There is a paucity of reliable and valid data and subsequently limited studies of IHCA incidence and outcomes among racial and ethnic minority populations. As discussed in Chapter 2, several studies of IHCA have noted disparate outcomes among African American and Hispanic populations, compared to that for white patients. According to the committee's commissioned analysis of GWTG-R data, African American patients were significantly less likely to survive to hospital discharge than were white patients following an IHCA (20.8 percent survival compared to 25.9 percent, respectively) (Chan, 2015). One study found that the disparate outcomes can be partially accounted for by differences in the proportion of shockable initial cardiac rhythm; African American and Hispanic patients had a shockable rhythm 17 and 21 percent of the time, respectively, compared to white patients who had a shockable rhythm 27 percent of the time (Meaney et al., 2010).

The increased IHCA incidence among racial and ethnic minority populations may be due, in part, to differences in socioeconomic factors or individual characteristics, but could also potentially be caused by elements of the health care system. One study found greater delays in time to defibrillation for African American patients compared to white patients (Chan et al., 2008). The same study also noted delayed defibrillation for Hispanic patients; however, these results were not statistically significant. Following arrest, studies have found that African Americans have longer lengths of stay in EDs compared to patients of other races and ethnicities. These longer lengths of stay are associated with adverse outcomes in ICU patients. Adjustment for the hospital location explains a large portion of these IHCA differences. IHCA incidence appears to be highest, and likelihood of survival lower, in hospitals with higher proportions of African American patients compared to hospitals that serve predominantly white populations (Chan et al., 2009). Additionally, decision-support tools to predict IHCA outcomes do not accurately predict mortality in African American patients, which could have profound effects on treatment courses and outcomes. In order to reduce IHCA events and improve survival for all racial and ethnic groups, it is imperative to examine overall process and quality measures in hospitals with high rates of IHCAs. Findings from these reviews must then be used to inform changes in practice that elevate accountability and work toward better outcomes for all patients.

Numerous studies have documented notable variation in outcomes for IHCA across institutions. One study reported that risk-adjusted survival rates varied from 12.4 percent in the bottom decile of hospitals to 22.7 percent in the top decile of hospitals included in the GWTG-R registry (Merchant et al., 2011). Similar variation across hospitals exists for pediatric IHCA survival rates as well, ranging from unadjusted rates of 29 to 48 percent (Jayaram et al., 2014). Differences in patient and health system characteristics can account for some of this variation. There are also additional limitations in availability of reliable, standardized IHCA data that make measurement and interpretation of patient outcomes challenging, described in the following section.

Hospital Response to IHCA

Cardiac arrest remains a largely unpredictable event that can happen at any time with outcomes that are highly dependent on rapid diagnosis and treatment. The nature of IHCA provides a number of challenges for hospitals and health care systems. For example, smaller facilities may have limited resources for 24-hour, on-site physician availability. Furthermore, many health care providers—including physicians with experience in medical specialties with a low rate of cardiac arrest—may lack the necessary experience and expertise to appropriately respond to an IHCA. A final factor that may affect IHCA outcomes is that most academic or teaching hospitals have historically relied on physicians-in-training (e.g., residents and fellows) to provide resuscitation care. Studies have shown that younger physicians and physicians-in-training may lack competence and confidence in the nontechnical skills, such as leadership and teamwork, required to respond to cardiac arrests (Hayes et al., 2007). Resuscitation teams may have limited opportunities to work together over time in emergency situations, frequently coming together on an ad hoc basis to respond to an IHCA. This approach is innately more stressful and requires greater levels of leadership and teamwork in order to successfully deliver resuscitation care.

Substantial variability in IHCA care delivery throughout the United States, which suggests an opportunity for improving IHCA care processes and closing gaps in care across hospitals. For example, one study determined that delayed defibrillation (defined as provision of defibrillation more than 2 minutes after the initial arrest) occurred in care for approximately 30 percent of patients and was associated with a significantly lower probability of surviving to hospital discharge after multivariable risk adjustment (Chan et al., 2008). Another study reported adjusted rates of delays in time to defibrillation that was nearly 25-fold (delayed defibrillation rates ranging from 2 to 51 percent) across hospitals for patients with VF and pVT cardiac arrests, likely because of differences in hospital-level factors (Chan et al., 2009; Merchant et al., 2009). More recently, Ornato and colleagues (2012) found system-based error rates during IHCA. Some errors identified include discrepancies in alerting hospital-wide resuscitation response, chest compressions, defibrillation, airway management, hyperventilation, medications, vascular access, leadership, protocol deviation, and equipment function problems (Abella et al., 2005; Donoghue et al., 2006; Ornato et al., 2012). Similar deficiencies, related to provision of incorrect compression rate and depth, delays to defibrillation and hyperventilation, have also been noted during IHCA resuscitation in children (Cheng et al., 2015a; McInnes et al., 2011; Sullivan et al., 2014; Sutton et al., 2009, 2013).

Overall IHCA incidence represents the patient burden of illness, the facility's ability to detect deterioration in patients and prevent the cardiac arrest from occuring, and the effectiveness of a faculty's resuscitation response system (Morrison et al., 2013). Hospitals and health care systems have developed a myriad of ways to evaluate and assess patients who suffer cardiac arrest using emergency response plans that are often tailored to their local resources. The following section first describes some of the standard responses used by hospitals across the nation in cardiac arrest care.

General Response

Individual hospitals have varying emergency response protocols and capacities for responding to cardiac arrests. With the exception of patients in CCUs, ICUs, and EDs, designated resuscitation teams are generally alerted to respond to an IHCA occurring anywhere within the hospital using a facility-wide activation system. Typically, team members provide immediate basic and advanced life support (CPR and defibrillation) before transferring patients who achieve ROSC to CCUs or cardiac catherization laboratories for continued diagnostic testing, advanced therapies, neurologic assessment, and post-arrest care. For patients who are deteriorating but have not yet experienced an IHCA, rapid response teams (RRTs), otherwise known as medical emergency teams (METs) in some hospitals, may be activated. These teams differ from resuscitation teams in that their purpose is to prevent an IHCA and not provide resuscitation, through quick evaluation and escalation of care as needed. Similar to resuscitation teams, the composition and organization of RRTs varies substantially across facilities. Box 5-1 describes some of the different types of response teams in the hospital, distinguishing between resuscitation teams and RRTs.

BOX 5-1

In-Hospital Cardiac Arrest Response Teams. Resuscitation Team (i.e., Emergency Code Team). Although The Joint Commission requires that staff be available to respond to the need for resuscitation, and be trained in the use of resuscitation equipment and (more...)

High-Functioning Resuscitation Teams in Hospitals

Hospital resuscitation teams are required to possess specific clinical skills and therefore, often include a respiratory therapist, critical care nurse, and a physician specializing in emergency or acute hospital care (Baxter et al., 2008). Training designed specifically for resuscitation teams is also common, and the content of these courses is mostly consistent across programs. Most training includes modules on CPR technique and ACLS medication protocols, identification and prevention, and the development of nontechnical skills such as communication, teamwork, leadership, and situational awareness (Baxter et al., 2008; Gordon et al., 2012; Jankouskas et al., 2011). One literature review identified common behaviors and attributes of existing resuscitation teams, such as mutual trust and respect among team members, adaptive leadership, open communication, and a shared conception among team members of the purpose of the team and their individual roles (Manser, 2009).

Guidelines from multiple professional organizations and scientific organizations highlight key resuscitation team components (see Table 5-2). The AHA and the International Liaison Committee on Resuscitation (ILCOR) recommend that all hospital resuscitation team programs must include components that detect cardiac arrests, trigger response mechanisms, monitor resuscitation team performance, and train resuscitation team members (Bhanji et al., 2010). These organizations have also recognized the importance of nontechnical training targeted to the development of team and leadership skills. ILCOR has developed a data reporting form that measures team performance along multiple, clinically relevant dimensions, including team composition, structure, coverage, activation, and interventions; the patient's physiological data prior to, and during, the resuscitation; and outcomes for both the patient and the hospital (Peberdy et al., 2007).

TABLE 5-2

Key Abilities of Resuscitation Teams.

Recent AHA and UK Resuscitation Council consensus statements have recognized the importance of developing systems-based approaches to IHCA response (Morrison et al., 2013; Resuscitation Council, 2013). The European consensus statement recommends direct oversight by a resuscitation officer at the facility level and suggests that at least two physicians with advanced life support training are included on the teams, but otherwise, largely avoids commenting on the composition of the team. Recently, there has been an increased emphasis on the importance of nontechnical skills (e.g., leadership and communication) within the resuscitation teams because of data demonstrating an association with improved outcomes, with these skills (Bhanji et al., 2010; Hunziker et al., 2011).

There is considerable variability in the implementation of these resuscitation teams. One study used data from a national survey of 439 hospitals from across the United States and found that nearly one-quarter of facilities failed to report having a pre-nontechnical designated, dedicated resuscitation team as part of their approach to IHCA response, while one-third did not have standardized defibrillators available throughout their facility (Edelson et al., 2014). Among those facilities that did have dedicated resuscitation teams, the composition, leadership roles, and structure of the teams also varied.

Overcoming these challenges has been the recent focus of small quality improvement efforts, many of which emphasize nontechnical skills in addition to core technical skills. In addition to overall leadership, the literature emphasizes the importance of identifying a team leader who is appropriately qualified and trained for this role (Hunziker et al., 2011). Ideally, facilities that have medical training programs should require that physicians in training be backed up by at least one attending physician whose specialty is hospital medicine, intensive care medicine, cardiovascular medicine, or emergency medicine. Teamwork also may be ensured prior to an emergency with a process that clearly delineates team member roles for health care providers who respond to a cardiac arrest. This could include the use of visual tools (e.g., lanyards and badges) and demarcation of positions around a patient (e.g., individual to the left of a patient would be responsible for delivering chest compressions). However, these approaches should never delay the necessary care for a patient experiencing a cardiac arrest. If a team member's arrival is delayed, then other team members must be prepared to fill in and take on other roles in responding to the IHCA.

Together, these sources describe a set of program components and team member actions and behaviors that clinicians and researchers alike consider to be associated with, or essential to, improved team performance and patient outcomes. Table 5-2 lists some of these attributes.

RRT or MET Instituting Earlier Recognition and Response to IHCA

Multiple studies suggest that health care providers often fail to detect changes or abnormalities in patient vital signs hours before an IHCA occurs. Family members or health care providers typically recognize IHCA when the patient has become acutely unresponsive or when an abnormal rhythm is noted on telemetry monitoring. As noted throughout the report, immediate action following collapse is believed to improve outcomes.

The idea of instituting earlier care builds on prior studies examining the use of RRTs (also referred to as METs in some facilities). Many hospitals have implemented RRTs and METs, although evidence demonstrating their effectiveness in improving overall survival rates remains controversial (Chan et al., 2010). In a report from Denmark, failure of RRTs to properly communicate and activate transitions of care for appropriate patients, was identified as a significant limitation. Similarly, several studies of pediatric RRT-MET teams, which are also triggered by the signs of deterioration prior to a cardiac arrest, have reported at best, modest success in reducing cardiac arrests outside the pediatric intensive care unit or reducing mortality overall (Bonafide et al., 2012a, 2014; Brilli et al., 2007; Hunt et al., 2008; Sharek et al., 2007; Tibballs and Kinney, 2009; Winberg et al., 2008). A major obstacle to demonstrating effectiveness of RRTs and METs is the low frequency of events overall, as well as a lack of a consensus on event definition.

Cardiac arrest investigators have also explored different methods for detecting deterioration prior to an IHCA using physiological data. Early recognition would allow for an escalation of care (e.g., transfer to ICU for patients on the general medical floor) prior to the event. Currently, multiple risk stratification tools for evaluating patients have been proposed, including the Modified Early Warning Score for adult and pediatric patients. These tools allow for the early assessment, prediction of IHCA, and possible ICU transfer based on vital signs (Ludikhuize et al., 2014). The Pediatric Early Warning Score (PEWS), first proposed in 2006, can provide more proximate outcome measures to identify deterioration in children in EDs and inpatient units and who were likely to need resuscitation (Duncan et al., 2006; Parshuram et al., 2011). The scores comprise multiple variables including vital signs, clinical assessment, and oxygen therapy, and they have been validated in multicenter studies with high sensitivity and specificity. Implementation of the score has been associated with reduction in clinical deterioration rates and emergency calls to the in-house pediatricians. Randhawa and colleagues (2011) found that cardiac arrest frequency was reduced by 23 percent after the implementation of a bedside PEWS tool. Studies have been performed recently in order to improve current systems by using additional information that is available through the electronic health record, such as clinical data and laboratory results (Churpek et al., 2014). Although such tools hold noteworthy promise, they are still in the early stages of development and implementation and have limitations regarding the generalizability for large-scale adoptions or specificity for IHCA.

Clinical deterioration risk scores that are based on non-vital sign criteria (e.g., age, presence of specific underlying disease, enteral tube, and hemoglobin levels) could also improve outcomes (Bonafide et al., 2012b, 2014; Winberg et al., 2008). Using clinical deterioration scores, combined with METs, the cost-benefit ratio of METs was positive, especially in hospitals with bundled reimbursement. Confirmation of these findings in a broader base of hospitals is needed to develop programs and responses to decrease cardiac arrest among hospitalized patients.

Research Priorities

Variability in the use of specific strategies and care processes and their links to patient outcomes has not been adequately studied to date. Box 5-2 presents the current gaps in evidence and points to future research needs.

BOX 5-2

Priority Areas for Research in In-Hospital Care. Transition of care: Research needed to understand how to best optimize care transitions for cardiac arrest patients at admission, at discharge, and within hospitals, including key elements of the cardiac (more...)

POST-ARREST CARE

Post–cardiac arrest syndrome is a complex clinical condition with four primary pathophysiological consequences, which can include any combination of myocardial dysfunction, neurologic injury, systemic injury because of oxygen loss (ischemia) and subsequent restoration of blood flow (reperfusion), and other precipitating factors (e.g., secondary cardiovascular or pulmonary diseases and pneumonia) (Morrison et al., 2013; Neumar et al., 2008). Post-arrest care therefore focuses on rapidly assessing cardiac arrest patients who have achieved ROSC, optimizing cardiopulmonary function, stabilizing blood flow, minimizing neurologic injury, controlling body temperature, establishing mechanical ventilation to minimize lung injury, and conducting other related prognostication (Peberdy et al., 2010).

Neurologic injury is a concerning and destructive consequence of cardiac arrest affecting the likelihood of short- and long-term survival, disability, and quality of life. One study reported that neurologic injury was the primary cause of death among 68 percent and 23 percent of OHCA and IHCA patients, respectively (Laver et al., 2004; Peberdy et al., 2010). Thus, many interventions related to enhancing post-arrest care are targeted at improving neurologic outcomes. Post–cardiac arrest cardiovascular injury also affects patient outcomes; approximately 30 percent of all deaths among cardiac arrest patients who were initially resuscitated were caused by reduced blood flow. However, multiple studies based on swine models suggest that permanent damage to the left ventricle can be avoided in the immediate period following resuscitation (Kern et al., 1997a,b; Neumar et al., 2008). Thus, it is possible for an individual patient to make a complete cardiac recovery with appropriate hemodynamic support (Laurent et al., 2002; Nolan et al., 2008). Successful management of post–cardiac arrest syndrome requires the availability of well-equipped medical facilities and ICUs, resources, and treatments that can contribute to the rapid stabilization and minimization of tissue damage and organ injuries.

Treatment

Evaluation and treatment of the patient's immediate clinical condition and prognosis occur in parallel and involve a multidisciplinary team (including emergency and critical care providers, neurologists, cardiologists, nurses, laboratory technicians, and other specialists) that often provides simultaneous expertise and care. Optimal post-arrest treatment begins when the patient achieves ROSC and can begin prior to an OHCA patient's arrival in the hospital ED. The time interval between the onset of the cardiac arrest and ROSC is a critical determinant of the severity of the post–cardiac arrest syndrome. With the exception of cardiac arrests that occur in an ICU, IHCA patients generally have intermediate periods of time between collapse and resuscitation. Collapse-to-treatment times for OHCA patients can be longer and more variable depending on a host of factors (e.g., whether the arrest was witnessed, availability of bystander CPR and EMS response times), thus differentially exposing patients to the conditions that result in post–cardiac arrest syndrome. Patients who experience a brief collapse-to-treatment interval (e.g., an intentionally or inadvertently induced cardiac arrest occurring in a cardiac catheterization or electrophysiology laboratory during diagnostic testing) often do not develop post–cardiac arrest syndrome. Because the cardiovascular system is far more resilient than the neurologic system, patients who achieve ROSC in 5 to 10 minutes may have their hemodynamic status restored, but are more likely to sustain some degree of brain injury. With yet longer delays in ROSC, the likelihood and severity of post–cardiac arrest syndrome increases, and neurologic, hemodynamic and metabolic support all become necessary and more critical for possible recovery.

Studies of optimal post-arrest care are evolving, but there are some important gaps in the current evidence base because of several factors. There is a paucity of published literature on post-arrest care by multidisciplinary investigators, limited basic science research, and relatively few randomized clinical trials evaluating the effectiveness of known postarrest care treatments. Often existing studies are less meaningful because of the small size of the population studied. There are additional gaps in evidence regarding long-term outcomes following post-arrest care. As a result of these limitations, the scientific evidence to support the therapies and care strategies offered for patients with post–cardiac arrest syndrome is less robust than that for the patients with other cardiovascular conditions such as acute myocardial infarction, often the precursor to cardiac arrest. However, a number of promising post-resuscitation treatments and therapies emerged over the past several decades and have demonstrated effectiveness in treating individual components of post–cardiac arrest syndrome in limited settings (Nolan et al., 2008).

Historically, the approach for treating post–cardiac arrest syndrome has been a one-size-fits-all strategy of care, with patients ideally receiving a range of available guideline-recommended treatments for a given clinical presentation whenever possible (e.g., therapeutic hypothermia and percutaneous coronary intervention), with the goal of mitigating neurologic injury. However, recent data have urged providers to customize post-arrest treatment protocol based on the neurologic and functional status of individual patients, which can range from the awake and stabilized to comatose patients with varying degrees of secondary clinical complications (Nolan et al., 2008; Rittenberger et al., 2011). This approach not only is beneficial to the individual patient, but also can reduce the cost of care. The goal of these therapies, described in Box 5-3, is to promote a full recovery and restore and preserve neurologic function.

BOX 5-3

Evidence on Common Treatments for Post-Arrest Syndrome. Targeted Temperature Management (TTM). TTM, also known as therapeutic hypothermia, is an early post-arrest intervention designed to reduce the body temperature in resuscitated, comatose cardiac arrest (more...)

Post-arrest care algorithms, supported by AHA guidelines, have proposed multidisciplinary early goal-directed therapy (EGDT) as part of an essential bundle of care to improve survival following cardiac arrest (Peberdy et al., 2010). The post-arrest patient may develop severe systemic inflammatory responses and septic shock syndromes that affect ultimate disability-free survival to hospital discharge. A number of studies have demonstrated a dramatic reduction in mortality in cases of severe sepsis or shock using EGDT, an intervention aimed at maintaining optimal central venous pressure and oxygen saturation (Rivers et al., 2001). Because of the pathophysiological similarities between sepsis and post–cardiac arrest syndrome, EGDT has been adapted for post-arrest care to provide hemodynamic and oxygenation monitoring, in combination with intravenous medication (Nichol et al., 2010). However, based on two recent studies that found no survival benefit related to EGDT in septic shock states, further evaluation of EGDT for the post–cardiac arrest state is needed (Peake et al., 2014; Yealy et al., 2014).

The data to support specific goal-directed therapies for pediatric patients are generally of low quality. Many therapies from adult care, animal models, or different patient populations who are critically ill with conditions other than cardiac arrest have been extrapolated to pediatric populations (Kleinman et al., 2010b). Examples of goal-directed pediatric therapies derived from other sources include titration of inspired oxygen concentration and target saturation, glucose management, vasoactive drugs, and hypothermia (Checchia et al., 2003; Eicher et al., 2005; Finfer et al., 2007; Gandhi et al., 2007; Gluckman et al., 2005; Kern et al., 1997b; Oksanen et al., 2007; Richards et al., 2007; Vasquez et al., 2004; Wiener et al., 2008).

Personalized Medical Care for Cardiac Arrest

Current cardiac arrest care protocols are largely based on formulaic algorithms and guidelines that do not account for individual needs and variations. Differences in etiology, patient characteristics, and rescuer competency can all contribute to variations in AHA-recommended treatment protocols. Personalized medicine, which employs genetic sequencing and other advanced techniques to customize medical care to the needs of the individual patient, represents the final stage in this ongoing progression from generalized to specific health care. With the growth in the catalogue of genetic mutations correlated with specific disease processes, and the equally rapid drop in the cost of gene sequencing, tests to assess a patient's risk for conditions that can precipitate a cardiac arrest are proliferating (Rubinstein et al., 2013). Long QT syndrome, brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, and hypertrophic cardiomyopathy are all recognized cardiac arrest risk factors that are also associated with one or more genetic mutations (Ackerman et al., 2011). Tests for these mutations exist and are recommended by the Heart Rhythm Society in some instances. Most importantly, genome-wide association studies have identified at least 36 genetic variants associated with coronary artery disease, which is present in more than 80 percent of patients who die from cardiac arrest in the United States (Roberts and Stewart, 2012). As other genetic risk factors for cardiac arrest are identified, clinicians will increasingly be able to proactively prescribe antiarrhythmic drugs, place implantable cardioverter-defibrillators, and correct structural cardiac abnormalities through surgical intervention.

Customized medicine in the context of cardiac arrest can alter treatment protocols for individual patients based on results from physiological measurements. In contrast to generalized consensus-based guidelines, one approach to individualized resuscitation employs physiologically guided CPR that uses sensor measurements, such as coronary perfusion pressure, blood pressure parameters, or carbon dioxide excretion, to guide a unique resuscitation protocol for each patient (Sutton et al., 2013). As patient monitoring techniques become more precise, CPR protocols can be adapted in real time to the changing physiological status of the arresting patient. In a recent study assessing the efficacy of a dynamic, personalized CPR protocol in animal models, chest compression depth and vasopressor dosage were respectively titrated to systolic blood pressure and coronary perfusion pressure, in order to reach target blood pressure levels. This “patient-centric” CPR protocol was correlated with a significant 24-hour survival benefit over CPR performed according to the AHA guidelines (Sutton et al., 2014b). Another study found that the same experimental protocol improved 45-minute survival over two protocols that coupled the AHA-recommended pharmacological interventions with audiovisual feedback to meet predetermined targets for chest compression depth (Sutton et al., 2014b). These studies support recommendations for physiological monitoring of CPR during resuscitation, in cases where the monitoring systems are already in place (Meaney et al., 2013). As a majority of IHCAs now occur in ICUs, where such monitoring is often already in place, the transition to resuscitation protocols that monitor and adapt to patient vital signs will potentially benefit a large proportion of cardiac arrest patients (Berg et al., 2013; Girotra et al., 2012; Sutton et al., 2014a).

In additional to advances in treatment, new and more powerful diagnostic and prognostic tools allow clinicians to better tailor preventive and emergent care to the needs of the individual patient (Chan et al., 2012). Highly sensitive imaging techniques such as cardiac magnetic resonance imaging (MRI) and cardiac CT tests can detect specific structural disorders that are known risk factors for cardiac arrest, allowing clinicians to employ preventative care efforts targeted to specific conditions (The Joint Commission, 2011). In post-arrest care, MRI-based imaging techniques provide sensitive and accurate methods of detecting brain lesions and other neurologic features that strongly correlate with poor neurologic outcomes (Choi et al., 2010; Galanaud and Puybasset, 2010; Wijman et al., 2009; Wu et al., 2009), while simple, bedside risk assessments allow for accurate predictions of long-term neurologic status (Chan et al., 2012).

As the list of known risk factors for cardiac arrest grows in tandem with the power of diagnostic tools, it will become easier to preventively treat patients for cardiac arrest, by addressing the specific conditions from which it precipitates. Thus, by fueling continuous refinements in the specificity of treatment protocols, diagnostic and prognostic tools, and preventive risk assessments, the drive to personalize and customize medicine may lead to improvements in cardiac arrest incidence and outcome.

Disparities in Post-Arrest Care

Currently, there is a paucity of literature that specifically examines questions about discrepancies in the application of post-arrest care treatments, leading to differences by gender, race, or ethnicity. The literature suggests that minority populations have not been studied as rigorously for potentially lifesaving therapies such as targeted temperature management (Hypothermia After Cardiac Arrest Study Group). Women were likely underrepresented in the TTM trials focused on patients with an initially shockable rhythm, because women are less likely to have VF as a presenting rhythm (Akahane et al., 2011). Even in more recent research, which included all initial rhythms, women accounted for less than 20 percent of subjects included in the trial (Bro-Jeppesen et al., 2014). Additionally, these studies did not report the racial or ethnic identities of individuals within. However, analysis of CARES data found that therapeutic hypothermia was not differentially used by race or gender among OHCA patients (Mader et al., 2014). Whether there are differences by race and ethnicity in the implementation of TTM in other large database studies, such as the GWTG-R or Resuscitation Outcomes Consortium, remains to be studied.

Disparities in the implementation of cardiac procedures in post-arrest care have been documented. After controlling for potential confounding factors, one study found that among patients admitted to hospitals in California with VF or ventricular tachycardia (VT) arrest, African American patients were significantly less likely than white patients to undergo electrophysiologic studies or to receive an implantable cardioverter-defibrillator (Alexander et al., 2002). Another study determined that younger African Americans had substantially lower odds of receiving at least one potentially lifesaving procedure (e.g., cardiac catheterization or cardioverter-defibrillator) when compared to white patients (Groeneveld et al., 2003). The same study noted a considerable differential in long-term survival, with the life expectancy for white patients (4.1 years) longer than that for African American patients (1.9 years) (Groeneveld et al., 2003). The use of implantable cardioverter-defibrillator has become more widely available, and the use of this technology has increased faster for African American patients than for other populations. However, the disparity in use still exists (Stanley et al., 2007). Similar differences in post-arrest care have been reported for Hispanic patients, with multiple studies demonstrating that Hispanics patients may have poor access to appropriate care with lower odds of receiving implantable defibrillators as well as electrophysiologic studies (Alexander et al., 2002; Groenveld et al., 2003). Although there is limited research devoted to cardiac arrest care for racial and ethnic minority patients, available evidence indicates disparities in both access to care and outcomes. Additional research is required to evaluate the burden of disease among minority populations and to determine the efficacy of appropriate post-arrest treatments for a broader population. Box 5-4 summarizes the key conclusions relevant to disparities in post-arrest treatments.

BOX 5-4

Disparities in Cardiac Arrest Treatments. Racial and ethnic minorities more frequently present nonshockable initial rhythms. Racial and ethnic minorities are more likely to have delayed defibrillation.

Assessment and Prognosis

Cardiac arrest survival with significant neurologic damage can be as devastating, but more burdensome, than death for survivors, family members, and society because it can influence both short-term prognosis and long-term quality of life. Neurologic and functional status needs to be evaluated and addressed promptly. Neurologic assessments may include multidisciplinary care coordination to appropriately and accurately evaluate and treat post–cardiac arrest survivors who do not immediately regain consciousness, in order to maximize the likelihood of complete recovery. The assessment may begin with a neurologic exam and urgent neurologic consultation in the ED, and continues as needed, until discharge. The most robust prognostic estimates are usually obtained from a combination of neurologic examinations and neuro-electrophysiological tests (Booth et al., 2004, Kamps et al., 2013). However, serial neurologic observations beyond the first 24 to 72 hours, and in some cases, more than 96 hours following an arrest, are often required to provide reliable prognostic information (Neumar et al., 2008; Peberdy et al., 2010). During serial observations, trained health care providers (including nurses) systematically record results from clinical neurologic exams in ICUs that use standardized scoring schemes for consciousness (Riker and Fugate, 2014). As shown in Box 5-5, multiple tools available for neurologic assessment and scoring have demonstrated prognostic value. However, more research is needed to refine neurologic prognostic scores and extend observations beyond the acute hospitalization phase of post–cardiac arrest care, in order to more accurately evaluate longer-term cognitive outcomes.

BOX 5-5

Available Tools for Neurologic Assessment Following Cardiac Arrest. Neurologic consultative expertise should be used to assess the patient within the first 24 hours of a cardiac arrest to provide a baseline comprehensive neurologic examination, interval (more...)

Similar to adults, no single test can clearly provide accurate prognostication in children. Information to guide clinicians on neuroprognostication in the pediatric population is even more limited than in adults, although assessment and testing to assess level of brain function are similar for both populations. Repeated examinations, electrophysiological assessment, and imaging all contribute to determining the extent of brain injury after a cardiac arrest. To date, there are no composite scores similar to CASPRI or GO-FAR (see Box 5-1) for children. The most commonly used score is the Pediatric Cerebral Performance Score, which also has significant shortcomings in differentiating mild from moderate disability and was designed to assess neurologic function after pediatric intensive care—not in-hospital cardiac arrest (Fiser et al., 2000). However, some literature suggests that pupillary response within 12 to 24 hours after arrest, NSE and biomarkers, and EEG findings may provide some guidance for clinicians on possible prognosis and outcomes (Nishisaki et al., 2007; Topjian et al., 2014b). Making predictions in children is further complicated by developmental stage and the recognized plasticity of the immature brain.

Appropriate Timing of Prognosis

Post-arrest patients often require sequential and frequent neurologic evaluations in the ICU. Determination of neurologic prognosis can be difficult during the period immediately following ROSC and, as a result, some experts have recommended waiting at least 72 hours or longer to allow the brain to recover from ischemia after an arrest before making major decisions (Neumar et al., 2008; Peberdy et al., 2010). Neuroprognostication is often delayed to beyond 96 hours for patients who have been treated with TTM, to allow recovery from the possible side effects of sedation and other drugs. One study among adult comatose patients treated with hypothermia, absence of pupillary light responses or corneal reflexes 72 hours after CPR, and absence of somatosensory evoked potentials during and after hypothermia were determined to be reliable predictors of poor outcomes. Other investigators confirm that the motor response to painful stimuli, corneal reflexes at 72 hours and neuron-specific enolase (NSE) levels after cardiac arrest were not a reliable tool for the early prediction of poor outcome for patients who had received TTM (Kamps et al., 2013). The GCS system can also reliable assess post–cardiac arrest patients who are no longer on sedatives and, as a result, its prognostication is delayed for patients who received TTM (Schefold et al., 2009).

Prognostication and Withdrawal of Care

Patient preferences should be of paramount importance in determining end-of-life care decisions (IOM, 2015). But clinical decisions regarding withdrawal of life support for comatose and unresponsive patients following cardiac arrest are complicated, particularly in the absence of advance directives. These decisions are determined by multiple factors: older age and secondary comorbidities of patients, race, a poor initial neurologic exam, and multiple organ failure (Albaeni et al., 2014). Factors such as the existence of living wills, health care proxies, family perspectives, and religious beliefs of patient and family members also influence such decisions.

Although neurologic prognostic assessments can provide reasonable accuracy regarding the likelihood of meaningful recovery, there are no clear guidelines beyond maintaining a 72 hours or longer observation period, with respect to termination of care for cardiac arrest patients.

Albaeni and colleagues found that post-arrest care is withdrawn early (within 48 hours of hospital admission) for more than half of all cardiac arrest patients (Albaeni et al., 2014). This is particularly alarming because less than 20 percent of these patients had advance directives authorizing early care withdrawal (Albaeni et al., 2014). Another study of 89 OHCA patients found that 10 patients regained consciousness 72 hours after receiving hypothermia, which suggests that early care withdrawal may prematurely terminate care that could result in survival with good neurologic recovery (Gold et al., 2014). The factors that influence such decisions have not been studied and require further research.

Existence and early implementation of a DNAR order portends a fatal outcome and has been associated with less aggressive hospital care (Jackson et al., 2004), including lower rates of potentially critical hospital interventions, procedures, and survival to discharge (Richardson et al., 2013). Although there is a paucity of literature on differences between DNAR orders in women versus men for cardiac arrest, evidence from other medical conditions (such as sepsis and trauma) suggests that early DNAR placement may partially explain the differences in postarrest interventions for women compared to men (Chang and Brass, 2014; Salottolo et al., 2015). However, it does not account for the lower rates of cardiac procedures and the placement of implantable cardioverter-defibrillator in racial and ethnic minority patients, because they are more likely to have lower rates of DNAR order placement compared to white patients (Richardson et al., 2013). Survival is never possible if care is withdrawn prematurely, but the patient's preferences and values should always be the guiding principles in customized approaches to care.

Cardiac Arrest Centers of Excellence

Because care for the post-arrest patient is complex and often requires multidisciplinary team approaches, some regions in the United States (Arizona, Minnesota, New York, Ohio, Texas, and Virginia) have developed regional systems-of-care to improve OHCA resuscitation care and patient outcomes (Nichol et al., 2010). The primary goal for regionalizing care is to improve health outcomes by transporting patients to medical facilities with optimal resources and expertise in cardiac arrest care (Bobrow and Kern, 2009; Lurie et al., 2005). However, these established systems do not have common process or performance standards or have similar funding and reimbursement criteria. Moreover, because of the lack of comprehensive evidence for a standard post-arrest care strategy, there are substantial differences between available treatments and therapies at these cardiac arrest centers of care. For example, in some regions, EMS is authorized to bypass the nearest hospital and transport patients to a facility capable of providing specific post-arrest care treatments such as TTM, while in other regions there are no such protocols in effect (Nichol et al., 2010). In spite of these preliminary efforts, regionalization of resuscitation care has not yet become a national practice in the United States (Nichol et al., 2010; van Diepen et al., 2013).

The body of evidence demonstrating the effectiveness of centers of excellence is expanding. A study of a statewide regionalization of postarrest care, along with the implementation of a bypass protocol that allowed EMS providers to transport select patients (comatose patients with ROSC) to specialized centers, was associated with improved survival and functional outcomes after OHCA (Spaite et al., 2014). A recent study proposed a tiered-transport concept, in which conscious patients with ROSC are transported to the nearest appropriate ED, according to local EMS jurisdictional policies, irrespective of bypass status. For more complicated post–cardiac arrest cases, the concepts of either bypass or early transfer to a higher level cardiac care facility promptly after initial stabilization in the closer facility are being evaluated as potentially useful strategies (Myerburg, 2014). Table 5-2 illustrates a four-tiered priority-based hospital bypass system, which aligns immediate post–cardiac arrest status of patients to the level of required care.

Much of the evidence for regionalization of care in the cardiac arrest field has been based on extrapolation from other similar fields such as trauma or stroke. The health care field has determined that these patients who experience similarly complex conditions (e.g., stroke) are better managed in centers of excellence, or within systems, that are equipped and designated to provide higher levels of advanced care. These centers of excellence have demonstrated improvement in patient outcomes and reduced costs by implementing guideline-based systemwide protocols within a region for prehospital and hospital care, enhancing communication capabilities and creating trauma registries (MacKenzie et al., 2006; Share et al., 2011; Singh and MacDonald, 2009). Outcomes for stroke have also improved because of greater regionalization of care. The American Stroke Association encouraged EMS integration into stroke systems of care and recommended the transport of stroke patients to a specialized facility whenever feasible (Acker et al., 2007).

In an ideal setting, cardiac arrest centers of excellence that receive post-arrest care patients should have the structural components (e.g., cardiac catheterization laboratory) and therapeutic capabilities (e.g., TTM, PCI, dialysis) to be able to provide a bundle of essential treatments that have demonstrated benefit in treating post-arrest care syndrome and improving patient outcomes. For example, patients commonly develop renal failure following cardiac arrest and may thus require hemodialysis (Neumar et al., 2008). These hospitals must also be able to provide a multidisciplinary team that has the requisite knowledge, skills, and abilities to provide advanced, coordinated post-resuscitation care. This multidisciplinary team will require the intensive care team to manage hemodynamic and metabolic status; the electrophysiology teams to assess and manage the arrhythmias; the neurology teams to manage, assess, and limit the CNS complications; and the cardiology team to perform cardiac catheterization and coronary angiography. Because of the limitations in scientific evidence described earlier, these elements have not yet been implemented uniformly across existing cardiac arrest centers of excellence.

FIGURE 5-2

Targeted urgency scale to reflect a priority-based hospital bypass system. NOTES: CCU = critical care unit; ED = emergency department; ICU = intensive care unit; NICU = neonatal intensive care unit; PCI = percutaneous coronary intervention; ROSC = return (more...)

Research Priorities

The complex nature of post-arrest syndrome and the multiple global body injuries that need to be managed simultaneously complicate studies of this condition. As a result, there is limited scientific evidence available that demonstrates the benefit of the therapies designed for post-arrest stabilization for patients who have varying degrees of post-arrest syndrome. In some instances, the justification for the use of the therapies that are described in this section is based on extrapolation of benefits that have been found in other clinical situations with the similar initial pathophysiology (e.g., acute myocardial infarction or sepsis). In other instances, the treatments discussed above have demonstrated effectiveness in limited settings using small cohorts, or are supported by using population health data, rather than in large randomized clinical trials. In spite of these challenges and existing knowledge gaps, health care systems and academic medical centers that practice aggressive, multidisciplinary post-resuscitation care often report excellent patient outcomes, with upward of 80 percent of survivors having favorable neurologic outcomes at discharge (Langhelle et al., 2003; Nolan et al., 2010). Some investigators have put forth the concept of a multilevel approach to care delivery based on whether the patient has neurologic function, is comatose, or has biomarkers of severe neurologic injury. This approach suggests a more aggressive treatment protocol (using PCI or hypothermia) in patients with neurologic function and a more metabolically directed approach to care in those with more severe injury. Thus, not only is this an area ripe for further investigation and evidence building, but also it is an area where emulation of local best practices could result in improved survival and outcomes on a broader scale throughout the nation. Box 5-6 presents the current gaps in evidence and points to future research needs.

BOX 5-6

Priority Areas for Next Steps in Post-Arrest Care Research. Implementation of documented plans and systems for care transitions Appropriate composition of the multidisciplinary teams, including skills related to emergency medicine, intensive care, acute (more...)

STRATEGIES TO IMPROVE THE QUALITY OF CARDIAC ARREST CARE IN HOSPITAL SETTINGS

The essential components of any continuous quality improvement (CQI) program are measurement of care processes and outcomes, benchmarking of performance within and among organizations, and implementation of changes in practice in an effort to improve quality and patient outcomes. These iterative processes also inform, and are informed by, revisions to consensus-based guidelines, as discussed in Chapter 6. Hospitals and EMS systems alike have reported improvements in cardiac arrest survival rates after implementing CQI programs (Ewy and Sanders, 2013; Girotra et al., 2013). Such results provide strong support for ongoing efforts to strengthen data collection, research, and CQI activities related to IHCA. Chapter 6 also discusses CQI on a broader level in terms of ensuring the implementation of effective treatments and care settings across communities.

Hospital-based resuscitation systems in the United States are an essential component of the cardiac arrest chain of survival and, in addition to responding to IHCA, provide the bulk of specialized post-arrest care for both OHCA and IHCA patients. Recognizing that there are some clear differences in the immediate treatments required by IHCA and post-arrest care patients and that care is provided by different providers, some common themes applicable to both have emerged. Multiple guidelines on IHCA and post-arrest care treatment protocols exist; however, the scientific evidence base demonstrating the effectiveness of specific protocols and guidelines are limited or, at best, mixed. Relatively few hospitals regularly monitor cardiac arrest outcomes, and there are currently few national standards that require performance benchmarking. This section explores some overarching themes and presents strategies to enhance the quality of care within hospitals.

Establish Separate Diagnosis Codes for IHCA and OHCA

Differences in epidemiology, etiology, and treatment for IHCA and OHCA exist. As compared to patients with OHCA, those experiencing a cardiac arrest in the hospital are fewer in number and more likely to survive. Additionally, IHCAs are less likely to occur as a result of preexisting cardiovascular disease and, notwithstanding substantial variations in the quality of care, IHCA patients are more likely to receive early treatment. Hospital systems can benefit from separate administrative billing codes for OHCA and IHCA, because the cost of inpatient care for IHCA patients and OHCA-patients who receive hospital-based post-arrest care are markedly different. To achieve a more nuanced understanding of the differences and commonalities between IHCA and OHCA, formal classification and codification to recognize the conditions as unique is needed.

As described earlier, identifying IHCA using hospital claims and administrative data is challenging because of the lack of a unique diagnostic code for this clinical condition. The ICD coding system, developed and maintained by the World Health Organization, defines medical diagnoses and procedure codes that are commonly used for data collection, research analysis, and billing purposes. The Centers for Disease Control and Prevention's North American Collaborating Center collaborates with the Centers for Medicare & Medicaid Services (CMS) to adapt ICD diagnosis codes for hospitals in the United States. Currently, no specific ICD diagnosis code exists for IHCA, although ICD-9 and -10 include codes for cardiac arrest in general (shown in Table 5-3). Select medical procedures (e.g., cardiac arrest during surgery, and anesthesia during pregnancy or labor) and at-risk populations (e.g., neonates) also have special codes for cardiac arrest.

TABLE 5-3

Examples of ICD-9 and -10 Codes for Cardiac Arrest.

Established ICD-9 coding practice defines primary and secondary diagnoses largely based on whether an underlying cause of cardiac arrest can be determined rather than on whether a patient arrives at a hospital in a state of cardiac arrest. As a result, researchers studying IHCA attempt to identify IHCA in administrative data using specific algorithms that often use a combination of diagnosis codes, hospital-specific procedure, and present on admission codes to make educated guesses about the location of the initial event. However, this procedure can be inaccurate. A number of situations may contribute to these low rates of accuracy. For example, if IHCA is identified using codes for the delivery of chest compressions in order to determine a numerator, an individual who dies from cardiac arrest, but does not receive CPR, is not counted in the numerator.

Moreover, current ICD-9 guidance instructs hospital coders not to code for cardiac arrest to indicate an inpatient death if the cause is known because the Uniform Hospital Discharge Data set uses a separate item. A recent study that tried to identify hospitalized patients who had IHCA (and did not have DNR orders) using the ICD-9 codes 427.5 (cardiac arrest), 99.60 (CPR), and 99.63 (closed chest massage) found that this method had only 76 percent positive predictive value (Bucy et al., 2015).

Other available codes do not adequately correct for the absence of separate ICD codes. Moreover, at this time there is only one diagnosis related group (DRG) code for all cardiac arrest used to determine Medicare reimbursement to hospitals for inpatient stays. Although a separate indicator code can be used to identify a diagnosis code (e.g., cardiac arrest) as present on admission, this code (by definition) does not attach to a patient unless that patient is admitted to the hospital. Thus, a person can have a cardiac arrest within a hospital, receive treatment but die within a hospital emergency department, and not be identified in the data as having experienced an IHCA. This affects efforts to measure and improve the quality of cardiac arrest care provided by hospital personnel, including initial resuscitation efforts and the post-arrest care of patients in ROSC. A separate ICD-10 code differentiating IHCA and OHCA would improve the reliability and validity of research, allow for precise calculation of incidence and survival.

Develop Standardized Performance Metrics

Accurate measurement is a cornerstone of a quality improvement program. Standards that require the collection of outcome metrics across the continuum of IHCA and post-arrest care are needed in order to promote meaningful improvements in hospitals across the United States. Performance measures are vital to the provision of quality health care because they allow for benchmarking across and within hospitals and provide firm evidentiary basis to guide clinical patient or family decision making.

There is a need for formally endorsed standards that allow benchmarking at the national level. However, currently no quality metrics are endorsed by The Joint Commission, National Quality Forum, or CMS that could be used to specifically assess quality of IHCA or post-arrest care. Hospitals that are accredited by The Joint Commission are required to adhere to some general standards for in-hospital resuscitation services. In 2008, The Joint Commission endorsed a patient safety goal aimed at improving recognition and response to changes in a patient's clinical condition (Revere, 2008). This could be adapted for assessment of IHCA quality of care, because these patients often present changes in vital signs and show clinical signs of deterioration prior to an arrest. There are general Joint Commission standards related to resuscitation services in hospitals for quality improvement review, evaluation, and action that apply to resuscitation care; however, none are specifically designed for in-hospital cardiac arrest (see Box 5-7 for a summary of relevant standards). Adding specificity to the general standards to support collection of common data elements to enable the identification of people that have experienced in-hospital adult and pediatric arrest would be a good first step to help organizations (and a national performance improvement effort) to understand how best to optimize the outcomes of arrest patients.

BOX 5-7

The Joint Commission Standards Related to Resuscitation Services in Hospitals. Standard PC.9.30 Resuscitation services are available throughout the hospital.

Efforts to develop national performance measures for IHCA and post-arrest care have been unsuccessful to date. In 2012, The Joint Commission, in collaboration with private corporations, completed pilot testing of four cardiac arrest–specific inpatient measures (shown in Table 5-4) that have demonstrated effectiveness in improving patient survival and neurologic outcomes (The Joint Commision, 2014). However, due to the small number of participating hospitals (seven) and the estimates of limited data reliability, the measures were not advanced for endorsement (The Joint Commission, 2014). These metrics also did not capture outcomes longitudinally across the continuum of care or include assessments of care related to the post–cardiac arrest state. Some of these proposed metrics may be difficult for some hospitals to achieve (e.g., determining timeliness to first defibrillation attempt), without making substantial improvements in the care delivery process.

TABLE 5-4

Relevant ICHA and Post-Arrest Measures Piloted by The Joint Commission.

The AHA recently developed a set of performance metrics related to IHCA. Unlike previously proposed quality standards, the AHA inpatient metrics aim to monitor overall incidence and survival rates, and CPR quality as a first step, rather than point toward many specific process of care measures. It includes the following metrics applicable to adult and pediatric IHCA populations: (1) IHCA survival rate, (2) IHCA incidence rate in noncritical care, nonprocedural, inpatient areas per 1,000 patient-days, (3) proportion of hospitals (with more than 200 beds) reporting IHCA to a national registry, and (4) proportion of IHCA with attempted resuscitation, in which CPR performance data were objectively monitored (Neumar, 2015). Studies of existing in-hospital registries such as GWTG-R have shown substantial improvements in patient outcomes over time (overall survival rate increased from approximately 13.7 percent to 22.3 percent from 2000 to 2009) among hospitals that regularly monitor and report data on cardiac arrest and resuscitation related variables. Adopting these standard metrics may be a potential next step in driving in-hospital resuscitation care and patient outcomes (Girotra et al., 2012).

Aligning improvements with related national initiatives has been successful in driving advances in quality of care for other conditions. For example, certified primary and comprehensive stroke centers were developed by The Joint Commission, in collaboration with the American Heart Association and the Brain Attack Coalition, after leaders recognized the parallels between stroke care for patients and the success of trauma centers in improving care and outcomes for people with traumatic injuries (Alberts, 2014). Since the launch of the stroke centers of excellence concept, standard performance measures for stroke treatment have been adopted, and certified centers are required to collect and benchmark their performance as part of CQI programs (The Joint Commision, 2015). Developing and formally endorsing standard performance metrics for cardiac arrest could improve resuscitation care processes, enhance patient outcomes, and support future research efforts to optimize care for IHCA, OHCA, and post-arrest care.

Implementing Patient- and Family-Centered Care

Patient-centered care is an increasingly recognized goal within many health care delivery systems. This can have unique challenges in the field of cardiac arrest, given that resuscitation, and continued post-arrest care may not be desirable for all patients given individual prognoses, care preferences, and values. Possible misconceptions about outcomes following CPR among the general public, and poor explanations about treatment options for cardiac arrest can affect patients and families decisions, which affects outcomes (both desired and unwanted). Recent studies suggest that patient knowledge of CPR is inadequate, but can be improved by brief education videos and discussions with providers (Heyland et al., 2006; Wilson et al., 2015). Many patients and family members may choose not to have aggressive care, when they are appropriately educated about resuscitation (Choudry et al., 2003). As discussed in earlier sections, there is wide variability in institutional withdrawal of care protocols for patients with severe neurologic deficit. Although advanced directives and end-of-life discussions are encouraged for many types of high-risk patients, large proportions of patients with significant cardiac comorbidities (such as advanced heart failure), implantable defibrillators, and pacemakers do not participate (Dunlay et al., 2012; Pasalic et al., 2014; Tajouri et al., 2012). Because withholding resuscitation care requires an order that establishes DNAR status, hospitals should have a standard protocol for discussing advance directives with patients, emphasizing patient autonomy and informed decision making. Studies have demonstrated that these discussions are not harmful and may ultimately reduce unnecessary or unwanted aggressive resuscitation and continued post-arrest care interventions in patients (Temel et al., 2010; Wright et al., 2008).

An important, but controversial, aspect of in-hospital resuscitation efforts involves whether, and in what way, family members should be present during resuscitation efforts following an IHCA (Kramer and Mitchell, 2013). Although there is no broad consensus, inviting family presence during resuscitation has been weakly endorsed by the AHA as being potentially beneficial, with no evidence of harm to family members at risk of posttraumatic stress or anxiety (Goldberger et al., 2015; Morrison et al., 2010). Theoretical benefits include transparency, a sense of closure for family members, and possible assurance that delivery of resuscitation was, in fact, congruent with patient wishes. Potential harms include introduction of legal risks, interference with resuscitation, and exposure of family members to what may be an intense and unsettling scene. Pediatric settings potentially magnify the need for transparency and closure for parents and loved ones of children experiencing cardiac arrest. Despite initial concerns, recent data indicate that both families and staff support the concept, with many families expressing a strong desire to be close to their child in the final moments of their life (Duran et al., 2007). Multiple pediatric associations support family presence (ENA, 2009; Henderson and Knapp, 2005; Kleinman et al., 2010a).

In either adults or children, the collective literature suggests that ideally family presence should not be an ad hoc experience. Rather, hospitals should have explicit, detailed policies regarding whether family presence will be invited. These policies should also identify specific roles for resuscitation team members, such as escorting family members to the scene, explaining the events, and—critically—debriefing with the family afterward to answer questions and identify potential adverse effects of the experience. Box 5-8 summarizes the key points in this chapter.

BOX 5-8

Chapter Summary and Key Points. In-Hospital Cardiac Arrest IHCA is in many ways different from OHCA, and represents a unique population subset.

CONCLUSION

There are many opportunities to improve and optimize care for cardiac arrest patients within hospitals, and to increase the likelihood of survival with good neurologic outcomes for all cardiac arrest patients. Today, there are remarkable variations between hospitals in treatments protocols for IHCA and post-arrest care, which lead to differential and often poor outcomes. These differences occur partially because of a lack of scientific evidence and known standards in resuscitation care. In response to the growing literature that highlights these systemic failures, experts in the resuscitation field, guideline-setting organizations, and some hospital administrators are placing an increased emphasis on developing quality improvement strategies. This requires stakeholders to sequentially prioritize performance-standard setting, the measurement and collection of patient data, and the development and implementation of continuous quality improvement programs within hospital-based resuscitation systems of care. This will allow each system to assess its performance and benchmark against other similar institutions and will drive improvements in quality of care.

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