2/8/2016

1

Improving Survival after In-hospital Cardiac Arrest:

Life after Death

Saket Girotra MD, SMAssistant Professor of Medicine

University of Iowa Carver College of Medicine

Disclosures

• Co-chair, Adult Research Task ForceGet With The Guidelines-Resuscitation American Heart Association

Learning Objectives

• Describe epidemiology of in-hospital cardiac arrest

• Describe processes of care associated with improved survival

• Outline potential strategies for improving survival and neurologic outcomes

2/8/2016

2

History of CPR

1500-1700

Modern History

• Peter Safar

– Head tilt, chin lift

– Mouth-to-mouth respiration

– ‘ABC’ of resuscitation

• William Kouvenhoven

– closed cardiac massage

• Bernard Lown

– Modern defibrillators

2/8/2016

3

Recommended Guidelines for Reviewing, Reporting, and Conducting Research on In-Hospital Resuscitation:

The In-Hospital ‘Utstein Style’

Richard O. Cummins, Douglas Chamberlain, Mary Fran Hazinski, Vinay Nadkarni, Walter Kloeck, Efraim Kramer, Lance Becker,

Colin Robertson, Rudi Koster, Arno Zaritsky, Leo Bossaert, Joseph P. Ornato, Victor Callanan, Mervyn Allen, Petter Steen,

Brian Connolly, Arthur Sanders, Ahamed Idris, and Stuart Cobbe

CirculationVolume 95(8):2213-2239

April 15, 1997

Copyright © American Heart Association, Inc. All rights reserved.

Conceptual Model

Cardiac Arrest“Surviving a code”

or ROSCNeurologically Intact Survival

Acute Resuscitation Phase

• Patient Factors(age, sex, co-morbidities)

• Cardiac arrest characteristics(rhythm, witnessed)

• Resuscitation response(response time, quality of CPR, timely defibrillation)

Post Resuscitation Phase

• Availability of treatment (hypothermia, cardiac cath)

• Supportive critical care(intensive care nurses, structured treatment protocols)

• Resources & Personnel (specialists, physicians)

• Variability in advanced care directives

National Registry of Cardiopulmonary Resuscitation (NRCPR)

• Established in 2000

• Based on the Utstein template for cardiac arrest

• Multi-center registry of IHCA

• Multi-pronged strategy for identifying IHCA

• Rich clinical data abstracted by trained personnel

• Focus – quality improvement

• Now “Get With The Guidelines-Resuscitation”

2/8/2016

4

Epidemiology of in-hospital CA

• 200,000 patients in U.S. every year

• 20% are black

• 25% of IHCA is due to VF/VT

• Burden of co-morbidities is higher

• Survival 17%Peberdy et al Resuscitation 2003Merchant et al Crit Care Med 2011

Delayed Defibrillation for VF/VT

2/8/2016

5

Survival to discharge RR

Unadjusted 0.73 (0.67-0.79)

Adjusted for age and sex 0.70 (0.64-0.76)

plus clinical characteristics 0.81 (0.75-0.86)

plus hospital characteristics 0.82 (0.76-0.89)

plus time to defibrillation 0.90 (0.83-0.96)

• N=84,625 patients between 2000-2009 at 374 hospitals

• Examined whether survival outcomes have improved over time using a GEE model

2/8/2016

6

Risk-Adjusted Survival to Discharge

10.7%

14.8%

Adj RR per-10 year = 1.42 (1.23-1.64)

13.717.1 18.2 17.8 18.9 20.0 20.5 21.2

23.3 22.3

0

10

20

30

40

50

60

70

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Su

rviv

al t

o D

isc

ha

rge

, %

P for trend < 0.001

OVERALL

Adj RR per-10 year = 1.42 (1.23-1.64)

Girotra et al NEJM 2012

Risk-AdjustedSurvival to Discharge -By Rhythm

10.7%

14.8%

Adj RR per-10 year = 1.42 (1.23-1.64)

28.6

41.5

6.8

13.3

0

10

20

30

40

50

60

70

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Su

rviv

al t

o D

isc

ha

rge

, %

P for trend < 0.001 for all

Adj RR per-10 year = 1.71 (1.39-2.10)

Adj RR per-10 year = 1.25 (1.08-1.44)

ASYSTOLE & PEA

VF & VT

Girotra et al NEJM 2012

Neurological Disability

10.7%

14.8%

Adj RR per-10 year = 1.42 (1.23-1.64)32.928.1

0

10

20

30

40

50

60

70

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Ne

uro

log

ica

l D

isa

bil

ity,

% (

CP

C >

1)

Adj RR per 10-year = 0.82 (0.74, 0.99)

OVERALL

P for trend 0.02

Girotra et al NEJM 2012

2/8/2016

7

Racial differences in survival trends

Overall Stratified by rhythm type

0

0.05

0.1

0.15

0.2

0.25

Su

rviv

al t

o d

isch

arg

e

White Black p<.0001

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

0.5

Su

rviv

al t

o d

isch

arg

e

VF and VT VF and VT

Asystole and PEA Asystole and PEA

p = 0.0037

p = 0.0739

Long-term survival

Chan et al NEJM 2013

Has improvement in survival been uniform, or

have some hospitals improved more than others

2/8/2016

8

Hospital variation in IHCA survival

0

10

20

30

40

50

60

0.12 to<0.14

0.14 to<0.16

0.16 to<0.18

0.18 to<0.20

0.20 to<0.22

0.22 to<0.24

0.24 to<0.26

0.26 to<0.28

0.28 to<0.30

0.30 to<0.32

0.32 to<0.34

0.34 to0.40

Ho

spit

als,

n

Risk-Standardized Hospital Survival Rate for Cardiac Arrest

Chan et al JACC 2013

Adjusted Hospital Trends

OVERALL1st Quartile (Bottom)

2nd Quartile 3rd Quartile4th Quartile

(Top)

Mean change 1.07 1.01 1.05 1.05 1.13

Range 0.97-1.18 0.97-1.03 1.03-1.07 1.04-1.07 1.11-1.18

Odds ratios

Num

ber of hospitals

1.00 1.05 1.10 1.15

05

1015

0

5

10

15

20

25

1 6 11 16 21 26 31

Nu

mb

er o

f H

osp

ital

s

Rate of Survival to Discharge

2000-2003

2007-2010

Hospital Rates of Survival to Discharge

2/8/2016

9

Association of Hospital Characteristics with Survival Improvement

Hospital Characteristic P for interaction

Census Region 0.81

Location (Urban or rural) 0.57

Ownership status 0.55

Bed size 0.73

Teaching 0.03

Post-resuscitation phase of IHCA

Post-resuscitation phase

• Accounts for nearly 40% of in-hospital cardiac arrest deaths

• Limited evidence regarding effectiveness of different strategies for improving post-resuscitation survival in IHCA

• Extrapolated from studies of OHCA

– Therapeutic hypothermia

– Early coronary angiography

2/8/2016

10

Hospital variation in post-resuscitation survival

Girotra et al Unpublished data

0

20

40

60

80

100

120

140

160

20% 25% 30% 35% 40% 45% 50% 55% 60%

Nu

mb

er

of

Ho

sp

ita

ls

Risk Standardized Survival to Discharge Rate

Hospital variation in IHCA survival

0

10

20

30

40

50

60

0.12 to<0.14

0.14 to<0.16

0.16 to<0.18

0.18 to<0.20

0.20 to<0.22

0.22 to<0.24

0.24 to<0.26

0.26 to<0.28

0.28 to<0.30

0.30 to<0.32

0.32 to<0.34

0.34 to0.40

Ho

spit

als,

n

Risk-Standardized Hospital Survival Rate for Cardiac Arrest

Lessons from STEMI Care

• Identified top-performers for STEMI care– Hospitals that had consistently shorter D2B

times

• Mixed-methods study– Site visits at top performing hospitals

– Key strategies at top performing hospitals

– Surveyed hospitals to narrow down

Bradley et al JACC 2006Bradley et al Circ 2006

2/8/2016

11

Bradley et al NEJM 2006

Trends in D2B time in recent years

Krumholz et al Circ 2011

Survey of hospital practices

• Therapeutic hypothermia

• Early coronary angiography

• Intensive care

• Nurse-patient ratio

• Structured treatment protocols

• Quality improvement activities

2/8/2016

12

Summary

• In-hospital cardiac arrest is common, and associated with poor survival

• Processes of care such as time to defibrillation can be important metrics to monitor resuscitation quality

• Survival after IHCA has improved in recent years, although the underlying factors remain unclear

Summary

• Marked variation in survival across hospitals persists

• Identifying best-practices related to resuscitation care at hospitals could be an innovative strategy to improve IHCA survival

Acknowledgements

• National Institutes of Health

– K08 Career Development Award

• American Heart Association

• Mentors

– Paul Chan

– Peter Cram

– Gary Rosenthal

• Mentees

– Ankur Vyas

– Lee Joseph

– Rohan Khera

2/8/2016

13

Thank you

Questions?

ADDITIONAL SLIDES

Hospital variation in post-resuscitation survival - unadjusted

0

10

20

30

40

50

60

70

80

90

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Nu

mb

er

of

Ho

sp

ita

ls

Unadjusted Survival to Discharge Rate

Girotra et al Unpublished data

2/8/2016

14

Trends in Survival

Acute Resuscitation Survival

42.7

54.1

10

20

30

40

50

60

70

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Su

rviv

al,

%

P for trend < 0.001

OVERALL

Post-resuscitation survival

32.0

42.9

10

20

30

40

50

60

70

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Po

st-R

esu

scit

atio

n S

urv

iva

l, %

P for trend < 0.05

OVERALL

Girotra et al NEJM 2012

Hospital Variation in Survival Trends

• N=93,342 IHCA patients at 231 hospitals

• Two-level hierarchical multivariable regression model (random intercept & random slope model)

• Magnitude of survival improvement at each hospital was quantified using odds ratio – Odds ratio = 1 (No improvement)

– Odds ratio > 1 (improvement in survival)

– Odds ratio < 1 (worsening of survival)

Girotra et al JAHA 2014

Hospital Characteristics

CHARACTERISTICS N=231

Census Region

North Mid-Atlantic 33 (14.3)

South Atlantic 59 (25.5)

North Central 52 (22.5)

South Central 41 (17.7)

Mountain/Pacific 46 (19.9)

Urban Location 207 (89.9)

Non-profit ownership 162 (70.1)

Bed size < 250 82 (35.5)

Major Teaching 55 (23.8)

2/8/2016

15

Unadjusted Hospital Trends

OVERALL1st Quartile (Bottom)

2nd Quartile 3rd Quartile4th Quartile

(Top)

Mean change 1.04 1.00 1.03 1.08 1.09

Range 0.97-1.12 0.97-1.01 1.01-1.04 1.07-1.10 1.07-1.12

Odd ti f

Num

ber of hos

pita

ls

1.00 1.05 1.10

05

1015

20

Hospital variation in post-resuscitation survival - unadjusted

0

10

20

30

40

50

60

70

80

90

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Nu

mb

er

of

Ho

sp

ita

ls

Unadjusted Survival to Discharge Rate

2/8/2016

16

Bradley et al NEJM 2006

Trends in D2B time in recent years

Krumholz et al Circ 2011

Epidemiology

• Cardiac arrest is the 3rd leading cause of death in the industrialized world

• In Canada, – 30,000-45,000 patients suffer an out-of-hospital cardiac

arrest

– Xxx patients suffer an in-hospital cardiac arrest

• In the United States,

– OHCA: 350,000 per-year

– IHCA 210,000 per-yearChan et al Circulation 2014 Go et al Circulation 2015Merchant et al Resuscitation 2011 Girotra NEJM 2012

2/8/2016

17

Conceptual Model

Cardiac Arrest“Surviving a code”

or ROSCNeurologically Intact Survival

Acute Resuscitation Phase

• Patient Factors(age, sex, co-morbidities)

• Cardiac arrest characteristics(rhythm, witnessed)

• Resuscitation response(response time, quality of CPR, timely defibrillation)

Post Resuscitation Phase

• Availability of treatment (hypothermia, cardiac cath)

• Supportive critical care(intensive care nurses, structured treatment protocols)

• Resources & Personnel (specialists, physicians)

• https://www.youtube.com/watch?v=ILxjxfB4zNk

Post-resuscitation phase

• Approximately 30-50% of cardiac arrest deaths occur during post-resuscitation phase

• Most of these deaths are due to deleterious consequences of no-flow state

• Emerging evidence that care during the post-resuscitation phase may impact patient outcomes

2/8/2016

18

IMPLICATIONS

• Assuming a stable incidence 200,000 cardiac arrests / year

2000 2009Net

Gain

Survival to discharge 27,400 44,600 17,200

No significant neurological disability

18,385 32,067 13,682