A Conceptual Framework to Reduce Inpatient Preventable Deaths.

BACKGROUND: Efforts to reduce preventable deaths in the in-hospital setting should target both cardiopulmonary arrest (CPA) prevention and optimal resuscitation. This requires consideration of a broad range of clinical issues and processes. A comprehensive, integrated system of care (SOC) that links data collection with a modular education program to reduce preventable deaths has not been defined. METHODS: This study was conducted in two urban university hospitals from 2005 to 2009. The Advanced Resuscitation Training (ART) program was implemented in 2007, incorporating hands-on resuscitative skills and in-hospital-specific training with an institutional resuscitation database. Linkage between the database and training modules occurs via the ART Matrix, which classifies all CPA events into the following etiologies: sepsis, hemorrhage, pulmonary embolus, heart failure, tachyarrhythmias, bradyarrhythmias, acute respiratory distress syndrome, non-intubated pulmonary disease, obstructive apnea, traumatic brain injury, ischemic brain injury, and intracranial mass lesions. This taxonomy was validated using descriptive statistics, before-and-after analysis evaluating CPA incidence, and multivariate logistic regression to predict CPA survival. RESULTS: A total of 336 inpatients suffered a cardiopulmonary arrest during the study period-187 in the pre-ART period and 149 in the post-ART period. The vast majority of CPA events were categorized using the ART Matrix with high inter-observer reliability. As anticipated, changes in CPA incidence and survival were observed for some Matrix categories but not others following ART implementation. In addition, multivariate logistic regression revealed strong independent associations between taxonomy classifications and outcome. CONCLUSION: A novel SOC using a unique taxonomy for arrest classification appears to be effective at reducing inpatient CPA incidence and outcome.

The impact of body mass index on patient survival after therapeutic hypothermia after resuscitation.

OBJECTIVES: Therapeutic hypothermia improves survival in patients after cardiac arrest, yet the impact of body mass index (BMI) on survival is lesser known. We hypothesized that nonobese patients would have greater survival post-therapeutic hypothermia than obese patients. METHODS: We retrospectively evaluated 164 patients who underwent therapeutic hypothermia after resuscitation for cardiac arrest from January 2012 to September 2014. Logistic regression analysis was used to assess for survival based upon BMI and comorbidities (odds ratio, 95% confidence interval). RESULTS: Forty-one percent of patients were obese. Obese patients presented less frequently with ventricular fibrillation (P=.046) but had similar rates of pulseless electrical activity (P=.479) and ventricular tachycardia (P=.262) to nonobese patients. In multivariable analysis, BMI less than 30 kg/m(2), hypertension, presence of pacemaker/implantable cardioverter-defibrillator, high glomerular filtration rate, and low neuron-specific enolase were all associated with increased survival post-therapeutic hypothermia, respectively: 0.36 (0.16-0.78), 0.28 (0.12-0.66), 0.23 (0.08-0.62), 0.25 (0.11-0.56), and 0.37 (0.14-0.96). Other comorbidities demonstrated no association with survival. CONCLUSIONS: Body mass index at least 30 kg/m(2) compared with BMI less than 30 kg/m(2) was a significant risk factor for mortality post-therapeutic hypothermia protocol. Absence of history of hypertension, lack of pacemaker/implantable cardioverter-defibrillator, high neuron-specific enolase, and renal disease had greater associations with death. Larger studies will be needed to validate these findings.

A focused investigation of expedited, stack of three shocks versus chest compressions first followed by single shocks for monitored ventricular fibrillation/ventricular tachycardia cardiopulmonary arrest in an in-hospital setting.

BACKGROUND: In cases of in-hospital-witnessed ventricular fibrillation/ventricular tachycardia (VF/VT) arrest, it is unclear whether cardiopulmonary resuscitation prior to defibrillation attempt or expedited stacked defibrillation attempt is superior. METHODS: Retrospective, observational study of all admitted patients with continuous cardiac monitoring who suffered VF/VT arrest between July 2005 and June 2013. In the stacked shock period (2005-2008), institutional protocols advocated early defibrillation with administration of 3 stacked shocks with brief pauses between each single defibrillation attempt to confirm sustained VF/VT. During the initial chest compression period (2008-2011), the protocol was modified to perform a 2-minute period of chest compressions prior to each defibrillation, including the initial. In the modified stack shock period (2011-2013), for a monitored arrest, defibrillation attempts were expedited with up to 3 successive shocks administered for persistent VF/VT. In unmonitored arrest, chest compressions and ventilations were initiated prior to defibrillation. The primary outcome measure was survival to hospital discharge. RESULTS: Six hundred sixty-one cardiopulmonary arrests were recorded during the study period, with 106 patients (16%) representing primary VF/VT. The incidence of VF/VT arrest did not vary significantly between the study periods (P= 0.16) Survival to hospital discharge for all primary VF/VT arrest victims decreased, then increased significantly from the stacked shock period to initial chest compression period to modified stacked shock period (58%, 18%, 71%, respectively, P < 0.01). Specific group differences were significant between the initial chest compression versus the stacked and modified stacked shock groups (all P < 0.01). CONCLUSION: Data suggest that monitored VF/VT should undergo expeditious defibrillation with use of stacked shocks.

A performance improvement-based resuscitation programme reduces arrest incidence and increases survival from in-hospital cardiac arrest.

BACKGROUND: Traditional resuscitation training models are inadequate to achieving and maintaining resuscitation competency. This analysis evaluates the effectiveness of a novel, performance improvement-based inpatient resuscitation programme. METHODS: This was a prospective, before-and-after study conducted in an urban, university-affiliated hospital system. All inpatient adult cardiac arrest victims without an active Do Not Attempt Resuscitation order from July 2005 to June 2012 were included. The advanced resuscitation training (ART) programme was implemented in Spring 2007 and included a unique treatment algorithm constructed around the capabilities of our providers and resuscitation equipment, a training programme with flexible format and content including early recognition concepts, and a comprehensive approach to performance improvement feeding directly back into training. Our inpatient resuscitation registry and electronic patient care record were used to quantify arrest rates and survival-to-hospital discharge before and after ART programme implementation. Multiple logistic regression analysis was used to adjust for age, gender, location of arrest, initial rhythm, and time of day. RESULTS: A total of 556 cardiac arrest victims were included (182 pre- and 374 post-ART). Arrest incidence decreased from 2.7 to 1.2 per 1000 patient discharges in non-ICU inpatient units, with no change in ICU arrest rate. An increase in survival-to-hospital discharge from 21 to 45% (p < 0.01) was observed following ART programme implementation. Adjusted odds ratios for survival-to-discharge (OR 2.2, 95% CI 1.4-3.4) and good neurological outcomes (OR 3.0, 95% CI 1.7-5.3) reflected similar improvements. Arrest-related deaths decreased from 2.1 to 0.5 deaths per 1000 patient discharges in non-ICU areas and from 1.5 to 1.3 deaths per 1000 patient discharges in ICU areas, and overall hospital mortality decreased from 2.2% to 1.8%. CONCLUSIONS: Implementation of a novel, performance improvement-based inpatient resuscitation programme was associated with a decrease in the incidence of cardiac arrest and improved clinical outcomes.

A novel configuration of a traditional rapid response team decreases non-intensive care unit arrests and overall hospital mortality.

BACKGROUND: In-hospital cardiopulmonary arrest (CPA) accounts for substantial morbidity and mortality. Rapid response teams (RRTs) are designed to prevent non-intensive care unit (ICU) CPA through early detection and intervention. However, existing evidence has not consistently demonstrated a clear benefit. OBJECTIVE: To explore the effectiveness of a novel RRT program design to decrease non-ICU CPA and overall hospital mortality. METHODS: This study was conducted from the start of fiscal year 2005 to 2011. In November 2007, our hospitals implemented RRTs as part of a novel resuscitation program. Charge nurses from each inpatient unit underwent training as unit-specific RRT members. Additionally, all inpatient staff received annual training in RRT concepts including surveillance and recognition of deterioration. We compared the incidence of ICU and non-ICU CPA from first complete preimplementation year 2006 to postimplementation years 2007 to 2011. Overall hospital mortality was also reported. RESULTS: The incidence of non-ICU CPA decreased, whereas the incidence of ICU CPA remained unchanged. Overall hospital mortality also decreased (2.12% to 1.74%, P < 0.001). The year-over-year change in RRT activations was inversely related to the change in Code Blue activations for each inpatient unit (r = -0.68, P < 0.001). CONCLUSION: Our novel RRT program was associated with a decreased incidence of non-ICU CPA and improved hospital mortality.

Preliminary report of a mathematical model of ventilation and intrathoracic pressure applied to prehospital patients with severe traumatic brain injury.

BACKGROUND: Inadvertent hyperventilation is associated with poor outcomes from traumatic brain injury (TBI). Hypocapnic cerebral vasoconstriction is well described and causes an immediate and profound decrease in cerebral perfusion. The hemodynamic effects of positive-pressure ventilation (PPV) remain incompletely understood but may be equally important, particularly in the hypovolemic patient with TBI. OBJECTIVE: Preliminary report on the application of a previously described mathematical model of perfusion and ventilation to prehospital data to predict intrathoracic pressure. METHODS: Ventilation data from 108 TBI patients (76 ground transported, 32 helicopter transported) were used for this analysis. Ventilation rate (VR) and end-tidal carbon dioxide (PetCO2) values were used to estimate tidal volume (VT). The values for VR and estimated VT were then applied to a previously described mathematical model of perfusion and ventilation. This model allows input of various lung parameters to define a pressure-volume relationship, then derives mean intrathoracic pressure (MITP) for various VT and VR values. For this analysis, normal lung parameters were utilized. Separate analyses were performed assuming either fixed or variable PaCO2-PetCO2 differences. Ground and air medical patients were compared with regard to VR, PetCO2, estimated VT, and predicted MITP. RESULTS: A total of 10,647 measurements were included from the 108 TBI patients, representing about 13 minutes of ventilation per patient. Mean VR values were higher for ground patients versus air patients (21.6 vs. 19.7 breaths/min; p < 0.01). Estimated VT values were similar for ground and air patients (399 mL vs. 392 mL; p = NS) in the fixed model but not the variable (636 vs. 688 mL, respectively; p < 0.01). Mean PetCO2 values were lower for ground versus air patients (30.6 vs. 33.8 mmHg; p < 0.01). Predicted MITP values were higher for ground versus air patients, assuming either fixed (9.0 vs. 8.1 mmHg; p < 0.01) or variable (10.9 vs. 9.7 mmHg; p < 0.01) PaCO2-PetCO2 differences. CONCLUSIONS: Predicted MITP values increased with ventilation rates. Future studies to externally validate this model are warranted.

Early coronary angiography and induced hypothermia are associated with survival and functional recovery after out-of-hospital cardiac arrest.

BACKGROUND: The rate and effect of coronary interventions and induced hypothermia after out-of-hospital cardiac arrest (OHCA) are unknown. We measured the association of early (≤24h after arrival) coronary angiography, reperfusion, and induced hypothermia with favorable outcome after OHCA. METHODS: We performed a secondary analysis of a multicenter clinical trial (NCT00394706) conducted between 2007 and 2009 in 10 North American regions. Subjects were adults (≥18 years) hospitalized after OHCA with pulses sustained ≥60min. We measured the association of early coronary catheterization, percutaneous coronary intervention, fibrinolysis, and induced hypothermia with survival to hospital discharge with favorable functional status (modified Rankin Score≤3). RESULTS: From 16,875 OHCA subjects, 3981 (23.6%) arrived at 151 hospitals with sustained pulses. 1317 (33.1%) survived to hospital discharge, with 1006 (25.3%) favorable outcomes. Rates of early coronary catheterization (19.2%), coronary reperfusion (17.7%) or induced hypothermia (39.3%) varied among hospitals, and were higher in hospitals treating more subjects per year. Odds of survival and favorable outcome increased with hospital volume (per 5 subjects/year OR 1.06; 95%CI: 1.04-1.08 and OR 1.06; 95%CI: 1.04, 1.08, respectively). Survival and favorable outcome were independently associated with early coronary angiography (OR 1.69; 95%CI 1.06-2.70 and OR 1.87; 95%CI 1.15-3.04), coronary reperfusion (OR 1.94; 95%CI 1.34-2.82 and OR 2.14; 95%CI 1.46-3.14), and induced hypothermia (OR 1.36; 95%CI 1.01-1.83 and OR 1.42; 95%CI 1.04-1.94). INTERPRETATION: Early coronary intervention and induced hypothermia are associated with favorable outcome and are more frequent in hospitals that treat higher numbers of OHCA subjects per year.

Electrical and mechanical recovery of cardiac function following out-of-hospital cardiac arrest.

BACKGROUND: Compression pauses may be particularly harmful following the electrical recovery but prior to the mechanical recovery from cardiopulmonary arrest. METHODS AND RESULTS: A convenience sample of patients with out-of-hospital cardiac arrest (OOHCA) were identified. Data were exported from defibrillators to define compression pauses, electrocardiogram rhythm, PetCO2, and the presence of palpable pulses. Pulse-check episodes were randomly assigned to a derivation set (one-third) and a validation set (two-thirds). Both an unweighted and a weighted receiver-operator curve (ROC) analysis were performed on the derivation set to identify optimal thresholds to predict ROSC using heart rate and PetCO2. A sequential decision guideline was generated to predict the presence of ROSC during compressions and confirm perfusion once compressions were stopped. The ability of this decision guideline to correctly identify pauses in which pulses were and were not palpated was then evaluated. A total of 145 patients with 349 compression pauses were included. The ROC analyses on the derivation set identified an optimal pre-pause heart rate threshold of >40 beats min(-1) and an optimal PetCO2 threshold of >20 mmHg to predict ROSC. A sequential decision guideline was developed using pre-pause heart rate and PetCO2 as well as the PetCO2 pattern during compression pauses to predict and rapidly confirm ROSC. This decision guideline demonstrated excellent predictive ability to identifying compression pauses with and without palpable pulses (positive predictive value 95%, negative predictive value 99%). The mean latency period between recovery of electrical and mechanical cardiac function was 78 s (95% CI 36-120 s). CONCLUSIONS: Heart rate and PetCO2 can predict ROSC without stopping compressions, and the PetCO2 pattern during compression pauses can rapidly confirm ROSC. Use of a sequential decision guideline using heart rate and PetCO2 may reduce unnecessary compression pauses during critical moments during recovery from cardiopulmonary arrest.