Disclosures Research support from UCOP CHQI In-Hospital Cardiac - PDF document

5/29/2014 Disclosures • Research support from UCOP CHQI In-Hospital Cardiac Arrest: award Measuring Effectiveness and Improving Outcomes J. Matthew Aldrich, MD Anesthesia & Critical Care UCSF Overview Cardiopulmonary Arrest: Quality Measures • Epidemiology of in-hospital cardiac • Incidence arrest (IHCA) • Outcomes – Definitions – Immediate survival – Outcomes – Survival to discharge • Guidelines – Survival to discharge with good • New approaches to IHCA neurological outcome • Process measures 1

5/29/2014 Definitions ICD-9 procedure codes • Lots of variability 99.60 – Ten different definitions for IHCA 99.63 ICD-9 • What’s a “Code”? CPT 427.5 121 427.4 – Activation of emergency team? – Chest compression and/or defibrillation? – Billing codes ? Cardiac Arrest Sandroni et al. ICM 2007, Morrison et al. Circulation 2013 More definitions Definitions • Immediate survival or “survived event” : • Utstein definition of cardiac arrest: sustained return of spontaneous “cessation of cardiac mechanical activity circulation for > 20 minutes confirmed by the absence of a detectable pulse, unresponsiveness, • Survival to discharge and apnea (or agonal respirations). – Generally, the gold standard • In reality, ( at least at UCSF): chest – Helpful to also track functional outcomes compressions or defibrillation (cerebral performance category or Mod Rankin score) Jacobs et al. Resuscitation 2004 2

5/29/2014 Incidence • Limited data • ~ 200,000 IHCA annually in the US • Based on both single institution and registry data, ~ 1-5/1000 hospitalized adults will experience a cardiac arrest • Incidence appears to be increasing CCM 2011 Practical issues with determining incidence and outcomes • Finding the “event” – Pager logs, code records, IRs, billing IHCA Outcomes codes, etc. • Determine the outcomes • Know the institutional DNAR rate – Before and after CPR – DNAR decisions after IHCA can dramatically impact survival statistics Peberdy et al. Resuscitation 2003 3

5/29/2014 Poor outcomes Factors associated with worse outcomes • Survival to discharge remains poor for IHCA • Rhythm: PEA, asystole • Registry based study outcomes • Race: black and other non-white – Nadkarni et al. JAMA 2006: 18% patients – Girotra et al. NEJM 2012: 17% • Time of day: nights and weekends – Goldberger et al. Lancet 2012: 15.4% • Time to defibrillation: delay > 2 minutes • Medicare data • Vasopressor use prior to arrest – Ehlenbach et al. NEJM 2009: 18.3% Nadkarni et al. JAMA 2006 ROSC Survival to Discharge VT 67.5% 36.9% ROSC Survival to Discharge VF 62.6% 37.3% VT/VF 62% 36% PEA 45.2% 11.9% PEA 42.9%% 11.2% Asystole 39.6% 10.8% Asystole 38.4% 10.6% Meaney et al. CCM 2010 4

5/29/2014 Race and Outcomes Nights & Weekends Peberdy et al. JAMA 2008 Ehlenbach et al. NEJM 2009 Time to Defibrillation is Critical AJRCCM 2010 • NRCPR data from 2000-2008 • Overall survival to discharge: 15.9% • Odds of survival 55% lower in patients taking pressors (OR 0.45, CI 0.42-0.48) • Pressor (s) + MV = 7.6% survival to discharge • Only 3.3% of patients having a CPA despite pressors discharged home with good Chan et al. neurologic outcome NEJM 2008 5

5/29/2014 A little hope? Process Measures • CPR performance – Time to compressions – Time to defibrillation – Interruptions in compressions – Compression depth and frequency • Postarrest care Girotra et al NEJM 2012 Training & Quality Improvement • Certification in advanced resuscitation techniques What, if anything, can be done – AHA: BLS and ACLS (2010) to improve outcomes? – European Resuscitation Guidelines (2010) • Quality Improvement at the institutional level – Device data – Post code debriefing 6

5/29/2014 AHA Chain of Survival 7

5/29/2014 ERC ERC Criticisms of ACLS • Not specific to IHCA • ACLS trainers often unaware of particular hospital concerns • Training is removed from inpatient environments • Trainer- trainee “mismatch” 8

5/29/2014 Advanced Resuscitation Training • UCSD program • Currently, the focus of a UCOP CHQI grant that includes Alternate Approaches – UCSD, UCSF, UCLA, UCD, UCI • Resuscitation management program that builds the framework for a “culture of resuscitation” ART Outcomes Specifics of ART • CQI • Enhanced training focused on provider- and unit-specific tasks • Novel treatment algorithms • Focus on early recognition UCSD Center for Resuscitation Science 9

5/29/2014 ACLS + AHA’s new focus on IHCA Simulation training ACLS Post- resuscitation A-ACLS pathways Circulation 2013 Key Points Best Practices: Prearrest • Acknowledges differences between • Equipment OHCA and IHCA • Code Teams • Comprehensive focus on: • Code team training – Reporting • Early recognition and intervention – Planning – Rapid Response – Best practices – Early warning systems • MEWS • DNAR orders 10

5/29/2014 Key RRT studies Rapid Response Teams • Hillman et al. (MERIT study) Lancet • Implemented to improve recognition and 2005 response – No change in composite outcome – Goal 16 of TJC’s 2009 NPSG • Priestley et al. ICM 2004 – Key strategy of IHI’s 100,000 Lives – Reduced in-hospital mortality Campaign • Chan et al. Arch Int Med 2010 • Mixed results – Meta-analysis of 18 studies • Variability in team design and mission – Reduced out-of-ICU cardiac arrest but no makes research challenging reduction in hospital mortality Best Practices: Intra-arrest • Structural aspects – Mechanical devices, AEDs • Care pathways Pooled estimated hospital mortality – Minimize interruptions in compressions, optimize depth, avoid hyperventilation, provide early defibrillation • Process issues – Use real-time feedback 11

5/29/2014 Best Practices: Post-arrest Public reporting • Goal-directed mild therapeutic • Many hospitals and physicians reluctant to publicly report “poor” outcomes hypothermia* • Coronary reperfusion • Must have standardized approach to – All patients with new LBBB or ST elevation tracking incidence and mortality rates should have emergent angiography • Need measurement tools that adjust for • Seizure monitoring severity of illness • Hemodynamic optimization • Prognostication Conclusions • No clear improvement in outcomes • Need to focus on IHCA as its own entity • Best hope likely exists in better reporting, training, and quality improvement efforts focusing on the “chain of survival” 12