Inter-hospital variability in post-cardiac arrest mortality

The Robert Wood Johnson Clinical Scholars Program, University of Pennsylvania School of Medicine (UPENN SOM), USA.
Resuscitation (Impact Factor: 4.17). 10/2008; 80(1):30-4. DOI: 10.1016/j.resuscitation.2008.09.001
Source: PubMed


A growing body of evidence suggests that variability in post-cardiac arrest care contributes to differential outcomes of patients with initial return of spontaneous circulation after cardiac arrest. We examined hospital-level variation in mortality of patients admitted to United States intensive care units (ICUs) with a diagnosis of cardiac arrest.
Patients with a primary ICU admission diagnosis of cardiac arrest were identified in the 2002--2005 Acute Physiology and Chronic Health Evaluation (APACHE) IV dataset, a multicenter clinical registry of ICU patients.
We identified 4674 patients from 39 hospitals. The median number of annual patients was 33 per hospital (range: 12-116). Mean APACHE score was 94 (+/-38), and overall mortality was 56.8%. Age, severity of illness (acute physiology score), and admission Glasgow Coma Scale were all associated with increased mortality (p<0.001). There was no survival difference for patients admitted from the emergency department vs. the inpatient floor. Among institutions, unadjusted in-hospital mortality ranged from 41% to 81%. After adjusting for age and severity of illness, institutional mortality ranged from 46% to 68%. Patients treated at higher volume centers were significantly less likely to die in the hospital.
We demonstrate hospital-level variation in severity adjusted mortality among patients admitted to the ICU after cardiac arrest. We identify a volume-outcome relationship showing lower mortality among patients admitted to ICUs that treat a high volume of post-cardiac arrest patients. Prospective studies should identify hospital-level and patient care factors that contribute to post-cardiac arrest survival.

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Available from: Andrew A. Kramer
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    • "Out-of-hospital cardiac arrest (OHCA) remains as a common public health problem and a leading cause of morbidity and mortality (1). Systematic, post-cardiac arrest care after return of spontaneous circulation (ROSC) can improve the survival and neurologic outcome of OHCA patients (2, 3). In particular, recent studies have demonstrated that therapeutic hypothermia (TH) is an important resuscitation therapy that improves the rate of survival and relieves unfavorable neurological outcomes in cardiac arrest survivors (2, 4). "
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    ABSTRACT: It has been proven that safety and efficiency of out-of-hospital cardiac arrest (OHCA) patients is transported to specialized hospitals that have the capability of performing therapeutic hypothermia (TH). However, the outcome of the patients who have been transferred after return of spontaneous circulation (ROSC) has not been well evaluated. We conducted a retrospective observational study between January 2010 to March 2012. There were primary outcomes as good neurofunctional status at 1 month and the secondary outcomes as the survivals at 1 month between Samsung Medical Center (SMC) group and transferred group. A total of 91 patients were enrolled this study. There was no statistical difference between good neurologic outcomes between both groups (38% transferred group vs. 40.6% SMC group, P=0.908). There was no statistical difference in 1 month survival between the 2 groups (66% transferred group vs. 75.6% SMC group, P=0.318). In the univariate and multivariate models, the ROSC to induction time and the induction time had no association with good neurologic outcomes. The good neurologic outcome and survival at 1 month had no significant differences between the 2 groups. This finding suggests the possibility of integrated post-cardiac arrest care for OHCA patients who are transferred from other hospitals after ROSC in the cardiac arrest center. Graphical Abstract
    Full-text · Article · Sep 2014 · Journal of Korean Medical Science
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    • "The first standardized algorithms for the postresuscitation-care period have just recently been implemented in the European guidelines for resuscitation [13]. Several hospital-related factors, such as hospital size and teaching status, have been identified to be of importance for the outcome after cardiac arrest, and regional differences have been described [10,14,15]. With regard to the role models of acute coronary care units, stroke-, trauma-, and burn-injury centers, specialized cardiac arrest-care centers, as well as predefined treatment bundles for the postresuscitation period have become a subject of discussion recently [16-24]. "
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    ABSTRACT: The study aimed to determine the impact of treatment frequency, hospital size and capability on mortality of patients admitted after cardiac arrest for postresuscitation care to different intensive care units. Prospectively recorded data from 242588 adults consecutively admitted to 87 Austrian intensive care units over a period of 13 years (1998 to 2010) were analyzed retrospectively. Multivariate analysis was used to assess the effect of the frequency of postresuscitation care on mortality, correcting for baseline parameters, severity of illness, hospital size and capability to perform coronary angiography and intervention. In total 5857 patients had suffered cardiac arrest and were admitted to an intensive care unit. Observed hospital mortality was 56% in the cardiac arrest cohort (3302 non survivors). Patients treated in intensive care units with a high frequency of postresuscitation care generally had high severity of illness (median Simplified Acute Physiology Score (SAPS II) 65). Intensive care units with a higher frequency of care showed improved risk adjusted mortality. The SAPS II adjusted, observed to expected mortality ratios (O/E-Ratios) in the three strata (less than <18; 18 to 26; more than 26 resuscitations per ICU per year) were 0.869 (95% confidence interval: 0.844 to 894), 0.876 (0.850 to 0.902) and 0.808 (0.784 to 0.833). In this database analysis a high frequency of post cardiac arrest care at an intensive care unit seemed to be associated with improved outcome of cardiac arrest patients. We were able to identify patients who seemed to profit more from high frequency of care, namely those with an intermediate severity of illness. Considering these findings, cardiac arrest care centers might be a reasonable step to improve outcome in this specific population of cardiac arrest patients.
    Full-text · Article · Apr 2014 · Critical care (London, England)
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    • "Hidden biases may remain, although our statistical approach should have reduced these levels. Finally, there was great variability in the baseline hospital characteristics and survival within different areas (29, 30). The results of this study may not be applicable to other hospitals in other regions since our study was based on the data from a single tertiary teaching hospital in Korea. "
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    ABSTRACT: The aim of this study was to describe the cause of the recent improvement in the outcomes of patients who experienced in-hospital cardiac arrest. We retrospectively analyzed the in-hospital arrest registry of a tertiary care university hospital in Korea between 2005 and 2009. Major changes to the in-hospital resuscitation policies occurred during the study period, which included the requirement of extensive education of basic life support and advanced cardiac life support, the reformation of cardiopulmonary resuscitation (CPR) team with trained physicians, and the activation of a medical emergency team. A total of 958 patients with in-hospital cardiac arrest were enrolled. A significant annual trend in in-hospital survival improvement (odds ratio = 0.77, 95% confidence interval 0.65-0.90) was observed in a multivariate model. The adjusted trend analysis of the return of spontaneous circulation, six-month survival, and survival with minimal neurologic impairment upon discharge and six-months afterward revealed similar results to the original analysis. These trends in outcome improvement throughout the study were apparent in non-ICU (Intensive Care Unit) areas. We report that the in-hospital survival of cardiac arrest patients gradually improved. Multidisciplinary hospital-based efforts that reinforce the Chain of Survival concept may have contributed to this improvement.
    Full-text · Article · Feb 2012 · Journal of Korean medical science
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