The association of fire or police first responder initiated interventions with out of hospital cardiac arrest survival.

OBJECTIVE: Fire and police first responders are often the first to arrive in medical emergencies and provide basic life support services until specialized personnel arrive. This study aims to evaluate rates of fire or police first responder-initiated cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use, as well as their associated impact on out-of-hospital cardiac arrest (OHCA) outcomes. METHODS: We completed a secondary data analysis of the MI-CARES registry from 2014 to 2019. We reported rates of CPR initiation and AED use by fire or police first responders. Multilevel modeling was utilized to evaluate the relationship between fire/police first responder-initiated interventions and outcomes of interest: ROSC upon emergency department arrival, survival to hospital discharge, and good neurologic outcome. RESULTS: Our cohort included 25,067 OHCA incidents. We found fire or police first responders initiated CPR in 31.8% of OHCA events and AED use in 6.1% of OHCA events. Likelihood of sustained ROSC on ED arrival after CPR initiated by a fire/police first responder was not statistically different as compared to EMS initiated CPR (aOR 1.01, CI 0.93-1.11). However, fire/police first responder interventions were associated with significantly higher odds of survival to hospital discharge and survival with good neurologic outcome (aOR 1.25, 95% CI 1.08-1.45 and aOR 1.40, 95% CI 1.18-1.65, respectively). Similar associations were see when examining fire or police initiated AED use. CONCLUSIONS: Fire or police first responders may be an underutilized, potentially powerful mechanism for improving OHCA survival. Future studies should investigate barriers and opportunities for increasing first responder interventions by these groups in OHCA.

Association Between Hospital Resuscitation Champion and Survival for In-Hospital Cardiac Arrest.

Background Although many hospitals have resuscitation champions, it is unknown if hospitals with very active physician or nonphysician champions have higher survival rates for in-hospital cardiac arrest (IHCA). Methods and Results We surveyed adult hospitals in Get With The Guidelines-Resuscitation about resuscitation practices, including about their resuscitation champion. Hospitals were categorized as having a very active physician champion, a very active nonphysician champion, or other (no champion or not very active champion). For each hospital, we calculated risk-standardized survival rates for IHCA during the period of 2016 to 2018 and categorized them into quintiles of risk-standardized survival rates. The association between a hospital's resuscitation champion type and their quintile of survival was evaluated using multivariable hierarchical proportional odds logistic regression. Overall, 192 hospitals (total of 44 477 IHCAs) comprised the study cohort. Risk-standardized survival rates for IHCA varied widely between hospitals (median: 24.7%; range: 9.2%-37.5%). Very active physician champions were present in 29 (15.1%) hospitals, 64 (33.3%) had very active nonphysician champions, and 99 (51.6%) did not have a very active champion. Compared with sites without a very active resuscitation champion, hospitals with a very active physician champion were 4 times more likely to be in a higher survival quintile, even after adjusting for resuscitation practices across hospital groups (adjusted odds ratio [OR], 3.90; 95% CI, 1.39-10.95). In contrast, there was no difference in survival between sites without very active champions and those with very active non-physician champions (adjusted OR, 1.28; 95% CI, 0.62-2.65). Conclusions The background and engagement level of a resuscitation champion is a critical factor in a hospital's survival outcomes for IHCA.

Variation in pre-hospital outcomes after out-of-hospital cardiac arrest in Michigan.

AIM: Care by emergency medical service (EMS) agencies is critical for optimizing prehospital outcomes following out-of-hospital cardiac arrest (OHCA). We explored whether substantial differences exist in prehospital outcomes across EMS agencies in Michigan-specifically focusing on rates of sustained return of spontaneous circulation (ROSC) upon emergency department (ED) arrival. METHODS: Using data from Michigan Cardiac Arrest Registry to Enhance Survival (MI-CARES) for years 2014-2017, we calculated rates of sustained ROSC upon ED arrival across EMS agencies in Michigan. We used hierarchical logistic regression models that accounted for patient, arrest-, community-, and response-level characteristics to determine adjusted rates of sustained ROSC among EMS agencies. RESULTS: A total of 103 EMS agencies and 20,897 OHCA cases were included. Average age of the cohort was 62.5 years (SD = 19.6), 39.7% were female, and 17.9% had an initial shockable rhythm due to ventricular fibrillation or pulseless ventricular tachycardia. The adjusted rate of sustained ROSC upon ED arrival across all EMS agencies was 23.8% with notable variation across EMS agencies (interquartile range [IQR], 20.5-29.2%). The top five EMS agencies had mean adjusted rates of sustained ROSC upon ED arrival of 42.7% (95% CI: 34.6-51.1%) while the bottom five had mean adjusted rates of 9.8% (95% CI: 7.6-12.7%). CONCLUSIONS: Substantial variation in sustained ROSC upon ED arrival exists across EMS agencies in Michigan after adjusting for patient-, arrest, community-, and response-level features. Such differences suggest opportunities to identify and improve best practices in EMS agencies to advance OHCA care.

Enhancing Prehospital Outcomes for Cardiac Arrest (EPOC) study: sequential mixed-methods study protocol in Michigan, USA.

INTRODUCTION: Out-of-hospital cardiac arrest (OHCA) is a common, life-threatening event encountered routinely by first responders, including police, fire and emergency medical services (EMS). Current literature suggests that there is significant regional variation in outcomes, some of which may be related to modifiable factors. Yet, there is a persistent knowledge gap regarding strategies to guide quality improvement efforts in OHCA care and, by extension, survival. The Enhancing Prehospital Outcomes for Cardiac Arrest (EPOC) study aims to fill these gaps and to improve outcomes. METHODS AND ANALYSIS: This mixed-methods study includes three aims. In aim I, we will define variation in OHCA survival to the emergency department (ED) among EMS agencies that participate in the Michigan Cardiac Arrest Registry to Enhance Survival (CARES) in order to sample EMS agencies with high-survival and low-survival outcomes. In aim II, we will conduct site visits to emergency medical systems-including 911/dispatch, police, non-transport fire, and EMS agencies-in approximately eight high-survival and low-survival communities identified in aim I. At each site, key informant interviews and a multidisciplinary focus group will identify themes associated with high OHCA survival. Transcripts will be coded using a structured codebook and analysed through thematic analysis. Results from aims I and II will inform the development of a survey instrument in aim III that will be administered to all EMS agencies in Michigan. This survey will test the generalisability of factors associated with increased OHCA survival in the qualitative work to ultimately build an EPOC Toolkit which will be distributed to a broad range of stakeholders as a practical 'how-to' guide to improve outcomes. ETHICS AND DISSEMINATION: The EPOC study was deemed exempt by the University of Michigan Institutional Review Board. Findings will be compiled in an 'EPOC Toolkit' and disseminated in the USA through partnerships including, but not limited to, policymakers, EMS leadership and health departments.

Nursing roles for in-hospital cardiac arrest response: higher versus lower performing hospitals.

BACKGROUND: Good outcomes for in-hospital cardiac arrest (IHCA) depend on a skilled resuscitation team, prompt initiation of high-quality cardiopulmonary resuscitation and defibrillation, and organisational structures to support IHCA response. We examined the role of nurses in resuscitation, contrasting higher versus lower performing hospitals in IHCA survival. METHODS: We conducted a descriptive qualitative study at nine hospitals in the American Heart Association's Get With The Guidelines-Resuscitation registry, purposefully sampling hospitals that varied in geography, academic status, and risk-standardised IHCA survival. We conducted 158 semistructured interviews with nurses, physicians, respiratory therapists, pharmacists, quality improvement staff, and administrators. Qualitative thematic text analysis followed by type-building text analysis identified distinct nursing roles in IHCA care and support for roles. RESULTS: Nurses played three major roles in IHCA response: bedside first responder, resuscitation team member, and clinical or administrative leader. We found distinctions between higher and lower performing hospitals in support for nurses. Higher performing hospitals emphasised training and competency of nurses at all levels; provided organisational flexibility and responsiveness with nursing roles; and empowered nurses to operate at a higher scope of clinical practice (eg, bedside defibrillation). Higher performing hospitals promoted nurses as leaders-administrators supporting nurses in resuscitation care at the institution, resuscitation team leaders during resuscitation and clinical champions for resuscitation care. Lower performing hospitals had more restrictive nurse roles with less emphasis on systematically identifying improvement needs. CONCLUSION: Hospitals that excelled in IHCA survival emphasised mentoring and empowering front-line nurses and ensured clinical competency and adequate nursing training for IHCA care. Though not proof of causation, nurses appear to be critical to effective IHCA response, and how to support their role to optimise outcomes warrants further investigation.

Assessment of Rapid Response Teams at Top-Performing Hospitals for In-Hospital Cardiac Arrest.

IMPORTANCE: Rapid response teams (RRTs) are foundational to hospital response to deteriorating conditions of patients. However, little is known about differences in RRT organization and function across top-performing and non-top-performing hospitals for in-hospital cardiac arrest (IHCA) care. OBJECTIVE: To evaluate differences in design and implementation of RRTs at top-performing and non-top-performing sites for survival of IHCA, which is known to be associated with hospital performance on IHCA incidence. DESIGN, SETTING, AND PARTICIPANTS: A qualitative analysis was performed of data from semistructured interviews of 158 hospital staff members (nurses, physicians, administrators, and staff) during site visits to 9 hospitals participating in the Get With The Guidelines-Resuscitation program and consistently ranked in the top, middle, and bottom quartiles for IHCA survival during 2012-2014. Site visits were conducted from April 19, 2016, to July 27, 2017. Data analysis was completed in January 2019. MAIN OUTCOMES AND MEASURES: Semistructured in-depth interviews were performed and thematic analysis was conducted on strategies for IHCA prevention, including RRT roles and responsibilities. RESULTS: Of the 158 participants, 72 were nurses (45.6%), 27 physicians (17.1%), 27 clinical staff (17.1%), and 32 administrators (20.3%). Between 12 and 30 people at each hospital participated in interviews. Differences in RRTs at top-performing and non-top-performing sites were found in the following 4 domains: team design and composition, RRT engagement in surveillance of at-risk patients, empowerment of bedside nurses to activate the RRT, and collaboration with bedside nurses during and after a rapid response. At top-performing hospitals, RRTs were typically staffed with dedicated team members without competing clinical responsibilities, who provided expertise to bedside nurses in managing patients who were at risk for deterioration, and collaborated with nurses during and after a rapid response. Bedside nurses were empowered to activate RRTs based on their judgment and experience without fear of reprisal from physicians or hospital staff. In contrast, RRT members at non-top-performing hospitals had competing clinical responsibilities and were generally less engaged with bedside nurses. Nurses at non-top-performing hospitals reported concerns about potential consequences from activating the RRT. CONCLUSIONS AND RELEVANCE: This qualitative study's findings suggest that top-performing hospitals feature RRTs with dedicated staff without competing clinical responsibilities, that work collaboratively with bedside nurses, and that can be activated without fear of reprisal. These findings provide unique insights into RRTs at hospitals with better IHCA outcomes.

Fractional flow reserve use during elective coronary angiography among elderly patients in the US.

Fractional flow reserve (FFR) is a physiologic measurement of coronary artery perfusion. Studies have demonstrated its benefit in lowering cost and improving outcomes in patients undergoing elective coronary angiography, though follow-up surveys have demonstrated low usage nationwide. We sought to investigate the actual usage in elderly patients undergoing elective coronary angiography. Overall utilization of FFR for elective coronary angiography was 6.3%. Age, sex, race, prior stress testing and region of the country were all statistically significant predictors for FFR use. There still exist many barriers to widespread adoption of this modality, which require further exploration.

Variation in Case-Mix Adjusted Unplanned Pediatric Cardiac ICU Readmission Rates.

OBJECTIVES: To identify modifiable factors leading to unplanned readmission and characterize differences in adjusted unplanned readmission rates across hospitals. DESIGN: Retrospective cohort study using prospectively collected clinical registry data SETTING:: Pediatric Cardiac Critical Care Consortium clinical registry. PATIENTS: Patients admitted to a pediatric cardiac ICU at Pediatric Cardiac Critical Care Consortium hospitals. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We examined pediatric cardiac ICU encounters in the Pediatric Cardiac Critical Care Consortium registry from October 2013 to March 2016. The primary outcomes were early (< 48 hr from pediatric cardiac ICU transfer) and late (2-7 d) unplanned readmission. Generalized logit models identified independent predictors of unplanned readmission. We then calculated observed-to-expected ratios of unplanned readmission and identified higher-than or lower-than-expected unplanned readmission rates for those with an observed-to-expected ratios greater than or less than 1, respectively, and a 95% CI that did not cross 1. Of 11,301 pediatric cardiac ICU encounters (16 hospitals), 62% were surgical, and 18% were neonates. There were 175 (1.6%) early unplanned readmission, and 300 (2.7%) late unplanned readmission, most commonly for respiratory (31%), or cardiac (28%) indications. In multivariable analysis, unique modifiable factors were associated with unplanned readmission. Although shorter time between discontinuation of vasoactive infusions and pediatric cardiac ICU transfer was associated with early unplanned readmission, nighttime discharge was independently associated with a greater likelihood of late unplanned readmission. Two hospitals had lower-than-expected unplanned readmission in both the early and late categories, whereas two other hospitals were higher-than-expected in both. CONCLUSIONS: This analysis demonstrated time from discontinuation of critical care therapies to pediatric cardiac ICU transfer as a significant, modifiable predictor of unplanned readmission. We identified two hospitals with lower-than-expected adjusted rates of both early and late unplanned readmission, suggesting that their systems are well designed to prevent unplanned readmission. This offers the possibility of disseminating best practices to other hospitals through collaborative learning.

How Do Resuscitation Teams at Top-Performing Hospitals for In-Hospital Cardiac Arrest Succeed? A Qualitative Study.

BACKGROUND: In-hospital cardiac arrest (IHCA) is common, and outcomes vary substantially across US hospitals, but reasons for these differences are largely unknown. We set out to better understand how top-performing hospitals organize their resuscitation teams to achieve high survival rates for IHCA. METHODS: We calculated risk-standardized IHCA survival to discharge rates across American Heart Association Get With The Guidelines-Resuscitation registry hospitals between 2012 and 2014. We identified geographically and academically diverse hospitals in the top, middle, and bottom quartiles of survival for IHCA and performed a qualitative study that included site visits with in-depth interviews of clinical and administrative staff at 9 hospitals. With the use of thematic analysis, data were analyzed to identify salient themes of perceived performance by informants. RESULTS: Across 9 hospitals, we interviewed 158 individuals from multiple disciplines including physicians (17.1%), nurses (45.6%), other clinical staff (17.1%), and administration (20.3%). We identified 4 broad themes related to resuscitation teams: (1) team design, (2) team composition and roles, (3) communication and leadership during IHCA, and (4) training and education. Resuscitation teams at top-performing hospitals demonstrated the following features: dedicated or designated resuscitation teams; participation of diverse disciplines as team members during IHCA; clear roles and responsibilities of team members; better communication and leadership during IHCA; and in-depth mock codes. CONCLUSIONS: Resuscitation teams at hospitals with high IHCA survival differ from non-top-performing hospitals. Our findings suggest core elements of successful resuscitation teams that are associated with better outcomes and form the basis for future work to improve IHCA.

Characteristics, Risk Factors, and Outcomes of Extracorporeal Membrane Oxygenation Use in Pediatric Cardiac ICUs: A Report From the Pediatric Cardiac Critical Care Consortium Registry.

OBJECTIVES: Cardiopulmonary failure in children with cardiac disease differs from the general pediatric critical care population, yet the epidemiology of extracorporeal membrane oxygenation support in cardiac ICUs has not been described. We aimed to characterize extracorporeal membrane oxygenation utilization and outcomes across surgical and medical patients in pediatric cardiac ICUs. DESIGN: Retrospective analysis of the Pediatric Cardiac Critical Care Consortium registry to describe extracorporeal membrane oxygenation frequency and outcomes. Within strata of medical and surgical hospitalizations, we identified risk factors associated with extracorporeal membrane oxygenation use through multivariate logistic regression. SETTING: Tertiary-care children's hospitals. PATIENTS: Neonates through adults with cardiac disease. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 14,526 eligible hospitalizations from August 1, 2014, to June 30, 2016; 449 (3.1%) included at least one extracorporeal membrane oxygenation run. Extracorporeal membrane oxygenation was used in 329 surgical (3.5%) and 120 medical (2.4%) hospitalizations. Systemic circulatory failure and extracorporeal cardiopulmonary resuscitation were the most common extracorporeal membrane oxygenation indications. In the surgical group, risk factors associated with postoperative extracorporeal membrane oxygenation use included younger age, extracardiac anomalies, preoperative comorbidity, higher Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery category, bypass time, postoperative mechanical ventilation, and arrhythmias (all p < 0.05). Bleeding requiring reoperation (25%) was the most common extracorporeal membrane oxygenation complication in the surgical group. In the medical group, risk factors associated with extracorporeal membrane oxygenation use included acute heart failure and higher Vasoactive Inotropic Score at cardiac ICU admission (both p < 0.0001). Stroke (15%) and renal failure (15%) were the most common extracorporeal membrane oxygenation complications in the medical group. Hospital mortality was 49% in the surgical group and 63% in the medical group; mortality rates for hospitalizations including extracorporeal cardiopulmonary resuscitation were 50% and 83%, respectively. CONCLUSIONS: This is the first multicenter study describing extracorporeal membrane oxygenation use and outcomes specific to the cardiac ICU and inclusive of surgical and medical cardiac disease. Mortality remains high, highlighting the importance of identifying levers to improve care. These data provide benchmarks for hospitals to assess their outcomes in extracorporeal membrane oxygenation patients and identify unique high-risk subgroups to target for quality initiatives.

Resuscitation Practices Associated With Survival After In-Hospital Cardiac Arrest: A Nationwide Survey.

IMPORTANCE: Although survival of patients with in-hospital cardiac arrest varies markedly among hospitals, specific resuscitation practices that distinguish sites with higher cardiac arrest survival rates remain unknown. OBJECTIVE: To identify resuscitation practices associated with higher rates of in-hospital cardiac arrest survival. DESIGN, SETTING, AND PARTICIPANTS: Nationwide survey of resuscitation practices at hospitals participating in the Get With the Guidelines-Resuscitation registry and with 20 or more adult in-hospital cardiac arrest cases from January 1, 2012, through December 31, 2013. Data analysis was performed from June 10 to December 22, 2015. MAIN OUTCOMES AND MEASURES: Risk-standardized survival rates for cardiac arrest were calculated at each hospital and were then used to categorize hospitals into quintiles of performance. The association between resuscitation practices and quintiles of survival was evaluated using hierarchical proportional odds logistic regression models. RESULTS: Overall, 150 (78.1%) of 192 eligible hospitals completed the study survey, and 131 facilities with 20 or more adult in-hospital cardiac arrest cases comprised the final study cohort. Risk-standardized survival rates after in-hospital cardiac arrest varied substantially (median, 23.7%; range, 9.2%-37.5%). Several resuscitation practices were associated with survival on bivariate analysis, although only 3 were significant after multivariable adjustment: monitoring for interruptions in chest compressions (adjusted odds ratio [OR] for being in a higher survival quintile category, 2.71; 95% CI, 1.24-5.93; P = .01), reviewing cardiac arrest cases monthly (adjusted OR for being in a higher survival quintile category, 8.55; 95% CI, 1.79-40.00) or quarterly (OR, 6.85; 95% CI, 1.49-31.30; P = .03), and adequate resuscitation training (adjusted OR, 3.23; 95% CI, 1.21-8.33; P = .02). CONCLUSIONS AND RELEVANCE: Using survey information from acute care hospitals participating in a national quality improvement registry, we identified 3 resuscitation strategies associated with higher hospital rates of survival for patients with in-hospital cardiac arrest. These strategies can form the foundation for best practices for resuscitation care at hospitals given the high incidence and variation in survival for in-hospital cardiac arrest.

Changes in the care of patients with cervical spine fractures following health reform in Massachusetts.

INTRODUCTION: There is a substantial concern among spine surgeons that healthcare reform efforts will alter the processes through which spinal care is delivered and decrease overall quality. We used the Statewide Inpatient Dataset for Massachusetts to evaluate changes in hospital processes and quality of care for patients with cervical fractures following the implementation of health reform. METHODS: This was a pre-post retrospective analysis of patients (n=9,387) treated for cervical fractures in Massachusetts between 2003-2006 and 2008-2010. Changes in hospital processes (surgical intervention, length of stay (LOS) and environment of care) and quality of care (mortality, complications, reoperation and failure to rescue (FTR)) were the outcomes of interest. FTR is a quality measure that evaluates a hospital's capacity to avoid mortality following the occurrence of a sentinel complication. Patients treated between 2003 and 2006 were considered the pre-reform group. The post-reform cohort consisted of those treated from 2008 to 2010. Baseline differences between cohorts were evaluated using chi-square or Mann-Whitney U tests. Unadjusted comparisons between the dependent variables and the onset of healthcare reform were performed, followed by regression techniques that adjusted for differences in case-mix and whether a surgical intervention was performed. Multivariable logistic regression was used for categorical variables and negative binomial regression was employed for continuous variables. RESULTS: The rates of surgical intervention remained unchanged pre- and post-reform (p=0.25). Hospital length of stay (RC: -0.18, 95% CI: -0.22, -0.14) and the FTR rate following surveillance insensitive complications (OR: 0.49, 95% CI: 0.25, 0.94) were significantly reduced following health reform. Post-reform, academic centers experienced a 22% reduction in mortality (95% CI: 0.61, 0.99) a 40% decrease in FTR (95% CI: 0.40, 0.89), a 30% decrease in surveillance insensitive complications (95% CI: 0.51, 0.96) and a 67% reduction in FTR after surveillance insensitive morbidity (95% CI: 0.11, 0.94). CONCLUSIONS: In the period following Massachusetts healthcare reform, significant improvements were noted in hospital process and quality measures around the care of patients with cervical spine fractures. Such findings were particularly robust among academic centers. These results may forecast changes in the delivery of spine surgical care following other health reform initiatives. Level of Evidence III.