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Both survival and neurologic outcomes have improved in recent years for in-hospital cardiac arrests at centers participating in a quality-improvement registry, researchers found.
Risk-adjusted survival to discharge increased from 13.7% in 2000 to 22.3% in 2009 (P<0.001 for trend), with gains seen across subgroups defined by initial rhythm, age, race, and sex, according to Saket Girotra, MD, of the University of Iowa Hospitals and Clinics in Iowa City, and colleagues.
At the same time, the rate of clinically significant neurologic disability among the survivors decreased from 32.9% to 28.1% (P=0.02 for trend), the researchers reported in the Nov. 15 issue of the New England Journal of Medicine.
"Future studies are needed to better understand which specific factors are responsible for improvements in survival after cardiac arrest so that survival gains can be consolidated and expanded to all hospitals," they wrote.
Quality-improvement initiatives have focused on survival and other outcomes following both out-of-hospital and in-hospital cardiac arrests. Although studies have shown improved survival following out-of-hospital arrests, whether a similar trend had occurred for in-hospital arrests was not clear.
To explore the issue, Girotra and colleagues turned to the American Heart Association's Get With the Guidelines-Resuscitation registry. They identified 84,625 hospitalized patients who had had a cardiac arrest in the intensive care unit or inpatient ward of one of 374 participating hospitals between 2000 and 2009.
Most of the patients (79.3%) had an initial rhythm of asystole or pulseless electrical activity and the rest had ventricular fibrillation or pulseless ventricular tachycardia. The percentage with asystole or pulseless electrical activity increased during the study period from 68.7% to 82.4% (P<0.001).
After adjustment for age, sex, race, coexisting conditions, therapeutic interventions being used at the time of the arrest, and characteristics of the arrest and the hospital, survival to discharge improved over time.
The gains involved increases in both acute resuscitation survival -- defined as the return of spontaneous circulation for at least 20 consecutive minutes at any time after the initial pulseless arrest -- and survival to discharge among those who survived the acute resuscitation (P≤0.001 for both trends).
Among the survivors, neurologic disability did not become more prevalent. There was a decline in the rate of clinically significant neurologic disability -- defined as a score greater than 1 on the cerebral-performance category (CPC) scale -- and no change in the rate of severe neurologic disability -- defined as a CPC score greater than 2.
Based on the findings, the researchers estimated that an additional 17,200 patients survived to discharge at the end of the study period compared with the beginning and that 13,000 cases of clinically significant neurologic disability were averted.
They acknowledged, however, that they could not determine whether the findings are related to the inclusion of hospitals motivated enough to participate in the registry or to nationwide changes in clinical practice, equipment, and recognition of illness acuity.
Also, they said, the trends possibly could reflect a decrease in baseline risk over time or increasing use of advanced directives and do-not-resuscitate orders, which could have introduced selection bias.
Other noted limitations included potential residual confounding, missing CPC scores for some survivors, and the lack of detailed information on specific variables related to the resuscitation process, treatments, and quality-improvement efforts at the individual hospitals.
From the American Heart Association:
- Heart & Stroke 2012 Statistical Update
- Acute Heart Failure Syndromes in the Emergency Department
- Cardiac Arrest Updates: Striving to Improve Outcomes
The Get With the Guidelines-Resuscitation program is overseen by the American Heart Association.
Girotra reported that he had no conflicts of interest. His co-authors reported relationships with Prescription Solutions, the National Heart, Lung, and Blood Institute, UnitedHealth, Medtronic, the NIH, and St. Jude Medical.
- Reviewed by Zalman S. Agus, MD Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner
New England Journal of MedicineSource Reference: Girotra S, et al "Trends in survival after in-hospital cardiac arrest" N Engl J Med 2012; 367: 1912-1920.