6

Enhancing Hospital Response to Cardiac Arrest

Hospitals and health care systems play major roles in optimal cardiac arrest response and treatment. Health care providers within these settings respond to cardiac arrests that occur on the premises (i.e., in-hospital cardiac arrests [IHCAs]); they facilitate smooth care transitions between emergency medical services (EMS) systems and hospital departments for out-of-hospital cardiac arrests (OHCAs); and they provide vital care after arrests. Variation in treatment, care delivery, and outcomes from one hospital to the next represents a significant opportunity to improve care across the United States (IOM, 2015a). Recommendations 4 and 5 from the Institute of Medicine’s (IOM’s) report describe mechanisms for developing and implementing standards of care and continuous quality improvement programs, which could serve as a basis for data collection and reporting (see Box 6-1).

CURRENT EFFORTS TO ACHIEVE HOSPITAL ACCREDITATION AND ACCOUNTABILITY IN CARDIAC ARREST

Mimi Peberdy, Virginia Commonwealth University

Hospitals’ responses to cardiac arrest vary substantially across the United States, said Mimi Peberdy. Risk-adjusted survival rates for adults following range from 12 to 23 percent (Merchant et al., 2014), and survival rates tend to be worse at night and on weekends (Peberdy et al., 2008), Risk-standardized survival rates following IHCA also vary for children

(Jayaram et al., 2014). Increases in survival rates between 2000 and 2010 also differ by hospital, ranging from 3 to 11 percent (Girotra et al., 2014). The rate of IHCAs differs greatly among hospitals, and increased rates of IHCAs have been associated with lower quality of care overall (Merchant et al., 2012).

In the United States, there are currently two organizations that provide guidance, standards, and quality measures related to cardiac arrest care in hospitals—the Joint Commission and the American Heart Association. Unfortunately, pilot programs to establish high-quality cardiac arrest performance measures experienced setbacks, and the Joint Commission never submitted measures to the National Quality Forum (NQF) for adoption. The American Heart Association also provides resuscitation guidelines for hospitals and uses data from the Get With the Guidelines–Resuscitation program to identify best practices and measures from the highest performing hospitals. The American Heart Association encour-

ages better performance and provides reward badges for improved performance, but participation is currently voluntary, said Peberdy. Thus, hospitals have little incentive to track resuscitation practices, which can lead to better outcomes.

There are many opportunities along the continuum of cardiac arrest care (i.e., before, during, and after resuscitation) where process measurement and modification could improve survival rates. “The best way to improve the outcome from a cardiac arrest is to prevent it from happening in the first place,” said Peberdy. Many patients experience a period of abnormal vital signs hours before the arrest that often go unrecognized and untreated. Hospitals with the highest rates of unevaluated, abnormal vital signs are linked with the lowest rates of IHCA survival, noted Peberdy. To improve outcomes, hospitals could dedicate more attention to these prearrest indicators and attempt to prevent arrests from happening.

After a cardiac arrest occurs, it is important to track what happens before return of spontaneous circulation. Existing technologies and equipment can maximize resuscitation performance, stated Peberdy. For example, many defibrillators can measure quality and physiological effects of cardiopulmonary resuscitation (CPR) (e.g., rate and depth of compressions, end-tidal carbon dioxide monitoring, feedback on hyperventilation). Monitoring physiological data throughout resuscitation has been connected with better survival rates and neurological outcomes (Sutton et al., 2016). Although these tools and data are readily available, said Peberdy, there are no guidelines or standards telling hospitals how these data should be measured and applied to improve care.

Resuscitation team composition and training offer other opportunities to enhance survival rates. Current Joint Commission standards generally require hospitals to have resuscitation services and equipment available, a trained response team, and data collection to monitor performance. These standards are vague, said Peberdy. They do not define optimal team composition, the necessary training and skill level of the team members, or how resuscitation skills should be retained (e.g., training modalities, frequency or intensity of training, and continuing education). Many team members may see only one or two cardiac arrests per year, and often the team members have never worked together. Successful teamwork requires high-quality training to ensure rapid response and resuscitation, reducing delays in defibrillation times and death rates (Chan et al., 2008). Peberdy suggested that crew resource management training, a method used in the aviation industry, could be applied in hospital settings to foster better team responses to cardiac arrest.

Postarrest care is a relatively new area of study. It offers additional opportunities to improve data collection and knowledge about factors influencing cardiac arrest survival rates, explained Peberdy. Some exam-

ples of important metrics include withdrawal of life support and electroencephalographic monitoring.

Peberdy noted that errors in cardiac arrest care are common, and these errors have been shown to decrease the likelihood of return of spontaneous circulation and survival. Yet failures to document critical clinical interventions persist. For example, one study found that placement of the endotracheal tube was not documented in 17.5 percent of cases observed, indicating either a documentation problem or a clinical practice problem, said Peberdy (Phelan et al., 2013).

Reducing variability and pursuing improvements in IHCA processes and outcomes will require mandatory performance measurement that includes quality measures that are based on reliable data sources and appropriately risk adjusted, said Peberdy. For example, presence of comorbid conditions, the existence of do-not-resuscitate orders, and resuscitations that occur in intensive care units should all be adjusted for when evaluating mortality, said Peberdy. Unfortunately, high-volume or high-target quality measures (e.g., survival) for hospital-based resuscitation are difficult to select, implement, and interpret, said Peberdy. She suggested developing smaller interim performance and outcome measures along the entire sequence of resuscitation events rather than focusing solely on the final outcome—neurologically intact survival to hospital discharge. Peberdy concluded, “the only thing we cannot afford to do, is to do nothing.”

One workshop participant highlighted a 2015 IOM report called Vital Signs: Core Metrics for Health and Health Care Progress (IOM, 2015b). The report noted that the expanding number of mandatory process measures is becoming burdensome to providers without evidence of improved outcomes. The report recommended a set of core measures meant to improve health, quality, cost, and engagement. The participant suggested that the resuscitation field may be better served if all hospitals and EMS systems track and report outcomes along with the best practices associated with changes in outcomes rather than asking the Joint Commission to assess specific process measures. Vinay Nadkarni, another panelist, generally agreed, but also emphasized appropriate risk adjustment. He also suggested the application of a few time-critical performance measures, called tracers, that all hospitals could easily measure and report.

CHILDREN AND CARDIAC ARREST: IMPLICATIONS OF THE IOM REPORT

Vinay Nadkarni, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine

Each day approximately 1,000 adults and 50 children experience a cardiac arrest in North America, began Vinay Nadkarni. Given current survival rates, this is the equivalent of two Boeing 747 airplanes full of adults and two small school buses full of children crashing every day with no survivors, he explained. Estimates suggest that adults lose about 10,000 quality-adjusted life years (QALYs) per day following a cardiac arrest, whereas children lose approximately 3,500 QALYs per day (Nadkarni, 2016). Because children usually arrest at very young ages and have a long life span, the public health burden is high. In addition to the two chains of survival for adult populations—one for IHCA and one for OHCA—there is also a third chain of survival that is dedicated to pediatric cardiac arrest, which places an increased emphasis on prevention of injury and cardiac arrest in pediatric populations, stated Nadkarni.

The etiology of cardiac arrest in children and babies differs from that in adults. The predominant causes of cardiac arrest in children are usually respiratory or hypoxic in nature, unlike the underlying coronary artery disease that often leads to arrest in adults, noted Nadkarni. At birth many babies require some form of immediate stimulation, whereas only 3 to 6 percent of the 136 million births annually worldwide require bag-and-mask ventilation and less than 1 percent require more advanced resuscitation (e.g., CPR, medication) (Lee et al., 2011).

In the United States, 80 percent of pediatric emergency room visits occur in community hospitals, not specialized children’s hospital settings (Nadkarni, 2016). Therefore, all hospitals need to be prepared to treat pediatric cardiovascular emergencies and cardiac arrest, he stated. Resuscitation interventions for pediatric populations are similar to those used for adults. In the prearrest phase, early identification and rapid response are paramount. During cardiac arrest, high-quality CPR, ventilation, and defibrillation for shockable rhythms are key elements of response. Health care providers should also consider the use of vasopressors and administer treatments for reversible causes of the arrest when applicable. In selected settings, extracorporeal cardiopulmonary resuscitation, extracorporeal membrane oxygenation (ECMO), and bypass CPR are also available for eligible pediatric patients. In the postarrest phase, the intervention targets in pediatric patients are generally the same as those in adult populations: targeted temperature management, blood pressure maintenance, oxygenation, ventilation, recognition and treatment of sei-

zures, and percutaneous coronary intervention (PCI) or thrombolysis, as necessary.

Preparing health care providers to respond to pediatric cardiac arrest can be accomplished through low-intensity, high-frequency training, said Nadkarni. Simulation, hands-on practice, real-time CPR feedback, and team prebriefing and debriefing are effective components of a team-based hospital training program. To evaluate readiness and team performance, simulation of identical pediatric cases can be applied across emergency departments or hospitals. The International Network for Simulation-based Pediatric Innovation, Research, & Education (INSPIRE) and ImPACTS investigators have developed a demonstration project that is being implemented in 30 hospitals (Auerbach et al., 2016). The project uses simulation to measure and compare performance scores on a range of cardiac arrest measures, such as appropriate compression and ventilation rates, use of a backboard, no interruptions in compressions, among many others. Nadkarni noted that the findings from this demonstration could be translated into Joint Commission or NQF quality measures, which could eventually be used to evaluate hospitals for readiness, teamwork, and time-critical performance.

The Get With the Guidelines–Resuscitation program includes a number of performance measures that could easily be adapted, measured, and compared across adult, pediatric, and neonatal populations in hospitals, suggested Nadkarni. For example, in adults and children, the administration of epinephrine within 5 minutes for arrests with asystole or pulseless electrical activity is a meaningful performance measure, but likely would need to be substituted for neonate populations due to lack of evidence. In the neonate population, the application of positive pressure ventilation within 1 minute of birth could be used as a comparable type of measure, suggested Nadkarni.

The research challenges for resuscitation research remain the same regardless of the population. There are challenges related to collecting data and ensuring its quality, processing research findings into knowledge, transferring that knowledge into guidelines and standards, and teaching those standard and guidelines to prompt actions that will benefit patients and improve outcomes. Specifically, Nadkarni highlighted obstacles in training teams and assessing performance in simulated environments and then being able to correlate simulated performance with real performance and meaningful clinical outcomes data.

In response to a question about the possible benefits and opportunities for collecting cardiac arrest data in hospitals, Nadkarni stated that the use of electronic health records (EHRs) for data collection in some ways represents the holy grail. The Get With the Guidelines program, for example, has partnered with the largest EHR companies to attempt to

develop pathways that allow relevant data (e.g., defibrillator sequence, electrocardiogram rhythms) to be transferred to the registry. Thus, the ability to transfer data automatically could facilitate quality improvement efforts. However, EHRs do not always capture what was actually done nor do they accurately account for time as a variable, Nadkarni said. Because many of the cardiac arrest processes are time critical, identifying start and end points and measuring time as a reliable and synchronized variable are beneficial. Dianne Atkins, the planning committee member who moderated this panel, described a CPR navigator module that her health care system designed to collect cardiac arrest data. Although data are often recorded after an event, the module is meant to be used in real time. Mobile computers in hospital units allow nurses to quickly record actions taken (e.g., epinephrine administered, ventilation provided) during the event by simply checking boxes.

FROM PLAYBOOK TO POLICY: ANTIMICROBIAL STEWARDSHIP

Edward Septimus, Hospital Corporation of America Healthcare System

Despite obvious differences between sepsis and cardiac arrest, a number of important similarities may prove informative, Septimus explained. Prevention, early recognition and response, and risk-adjusted outcomes are common elements of concern for health care providers and researchers in both the infectious disease and resuscitation fields. For leaders in both fields, there are two pathways forward, he said: “We can either put our heads in the sand and wait for a crisis to develop or we can proactively come up with some successful strategies before regulatory levers force action.” One of the key conclusions from the IOM report Crossing the Quality Chasm noted that it takes an average of 17 years for best practices to take hold (IOM, 2001). That is far too long to wait, said Septimus—patients deserve better. Reiterating opening remarks from Tom Aufderheide, Septimus supported the development of collaborative action to overcome cultures of inaction in the health care field.

When asked about major advances in public health during the past century, most experts cite the discovery of antibiotics and vaccines. However, in recent years the world has experienced setbacks in both of these areas, said Septimus. The overuse and misuse of antibiotics across the continuum of care and in animals has led to antimicrobial resistance, which is having adverse effects on patients and societies worldwide. In fact, the World Health Organization considers antimicrobial resistance to be an emerging threat to global stabilization.

Similar to the challenges that the resuscitation field faces with improving rates of CPR and cardiac arrest outcomes, antimicrobial resistance is

a complex and persistent problem that requires changes in physician behavior and public awareness. Unfortunately, this is not a new problem, and little has been done to rectify the situation, said Septimus.

Collaborative Action to Stem Antimicrobial Resistance

In 2015 the President’s Council of Advisors on Science and Technology (PCAST) released a report titled The National Action Plan for Combating Antibiotic-Resistant Bacteria (PCAST, 2015). Septimus noted there were a number of recommended public policy changes that were similar to the recommendations in the IOM’s report on cardiac arrest. For example, the PCAST report called for the development of accreditation standards—similar to the fourth recommendation in the cardiac arrest report. The report also recommended tracking of inpatient and outpatient antibiotic use and annual reporting, which is similar to many aspects of the registry recommended in the IOM report’s first recommendation. The PCAST report also called for hospitals and health care settings to better align and comply with the Centers for Disease Control and Prevention’s (CDC’s) Core Elements of Hospital Antibiotic Stewardship Programs (CDC, 2014), the Centers for Medicare & Medicaid Services’s (CMS’s) proposed rules related to antibiotic stewardship programs (CMS, 2016), and the Joint Commission’s Antimicrobial Stewardship Standard (Joint Commission, 2016).

To accomplish the goals and objectives described in the PCAST report, a wide range of stakeholder support and engagement could be developed from many entities, including the White House, CDC, CMS, the Joint Commission, NQF, the American Hospital Association, key professional societies, and many others. Success will require strong leadership and accountability from within hospitals and across the health care system; the ability to reliably track, measure, and report on data and outcomes; the capability to develop, test, and modify interventions; and education for providers, patients, and families. Septimus noted that all of these actions mirror the actions that the resuscitation field will need to take to advance the recommendations from the IOM’s 2015 report. However, in considering the development and application of process measures, Septimus said that all process measures must be linked to better outcomes; unintended consequences must be considered when developing and implementing new process measures; and reportable measures must not create a sizable burden on health care providers.

Building on the synergy of the PCAST report, NQF and CDC partnered with a group of public- and private-sector leaders—the Antibiotic Stewardship Action Team—in 2015 to develop the guide National Quality Partners Playbook: Antibiotic Stewardship in Acute Care (NQF, 2016). The

playbook is the collaborative product of more than 30 prominent government agencies, hospital organizations, consumer groups, professional organizations, and research centers. It was designed to provide hospitals, accreditation bodies, and patient and consumer groups with a common agenda, guidance, and achievable strategies for implementing a sustainable, effective stewardship program at the local level. The playbook is based on CDC’s Core Elements and incorporates examples of success, possible solutions to common barriers, potential measurement strategies, and viable future directions. Septimus said the playbook was not meant to be a mandatory must-do list, but rather a resource of options that can be adopted depending on local circumstances, needs, and available resources.

Numerous lessons from the development of the playbook can be transferred to the resuscitation community. First, the playbook was developed by convening a diverse group of national experts from leading organizations who reinforced antimicrobial stewardship as a national priority. This effort was not unlike the dissemination workshop and collaborative efforts being discussed at the workshop, noted Septimus. Additionally, Septimus emphasized the importance of engaging and collaborating with patients and consumers throughout the entire process, saying that these individuals can provide indispensable passion, advocacy, and powerful personal stories that can motivate change. Rather than adding a new layer of guidance, the playbook aligns perfectly with and builds on existing and proposed guidance from CDC, CMS, and the Joint Commission. It provides actionable suggestions and examples that can be adopted by organizations regardless of size or budget, so it is scalable and manageable for all systems. The online edition of the playbook also links to critical resources that can be leveraged for success. Following the success of the playbook, there have been discussions among the partners about using the same collaborative model to develop a playbook for long-term care.

BREAKOUT SESSION REPORT: IMPROVING THE QUALITY OF HOSPITAL RESPONSE TO CARDIAC ARREST

Dianne Atkins, Planning Committee Member¹

Atkins facilitated a breakout session on improving the quality of hospital response to cardiac arrest, which responded to the fourth recommendation in the IOM’s report (see Appendix A). The breakout group consid-

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¹ Breakout session presenters were asked to summarize the major ideas and opinions proposed by individual participants during their respective breakout sessions. Individual statements described below are not necessarily the position of the presenter and should

ered a range of strategies that could be used to more broadly enhance the quality of hospital response and care for cardiac arrest.

Atkins highlighted some of the major barriers identified in her breakout session relevant to quality improvement, many of which relate to challenges with data collection and availability. For example, Atkins pointed out that in general there is a resistance within hospitals against publicly reporting data and that existing data are inadequate. The lack of specificity in coding to distinguish IHCA from OHCA and the inadequacy of Current Procedural Terminology (CPT) codes for cardiac arrest treatments also present challenges for establishing and implementing accreditation standards. A number of workshop participants commented on challenges associated with data collection and analysis and how these challenges impede progress in quality improvement efforts. Three participants described limitations of current coding systems, noting that the lack of separate codes for in-hospital, out-of-hospital, and pediatric cardiac arrests created problems when trying to conduct research related to cardiac arrests that occur in a specific setting or population. One of these participants also noted that the lack of available coding for specific cardiac arrest therapies (e.g., therapeutic temperature management) creates difficulties for health care systems that want to study outcomes following various treatments.

Factors related to risk adjustment and differentiating between standards and metrics are also challenges that will need to be resolved, noted Atkins. To overcome these challenges and move forward with development and adoption of accreditation standards, strong leadership within the hospitals will be required, said Atkins. Individual participants in the breakout group also identified a range of stakeholders that should be consulted throughout the development and implementation phases (see Box 6-2).

Atkins noted that the breakout session members identified a number of steps that would likely need to occur before accreditation standards could be broadly implemented. For example, hospital recognition programs could be developed to encourage the adoption of process and quality improvement initiatives within hospitals, similar to the Get With the Guidelines programs in resuscitation, stroke, and myocardial infarction. These programs can reward participation and recognize benchmark achievements, said Atkins, while collecting data relevant to process improvement and adherence to existing guidelines. This approach benefits from a gradual rollout and tailoring to the needs of hospitals, but it is completely voluntary. Some members of the breakout group

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not be interpreted as consensus statements from the breakout group as a whole or of the National Academies of Sciences, Engineering, and Medicine.

also suggested the development of cardiac arrest centers of excellence or cardiac arrest–ready hospitals in order to identify hospitals that provide high-quality, evidence-based care for cardiac arrest patients (see also Chapters 2 and 7). Atkins noted that combining these two strategies could naturally lead to the development of metrics and standards, which could then be implemented more broadly.

Other members of the group suggested that quality improvement efforts for cardiac arrest be closely tied to patient safety initiatives and team training opportunities. For example, two workshop participants suggested using prehospital providers (e.g., paramedics) as instructors to provide CPR and resuscitation training to response teams in hospital settings. In considering implementation of improvement efforts, Atkins warned that process variability and technological challenges across settings are common and will need to be considered. Several breakout participants also discussed the potential value of developing a cardiac arrest coalition and playbook, similar to the National Quality Partners Playbook: Antibiotic Stewardship in Acute Care (NQF, 2016). Although engaging a wide range of stakeholders could be difficult, the coalition and playbook could provide a national roadmap for ensuring high-quality, evidence-

based cardiac arrest care across hospital and health care settings throughout the United States, said Atkins.

REFERENCES

Merchant, R. M., R. A. Berg, L. Yang, L. B. Becker, P. W. Groeneveld, and P. S. Chan. 2014. Hospital variation in survival after in-hospital cardiac arrest. Prepared for the American Heart Association’s Get With the Guidelines−Resuscitation Investigators. Journal of the American Heart Association 3(1):1–7.

Nadkarni, V. 2016. Enhancing hospital response to cardiac arrest. Presentation at the Dissemination Workshop on the Report, Strategies to Improve Cardiac Arrest Survival: A Time to Act, Washington, DC. http://www.nationalacademies.org/hmd/~/media/Files/Activity%20Files/PublicHealth/TreatmentofCardiacArrest/JULY%202016%20Workshop/Nadkarni.pdf (accessed October 30, 2016).

NQF (National Quality Forum). 2016. National quality partners playbook: Antibiotic stewardship in acute care. Washington, DC: NQF. http://www.qualityforum.org/Publications/2016/05/Antibiotic_Stewardship_Playbook.aspx (accessed October 3, 2016).

PCAST (President’s Council of Advisors on Science and Technology). 2015. National Action Plan for combating antibiotic-resistant bacteria. Washington, DC: White House. https://www.whitehouse.gov/sites/default/files/docs/national_action_plan_for_combating_antibotic-resistant_bacteria.pdf (accessed December 5, 2016).

Peberdy, M. A., J. P. Ornato, G. L. Larkin, R. S. Braithwaite, T. M. Kashner, S. M. Carey, P. A. Meaney, L. Cen, V. M. Nadkarni, A. H. Praestgaard, and R. A. Berg. 2008. Survival from in-hospital cardiac arrest during night. Prepared for the National Registry of Cardiopulmonary Resuscitation Investigators. JAMA 299(7):785–792.

Phelan, M. P., J. P. Ornato, M. A. Peberdy, and F. M. Hustey. 2013. Appropriate documentation of confirmation of endotracheal tube position and relationship to patient outcome from in-hospital cardiac arrest. Prepared for the American Heart Association’s Get With the Guidelines−Resuscitation Investigators. Resuscitation 84(1):31–36.

Sutton, R. M., B. French, P.A. Meaney, A. A. Topjian, C. S. Parshuram, D. P. Edelson, S. Schexnayder, B. S. Abella, R. M. Merchant, M. Bembea, R. A. Berg, and V. M. Nadkarni. 2016. Physiologic monitoring of CPR quality during adult cardiac arrest: A propensity-matched cohort study. Prepared for the American Heart Association’s Get With the Guidelines–Resuscitation Investigators. Resuscitation 106:76–82.

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