Top-performing hospitals for in-hospital cardiac arrest (IHCA) not only have improved outcomes, but fundamentally different organization, composition and function, according to the results of a National Heart, Lung, and Blood Institute-funded study presented Saturday during the Resuscitation Science Symposium.
The study was presented by Brahmajee K. Nallamothu, MD, professor in the division of cardiovascular diseases and the department of internal medicine at the University of Michigan, Ann Arbor. Nallamothu and colleagues identified several themes to summarize the differences in resuscitation approaches at top-performing hospitals compared with middle- and bottom-performing hospitals.
Nallamothu and colleagues used risk-standardized IHCA survival discharge rates to identify nine geographically and academically diverse hospitals in the AHA Get With The Guidelines®-Resuscitation registry from 2012 and 2014. They included five hospitals in the top quartile of IHCA survival, one in the middle quartile and three in the bottom quartile.
The researchers conducted one- to two-day site visits with in-depth interviews of clinical and administrative staff. Of the 158 interviews conducted, 20.9 percent were with physicians, 49.4 percent with nurses, 7 percent with respiratory therapists and 22.7 percent with quality improvement staff, administration and other staff. Based on these interviews, the researchers identified five large themes related to improved IHCA outcomes.
“The first theme we identified was that resuscitation team design makes a difference,” Nallamothu said. “We found that if you looked at top-performing hospitals, they consistently described having either dedicated or designated resuscitation teams.”
Dedicated teams included nurses and other clinical providers whose primary responsibility was resuscitation and responding to emergency situations. Top-performing hospitals that didn’t have dedicated teams instead had designated teams with members who were able to respond to an arrest right away, even if they had primary patient care duties, thanks to established procedures that relieved them from their current task. Middle- and bottom-performing hospitals had resuscitation teams formed on more of an ad hoc basis, Nallamothu said.
The second theme was team composition, or the size and types of team members. The third theme was roles and responsibilities of team members.
“Top-performing hospitals seem to be very specific about how they thought about individual roles,” Nallamothu said. “People knew beforehand what they were supposed to do. For example, an ICU nurse might know that it was his or her job to immediately go and ensure IV access.”
In contrast, one interviewee at a bottom-performing hospital mentioned walking into a room during an arrest and seeing two people working on IV access while nobody was focused on chest compressions.
The fourth theme was that top-performing hospitals thought about their resuscitation team in terms of communication and leadership much differently than middle- and bottom-performing hospitals.
“They still struggled with this area but seemed to think about them in a more sophisticated way and had mechanisms in place if there was a failure in communication or leadership,” Nallamothu said.
Finally, top-performing hospitals considered quality improvements and education events for their resuscitation teams differently. For example, in top-performing hospitals, mock codes were taken very seriously and were followed with in-depth debriefings. In contrast, other hospitals did mock codes but struggled to get personnel to participate.
“Resuscitation teams are a big part of every hospital in the United States, yet we understand very little about how we got the current system we have,” Nallamothu said. “Even though we have had this system for five decades, until now, no one really has thought very systemically about how they could be designed for the output that we all want with improved performance and outcomes.”