Hospitals vary considerably in how often epinephrine administration is delayed beyond 5 minutes in cardiac arrest with nonshockable rhythm, suggests a new study, in which more frequent delays were also related to lower survival.
“Based on the findings of our study, cardiologists and other physicians should actively engage in understanding how well currently accepted resuscitation guidelines are being applied during an in-hospital cardiac arrest at their respective institutions,” Dr Rohan Khera (UT Southwestern Medical Center) told Medscape.
“Specifically, there needs to be a wider emphasis on simulation training for resuscitation, wherein cardiac arrest in hospitalized adults that is not amenable to defibrillation therapy is treated with CPR and epinephrine in a timely manner,” he said.
Khera and colleagues analyzed data from the American Heart Association’s Get With the Guidelines–Resuscitation registry to evaluate hospitals’ rates of delayed epinephrine treatment and how the rates may have implications for overall survival and survival with functional recovery.
They identified 123,649 adults at least 18 years old who experienced an in-hospital cardiac arrest due to asystole or pulseless electrical activity (PEA) between January 2000 and the end of 2014. For their final analysis they included 103,932 patients at 548 hospitals.
Survival to discharge was the primary outcome, with survival with functional recovery (cerebral performance category scores 1 or 2) as a secondary outcome.
They obtained hospital characteristics from the American Hospital Association database; analysis variables included admission volume, number of beds, proportion of intensive-care-unit (ICU) beds, geography, and teaching status.
The rate of delayed administration of epinephrine varied widely, from 0% to 53.8% of patients, with the overall rate coming to 12.7%.
The researchers divided the hospitals into quartiles based on the proportion of patients with delayed epinephrine (beyond 5 minutes). The quartiles ranged from 0% to 9.95% to 19.0% to 53.8%.
Patients in the highest quartile for delayed epinephrine were slightly older (mean age ranged from 66.0 to 66.8 from quartile 1 to 4), were more likely men, and more likely to have renal insufficiency, hepatic insufficiency, septicemia, PEA as the initial rhythm, and to be in the ICU at the time of cardiac arrest (P<0.0001 for all). They were less likely to be receiving vasopressors or mechanical ventilation (P<0.0001 for both).
Hospitals in the highest quartile were more likely not teaching hospitals, had lower volume of nonshockable cardiac arrest, lower overall admission volume, and fewer beds. Low hospital case volume (<100 cases) was the only characteristic associated with delayed epinephrine administration (odds ratio [OR] 1.30, 95% CI 1.17–1.44).
The researchers found the overall patient-level rate of survival to discharge to be 12.3% and the survival with functional recovery to be 7.8%. They found hospital rate of delayed epinephrine to be inversely correlated with unadjusted rates of survival to discharge (P=0.0001) and survival with functional recovery (P=0.0005).
The researchers calculated a risk-standardized survival ratio (RSSR) as the ratio of predicted-to-expected number of survivors at each hospital multiplied by unadjusted survival rate. They found hospital epinephrine-administration performance to be significantly associated with RSSR, including after adjustment for hospital volume. Hospitals with lower survival had more frequent delays.
“Given the observational nature of our study, we cannot definitively conclude that a hospital’s rate of delayed epinephrine use was causally associated with its outcomes,” Khera told heartwire . “We performed robust risk adjustment where we accounted for all potential confounders, including the underlying health status of patients at these hospitals and timelines of chest compression. However, we cannot rule out unmeasured confounders.
“Hospital administrators may consider focusing on the ‘code blue’ team dynamics at their respective institutions,” he continued. “There needs to be an emphasis on funding simulation training, particularly, at low-performing hospitals. Such training may help improve a hospital’s compliance to time-sensitive resuscitation care, including timely epinephrine, and may potentially have a positive impact on the number of patients surviving nonshockable cardiac arrests at these hospitals.”
Coauthor Dr Paul S Chan (Saint Luke’s Health System, Kansas City, MO) said, “Hospitals that are measuring their outcomes for cardiac arrest in the hospital setting should look at how promptly they get to patients for both defibrillation and epinephrine. If they’re seeing themselves frequently having delays, and if they’re participating in a registry, if they recognize that they’re below median, it probably should prompt an evaluation with the code blue committee, with the resuscitation committee.”
A major question, he continued, “is whether the time at which patients are getting epinephrine is a real relationship with survival or whether it is a marker of the quality of resuscitation care at the hospital. That includes epinephrine, but it also probably includes things like chest compressions and how high quality the CPR is. Whether or not this variation in delays in epinephrine really also measures variation in quality of CPR overall at these hospitals is harder to tease out.”
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