Jessica Lehrich

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 hospitals 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.

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.

Cardiac Stress Testing and the Radiotracer Supply Chain: Nuclear Freeze

Cardiac Stress Testing and the Radiotracer Supply Chain: Nuclear Freeze Nearly 15 million doses of technetium Tc 99m (99mTc) are used annually in the United States, most of which for cardiac stress testing with single-photon emission computed tomography myocardial perfusion imaging (SPECTMPI). Technetium Tc 99m is produced largely from “weapons-grade” highly enriched uranium (HEU). None of the nuclear reactors that produce molybdenum Mo 99 (99Mo), the parent isotope of 99mTc, are located in the United States and all are at least 50 years old, with repeated shortages of 99mTc occurring owing to required repairs. Although widely discussed,1,2 the clinical implications of these shortages have not been well studied. If 99mTc is unavailable, physicians may choose an older radiotracer, thallium Tl 201, or alternative tests. Such abrupt shifts could affect test quality and the use of downstream procedures including cardiac catheterization. We explored the clinical effects of a 6-month shortage (March-August 2010) for 99mTc resulting from shutdowns of 2 major nuclear reactors.

CHARACTERISTICS, RISK FACTORS & OUTCOMES OF EXTRACORPOREAL MEMBRANE OXYGENATION USE IN THE PEDIATRIC CARDIAC INTENSIVE CARE UNIT

Background: Extracorporeal Membrane Oxygenation (ECMO) is used to support pediatric patients with medical and surgical cardiac disease. We aimed to characterize ECMO use across a multicenter cohort. Methods: Retrospective analysis of the Pediatric Cardiac Critical Care Consortium (PC4) clinical

Greening Cardiology: Exploring the Sustainability Practices of Healthcare Workers in the Cardiac Catheterization Laboratory

Background: Hospitals produce a substantial amounts of waste. To understand the potential role of employees in reducing waste, we surveyed healthcare workers in the cardiac catheterization laboratory-a resource-intensive hospital area – about their personal practices regarding sustainability at work and at home. Methods and results: We surveyed 52 full-time employees of the University of Michigan Cardiac Catheterization Laboratories using an anonymous online survey. Employees included all individuals working in a patient care capacity, such as physicians, nurses, technicians, medical assistants and administrators. Paired t-tests compared responses to parallel questions about recycling and energy saving habits between work and home. A total of 42 of 52 (80.8%) respondents completed the survey with 12 (28.6%) physicians and 30 (71.4%) non-physicians. Recycling and energy saving habits were more evident on average at home than in the workplace across the majority of areas examined. Comparing sustainability habits between subpopulations, physicians were found to engage in energy saving habits at home significantly less often than non-physician employees (mean score, 2.3 versus 2.9; p=0.0014) and employees under 40 years of age engaged in energy saving habits significantly less at work than employees over 40 years of age (mean score, 1.7 versus 2.1; p=0.0322).