is participation in get with the guidelines-resuscitation program associated with improved quality...

Is Participation in Get With the Guidelines-Resuscitation Program Associated with Improved Quality of Cardiac Arrest Care?

Monique L. Anderson, MD, Graham Nichol, MD; David Dai, Ph.D; Paul S. Chan, MD, MSc; Steven Bradley, MD; Sana M. Al-Khatib, MD, MHS; Eric D. Peterson, MD, MPH for the AHA GWTG Investigators

All Rights Reserved, Duke Medicine 2007

• M.L. Anderson: None• G. Nichol: Research Grant- Minor; Contract from Philips Healthcare Inc.

Andover MA for study of US during resuscitation (PI); Contract from Velomedix Inc. Menlo Park CA for pilot study of hypothermia in patients with STEMI (National co PI, waived personal compensation); Contracts from Cardiac Science Corp., Waukesha, WI; HeartSine Technologies Inc., Newtown, PA; Philips Healthcare Inc.; Physio-Control Inc., Redmond WA and ZOLL Inc., Chelmsford MA for Dynamic AED Registry (PI).

• D. Dai: None• P.S. Chan: None• S. Bradley: None• S.M. Al-Khatib: None• E.D. Peterson: PI of the AHA GWTG data analysis center

Disclosures


Background• Large geographic variations in outcomes after sudden cardiac

arrest.• Certain care processes are associated with improved outcome

after in-hospital cardiac arrest:– Monitored or Witnessed Events1

– Time to Defibrillation2

– Endotracheal tube confirmation3

• GWTG- Resuscitation is a national quality improvement program for in-hospital cardiac arrest

• It is unknown whether duration of hospital participation in GWTG-R is associated with improved quality of care. 1Brady, W. J., K. K. Gurka, et al. (2011). "In-hospital cardiac arrest: impact of monitoring and witnessed event on patient survival and neurologic status at hospital discharge." Resuscitation 82(7): 845-852.2Chan, P. S., H. M. Krumholz, et al. (2008). "Delayed time to defibrillation after in-hospital cardiac arrest." N Engl J Med 358(1): 9-17.3Phelan, M. P., J. P. Ornato, et al. (2013). "Appropriate documentation of confirmation of endotracheal tube position and relationship to patient outcome from in-hospital cardiac arrest." Resuscitation 84(1): 31-36.


• To determine if ongoing participation in GWTG-R is associated with greater adherence to quality measures.

• To create an in-hospital cardiac arrest composite quality score and determine whether hospital composite performance has improved overtime.

• To determine types of hospitals deriving benefit from participation in GWTG-R.

Aims


• 6 quality measures based on strength of evidence, clinical relevance, and/or magnitude of relationship between quality measure and outcome:

– Device Confirmation of Correct Endotracheal Tube Placement– Monitored and/or Witnessed Event– Time to First Compressions <= 1 min– Time to First Shock <= 2 min for pulseless VT/VF– Time to IV/IO Epinephrine/Vasopressin ≤ 5 min– Subsequent Shock Delivered >= 2 min after previous shock

• Composite measure score:– Opportunity based score encompassing 6 quality measures – total # care processes correctly performed in eligible patients total # of care opportunities among eligible patients

Quality Measures


• Study Population– Adults ≥ 18 yrs of age, index cardiac arrest– Location in ICU or inpatient wards– Hospitals

Participation > 1 yr >5 cardiac arrests per yr

– Jan 1, 2000 until Dec 31, 2012• Multivariable Logistic Regression with GEE

– To create the composite score– To determine independent effect of time in GWTG-R– To determine if programs benefit equally from participation

(Interaction testing)

Statistical Analysis


Baseline Characteristics of Study Population


Hospital Characteristics


Change in Individual Measures

Δ +35.8

Δ +7.1 Δ +4.8

Δ -2.7

Δ +8.1

Δ +35.6

p<0.001, except time to defib p=0.369


Change in Composite Measure Over TimeΔ 13.1; p<0.001


Impact of Time in GWTG-R on Composite Score

Odd Ratio 95% CI

Time in GWTG (per yr of participation) 1.15 1.14-1.16

Adjusted for Time in GWTG-R + Patient and Hospital Characteristics1

1.14 1.13-1.15

Adjusted for Time in GWTG-R + Patient and Hospital Characteristics1 + calendar time

1.04 1.02-1.06

1Adjusted for patient characteristics-age, sex, race, pre-existing conditions (diabetes, abnormal electrolytes, MI, CHF, hepatic Insufficiency, arrhythmia, pneumonia, HIV, AIDS, cancer, renal insufficiency, asystole/PEA, sepsis, respiratory insufficiency, prior MI, prior CHF, acute stroke, arrest at night, arrest on weekends, location of arrest, illness category (medicine vs surgery); Interventions in Place at Time of Arrest (Vascular Access, PA catheter, Arterial Catheter, Hemodialysis, IABP, or mechanical ventilation. Hospital Characteristics- nurse to bed ratio, hospital ownership, geographic region, cardiac surgery capability, hospital bedside, rural vs urban, trauma services, teaching hospital, percentage of ICU beds.


Impact of time in GWTG-R on Composite Performance by Hospital Types


• Program participation is voluntary; study findings may not be applicable to hospitals that choose not to participate.

• Eligibility for a particular measure may have been limited by data collection. Quality and composite score might be lower (e.g. endotracheal tube confirmation). Despite this, clear trends in improvement of adherence to measures over time.

Limitations


• Duration of hospital participation in GWTG-R is associated with improved quality of care over time.

• While there is evidence of overall improvement, there are still areas where care has not improved: e.g. time to first defibrillation shock for pulseless VF/VT patients.

• Improvements in resuscitation quality of care observed among most hospital types– Rural hospitals may need more attention in GWTG-R to derive benefit– Larger hospitals derive greater benefit from participation over time

compared to smaller hospitals• Future work will examine relationship between composite adherence

and in-hospital outcomes of cardiac arrest.

Summary


AcknowledgementsEric D. Peterson, MD, MPHGraham Nichol, MD, MPH

David Dai, Ph.D.Paul S. Chan, MD, MSc

Steven Bradley, MDSana M. Al-Khatib, MD, MHS

GWTG- R Investigators


Additional Slides


Distribution of Hospital Composite Measure Scores


Example Eligibility Criteria VT/VF <= 2 min

• Denominator1. All patients who were pulseless when need for chest

compressions and/or defibrillation arose2. First documented rhythm is pulseless VF/VT3. Exclusions:

1. Date/Time for chest compressions or defibrillations not provided

2. Patient did not have documented VF/VT3. Advanced Directive in Place4. ROSC before 2 min

• Numerator1. Time to first shock less than or equal to 2 minutes.


Eligible Measures for Study• Composite Score Variables

– Monitored and/or Witnessed Event– Time to First Compressions <= 1 min– Time to First Shock <= 2 min for VT/VF– Time to IV/IO Epinephrine/Vasopressin– Subsequent Shock Delivered >= 2 min after previous shock– Device Confirmation of Correct Endotracheal Tube Placement

• Not Included– Time to first assisted ventilation <= 1 min– Chest compressions provided– Defibrillation shock provided for pulseless VF/VT– Shock energy (360J for monophasic/>=120 J for biphasic


Baseline Duration Determination

is participation in get with the guidelines-resuscitation program associated with improved quality...

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