Elsevier

Resuscitation

Volume 83, Issue 1, January 2012, Pages 63-69
Resuscitation

Clinical Paper
Impact of resuscitation system errors on survival from in-hospital cardiac arrest

https://doi.org/10.1016/j.resuscitation.2011.09.009Get rights and content

Abstract

Background

An estimated 350,000–750,000 adult, in-hospital cardiac arrest (IHCA) events occur annually in the United States. The impact of resuscitation system errors on survival during IHCA resuscitation has not been evaluated. The purpose of this paper was to evaluate the impact of resuscitation system errors on survival to hospital discharge after IHCA.

Methods and results

We evaluated subjective and objective errors in 118,387 consecutive, adult, index IHCA cases entered into the Get with the Guidelines National Registry of Cardiopulmonary Resuscitation database from January 1, 2000 through August 26, 2008. Cox regression analysis was used to determine the relationship between reported resuscitation system errors and other important clinical variables and the hazard ratio for death prior to hospital discharge. Of the 108,636 patients whose initial IHCA rhythm was recorded, resuscitation system errors were committed in 9,894/24,467 (40.4%) of those with an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) and in 22,599/84,169 (26.8%) of those with non-VF/pVT. The most frequent system errors related to delay in medication administration (>5 min time from event recognition to first dose of a vasoconstrictor), defibrillation, airway management, and chest compression performance errors. The presence of documented resuscitation system errors on an IHCA event was associated with decreased rates of return of spontaneous circulation, survival to 24 h, and survival to hospital discharge. The relative risk of death prior to hospital discharge based on hazard ratio analysis was 9.9% (95% CI 7.8, 12.0) more likely for patients whose initial documented rhythm was non-VF/pVT when resuscitation system errors were reported compared to when no errors were reported. It was 34.2% (95% CI 29.5, 39.1) more likely for those with VF/pVT.

Conclusions

The presence of resuscitation system errors that are evident from review of the resuscitation record is associated with decreased survival from IHCA in adults. Hospitals should target the training of first responders and code team personnel to emphasize the importance of early defibrillation, early use of vasoconstrictor medication, and compliance with ACLS protocols.

Introduction

The Institutes of Medicine (IOM) landmark publication (“To Err is Human”) estimated that at least 44,000 and perhaps as many as 98,000 Americans die in hospitals each year as a result of medical errors.1 Although the magnitude of the problem has been questioned,2 the Canadian Adverse Events (AE) Study confirms an alarming frequency of in-hospital AEs (7.5 per 100 hospital admissions; 95% confidence interval [CI], 5.7–9.3), 36.9% (95% CI, 32.0–41.8%) of which are potentially preventable. Death occurred in 20.8% (95% CI, 7.8–33.8%) of cases.

The American Heart Association (AHA) Get with the Guidelines National Registry of Cardiopulmonary Resuscitation (NRCPR) collects data on adult and pediatric in-hospital cardiac arrest (IHCA) events from approximately 10% of hospitals in the United States.3 From this registry, NRCPR investigators have documented lower survival from adult in-hospital cardiac arrest (1) on nights and weekends likely due, at least in part, to system factors,3 (2) when defibrillation is delayed greater than 2 min in patients whose initial IHCA rhythm is ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT),4 and (3) in certain hospital locations.5

The purpose of this paper was to determine whether the presence of resuscitation system errors reported to NRCPR are associated with lower likelihood of survival in adult patients who experience an IHCA.

Section snippets

Data collection and integrity

NRCPR is a prospective, observational, multi-center performance improvement registry of IHCA events. Hospitals join voluntarily and pay an annual fee for data support and report generation.

Hospital medical records on sequential IHCA events are abstracted by trained, NRCPR-certified, performance improvement personnel at each participating institution. All data elements have standardized definitions allowing aggregate data analysis from multiple sites, and all data transfer is in compliance with

Results

A total of 118,387 in-hospital, adult, index IHCA cases were entered into the NRCPR database from January 1, 2000 through August 26, 2008. Of these, 84,440 (71.3%) had no system errors recorded and 33,947 (28.7%) had one or more system errors recorded. Of the cases with system errors, 26,919 (22.7%) had 1 error, 5614 (4.7%) had 2 system errors, and 1414 (1.2%) had 3 or more system errors. Of all cases in which the initial rhythm was recorded, 84,169/108,636 (77.5%) had non VF/pVT and

Discussion

The principal finding in this study is that the presence of resuscitation system errors is associated with decreased survival from IHCA in adults. More errors were noted in patients whose initial documented IHCA rhythm was VF/pVT as opposed to those with non-shock-able rhythms. This finding is particularly relevant clinically, given that the majority of survivors of IHCA are those with initial VF/pVT.3

Our findings, although much broader, support those reported by Chan et al.4 who evaluated 6789

Conclusions

We conclude that the presence of resuscitation system errors that are evident from review of the resuscitation record is associated with decreased survival from IHCA in adults. Hospitals should target their training of first responders and code team personnel to emphasize the importance of early defibrillation when indicated, early use of vasoconstrictor medication, and compliance with established AHA ACLS resuscitation protocols.

Conflict of interest statement

None of the authors have any relevant conflicts.

Funding sources

None.

Acknowledgement

None.

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    A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.09.009.

    c

    For the American Heart Association's Get With the Guidelines – Resuscitation (National Registry of Cardiopulmonary Resuscitation) Investigators, see Appendix A.

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