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
Disclosures
• 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
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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.
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Aims
• 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.
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Quality Measures
• 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
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Statistical Analysis
• 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)
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Baseline Characteristics of Study Population
Age Median, IQR
Men, %
Race/Ethnicity, %
White
Black
Hispanic
Other
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Overall
2000
2006
2012
N=149, 551 N=1706 N=13852 N=7159
P-Value
68 (56, 78) 71 (59, 79) 68(56, 78) 67 (55, 77) <0.001
57.8
55.6
57.9
58
0.15
<0.001
66.3
69.2
64.6
66.6
21.0
22.1
21.8
23.2
5.3
2.2
6.1
3.9
7.4
6.6
7.5
6.3
Baseline Characteristics of Study Population
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Hospital Characteristics
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Change in Individual Measures
Δ +7.1
Δ +4.8
Δ +8.1
Δ +35.8
Δ -2.7
Δ +35.6
p<0.001, except time to defib p=0.369
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Change in Composite Measure Over Time
Δ 13.1; p<0.001
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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.
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Impact of time in GWTG-R on Composite Performance by Hospital Types
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Limitations
• 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.
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Summary
• 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.
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Acknowledgements
Eric D. Peterson, MD, MPH
Graham Nichol, MD, MPH
David Dai, Ph.D.
Paul S. Chan, MD, MSc
Steven Bradley, MD
Sana M. Al-Khatib, MD, MHS
GWTG- R Investigators
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Additional Slides
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Distribution of Hospital Composite Measure Scores
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Example Eligibility Criteria
VT/VF <= 2 min
• Denominator
1. All patients who were pulseless when need for chest
compressions and/or defibrillation arose
2. First documented rhythm is pulseless VF/VT
3. Exclusions:
1. Date/Time for chest compressions or defibrillations not
provided
2. Patient did not have documented VF/VT
3. Advanced Directive in Place
4. ROSC before 2 min
• Numerator
1. Time to first shock less than or equal to 2 minutes.
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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
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Baseline Duration Determination
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