Elsevier

Resuscitation

Volume 60, Issue 3, March 2004, Pages 263-269
Resuscitation

Can successful treatment of cardiac arrest be a performance indicator for hospitals?☆

https://doi.org/10.1016/j.resuscitation.2003.11.013Get rights and content

Abstract

Background: Although resuscitation from cardiac arrest prevents more deaths from acute myocardial infarction (MI) than any other treatment, results have not been audited widely nor performance standards proposed. Methods: The Myocardial Infarction National Audit Project (MINAP) uses electronic transmission of a 53-item dataset to a central cardiac audit database (CCAD). From October 2000 to August 2002, transmission by 218 hospitals of data from 55,906 cases of MI with 4934 attempted resuscitations from a first arrest, allowed for examination of factors determining survival, and for possible future measurement of success in resuscitation as a performance indicator. We investigated two possible indicators: (i) numbers of survivors from arrest in ventricular fibrillation or pulseless ventricular tachycardia (VF/VT) per 1000 cases of MI; and (ii) observed/expected (O/E) ratios for survival taking all VF/VT arrests rather than MI as the denominator, and adjusting for differing age structures and admission delays among individual hospitals. Findings: Of the 4934 reported patients suffering a first arrest, 1778 (36%) survived to be discharged from hospital. The presenting rhythm was VF/VT in 2321 (47%) patients of whom 1461 (63%) survived. Survival for all 218 hospitals together had the relatively small 95% confidence limits of 26 (25–27) survivors from VF/VT per 1000 MI. However, the small numbers from individual hospitals made it impossible in most cases, whichever of the two indicators was used, to separate quality of performance and completeness of reporting from the factor of chance. Interpretation: Audit of success in resuscitation is essential if performance in the treatment of MI is to be assessed. However, the relatively small numbers of arrests occurring in individual hospitals means that if year on year improvements are to be documented, audit must be carried out among groups of hospitals or on a national scale.

Sumàrio

Introdução:Embora a reanimação da paragem cardı́aca previna mais mortes no enfarte agudo do miocárdio (MI) do que qualquer outro tratamento, os seus resultados não foram amplamente auditados nem propostos critérios de boas práticas. Métodos: O Miocardial Infarction National Audit Project (MINAP) utiliza a transmissão electrónica de um conjunto de dados com 53-items para uma base de dados central de auditoria cardı́aca (CCAD). Entre Outubro de 2000 e Agosto de 2002, o envio por 218 hospitais dos dados de 55,906 casos de MI com 4934 tentativas de reanimação após paragem cardı́aca, permitiram estudar os factores determinantes da sobrevivência e possı́veis medidas de sucesso na reanimação como indicadores de boas práticas. Avaliamos dois indicadores: (i) o número de sobreviventes de paragem cardı́aca em fibrilhação ventricular ou taquicardia ventricular sem pulso (VF/VT) por 1000 casos de MI; e (ii) a relação entre observado/esperado (O/E) para a sobrevivência tendo todas as paragens em VF/VT como denominador em vez de todos os MI como denominador, ajustando tempos entre estruturas e atrasos na admissão entre hospitais individuais. Achados: Tiveram alta vivos 1778 (36%) dos 4934 doentes com paragem cardı́aca inicial. O ritmo inicial foi VF/VT em 2321 (47%) doentes, dos quais sobreviveram 1461 (63%). A sobrevivência conjunta de todos os 218 hospitais teve de 26 (25–27) sobreviventes de VF/VT por cada 1000 MI, limites de confiança a 95%. No entanto, os pequenos números obtidos de cada hospital individual tornou, na sua maioria, impossı́vel separar a qualidade da actuação do acaso, e do preenchimento dos dados, para qualquer dos dois indicadores utilizados. Interpretação:Auditar o sucesso na reanimação é essencial se queremos avaliar as boas práticas no tratamento do MI. No entanto, o número de casos de paragem que ocorre me hospitais individuais, relativamente pequeno, significa que, se queremos documentar melhorias ano a ano, esta auditoria deve ser levada a efeito entre grupos de hospitais ou à escala nacional.

Resumen

Antecedentes: Aunque la resucitación del paro cardı́aco previene mas muertes por infarto agudo de miocardio(MI) que cualquier otro tratamiento, los resultados no han sido revisados ampliamente ni se han propuesto estándares de desempeño. Métodos: El Proyecto nacional de revisión de Infarto de Miocardio (MINAP) usa transmisión electrónica de un conjunto de datos de 53 ı́tem a una base central de datos de auditoria cardı́aca (CCAD). De Octubre 2000 hasta Agosto 2002, la trasmisión de datos de 218 hospitales de 55,906 casos de MI con 4934 resucitaciones intentadas en primer paro, permitió el examen de factores que determinan sobrevida, y para futuras posibles mediciones de éxito en resucitación como indicadores de desempeño. Investigamos dos posibles indicadores: (i) numero de sobrevivientes de paro cardı́aco en fibrilación ventricular o taquicardia ventricular sin pulso (VF/VT) por 1000 casos de MI; y (ii) relación sobrevida observada /esperada (O /E) tomando todos los paros en VF/VT mas que los MI como denominador, y ajustando por distintas estructuras etáreas y demoras en admisión entre hospitales individuales. Hallazgos: De los 4934 pacientes reportados como sufriendo su primer paro cardı́aco, 1778 (36%) sobrevivieron y fueron dados de alta del hospital. El ritmo de presentación fue VF/VT en 2321 (47%) pacientes en quienes 1461 (63%) sobrevivió. La sobrevida en los 218 hospitales juntos tuvo un limite de confianza de 95% relativamente pequeño de 26(25–27) sobrevivientes de VF/VT por 1000 MI. Sin embargo, los pequeños números de los hospitales individuales lo hicieron imposible en la mayorı́a de los casos, separar la calidad de desempeño y lo completo del reporte del factor a analizar, cualquiera de los indicadores que se usara. Interpretación: Evaluar el éxito en resucitación es esencial si el desempeño en el tratamiento del MI debe evaluarse. Sin embargo, el número relativamente pequeño de paros cardı́acos que ocurren en hospitales individuales significa que si debe documentarse, la revisión debe ser llevada a cabo entre grupos de hospitales o en una escala nacional.

Introduction

Despite improved survival from acute myocardial infarction due to fibrinolytic therapy, the most effective treatment for prevention of death from heart attack remains resuscitation from cardiac arrest [1], [2], [3]. The UK Myocardial Infarction National Audit Project (MINAP) [4], [5] which was introduced in response to the National Service Framework (NSF) for cardiac disease [6], has for the first time provided national data on the management of acute myocardial infarction (MI) including the success of hospital-based resuscitation. Because the NSF does not specifically mention resuscitation in hospital as a performance indicator, emphasis in MINAP has so far been on audit of the delivery of thrombolytic treatment and initiation of secondary prevention in hospitals [7]. In order to establish an index of success in resuscitation which might in the future be audited as a performance indicator, we examined the treatment of cardiac arrests in English hospitals from reports generated during the first 2 years of MINAP. We were able to examine completeness of reporting by reference to two previous research studies [1], [2].

Section snippets

Methods

MINAP is a national hospital-based audit of MI that is administered by the Clinical Effectiveness and Evaluation Unit (CEEU) at the Royal College of Physicians, London. It uses a strictly defined core dataset of 53 items [4] and electronic transmission to a central cardiac audit database (CCAD) [8]. A final diagnosis of MI requires enzyme release greater than twice the upper limit of normal unless death occurs before enzymes can be measured (MI unconfirmed). Strict quality control of data is

Results

The total database from 218 hospitals contained data on 78,956 hospital episodes of which 55,906 (71%) were given the final diagnosis MI (definite, threatened or unconfirmed). Thrombolytic treatment was given to 30,419/55,906 (54%) patients (77% within 6 h of symptom onset). A first cardiac arrest in hospital for which resuscitation had been attempted was recorded in 4934 cases (9% of those with final diagnosis of MI). Reported numbers presenting with VF/VT, asystole/EMD or rhythm not recorded,

The need for a performance indicator for treatment of cardiac arrest

Although evidence-based guidelines for the treatment and secondary prevention of acute myocardial infarction have been published [9], [10], [11], [12] as have audit projects to discover to what extent they are being implemented [13], [14], [15], there has been little or no emphasis in these guidelines or audits on the treatment of cardiac arrest in the context of acute MI. The reason perhaps is that resuscitation from arrest is not “evidence based” in that it has never been the subject of a

Conclusion

Both of the performance indicators which have been discussed, because of the factor of chance, are of limited value for describing the performance of individual hospitals, but indicator B, which uses VF/VT arrests as the denominator, is the more likely to show changes in groups of hospitals from 1 year to the next. The disadvantage of this indicator is its sensitivity to under-reporting of unsuccessful resuscitation attempts, but this could be overcome by careful validation of resuscitation

Acknowledgements

We are grateful to Professor Richard Vincent and Professor Desmond Julian for helpful comments and advice. MINAP was supported by the UK National Institute of Clinical Excellence (NICE).

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Data from the Myocardial Infarction National Audit Project (MINAP).

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