In-hospital cardiac arrests are a common and lethal problem, accounting for approximately 160,000 deaths every year in the United States. Previous efforts to improve cardiac arrest outcomes have largely focused on pre-arrest (e.g., rapid response teams) and intra-arrest factors (e.g., quality of cardiopulmonary resuscitation [CPR]); much less emphasis has been placed on post-arrest factors or post-resuscitation care. Yet, nearly 50% of all deaths due to a cardiac arrest occur during the post-resuscitation phase and there is widespread belief that survival can be improved substantially. The importance of the post-resuscitation phase has been recently recognized by professional societies like the American Heart Association. However, our understanding of the critical elements of post-resuscitation care that might improve patient outcomes remains severely limited; we do not understand precisely which therapies, protocols and organizational factors are effective. The research proposed in this application has been designed to advance the science and knowledge regarding post- resuscitation care as well as support the continued development of Dr. Saket Girotra- an extremely promising cardiologist with interest and training in health services research.
Aim 1 will involve a systematic review of the existing literature to comprehensively synthesize all interventions (therapies, processes of care, organizational interventions) that have been studied for improving survival during the post-resuscitation phase. The available evidence will be systematically synthesized using both qualitative and quantitative (e.g., meta-analysis) methods.
Aim 2 will examine hospital-level variation in post-resuscitation survival using data from the Get With The Guidelines-Resuscitation (GWTG-Resuscitation) registry. Using hierarchical models, we will estimate risk- adjusted rates of post-resuscitation survival at each hospital. We will identify hospitals with exceptionally good survival rates (high-performing hospitals) using a deviance approach. This work will lay the foundation of our efforts to identify specific practices at high-performing hospitals that allow them to achieve superior outcomes.
Aim 3 will involve development and implementation of a survey of key informants at participating hospitals in GWTG-Resuscitation to obtain detailed information regarding hospital-specific post-resuscitation care practices. The survey will allow us to identify which specific strategies are used by high performing hospitals that allow them to achieve their exceptional outcomes. We hypothesize that these strategies will be multi- faceted and include specific treatments, processes of care, personnel, as well as organizational factors (e.g., leadership, communication). Identifying strategies that are most effective in improving post-resuscitation care (best practices) will inform on the design of a quality improvement intervention geared towards improving post -resuscitation care at all hospitals. This will be the subject of a future R01 by the applicant.

Public Health Relevance

Sudden death due to the heart stopping (i.e., cardiac arrest) occurs commonly among hospitalized patients in the United States. Even after successful revival with CPR, many cardiac arrest patients eventually die during the hospital stay. A patient's chance of surviving a cardiac arrest depends on the hospital in which they receive care. In other words, some hospitals are better than others in saving lives. This research project will identify hospitals that offer the best chance of survival to a cardiac arrest patient who has been successfully revived with CPR, and understand how these hospitals achieve their superior results. This knowledge will help us learn from the example of the 'best hospitals' and provide guidance on how to improve care so that all patients at all hospitals can be benefited.

National Institute of Health (NIH)
National Heart, Lung, and Blood Institute (NHLBI)
Clinical Investigator Award (CIA) (K08)
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Study Section
Special Emphasis Panel (ZHL1-CSR-K (F2))
Program Officer
Cooper, Lawton S
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University of Iowa
Internal Medicine/Medicine
Schools of Medicine
Iowa City
United States
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Joseph, Lee; Chan, Paul S; Bradley, Steven M et al. (2017) Temporal Changes in the Racial Gap in Survival After In-Hospital Cardiac Arrest. JAMA Cardiol 2:976-984
Jain, Snigdha; Khera, Rohan; Girotra, Saket et al. (2017) Comparative Effectiveness of Pharmacologic Interventions for Pulmonary Arterial Hypertension: A Systematic Review and Network Meta-Analysis. Chest 151:90-105
Bradley, Steven M; Liu, Wenhui; Chan, Paul S et al. (2017) Duration of resuscitation efforts for in-hospital cardiac arrest by predicted outcomes: Insights from Get With The Guidelines - Resuscitation. Resuscitation 113:128-134
Khera, Rohan; Angraal, Suveen; Couch, Tyler et al. (2017) Adherence to Methodological Standards in Research Using the National Inpatient Sample. JAMA 318:2011-2018
Khera, Rohan; Spertus, John A; Starks, Monique A et al. (2017) Administrative Codes for Capturing In-Hospital Cardiac Arrest. JAMA Cardiol 2:1275-1277
Giacomino, Bria D; Cram, Peter; Vaughan-Sarrazin, Mary et al. (2016) Association of Hospital Prices for Coronary Artery Bypass Grafting With Hospital Quality and Reimbursement. Am J Cardiol 117:1101-6
Khera, Rohan; Chan, Paul S; Donnino, Michael et al. (2016) Hospital Variation in Time to Epinephrine for Nonshockable In-Hospital Cardiac Arrest. Circulation 134:2105-2114
Girotra, Saket (2016) Post-cardiac arrest mortality is declining in the UK. Crit Care 20:304
Pandey, Ambarish; Khera, Rohan; Kumar, Nilay et al. (2016) Use of Pulmonary Artery Catheterization in US Patients With Heart Failure, 2001-2012. JAMA Intern Med 176:129-32
Khera, Rohan; Light-McGroary, KellyAnn; Zahr, Firas et al. (2016) Trends in hospitalization for takotsubo cardiomyopathy in the United States. Am Heart J 172:53-63

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