Key Words: cardiac arrest, sudden ◼ cardiopulmonary resuscitation ◼ health services research ◼ quality improvement ◼ qualitative research Sources of Funding, see page 162Editorial, see p 164 BACKGROUND: In-hospital cardiac arrest (IHCA) is common, and outcomes vary substantially across US hospitals, but reasons for these differences are largely unknown. We set out to better understand how top-performing hospitals organize their resuscitation teams to achieve high survival rates for IHCA. METHODS:We calculated risk-standardized IHCA survival to discharge rates across American Heart Association Get With The Guidelines-Resuscitation registry hospitals between 2012 and 2014. We identified geographically and academically diverse hospitals in the top, middle, and bottom quartiles of survival for IHCA and performed a qualitative study that included site visits with in-depth interviews of clinical and administrative staff at 9 hospitals. With the use of thematic analysis, data were analyzed to identify salient themes of perceived performance by informants. RESULTS:Across 9 hospitals, we interviewed 158 individuals from multiple disciplines including physicians (17.1%), nurses (45.6%), other clinical staff (17.1%), and administration (20.3%). We identified 4 broad themes related to resuscitation teams: (1) team design, (2) team composition and roles, (3) communication and leadership during IHCA, and (4) training and education. Resuscitation teams at top-performing hospitals demonstrated the following features: dedicated or designated resuscitation teams; participation of diverse disciplines as team members during IHCA; clear roles and responsibilities of team members; better communication and leadership during IHCA; and in-depth mock codes. CONCLUSIONS:Resuscitation teams at hospitals with high IHCA survival differ from non-top-performing hospitals. Our findings suggest core elements of successful resuscitation teams that are associated with better outcomes and form the basis for future work to improve IHCA. 2 It is not surprising that hospitals have chosen to dedicate substantial resources to train healthcare providers in resuscitation and establish facility-wide emergency response systems to optimize their performance and improve outcomes of patients experiencing cardiac arrest. Despite these sizeable investments, however, overall rates of in-hospital survival after these events remain poor, with substantial variation noted across facilities. 3,4 On the surface, this variation in survival following IHCA may seem surprising. Established guidelines provide logical, sequential algorithms for advanced cardiac life support (ACLS) that are widely accepted and used across much of the world; thus, providers at most hospitals attempt to deliver the same treatments for the same reasons after the same ACLS training. 5,6 Yet, these algorithms largely focus on guiding individuals on technical tasks at a patient's bedside. They have less frequently addressed complex issues surrounding the implementation of these algorithms in real-w...

Importance Although hospitals vary markedly in survival for their patients with in-hospital cardiac arrest, specific resuscitation practices that distinguish sites with higher cardiac arrest survival remain unknown. Objective To identify resuscitation practices associated with higher rates of in-hospital cardiac arrest survival. Design, Setting, and Participants Nationwide survey of resuscitation practices at adult hospitals participating in the Get With The Guidelines (GWTG)-Resuscitation registry and with ≥ 20 adult in-hospital cardiac arrest cases between 2012 and 2013. Main Outcomes and Measures Risk-standardized survival rates for cardiac arrest were calculated at each hospital, and these were then used to categorize hospitals into quintiles of performance. The association between resuscitation practices and quintiles of survival was evaluated using hierarchical proportional odds logistic regression models. Results Overall, 150 of 192 eligible hospitals (78.1%) completed the study survey and 131 facilities with ≥ 20 cases comprised the final study cohort. Risk-standardized survival rates after in-hospital cardiac arrest varied substantially (median: 23.7%; range: 9.2% to 37.5%). Several resuscitation practices were associated with survival on bivariate analysis, although only three were significant after multivariable adjustment: tracking interruptions in chest compressions (adjusted OR for being in a higher survival quintile category, 2.71 [95% CI: 1.24, 5.93]; P=0.01); reviewing cardiac arrest cases monthly or quarterly (adjusted OR for being in a higher survival quintile category, 8.55 [1.79, 40.0] for monthly and 6.85 [1.49, 31.3] for quarterly; P=0.03); and adequate resuscitation training (adjusted OR, 3.23 [1.21, 8.33]; P=0.02). Conclusions and Relevance Using survey information from acute care hospitals participating in a national quality improvement registry, we identified three resuscitation strategies associated with higher hospital rates of survival for patients with in-hospital cardiac arrest. These strategies can form the foundation for best practices for resuscitation care at hospitals, given the high incidence and variation in survival for in-hospital cardiac arrest.

IMPORTANCE Rapid response teams (RRTs) are foundational to hospital response to deteriorating conditions of patients. However, little is known about differences in RRT organization and function across top-performing and non-top-performing hospitals for in-hospital cardiac arrest (IHCA) care. OBJECTIVE To evaluate differences in design and implementation of RRTs at top-performing and non-top-performing sites for survival of IHCA, which is known to be associated with hospital performance on IHCA incidence. DESIGN, SETTING, AND PARTICIPANTS A qualitative analysis was performed of data from semistructured interviews of 158 hospital staff members (nurses, physicians, administrators, and staff) during site visits to 9 hospitals participating in the Get With The Guidelines-Resuscitation program and consistently ranked in the top, middle, and bottom quartiles for IHCA survival during 2012-2014. Site visits were conducted from April 19, 2016, to July 27, 2017. Data analysis was completed in January 2019. MAIN OUTCOMES AND MEASURES Semistructured in-depth interviews were performed and thematic analysis was conducted on strategies for IHCA prevention, including RRT roles and responsibilities. RESULTS Of the 158 participants, 72 were nurses (45.6%), 27 physicians (17.1%), 27 clinical staff (17.1%), and 32 administrators (20.3%). Between 12 and 30 people at each hospital participated in interviews. Differences in RRTs at top-performing and non-top-performing sites were found in the following 4 domains: team design and composition, RRT engagement in surveillance of at-risk patients, empowerment of bedside nurses to activate the RRT, and collaboration with bedside nurses during and after a rapid response. At top-performing hospitals, RRTs were typically staffed with dedicated team members without competing clinical responsibilities, who provided expertise to bedside nurses in managing patients who were at risk for deterioration, and collaborated with nurses during and after a rapid response. Bedside nurses were empowered to activate RRTs based on their judgment and experience without fear of reprisal from physicians or hospital staff. In contrast, RRT members at non-top-performing hospitals had competing clinical responsibilities and were generally less engaged with bedside nurses. Nurses at non-top-performing hospitals reported concerns about potential consequences from activating the RRT. CONCLUSIONS AND RELEVANCE This qualitative study's findings suggest that top-performing hospitals feature RRTs with dedicated staff without competing clinical responsibilities, that work collaboratively with bedside nurses, and that can be activated without fear of reprisal. These findings provide unique insights into RRTs at hospitals with better IHCA outcomes.

BackgroundGood outcomes for in-hospital cardiac arrest (IHCA) depend on a skilled resuscitation team, prompt initiation of high-quality cardiopulmonary resuscitation and defibrillation, and organisational structures to support IHCA response. We examined the role of nurses in resuscitation, contrasting higher versus lower performing hospitals in IHCA survival.MethodsWe conducted a descriptive qualitative study at nine hospitals in the American Heart Association’s Get With The Guidelines-Resuscitation registry, purposefully sampling hospitals that varied in geography, academic status, and risk-standardised IHCA survival. We conducted 158 semistructured interviews with nurses, physicians, respiratory therapists, pharmacists, quality improvement staff, and administrators. Qualitative thematic text analysis followed by type-building text analysis identified distinct nursing roles in IHCA care and support for roles.ResultsNurses played three major roles in IHCA response: bedside first responder, resuscitation team member, and clinical or administrative leader. We found distinctions between higher and lower performing hospitals in support for nurses. Higher performing hospitals emphasised training and competency of nurses at all levels; provided organisational flexibility and responsiveness with nursing roles; and empowered nurses to operate at a higher scope of clinical practice (eg, bedside defibrillation). Higher performing hospitals promoted nurses as leaders—administrators supporting nurses in resuscitation care at the institution, resuscitation team leaders during resuscitation and clinical champions for resuscitation care. Lower performing hospitals had more restrictive nurse roles with less emphasis on systematically identifying improvement needs.ConclusionHospitals that excelled in IHCA survival emphasised mentoring and empowering front-line nurses and ensured clinical competency and adequate nursing training for IHCA care. Though not proof of causation, nurses appear to be critical to effective IHCA response, and how to support their role to optimise outcomes warrants further investigation.

This is the first multicenter study describing extracorporeal membrane oxygenation use and outcomes specific to the cardiac ICU and inclusive of surgical and medical cardiac disease. Mortality remains high, highlighting the importance of identifying levers to improve care. These data provide benchmarks for hospitals to assess their outcomes in extracorporeal membrane oxygenation patients and identify unique high-risk subgroups to target for quality initiatives.