BACKGROUND Despite numerous advances in resuscitation care in recent years, it remains unknown whether survival and neurological function after in-hospital cardiac arrest has improved over time. METHODS We identified all adults with an index in-hospital cardiac arrest at 374 hospitals in the Get With The Guidelines-Resuscitation registry between 2000 and 2009. Using multivariable regression, we examined temporal trends in risk-adjusted rates of survival to discharge. Additional analyses explored whether trends: (1) were due to improved survival during the acute resuscitation or post-resuscitation care and (2) occurred at the expense of greater neurological disability among survivors. RESULTS Among 84,625 hospitalized patients with cardiac arrest, 67,135 (79.3%) had an initial rhythm of asystole or pulseless electrical activity while 17,490 (20.7%) had ventricular fibrillation or pulseless ventricular tachycardia. The proportion of cardiac arrests due to asystole or pulseless electrical activity increased over time (P for trend <0.001). Risk-adjusted rates of survival to discharge in the overall cohort increased from 13.7% in 2000 to 22.4% in 2009 (adjusted rate-ratio per 1-year: 1.04, 95% CI [1.02–1.05]; P for trend <0.001). Survival improvement was similar in both rhythm groups and largely due to improved survival from the acute resuscitation (risk-adjusted rates: 42.7% in 2000, 54.1% in 2009; adjusted rate-ratio per 1-year: 1.03, 95% CI [1.02–1.04]; P for trend <0.001). Importantly, rates of neurological disability among survivors decreased over time (risk-adjusted rates: 32.9% in 2000, 28.1% in 2009; P for trend=0.02). CONCLUSIONS Both survival and neurological outcomes after in-hospital cardiac arrest have improved over the past decade.

The fundamentals of cardiac resuscitation include the immediate provision of high-quality cardiopulmonary resuscitation combined with rapid defibrillation (as appropriate). These mainstays of therapy set the groundwork for other possible interventions such as medications, advanced airways, extracorporeal cardiopulmonary resuscitation, and post–cardiac arrest care, including targeted temperature management, cardiorespiratory support, and percutaneous coronary intervention. Since 2015, an increased number of studies have been published evaluating some of these interventions, requiring a reassessment of their use and impact on survival from cardiac arrest. This 2019 focused update to the American Heart Association advanced cardiovascular life support guidelines summarizes the most recent published evidence for and recommendations on the use of advanced airways, vasopressors, and extracorporeal cardiopulmonary resuscitation during cardiac arrest. It includes revised recommendations for all 3 areas, including the choice of advanced airway devices and strategies during cardiac arrest (eg, bag-mask ventilation, supraglottic airway, or endotracheal intubation), the training and retraining required, the administration of standard-dose epinephrine, and the decisions involved in the application of extracorporeal cardiopulmonary resuscitation and its potential impact on cardiac arrest survival.

Delayed defibrillation is common and is associated with lower rates of survival after in-hospital cardiac arrest.

Context Little is known about the impact of low health literacy among patients with heart failure (HF), a condition that requires self-management and frequent interactions with the healthcare system. Objective Evaluate the association between low health literacy and all-cause rehospitalization and mortality among outpatients with HF. Design and Setting Retrospective cohort study performed at Kaiser Permanente Colorado, an integrated managed care organization. Patients with HF were identified between Jan, 2001 and May, 2008 and followed for a mean of 1.2 years. Patients were surveyed. Health literacy was assessed using three established screening questions and categorized as adequate or low. Patients Outpatients with HF. Main Outcomes All-cause mortality and hospitalization. Results The survey response rate was 72%. Of 1494 patients, 262 (17.5%) had low health literacy. Patients with low health literacy were older, of lower socioeconomic status, less likely to have at least a high school education and had higher rates of coexisting illnesses. In multivariable Cox regression, low health literacy was independently associated with higher mortality (unadjusted 17.6% vs. 6.3%; adjusted hazard ratio [HR]: 1.61; 95% CI 1.06–2.43; p=0.026), but not hospitalization (30.5% vs. 23.2%; HR:1.04; 95% CI 0.79–1.37; p=0.760). Conclusions Among patients with HF in an integrated managed care organization, low health literacy was significantly associated with higher all-cause mortality.

June 23/30, 2020 e933 Existing American Heart Association cardiopulmonary resuscitation (CPR) guidelines do not address the challenges of providing resuscitation in the setting of the coronavirus disease 2019 (COVID-19) global pandemic, wherein rescuers must continuously balance the immediate needs of the patients with their own safety. To address this gap, the American Heart Association, in collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists, and with the support of the American Association of Critical Care Nurses and National Association of EMS Physicians, has compiled interim guidance to help rescuers treat individuals with cardiac arrest with suspected or confirmed COVID-19.Over the past 2 decades, there has been a steady improvement in survival after cardiac arrest occurring both inside and outside the hospital. 1 That success has relied on initiating proven resuscitation interventions such as high-quality chest compressions and defibrillation within seconds to minutes. The evolving and expanding outbreak of severe acute respiratory syndrome coronavirus 2 infections has created important challenges to such resuscitation efforts and requires potential modifications of established processes and practices. The challenge is to ensure that patients with or without COVID-19 who experience cardiac arrest get the best possible chance of survival without compromising the safety of rescuers, who will be needed to care for future patients. Complicating the emergency response to both out-of-hospital and in-hospital cardiac arrest is that COVID-19 is highly transmissible, particularly during resuscitation, and carries a high morbidity and mortality.Approximately 12% to 19% of COVID-positive patients require hospital admission, and 3% to 6% become critically ill. [2][3][4] Hypoxemic respiratory failure secondary to acute respiratory distress syndrome, myocardial injury, ventricular arrhythmias, and shock are common among critically ill patients and predispose them to cardiac arrest, [5][6][7][8] as do some of the proposed treatments such as hydroxychloroquine and azithromycin, which can prolong the QT. 9 With infections currently growing exponentially in the United States and internationally, the percentage of patients with cardiac arrests and COVID-19 is likely to increase.Healthcare workers are already the highest-risk profession for contracting the disease. 10 This risk is compounded by worldwide shortages of personal protective equipment (PPE). Resuscitations carry added risk to healthcare workers for many reasons. First, the administration of CPR involves performing numerous aerosol-generating procedures, including chest compressions, positive-pressure ventilation, and establishment of an advanced airway. During those procedures, viral particles can remain suspended in the air with a half-life of ≈1 hour and

Background Despite intensive efforts over many years, the U.S. has made limited progress in improving rates of survival from out-of-hospital cardiac arrest (OHCA). Recently, national organizations, such as the American Heart Association, have focused on promoting bystander cardiopulmonary resuscitation (CPR), use of automated external defibrillators (AEDs), and other performance improvement efforts. Methods and Results Using the Cardiac Arrest Registry to Enhance Survival (CARES), a prospective clinical registry, we identified 70,027 U.S. patients who experienced an OHCA between October 2005 and December 2012. Using multilevel Poisson regression, we examined temporal trends in risk-adjusted survival. After adjusting for patient and cardiac arrest characteristics, risk-adjusted rates of OHCA survival increased from 5.7% in the reference period of 2005-2006 to 7.2% in 2008 (adjusted risk ratio, 1.27; 95% CI, 1.12-1.43; P<0.001). Survival improved more modestly to 8.3% in 2012 (adjusted risk ratio, 1.47; 95% CI, 1.26-1.70; P<0.001). This improvement in survival occurred in both shockable and non-shockable arrest rhythms (P for interaction=0.22) and was also accompanied by better neurological outcomes among survivors (P for trend=0.01). Improved survival was due to both higher rates of pre-hospital survival, where risk-adjusted rates increased from 14.3% in 2005-2006 to 20.8% in 2012 (P for trend<0.001), and in-hospital survival (P for trend=0.015). Rates of bystander CPR and AED use modestly increased during the study period and partly accounted for pre-hospital survival trends. Conclusions Data drawn from a large subset of U.S communities suggest that rates of survival from OHCA have improved among sites participating in a performance improvement registry.

Importance Publicly available datasets hold much potential, but their unique design may require specific analytic approaches. Objective To determine adherence to appropriate research practices for a frequently used large public database, the National Inpatient Sample (NIS) of the Agency for Healthcare Research and Quality (AHRQ). Design, Setting and Participants In this observational study, of the 1082 studies published using the NIS from January 2015 – December 2016, a representative sample of 120 studies was systematically evaluated for adherence to practices required by AHRQ for design and conduct of research using the NIS. Exposure None Main Outcomes All studies were evaluated on 7 required research practices based on AHRQ’s recommendations, compiled under 3 domains: (A) data interpretation (interpreting data as hospitalization records rather than unique patients); (B) research design (avoiding use in performing state-, hospital-, and physician-level assessments where inappropriate; not using non-specific administrative secondary diagnosis codes to study in-hospital events), and (C) data analysis (accounting for complex survey design of the NIS and changes in data structure over time). Results Of 120 published studies, 85% (n=102) did not adhere to ≥1 required practices and 62% (n=74) did not adhere to ≥2 required practices. An estimated 925 (95% CI 852–998) and 696 (95% CI 596–796) NIS publications had violations of ≥1 and ≥2 required practices, respectively. A total of 79 sampled studies, representing 68.3% (95% CI 59.3–77.3) of the 1082 NIS studies, did not account for the effects of sampling error, clustering, and stratification; 62 (54.4%, 95% CI 44.7–64.0) extrapolated non-specific secondary diagnoses to infer in-hospital events; 45 (40.4%, 95% CI 30.9–50.0) miscategorized hospitalizations as individual patients; 10 (7.1%, 95% CI 2.1–12.1) performed state-level analyses; and 3 (2.9%, 95% CI 0.0–6.2) reported physician-level volume estimates. Of 27 studies (weighted: 218 studies, 95% CI 134–303) spanning periods of major changes in the data structure of the NIS, 21 (79.7%, 95% CI 62.5–97.0) did not account for the changes. Among the 24 studies published in journals with an impact factor ≥10, 16 (67%) and 9 (38%) did not adhere to ≥1 and ≥2 practices, respectively. Conclusions and Relevance In this study of 120 recent publications that used data from the NIS, the majority did not adhere to required practices. Further research is needed to identify strategies to improve the quality of research using the NIS and assess whether there are similar problems with use of other publicly available data sets.

The formula for survival in resuscitation describes educational efficiency and local implementation as key determinants in survival after cardiac arrest. Current educational offerings in the form of standardized online and face-to-face courses are falling short, with providers demonstrating a decay of skills over time. This translates to suboptimal clinical care and poor survival outcomes from cardiac arrest. In many institutions, guidelines taught in courses are not thoughtfully implemented in the clinical environment. A current synthesis of the evidence supporting best educational and knowledge translation strategies in resuscitation is lacking. In this American Heart Association scientific statement, we provide a review of the literature describing key elements of educational efficiency and local implementation, including mastery learning and deliberate practice, spaced practice, contextual learning, feedback and debriefing, assessment, innovative educational strategies, faculty development, and knowledge translation and implementation. For each topic, we provide suggestions for improving provider performance that may ultimately optimize patient outcomes from cardiac arrest.