Improving in-hospital cardiac arrest (IHCA) quality of care for requires a comprehensive set of actions. This article summarizes key points from the recently published Ten Steps toward Improving In-Hospital Cardiac Arrest Quality of Care and Outcomes, by the International Liaison Committee on Resuscitation (ILCOR).
In-hospital cardiac arrest (IHCA) is correlated with notable morbidity and mortality rates. The incidence of IHCA is between 1.2 and 10 per 1000 hospital admissions worldwide. In the United States, 300 000 IHCA events occur yearly with a survival to hospital discharge rate of 25%. However, the quality of IHCA care remains suboptimal and varies worldwide. As such, the International Liaison Committee on Resuscitation (ILCOR) launched an initiative to improve IHCA care, culminating in The Ten Steps Toward Improving In-Hospital Cardiac Arrest Quality of Care and Outcomes.
Enhancing care for in-hospital cardiac arrest (IHCA) necessitates a comprehensive array of measures integrated into a care system that (1) strategizes and readies for IHCA occurrences, (2) prevents IHCA where possible, (3) provides high-quality resuscitation aligned with guidelines, and (4) consistently assesses and enhances itself within a culture centered on individualized care.
Step 1: Establishing and reinforcing governance and infrastructure
Strong governance with leadership committed to advancing resuscitation care is key to improving IHCA survival. This requires structures including equipment and trained personnel, as well as processes including evidence-based protocols and policies, held together by a framework of continuous quality improvement. Local operational champions drawn from multiple disciplines including medical, nursing, respiratory therapy and pharmacy, can engage administrative leadership to obtain resources required.
Step 2: Gather data to evaluate and enhance the processes and results of resuscitation
Measurement is the cornerstone of quality improvement. This should include measuring cardiac arrest occurrence and survival outcomes, and other aspects of in-hospital resuscitation care. The ILCOR Utstein reporting statement for IHCA represents one example for data collection, providing guidance for developing data elements across 6 domains: hospital, patients, pre-event, cardiac arrest process, post- resuscitation process, and outcomes.
Engagement in a cardiac arrest registry can stimulate quality improvement by facilitating benchmarking. For example, Get with the Guidelines-Resuscitation registry participation duration is associated with an improvement in IHCA quality of care and survival.
Step 3: Execute efficient education and training programs for resuscitation
Training programs for resuscitation are indispensable for all hospital personnel. Effective leadership is crucial in prioritizing resuscitation education for successful training. These educational initiatives should be guideline-based and be customized to suit the specific needs of employees. Knowledge acquisition can be facilitated through didactic lectures, blended or online learning. Training should emphasize team competencies, prompt recognition of cardiac arrest, and hands-on practice for delivering high-quality CPR, including early defibrillation when appropriate. Ideally, education should be spaced out over time in a low-dose, high-frequency approach. In-situ simulations, whether planned or unannounced, can be utilized to assess the system and uncover latent safety threast. Debriefing sessions following clinical cardiac arrests enable participants to reflect on their performance and identify areas for improvement, which has been linked to enhanced patient outcomes.
Step 4: Establish treatment objectives with patients and their families early and review regularly
Goals of treatment discussions are crucial in patient care. These should ideally occur before hospital admission and involve the patient and their primary care practitioner, considering realistic treatment goals alongside patients’ values and preferences. Upon admission, it is essential to revisit clear goals of treatment including relevant treatment options, limited time treatment trials, and administration of CPR. These should be reassessed as patients’ illness and preferences evolve. Culturally sensitive structured communication tools improve the quality of communication, patient involvement, and documentation of patient wishes and treatment plans.
Step 5: Stop Preventable IHCA
Stopping preventable IHCA is key toward saving lives. This requires afferent alert and efferent rapid response systems. The ILCOR Consensus on Science With Treatment Recommendations proposes implementing a rapid response system to attend to deteriorating patients and decrease IHCA incidence.. As escalation of care is often driven by vital sign abnormalities or clinician concern, regular measurement and interpretation of vital signs is critical to IHCA prvention. Severity-of-illness scoring systems can be used for detection of deterioration. There is increasing interest in integrating machine learning and artificial intelligence to enable early detection of the deteriorating patient.
Step 6: Crease and implement an effective resuscitation response system
Early detection of cardiac arrest and delivery of basic life support are critical. Strategies for implementing resuscitation teams at hospitals that consistently achieve high IHCA survival include pre-assigned designated resuscitation teams, multidisciplinary team members with clear roles, and effective communication and leadership during IHCA.
Step 7: Deliver Guideline-Based Resuscitation Care
Adherence to IHCA guidelines is associated with improved rates of return of spontaneous circulation (ROSC), survival to hospital discharge, and long-term neurological outcome and quality of life. Key components include prompt initiation of high-performance CPR by assessing the rate, depth, recoil, and compression fraction, early defibrillation when indicated, and interventions to address the etiology of IHCA. Non-recommended drugs, interventions, and early termination of resuscitation should be avoided.
Step 8: Deliver Guideline-Based Postcardiac Arrest Care
Post–cardiac arrest care begins upon ROSC and should be delivered by a multidisciplinary team, addressing pathophysiology, psychology, and stress syndromes. Accurately assessing the patient’s prognosis helps families prepare for potential outcomes and informs decisions about the benefits and risks of life-sustaining treatments. However, the accuracy of prognostication at the individual level is limited in the early period after ROSC and typically is deferred for at least 72 hours under current guidelines. It is recommended that hospitals use > 1 validated predictor of poor neurological outcome when making decisions about limiting life-sustaining therapy as no modality is completely accurate.
Step 9: Establish a culture centered on person-focused excellence in care
Family-centered care during IHCA embraces policies that enhance patient well-being, including consideration of the family context, illness-specific education for staff, and collaboration between patient, family, and health care professionals. IHCA survivorship rehabilitation and recovery plans as well as end-of- life care are also a crucial components of person-centered care.
Step 10: Safeguard health care professional well-being
The emotional and physical demands of resuscitations can result in significant psychological burden.
A comprehensive approach should prioritize the psychological, physical, and spiritual well-being of healthcare professionals. By attending to the needs of the care team, the quality of treatment for IHCA patients can be maintained at a high standard.
Summary
The Ten Steps provides a framework for all stakeholders to analyze their strengths and weaknesses in their response to IHCA. They reflect current knowledge of best practices within resuscitation systems and serve as a foundation for improving IHCA quality of care and outcomes across different settings.
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