Ten Steps toward Improving In-Hospital Cardiac Arrest Quality of Care and Outcomes

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.


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.


1. Andersen LW, Holmberg MJ, Berg KM, Donnino MW, Granfeldt A. In-Hospital Cardiac Arrest: A Review. JAMA. 2019;321(12):1200-1210. doi:10.1001/JAMA.2019.1696

2. Holmberg MJ, Ross CE, Fitzmaurice GM, et al. Annual Incidence of Adult and Pediatric In-Hospital Cardiac Arrest in the United States. Circ Cardiovasc Qual Outcomes. 2019;12(7):e005580. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6758564/

3. Penketh J, Nolan JP. In-hospital cardiac arrest: the state of the art. Crit Care. 2022;26(1):1-8. doi:10.1186/S13054-022-04247-Y/FIGURES/1

4. Semeraro F, Greif R, Böttiger BW, et al. European Resuscitation Council Guidelines 2021: Systems saving lives. Resuscitation. 2021;161:80-97. doi:10.1016/j.resuscitation.2021.02.008

5. Nolan JP, Berg RA, Andersen LW, et al. Cardiac Arrest and Cardiopulmonary Resuscitation Outcome Reports: Update of the Utstein Resuscitation Registry Template for In-Hospital Cardiac Arrest: A Consensus Report From a Task Force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asi. Circulation. 2019;140(18):e746-e757. doi:10.1161/CIR.0000000000000710

6. Girotra S, Nallamothu BK, Spertus JA, Li Y, Krumholz HM, Chan PS. Trends in survival after in-hospital cardiac arrest. N Engl J Med. 2012;367(20):1912-1920. doi:10.1056/NEJMoa1109148

7. Anderson TM, Secrest K, Krein SL, et al. Best Practices for Education and Training of Resuscitation Teams for In-Hospital Cardiac Arrest. Circ Cardiovasc Qual Outcomes. 2021;14(12):E008587. doi:10.1161/CIRCOUTCOMES.121.008587

8. Are cardiac arrest patient outcomes improved as a result of a member of the resuscitation team having attended an accredited advanced life support course: EIT 4000. Accessed January 27, 2024. https://costr.ilcor.org/document/are-cardiac-arrest-patient-outcomes-improved-as-a-result-of-a-member-of-the-resuscitation-team-having-attended-an-accredited-advanced-life-support-course-eit-4000

9. Yeung J, Djarv T, Hsieh MJ, et al. Spaced learning versus massed learning in resuscitation - A systematic review. Resuscitation. 2020;156:61-71. doi:10.1016/J.RESUSCITATION.2020.08.132

10. Stærk M, Lauridsen KG, Johnsen J, Løfgren B, Krogh K. In-situ simulations to detect patient safety threats during in-hospital cardiac arrest. Resusc Plus. 2023;14:100410. doi:10.1016/J.RESPLU.2023.100410

11. Mentzelopoulos SD, Couper K, Voorde P Van de, et al. European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions. Resuscitation. 2021;161:408-432. doi:10.1016/J.RESUSCITATION.2021.02.017

12. Field RA, Fritz Z, Baker A, Grove A, Perkins GD. Systematic review of interventions to improve appropriate use and outcomes associated with do-not-attempt-cardiopulmonary-resuscitation decisions. Resuscitation. 2014;85(11):1418-1431. doi:10.1016/J.RESUSCITATION.2014.08.024

13. Greif R, Bhanji F, Bigham BL, et al. Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020;142(1):S222-S283. doi:10.1161/CIR.0000000000000896

14. Winslow CJ, Edelson DP, Churpek MM, et al. The Impact of a Machine Learning Early Warning Score on Hospital Mortality: A Multicenter Clinical Intervention Trial. Crit Care Med. 2022;50(9):1339-1347. doi:10.1097/CCM.0000000000005492

15. Nallamothu BK, Guetterman TC, Harrod M, et al. How Do Resuscitation Teams at Top-Performing Hospitals for In-Hospital Cardiac Arrest Succeed? A Qualitative Study. Circulation. 2018;138(2):154-163. doi:10.1161/CIRCULATIONAHA.118.033674

16. Crowley CP, Salciccioli JD, Kim EY. The association between ACLS guideline deviations and outcomes from in-hospital cardiac arrest. Resuscitation. 2020;153:65-70. doi:10.1016/J.RESUSCITATION.2020.05.042

17. Nolan JP, Maconochie I, Soar J, et al. Executive Summary: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020;142(16_suppl_1):S2-S27. doi:10.1161/CIR.0000000000000890




Dr. Carrie Kah-Lai Leong

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Dr. Carrie Kah-Lai Leong is a consultant respiratory physician, intensivist, interventional pulmonologist, and clinical assistant professor at the Department of Respiratory and Critical Care Medicine, Singapore General Hospital and Singhealth Duke-NUS Lung Center, Singapore. She is a member of the International Liaison Committee on Resuscitation (ILCOR).