The Association of Duration of participation in get with the guidelines-resuscitation with quality of Care for in-Hospital Cardiac Arrest

Synthetic Data for the Get With The Guidelines-Stroke Registry

The American Heart Association's Get With The Guidelines-Quality Improvement registry is a vital resource for real-world cardiovascular and stroke data and research, containing >14 million records from >2800 participating hospitals. To facilitate and streamline research, we aim to generate a synthetic data set that increases access to real-world data and facilitates data exploration of the Get With The Guidelines-Stroke registry. We first randomly sampled 1000 records from the entire registry data set from 2005 to 2021 containing 7.8 million records. To preserve privacy and break the links from the original data, we shifted all data time variables and replaced all patient identifiers. To evaluate the generated synthetic data, we compared the distributions of patient demographics (eg, age, race, sex) and other key stroke-related measures. The generated synthetic data exhibited similar distributions in age, race, sex, and time-sensitive metrics such as door-to-needle time and time to intravenous thrombolytic therapy, demonstrating that this open access data set can provide all researchers the opportunity to explore real-world cardiovascular and stroke data.

In-hospital cardiac arrest characteristics, causes and outcomes in patients with cardiovascular disease across different departments: a retrospective study

BACKGROUND

Cardiac etiologies arrest accounts for almost half of all in-hospital cardiac arrest (IHCA), and previous studies have shown that the location of IHCA is an important factor affecting patient outcomes. The aim was to compare the characteristics, causes and outcomes of cardiovascular disease in patients suffering IHCA from different departments of Fuwai hospital in Beijing, China.

METHODS

We included patients who were resuscitated after IHCA at Fuwai hospital between March 2017 and August 2022. We categorized the departments where cardiac arrest occurred as cardiac surgical or non-surgical units. Independent predictors of in-hospital survival were assessed by logistic regression.

RESULTS

A total of 119 patients with IHCA were analysed, 58 (48.7%) patients with cardiac arrest were in non-surgical units, and 61 (51.3%) were in cardiac surgical units. In non-surgical units, acute myocardial infarction/cardiogenic shock (48.3%) was the main cause of IHCA. Cardiac arrest in cardiac surgical units occurred mainly in patients who were planning or had undergone complex aortic replacement (32.8%). Shockable rhythms (ventricular fibrillation/ventricular tachycardia) were observed in approximately one-third of all initial rhythms in both units. Patients who suffered cardiac arrest in cardiac surgical units were more likely to return to spontaneous circulation (59.0% vs. 24.1%) and survive to hospital discharge (40.0% vs. 10.2%). On multivariable regression analysis, IHCA in cardiac surgical units (OR 5.39, 95% CI 1.90-15.26) and a shorter duration of resuscitation efforts (≤ 30 min) (OR 6.76, 95% CI 2.27-20.09) were associated with greater survival rate at discharge.

CONCLUSION

IHCA occurring in cardiac surgical units and a duration of resuscitation efforts less than 30 min were associated with potentially increased rates of survival to discharge.

Empowering Research With the American Heart Association Get With The Guidelines Registries Through Integration of a Database and Research Tools

BACKGROUND

The American Heart Association's Get With The Guidelines (GWTG) has emerged as a vital resource in advancing the standards and practices of inpatient care across stroke, heart failure, coronary artery disease, atrial fibrillation, and resuscitation focus areas. The GWTG registry data have also created new opportunities for secondary use of real-world clinical data in biomedical research. Our goal was to implement a scalable database with an integrated user interface (UI) to improve GWTG data management and accessibility.

METHODS

The curation of registry data begins by going through a data processing and quality control pipeline programmed in Python. This pipeline includes data cleaning and record exclusion, variable derivation and unit harmonization, limited data set preparation, and documentation generation of the registry data. The database was built using PostgreSQL, and integrations between the database and the UI were built using the Django Web Framework in Python. Smaller subsets of data were created using SQLite database files for distribution purposes. Use cases of these tools are provided in the article.

RESULTS

We implemented an automated data curation pipeline, centralized database, and UI application for the American Heart Association GWTG registry data. The database and the UI are accessible through a Precision Medicine Platform workspace. As of March 2024, the database contains over 13.2 million cleaned GWTG patient records. The SQLite subsets benefit researchers by optimizing data extraction and manipulation using Structured Query Language. The UI improves accessibility for nontechnical researchers by presenting data in a user-friendly tabular format with intuitive filtering options.

CONCLUSIONS

With the implementation of the GWTG database and UI application, we addressed data management and accessibility concerns despite its growing scale. We have launched tools to provide streamlined access and accessibility of GWTG registry data to all researchers, regardless of familiarity or experience in coding.

Outcomes in non-ST-segment elevation myocardial infarction complicated by in-hospital cardiac arrest based on management strategy

BACKGROUND

There are limited data on in-hospital cardiac arrest (IHCA) complicating non-ST-segment-elevation myocardial infarction (NSTEMI) based on management strategy.

METHODS

We used National Inpatient Sample (2000-2017) to identify adults with NSTEMI (not undergoing coronary artery bypass grafting) and concomitant IHCA. The cohort was stratified based on use of early (hospital day 0) or delayed (≥hospital day 1) coronary angiography (CAG), percutaneous coronary intervention (PCI), and medical management. Outcomes included incidence of IHCA, in-hospital mortality, adverse events, length of stay, and hospitalization costs.

RESULTS

Of 6,583,662 NSTEMI admissions, 375,873 (5.7 %) underwent early CAG, 1,133,143 (17.2 %) received delayed CAG, 2,326,391 (35.3 %) underwent PCI, and 2,748,255 (41.7 %) admissions were managed medically. The medical management cohort was older, predominantly female, and with higher comorbidities. Overall, 63,085 (1.0 %) admissions had IHCA, and incidence of IHCA was highest in the medical management group (1.4 % vs 1.1 % vs 0.7 % vs 0.6 %, p < 0.001) compared to early CAG, delayed CAG and PCI groups, respectively. In adjusted analysis, early CAG (adjusted OR [aOR] 0.67 [95 % confidence interval {CI} 0.65-0.69]; p < 0.001), delayed CAG (aOR 0.49 [95 % CI 0.48-0.50]; p < 0.001), and PCI (aOR 0.42 [95 % CI 0.41-0.43]; p < 0.001) were associated with lower incidence of IHCA compared to medical management. Compared to medical management, early CAG (adjusted OR 0.53, CI: 0.49-0.58), delayed CAG (adjusted OR 0.34, CI: 0.32-0.36) and PCI (adjusted OR 0.19, CI: 0.18-0.20) were associated with lower in-hospital mortality (all p < 0.001).

CONCLUSION

Early CAG and PCI in NSTEMI was associated with lower incidence of IHCA and lower mortality among NSTEMI-IHCA admissions.

Residual Psychomotor Skills of Orderlies After a Novel Chest Compression Training Intervention

BACKGROUND

High-quality chest compressions are essential to favorable patient outcomes after in-hospital cardiac arrest. Without frequent training, however, skill in performing compressions declines considerably. The Timely Chest Compression Training (T-CCT) intervention was introduced in 2019 as a quality improvement initiative to address this problem. The long-term impact of the T-CCT is unknown.

METHODS

A cohort study was conducted at a university-affiliated hospital in Quebec, Canada. Chest compression performance among orderlies was measured by using a subtractive scoring model and mannequins. The association of exposure to the T-CCT 10 months earlier with having an excellent chest compression performance (score ≥90 out of 100), after adjusting for potential confounders, was examined.

RESULTS

A total of 412 orderlies participated in the study. More than half (n = 232, 56%) had been exposed to the T-CCT, and the rest (n = 180, 44%) had not. Nearly half (n = 106, 46%) of orderlies exposed to the T-CCT had an excellent performance, compared with less than one-third (n = 53, 30%) of nonexposed orderlies. In univariable analysis, previous exposure to the T-CCT was associated with 1.53 times greater risk of having an excellent performance (risk ratio, 1.53; 95% CI, 1.17-1.99). This effect remained after adjustment for potential confounders (risk ratio, 1.57; 95% CI, 1.19-2.07).

CONCLUSION

The results of this study suggest that the T-CCT has a lasting effect on the psychomotor skills of orderlies 10 months after initial exposure. Further research should investigate the impact of the intervention on patient outcomes after in-hospital cardiac arrest.

In-hospital cardiac arrest: the state of the art

In-hospital cardiac arrest (IHCA) is associated with a high risk of death, but mortality rates are decreasing. The latest epidemiological and outcome data from several cardiac arrest registries are helping to shape our understanding of IHCA. The introduction of rapid response teams has been associated with a downward trend in hospital mortality. Technology and access to defibrillators continues to progress. The optimal method of airway management during IHCA remains uncertain, but there is a trend for decreasing use of tracheal intubation and increased use of supraglottic airway devices. The first randomised clinical trial of airway management during IHCA is ongoing in the UK. Retrospective and observational studies have shown that several pre-arrest factors are strongly associated with outcome after IHCA, but the risk of bias in such studies makes prognostication of individual cases potentially unreliable. Shared decision making and advanced care planning will increase application of appropriate DNACPR decisions and decrease rates of resuscitation attempts following IHCA.

Composite measures of quality of health care: Evidence mapping of methodology and reporting

Background

Quality indicators are used to quantify the quality of care. A large number of quality indicators makes assessment of overall quality difficult, time consuming and impractical. There is consequently an increasing interest for composite measures based on a combination of multiple indicators.

Objective

To examine the use of different approaches to construct composite measures of quality of care and to assess the use of methodological considerations and justifications.

Methods

We conducted a literature search on PubMed and EMBASE databases (latest update 1 December 2020). For each publication, we extracted information on the weighting and aggregation methodology that had been used to construct composite indicator(s).

Results

A total of 2711 publications were identified of which 145 were included after a screening process. Opportunity scoring with equal weights was the most used approach (86/145, 59%) followed by all-or-none scoring (48/145, 33%). Other approaches regarding aggregation or weighting of individual indicators were used in 32 publications (22%). The rationale for selecting a specific type of composite measure was reported in 36 publications (25%), whereas 22 papers (15%) addressed limitations regarding the composite measure.

Conclusion

Opportunity scoring and all-or-none scoring are the most frequently used approaches when constructing composite measures of quality of care. The attention towards the rationale and limitations of the composite measures appears low.

Discussion

Considering the widespread use and the potential implications for decision-making of composite measures, a high level of transparency regarding the construction process of the composite and the functionality of the measures is crucial.

Comparison of two strategies for managing in-hospital cardiac arrest

In-hospital cardiac arrest (IHCA) is associated with poor outcomes. There are currently no standards for cardiac arrest teams in terms of member composition and task allocation. Here we aimed to compare two different cardiac arrest team concepts to cover IHCA management in terms of survival and neurological outcomes. This prospective study enrolled 412 patients with IHCA from general medical wards. From May 2014 to April 2016, 228 patients were directly transferred to the intensive care unit (ICU) for ongoing resuscitation. In the ICU, resuscitation was extended to advanced cardiac life support (ACLS) (Load-and-Go [LaG] group). By May 2016, a dedicated cardiac arrest team provided by the ICU provided ACLS in the ward. After return of spontaneous circulation (ROSC), the patients (n = 184) were transferred to the ICU (Stay-and-Treat [SaT] group). Overall, baseline characteristics, aetiologies, and characteristics of cardiac arrest were similar between groups. The time to endotracheal intubation was longer in the LaG group than in the SaT group (6 [5, 8] min versus 4 [2, 5] min, p = 0.001). In the LaG group, 96% of the patients were transferred to the ICU regardless of ROSC achievement. In the SaT group, 83% of patients were transferred to the ICU (p = 0.001). Survival to discharge did not differ between the LaG (33%) and the SaT (35%) groups (p = 0.758). Ultimately, 22% of patients in the LaG group versus 21% in the SaT group were discharged with good neurological outcomes (p = 0.857). In conclusion, we demonstrated that the cardiac arrest team concepts for the management of IHCA did not differ in terms of survival and neurological outcomes. However, a dedicated (intensive care) cardiac arrest team could take some load off the ICU.

Cardiogenic Shock: Protocols, Teams, Centers, and Networks

The mortality of cardiogenic shock (CS) remains unacceptably high. Delays in the recognition of CS and access to disease-modifying or hemodynamically stabilizing interventions likely contribute to poor outcomes. In parallel to successful initiatives in other disease states, such as acute ST-elevation MI and major trauma, institutions are increasingly advocating the use of a multidisciplinary 'shock team' approach to CS management. A volume-outcome relationship exists in CS, as with many other acute cardiovascular conditions, and the emergence of 'shock hubs' as experienced facilities with an interest in improving CS outcomes through a hub-and-spoke 'shock network' approach provides another opportunity to deliver improved CS care as widely and equitably as possible. This narrative review outlines improvements from a networked approach to care, discusses a team-based and protocolized approach to CS management, reviews the available evidence and discusses the potential benefits, challenges, and opportunities of such systems of care.

Errors of Commission in Cardiac Arrest Care in the Intensive Care Unit

INTRODUCTION

Cardiopulmonary arrests (CPAs) are common in the intensive care unit (ICU). However, effects of protocol deviations on CPA outcomes in the ICU are relatively unknown.

OBJECTIVES

To establish the frequency of errors of commission (EOCs) during CPAs in the ICU and their relationship with CPA outcomes.

METHODS

Retrospective analysis of data entered into institutional registry with inclusion criteria of age >18 years and non-traumatic cardiac arrest in the ICU. EOCs consist of administration of drugs or procedures performed during a CPA that are not recommended by ACLS guidelines.Primary outcome: relationship of EOCs with likelihood of return of spontaneous circulation (ROSC). Secondary outcomes: relationship of specific EOCs to ROSC and relationship of EOCs and CPA length on ROSC.

RESULTS

Among 120 CPAs studied, there was a cumulative ROSC rate of 66%. Cumulatively, EOCs were associated with a decreased likelihood of ROSC (OR: 0.534, 95% CI: 0.387-0.644). Specifically, administration of sodium bicarbonate (OR: 0.233, 95% CI: 0.084-0.644) and calcium chloride (OR: 0.278, 95% CI: 0.098-0.790) were the EOCs that significantly reduced likelihood of attaining ROSC. Each 5-minute increment in CPA duration and/or increase in number of EOCs corresponded to fewer patients sustaining ROSC.

CONCLUSIONS

EOCs during CPAs in the ICU were common. Among all EOCs studied, sodium bicarbonate and calcium chloride seemed to have the greatest association with decreased likelihood of attaining ROSC. Number of EOCs and CPA duration both seemed to have an inversely proportional relationship with the likelihood of attaining and sustaining ROSC. EOCs represent potentially modifiable human factors during a CPA through resources such as life safety nurses.

How long should we run the code? Survival analysis based on location and duration of cardiopulmonary resuscitation (CPR) after in-hospital cardiac arrest

Background: The duration of cardiopulmonary resuscitation (CPR) significantly affects long-term survival in patients with in-hospital cardiac arrests (IHCA). In this study, we questioned the long-term clinical benefits of extending CPR beyond twenty minutes for patients with in-hospital cardiac arrest. Additionally, we aimed to compare the outcomes of CPR at different locations of a large tertiary care community hospital.

Methods: This study was a retrospective chart review of 169 patients with IHCA recorded between 1 January 2016, and 31 December 2018, at a large volume tertiary care community hospital.

Results: Of the 169 patients suffering from cardiac arrest during hospitalization, 44.4% arrested in the intensive care unit (ICU) and 55.6% in a non-critical care setting. Return of spontaneous circulation (ROSC) was achieved in 60% of ICU and 70.2% of non-ICU patients. While only 20% of ICU patients survived the cardiac arrest, the overall survival for non-ICU patients was 31.9%. Despite the significant difference in percentage survival, survival difference did not reach statistical significance (p = 0.082) due to the small sample size. Overall survival was 26.6%. An initial shockable rhythm was associated with improved survival compared to a non-shockable rhythm (41% vs. 22.5%, p = 0.022).

In patients who had cardiac arrest for less than 20 minutes, 60.9% of patients achieved ROSC, compared to 37.9% who arrested for more than 20 minutes. Survival to hospital discharge was significantly lower for patients who had cardiac arrest for more than 20 minutes, compared to patients who were arrested for less than 20 minutes (3.1% vs. 41.3%, p = <0.0001). For patients who had a cardiac arrest for more than 30 minutes, ROSC was achieved in only 14.8% of patients. None of these patients survived to be discharged from the hospital (p = <0.0001).

The mean age for the patients in this study was 70 years. 52.6% of subjects were male, and 47.4% were females. Older age was not related to shorter duration of CPR (Pearson correlation: 0.030, P = 0.69).

Conclusion: Survival was significantly lower when CPR was unsuccessful for twenty minutes, and there is no survival benefit of extending CRP for more than 30 minutes. Lowest survival after a cardiac arrest on the general medical floor, compared to telemetry and ICU, may be related to delay in recognizing cardiac arrest and barriers in implementing standardized advanced cardiac life support (ACLS) protocol.

Characteristics and Outcomes of In-Hospital Cardiac Arrest Events During the COVID-19 Pandemic: A Single-Center Experience From a New York City Public Hospital

Supplemental Digital Content is available in the text.

Background:

Patients hospitalized for severe coronavirus disease 2019 (COVID-19) infection are at risk for in-hospital cardiac arrest (IHCA). It is unknown whether certain characteristics of cardiac arrest care and outcomes of IHCAs during the COVID-19 pandemic differed compared with a pre-COVID-19 period.

Methods:

All patients who experienced an IHCA at our hospital from March 1, 2020 through May 15, 2020, during the peak of the COVID-19 pandemic, and those who had an IHCA from January 1, 2019 to December 31, 2019 were identified. All patient data were extracted from our hospital’s Get With The Guidelines–Resuscitation registry, a prospective hospital-based archive of IHCA data. Baseline characteristics of patients, interventions, and overall outcomes of IHCAs during the COVID-19 pandemic were compared with IHCAs in 2019, before the COVID-19 pandemic.

Results:

There were 125 IHCAs during a 2.5-month period at our hospital during the peak of the COVID-19 pandemic compared with 117 IHCAs in all of 2019. IHCAs during the COVID-19 pandemic occurred more often on general medicine wards than in intensive care units (46% versus 33%; 19% versus 60% in 2019; P<0.001), were overall shorter in duration (median time of 11 minutes [8.5–26.5] versus 15 minutes [7.0–20.0], P=0.001), led to fewer endotracheal intubations (52% versus 85%, P<0.001), and had overall worse survival rates (3% versus 13%; P=0.007) compared with IHCAs before the COVID-19 pandemic.

Conclusions:

Patients who experienced an IHCA during the COVID-19 pandemic had overall worse survival compared with those who had an IHCA before the COVID-19 pandemic. Our findings highlight important differences between these 2 time periods. Further study is needed on cardiac arrest care in patients with COVID-19.

Factors Affecting Attitudes Toward Defibrillator Use Among Clinical Nurses in South Korea: A Cross-Sectional Study

INTRODUCTION

Nurses are often first responders to in-hospital cardiac arrests. However, many nurses do not perform defibrillation even when required. Nurses' attitudes toward defibrillator use are influenced by social and psychological context. This descriptive, cross-sectional study explored factors affecting attitudes toward defibrillator use among nurses in South Korea.

METHODS

A total of 280 nurses with a minimum of 6 months' clinical experience were included. The data were acquired through a self-administered questionnaire. Regression analysis was used to determine factors significantly associated with attitudes toward defibrillator use.

RESULTS

Only 13.6% of the participating nurses had experience with defibrillator use in a cardiopulmonary resuscitation situation, whereas 94.6% of the nurses had received training on defibrillator use. Attitudes toward defibrillator use accounted for 37% of variance in measures of self-confidence, image, and job fit.

DISCUSSION

To improve clinical nurses' attitudes toward defibrillator use, improving their self-confidence, image, and job fit through ongoing assessment and retraining on defibrillation is required. In addition, relevant institutional support and systematic guidelines should be provided.

The impact of resuscitation system factors on in-hospital cardiac arrest outcomes across UK hospitals: An observational study

PURPOSE OF THE STUDY

To explore whether variation in in-hospital cardiac arrest (IHCA) survival can be explained by differences in resuscitation service provision across UK acute hospitals.

METHODS

We linked information on key clinical practices with patient data of adults who had a cardiac arrest on a general hospital ward or emergency admissions unit in 2016/17. We used multi-level Bayesian models to explore associations between system quality indicators (number of resuscitation officers, audits time to first shock, review unexpected non-survivors, arrest team meets at handover, hot debrief, cold debrief, real-time audio-visual feedback, frequency of mock arrest provision) and adjusted hospital survival.

RESULTS

We received survey responses from 110 out of 180 eligible hospitals (response rate 61%) relating to 12,285 cardiac arrest cases. Variation across trusts was observed in the number of resuscitation officers (median 0.7 (interquartile range 0.5, 0.9) per 750 clinical staff employed. Key system quality indicators were undertaken infrequently: audit of time to first shock (44.7%), arrest team meeting at handover (28.9%), mock arrests ≥ monthly (22.4%), and use of CPR feedback devices (18.4%). The probability that the system quality indicators had a positive effect on hospital survival ranged from 10% to 89%. However, there was uncertainty in the estimated odds ratios and we cannot exclude the possibility of a clinical benefit. Findings were consistent across secondary outcomes.

CONCLUSION

In this study, we identified variation in implementation of system quality indicators. Amongst hospitals that responded to our survey, the probability that individual factors increase the odds of hospital survival ranges from 10 to 89%.

Prospective Evaluation of Cardiopulmonary Resuscitation Performed in Dogs and Cats According to the RECOVER Guidelines. Part 2: Patient Outcomes and CPR Practice Since Guideline Implementation

Cardiopulmonary resuscitation (CPR) outcomes have not been prospectively described since implementation of the Reassessment Campaign on Veterinary Resuscitation (RECOVER) guidelines. This study aimed to prospectively describe CPR outcomes and document arrest variables in dogs and cats at a U.S. veterinary teaching hospital since implementation of the RECOVER guidelines using the 2016 veterinary Utstein-style CPR reporting guidelines. One-hundred and seventy-two dogs and 47 cats that experienced cardiopulmonary arrest (CPA) underwent CPR following implementation of the RECOVER guidelines and were prospectively included. Supervising clinicians completed a data form for CPR events immediately following completion of CPR from December 2013 to June 2018. Seventy-five (44%) dogs and 26 (55%) cats attained return of spontaneous circulation (ROSC), 45 dogs (26%) and 16 cats (34%) had ROSC ≥ 20 min, 13 dogs (8%) and 10 cats (21%) were alive 24 h after CPR, and 12 dogs (7%) and 9 cats (19%) survived to hospital discharge. The most common cause of death in animals with ROSC ≥ 20 min was euthanasia. Patient outcomes were not significantly different since publication of the RECOVER guidelines except for a higher feline survival to hospital discharge rate. Dogs (p = 0.02) but not cats with initial shockable rhythms had increased rates of ROSC while the development of a shockable rhythm during CPR efforts was not associated with ROSC (p = 0.30). In closed chest CPR an end-tidal carbon dioxide (EtCO₂) value of >16.5 mmHg was associated with a 75% sensitivity and 64% specificity for achieving ROSC. Since publication of the RECOVER guidelines, CPR practice did not clinically significantly change at our institution and no improvement of already high ROSC rates was noted. The percentage of cats surviving to hospital discharge was higher than previously reported and the reason for this improvement is not evident with these results. Euthanasia remains a major confounding factor in assessing intermediate and long-term CPR outcomes in dogs and cats.

In-Hospital Cardiac Arrest: A Review

IMPORTANCE

In-hospital cardiac arrest is common and associated with a high mortality rate. Despite this, in-hospital cardiac arrest has received little attention compared with other high-risk cardiovascular conditions, such as stroke, myocardial infarction, and out-of-hospital cardiac arrest.

OBSERVATIONS

In-hospital cardiac arrest occurs in over 290 000 adults each year in the United States. Cohort data from the United States indicate that the mean age of patients with in-hospital cardiac arrest is 66 years, 58% are men, and the presenting rhythm is most often (81%) nonshockable (ie, asystole or pulseless electrical activity). The cause of the cardiac arrest is most often cardiac (50%-60%), followed by respiratory insufficiency (15%-40%). Efforts to prevent in-hospital cardiac arrest require both a system for identifying deteriorating patients and an appropriate interventional response (eg, rapid response teams). The key elements of treatment during cardiac arrest include chest compressions, ventilation, early defibrillation, when applicable, and immediate attention to potentially reversible causes, such as hyperkalemia or hypoxia. There is limited evidence to support more advanced treatments. Post-cardiac arrest care is focused on identification and treatment of the underlying cause, hemodynamic and respiratory support, and potentially employing neuroprotective strategies (eg, targeted temperature management). Although multiple individual factors are associated with outcomes (eg, age, initial rhythm, duration of the cardiac arrest), a multifaceted approach considering both potential for neurological recovery and ongoing multiorgan failure is warranted for prognostication and clinical decision-making in the post-cardiac arrest period. Withdrawal of care in the absence of definite prognostic signs both during and after cardiac arrest should be avoided. Hospitals are encouraged to participate in national quality-improvement initiatives.

CONCLUSIONS AND RELEVANCE

An estimated 290 000 in-hospital cardiac arrests occur each year in the United States. However, there is limited evidence to support clinical decision making. An increased awareness with regard to optimizing clinical care and new research might improve outcomes.