Strategies to Improve Cardiac Arrest Survival A Time to Act (2015) / Chapter Skim
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2 Understanding the Public Health Burden of Cardiac Arrest: The Need for National Surveillance
2 Understanding the Public Health Burden of Cardiac Arrest: The Need for National Surveillance
Pages 49-100
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From page 49... ...
A paucity of evidence is available about important non-mortality-related quality measures such as neurologic outcomes, functional status, and the long-term survival potential of cardiac arrest survivors, making it difficult to measure the burden of neurologic injury that can result from cardiac arrest. Long-standing efforts to improve nationwide survival rates and patient outcomes have resulted in limited success, although surveillance systems that combine data collection with some element of continuous quality improvement have demonstrated the ability to improve cardiac arrest outcomes in a number of communities, as described in Chapter 6.
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CARDIAC ARREST INCIDENCE AND OUTCOMES IN THE UNITED STATES Recent estimates suggest that approximately 395,000 cases of OHCA occur in the United States every year among patients of all ages, in which only 5.5 percent of all patients survive to hospital discharge (Daya et al., 2015a) .1 An estimated 200,000 IHCAs of presumed cardiac origin also occur annually, with national survival rates of approximately 24 percent (Chan, 2015; Go et al., 2014; Merchant et al., 2011)
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. The committee's commissioned analyses also found incremental increases in cardiac arrest survival rates over time (Chan, 2015; Daya et al., 2015a,b)
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NOTE: The ROC Epistry incidence includes all cardiac arrests (with cardiac and noncardiac etiology) , whereas the CARES incidence counts include cardiac arrest of presumed cardiac origin only.
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For example, there was a substantial increase in nationwide 30-day and 1-year OHCA survival rates reported by the Danish Cardiac Arrest Registry between 2001 and 2010 (Wissenberg et al., 2013)
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. For instance, pediatric survival rates can range from 27 to 48.7 percent (Lopez-Herce et al., 2013; Meert et al., 2009; Nadkarni et al., 2006)
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For example, Girotra and colleagues (2014) also found a significant decrease in age, prevalence of heart failure and myocardial infarction, and cardiac arrests due to shockable rhythms, among IHCA patients, all of which are known to influence outcomes following cardiac arrest.
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. Some risk factors that affect patient outcomes are modifiable and include the elements related to health care delivery and system performance.
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The next section focuses on describing trends in cardiac arrest incidence and outcomes, depending on location of arrest, as well as patient demographic factors such as age, gender, and race and ethnicity. Location of Arrest Survival rates greatly depend on where the cardiac arrest occurs.
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. Potential confounding factors such as availability of bystander CPR and initial cardiac rhythm (also known as first recorded rhythm)
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, as well as availability of bystander CPR (e.g., health care facility versus public highway) , may additionally account for differential survival rates between locations.
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. Survival rates from pediatric cardiac arrests are comparable, or higher in European countries.
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. Older Adults The committee's commissioned analyses confirmed that elderly patients, those who are older than 70, were more likely to have lower shortand long-term survival rates than younger adults (Chan, 2015; Daya et al., 2015a; Vellano et al., 2015)
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From page 62... ...
The committee's commissioned analyses of CARES and ROC data found that approximately three in five cardiac arrests occurred in men. While the survival rate following OHCA is higher among men, survival rates following IHCA appear to be similar in both groups (see Table 2-4)
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. Studies of OHCA conducted in Chicago and New York found that white patients were twice as likely to survive to hospital discharge as African American patients (Becker et al., 1993; Galea et al., 2007)
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From page 64... ...
One-year readmission rates are higher, and long-term survival rates are lower among African American IHCA patients. The maldistribution of risk factors for cardiac arrest and patient health factors in vulnerable populations, such as the number of preexisting conditions and illness severity, plays a crucial role in observed cardiac arrest outcome disparities.
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As noted throughout the report, the utility of existing cardiac arrest registries is limited because of missing data on race and ethnicity and socioeconomic factors. More research is needed to determine the precise influence of these factors on cardiac arrest survival and neurologic outcomes.
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. By contrast, 90 percent of patients with VF or pVT as the initial cardiac rhythm who survive have favorable neurologic outcomes, defined as a CPC score of 1 or 2 (Vellano et al., 2015)
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CARDIAC ARREST SURVEILLANCE Determining the magnitude of the public health burden of cardiac arrest is vital for improving patient outcomes in all communities. As discussed previously, incidence and survival are influenced by a number of modifiable (e.g., health care service characteristics)
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Pediatric Cardiac Arrest database) are also being developed to supplement existing cardiac arrest surveillance efforts.
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. Unlike CARES, NEMSIS collects data from participating EMS agencies only and therefore does not include patient outcomes and discharge data from hospitals.
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; supplemental information from 911 centers includes time variables (e.g., time of initial call and response times) , and hospital data include patient outcomes (e.g., emergency department outcome, hypothermia use, and neurologic outcome at discharge)
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OHCA: Resuscitation Outcomes Consortium (ROC) Epistry ROC, a national network of research institutions, was established in 2004 to conduct randomized clinical trials that evaluate promising treatments and therapies for patients with OHCA and life-threatening trauma.
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.6 The new network will continue the work of ROC and the NIH-supported Neurological Emergencies Treatment Trials, with the goal of designing clinical trials for patients with cardiac, neurologic, pulmonary, hematologic, and traumatic medical and surgical emergencies. These multidisciplinary research networks have the potential to improve research on cardiac arrest resuscitation and post-arrest care, by lowering the overall cost of conducting clinical trials research and creating a richer data source for assessing the complex treatments needed to improve rates of neurologically intact survival following cardiac arrest.
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Like CARES and the ROC Epistry, the ability of the GWTG-R registry to report incidence or survival for specific patient groups (pediatrics or racial and ethnic minorities) , or to examine the effects of confounding factors on outcomes, is fairly limited because of small sample sizes and missing data.
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From page 74... ...
In the absence of mandatory reporting requirements for OHCA and IHCA, many communities currently do not track any cardiac arrest outcomes at all. As a result, cardiac arrest incidence and outcomes data based on current surveillance systems may not be representative of the national state of cardiac arrest (Nichol et al., 2008b)
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. Research in Japan, Denmark, and more recently in the United States has attributed these increases to the Hawthorne effect; in other words, experts determined that communities that routinely monitor cardiac arrest responses and survival rates will improve their care over time, leading to better patient outcomes (Chan et al., 2014; Kellum et al., 2006)
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From page 76... ...
that have a substantial public health burden. With many existing registries struggling and even competing for the scare funds required to create a robust surveillance systems, it is both logical and necessary to integrate current efforts into one cohesive national surveillance system for continuous and systematic monitoring, reporting, and analysis of cardiac arrest data.
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Identifying this gap led to the development of a standardized template for measuring cardiac arrest survival rates (Cummins et al., 1991)
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based on the Cares Arrest Registry to Enhance Survival Europeb European Registry of 2007 Managed and funded by Voluntary Includes prospective Cardiac Arrest (EuReCa) the European Resuscitation Council data from 25 countries National Denmarkc Danish Cardiac Arrest 2000 Database owned by EMS Voluntary Registry Funded by TrygFonden, a private foundation Germanyd German Resuscitation 2007 German Resuscitation Council Voluntary Records data on a Registry national level, but participating centers represent only 9 percent of total population Irelande National Out-of-Hospital 2007 Pre-Hospital Emergency Care Nonvoluntary Monthly reporting to Cardiac Arrest Register Council and the National Ambu- National Ambulance Project lance Service; administered and Services; national supported by the Discipline of Gen- registry eral Practice at the National Uni versity of Ireland–Galway
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From page 79... ...
Year Registry Management and Location Registry Name Established Funding Participation Additional Information Koreag National Emergency De- 2005 Supported by the National Voluntary Registry structure partment Information Emergency Medical Center in similar to CARES System for Cardiac collaboration with the Korean Arrest (NEDIS-CA) Association of Cardiopulmonary registry Resuscitation Norwayh Norwegian Cardiovascular 2012 Norwegian Institute of Public Non- Does not require Diseases Registry Health voluntary consent of individual Swedeni Swedish Cardiac Arrest 1990 Funded by Swedish National Board Voluntary Register of Health and Welfare since 1993 Regional Victoria, Victorian Ambulance 1999 Managed by Ambulance Victoria, Data collected from Australiaj Cardiac Arrest Registry the sole EMS in Victoria; funded prehospital through by government of Victoria 1-year post arrest (excluding children)
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Historically, resuscitation experts have measured patient outcomes primarily in terms of survival rates, including survival to hospital discharge, survival to hospital admission, or long-term survival (30-90 days, 1 year, or 5 years following discharge)
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In order to improve patient outcomes following cardiac arrest, it is imperative that
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The availability of data derived from these variables is also needed in order to guide future resuscitation research priorities. Standardized data on factors that influence a patient's likelihood of survival with positive neurologic outcomes (e.g., patient demographic characteristics, EMS and health system processes, location and geographic characteristics, and bystander CPR and AED use)
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. This enriches the data source by allowing researchers to assess the cost-effectiveness of specific treatments and therapies, by linking cost data with patient outcomes.
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As data sources and collection activities expand, additional protections may be necessary, including security of the data system, quality control measures, procedures for protection of personal health information, deidentification of data as needed, and data reporting and analytic capabilities. Engage State Support in Mandatory Reporting of Cardiac Arrest, Improving Data Integration and Outcomes Assessment Involving state governments and health agencies, along with CDC, in activities related to a national surveillance system for cardiac arrest is necessary, because states would be responsible for providing technical assistance and training for participating hospitals, EMS agencies, and related staff, as well as for aggregating state-level data from multiple sources.
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From page 85... ...
Currently, one-fifth of EMS systems and several hundred hospitals in the United States systematically collect and report data on OHCA and IHCA to a larger registry, and as a result these systems and hospitals can benchmark their performance against other communities. Although some EMS and health systems informally monitor patient and process outcomes to implement quality improvement strategies within their own system, patient outcomes data from EMS and hospitals are not harmonized across an integrated platform.
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From page 86... ...
Communities that continuously measure their performance and benchmark against national standards have made strides in improving population rates of survival with favorable neurologic outcomes. The cardiac arrest field would be substantially enhanced through the establishment of a national surveillance system for cardiac arrest, with mandatory data reporting for both
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From page 87... ...
It has become apparent that cardiac arrest and resuscitation systems, both in the hospital and out of the hospital, must know, measure, and understand local survival rates, and identify the factors that determine those outcomes, in order to promote system improvement. The creation of a national database, and mandatory reporting of cardiac arrest, may represent one of the most effective methods for driving improvements in nationwide survival.
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2010. Global incidences of out-of-hospital cardiac arrest and survival rates: Systematic review of 67 prospective studies.
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K Nallamothu, and American Heart Association National Registry of Cardiopulmonary Resuscitation (NRCPR)
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2015b. Out-of hospital cardiac arrest survival improving over time: Results from the Re suscitation Outcomes Consortium (ROC)
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2012. Wide variability in drug use in out-of-hospital cardiac arrest: A report from the Resuscitation Outcomes Consortium.
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From page 92... ...
A statement for health care professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Councils of Southern Africa)
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2010. Pre resuscitation factors associated with mortality in 49,130 cases of in-hospital cardiac arrest: A report from the national registry for cardiopulmonary resuscitation.
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2011. Out of-hospital cardiac arrest surveillance -- Cardiac Arrest Registry to Enhance Survival (CARES)
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2014a. The significance of pre-arrest factors in out-of-hospital cardiac arrests witnessed by emergency medical services: A report from the Victorian Ambulance Cardiac Arrest Registry.
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2011. Implementation strategies for improving survival after out-of-hospital cardiac arrest in the United States: Consensus recommendations from the 2009 American Heart Association Cardiac Arrest Survival Summit.
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From page 97... ...
A Statement for healthcare professionals 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 Asia) ; and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation.
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2014. Public health burden of sudden cardiac death in the United States.
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2010. Women of child-bearing age have better inhospital cardiac arrest survival outcomes than do equal-aged men.
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2011. Variation in out of-hospital cardiac arrest resuscitation and transport practices in the Resus citation Outcomes Consortium: ROC Epistry–Cardiac Arrest.
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